We've been at Kibuye Hope Hospital (or Hopital Espoir de Kibuye in French) in central Burundi for about a week and a half now. We're adjusting to life here and I have enjoyed being back in the OR. William has been working on several projects and has been staying busy.
To say the cases here are challenging would be an understatement. I have not had an 'easy' case yet. Everything is complicated by late presentation, malunion, or nonunion, as many people do not have good access to care here and only present when things are really, really bad. It's absolutely fascinating for me to see people limping in with a tibia fracture from 4 months ago, now with horrible alignment. Most of the femur fractures I operated on this week were at least three months old. Can you imagine living with a broken femur, unable to walk but still going about your daily life and using a stick to get around? I certainly cannot. But these people do, and it's incredible. It also makes for very difficult surgical decision making.
Take, for example, this 22F with a four month old intraarticular distal femur fracture. Her bone was almost about to come through the skin. She had callus formation around the fractured pieces, which made getting a reduction difficult. I decided to use a nail rather than a plate, and I was pleased with the reduction (even though it isn't perfect). I hope she goes on to heal (still a little worried about that lateral side, I wonder if I should have added a lateral plate).
I find myself agonizing over treatment decisions. These cases are difficult, not only because of the fractures themselves, but because of the resources available. There is no intraoperative XR, which is hard because I can't see if I've reduced a fracture enough or too much. I can only tell on the postoperative XR, which is taken usually about 6-18 hours after surgery. There are limited screws and plate options. Patients can barely afford surgery, let alone multiple procedures. It's frustrating to see a postop XR and feel like I could have done a better job for the patient. But, I'm learning to adapt to my circumstances and change my expectations.
I gave two lectures this past week to the PAACS residents. There are five PGY1 residents and one visiting PGY4 resident from Cameroon. My first lecture was on describing XR and fracture patterns, followed by a lecture on fracture healing and operative techniques. They asked great questions and I felt like they learned a lot, which was really encouraging!
This past weekend we went with two of the American doctors, Ben (general surgeon) and Selina (family medicine) to 'the cliffs'. It was about an hour drive east over the most rocky and pitted road you can imagine, dodging pedestrians and 'pikis' (motorbikes). The cliffs were beautiful, and we hiked six miles around the rim. In the distance, you could see Tanzania.
Here's to another week of challenges!
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