First, Do No Harm: NWOS Medical Missions
Sometimes the best help is to teach someone to help others
While most people see an orthopedic surgeon for fractures, sprains, joint replacements, and sports injuries, this is only a small portion of the skills and knowledge each orthopedist carries with them after years of advanced education, countless hours of continuing education and years of surgical practice. Orthopedic surgeons treat congenital conditions, diseases and traumatic injuries as a result of car accidents, natural disasters, violence and conflict.
Thankfully, most of us will never have to experience a devastating natural disaster or war in our region, but several of the doctors at Northwest Orthopedic Specialists travel to developing countries on medical missions to treat patients after earthquakes, cyclones, fires, terrorism and during times of humanitarian crisis.
There are many considerations when planning a medical mission. Time away from the office and leaving patients is a big concern. These busy surgeons could easily maintain their daily routine in the safety of Spokane, but they know this journey will be life-changing — both for those they touch and themselves. NWOS patients are very understanding and encouraging when scheduling with a surgeon on a medical mission, knowing their doctor is helping other patients in remote areas — which helps everyone feel like they are making a difference.
For nearly 20 years, surgeons from Northwest Orthopedic Specialists have traveled to developing countries to provide medical relief in humanitarian, disaster and conflict situations in addition to teaching in-country doctors. Each of these settings has a unique set of expectations, traditions, cultural requirements, medical obstacles, language barriers and politics. NWOS doctors become unofficial ambassadors of goodwill from the United States and strive to help where they can.
Dr. Jonathan P. Keeve and Dr. A. Kirk Reichard have traveled on separate missions to many countries including Vietnam, Bhutan, Myanmar, Haiti and Panama. While there, they used their unparalleled skill set to treat traumatic, debilitating and infectious injuries caused by earthquakes, war and remnant IEDs, motor vehicles, and many others. In these countries, Dr. Keeve and Dr. Reichard each have had to decide if doing something will cause more harm than good for the patient. Will treating this cause a more significant problem? Is this something doctors in-country can continue to treat? These questions plague each new and unexpected case. Sometimes, a patient presents with a rare condition the doctors have never seen before but must still decide how to treat. Above all, they adhere to Hippocratic Oath "to abstain from doing harm" or, “first, do no harm.
Arriving doctors find a host of issues including the volume of patients, range of cases, evaluation, triage, transport, stabilization, definitive care, technical limitations and rehabilitation. Providing care and teaching medical procedures that are both culturally appropriate and sustainable are a top priority. Doctors often work with inadequate tools and make do with what is on hand. Even when supplies are donated, the equipment may not fit the need when it arises. Fractures, sutures, and injuries requiring surgery are common. Many injuries have been untreated for weeks before the patient sees a doctor.
For patients, traveling to a hospital is often difficult and may take days of walking or driving. Once there, it may be impossible to find an orthopedist. For example, in Bhutan, there is one orthopedist for the entire country of 700,000 people. Orthopedic care is so limited that 50 people can quickly line up to see a visiting orthopedist.
A simple infection in these regions, treatable in the United States with antibiotics, can be devastating to people in remote locations. NWOS doctors know that treating one individual, especially the family breadwinner, has a ripple effect and may have life-saving implications for the other members of his or her family.
Those on medical missions give up the comforts of home and adapt to new foods, climate and physical challenges. Working in extreme heat is not uncommon. Personal safety is also a concern, as it was in January 2010 for Dr. Keeve in a riot-filled and destroyed Haiti after the earthquake that killed over 200,000.
In Haiti, much of the care occurred on the USNS Comfort, a 900-foot long 1,000-bed floating hospital in a converted oil tanker. The ship was slow to move and took ten days to reach Haiti from the United States. 140 agencies rushed in to provide care which was uncoordinated, often overlapping and inefficient. Without a central command center, relief efforts are often haphazard and temporary leaving the community with additional problems and needs, albeit different than the initial need.
The Comfort’s only orthopedist carried a caseload of 450 patients. A daunting task. There were so many injured that a helicopter carrying them landed on the ship every 3-5 minutes. Three weeks after the earthquake, Dr. Keeve got an urgent call and was brought on board, along with nine other orthopedic trauma surgeons, to treat severe injuries often complicated by delayed treatment.
Battambang, Cambodia (2017)
Four million unexploded landmines from three decades of war litter the Cambodian landscape. These remnants create horrific injuries. Cambodia has one of the highest rates of amputees in the world. Dr. Keeve served in a hospital for landmine victims and taught surgery. Adaptability is important. What is sized to the average American is oversize to a Cambodian. Gloves and gowns are too small for visiting doctors. Technology is limited, and language barriers pose a problem. Although English is the universal language of medicine, drawings and diagrams are still required to break through the language barriers and communicate. Through it all, the tenacity and determination of all doctors involved overcame barriers and provided specialized care which would normally be unavailable to patients in the region.
Panama City, Panama (2018)
Dr. Reichard knew that many people in Panama with painful degenerative hip and knee conditions needed his help. He joined the team from Operation Walk USA in April 2018 to provide that care at Hospital Santo Thomás, the largest public hospital in Panama City. The group shipped over 400 boxes of supplies to Panama. It was a whirlwind of a trip and indeed “baptism by fire.” Dr. Reichard worked at a fast pace to do 60 joint replacements in three days using donated equipment. At one point, he did 12 surgeries in one hour.
The heat and humidity drenched his scrubs and buckets caught the many areas where rain seeped through the roof. Blood loss was a primary concern. Thankfully, Dr. Reichard had access to tranexamic acid which reduced the need for blood transfusions during hip and knee replacements. Previously, 75% of patients needed a blood transfusion. Use of tranexamic acid decreased potential other complications that could delay the patient’s recovery. Pain medication was scarce, but his patient’s resilience and resolve were phenomenal.
The Work Continues
Several groups in the United States coordinate medical missions. Dr. Keeve and Dr. Reichard have both done work with Operation Walk Virginia and others. If you are interested in learning more, please see the resources at the end of this section.
Dr. Keeve works with SIGN Fracture Care International is based in Richland, Washington. Dr. Lewis J. Zirkle, the founder of SIGN, treated U.S. soldiers and native Vietnamese as a corpsman during the war and made it his mission to provide fracture care to developing countries. SIGN manufactures implants and equipment specifically for medical missions and includes training and follow-up.
Medical care available in the U.S. is starkly different than in developing countries — as are the medical conditions and severity of injuries of the residents. Many have lived with their debilitating condition for years. The gratitude of patients helped through these programs is immense. Doctors leave the country with an overwhelming sense it has changed the lives of those they touched — and their life as well. Surgeons are pushed to perform in challenging circumstances and must do a lot more with less. Beyond it all, they always remember to first, do no harm.