Gaining some clinical context, Lilongwe, Malawi

Kiran Agarwal-Harding, MD

Harvard Combined Orthopaedic Residency Program

PGY4

Gaining some clinical context, Lilongwe, Malawi

The Malawian Ministry of Health, Lilongwe, Malawi

During my time in Malawi thus far, I’d heard a great deal from my Malawian colleagues and mentors about the many barriers to delivering quality orthopedic trauma care. Their insights had been critical to developing the projects I was hoping to present to the Ministry of Health. To better understand the reality of clinical practice in Malawi, I was invited by Dr. Leonard Banza, an orthopaedic traumatologist, to observe him for a day.

On the morning of Tuesday, January 30th, I joined Dr. Banza at Kamuzu Central Hospital, the large government referral center in Lilongwe. We sat together on rounds and heard report on the various patients who came to the hospital overnight. The consult list resembled a typical night at Mass General. The only difference was the treatment available for these patients.

The operating theater, Kamuzu Central Hospital

The operating tables at Kamuzu Central Hospital

 

 

 

The operating tables at Kamuzu Central Hospital

 

Malawi is a small, low-income country in southeastern Africa, with a disproportionately high burden of trauma, ranking third worldwide for annual road traffic deaths per capita. Fewer than a dozen orthopedic surgeons serve a population of 17 million people, hospitals are strained passed capacity with limited operating theater availability, and the vast majority of orthopedic implants and equipment are donated. This means that, in Malawi, most patients with musculoskeletal injuries are managed nonoperatively by necessity, usually by an orthopedic clinical officer (OCO), or clinician with a post-secondary school diploma in basic management of orthopedic injuries.

For example, one of the patients who had presented overnight was a young woman with a femoral shaft fracture after a road traffic collision. In the US, she would typically be treated surgically with an intramedullary (IM) nail: a metal rod in the medullary canal of the bone, fixed with interlocking screws to the bone proximally and distally. The bone would be thus stabilized in length, alignment, and rotation, and she would be able to bear weight on the leg the day after surgery. If the surgery were to be performed well, the patient would enjoy a low complication rate and high likelihood of successful healing.

Instead, this patient was placed in skeletal traction: a pin in the proximal tibia connected to weights off the end of the bed, pulling the leg out to length. This treatment, while certainly better than nothing, is rife with difficulties for the patient and the hospital system. The patient will be bed bound for months, and has a high likelihood of not healing her fracture or healing with the bones shortened or angulated, limiting her function, and potentially her ability to support herself and her family.

However, this is starting to change. An NGO called SIGN Fracture Care has developed a low cost IM nailing system that is growing in popularity throughout the developing world for several reasons. First, the nail is designed with the low resource setting in mind, meaning it can be placed using hand-powered reamers and drills, and without the need for intraoperative x-ray to place the interlocking screws. Second, the nails are donated by SIGN. In Malawi, SIGN nails are now increasingly used to treat long bone fractures, some even being placed by OCOs.

I followed Dr. Banza to the operating theatre for the first case of the day - a young woman with a tibial shaft fracture, planned for a SIGN nail. The operating theater is a small room, with two operating tables, shared on Tuesday by Orthopaedics and Oral Surgery. It’s basic, but functional. The room smelled strongly of the disinfecting agent used to clean every surface. There is a simple anesthesia machine for each operating table, and a donated c-arm for intraoperative x-ray. With a limited supply of endotracheal tubes, the nurse anesthetist used a bag mask to manually ventilate patients after induction of anesthesia.

The first patient of the day was a paying patient, which meant her care had been expedited, and she would return after surgery to her private room, away from the packed public wards. She made it to the operating theater just a week after injury, so her fracture had not yet started to heal in an incorrect position, making her fracture reduction much easier. Dr. Banza reduced her fracture and placed the nail, using the system’s external target arm to place the interlocking screws. Though designed to be used without intraoperative x-ray, the placement of the distal interlocking screws is not trivial. For this particular patient, the natural bow of her tibia deformed the shape of the IM nail just enough so that the distal interlocking screws missed their target. Dr. Banza recognized this and used the c-arm to correct the position of the target arm and place the screws correctly.

The second case of the day was a young man with a femoral shaft fracture originally treated with skeletal traction, which had left his knee extremely stiff. He had subsequently been treated with a SIGN nail, but the OCO who placed the nail had also had difficulty placing the distal interlocking screws. The patient’s x-ray showed multiple incorrectly placed drill holes and two screws that had missed their target of interlocking with the IM nail. Dr. Banza removed the erroneously placed screws and revised them. The c-arm he used for intraoperative x-ray had been donated by a hospital in Norway, where it had already been used for decades. It’s an essential, albeit temperamental device. Just as Dr. Banza was getting ready to line up his screw to interlock with the nail, the c-arm went dead. Was it the power cut that had fused something internal? Or maybe a software error we didn’t know how to solve? The circulating nurse called for help from the engineering department while Dr. Banza tried to make do, knowing all too well that the problem wasn’t likely to be solved quickly. However, by some miracle, a minor adjustment in the c-arm position must have shifted a loose connection, the c-arm sprung back to life, and Dr. Banza finished placing the screws.

The third case was another young man with a femoral shaft fracture, treated with a SIGN nail, now with a postsurgical infection. In recent weeks, Dr. Banza had noted a rash of post surgical infections. There were plenty of suspected reasons, but no one had as of yet identified how to curb this trend. Dr. Banza washed the wound out with copious irrigation that soaked the reusable cloth surgical drapes. He put one of the medical students on fly-swatting duty. The patient’s cultures had grown out multi-drug resistant bacteria, which were proving difficult to manage given the hospital’s limited access to antibiotics. At this stage, Dr. Banza hoped that he could suppress the infection long enough to allow the patient’s femur to heal, then remove all the hardware once and for all and eradicate the infection.

The last case of the day was a teenage girl who Dr. Banza knew very well. Two years ago, she was attacked by a man who tried to rape her. As she struggled to escape, her attacker stabbed her in the back, severing her spinal cord and leaving her paraplegic. She developed severe pressure ulcers, which had required negative pressure wound therapy, multiple debridements, and skin grafts. Most of her nurses and guardians had begun to view her as a hopeless case, and had lost motivation to mobilize her or care for her wounds. Dr. Banza had spent the last several months visiting her every week to change her dressings himself. He had been prodding the physical therapy team to keep her moving, but to no avail - unfortunately her knees were now dislocated and stiff in full extension, making sitting nearly impossible and leaving her trapped in her bed. This had real consequences for the patient. Her attacker was released from prison on bail and the case against him would not be heard without her personal testimony, something she could not provide without a safe means of getting to the courthouse.

On this particular day in the operating theater, Dr. Banza performed a skin graft over a wound on her sacrum. This took some convincing, as the anesthesia and nursing team were ready to call it a day once the clock struck 4pm. Dr. Banza chided them gently, reminding them that he himself had opened the theater this morning, and didn’t begin operating until 10am when his first patient arrived.

The c-arm in the operating theater, donated by a hospital in Norway

We finished the day exhausted. Dr. Banza and I drove home together and reflected on the difficulties of the day. Systems to deliver quality trauma care are by necessity highly complex. The people, equipment, and infrastructure required are so intricately connected that it can be hard to figure out where to even start when trying to improve the system as a whole. A supply of SIGN nails only benefits patients when surgery is done well, operating rooms are clean, and surgeons and resources are available to manage complications. A donated c-arm can transform the care that an orthopedic service can provide, but only so long as the c-arm is maintained and functional, serviced by well-trained staff, and used appropriately. I finished the day feeling overwhelmed by the many challenges Dr. Banza and his colleagues face, but extremely moved by their dedication to their patients in the face of these difficulties. It is this dedication - moving a mountain one stone at a time - that remains with me today.