Basic Orthopedic Care
In many resource-limited environments trauma victims have no access to even basic orthopedic trauma care. Hospitals don’t have the trained staff and the necessary infrastructure, in terms of equipment and material. In cooperation with NGOs and Health Departments Volker and his small team offer training workshops and equipment support to improve access to basic orthopedic care.
Activities
Training workshops
Trauma care in the context of limited resources needs skills in diagnostics and context-adapted treatment plans. A special focus should be on conservative treatment, cast immobilization, skeletal traction and the use of external fixator. Reduction of fractures without c-arm is another aspect to be considered. In a workshop for basic trauma care, lessons adapted to the rural trauma surgeons need are accompanied by skills stations for the use of external fixator, tendon reconstruction and auto-production of atraumatic sutures with fishing line and needles. Visiting other institutions (Prosthetics Workshop of the Government Hospital, NGO that manufactures fuel-efficient cook stoves) is part of the networking, to widen the view to postoperative care and burns prophylaxis.
Assisting in orthopedic surgery
Teaching in the local environment with locally available equipment to care for local conditions is one key principle. In Madagascar a friendship of more than 20 years exists with the PAACS-trained experienced surgeon at Antsirabe (PAACS stands for Pan African Academy of Christian Surgeons). He is the cornerstone of teaching the next generation of surgeons. Teaching by example, practicing sound communication along with a thorough knowledge of the problem and the various solutions are essential components. To be complete, every surgical case should follow a preoperative plan and a postoperative follow-up. The use of the WHO Checklist for Safe Surgery, writing a postoperative documentation and instructions for postoperative treatment are important steps as well.
Instruments and equipment for basic trauma care
When talking about orthopedic trauma surgery, we have to keep in mind that sterility is crucial in the operation room. When intramedullary nailing and bone plating are done, the sterility has to be on an excellent level. For many hospitals basic equipment like external fixator and K-wires are an alternative to be considered. This allows for stabilization of open or comminuted fractures with limited risk of infection. To apply an external fixator, a power drill is necessary. The simplest solutions are context appropriate battery-operated power drills. When we talk about open fractures and their often-late presentation serial debridement might be necessary. A debridement set with chisels and bone curettes must be part of the basic equipment set, as well as instruments for skeletal traction, skin graft and amputation.
Advocating the SIGN Nailing System
As an answer to the rising numbers of trauma victims in the Global South the American orthopedic surgeon Lewis Zirkle developed the SIGN nail and created SIGN Fracture Care International. This organization builds sustainable orthopedic capacity in the Global South by providing relevant education to surgeons, then manufacturing and donating the instruments and implants needed to treat fractures. The SIGN surgeons report the injury, the surgery performed including x-rays and the controls at 6 weeks and 6 months. This runs into the huge SIGN database.
The SIGN nail system can treat fractures of humerus femur and tibia. A fin nail and a SIGN pediatric nail are also available.
I learned the SIGN nailing technique at the Muhimbili Orthopedic Institute in Dar es Salaam, Tanzania ant at St. Orsola Hospital, Matiri, Kenya. In Cameroon I supported the implementation of the SIGN technique at the Lutheran Hospital of Ngaoundéré.
When introducing intramedullary nailing, be aware of the sterility requirements in the OR.
Context-adapted equipment
To avoid broken medical equipment piling up in a remote storeroom, the donation as well as the purchase should be done with care. Those are steps to follow, making equipment work for its lifetime:
Planning and procurement: New equipment meets clinical needs, that are identified by the medical team of the hospital and are in line with a standardization effort of the health department
Installation in reliable infrastructure to operate the equipment: stable power and water supply
Practical training: for clinical staff (user training) and for the technical staff who maintain it
Maintenance systems: team of trained hospital technicians with a workshop, tools, information resources and spare parts
Image: Diamedica Glostavent® Helix at the SICA-Hospital of Doctors without Borders, Bangui, RCA. The MSF standard anesthesia machine is equipped with a built-in ventilator and an oxygen concentrator (no external gas needed). It can operate without power supply for a limited period of time. Available from Medical Aid Internat.
Tools for patient security, organization and quality of care
The WHO Checklist for safe surgery is a barrier to prevent perioperative adverse events. It has shown its efficacy over decades in various surgical environments. In those with limited resources a poster-like laminated version, fixed to the OR-wall, allows for visually going through the checklist and documenting it in the patient's file.
Standard Operating Procedures have gained wide acceptance in medical care. 5 reasons to develop SOPs: transfer of knowledge - quality control - performance - patient security - standardization. Teaching for example skeletal traction is more sustainable if, the team can rely on an SOP in the daily work.
Standard treatment protocols help in the correct use of antibiotics for perioperative prophylaxis and treatment of surgical infections. The MSF Clinical Guidelines are an excellent resource for a variety of conditions. The financial accessibility of the treatment for patients often limits the adherence to a protocol and needs sound judgment for an adapted approach.
Gallery Global Orthopedics
Caring for injuries in austere settings is a rewarding task and a challenge for all involved
Become part of the effort for global surgery and global orthopedics by creating equitable partnerships
The small Team
Nicola Kläber and Volker Roth
Volker is a general and orthopedic surgeon with a focus on trauma care. In his early years as a medical doctor, he spent five years in a rural hospital in Cameroon, sent by Service Overseas of the German Protestant Church. After specializing in general, trauma and orthopedic surgery he worked in a regional hospital. In short term fellowships in hospitals of the Global South he was introduced to the special challenges of austere settings. Volunteering in Nepal, Madagascar, Kenya, the Central African Republic and Cameroon allowed the exchange with colleagues of the Global South.
Nicola and Volker are married. She is a general surgeon and more important an experienced hand surgeon. As part of the Interplast-Team for reconstructive surgery of her late chief medical officer she made two trips to Guatemala. Following her interest in medical care in the Global South, she completed the Swiss Tropical Health course for International Cooperation and Global Health. She was part of the team in all the volunteering trips.
Connect with Volker if interested in Global Orthopedics. There are options to get involved.
Find out what you can offer in terms of experience, context-adapted orthopedic knowledge, willingness to cope with unexpected limitations and a different medical culture. Many orthopedic surgeons seek opportunities to provide specialty medical assistance to populations in need, with the majority volunteering in the Global South. Conducting orthopedic surgery missions overseas requires partners and an infrastructure. The logistical planning behind clinical volunteer opportunities can be a difficult task and, in many circumstances, it may be easier to join a well-established organization. An equitable partnership with a surgical team in the Global South should consider that the limited resources are often the biggest problem. The goal must be to bring added knowledge to the team while being careful not to underestimate the skills and experience of local surgeons. Visiting orthopedic surgeons should not supervise or promote a particular approach, but rather provide additional support to local physicians, as needed. In this sense, volunteer orthopedic clinical work should aim to improve care, enhance collaboration and foster goodwill.
If you want to know more about opportunities,
get to know NGOs
get in contact with interesting suppliers for context-adapted medical equipment or
plan a training program,
don't hesitate to contact me for an exchange of ideas.
My journey to Global Orthopedics
How it began
The five years in the 200-bed hospital in the Cameroon Littoral Province focused on the organization of a medical district. Surgery, gynecology, pediatrics and tropical medicine were practiced in the hospital. In the medical district with 5 dispensaries and 10-15 village health workers organization of drugs and medical supplies, standardization of treatment protocols, vaccination campaigns and supervision were the activities. The two volumes of 'Primary Surgery', edited by Maurice King, brought me on the surgical path.
Getting familiar with orthopedic surgery under austere conditions
Having heard from the SIGN nailing technique I got in contact with SIGN Fracture Care International. They organized a short-term fellowship with the trauma surgeons at Muhimbili Orthopedic Institute at Dar es Salaam. They are the most experienced SIGN surgeons. I saw many different long-bone fractures treated without C-arm and therefore with open reduction.
Another valuable insight into a well-organized hospital with competent staff we got at United mission Hospital Tansen in Nepal. In a second visit we were able to work in the hospital and replace Nepali surgeons, treating earthquake victims in the disaster zone.
Volunteering in different places
In the Lutheran Hospital at Ngaoudéré in Cameroon I helped introduce the SIGN nailing technique. Nails of course, are not the solution to everything. We had cases for external fixation, hand and reconstructive surgery, the latter done by Nicola.
Several trips to Madagascar brought us in close contact to the Malagasy doctors of the Health Department of the Malagasy Lutheran Church. Workshops on hospital administration, use of external fixator, ultrasound for surgery, gynecology and obstetrics as well as regional anesthesia techniques were organized. This was the base of friendships for years.
At St. Orsola Hospital in Matiri, Kenya I have been twice. The enormous caseload of trauma patients is managed by an skilled and charismatic Italian catholic father and surgeon. He is Kenya's most experienced SIGN surgeon.
Invited by a dedicated young German orthopedic surgeon to the Protestant Hospital of Mbouo in the Bamileke region of Cameroon, I realized that a Hospital Partnership can shape a health system.
With Doctors without Borders (MSF) in the Central African Republic
In the capital of the civil war ridden Central African Republic MSF runs the SIKA-Hospital. There I was exposed to war surgery for the first time. We had to treat mainly gunshot wounds, beside high-velocity injuries from car or motorbike accidents. With no C-arm available and external fixator and K-wires as the only orthopedic implants, the surgeons had to exploit the full potential of the external fixator. Beside these limitations the MSF hospital is well organized with treatment standards and SOPs for many procedures. An antibiotic stewardship program is established and was run by a skilled CAR doctor. We could rely on a well-equipped physiotherapy department with a qualified team. Security is always a concern in MSF hospitals, as they are located in zones of war or unrest.
Hospital Partnership Doctors for Madagascar - Malagasy Lutheran Hospitals
In January 2023 Dr. Harison, the medical director of the Andranomadio Lutheran Hospital in Antsirabe, organized a 3-weeks workshop for the doctors from the six different hospitals. The goal was to train a future generation of young surgeons. The workshop consisted of lectures, practical exercises and assisted surgery. The focus was on general surgery, orthopedic trauma, hand surgery and radiology. Together with friends from our region (a general surgeon and a radiologist) we were part of the team. Surgery for orthopedic trauma is possible at Andranomadio hospital, but due to lack of basic instruments and implants, not at the other hospitals.
As a result of the course, a Hospital Partnership was established that brought together the German NGO 'Doctors for Madagascar' and the Health Department of the Malagasy Lutheran Church (SALFA). Doctors for Madagascar has worked together with SALFA over many years and in various partnership programs, that were centered on the SALFA hospitals and dispensaries in the poor southern part of the island. Our Partnership wants to improve access to basic orthopedic care for trauma patients.
Context-adapted equipment has been purchased from an Indian Manufacturer. This strategy makes supplies more accessible for health systems with limited financial resources and allows a supply chain to be established.
A training workshop combined lectures and practical exercises. The participants were medical doctors in charge of surgery and the nurses of the OR-team. By giving them the same training opportunity, we hope to strengthen the team approach.
A follow-up visit in the end of 2025 will meet the surgical teams of 8 SALFA hospitals, exchange on the orthopedic patients treated, check the equipment function and discuss further support.
Questions that might arise
Where do Volker and Nicola live?
We live in Germany in a small village at the southern slope of Black Forest close to the Rhine. The distance to Basel in Switzerland is 40 km, to Freiburg 100 km.
Is there a textbook on Global Orthopedics to be recommended?
Global Orthopedics Caring for Musculoskeletal Conditions and Injuries in Austere Settings
Second Edition
Richard A. Gosselin, David A. Spiegel, Michelle Foltz • Editors, Springer 2020
This is an extraordinary book that offers a detailed overview and practical solutions. As a PDF edition it is a much-valued companion on every mission.
Is there an App available with answers for orthopedic surgery in the Global South?
Over many years I have used the app 'AO Surgery Reference' in my orthopedic surgical work and for teaching. It allows to select the treatment plan according to the resources available in terms of equipment and surgical knowledge. So, there are treatments described for hospitals in austere settings.
Which organizations finance and support Hospital Partnerships?
There are Hospital Partnership programs in the US (now probably unfunded) and many European countries. In Germany the Ministry of Economic Cooperation started the Health Funding Program 'Hospital Partnerships', where medical professionals from German hospitals or NGOs partner with colleagues from hospitals of the Global South. Currently there exist around 400 Hospital Partnerships in 66 countries. The program is implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). There are two arms of the program: one called 'Global' and the other 'Academic'. The Hospital Partnership programs of the 'Global' arm run over a period of 2 years with a maximum funding of € 50.000.
What does the NGO 'Doctors for Madagascar' stand for?
The registered charity 'Ärzte für Madagaskar - Doctors for Madagascar' was founded in Summer 2011 by German doctors who had experienced both the desperate lack of medical treatment in Southern Madagascar, but also the selfless commitment and the medical abilities of their Malagasy colleagues.
In Madagascar, about 80 staff members in permanent positions are currently working towards the goals of the organization, including doctors, midwives, accountants, logisticians, drivers and many more. On the German side, a project coordinator as well as a communications officer work in a small office in Berlin. Beyond this, the work of the charity is carried out to a large extent through the voluntary engagement of experienced doctors, nurses, construction experts, technicians, accountants and interns.
Doctors for Madagascar provides direct medical aid with the goal of improving medical treatment in Madagascar in the long-term. They support hospitals and other medical institutions with donations in money and in kind; offer medical training for local doctors and nurses; build facilities; and send teams of doctors and construction experts.
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