While I am slogging away in Kenya - waking up at 5:20am and working until after dark - Dr. Zirkle arrives in Bangladesh and also works long days. The pace there is the same as here in Kenya. Although I am getting work done, it seems to barely make a dent: finish three cases and five new traumas arrive, finish five cases and there are seven new operative cases in the clinic. The amount of work to be done is staggering. Everything is uphill.
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| Dr. Isidor putting our patient through his paces. This man had a chronic lunate dislocation - life was good post-op. |
At the same time, hundreds of surgeons, medics, physiotherapists, CEO's, teachers, and even accountants are traveling with organizations to care for patients, run orphanages, keep books, and teach teachers. They are traveling with MSF, Unicef, The Peace Corps, SIGN, and hundreds of other organizations. They all have something in common. All of these people, I believe, strive for a greater level of equality among humans.
It is a giant quest and the climb seems unconquerable. I believe that it is not. Dr. Asle, an anesthesiologist from Norway, was amused by my energy and by my frustration when we met in Ethiopia. I am naive, he is wise. His thoughts are complex, mine are simple. He told me some words that I'll never forget. He likened the inequality in the world today to racial segregation in North America some 50-70 years ago. Our grandparents tolerated this behavior. Segregation seemed ok. Some people spoke out, but most did not though they knew it was wrong. They sat back quietly shaking their heads. Five decades later it seems proposterous that this occurred on North American soil less than two generations ago. Of course racial issues in the USA are far from solved but they have clearly come a long way in the short period of time. I am not sure that I have what it takes to affect change in the world (in fact I am quite sure I do not) but I am sure, as Dr. Asle, that I won't sit back and watch. I'll try and do my bit.
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| Squat and smile. This is a simple way to asses fracture healing for both the femur and the tibia. Squatting requires composite motion of the ankles, knees and hips, while smiling is a good indicator that the patient is pain free. |
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| Some patients enjoying a rare break from the rain in Kijabe. |
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| The street outside of Black Lion Hospital in Addis. The tarp on the right is 'higher-end' squatting. It is common to see a family arise from a five foot fort at sunrise. The streets are lined with people bunking down every night after dark. There are a rumoured 100,00 street kids in Addis Ababa. Staggering. |
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| When dinner and warmth rely on having something to burn, one learns how to yield a machete at an early age. Kijabe, Kenya. |
Home now. Thanks for reading. The End.
Dr. Neil. J. White
Some points of follow-up:
-Penina is recovering well from her surgery in Tanzania. The right hand is functioning better but she still complains with inner grip and full extension. Ken Moghadam and Steve Scott from Cascade Orthotis in Calgary have agreed to provide a free custom left arm prosthesis. Dr. Ryan Frank has agreed to assess Penina for facial surgery and if indicated, provide said surgery for free. All of this will take place during a two week visit to Calgary, Alberta, Canada for Penina and her mom. We are working on visas. They will billet with medical colleagues of mine (although I have not informed them yet --you know who you are!), and I just need to raise about $5,000 USD for flights.
-This is follow-up on a case I have not yet talked about. Before I left Ethiopia, I did a really tough case. I don't like taking on tough cases just before leaving--It does not seem right to be unable to follow these patients--a young man presented with a neglected open knee fracture dislocation.
We washed out the infection and then fixed the knee with small plates and a spanning fixator (I would never do this at home but was doing the best I could with what I had). The patellar tendon was completely ruptured off the tubercle and tied over a post. So, he did great. After I left Ethiopia for Tanzania his wound dehisced (broke open). Meanwhile, Dr. Sami Hailu had just returned from the SIGN conference. While in the USA, Dr. Sami went to the SIGN Flaps Course in San Francisco (this is a course where surgeons learn to cover wounds with local flaps - they do not have the support from plastic surgery that we get at home). He learned how to manage problems exactly like a dehisced wound about the knee. He emailed me to discuss this potentially catastrophic complication. His surgical plan was good, and after our discussion, he took this patient back to the OR and covered the knee wound with a medial gastroc flap. It worked.
It was Sami's first time doing that surgery (other than on a cadaver). Of course I was disappointed that our patient had this complication but was equally elated, however, that Sami had acquired the skills and executed a well thought out plan to rectify the problem. This was great for the patient and averted disaster. It was equally great for Dr. Sami to be given an opportunity to use his new skills so fresh off the course and to gain the associated surgical confidence. I am proud of him.
-Open Tibia Protocol: It looks like the Open Tibia Protocol will be starting at Black Lion Hospital in Addis during mid January. I think this has the potential to be groundbreaking for open fracture care in the developing world. We will aim for the stars with this project and, if at all possible, I will go back to facilitate and trouble shoot.
-The fasciocutaneous flap: I learned this from Dr. Duane Anderson in Soddo. We did one together and was then able to do three in Addis with the help of keen residents. I later received a letter from Dr. Geletaw (one of those residents) who has now done two successful fasciocutaneous flaps autonomously. This technique has averted major potential morbidity for those patients. It is nice to teach, it is nice to learn, it is especially nice to pass on knowledge and know that it is being passed on further.
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| Stiff elbows are a real problem all over the world. This can usually be prevented by appropriate intitial treatment. The operation to get the elbow moving is a big one - another tough problem. We operated on many stiff elbows. |
-I logged 122 surgeries while away. I was pretty good at logging, but not perfect. This does not include simple debridements. I did 25 SIGN nails (including two FIN nails). I was most productive at Kijabe doing 39 cases in 12 operative days and also very prodictive at both sites in Ethiopia. At Bugando we managed only 17 cases in 15 potential operating days (I also logged 25 cases discussed and listed but not done due to lack of OR time). Including the complication described above, I know of three significant complications: wound dehiscence (described above), failed skin graft (revised with repeat graft), and radial nerve palsy from excessive traction during chronic shoulder dislocation (I have yet to hear if this has resolved).
I am sure there will be more complications, in fact I keep thinking there is another one but I can't seem to remember at the moment. Hopefully this will come back to me. We are a pointless profession without follow-up -- - - I remembered another complication (amazing how one tries to block out the bad) - in my final week in Kijabe I manipulated a stiff knee in a young nurse with neglected femur and tibia fractures. We had eradicated the femur infection and done a staged SIGN nail with cement spacer. She had less than five degrees of motion in the knee and I manipulated her to 60 degrees before re-breaking her tibia. I was very disappointed. She understood. I expect this low energy fracture will heal without consequence but it sure did not help her knee motion. This is a humbling profession.
Once again in follow-up, thanks for reading.
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