HONDURAS: DAY TWO

Source: Blog Post

Today we began our first day of operative cases at La Providencia.  Energy and excitement filled our bus as we returned to La Clinica.  The eight cases we chose for today were a combination of complicated patients that may require a prolonged stay or patients who had traveled a great distance.  Many of our patients travel a great distance—some from over 9 hours away requiring multiple bus connections or travel by horse.  If patients are unable to return to their homes prior to surgery, they are housed in town by volunteers or families affiliated with the clinic.

We arrived shortly before 8:30 a.m. with patients waiting for us.  The team realizes this is going to be a long day of surgery in two operating rooms.  The schedule is more than packed.  There are several procedures for children with neglected fractures: open treatment of a neglected lateral condyle fracture-dislocation, open reduction of a chronic elbow dislocation and medial epicondyle fracture, and corrective radial and ulnar osteotomies for a malunited forearm fracture.  Other cases include open reduction and plating of a segmental both bone forearm fracture in a professional soccer player, reconstruction of a Flatt-Wassel type III thumb duplication, carpal wedge osteotomy and flexor tendon lengthenings in a 12-year-old child with arthrogryposis, and two external rotation osteotomies of the humerus in children with brachial plexus birth injuries.

In the pre-op area, all children receive a handmade donated quilt from the United States, a stuffed animal and an activity pack containing crayons, stickers and assorted toys.  The children are delighted and the families are incredibly grateful.  These quilts are taken into the operating room with the child to keep them warm during the case. 

 

The most challenging case of the day was a 17-year-old male with a chronic elbow dislocation and medial epicondyle fracture.  The case required both a medial and lateral approach to remove scar tissue both anteriorly and posteriorly.  The ulnar nerve was carefully dissected and transposed.   The medial epicondyle fragment had scarred distally and needed to be extensively mobilized to reattach to the humerus.  Once the tissue was freed, the elbow was relocated and the medial epicondyle was reattached with 4-0 partially threaded cancellous screws.    The patient will remain in a cast for four weeks and then be placed into a removable elbow splint while performing range of motion.  While the case was very difficult the end result was incredibly satisfying.  We will be excited to see him next year for follow-up.

Hand surgeons Ericka Lawler and Apurva Shah took time out at the end of the day to reflect on the challenge of operating on children with neglected fractures and dislocations.  These operations are often extremely difficult, and require a high level of preparation in order to execute well.  As both physicians have been in practice for a number of years, these cases bring a renewed sense of excitement as they serve as a reminder of our days as trainees when the most routine cases required daily preparation.  This is a concept we should emphasize to our residents and fellows.  No matter what your years of experience, the demands of being a surgeon require that you continue to educate yourself and take time to prepare.  The responsibility of taking care of patients should never be taken lightly.   

All equipment, supplies, and sutures are donated by various organizations through the efforts of team leader Mary Dowling assisted by Wendy Read.  We utilized many of the same instruments and equipment that we do in the United States, making adjustments when necessary.  Irrespective of equipment availability, the team is committed to delivering the highest standard of care.  Creativity and thoughtful use of the team’s collective experience allows us to make adjustments as necessary.

 

Our great OR nursing team (Elisabeth Alonso-Hohman, Kelly Beard, Lynn Burleson, Deb Fuhr and Andrew Kinsing) wears many hats including taking on the thankless work of instrument cleaning and processing at the end of the day.  The entire team reviews the cases for the next day and makes plans for instrumentation and surgical timing.   Additionally we make rounds on patients who are staying overnight before heading home for the day.  Our final patient of day rolled into the recovery room at 10pm.  We are exhausted, but overall it was an exciting and rewarding day.

“The best antidote I know for worry is work.  The best cure for weariness is the challenge of helping someone who is even more tired.  One of the great ironies of life is this: he or she who serves almost always benefits more than he or she who is served.”  --Gordon B. Hinckley