School of Medicine - Orthopaedic Surgery
With this elective, I hope to connect two organizations that are dedicated to local capacity building: Andean Health & Development’s (AHD) sustainable rural teaching hospital model and SIGN Fracture Care International’s network of surgeon training. The SIGN organization provides free orthopaedic implants that are designed to be used in low-resource environments. Specifically, the implants are used for treating fractures of the femur, tibia and humerus in adults and children without requiring intra-operative fluoroscopy. My previous education in global health includes a year-long course of preparation for and reflection upon a two-month public health service-learning experience in Ecuador. During that experience, I witnessed the challenges of providing fracture care to the population served by AHD. Since then, three hospitals in Ecuador have joined the SIGN program. My primary goal of this elective is to establish AHD’s Hesburgh Hospital as a participating member of the SIGN surgeon network. My secondary goal is to learn the SIGN methods of fracture care so that I can be part of this global network of surgeons and participate in future efforts to improve orthopaedic care in low-resource settings. These techniques complement the other methods of intramedullary fixation that I have learned at Johns Hopkins and represent variations of the core cases with minimum requirements for all graduating orthopaedic residents. I plan to accomplish these goals by learning from our Hopkins faculty who are SIGN members and travelling to observe surgeons in Ecuador.
SIGN FRacture Care International
Santo Domingo, Ecuador
Ethiopians take great pride not only in their coffee, which is said to have been discovered by a goat herder in the Kaffa province, but also in their hospitality. Both of these were evident to me upon arrival to Black Lion Hospital, the premiere referral university hospital in Addis Ababa. The hospital’s 30 orthopedic residents, supervised by six faculty, including department chairman Dr. Biruk Wamisho, warmly welcomed me with overflowing ceremonial cups of coffee, which helped me adapt quickly to the eight-hour time zone difference. Less than an hour after clearing customs, I joined the group in their weekly education session. Any concerns that I had about adapting to the new culture disappeared shortly after I walked into the conference room. Just as we do in my residency program, the assembled group was reviewing radiographs on a Thursday morning, with a skeleton looking on from the corner. The presenting resident systematically described the “six lines” on a pelvis film showing an acetabular fracture, classifying it by the same method I would use; some aspects of fracture care are universal. As one of the consultants sharply criticized the presenting resident for a small error, I realized some aspects of surgical culture are global as well. A plaque on the wall proclaimed, “This is a house where orthopaedic children grow, mature, and shoulder responsibility. RESIDENTS ARE OUR MAIN AGENDA.”
Outside the conference room, the similarities to home became scarce. Accompanying the residents to see a patient in the dimly lit Emergency Department, I squeezed past rows of stretchers pressed up against each other so that three patients could occupy two stretchers. Past the stretchers, patients sat on chairs, sharing oxygen tanks. Beyond the chairs, they lay on the concrete floor, attended to by family members. There we found a man who sustained a tibia shaft fracture in a motorcycle accident. He had been on the floor for hours before a splint was applied. The residents wanted my opinion about whether he had compartment syndrome, a problem of muscle ischemia due to swelling. Compartment syndrome is notoriously difficult to determine by physical examination, and a missed diagnosis can lead to permanent disability. At home, I could use a pressure monitor to determine whether to perform fasciotomies, incisions from the knee to the ankle on both sides of the leg, to relieve the swelling. I advised serial examination, and thankfully he did not develop compartment syndrome.
In Baltimore, I could fix that patient’s fracture with an intramedullary nail system that relies on intra-operative x-rays, but in Ethiopia, x-rays are usually not available during surgery. The Surgical Implant Generation Network nail system was designed for use in these conditions, and is provided without charge to qualified surgeons who report outcomes data to the organization. It has been used in more than 100,000 patients, and early studies are now available describing the treatment outcomes. Given the challenges of providing care with limited resources, development of clinical research capacity among Ethiopian orthopaedic surgeons is needed to compare treatment options for patients in this setting.
Left: Visiting resident Brett Shannon (left) assisting at a SIGN implant surgery at CURE hospital in Addis Ababa, Ethiopia. Right: Visiting resident Brett Shannon teaching residents at Black Lion Hospital (Addis Ababa, Ethiopia) a systematic way to appraise and present contemporary clinical research articles.
As a peer trainee, I sought opportunities to learn from and contribute to the residency program. I participated in a handful of operations, but since 6-10 residents gathered around each case to observe, I was mindful of displacing another learner from the surgical field. At the residents’ request, I taught about children’s elbow fractures. Recognizing that it may not be helpful to illustrate our techniques, which often rely on x-rays, I chose instead to focusing on research capacity building. In collaboration with a senior Ethiopian resident, I conducted an educational needs assessment, presented a systematic method to critically review clinical research articles, and established a recurring moderated journal club program.
The burden of road traffic accidents and their associated fractures weighs heavily on Ethiopia, and can be measured not only in morbidity and mortality, but also in financial losses due to disability in a young, laboring population. Accidents are a larger cause of death than HIV, malaria, and tuberculosis combined, and safe roads and trauma care should be a top priority of international health organizations. Proportional to the burden of illness, trauma research is severely underfunded compared to infectious disease research. The development of clinical research capacity among Ethiopian orthopaedic surgeons may help this country overcome one its greatest challenges, and I hope that my work as a visitor may be a small contribution.