BLOG: Nicaraguan heroes: Lessons learned from Lenin Fonseca

I recently returned from an orthopedic service trip to Nicaragua organized by the generous efforts of Health Volunteers Overseas, a nonprofit organization dedicated to improving the medical care of underserved areas. My wife, Marie, and I spent most of our time at a government-run hospital called Lenin Fonseca, which offered free care to the poor and uninsured residents of Managua. The resources afforded to the orthopedic service were well-below meager standards and, if it were not for the resilience and spirit of the residents, virtually no care would be rendered to these patients.

The trauma service at Lenin Fonseco was busy, to say the least, with fracture upon fracture stockpiling the wards each day. Open fractures of all long bones, nonunions and infections were the order of the day. The resident staff, like all orthopedic residents, were naturally eager to partake in as many surgeries as possible. Yet, often there was no equipment. Even surgical masks and caps were valuable commodities.

On my first day, we rodded a femur on a marginal fracture table without X-ray. There was no fluoroscopy unit. This, not to mention, was the first time since my residency that I used such an antiquated nail. I thanked God for my “gray hairs” and modest trauma experience, which proved invaluable in seeing the case to completion. Of course, the determination of the residents proved to be even more important than my pedestrian trauma skills.

As a shoulder specialist, I was delighted to find a patient who needed a rotator cuff repair. However, shoulder arthroscopy was essentially never performed in this facility and was reserved for more privileged patients in the private sector.

Spirit of the staff saves the day

We figured out how to “jury rig” a body positioner and arm holder to afford a lateral decubitus position. Using well-outdated anchors, we were able to complete the repair under challenging conditions. Implant inventory was one cardboard box containing outdated (and presumed sterile) anchors. Hypotensive anesthesia was not an option, and thermal instruments were found only in the ultra-private hospitals. Thankfully my wife literally had to manually squeeze IV bags to maintain shoulder distention.

On the second day, we had to cancel two fracture cases — there were no drills available in the hospital. Thankfully, a hand drill manifested and I helped guide a remarkable resident through an external fixation application to an open pilon fracture. This was my second fracture case without an X-ray. Thank goodness the bone quality was poor.

That afternoon, an inspiring and selfless American orthopedic resident, Ronna Parsa, MD, took it upon herself to go to the local hardware store and purchase a drill. This legacy of Ronna, later determined to be non-sterilizable, now resides in the emergency room where residents use it to insert traction pins.

 

Countless other cases had to be cancelled due to the paucity of 4.5-mm screws available. For some reason, there was a dearth of large fragment screws. Again, the indomitable spirit of the residents prevailed. They often would cut available screws to the needed length with sterile bolt cutters.  Other more resourceful residents resorted to cutting the screws at home. These heroes found a way, whenever humanly possible, to get cases completed.

All my humble arthroscopic skills were tested when I performed a PCL reconstruction with lateral side imbrication. With no electrothermal cautery, adequate cannulas and suture-passing instruments, the challenges were formidable. Thankfully, approximately 90 minutes and 20 Hail Marys later, our patient had a stable knee. And, yes, we did have a drill that day.

Conditions

Clinics were beyond crowded, and the exam rooms were oppressively hot. Air conditioning was a luxury, available only in more privileged areas of the hospital. The wards were similarly intolerably warm and humid with patients crammed into packed rooms with beds often lacking sheets. Traction was usually an IV pole housing a rope connecting a tibial pin to a bag containing water bottles for weight.

Machete injuries were common. I will never forget beholding one young woman who suffered catastrophic machete wounds at the hands of a jealous husband. Her wounds included a traumatic amputation of the left hand and numerous disfiguring facial lacerations.

Bed after bed seemed to contain one hip fracture after another awaiting surgery, languishing principally because of lack of implants. My obvious concern was the seemingly imminent onset of pneumonia or pulmonary embolus. Surprisingly, the prevalence of these dreaded complications appeared low. Perplexed, I asked a young and talented surgeon, Mario Cuadra, MD, why the prevalence of complications was not higher. He replied that his mentor and former chief of orthopedics at Lenin Fonseca, Dino Aguilar, MD, popularized a saying “Dios cuida de su animalites” or “God takes care of his little creatures.”

Sense of gratitude

It is indeed a profound privilege to practice orthopedic surgery in the United States. Perspective gained from service trips can result in an overwhelming sense of appreciation for our imperfect, yet lavish health care system.

 

When I returned home, I was overcome with gratitude. After office hours in my air-conditioned facility with the trusty help of a physician assistant, athletic trainer and resident, I was treated to my OR day, replete with two ultra-furnished rooms. My drills were fully functional, and two spares resided in the supply room in the event of any malfunction. Shoulder cases flowed lyrically with hypotensive anesthesia, thermal ablation, cannulas and the latest bioabsorbable “implant du jour” all at my disposal. Inventory was bountiful, and all instruments were at my beck-and-call. Surgical masks and caps were freely available. Life is good here.

Next time the OR start is a little delayed or the block team is taking a little longer than expected, the wrong size cannula is opened, or the pump pressure is a little off, think of the heroes at Lenin Fonseca Hospital. They may never realize the abundance we enjoy daily.

In one day, we discard volumes of equipment that my Nicaraguan colleagues would greatly appreciate. Organizations, such as Health Volunteers Overseas, welcome any efforts from hospitals or health care organizations to donate unused or even outdated equipment.

Help and heroes

Service trips are rewarding. Rendering care to the underserved resonates with the essence of why most of us chose to go to medical school. But, the real heroes in Managua, Nicaragua, are not the visiting surgeons from the United States. They are the men and women who, despite formidable odds and conditions, render compassionate and skilled care to the poor day in and day out.

I was indelibly impressed by the surgical skill, ingenuity and most important of all, indomitable spirit of the orthopedic residents of Lenin Fonseco. It is thanks to the leadership of men like Dr. Aquilar, that they find a way to get the job done.

Reference:

www.hvousa.org

 

Disclosure: Kelly reports no relevant financial disclosures.