Published 11/1/2010
Richard A. Gosselin, MD

Be an orthopaedist without borders

Don’t pass up the opportunity to serve

I have had the opportunity to work as an orthopaedist for Doctors Without Borders, also known as Médecins Sans Frontières (MSF), in Haiti, Iraq, Nigeria, and Sri Lanka. Each experience been both challenging and rewarding.

Surgical programs for MSF include obstetrics, general and reconstructive surgery, and orthopaedics. Each orthopaedic program is context-specific: The pathology seen in rural eastern Congo will differ somewhat from that seen in urban southeastern Nigeria.

For the most part, patients have acute or neglected trauma from war injuries, natural disasters, urban violence, or road traffic crashes—the latest epidemic in developing countries. Acute or chronic musculoskeletal infections such as osteomyelitis, tuberculosis, or pyomyositis are common in some sites, particularly in areas with a high prevalence of HIV infection.

A typical team
A typical surgical team includes anesthesiologists, a general surgeon, an orthopaedic surgeon, an operating room nurse, ward nurses, and the supporting staff for logistics and administration. Their efforts are complemented by the work of qualified local counterparts: physicians, nurses, administrators, and support staff.

I’ve made long-lasting friendships with local orthopaedists, such as Sydney E. Ibeanusi, MD, in Nigeria, or Preden Morinville in Haiti, cemented over marathon surgical sessions. The type of infrastructure varies; usually we work in an already existing hospital or surgical facility, after appropriate upgrades, if necessary.

MSF can also provide “inflatable surgical suites” for rapid deployment in mass-casualtysituations, as recently seen in Haiti. A sterile surgical environment is a prerequisite for orthopaedic surgery, and it is frequently monitored by a quality-assurance team that includes sterilization specialists and microbiologists.

In general, we have at least two operating rooms—one for “clean” orthopaedic cases, the other for “dirty” cases. Equipment and supplies include an anesthesia machine and monitor, overhead lighting, an operating table, suction and diathermia, and an uninterrupted water and power supply.

For special programs, such as the orthopaedic reconstructive surgery recently started in northern Sri Lanka, MSF has built and equipped a dedicated operating room that would be the envy of many North American centers.

Most sites have a functional C-arm, with lead protection, and a fracture table. Supplies such as sutures, drains, dressings, and plaster of Paris are also standard. A list of standard basic orthopaedic trays has been developed, providing basic instrumentation for any case. All sites also have instrument sets for external fixation, for internal fixation with pins, for plates and screws (small and large fragment sets), for intramedullary nailing (Surgical Implant Generation Network, or SIGN system), and the power equipment to use them.

Medication and postoperative wound management follow well-established and time-proven MSF protocols. Rehabilitation services are occasionally available.

In conflict areas
Security is a serious issue. Risk assessment, situational analysis, and key informants are regularly used by each team’s security experts to assess the threat level and determine security protocols, including extraction, if it gets too “hot.”

The security team often includes a national key informant who has local knowledge and interacts with key players. Security and well being at home, at work, and in-between is priority one.

What you’ll need
Although the contexts may be different, sound fundamental surgical principles are the same everywhere. Knowledge of basic war wound treatment, mass-casualty triage, and wound management is mandatory. When hundreds of patients are awaiting surgery after an earthquake, mangled extremities are often best treated by amputation, rather than a multistaged limb-salvage procedure.

Good training, which should include knowledge of basic wound and fracture healing principles, and good common sense are your best allies. The ability to do skin grafting and some basic rotation flaps is definitely a plus.

Another prerequisite is knowledge and respect of the local cultural and religious environment. This is not always easy. Life- or limb-saving procedures, such as amputations, may be refused by patients (or worse, by their husbands, parents, clan leaders, or military commander). It is difficult to stand by and accept some decisions when you know you have something to offer.

I remember waiting for the father of a teenage girl in Nigeria, who had open tibial fractures in both legs, to give consent for amputation, at least on one side. Even after seeing the extent of the damage with his own eyes, he refused and took her to the traditional healer. We knew she was going to die and, by the look in her eyes, she knew it too.

My first visit to Nigeria coincided with the relatively recent introduction of the SIGN intramedullary nailing system, a user-friendly system that allows interlocking without fluoroscopy. Until then, all fresh femoral shaft fractures had been treated conservatively with traction. The SIGN system was well received, improving both clinical outcomes and the effectiveness of bed utilization.

One young man in his late 20s had a hypertrophic grossly mobile nonunion. He had been on crutches and unable to provide for his family for more than 5 years. The SIGN procedure dramatically improved his quality of life and earning ability. In similar cases, internal fixation has proven to be a great step forward. Still, its judicious use, in terms of indication and timing, rests with the surgeon, who has no colleagues to consult, but is both challenged and intellectually stimulated.

In more elective situations, the most common error is “trying to do too much” and aiming for first world results while forgetting the third world environment. Unfortunately, even I have proven the inescapable truth of the old maxim: The best is the enemy of good.

The ultimate challenge
Dealing with these diverse and often complex orthopaedic problems, in unfamiliar environments and often under stress, is the ultimate professional challenge. It calls upon all of your knowledge; clinical, surgical, and technical skills; judgment; experience; and confidence. It requires you to be both self-sufficient and a team player. Things may not always go as you wish, but every small success brings large rewards to you and to a patient who would never have received treatment otherwise.

I have often heard orthopaedic surgeons in the field say, “If you are able to do this here, you can do anything at home…” I don’t know if that’s true, but working with an organization like MSF does allow you to be all the orthopaedic surgeon you trained to be.

Richard A. Gosselin, MD, MPH, MSC, FRCS(C), is codirector of the Institute for Global Orthopedics and Traumatology at the University of California at San Francisco.

About Doctors Without Borders/Médecins Sans Frontières (MSF)
Doctors Without Borders/Médecins Sans Frontières (MSF) is an emergency medical organization that operates in more than 60 countries. Its activities span the spectrum of health care—from primary care and nutrition programs to mental health programs and surgery.

MSF also advocates for healthcare rights of the underserved, including provision of free or low-cost medication for people who have HIV, tuberculosis, malaria, or neglected diseases, and for better access to quality care for the most vulnerable—women, children, the elderly, and the handicapped.

For more information on MSF, visit its Web site, www.doctorswithoutborders.org