Activities
Training workshops
Trauma care in the context of limited resources needs skills in diagnostics and context-adapted treatment plans. A special focus should be on conservative treatment, cast immobilization, skeletal traction and the use of external fixator. Reduction of fractures without c-arm is another aspect to be considered. In a workshop for basic trauma care, lessons adapted to the rural trauma surgeons need are accompanied by skills stations for the use of external fixator, tendon reconstruction and auto-production of atraumatic sutures with fishing line and needles. Visiting other institutions (Prosthetics Workshop of the Government Hospital, NGO that manufactures fuel-efficient cook stoves) is part of the networking, to widen the view to postoperative care and burns prophylaxis.
Assisting in orthopedic surgery
Teaching in the local environment with locally available equipment to care for local conditions is one key principle. In Madagascar a friendship of more than 20 years exists with the PAACS-trained experienced surgeon at Antsirabe (PAACS stands for Pan African Academy of Christian Surgeons). He is the cornerstone of teaching the next generation of surgeons. Teaching by example, practicing sound communication along with a thorough knowledge of the problem and the various solutions are essential components. To be complete, every surgical case should follow a preoperative plan and a postoperative follow-up. The use of the WHO Checklist for Safe Surgery, writing a postoperative documentation and instructions for postoperative treatment are important steps as well.
Instruments, equipment for basic trauma care
When talking about orthopedic trauma surgery, we have to keep in mind that sterility is crucial in the operation room. When intramedullary nailing and bone plating are done, the sterility has to be on an excellent level. For many hospitals basic equipment like external fixator and K-wires are an alternative to be considered. This allows for stabilization of open or comminuted fractures with limited risk of infection. To apply an external fixator, a power drill is necessary. The simplest solutions are context appropriate battery-operated power drills. When we talk about open fractures and their often-late presentation serial debridement might be necessary. A debridement set with chisels and bone curettes must be part of the basic equipment set, as well as instruments for skeletal traction, skin graft and amputation.
Advocating the SIGN nailing system
As an answer to the rising numbers of trauma victims in the Global South the American orthopedic surgeon Lewis Zirkle developed the SIGN nail and created SIGN Fracture Care International. This organization builds sustainable orthopedic capacity in the Global South by providing relevant education to surgeons, then manufacturing and donating the instruments and implants needed to treat fractures. The SIGN surgeons report the injury, the surgery performed including x-rays and the controls at 6 weeks and 6 months. This runs into the huge SIGN database.
The SIGN nail system can treat fractures of humerus femur and tibia. A fin nail and a SIGN pediatric nail are also available.
I learned the SIGN nailing technique at the Muhimbili Orthopedic Institute in Dar es Salaam, Tanzania ant at St. Orsola Hospital, Matiri, Kenya. In Cameroon I supported the implementation of the SIGN technique at the Lutheran Hospital of Ngaoundéré.
When introducing intramedullary nailing, be aware of the sterility requirements in the OR.
Context-adapted equipment
To avoid broken medical equipment piling up in a remote storeroom, the donation as well as the purchase should be done with care. Those are steps to follow, making equipment work for its lifetime:
- Planning and procurement: New equipment meets clinical needs, that are identified by the medical team of the hospital and are in line with a standardization effort of the health department
- Installation in reliable infrastructure to operate the equipment: stable power and water supply
- Practical training: for clinical staff (user training) and for the technical staff who maintain it
- Maintenance systems: team of trained hospital technicians with a workshop, tools, information resources and spare parts
Image: Diamedica Glostavent® Helix at the SICA-Hospital of Doctors without Borders, Bangui, RCA. The MSF standard anesthesia machine is equipped with a built-in ventilator and an oxygen concentrator (no external gas needed). It can operate without power supply for a limited period of time. Available from Medical Aid International.
Tools for patient security, organization and quality of care
- The WHO Checklist for safe surgery is a barrier to prevent perioperative adverse events. It has shown its efficacy over decades in various surgical environments. In those with limited resources a poster-like laminated version, fixed to the OR-wall, allows for visually going through the checklist and documenting it in the patient's file.
- Standard Operating Procedures have gained wide acceptance in medical care. 5 reasons to develop SOPs: transfer of knowledge - quality control - performance - patient security - standardization. Teaching for example skeletal traction is more sustainable if, the team can rely on an SOP in the daily work.
- Standard treatment protocols help in the correct use of antibiotics for perioperative prophylaxis and treatment of surgical infections. The MSF Clinical Guidelines are an excellent resource for a variety of conditions. The financial accessibility of the treatment for patients often limits the adherence to a protocol and needs sound judgment for an adapted approach.
