I am currently on the plane back to the U.S after an amazing mission trip to the Dominican Republic. We were working out of the CURE International hospital there which is dedicated to providing free pediatric orthopaedic care to poor children in the country (awesome right?). I first found out about this hospital from one of my mentors Scott Nelson who is currently a pediatric orthopod at LLU (my previous medical school for new readers). He spent over 5 years at the CURE Hospital in the DR and turned the hospital into a truly top rate facility where they were not just providing some care for poor kids, but the same type of care they would get in America. It’s this model that I am now convinced needs to be applied to all mission hospitals, but I will talk about that later. Another pediatric orthopod (Dan Ruggles) flew down with one of his residents to provide surgical care for patients that had complex orthopaedic disorders.
My first day was last Sunday, and we basically held a special pre-op clinic where all of the patients who had conditions or deformities that were overly severe were evaluated to decide if they were a candidate for surgery that week or would be better served non-operative management. Not that it is related to their care, but I have to pause and mention that Dominican children are some of the cutest kids I have seen; the combination of African and Hispanic heritage is amazing. So to continue, I saw a host of pelvic and limb deformities that were often times and unfortunately a result of the poor care that kids received from hopefully well intentioned but incapable local surgeons in the DR. I am certainly not talking about all surgeons here, but more than I would like to admit. Many children with previous osteomyelitis were missing large segments (10+ cm) of their femur or tibia after having it removed by the local orthopod instead of the surgeon first trying a course of antibiotics to identify the involucrum such as is seen below.
Many of the surgeons here simply open of the site of infection and start chopping away leaving the child with such significant bone defects as seen below). There was also a host of children who simply had congenital limb deformities such as tibial hemimelia or congenital femoral deficiency as seen below:
I also saw numerous examples of what happens to kids with Blount’s disease who either go untreated or were treated inappropriately given there combined femoral and tibial deformities or who were treated appropriately with an 8-plate but for various reasons did not return for normal follow up until years later as seen below:
Clinic also consisted of observations of numerous types of gait in kids with limb deformities to see how their bony alignment affected their functional ability. Below is the xray and associated video of a little girl with untreated hip dysplasia and her associated gait:
Below is a video of a little boy with untreated club feet and some other unknown lower extremity MSK disorder. You can see here how he ambulates pretty well given his considerable bony malalignment:
I could go on and on with the disorders that I saw, but the much cooler part of the mission trip was getting to operate on these children and see them get better. We started operating this past Monday basically non-stop until Friday. Operating overseas, even in a hospital as amazing the CURE hospital is definitely an eye-opening experience and showed me what is in store for my wife and I when we finally go overseas. Unlike the cush U.S. there are no Synthes, Stryker, or Depuy reps on hand to organize and replenish the instrument trays before and after surgery, so it was the task of the the residents and surgeons to rumage through the storage room seen below:
Once the instruments are pulled and sterilized we go downstairs to the inpatient ward to see how the patients were doing that we operated on the previous day. The inpatient ward is painted wall to wall with beautiful murals of nature and really provides a peaceful setting for these kids who are often in more pain than we would like…not because they don’t have pain medication but because the nursing often doesn’t give the medication as prescribed.
After rounds we head to the OR. Below is a video of what the OR suite looks like. And again, as I have seen mission hospitals in other countries, I was very impressed with the facilities. If you were blind folded and brought in you might not be able to tell that you weren’t in America..except for the fact that everyone only spoke in Spanish.
The highlight of my time again was working with the pediatric orthopods that flew down to take care of these big deformity cases. We performed big cases from Dega osteotomies w/ VDROs, medial plateau elevation osteotomies and application of taylor spatial frames, bilateral tibial and femoral osteotomies of severe blount’s disease, and the highlight was a rotationplasty performed for an iatrogenic short femoral (more handwork of a local orthopod). The xray below is of a 10 yo F who had a really short femur after a local orthopod removed a ridiculously large segment of her femur to treat her osteomyelitis:
The defect was too large to perform a bone transport procedure so it was decided that the best way to treat her and get her walking again was to perform a rotationplasty. A rotationplasty in layman’s terms is where you turn the leg (from the knee to the foot) 180 degrees so that its facing backwards. This effectively makes the ankle joint into a knee joint and then they are able to walking with a prosthesis that is specially fashioned for them. This Mayo clinic video better explains it:
So we finally started the case and while tense at times, it was a great refresher on anatomy as we basically had to isolate all of the structures that cross the knee or attach at the knee. Afterwards, the relevant muscles are detached and tagged for later repair. The most difficult part of the case is dissecting out the femoral artery and nerve and its many branches. It makes it more difficult when these structures are covered with fibrous tissue as was the case in this girl. Nevertheless, with careful dissection and attention to detail and some praying, it all went well, as you can see below:
There were a whole host other cool cases, like the opportunity I got to do a SIGN nail (http://signfracturecare.org/) which is the defacto intramedullary nail for cash strapped mission hospitals. Below is a cheesy picture of me with Scott Nelson putting one in:
I also saw the amazing ingenuity that goes into many processes that we take for granted in the U.S. Like putting on a spica cast after perform a pelvic osteotomy for developmental hip dysplasia. I’m so used to seeing this and performing this on a true spica table, but they dont’ have one of those, or they had it and it broke. So they use a long stick, lot’s of plasty, and a thin layer of fiberglass and the results are pretty much the same as seen below:
I have numerous more pictures, but that would make this post longer than it really needs to be. To summarize, I had an amazing experience operating on these kids and they will forever be in my mind and heart. I am more sure than ever that peds ortho is the field for me and I’m excited about the prospect of spending a more long term mission period overseas once I’m done with my training in the U.S.