I just finished my last week in Burundi. It feels like the last 6 weeks have flown by. I had a few really challenging cases on my last week, including a femoral shaft nonunion. A 40 year old man had sustained a closed femur fracture while working on a farm one year ago, and either wasn't able to access or afford care. He went one year with a broken femur, which partially healed with his leg about 5 inches short. He was able to hobble around with the use of crutches, but wasn't able to walk normally. I don't know what brought him to the hospital after one year, but he came to Kibuye and was scheduled for fixation.
There's a couple difficult things about this case. One is that some callus (hard bone) has formed between the two fragments. It's located right where the femoral artery runs, so I decided to do a medial approach to find the artery & protect it before breaking up this connection and reducing the fracture. Since we had limited equipment & resources, operating around the femoral artery was even more nerve-racking than normal. The other problem was how much his bone was displaced and for how long. The muscles have now been used to his femur being about 5 inches shorter for the last year, and it was extremely difficult to try to bring the bone ends out to length. I had to cut some of the bone on either side to help get it reduced, but it was still a struggle. He ended up being about 2 inches short, rather than 5 inches short. Hopefully he will be able to use a shoe lift to even out his legs further. His femoral artery was just fine :)
Another challenging case that I had was a chronic knee dislocation for five years. The femoral condyle and tibial plateau had basically disintegrated. We ended up doing a knee fusion on him- so he won't be able to bend his knee, but at least he will have a stable leg.
My last case was an open tibia fracture with Tanye- one of the residents. It was Friday at 7pm- classic!
I did my last lecture for the residents- this one on orthopaedic oncology. I will miss working with these guys- what an amazing group! From left to right: Raoul, Dickson, Tanye, Danny, Alain, Levis.
I was also asked to give the chapel message on one of my last days. Every morning at 730, the hospital staff gets together for a worship song & a short sermon. Usually, one of the chaplains or doctors gives the message, but Eric (one of the family medicine doctors) asked if I could speak. I agreed, and he told me I could pick whatever topic I wanted to. I decided to focus on perseverance. Eric suggested I write it down, which would make it easier for me to speak & him to translate into French. Here is a transcript:
"My name is Julia Quirion and I have had the privilege of working with you for the past six weeks. This is my last week here at Kibuye before I go back home to the United States.
In my time here, I have seen the amazing work you have done, but also the great need around you. A hospital is a place of human suffering, concentrated into one building. No matter where you are in the world, a hospital is a place where people who are broken come for help and healing. We are surrounded by people’s pain, suffering, and emotion- sometimes happiness, sadness, or anger. It can weigh heavy on us to be here, day in and day out, trying to meet the needs of needy people.
Many times I have looked around the hospital and felt overwhelmed with how much work there is to do, and that the work never ends. Tomorrow there will be another patient, and then the next day after that. I can become easily discouraged.
Regardless of the enormity of the task in front of us, God has called us to continue.
James 1:2-4 says “Consider it pure joy, my brothers and sisters, whenever you face trials of many kinds because you know that the testing of your faith produces perseverance. Let perseverance finish its work so that you may be mature and complete, not lacking anything.
God calls us to continue to serve others, even when it’s hard, not only for the people we serve, but for us as well. Perseverance helps us to grow and mature into the people that God wants us to be. He also asks us to consider it joy, or choose joy, when we face difficulties.
Similarly, in Romans 5:3-5, Paul tells us “…we rejoice in our sufferings, knowing that suffering produces perseverance, and perseverance produces character, and character produces hope, and hope does not disappoint us, because God’s love has been poured into our hearts through the Holy Spirit who has been given to us.”
One thing that I have seen here at Kibuye much more than in the US is the joy that I see, even in the midst of difficult circumstances. I will remember that and take your joy home with me as a reminder.
I think we can also learn from our patients. Many of them have suffered with their illnesses or injuries for a long time. Some of the patients I have operated on have had a femur fracture for over 6 months, and yet they still smile and show kindness to those around them. I honestly do not think that I would have as much endurance as them and still find joy in my circumstances.
On one of the days I felt overwhelmed with the amount of work to be done, I read a quote referencing Micah 6:8: “Do not be daunted by the enormity of the world’s grief. Do justly now. Do mercy now. Walk humbly now. You are not obligated to complete the work, but neither are you free to abandon it.”
God wants us to persevere, and stay with the work, but he does not leave us to do it by ourselves. Philippians 4:19 says "But my God shall supply all your need according to his riches in glory by Christ Jesus."If God has called us to something, he will see that we are equipped. Not by our own strength, but by what he can supply for us.
Whatever the task ahead of you, whether it is another day of serving people, or completing a training program, or even starting a hospital, God calls us to persevere, and he will provide us what we need to do it. We cannot go around trials, and God even wants us to go through them so that we can develop our character and faith. We may not choose our difficulties, but we can choose joy during these times."
I will miss morning chapel!
We celebrated American Thanksgiving with the team on Saturday with a big potluck. There was a turkey, ham, and a bunch of sides. Some were pretty traditional- green bean casserole, mashed potatoes- but some had more of a Burundian flair, like rice & beans. It was fun gathering with a big crew!
I made sure to get a picture with Michael & Jenn Harling- the reason I came to Burundi. We all did residency in Greenville, SC. Michael (general surgery) and his wife Jenn (pediatrics) were a few years ahead of me, but I stayed in touch over the years. I didn't really know them at all when I came out to Burundi, but I can honestly say we left as friends. What an awesome family.
One of my favorite things was going for a walk in the beautiful hills surrounding the hospitals. I went for a walk with Selina, one of the family medicine physicians, and we started gathering a little crowd of Burundian children behind us. Mostly it was the novelty of seeing two white people (or mizungus) outside of the hospital, and they had a great time following us and hiding when we turned around. It turned into a little game and I was cracking up.
I went on one final walk on Saturday, and it started pouring... I got completely soaked and muddy. They don't call it the rainy season for nothing.
I left Burundi on Sunday afternoon with a drive back to Bujumbura, flight to Entebbe--> Brussels-->Newark--> Phoenix. It took about 36 hours and I was exhausted.
I am excited to be back in the States, and I loved being reunited with Hazel! William is still on the East coast, so I will get to see him later this week. However, I was sad to leave Kibuye. There is still so much work to be done. I am hopeful that I will still get to be involved with Kibuye in the future. One area I hope to do this is helping to create an open fracture protocol.
For reference, in the US, the gold standard for open fractures is IV antibiotics as soon as possible, then early washout in the OR and fixation of the bone, with soft tissue closure at that point if possible or definitive closure within 5 days if the patient needs a flap or graft. In Burundi, patients almost always show up at least 24 hours after their initial injury, and they may or may not get antibiotics, depending on where they go first. Some people go to local health clinics, where they get an XR and are referred to Kibuye. Once they arrive at the hospital, they usually get a superficial cleaning of the wound and closure with stitches. Then they wait until the can pay for surgery and the surgery schedule has an opening for them to go to the OR. By that point, they are usually grossly infected and require an extensive debridement. Common practice is to avoid implanting any metal in a grossly infected wound, so the patient usually gets an external fixator or a cast to temporarily stabilize the bone while the clear the infection. This is now very difficult because the infection is now really bad. The open wound may heal with time, but the bone usually doesn't heal because it hasn't been fixed with a nail or screws/plates. If the bone isn't fixed well, the soft tissue usually doesn't heal well because it doesn't have the appropriate scaffolding. So the patient develops two problems- osteomyelitis (infected bone) and nonunion (unhealed bone). Osteomyelitis is very hard to treat under the best of circumstances- usually six or more weeks of IV antibiotics- which patients cannot afford. I saw so many patients with infected nonunions in my time there. These cases are very challenging, and you typically don't get a great outcome.
I discussed my observations with the surgeons and we came up with a possible plan- the open fracture protocol. In this system, when a patient shows up with an open fracture, they will immediately get IV antibiotics, no matter how long ago the fracture was. They will not get a superficial washout (honestly it just pushes the bacteria further in the wound) but will go to the OR for a more thorough washout. We can cut costs by using regular water with bleach or chlorhexidine rather than saline (which is expensive for patients). Ideally, the patients will get to the OR within 24 hours for an extensive washout. If the wound doesn't look too bad, the bone can be definitively fixed at that time. The soft tissues can also be closed at that time if possible. Hopefully, fixing the bone early will prevent some of the nonunions. The potential for infection will still be there, but doing a washout early could prevent the infection from becoming too bad in the first place. In the long term, it should decrease the need for additional surgeries and therefore cost. However, it does require some up front funding. One of the problems is that some patients have difficulty with coming up with the money for surgery (even though Kibuye has some of the lowest prices in the country) and they have to wait to get to the OR. If patients were able to pay afterwards, and the surgeons think that most of them will, they could get to the OR sooner. Of course, some people will never be able to pay, which is why Kibuye has the 'needy patient fund'. Normally, if patients cannot pay, they are referred to 'Mama Kenny' a Burundian woman who works in the office and does some background work to make sure they really are in need. If she approves, then their care is covered by the fund (which comes from donations). The 'needy patient fund' could be a good route for open fracture patients to ensure the hospital is getting paid for the surgeries but that the care is still timely. There are a lot of considerations and a lot of work to be done, but I really think this could be a practical way to improve orthopaedic care in Burundi. If you are at all interested, I have the link for how to give to the needy patient fund. I personally have used this fund so that patients who could not otherwise afford care can get what they need.
Hopefully, the open fracture protocol will become a reality and can tanglibly improve outcomes for patients in Burundi.
What an amazing six weeks. I learned so much and I am so grateful for all the people we've met at Kibuye.
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