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Rick Wilkerson, DO, treats a multiligament knee injury with open reconstructive surgery.
Courtesy of Health Volunteers Overseas

AAOS Now

Published 9/1/2008
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Rick Wilkerson, DO

Orthopaedics in Uganda

A volunteer placement becomes an unforgettable family experience

A year ago my wife and I, along with four of our eight children and a friend of one of our daughters, spent a month working with Orthopaedics Overseas (OO) at Mulago Hospital in Kampala, Uganda. Twelve years earlier, we had taken a similar trip to Bhutan with OO. That experience had proved to be one of the most memorable and, I think, valuable trips our children have experienced. After discussing the many different orthopaedic program opportunities with the Health Volunteers Overseas (HVO) staff, we chose Uganda as our next destination.

About Uganda
Uganda, a beautiful country in Eastern Africa, currently offers the only orthopaedic training program in the region. Its history under the rule of Idi Amin in the 1970s is familiar to most and was the basis of the movie “The Last King of Scotland.” Mulago Hospital is featured in one of the more gruesome scenes of the movie.

Since 1986, Uganda has been working toward peace and development with reasonable success. The exception to the peace is the strife in the north from the Lord’s Resistance Army (LRA), which for the last year has had a cease fire agreement with the government as a permanent peace is negotiated. During this time, Kampala—the country’s capital—has been untouched by the unrest.

Uganda—a landlocked country roughly the size of Iowa—has about 27 million people. Sir Winston Churchill described it as “the Pearl of Africa.” The country includes rain forest and mountains, home to gorillas and other wildlife, as well as wildlife savannahs and fertile agricultural lands. Uganda is the source of the world’s longest river, the Nile, and borders the third largest lake in the world, Lake Victoria. The many national parks add to the attractiveness of this wonderful country. The most valuable asset of Uganda, however, is none of these natural wonders, but the friendly, hard-working people who live in this bustling, growing country.

Orthopaedics in Uganda
The orthopaedic training program in Uganda was started by Rodney L. Belcher, MD, in 1989; the first graduates achieved their Masters of Medicine degrees in orthopaedics in 1997. The program he so successfully started has grown and now has groups of 4 residents per year for 3 years of training. The residents have all completed their internship and have been practicing primary care for at least 2 years. Many come from other countries in Eastern Africa such as Tanzania, Kenya, and the Democratic Republic of the Congo.

The permanent orthopaedic department has six professors, each with an area of interest—spine, trauma, pediatrics, sports, and probably the most developed Ponsetti Clubfoot program outside the United States. Dr. Patrick Sekimpi has been trained in the use of Surgical Implant Generation Network instrumentation for trauma and is very skilled. The entire staff is bright, energetic, and eager to share and learn. The residents are hard-working, bright students with a keen desire to help improve the healthcare system in Uganda.

A typical day
I would meet the second-year resident at the trauma ward (Casualty Ward) each morning to visit patients admitted the previous night. On an average day, we would see 15 to 30 patients with open fractures; most had received no treatment during the evening and were awaiting transfer to the operating room (OR) for initial débridement and stabilization, either with external fixation or a plaster cast. Patients would then be admitted to an inpatient ward until a bed on the orthopaedic ward was available. It might be 2 to 3 weeks before patients could be scheduled in the OR for definitive care.

During these rounds, I could accomplish a great deal of bedside teaching. The Casualty OR is staffed by the second-year resident and, if available, the visiting OO professor. Time permitting, radiograph rounds were held on Mondays, although I was unable to attend due to my responsibilities in the OR.

On Monday, operating day, I would meet with the staff and residents to perform surgery. The cases consisted primarily of trauma from road traffic accidents, sepsis, tumors, injection paralysis of the lower extremity, malunions or nonunions, and old, missed traumas such as shoulder dislocations or multiligament knee injuries. Two ORs, each with three to four patients per day, were available; the limiting factor was the availability of anesthesia providers. The OR equipment was all donated by previous volunteers. The one C-arm works quite well; however, plates, screws, external fixators, and all other imaginable equipment are needed to maintain the available orthopaedic supplies.

Rick Wilkerson, DO, treats a multiligament knee injury with open reconstructive surgery.
Courtesy of Health Volunteers Overseas
Patients with various orthopaedic conditions wait to see Dr. Wilkerson at the Mulago Hospital in Kampala, Uganda.
Courtesy of Health Volunteers Overseas
Orthopaedics Overseas (OO) has been sending volunteers abroad since 1959. In 1986, OO became the founding division of Health Volunteers Overseas (HVO), which now offers a broad spectrum of volunteer placement opportunities for healthcare professionals. For more information, visit the HVO Web site, www.hvousa.org

On Tuesdays, during rounds on the orthopaedic ward, we had another excellent opportunity to teach and learn; these rounds always generated excellent discussions. Rounds continued with one or two of the orthopaedic staff and the residents at the orthopaedic wards in the main hospital. We would normally see 135 to 150 patients; during this session, we would select the patients who would be prepared for surgery the following week. The ward managers are orthopaedic house officers, equivalent to our orthopaedic physician assistants. It was not unusual to see 2 or 3 patients with chronic cervical spine perched facets who were awaiting surgical stabilization. The variety of cases was remarkable and always of interest.

The rest of the week was filled with surgery and rounds. Each evening, I visited the Casualty OR to assist the resident on duty. Residents typically work all night and through the next day. These young physicians are truly remarkable in their work ethic. They must pay for their residency either from their own earnings or from the sponsorship of nongovernmental organization hospitals where they will work after completing the program. To advance to the next year of training they must pass both a written and an oral exam. These exams took place while I was there and I was fortunate to be asked to assist in the oral exams. I have been an oral examiner in the United States and found the contrast between the two systems very interesting.

A family affair
One of the features of the Uganda site is the presence of other HVO volunteers, including nurse educators, pediatricians, and internists. During our stay, my wife, a pediatric nurse practitioner, worked in the pediatric department. The shortage of equipment and nursing staff was challenging, but it was also a very rewarding opportunity. She was able to assist in developing the pediatric intensive care unit’s standard operating procedures for provision of oxygen for patients on the pediatric ward.

My four children (ages 18, 11, 10, and 7) and our family friend were able to create a children’s playroom on the pediatric ward. They held daily lessons, teaching letters, numbers, games, and coloring to the children. They formed many friendships and were able to see firsthand the struggles that many children in this world must face.

Our living quarters, provided at the rate of $10 per day per person, were quite adequate with a kitchen and bathroom with shower and hot water. The staff at the guest house was very helpful. We found a number of fairly inexpensive restaurants within walking distance (less than 2 miles) and enjoyed wireless Internet service on an intermittent basis from the Guest House and many Internet cafes in the city. Vegetable markets are abundant and enjoyable places to shop.

The Uganda program is unique in that it has a permanent HVO staff coordinator, who is very kind and helpful. She is always available to volunteers and is a fount of information. She was quite helpful in arranging weekend trips to the national parks, the Nile River, Lake Victoria, and many other sites of interest.

Reflecting upon our trip to Uganda, I can say that it was one of the most enjoyable months I have spent with my family. The return to simplicity was refreshing and forces one to reprioritize from the usual stresses of the typical day at home. My children, my wife, and I have maintained contact, via mail and Internet, with friends we made.

For those contemplating whether or not to do similar work with your family, I can only say “don’t wait.” You and your family will forever hold dear these new friendships and will consider the memories of your newly found peers and patients among your fondest.

Rick Wilkerson, DO, is in private practice in Spencer, Iowa, and a frequent volunteer with Orthopaedics Overseas.

About Orthopaedics Overseas