Report from Operation Walk 2016: Dr. Miguel Arango and Dr. Bethany Oeming (PGY2) share insights from their recent trip to Ecuador

I had the pleasure of taking part in the Operation Walk mission this year to Cuenca, Ecuador from April 7th-14th. This is a short summary of my experience working at the Santa Ines Hospital, a private hospital with approximately 150 beds located in the city of Cuenca.

Operation Walk is a non-profit volunteer medical organization that provides total joint replacement surgery to patients living in Ecuador and Guatemala with advanced and severe osteoarthritis that don't have access to specialized surgical care locally. My mentor and primary supervisor on the trip was Dr. Miguel Arango, who has been an integral member of Operation Walk since it began.

The surgeries are often complex and challenging procedures to treat developmental dysplasia of the hip (DDH), a condition which in Canada is often diagnosed and treated much earlier in a patient’s life, with excellent prognosis for a normal hip joint. Unfortunately, in developing countries such as Ecuador, this condition often goes untreated and undiagnosed which results in osteoarthritis, significant hip deformities, leg length discrepancies and often disabling pain. Interestingly, one of the major causes of DDH can be attributed to the way in which mothers swaddle their babies from birth with the hips and knees in extension. This can cause joint dislocation and the formation of a pseudo hip joint higher up on the pelvis (see first picture below).

At the start of the trip, we began with a clinic to identify patients who would most benefit from surgical procedures. The patients were pre-screened by a local physician, Dr. Manuel, who was also a major part of the mission. This clinic ran in much the way our pre-admission clinics do at home, with the addition of translators and an absence of pre-operative testing. We were lucky if we had a Complete Blood Count and therefore relied on history and physical exam to exclude any patients with major comorbidities.

One patient in her mid-70's had to be turned down as she was extremely weak and deconditioned, wheelchair bound, and likely had an undiagnosed inflammatory arthritis condition. She could not flex/extend her cervical spine, had significant scoliosis of the lumbar spine and had other clinical findings consistent with a rheumatoid arthritis picture. In discussion with the surgical team, we had to make the decision not to offer this lady an operation for her painful hip given the lack of resources (including the potential requirement for ICU post-operatively), potential for difficult intubation and/or spinal technique, and the fact that we were leaving in 6 days and may have trouble with post-operative complications. This was a learning opportunity for me with respect to patient selection within a limited resource setting.

By the end of the afternoon, we had selected our patients (3 patients per OR team per day for 4 days). Next was organizing all our anesthesia supplies for work the next day. Quickly I learned that we had a number of items that had been left behind. These included medications such as phenylephrine, rocuronium, succinylcholine, atropine, glycopyrrolate and ephedrine. We also had only one face mask and two extra circuits. Fortunately, we were able to purchase medications from the local pharmacy to fill in the gaps. They did not carry phenylephrine, however, so we had to substitute it with ephedrine. I was nervous about this in particular because I am used to using phenylephrine to treat spinal-anesthetic related hypotension. We also had to make sure we had enough midazolam, propofol, tranexamic acid and 0.5% bupivacaine for the 4 days. I have never had to work in a setting with limited resources, and I learned first hand that this situation required an even greater focus on patient safety.

Getting into the operating rooms, there were a number of things I noticed. First off, the anesthesia machines were different in every OR and much older models. There was no backup oxygen supply. There was no scavenging system for the inhalational agents (sevoflurane and desflurane). There was only one suction supply which was being used by the surgical team. In the event we were to need urgent suction, we had to come up with a plan to quickly alert the surgical team and switch the suction onto a Yankaur for our use. I had to think and plan in a way that would not normally have been required at home.

There were two operating teams. The London team consisted of the head of Orthopedics in London, Dr. Jamie Howard, his fellow Dr. Steve Preston, and 4th year resident Dr. Erin Donohue. The other team was from Lima, Ohio and was lead by Dr. Jim Patterson. The anesthesiologist from Ohio was Dr. Paul Schweiller. I was the only Anesthesiology resident on the trip, which was to my benefit as I got to do the spinal procedures for both operating rooms. Overall, we performed 25 Total Hip Arthroplasties (many of which included shortening osteotomies) and one femur fracture repair. I completed a total of 24 spinals in four days.

I worked closely with the two anesthesiologists Dr. Schweiller and Dr. Arango. Dr. Schweiller works at a private orthopedic hospital in Lima, Ohio and he does all of the regional blocks and spinals working alongside Nurse Anesthetists. He was a fabulous teacher and I learned a lot from him. You both know Miguel, of course, and he was an exceptional mentor throughout the trip.

One of the memorable cases on the second day was that of a complicated total hip arthroplasty with shortening osteotomy who developed hemodynamic instability following bleeding. A large vein had been transected and the surgical clips were too small to contain it. The patient lost around 1L of blood and began to get hypotensive, tachycardia, and restless. Given the ongoing attempts by the surgical team to control bleeding, we had to act quickly and convert to a general anesthetic. As the patient was in the lateral position, I intubated for the first time in this position. We had to start a second large bore IV and call for blood. Blood products were an interesting aspect of the trip as well. Prior to coming into hospital, patient's had to get family members to donate blood and they each came with one unit of whole blood. If more was needed, the process needed to be repeated and it could take up to an hour to get more blood. We therefore decided early to ask for this to be arranged.

Overall, this trip was an invaluable experience in teamwork, resource management, working with translators and dealing with language barriers, practicing medicine in a developing country, and learning from a dedicated team of nurses, nurse practitioners, general practitioners, surgeons, physiotherapists, pedorthists, and volunteers. Not to mention an excellent way to practice my spinals!

The patients themselves were some of the most memorable people I have ever encountered. It was an emotional last day wishing them the best with their recovery and saying goodbye. They were so grateful and expressed such sincere gratitude for the opportunity to be able to walk again. Operation Walk is an incredible opportunity for anesthesia residents to get involved with global health initiatives and I am grateful to Dr. Miguel Arango and the department for giving me the chance to be a part of the 2016 team. If you would like more information or have any questions, please don't hesitate to ask!

Sincerely,

Bethany