The following is adapted from an article published in the June 2012 Volume I of the University of New Mexico Quality Improvement and Ethics Journal
“So you just went to a foreign country and operated on a bunch of patients you’re never going to see again. . . .” – UNMH orthopedics attending.
I encountered many reactions when I returned from a week in Guayaquil, Ecuador with Dr. Elizabeth Szalay, one of our pediatric orthopedic attendings. My fellow residents asked about case volume, type of procedures performed, and my level of participation in the cases (we are orthopedic residents after all). Family and friends were more interested in my depiction of poverty, neglect, and miracle fixes. But one thoughtful attending didn’t sugar coat it when he asked, “What if they have a complication?”
During my first two years of medical school, we had a weekly class on medical ethics. The class began with the definition of ethics (the study of morality, or right and wrong) and the six primary values of medical ethics: autonomy, beneficence, non-maleficence, justice, dignity, and truthfulness. Each week we reviewed three cases, addressing each value in turn. I hadn’t thought much about this exercise since becoming a resident, and I certainly hadn’t run this list prior to going to Ecuador. But my attending’s question made me think: is a week’s worth of surgery helpful or harmful?
My trip was organized and funded by a small non-governmental organization called Project Perfect World. We worked with three pediatric orthopedic surgeons at the Hospital de Niños, which is funded by the national lottery and provides care for impoverished children. Patients pay a $20 co-pay per visit, which is covered by Project Perfect World. Many patients traveled hours by bus to see us. Parents slept in chairs or on the floor of the pediatric post-op ward (one room full of 30 beds).
Our team performed 24 procedures, the majority of which were on patients with developmental hip dysplasia (DDH). While this diagnosis is quite common in children, in the U.S it is identified early, with definitive diagnosis made by ultrasound. However, in developing countries the system to diagnose infants is not in place, and many infants are not diagnosed until they become ambulatory with a limp due to significant leg length discrepancy from the dislocated hip. There is great debate about the long term success and utility of osteotomies for DDH, but most pediatric orthopedic surgeons would agree that children of walking age treated with surgical hip reduction and osteotomies have better functional outcomes as they age. Unfortunately, the countries that most need surgeons trained to perform these procedures are the least likely to have them. Therefore, surgeons traveling on medical mission trips may be the only opportunity for these children to receive treatment for DDH.
Did we fulfill the medical ethical standards?
Reflecting now on my experience, I feel fairly confident that our trip helped the Ecuadorians. Teaching, both in the clinical setting and through lectures, was a primary focus of our trip. We teamed up with two local pediatric orthopedic surgeons in both the clinic and the operative suite where we exchanged common practices.
With regard to cultural integration, we were very blessed to have the assistance of Sister Anne, a local nun who built and now runs a home for those suffering from Hanson’s Disease (more commonly known as leprosy). Sister Anne and several volunteers helped with translation, organized lodging and transportation for patients, and helped us understand our interventions in light of our patients’ culture and living circumstances. Patients had follow-up with local providers and their care was discussed and documented prior to discharge. We applied appropriate technology for the region and economy, primarily using spica casts, basic plates, and k-wire. Finally, we practiced within the scope of Dr. Elizabeth Szalay’s typical practice.
Surgical interventions were only performed in patients who we felt would greatly benefit with minimal risk. Patients and their families were educated on the need for surgical intervention and possible risks both by the local physicians and again by our staff through local translators. We were providing care to the poorest in the region who otherwise could not receive this care.
And, finally, we treated all patients and family with dignity.
Preventive practices is a major void that we are working to fill. While the local surgeons were well trained, they lacked the technology and resources needed for practices that would have prevented the majority of cases we performed, such as the Ponsetti technique for clubfoot and screening for DDH using ultrasound. As we continue our relationship with Project Perfect World, these are some of the areas we can improve upon in order to improve our long-term impact on this community.
Dr. Jenna Godfrey is an orthopedic surgery resident at the University of New Mexico and a CIR Regional Vice President.