Honduras: Day 5

Source: Blog Post

Today was our final day at La Providencia.  Per routine, we began our morning rounds on patients who stayed overnight.  The 10-year-old girl who underwent open treatment of a lateral condyle nonunion and the 9-year-old who underwent an ulnar osteotomy and annular ligament reconstruction for a chronic Monteggia injury both remained comfortable overnight with careful monitoring by nurses at La Providencia.  All of our patients this week have received exceptional post-operative care, in no small part due to the vigilance and attention-to-detail by recovery nurses Mary Dowling and Wendy Read along with physician assistant Anju Thomas and occupational therapist Meagan Pehnke. 

One of today’s patients is Kamilah, a 9-year-old girl with bilateral radiohumeral synostosis with both elbows positioned in 110° of extension.  We first met Kamilah during a mission two years ago at which time neither hand could be used for toileting or feeding.  In 2017, we performed a right humerus internal rotation osteotomy to correct exaggerated external rotation posturing. This allowed her to use the toilet independently for the first time.  Both Kamila and her mother have expressed immense gratitude for this life changing operation.  Today, we performed a flexion osteotomy of the contralateral left distal humerus to permit self-feeding and facial care.  An extensile lateral approach was utilized.  After identifying the radial nerve, a closing wedge osteotomy was performed and fixation was achieved with two 4.0 mm cannulated screws and a supplemental mini-fragment plate.  Though Kamila expressed discomfort after surgery, her face ripened into a smile when she demonstrated that she could reach her mouth for the first time in her life.

The team also performed 4 procedures for children with spastic hemiplegia.  Anecdotally, the prevalence of cerebral palsy in Honduras is strikingly high.  Many of these patients do not have access to medical care or therapists.  Patient evaluation and surgical planning is especially challenging with an isolated evaluation.  At home these patients are followed over the course of years with the help of an occupational therapy evaluation.  In Honduras we collaboratively evaluate all patients with cerebral palsy to help develop the most appropriate plan.

Other procedures included a humerus external rotation osteotomy for a 17-year-old boy with a brachial plexus birth injury, excision of a volar wrist ganglion cyst, and a soft tissue release with skin grafting for a 3-year-old girl with a burn injury.   Genesis had been burned during a corn harvest two years prior.  Last year the left thumb was reconstructed with a soft tissue release, capsulotomy and skin grafting.  The metacarpophalangeal joints were released and grafted as well.  She and her parents are very happy with her outcome and had been very diligent with her splinting.   She returned this year with the ability to perform grasp with that hand.  Further work was done on the ipsilateral hand to release the long, ring and small fingers to allow her more finger extension. 

The success of our pediatric hand surgery missions over the last four years has been greatly enhanced by occupational therapist Meagan Pehnke’s tireless work (always with a big heart and a huge smile).  We identified several patients this year that were not candidates for surgery including patients with cerebral palsy, brachial plexus birth injuries, congenital hand differences, burn contractures, and even a girl with post-Zika microcephaly.  Throughout the week, these non-operative patients and post-operative patients were scheduled for intensive occupational therapy sessions during which they were instructed in home exercise programs and received custom-made splints.  The majority of these patients had never received therapy services and were eager to learn what they could to improve their function.  Over the course of the week, Meagan worked with 34 patients and made 47 custom splints!

Since this was our final day at La Providencia, our tireless OR nursing team (Elisabeth Alonso-Hohman, Kelly Beard, Lynn Burleson, Deb Fuhr and Kathleen Marascio) spent a few hours over the course of the day organizing supplies and equipment in preparation for a lower extremity orthopaedic team (led by Kenneth Noonan from the University of Wisconsin) to return in January 2020.  Over the years, we have accumulated enough donated equipment to create four well-stocked hand trays that includes equipment favored by our two pediatric hand surgeons: sharp tenotomy scissors, an assortment of skin hooks and small retractors (e.g. Ragnells), bipolar forceps, and our beloved 0.5 mm Castro-Viejo forceps.  This year we also debuted a few coveted specialty instruments including a smooth lamina spreader (useful for lengthening bones) and a straight tendon weaver. 

However, it would be an understatement to say that the team still lacks some equipment and implants (e.g. well-maintained needle drivers, casting supplies, bone hooks, modular hand plates/screws).  There are other daily challenges: power outages in the middle of surgery, flies that sneak into the operating rooms, lack of high resolution fluoroscopy, and outdated anesthesia machines.  In each and every operation, creativity is required by our nursing team and surgeons to successfully overcome unexpected challenges.  Hand surgeons Ericka Lawler, MD and Apurva Shah, MD MBA have found that the flexibility and creativity required to perform surgery at a high level in Honduras has helped develop their basic understanding of the pediatric upper limb, and greatly improved their technical acumen. 

The team is happy to see the week end safely.  The mission has been a success.  We think that we have meaningfully changed the lives of dozens of children, and their families.  But there is always a sense of sadness when leaving Siguatepeque.  Part of this feeling comes from the realization that we have received far more than we have given.  Just before leaving La Providencia, nurse Elisabeth Alonso reflected on her experience.  “I looked around the room and took it all in.  The sights, the sounds, and the whole energy in the room.  It was a bittersweet moment because I felt sad that this year’s mission was over but also had extreme gratitude for the entire experience.” 

On a final note, the team would like to thank and recognize our team leaders – Wendy Read, RN and Mary Dowling, RN.  For Mary, this pediatric hand surgery mission to Honduras is the 75th mission in her career.  Over last few decades, she has been to Nicaragua, Guatemala, Peru, El Salvador, and Guinea West Africa.  For Wendy, this is her 22nd mission to Honduras.  These two women are real life superheroes.  They do a mountain of unglamorous work behind the scenes to make this mission safe and possible.  Mary always reminds us of the ripple effect of helping a single child – that we have helped their families, their community & their country.  Additionally – she reminds us of the trust bestowed upon us by the parents of our patients – despite never having met us.  This is a remarkable leap of faith, and each of us has felt the immense gratitude of the children and their families this week.

“What is the essence of life?  To serve others and to do good.” – Aristotle