2018 Ghana Mission Blog by Dr. John Parker

Throughout the 2018 Operation Walk New York mission trip, Dr. John Parker will be writing about the team’s experience.

November 8, 2018

“The spinal is in. Let’s get the patient positioned.” I looked around for the hip positioner, that crucial and surprisingly complex instrument that keeps the patient stable on the bed during hip surgery. It’s hard to put a hip in straight without it.

After completing our four full surgical days late last night, we had arrived at St. Joseph Hospital this morning to break everything down, make our final rounds, and get out of Dodge. But then we learned that one of the hips we replaced yesterday had dislocated overnight, and, upon being put back in place, it came out again, suggesting that it was unstable. This is a thing: it happens. And at home, we take the patient back to the OR and reposition the cup, or lengthen the femoral component, and: Problem solved.

But here in Koforidua, the system was already dismantled, and so was the hip positioner. Our surgical equipment was already in boxes, and our big bus was iding outside the hospital. We were scheduled to depart very shortly.

“Here.” Our equipment person dropped a big black plastic box in front of me. Inside was a tangle of parts and components that vaguely resembled the hip position, but dissembled. Very completely dissembled. And I realized that reassembling the hip positioner was going to take longer than the operation. And I had no choice but to - for the first and only time in my career - put together the fricking hip positioner.

Let’s end the suspense: I got it together, we did the operation to reposition the cup and put on a longer head, the hip was stable, the patient recovered, and we made our bus in time without having to alter or delay our travel plans. Phew. But the experience drove home a couple truths.

First: Every process has a series of steps, and each step must be completed before the next can be undertaken. You can’t position the patient until you assemble the hip positioner correctly. This is true of most systems-based undertakings - surgery, flying an airplane, building a house. Learn the system, and its sequence of steps, and things will get easy.

And second: Sometimes, when you’ve got everything broken down, you unexpectedly have to put it all back together again. And you do it methodically, one simple step at a time. Maybe looking at the entire endeavor can be overwhelming. But break it down into manageable, bite-sized portions... and you can eat the whole enchilada.

The 44 members of Operation Walk Syracuse are en route back to the US. We have gone to new places, met new friends and colleagues, learned a great deal (the old-fashioned way) about the unique skeletal anatomy of the Ghanaian people, and, we hope, sprinkled some grains of goodwill over this part of the world. And we left 84 hips and knees way better than we found them. A few lives have been changed - and I’m not just talking about our patients.

It’s a tired cliché: we went somewhere and did something to help others, but in the end, it was we who benefitted most. Yawn.

But it’s all absolutely true. It’s not hyperbole to say that these trips are transformative for us. They let us view the world through a different lens, and this informs the work we do and the interaction we have back home. We are granted the enviable luxury of a formidable new perspective on what we do and what we have.

One last thing: our ranks have grown and broadened, and Operation Walk Syracuse has become Operation Walk New York. And we look forward to expanding our circle farther in the years ahead.

We at OpWalkNY would like to thank you for joining us on this trip, and for making the whole thing possible, through your interest, support and donations. As we hope you can tell, it is a remarkably good cause, one that is worthy of your support. Stay tuned for 2019, when we put the whole enchilada back together again.

November 6, 2018

When the power momentarily goes out in Operating Room 4, it seems like no big deal. The room goes a bit dark, though the windows provide some light. The suction and electrocautery machines go quiet. But we keep operating, mostly because: What other option is there? And the power typically comes back on in a few seconds. We make it work.

But that flicker of power has greater ramifications, because OR 4 is on the same breaker as the autoclaves - the enormous, modern machines that sterilize our surgical tools and equipment. And when the autoclaves go down, they require a much longer process to restart. And without those autoclaves, we are quite simply dead in the water.

We had an autoclave-related delay yesterday, and there was concern that today’s schedule might be truncated - or even cancelled - because the autoclaves would be down.

But it didn’t happen. The staff at St. Joseph Hospital in Koforidua, Ghana, pulled their boots up and kept the machines running. And today, our third of four operative days, working out of four ORs, we replaced 24 joints in 22 patients - 18 hips, including two sets of bilaterals, and 6 knees.

The experience of performing joint replacement here in Ghana is very different than at home. The patients are much younger, with an average age of around 30, and their deformities are profound - typically much, much worse than we see at home. And they come from much farther away. They get subcutaneous absorbable sutures for wound closure, as there would be no reliable way to have surgical staples removed at 10-14 days post-op, because their rural home is a 12-hour drive from Koforidua.

Then there is the issue of resources. Simply put, the most remote community hospital in the US gleams with technology in comparison to our St. Joseph’s Hospital in Koforidua. Every item in the hospital (like... EVERY item) bears a handwritten code which delineates what it is, where it belongs, and the year it was acquired. And those codes suggest that many of the items we use have been there a long, long time. It’s actually a pretty interesting sociological observation to wonder who else has sat in this chair, which is marked “SJH/THE/CHA 1987.”

But they make it work. A brief review of the surgical logbook here at SJH in Koforidua shows that they routinely perform orthopedic trauma cases - fixing broken bones which are shipped in from hours away. And hidden behind the well-used doors and windows here are serviceable surgical technology - autoclaves, lights, anesthesia machines - and a dedicated staff of medical professionals who reliably provide surgical orthopedic trauma care.

We have noticed this week that the hospital here seems to have improved notably since we first came in 2016. It’s been painted. The Snack Bar is open. It’s noticeably cleaner. And the surgical assistants who help us are capable and clearly experienced.

And if there is anything more charming and inspiring than happening upon a group of uniform-clad Ghanaian nursing student on the floors of the hospital, then I have not seen it. With their green uniforms and their broad and infectious smiles, they clearly tell a wonderful story about the future of medical care in Ghana. They’re making it work.

There has clearly been a flicker of power, and of light, here in Koforidua, and the health care machine seems to be up and running. Like so many regions of the world, Ghana has challenges. And we can’t change the world. But maybe we can help change some lives.

Thanks so much for your interest and your help. We are cranking as hard as we can to replace as many joints as possible during our brief stay.

Operation Walk happens because of you and your support. And we are immeasurably appreciative - as are our patients.

November 5, 2018

In the course of your life, you have learned the concept of force modulation. Through a process of trial and error, you have learned how hard to close a car door, how gently to open a sugar packet, how carefully to hammer in a nail, and how cautiously to pass a thread through the eye of a needle. It takes practice, practice you sometimes don’t even realize you’re doing. But anyone who has successfully obtained toothpaste from a tube knows what I’m talking about.

In orthopedics, we learn the same concept. Through a rigorous and well-governed training process, we learn how hard you can pound a hip stem into a femur, or how tightly you can turn a screw into bone. Sometimes - and this is a universal truth - we learn things the hard way. We learn to do it right by doing it wrong. But learn it, we do.

But imagine if you suddenly found yourself in a world where those rules of force modulation were suddenly inapplicable. You push a car door shut - and it barely moves. You go to open a bag of salt & vinegar potato chips, and it doesn’t open. So you pull as hard as you can AND IT STILL DOESN’T OPEN. Wait... what?

This is joint replacement surgery in Ghana. The bone we have learned to handle so carefully in the States is as hard as granite here. This is a result of genetics, and a pathological issue known as osteonecrosis - “bone death.” People with the sickle cell trait have a predilection to clotting crises, and this results in abnormally hard bone. And in some of these Ghanaian patients, the bone is literally like stone. We deplete batteries and wear down metal saw blades just trying to cut through their bones.

So the usual rules no longer apply. We have had to re-educate ourselves with respect to the amount of force we have to apply to our tools. (And - let’s be honest - educating orthopedic surgeons is no picnic the first time around, never mind the second.)

Today was the second of four surgical days. So far we have replaced 45 joints: 38 hips and 7 knees. We continue to see cases of a complexity that is almost never seen in the US. And, from this experience, we continue to learn how best to provide care for these patients.

Thank you, as always, for your attention and support.

November 3, 2018- Screening Day

It’s a hard thing to put a finger on, but part of the thrill of traveling is seeing the world through a different lens. In nations or cultures different from our own, things work differently. Road signs are different. Light switches are different. And the habits of communication are different. Experiencing these things, and figuring out how local systems work, are part of the challenge and excitement of being someplace new.

And, as a system, health care is indescribably complex. (“Who knew...?” We all knew.) And that system is always challenged to function efficiently in any culture.

So mixing these two elements together - trying to create a system that will allow the administration of a complex health care need like joint replacement, in a locale where every little thing is quite different - is a unique difficult undertaking.

Today is Screening Day. Working in four screening teams, we meet and examine about 140 patients, to assess their medical and orthopedic suitability to have a joint (or joints) replaced.

It’s on Screening Day that the exchange of information is most crucial, so this is the day where the differences between our cultures are most apparent. Communication challenges abound. Both we and the majority of the patients are all speaking mostly what we think of as English, but we commonly require the use of English-to-English translators.

And the Ghanaian voice, it seems, is commonly soft, and it’s often necessary to move in quite close to hear and understand what’s being said. In our American culture, it’s more common to step back, and speak up. This lends itself to a certain degree of cross-culture awkwardness (Except for Seth. Seth is a close talker).

Screening Day also makes an impression emotionally, when we see the pathology that these patients have been living with for so long. The easiest case of the week here is the hardest case in three months back at home. The degree of deformity and disability can be striking, and moving.

One 22-year-old presented with a dislocated right hip from a car accident, and his right leg was 10 cm shorter than his left. When asked when his injury occurred, he replied “7 years.”

Another young woman presented with two crutches and a ridiculous arthritic deformity in each hip for many years. And a broad smile. When we checked her age? 21.

In America, these extreme examples of orthopedic pathology are rarely encountered, simply because they get fixed way before they get this bad. But in Ghana, they are much more common.

Patient screening is followed by a long conference in which our entire surgical team reviews each case and discusses the appropriateness of surgery for each patient. X-rays are reviewed and patient comorbidities (malaria, sickle cell disease, hypertension, etc.) are reviewed. Surgical candidacy is narrowed down to a number that our resources can accommodate. Then a smaller team sits down and puts together the surgical schedule for the next four days.

While we screen patients, our OR prep team is working hard to create a small area of familiarity for us in the operating rooms. This is a crucial component of our success - surgically, we will do our best to play our home game. And tomorrow, as we move from screening into our first of four consecutive surgical days, running three rooms, we will pursue the actual surgeries with as much routine and normalcy as we can.

In Ghana.

As always, we thank you for your attention and support. Operation Walk works entirely because of supporters like you.