As we arrived in Blantyre, Malawi last Monday with our crates of orthopaedic implants, the excitement amongst our local hosts was palpable. In a country with such limited resources, our packages brought necessary operations to several Malawians this past week.
To begin with, the people of Malawi truly live up to their reputation as “the friendliest in Africa.” We were immediately greeted with smiles and many thanks by the staff, patients, and surgeons of Queen Elizabeth Central Hospital. We were welcomed into their morning report, their ward rounds, and their operating rooms. We immediately felt a part of their community.
Our local host, Dr. Jes Bates, picked us up from the airport and greeted us with a case of his church’s own bottled water – Mkokomo, which means “sound of many waters” in Chichewa, the native language of Malawi. Although Jes was excited to see what implants we had brought with us, his main concern was getting us acquainted with our new surroundings. We were given a tour of the hospital, and we quickly came to appreciate the great need at this public facility, the only one in Malawi providing orthopaedic surgery.
Shortages were everywhere at Queen Elizabeth. From nurses to ventilators (of which they only had 1 in the ICU!), it was quickly apparent that many of the resources we take for granted in the United States are luxuries in other parts of the world. However, what they lacked in material goods they more than made up for in medical expertise. Most of their surgeons, including Dr. Bates and the chairman of Orthopaedics Dr. Nyengo Mkandawire, were trained abroad and chose to return to Malawi to practice. It was quickly obvious that a limiting factor in treating many traumatic injuries was a shortage of implants.
From an orthopaedic standpoint, lack of implants is a major issue at Queens. Fractures that we in the States routinely treat with surgery – such as forearm fractures – remain in casts because of a lack of plates and screws. These injuries are left to heal on their own, and more often than not heal abnormally, which severely limits the movement of the elbow and wrist. The story of a young Malawian male vividly captures the impact of this lack of orthopaedic implants.
Mafuno Magonja is a 24 year old farmer from a town just outside of Blantyre. He fell off his bike in July, and was placed in a cast by Dr Bates. After being seen in clinic and diagnosed with a radius and ulna fracture, he was told by Dr. Bates that his injury would be treated with a cast for the time being, because he the implants needed for his surgery were not available. Mafuno was starting to raise money to go to South Africa for his surgery, but Dr Bates persuaded him to hang on and wait for Orthopaedic Link’s arrival.
By the time we arrived, Mafuno’s fracture had almost healed, but in a crooked, nonfunctional position. Last week Mafuno Magonja went to the operating room (‘theatre’) at Queen Elizabeth and received his surgery with the appropriate plates and screws – taking his poorly functioning forearm and giving him a good chance at a great outcome. I was fortunate to be involved in this particular case, assisting Dr. Bates and his fellow Dr. Kevin Lakati (a senior registrar from Kenya training with Dr Bates for 6 months) in the operating room. The surgery went very well, and despite being trained worlds apart, the three of us – tied by common AO principles (www.aofoundation.org)– worked our way through the procedure using the Synthes instruments and implants brought by Orthopaedic Link.
This is just one of many stories we heard this past week in Blantyre, and there remains a huge need in this country for so many medical supplies. However, it was clear from our experience that Orthopaedic Link could have an enormous impact on the lives of many Malawians affected by musculoskeletal disease. We hope to continue our efforts!
Becoming A Spine Surgeon
I was 27 years old when I decided to be a spine surgeon. Like the other subspecialties in orthopedics, in a way it was almost messianic in its potential, it could make the lame walk. But on the other hand it could cause injury or worse, be fatal to the patient. Second only to deaths caused by complications with diabetic feet, injuries to the spine were the most common cause of death in our ward. It was to me the most challenging field in Orthopedics.
I have worked as a resident in a government training hospital in the Philippines. Understaffed, under equipped and overcrowded, we had a lot of patients with spine injuries. Unfortunately we do not have the hardware to deal with them. Spine patients who could not afford the implants and instrumentation necessary for spine surgery had to be treated conservatively and sent home less they acquire pneumonia in the wards.
Our patients consisted mostly of the poor and the destitute from the surrounding areas. Farmers falling off their carabaos (water buffalo), laborers caught in industrial accidents, loggers felled by trees, all of them were part of the lowest social economic bracket of our local population. Our patients have annual average income of less than $1,000 and live a mostly hand to mouth existence. What hope could they have of being able to afford spinal implants and instrumentation that cost more than 5 years worth of their income? Income from which only 2% goes to health care.
Not being able to take care of themselves, depressed and abandoned by friends and family these patients were literally wasting away. Life expectancy for a spinal cord injury patient is generally poor. It becomes more painful when their loved ones are aware that there are modalities of care for the patients but are just too expensive.
In short spine surgery was only available to the rich and capable in our hospital. I was aching to help people by doing spine surgery. But not having the necessary implants and instruments to perform it was depressingly frustrating. There were alternative cheap locally available implants, but these were substandard and prone to fail leading to further complications.
As a resident, doing spine surgery meant finishing four years of training in general orthopedics, then further training was done in spine centers overseas. It was only then that residents like me would have access to standard spinal instrumentation and implants. But spine surgery fellowships are few and far between. Dreaming of being a spine surgeon was just that. A dream.
But that was three years ago.
I am still a resident in a government hospital in a developing country and a few days ago, I was able to do my 1st spine surgery. Assisted by our spine consultant, I was able to operate on a patient who had an unfortunate fracture of his spine when he dove in a river with his friends. He had an incomplete spinal cord injury, which meant he was not paralyzed, but his leg muscles were weak and he could not stand. As a young man, he was expected to work for his family. Not being able to walk and work, we aligned his deformity, put in titanium screws and rods and decompressed his spinal cord.
Thanks to the implants he will be able to stand, walk and work again. He will not be depressed in a bed unable to stand. He will not be dependent on a younger sibling who would otherwise stop his or her education to be caretaker. He will be able to support his family and probably start his own. All thanks to the screws and rods that are keeping his spine straight.
Oh, did I mention that the implants were free?
Given the means to operate with international standard implants and instruments, I have scrubbed in more than 30 spine surgeries in 2 years. Not an impressive number in most spine centers, but in our country where instrumented spine surgeries is rare or non-existent in government hospitals, this is already a gold mine of surgical experience.
Inspired by the generosity and selflessness of the people who have given our center spinal implants and instruments, I have realized that the dream of becoming a spine surgeon was not out of reach after all. Working with what we had, our center pioneered not only surgical management that was the standard in the country, we also improved our non surgical care for our spine patients. We started the 1st scoliosis screening in our country and gave options for their families. Using locally available materials and internationally accepted principles, we were able to design and fabricate scoliosis braces for our patients.
Surgical or non surgical, the experience we have had with our patients taught us enough to share this knowledge with the world. Even as residents, we have been to North America and Europe sharing our experience and information, and in return learning more in international orthopedic conventions. We were even able to observe operations in some of the best centers in the United States under the tutelage of best surgeons of the world.
It was through Orthopedic Link that all of this came true. It was three years ago that they gave us the gift that still keeps on giving. They didn’t just give us implants and instruments. We got knowledge, experience, skill, the ability to care for our patients like never before.
And the truth is it doesn’t stop there. Since we have seen the centers overseas, it is now our dream to have a Spine/Trauma center of our own. For now that is still a dream, but maybe again in 3 years, it wouldn’t be a dream anymore.