A CALL TO ACTION
In 2013, Orthopaedic Institute for Children Foundation funded a joint team from OIC and UCLA to explore ways to help orthopaedic surgeon Duane Anderson serve the injured in Ethiopia, Somalia and Eritrea. Led by Dr. Nicholas Bernthal, the team’s cross-cultural exchange of ideas during that first visit inspired an official partnership between OIC/UCLA and Soddo Christian Hospital. Philanthropist Jean-Marc Chapus, a UCLA Medical Center—Santa Monica board member, was moved when he learned about the initiative and offered to generously underwrite the project for four years. Since then, OIC/UCLA residents have made the trip to Soddo, Ethiopia.
MEET DR. EDWARD CHEUNG
OIC/UCLA Resident Dr. Ed Cheung attended undergraduate school at Brown University. During his time there, he studied international relations with an emphasis in global health. He also spent time working in the Dominican Republic at a local clinic while in undergraduate and medical school. Dr. Cheung partnered with the clinic to help empower youth to become future leaders who improve access to healthcare, education and economic opportunities. He is the first OIC/UCLA orthopaedic resident this year to visit Soddo Christian Hospital. He will blog about life on the ground during his April 1—16, 2017 trip.
BLOG POST #1: A NEED MUCH GREATER THAN ANTICIPATED
I just arrived in Ethiopia, and it was a whirlwind getting here. I left Los Angeles on Friday, March 31 and arrived in Soddo two days later. The trip required four flights and a two-hour car ride. Throughout my journey, I reflected on how fortunate I was to have the means to travel by plane to a place halfway around the world that is so vastly different. As I looked out of the window during my flights, I tried to imagine what life must be like living in Ethiopia. The landscape is mostly desert with very few trees, but Soddo Christian Hospital is fortunate to be located at higher altitude where they receive more rain. The area feels semi-tropical and it reminds me of Latin America, where I’ve spent sometime.
I am working with Dr. Duane Anderson, a former private practice general orthopaedic surgeon who moved to Ethiopia years ago and has dedicated his life to serving the people here. We conducted patient rounds at 7am with four Ethiopian orthopaedic residents, physical therapists and nurses. We cared for the 50 orthopaedic patients who filled the orthopaedic beds in the hospital. There were more than 20 families waiting outside in the courtyard for an empty bed. The injuries we saw varied widely. Most patients had open fractures or infections. After deciding who would receive surgery that day, we moved to the operating room. We often didn’t have all of the instruments or resources needed, but all of the patients received regional anesthesia (performed more efficiently than I’ve ever seen). I kept reflecting on how much of a fuss we would have put up back at home if forced to work in these types of conditions. The need is much greater than I thought and I am happy to be here to help. It’s been an incredible experience so far, and it’s only been one day.
BLOG POST #2: THE STORY OF THE WOGESHA
I finished my first week here in Ethiopia. It has been full days of 8-15 surgical cases performed each day, in addition to 30-40 outpatient visits. The amount of traumatic injuries I’ve seen due to road traffic accidents is astounding. Given the complexity of some of the trauma cases, the one thing I am impressed with is the high quality of care that can be delivered with so few resources. As an example, after sterile gloves are used in the operating room, they are washed and re-used as patient exam gloves. For orthopaedic implants, when a plate is needed, a sterile box of miscellaneous plates (many of which have been removed from former patients or donated from the United States and sterilized) is opened, and we hand pick the implant that fits the best.
In spite of these conditions, one thing that I really enjoy is the amount of creativity that is applied when resources are limited. In the United States, a specialized implant made of high tensile strength suture and 2 “buttons” called a tightrope, can be used to hold an ankle ligament together. The implant itself can cost hundreds of dollars. Long screws can also be used, but these can break over time, and the long screws are scarce in the operating room. To overcome these challenges here, we use thin wire (which costs a few cents), and use the wire to create a tightrope out of metal. Though a little more time-consuming, the outcome is just about the same, and we are also able to save resources in the process.
In addition to resource challenges, differences in culture present unique situations when patients present themselves with injuries at the hospital. Like many cultures and countries, Ethiopia has traditional healers. Here, they are known as Wogeshas. Many people still go to these healers for fractures, where bones are “massaged” back into place and oils are rubbed onto their injured extremities. During our clinics, we have seen patients with tuberculous arthritis (something that I have never seen in the United States), polio, and open fractures with bones protruding from the skin. These patients have often visited Wogeshas on multiple occasions. When deformities set in or pain persists after several visits to a Wogesha, these patients end up coming to the hospital for treatment.
This week, I was amazed at how crowded the hospital is. In the pediatric ward, which is one large room with multiple beds, it is not uncommon to see family members share a bed or sleep on the ground next to the hospital bed. If you’re reading this and you have not seen anything like it, imagine six families sharing six hospital beds in one large room.
Today, we took care of a four-year old child who had fallen from a mango tree, had an open distal radius and ulna fracture with the radius coming out of the skin. There was mud and grass on the visible end of the bone coming through the skin. We were able to operate, remove the debris and mud, reduce the fracture and pin it back into place. Dilute bleach is used as irrigation in the operating room, and is also used to effectively clean patient’s wounds daily.
I am grateful to OIC/UCLA for the opportunity to be here, and I’m looking forward to another exciting week!
BLOG POST #3: DEAL WITH IT
The compound of Soddo Christian Hospital is very nice. There’s a small community of missionaries and visitors who live comfortably in residences with concrete floors, refrigerators, electricity and very reliable internet. As a visitor myself, it made the transition to working in the hospital much easier. Though the long-term hospital staff like Dr. Anderson and his family enjoy the relative luxury of the residences, it is clear that the resilience and attitude of the Ethiopians who deal with the struggles of life outside the hospital compound has rubbed off on them. Even though I am only here for a couple weeks, I hope to bring back a little bit of this Ethiopian toughness home.
In speaking with hospital staff that I have gotten to know, and through my experiences working in the operating room over the past week, things are far from perfect. However, to put things into perspective, Soddo Christian Hospital is one of the few hospitals in Ethiopia, and perhaps the East African region that perform ACL reconstructions, pelvic and acetabular surgery, hemiarthroplasty for hip fractures, and corrective osteotomies for deformities secondary to trauma or polio among a multitude of other surgical operations. This is because other hospitals in the country do not have the equipment or expertise to perform these surgeries. There are orthopaedic residents who are being trained, but when they complete training, the hospitals where many of them find jobs do not have the equipment for them to perform many of the operations they’ve learned to do. The residents, staff and surgeons, like the population here, simply deal with issues as they arise without complaint. Dr. Anderson bought a grider (pictured below) to sharpen drill bits, screw drivers and other instruments (sometimes intraoperatively as also seen below) in order to complete the surgery. All of us wear headlights to operate in case the lights go out. When they do go out, no one mentions it or misses a step. All patients are NPO (nothing by mouth) until rounds are complete, because any one of them could be taken into the OR for surgery that day. Still, there are very few complaints. Everyone just takes things in stride.
This weekend, I had the opportunity for the first time to venture out of the hospital compound. The attitude of the people makes so much more sense after seeing life outside the bubble of the hospital walls. There are no stoplights or stop signs. Goats, cows, people, Bajaj’s (or tuk tuk like 3 wheeled taxis imported from India), motorcycles, buses, vans, semi-trucks, all intermingle with seemingly no organization. Driving on the right side of the road is more of a suggestion. Like many of the instruments in the OR, many of these vehicles are patched together but seem to work relatively well.
Soddo has a lot of hills. Children age 4 or 5 are often in charge of herding goats or carrying bags of supplies seemingly the same size as them. Grandmothers in their 90s carry tree branches for their stoves and heavy shopping bags. They walk with relative ease through this maze of activity while chatting with strangers. It makes sense why families and OR staff just deal with what happens in the OR. It’s just what people do to survive on a daily basis.
Yesterday, Hasabu and Asarat, two scrub techs from the OR, were kind enough to show me around town. Hasabu is somewhat of a celebrity. He grew up in town, did well in school, showed Dr. Anderson and his wife Jackie around when they first arrived in Soddo 11 years ago, and is now getting sponsored to go to medical school in Addis Ababa. He’s back visiting. Everyone seems to know him, shake his hand and give him a hug. He is well liked by the town as well as in the hospital. Asarat is in charge of all the orthopaedic equipment at the hospital. If you need anything at all, he’s your guy. The two of them suggested I go for a hike with Asarat today to see some views of Soddo. I agreed, and Asarat said he’d call me this morning to go.
I woke up to my phone ringing at 6:15a.m. Asarat said he was waiting outside. I quickly headed outside. I didn’t bring water or a jacket (it’s generally about 70-80 degrees here). As we started walking, I realized we would be walking to the top of the highest hill in Soddo. I was not prepared. The hike was akin to my experience climbing Kilimanjaro or Machu Picchu. It was STEEP. The hospital sits at 7,000 feet and we walked up. I was out of breath. Small boys and grandmothers passed me and Asarat (who was wearing jeans and a leather jacket like he was going out for the evening) was seemingly running up the rocky terrain. It took us 2 hours to get to the top where it was windy and quite chilly (I was wearing shorts and a t-shirt). Asarat asked some of the people who lived at the top of the mountain how many times they went back and forth a day. They said two to three times. The little boy pictured below followed us just because. I hope he lived at the top, because he certainly walked a long way just to see what we were doing. In general, the Ethiopians I’ve met seem to be prepared to deal with anything. I hope to adopt the attitude of being ready to deal with whatever comes through the hospital and OR doors. Also, after seeing the commute that some of the people in Soddo deal with, I hope to never complain about commutes in Los Angeles again.
BLOG POST #4: WE DO WHAT WE CAN
It takes a huge team to care for everyone here. There is a picture below of the multidisciplinary team that makes orthopaedic patient rounds each day. They are truly doing a wonderful job caring for patients in very challenging situations.
It’s been a tough week here. There are so many people that come to Soddo Christian Hospital from all over the Eastern part of Africa and Ethiopia, and there’s only so much time and resources in a day to help them. There is such an inundation of trauma from road traffic accidents and infections (often from people having to wait to see a physician or travel for days). Unfortunately, the timing for treatment is often delayed and there is a certain amount of triage time that occurs each day. For example, all hip fractures are generally treated within 24-48 hours in order to reduce morbidity and complications from immobility and pain. We saw a patient who had a hip fracture for two months, but only presented in the hospital last week. He is in need of hip implants, which are on the way, but are held up in customs in Addis Ababa. They should arrive next week.
Over the past week, we’ve had some complex cases. As a team, we were able to perform two complex pelvic operations and a scapular fracture and glenoid fracture were fixed. Additionally, we had a couple patients with multiple knee ligament injuries. Given my interest in sports medicine, and the presence of an arthroscopy tower in the OR (one of the few in the country), Dr. Anderson challenged me to take care of a couple of the knee ligament injuries and expose the Ethiopian residents to arthroscopy. I quickly realized that arthroscopic surgery in Ethiopia - where the power goes out frequently, where the staff is used to dealing with trauma and all arthroscopic instruments are new, and our language barrier - made those surgeries extremely challenging. When I hesitated, Dr. Anderson motivated me by explaining that we were likely the only people in Ethiopia who had the equipment and the ability to treat these injuries. We were successful, but it took time and quite a bit of energy.
As I reflect on my last day operating here (tomorrow is Good Friday, and is a holiday at the hospital), I think there’s a bright outlook for this country. I’m encouraged because we helped expose the Ethiopian residents to arthroscopic surgery. I was very impressed with them. Though I’m sure my attending physicians at UCLA/OIC could do what I did in a much more efficient manner, I am grateful for the training they gave me, allowing me to now perform these cases independently and teach others. Lastly, Dr. Anderson’s knowledge and ability is inspiring. Soddo Christian Hospital’s resources, though limited compared to the U.S., provide an orthopaedic mecca for the Ethiopian residents here. I’m hopeful that the partnership with UCLA/OIC will continue to bring U.S. residents with different interests to Ethiopia, where we can learn from Dr. Anderson and the residents, and give back however we can.