Improving access to musculoskeletal trauma care in Malawi We are working in collaboration with Beit Cure Hospital, Queen Elizabeth Central Hospital, Kamuzu Central Hospital, the AO Alliance Foundation, and the Malawian Ministry of Health on a variety of projects aimed at improving access to musculoskeletal trauma care in Malawi, particularly for the rural poor.
We are examining risk factors for delayed presentation to hospital, health system navigation by patients with femoral fractures, the financial impact of injury on patients with femur fracture as well as the cost effectiveness of treatment in collaboration with UCSF IGOT , and the capacity to manage musculoskeletal trauma in the public hospitals.
Low-cost negative pressure wound therapy in Cameroon Learning from our colleagues in Haiti, and addressing a need expressed by our colleagues in Cameroon, we built low-cost negative pressure wound therapy pumps which are now being used for clinical care by our partners in the Cameroon Baptist Convention Health Services hospitals.
We are investigating the feasibility and clinical efficacy of using these devices in the Cameroonian context to help manage open fractures. We are working with clinical providers across sub-Saharan Africa to identify the most common hand and upper extremity pathologies in each country and the local capacity to manage these conditions.
The goal is to develop priorities and core competencies for training in hand surgery by country and region. The entire process is a controlled chaos, where attendings are having heated bedside debates, and will occasionally call residents, nurses, and other students into the rooms to comment on the care they have provided or simply to teach a salient point to the providers present.
The residents were insistent on making me the primary surgeon for all SIGN nail cases, because they were so interested in teaching, but also because they are so facile at the management of those injuries.
Upper extremity injuries are usually treated with percutaneous pinning or non-locked internal fixation from a piecemeal small fragment set. Closed lower extremity long bones are nailed using SIGN implants. Almost all of their open fractures are treated initially in external fixators, and often the elective cases for the day are to manage the resulting non-unions.
There is often a significant delay often greater than 7 days between injury and operative intervention, in stark contrast to our typical operative approach in this country. Kossamak Hospital does have an intra-operative fluoroscopic unit donated by a hospital in Perth, Australia , but it is rarely used.
The machine often breaks, there are no sterile covers, no trained techs to operate it, and only two lead aprons for a surgical team of members. As such, the team does not wish to become too reliant on a technology that is still a luxury and often unavailable at their facility.
The scheduled operative cases usually finish in the early afternoon, which frees the attendings to manage their private clinics. The residents then will either say at the hospital if they are on call , head home, or most likely, head to a private clinic or call shift that they take to moonlight and make extra money.
While in Cambodia I had the weekend in the middle of my two week stay available for a trip to Siem Reap and the temple complexes at Angkor Wat and Angkor Thom. I spent the weekend exploring the ruins and taking as many pictures as I could manage. The weekend that I was leaving also happened to be a holiday weekend, a three-day celebration for the King of Cambodia. Again, I took advantage of the weekend off to enjoy exploring the capital city.
As part of French Indochina, the city has portions that are heavily influenced by French colonial architecture, as seen in some of the buildings built at the turn of the 20th century along the river. I am very thankful for the opportunity to take this trip. It was a phenomenal experience to see how an aid organization such as SIGN can have a long-lasting and meaningful relationship with a hospital in the developing world. I hope to be able to contribute in a similar way in my own career and forge a lasting relationship with hospitals and residency programs in the developing world.
This group supplies hospitals around the world with a unique brand of intramedullary nails that do not require intraoperative fluoroscopy, utilizing an aiming arm for both proximal and distal interlocking screws. Kossmak, which is a public hospital that primarily deals with uninsured trauma patients who come from both the city and from surrounding provinces. The use of this device over the past 15 years has dramatically changed the quality of care provided to their patients, who are largely unable to afford any aspect of their medical care.
Their trauma is largely fueled by the wildly chaotic driving conditions around the city. Traffic laws are more like traffic suggestions, and the only true rule of the road that everyone seems to share is to drive as quickly as possible and try your best not to get hit. People on motorcycles and rickshaws zip in between cars, through intersections and against traffic. The majority of their residency experience revolves around the trauma they take care of at Kossamak, although residents are able to do short rotations at other private hospitals around the city where they can have exposure to pediatrics, arthroscopy and arthroplasty.
They take Q3 call while at Kossamak and often do cases through the night. Most open fractures are taken immediately to the OR and placed into external fixators, as there is no efficient medical transportation to get the patients to Kossamak in a timely fashion. The patients then have to wait for a variable amount of time sometimes over a week! I was incredibly impressed by the operative skill of their residents and attendings.
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