NICARAGUA, APRIL 2016 – Matt Smith MD, Class of 2016

“Having never practiced medicine outside of the Midwest, traveling to Central America and operating in a Nicaraguan hospital for a week was a bit of a culture shock. I had been mentally preparing for this trip for years. I had hoped that I would be able to attend the trip ever since hearing about its existence when I was an intern, and as such I always attentively listened to the stories of the residents coming back. I had a general idea of what we would be doing in this country, but aside from that I was nearly flying blind as to any of the specifics. It didn’t dawn on me the level of my ignorance until I had to fill out the customs paperwork in Nicaragua and I realized that I had no idea the name of the city in which I would be staying. Once this minor detail was figured out, we worked our way through customs and then traveled on to our hotel.

The real work started a couple days later when we had our one clinic day. Roughly 50-60 patients showed up and waited in line in an auditorium for their chance to be seen by our team of orthopaedic surgeons. We had two makeshift exam rooms in the back of the auditorium with privacy supplied by bedsheets strewn across wires. Translation was provided by three people including two surgeons from Nicaragua and one medical student from Nicaragua. Clinic itself was a mixture of adult and pediatric orthopaedic pathology with a heavy leaning toward the pediatric. A large majority of the visits were spent providing non-operative advice, telling people that their previous surgery went well or convincing people that they did not in fact have a problem. That being said, a few gems of complex orthopaedic patients found their way to our doorstep.

One patient in particular that stuck out was a 32 year old laborer who, 9 months earlier, had fallen off his motorcycle and broken his wrist. At the time, an attempt at treating him with a cast was made with initial short term success; however the fracture did not remain well aligned. Now, his dominant hand was severely malaligned due to a malunion of his distal radius, rendering his right hand nearly functionless. As I continue to reflect on this case I still struggle with the vast disparity that exists between orthopaedic care in my home and in Nicaragua. In any modern orthopaedic practice, his fracture would require surgery, at the very least a few K wires (which cost a paltry amount), or potentially a more expensive plate and formal surgery. However, in this country, this patient could not afford the K wire and as such he was treated with plaster. We had the opportunity to help this man by reorienting his wrist with a distal radius osteotomy held in place with a plate and screws and some bone graft all of which we brought with us.

On a daily basis at work I think about this man and his surgery. At home, we use K-wires for the purposes of provisionally aligning fractures prior to placing plates and screws; however thousands of miles away this same K wire may have saved this man nearly a year of disability. Furthermore, we used an old set of plate and screws donated for our trip because they are too outdated for our daily use. My continued reflection forces me to rethink decisions I make in the OR as I realize simple solutions may remain the best solutions and furthermore these same simple solutions may be the best solutions when providing care overseas.”