Ethiopia

ADFA Report by Tony Jeffries Ethiopia, 14th to 29th August 2010

ADFA conducted an orthopaedic visit to the Black Lion Hospital in Addis Ababa.

The Team consisted of :

Tony Jeffries, Orthopaedic Surgeon
Tim Fletcher, Orthopaedic Surgical Registrar
Evelyn Fletcher, Junior Doctor
Paul Maloney, Orthopaedic Technician
Victoria Gibson, Operating Theatre Nurse
Rhonda Milner, Photo Journalist and Registered Nurse

The visit was conducted similarly to previous orthopaedic visits. The Team involved itself in all aspects of orthopaedic management at the Black Lion Hospital in co-operation with the Orthopaedic Department of the hospital. Functions at the Black Lion were as follows :

1. Orthopaedic and Fracture Clinic.
We attended as many Clinics as possible, mainly supervising and offering advice. A large number of complex orthopaedic problems including complex fractures, non unions, mal unions, bone and joint deformity, bone tumours were seen. Clinical teaching was also carried out.

2. Ward Rounds.
The Team attended various morning ward rounds. A large number of complex problems were seen. There seemed to be a particular focus on extensive degloving and soft tissue wounds and complex open tibial fractures. Rounds were largely conducted with the junior staff who have a difficult task prioritising cases for the limited operating theatre time.

3. Operating Theatre.
A large amount of time was spent in the Operating Theatre both as the primary surgeons and assisting the Ethiopian Doctors. The condition of the Operating Theatres was similar to in 2009. The general cleanliness of the Theatres is relatively poor. The Theatre discipline is somewhat lacking in that doors and windows are often left open and there is a free flow of various staff members through the Operating Theatres. There is no intra-operative x-ray available. The general quality of instruments is still somewhat below what is required for sophisticated modern orthopaedic surgery.

One definite improvement this year was the use of low cost hardware type power tools placed in a sterile bag. The sterility of these drills is still slightly questionable. Their use certainly facilitates open reduction and internal fixation and application of external fixateurs.

Victoria Gibson worked very hard to improve the sterility and sterile technique within the Operating Theatres. She brought with her a lot of sterile disposable equipment which made a huge difference, particularly with dressings.

The opening of the Operating Theatres on Saturdays and Sundays, which is being financed by ADFA, has made a very significant difference to the number of cases which can be performed. A large number of cases were performed during our two week visit. The presence of two surgeons, ie Tony Jeffries and Tim Fletcher, certainly allowed us to perform many more cases than previously. The procedures we were involved in included the following :

  1. Debridement and external fixation of open tibial fractures [5]
  2. Open reduction and internal fixation of various upper limb fractures including a fracture of the proximal humerus, displaced intercondylar fracture of the right distal humerus and a mal union of a supracondylar humeral fracture.
  3. Debridement and external fixation of severe upper limb gunshot wounds [4].
  4. Open procedures for anterior shoulder instability [2]
  5. Open reduction, internal fixation of closed femoral and tibial fractures including use of the sign nail.
  6. Upper limb amputations for gangrene [2]

4. Morning X-ray Meetings and Thursday Resident Teaching.
The Team attended all the morning x-ray meetings and contributed to the discussion of the various x-rays presented. Presentations were given by Tim Fletcher on basic fracture management and Tony Jeffries on adhesive capsulitis of the shoulder and examination of the shoulder.

5. Orthopaedic Technician, Mr Paul Maloney worked extensively in the Operating Theatre. He was responsible for cataloguing and improving the orthopaedic equipment.

6. Operating Theatre Nurse Victoria Gibson, spent considerable time again teaching the Operating Theatre Nurses. She also reviewed the plans for the new Operating Theatres.

7. Photo Journalist, Rhonda Milner, attended the ward rounds, clinics and operating sessions taking hundreds of photographs of the patients and the teams work. She is also preparing an article for Australian Doctor Magazine.

8. Visits to other hospitals.
The Team undertook a visit to the Alert Leprosy Hospital. We were again privileged to meet Dr Solomon and to be shown over the facilities.

Dr Woubalem has indicated that the Orthopaedic Residents at the Back Lion Hospital will be soon undertaking a six week rotation to the Alert Hospital which, no doubt, will be of considerable value to them in their training.

CONCLUSION :

I am sure that this ADFA visit to the Black Lion Hospital again made a significant contribution to orthopaedics in Addis Ababa. All members of the Team worked very hard for the full duration of the visit including operating on the weekend days. All members of the Team greatly enjoyed the visit and are certainly keen to return to the Black Lion again next year.

I sincerely thank ADFA and their sponsors for the opportunity and we all look forward to returning in 2011.

Yours faithfully,

A O JEFFRIES
ORTHOPAEDIC SURGEON

Visit to Ethiopia & Somaliland, 8th March 2010 to 21st March 2010

Graham Forward - Cathlin Hamlin

Travelling from Perth, Dr Graham Forward met up with Dr Tim Keenan, orthopaedic surgeon in Dubai. Airfares had been provided for this visit by the Emirates Foundation with much gratitude from Australian Doctors for Africa.

We continued onto Ethiopia and on arrival were assisted with customs clearance of a considerable amount of equipment by Dr Woubelam, head of department of the Black Lion Hospital in Addis Ababa.

We immediately attended the afternoon referral clinic in the Orthopaedic Department at the Black Lion Hospital.

The pattern of subsequent days was to attend the excellent 8.00am trauma meeting and then to involve ourselves heavily in the subsequent fracture clinics, referral clinics, talipes referral clinics, theatre operating sessions and teaching sessions with the residents. Dr Fintan Shannon was visiting at the same time and we were careful to coordinate our involvement with him. This led to the suggestion of a website – Friends of Black Lion Orthopaedics – to assist international communication.

The team work amongst the consultants at the Orthopaedic Department at the Black Lion Hospital remains excellent thanks to the leadership of Dr Woubelam. It is perhaps understandable that the opportunity is taken to work on committee meetings and other pressing administration business when visitors are present to shoulder some of the clinical load.

Graham Forward - Baby 1

There are eight new first year residents who have joined the orthopaedic programme and the quality of these residents is the best for some long time. In particular there are four who represent outstanding potential and the others are sound. This represents a wonderful opportunity to train young orthopaedic surgeons in the correct way over the next four years.

The small theatre adjacent to the emergency department was visited and this is planned to be handed over to the orthopaedic department with anaesthetic cover for debridement under anaesthesia, simple manipulations and reduction of dislocations. This should make a big difference to the quality of the debridement which is carried out on open fractures.

The next large project is to convert the available space in the new rehabilitation block to three orthopaedic theatres. This represents a significant capital expenditure but will give the orthopaedic department control of clean/sterile theatres with adequate operating time. For the interim the Saturday operating sessions are going well with the generous support of the orthopaedic consultants and residents.

There is a continued usage of small fragment plates and screws and ADFA has placed an order through an Indian supplier for direct delivery of these and replacement of the hemi-arthroplasties which have been used.

Graham Forward - Baby 2

The next visit of Australian Doctors for Africa has been scheduled for 26th August 2010 which will be led by Dr Tony Jeffries. He will take Dr Tim Fletcher, orthopaedic registrar as well as Paul Maloney, orthopaedic technician and Victoria Gibson and another experienced theatre nurse. The main effort here will be to work on upper limb surgery and also progress the knowledge of sterile technique in theatre by the nurses, residents and consultants.

During this visit Graham Forward travelled via Djibouti to Hargeisa in Somaliland. The purpose of this was to make preparations with Dr Ereg, the Dean of the Hargeisa Medical School for the visit of teaching doctors from Australia. The Edna Aden Hospital was visited to help clarify the dwindling water supply and make plans for possible assistance from Australia. A comprehensive visit to the Hargeisa Group Hospital, the main public hospital for Somaliland, was made. A commitment was given for Australian Doctors for Africa to work to renovate the laundry room with the assistance of the Taakulo Somaliland Community. A memorandum of understanding has been agreed to with TSC and ADFA for the assistance on the ground in Hargeisa to renovate this laundry. Hopefully this will lead to a more significant and longstanding undertaking in the future.

Hargeisa Group Hospital would benefit from a planned orthopaedic visit and the supply of small fragment sets, circlage wires and other instruments to allow relatively simple fractures to be dealt with. At this stage no date has been fixed for such a visit but Australian Doctors for Africa will now search for a suitable orthopaedic surgeon to make that visit and couple this with a teaching visit to the University of Hargeisa Medical School.

Overall this was a very productive and positive trip which has seen progress made at the Black Lion Hospital and concrete plans set for the future.



Graham Forward
29th March 2010

Assessment of Black Lion Orthopaedic Departments, July 2008

Map Of Africa - Ethiopia

Background

Thank you to Dr Paul Baxt from Orthopaedics Overseas for coming to Addis at the same time as ADFA to find a way forward for overseas volunteers at the Black Lion. He will make his own report but broadly we are in agreement.

The role of visitors in the past had become counterproductive for both Black Lion staff and for the visitors as testified to by many carefully constructed negative reports. To the point where many individuals and organisations have removed their commitment to service at the Black Lion.

There has been sufficient improvement in the attitude of the staff, the support of the university and the effectiveness of the government’s BPR programme to give optimism. The Black Lion is under funded and overwhelmed but remains the largest referral hospital in Ethiopia and the main teaching hospital providing a multiplier effect for visitors efforts to train residents.

This current combined visit of Orthopaedics Overseas and Australian Doctors for Africa has resulted in the following guidelines, objectives and means which encourage visitors to return to the Black Lion.

Guidelines

Proposal

  1. It is necessary to coordinate the efforts of a large number of visitors and organisations from UK, USA, Australian, Korea, China, Sweden and other countries. I would suggest a combined effort by 6 – 8 individuals each prepared to make 2 visits of 2 – 4 weeks over the next 18 – 24 months, followed by a progress review. This group could communicate with each other, and their umbrella organisations, to ensure the visitors programme is cohesive and constructive. There would still be room for other, ad hoc visitors but they would be requested to fit in with the framework programme.
  2. To do this requires a blueprint based on the concept of a number of projects which are sequentially accomplished. The blueprint below has been developed in consultation with all the orthopaedic consultants, the Medical Director, the Office of the Dean, Orthopaedics Overseas directly with Dr Paul Baxt, W.O.C. indirectly by email and telephone with Dr Dalton Boot and the Korean military visiting surgeon.
  3. The aims of the core group of repeat visitors is to support and improve the teaching programme. To support and consolidate the gains made so far, for example the talipes clinic, Sign nail introduction; the cohesiveness and commitment of the consultants group to work towards the achievable objectives, one by one, on a project basis.

Positives

University

There has been an increased commitment from the government and university with World Bank assistance. There is a new orthopaedic block (construction completed), there are ideas to give financial incentives including rights of private practice to the consultants, there is recognition from the Dean and Medical Director of the significance of orthopaedic surgery.

Department of Orthopaedics

There is a larger and more committed group of seniors than before, young and aware of the benefits of private practice, but willing to commit to the Black Lion. Leadership of the Deputy Head of Department Dr Bahiru is visionary and inclusive and the team around him is supportive. The other consultants now are

Dr Daniel with an interest in bone tumours and trauma
Dr Biruk general trauma management, teaching arthroscopy
Dr Elias Sign nail, surgical management of fractures
Dr ?, Korean military visiting consultant, trauma
Dr Wobalem talipes clinic pioneer, currently in the USA, status uncertain. We need to encourage her to return to Black Lion.

Residents

Two residents have recently had their training time extended following the recent examinations and this has had a positive effect on the morale of some and a destructive effect on others who are openly critical of at least one of the consultants. Of the 7 residents, 4 have excellent potential. (They shall be anonymous to ensure fair treatment off all)

Programme Organisation

The weekly orthopaedic programme is very well organised and adhered to. Beginning with the 8.00am morning meeting (followed by a short, working coffee stop by all the consultants) the staff are divided into two groups. The schedule is publicised and a copy is below.

Teaching Programme

The Thursday afternoon teaching programme is outlined well in advance, is well attended for 3 – 4 hours and is the backbone of a comprehensive orthopaedic course.

Special Meetings

The weekly clinical case conferences are well organised and provide an excellent structured session for visitors to teach and learn.

The Thursday morning radiology meeting is top class (I suggest volunteers read up about bone tumour differential diagnosis and management for this meeting).

Ward Rounds

These are conducted twice weekly by each group and are well attended by consultants, residents, nursing staff, physiotherapist, students and visitors.

Referral Clinics and Fracture Clinics

The number of patients, 60 per clinic by 9 clinics per week are overwhelming the staff. During my stay attendance by seniors was good with one senior in the centre of the room overseeing 3 or 4 residents consulting with patients in the corners.

Certain Areas of Orthopaedic Surgery

Blueprint

The idea is that a volunteer should choose an achievable objective as a project during his two visits over the next two years, or assist another volunteer with the project he has chosen. Work towards the completion of that project so the Black Lion is able to bring another area of competence within its group.

At the same time be aware of the other projects under way and provide assistance and support. Consult with the other six or eight volunteers about progress, problems and decision making. Keep checking with the Black Lion consultants that we are on the right track.

Achievable Objectives and May How to Achieve Them

  1. Hip Hemiarthroplasties
    Problem:
    Vertical, unstable intracapsular hip fractures are common. Following an inventory of 40 prosthesis on hand, only two fall in the range 40 – 50mm diameter. Most common Ethiopian acetabular sizes are 42/44 for women, 46/48/50 for men. The surgeons are able to operate either Hardinge or posterior approach but need some more training.

    Pathway:
    - Identify a supplier of suitable hemiarthroplasty – (non-cemented).
    - If Indian ensure metallurgical testing.
    - Arrange funding for an initial order of 100 of the above sizes.
    - Ask Dr Bahiru to place the order directly, arrange transport, customs clearances and taxes.
    - Have the supplier invoice the funding source directly.
    - Set up an inventory system with the chief nurse (Workeye) to enable 3 monthly restocking.
  2. Intertrochanteric Hip Fractures
    Problem:
    Treated at the moment with angled blade plates introduced ‘blind’ or with traction and subsequent blocking of beds and shortening or malunion. The two C-arms in theatre cannot be repaired despite the best efforts of USA, British, Australian and Ethiopian surgeons.

    Pathway:
    - Authorise the Department of Orthopaedic to discard the broken C-arms and purchase a C-arm. (Paul Baxt has made initial enquiries; 2 machines from China and Japan are distributed in Ethiopia by AGHAS and KAM Produces, costings approx $US60,000.00 with variable maintenance and service commitments.)
    - Rehabilitate the fracture table which will require some new fittings, screws, clamps and service of mechanisms.
    - Assess the inventory of available hip screw devices and guide wires, reamers, T handles.
    - Order replacement and additional instruments to make up two complete sets of spares.
    - Find a donor of 4 hole, 135˚ plates and lag screws ranging from 70 – 90 mm approx 100. Or
    - Locate funds to purchase through a supplier (Indian or otherwise) and receive invoice directly.
    - Communicate with Dr Bahiru regarding transport, customs clearance, taxes and duty.
    - Pay supplier and send the plates and screws.
    - Visit the Black Lion to train the residents and consultants in the use of the C-arm, fracture table and hip screws.
    - Work with the theatre head nurse to maintain inventory of appliances to enable 3 monthly re-ordering.
  3. Improve the Teaching Problem:
    The teaching programme is fairly comprehensive but could be improved. The sessions are well attended and levels of interest are high. More interest is shown and more is known about high-tech subjects than about basic history and clinical examination. Few pocket text books/handy guides/palm pilots are carried.

    Pathway:
    - Work with Dr Elias and other interested parties to see if he would appreciate an evaluation of the Residents’ training curriculum.
    - Perhaps integrate the existing curriculum with one such as used by the Western Australian Bone School.
    - Schedule the Thursday afternoon topics 1 year in advance.
    - Allocate visiting surgeons to the topics of their expertise or ask visitors to read up about the topics planned for presentation during their visit.
    - Encourage Ethiopian consultants to actively participate at every meeting whether visitors are present or not.
    - Return repeatedly to History and Clinical Examination with Look/Feel/Move at every session.
    - Obtain and distribute an agreed basic orthopaedic pocket text (e.g. Apley;Adams) and ensure all residents and consultants carry them and refer to them.
    - Support and build up the Consultant’s efforts to teach the Residents.
    - Power point projector and screen are available so prepared
    presentations can be shown if you take thumb drive, CD or your own laptop. - Institute a cash prize for the best teaching consultant and resident every six months.
  4. Supracondylar Elbow Fractures
    Problem:
    A repeated criticism by many volunteers over the years and an area for concern of the Black Lion seniors is the large number of poor outcomes from children’s supracondylar fracture management.

    It is time for a revamp of the protocol and management of these fractures.
    Pathway:
    - Develop an algorithm for management that includes closed reduction and backslab/open reduction and wire stabilisation/90/90 traction.
    - Work with Dr Bahiru and the other consultants to achieve outpatient anaesthetic facilities and x-ray.
    - Recruit a resident to follow up and document the progress of all supracondylar fractures at the Black Lion and present this to a meeting, e.g. East African Surgical Association.
    - Identify and acquire resources needed to achieve acceptable outcomes.
    - Develop a monitoring system/separate clinic.
    - Expand into a community education programme so that these fractures present early and are not treated with tight tourniquet resulting in (common) forearm ischaemia.
    - Institute a prize for the consultant and resident who achieve the best results each year.
  5. Sort Out the Orthopaedic Side Room Equipment
    Problem:
    There are massive numbers of plates, screws, instruments of various vintages, manufacturers, countries of origin in the orthopaedic side room. These are jumbled, boxed, dirty, but much is of practical use.

    Pathway:
    - Find someone to spend time with Workeye and the residents and organise, sort, classify. The volunteer could do this (I spent four days with two of the residents) or take an orthopaedic theatre nurse or orthopaedic technician (I have someone in mind who could join you in Addis).
    - Classify into:
    • Useful sets: Make into complete sets, put into trays, label the sets, store in easy access, labelled work cupboard.
    • Useful spares/back up – Label and put on the shelf below.
    • Maybe useful - Label and put into the back store room.
    • Useless/dangerous/war relic – Consult with the Orthopaedic Chief (Dr Bahiru) and throw in the rubbish bin.
    - Continue to work on the inventory system.
    - Develop a re-order system for commonly used equipment.
    - Make an update to the list of equipment needed.
    - Plan for laptop storage of inventory/re-ordering.
    - Include the consultants/residents in the process of sorting/classifying, using the time to teach them about plates/screws/taps etc.
    - Think about running an AO basic course for seniors/residents and key nurses in Addis.
  6. External Fixateurs
    Problem:
    There are a large number of Grade III open tibial fractures and many other fractures presenting late, open and infected for which ex-fix is indicated. The sets regularly are disrupted because rural patients do not return for review and the ex-fix and pieces are lost. There are however two new and complete ex-fix sets (Aesculap Uniplanar system; AO 1st Generation ex-fix).

    Pathway:
    Obtain/purchase more pins, connectors, carbon rods, spacers for the Aesculap ex-fix system and take them to Addis.
    Teach the seniors and residents the principles of ex-fix fracture management.
    - Develop wall charts, laminated to reinforce the principles.
    Work with Admin and the doctors to develop a deposit system/tracking system for ex-fix.
    Don’t worry about losing some to the rural areas. Get more pins and rods and connectors.
    Develop a relationship with Aesculap or AO for ongoing donation of ex-fix.
    Think about needs for Ilizarov, training and equipment.
    Develop ex-fix inventory system.
  7. Osteotomy Staple Set
    Problem:
    If they have staples and an impactor set, I couldn’t find it. Need has been expressed for staples for upper tibial Osteotomy and triple arthrodesis.

    Pathway:
    - Find a staple impactor and removal set and a good supply of large, medium and small staples (20/30 or each) and take to Addis in your suitcase.
    - Show selected consultants and residents how to use.
    - Label the set and the spares.
    - Begin an inventory for replacement.
    - Lobby for an orthopaedic technician position to be appointed to maintain/organise and inventory and re-order.

  8. Physical Environment
    Problem:
    The WOC apartment is well located and spacious. The approach and stairwell are tawdry, the interior is modest. There are no Ethiopian funds to refurbish it. Geoffrey Walker stays there and surely others will want to if it could be upgraded to 3/4star internal status.

    Pathway:
    - Below is the list of items suggested following a recent survey by myself and Dr Bahiru.
    - Dr Biruk has taken it upon himself to coordinate improvements. Plumbing, tiling, plastering, electrics need to be done in Addis before the visitor arrives and the tradesmen paid directly upon arrival.
    - Raise funds, approx $US10,000.00 and take to Addis for payment of tradesmen and purchase, by the visitor himself of furniture and fittings with the help of Biruk.
    - Ensure housekeeping continues, attend to security.
    - Help Yimenashu in the orthopaedic office maintain bookings register.
    - Items suggested for improvement of WOC apartment.

    Living Room
    Satellite dish/TV
    Rug for floor
    Comfortable couch/chair
    Small bookcase

    Bedroom
    One large bed – remove two single beds
    Sheets (large)
    Pillows x 4

    Shower Room
    Painting/tiling/light

    Toilet
    New seat

    Kitchen
    New plates
    Cutlery
    Gas stove
    Microwave
    Ironing board

    - Take some ‘stick on’ coat hooks for the walls in theatre change rooms.

  9. Furnish the New Theatres
    Problem:
    In the new orthopaedic building there is space for two dedicated orthopaedic theatres, the funding for which is being negotiated. Expected cost Birr 5 million = $US600,000.

    The wards, fracture clinic and paediatric clinics all need furnishing and the theatre budget is unlikely to cover this.

    Pathway:
    The Australian Doctors for Africa have undertaken to obtain equipment and send a container to the Black Lion with the hospital arranging customs clearance, import duty payment and receipt and disbursement of the contents. Requested items are:
    Hydraulic hospital beds
    Mattresses
    Sheets/pillows
    Knee extension splints (Richards)
    Plaster bowls, cutters, spreaders, plaster saw
    Plaster trolleys x 2
    Wheelchairs
    POP (5cm/10cm/20cm) and padding underlay (Velband/Webril)
    Paediatric hospital beds

  10. Ancillary Orthopaedic Training
    Problem:
    There is only one plaster of Paris technician.
    There is no orthopaedic technician to sharpen, maintain, organise equipment in theatre.
    The main orthopaedic theatre nurse is excellent but is overworked and needs help to train the other theatre nurses.
    The orthopaedic physiotherapists are inexperienced.

    Pathway:
    - Future visits by orthopaedic surgeons could consider taking one of the above people to support and train Ethiopian staff.
    - Selected individuals from the Black Lion could be sponsored for short courses in India, Australia, the UK or the US for specific training. (In general I am not in favour of prolonged absences by staff and suggest 4 – 6 weeks as a maximum)
  11. Arthroscopy
    Problem:
    The single arthroscopy trolley functions well but has no back up for electrical/optical/mechanical failure. The staff have yet to have sufficient numbers of cases to achieve triangulation or technical competence. The instruments for meniscectomy could do with some additions.

    Overall, the major work of the Black Lion is as a trauma and neoplasia referral facility and perhaps arthroscopy is not the main priority at the moment.

    Pathway:
    Any individual interested in promoting arthroscopy at the Black Lion should at least take:
    Giving sets to increase fluid flow.
    Suitable tourniquets for leg with a hand pump, functional valves and pressure gauge.
    Supporting knee brace to allow valgus/varus strain.
    30˚ up-biting duck-bill cutters for medial meniscectomy.
    Knee model for arthroscopy teaching and triangulation skills.

Ethiopia 2007

During July 2007 Dr Tim Keenan visited the Black Lion Hospital in Addis Ababa. Tim carried out operating sessions and attended ward rounds with the resident staff at Tikur Ambessa (Black Lion Hospital).

In particular arthroscopic surgery was carried out requiring repair and assembling of the arthroscopic equipment which had previously been donated by another organisation to the hospital.

Ongoing meetings and discussions were had with Dr Tezera, Head of the Department of Orthopaedics regarding the organisation of the orthopaedic services. Tim identified needs which can be directly addressed in synchronisation with other voluntary organisations who help out with orthopaedics in Ethiopia.

There are some good young orthopaedic surgeons, notably Dr Elias and Dr Biruk who may be suitable for training in the use of Sign Nail. Dr Graham Forward and Dr Tim Keenan had previously attended a Sign Nail conference to progress the idea of introducing this device for fixing long bone fractures in Ethiopia.

In Addis Abab there are some concrete suggestions as to how Australian Doctors for Africa can assist and the process of working through these with Dr Tezera is underway.