When We Come To It

Wheels up!

After weeks of packing, months of discussions, and years of anticipation.  We are back in the air heading for Tanzania!

The initial group consists of two chief residents, a retired pediatrician, and myself.  We have loaded down with loads of soft good – dressings, slings, caps, gloves, and masks.  We even managed to bring along some cards , and just maybe, a guitar followed me here from home.  I am sure these travelers will have a better appreciation for my musical talents than my young adult sons!

The crazy start to this trip is the lack of previous relationships.  I have spent many zoom hours with one of the residents but really just spoken a few times with the other.  However, our first in-person discussions are off to a great start.  They are enthusiastic, motivated, and a little scared – in my opinion, a perfect combination.  We’ve shared a few stories and are getting a feel for each other.  Jen (the retired pediatrician) will be our glue for the trip and hopefully our coordinator.

Both of the residents are planning fellowships next year and both have signed contracts with new practices.  That excitement is so fun! 

Wheels up for our first leg – more musings when we start  the long leg from New York to Doha!

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So, truth be told. After a long second leg, the lag and lack of sleep drove everyone away from anything resembling productive blogging. We had a safe, uneventful trip and are slowly recovering from the time zone adjustments.

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Day One-

At 0710, we trekked to the hospital and got our first taste of the orthopedic wards. At 0730, the resident room was not yet open but within 5 minutes it was and folks began filtering in for our first morning report. Matt, Natalie, Jen, and I were all seated together and the presentations began.

Like before, the patient reports were lengthy H&P with lots of information regarding the patient’s history, but often little focus on the acute problem at hand. Our group began slowly with a few remarks here and there. The final case was a pediatric distal radial fracture in an 8yo male. Along with Dr Charity – who completed her stay today – we had a lively discussion on the Salter Harris classification system and why it mattered. This led to a nice discussion of the plan for this particular patient – who had been scheduled for surgery, but only would require a cast.

Following, that cases, the OR cases for the day were revealed. 3 spine cases were scheduled in one room (Not my group’s field) and a infected femur sequestrectomy was scheduled in the “dirty room”. I do not intend to use this space as an orthopedic teaching resource, so I will not belabor the details, but the entire femur was infected with clear infectious changes through out its length. Matt led a nice discussion of the potential pitfalls of the debridement due to cortical deficiencies and areas of canal ossification. He was asked to join the case which he enthusiastically agreed. Natalie has some nice pointers on treatment of infected bone. She discussed antibiotic nails and local use of high concentrations of antibiotics.

From there, ward rounds began. As we waited for the cases to begin we had a chance to start developing a list of needed surgeries on the ward. We debated the diagnosis of spine tumor vs Potts disease, need for traction pins in femoral neck fractures, treatment of femoral nonunions in uncontrolled HIV – just to name a few. A resident pulled Maat and I aside for advice on 2 ankle deformity cases.

Matt left to begin his case with 2 KCMC residents. At nearly the same moment, one of the staff physicians asked Natalie and myself to come investigate a consult from dermatology. Jen departed for some household shopping and we trekked to the dermatology unit. There is an entire wing for dermatology with inpatients and their own surgical OR – very different from back home. The patient was diagnosed with mycetoma – a tropical fungal infection seen in farmers and shepherds. The dermatology group had completed several debridement superficially but felt they had lost control of the infection. One thing led to another and we met the patient in the oR shortly before he went under anesthesia. The infection obviously penetrated multiple tissue plans in the forefoot, and soon Natalie & I were scrubbing our hands to perform the case.

Myectoma is not a diagnosis I have seen and Natalie believed she had one case early in her career. But infection is infection. We performed a thorough debridement and found, not pus but a copious collection of black granules (like sand) that the dermatology resident said were hallmarks of this disease. We washed the foot and packed the wound. Successful first case and I had a good chuckle that Natalie’s first case was in the dermatology ward.

Lunch was chicken, rice, and beans. We headed to Charity’s final lecture and met Matt fresh from his debridement. I was very impressed with his report for helping coach the residents through a difficult debridement and the speed bumps they encountered on the way.

Tomorrow’s cases are 2 hemiarthroplasties (half a hip replacement) for femoral neck fractures. Not an uncommon surgery in the US, but the catch for tomorrow is implant availability and instrumentation. We have the option of 1 stem size and no cement. Certainly less than ideal to create a stable, useful artificial hip. However, alternatives are not likely to be available. The 3 of us worked with the OR staff to familiarize ourselves with available instruments and look forward to tomorrow’s challenge.

We return home to find that Jen has found mosquito netting for the beds (yes, we have seen some mosquitos this trip) and a fan for each room. It’s been mid nineties and quite hot. Everyone is tired but there is a clear sense of success of the first day. I couldn’t be more impressed with both the residents today who displayed a strong confidence that quickly won over the local residents. Especially pleased to see how Natalie has rapidly been accepted into a male dominated room in a male dominated society and is gaining the local residents trust!

Tomorrow will bring new challenges. We all look forward to a full nights sleep – wish us luck!