Wednesdays are famous at Kijabe Hospital as the day of the orthopaedic surgery clinic. Clinicians in other departments try not to order X-rays on Wednesdays, as the huge volume of orthopaedic patients causes terrible delays. As you approach the hospital on Wednesday mornings, a line of matatus delivers its human cargo of injured and infirm. Wheelchairs with no rubber left on the wheels screech across the road. Crude home-made crutches and walking sticks assist the more able- bodied. Strikingly sophisticated urban Somalis stride past in black burkas and elegant suits. Their rural country men are equally striking with red-dyed beards and traditional clothing. Parents carry small children with splints and bandages telling the opening lines of their story of suffering. A typical Wednesday clinic sees between 120 and 160 complex patients evaluated by the Kijabe Hospital orthopaedic team.
The severity and complexity of the patients’ problems is beyond what would typically be seen at even the most advanced referral hospital in the US. Due to the severe limits on accessibility of care, patients tend to put up with far too much and present only when the problems are very difficult to treat.
In the US, I would see a patient with a dislocated hip from an automobile accident or ski injury a few times per year. These patients are typically writhing in agony as the dislocated hip bones rub against each other and the adjacent sciatic nerve. The treatment is to urgently put the patient under anesthesia, and pull the hip back into the socket. The patient experiences immediate and lasting pain relief, and usually goes on to have no complications or further problems.
I saw a lady today who slipped in soapy water while cleaning a floor, dislocating her hip. As I flipped through her chart in the examination room, I noticed that this had happened in June. She looked pleasant and comfortable as I was talking with her. As I continued to flip through her chart, though, I couldn’t find anyplace documenting that the hip had been put back in the socket. It slowly dawned on me that she was sitting there, with a hip that had been dislocated for four months! After her injury in June, she hadn’t sought treatment for about a month, just put up with an excruciatingly painful hip. She then sought treatment at another facility, where they had tried unsuccessfully to pull her hip back in. It then took her another three months to gather the resources to make the trip to Kijabe for treatment. At this point, it will require a major surgical procedure to put her hip back in the socket, and there’s a high chance the hip has lost blood supply and will die. What would have been a brief but miserable outpatient event has turned into a life changing and potentially crippling injury. All due to poverty and lack of access to basic medical care.
This serious little girl suffers from a similar lack of access to care. After suffering a fall from a tree, this eight year old child was found not to be able to move her left arm. She was admitted to another hospital, but once discharged received no further care. Now about 6 months out from her fall, her wrist is held rigidly flexed, unable to be extended. Piecing the history together here is often challenging, partially due to language barriers, and partially due to lack of communication between clinicians and patients. I’ve noticed that the Kijabe staff takes great effort to make sure the patients are kept well informed and are encouraged to ask questions. In any event, it would appear that this little one suffered a stretch to the nerves to her arm, called a brachial plexus injury. Most of the nerves recovered, except for the one responsible for the ability to extend the wrist. Hopefully, a series of casts will allow the wrist to be stretched back in to position, and a small surgical procedure called a tendon transfer will restore near normal hand function.
The last case of the day is truly heartbreaking. An elderly woman presented with a mass on her upper arm, slowly growing for months to years. The X-ray reveals a disturbing appearance, likely representing a very large and dangerous malignancy called chondrosarcoma. We scheduled a biopsy, hoping we’re wrong. The good news would be that her shoulder has been destroyed by tuberculosis, as at least that would be treatable.
The thing that gives me hope, the reason I feel called here, is that Kijabe Orthopaedics is teaching a new generation of kind, dedicated, Christian, highly trained orthopaedic surgeons. Kenya has more than it’s share of orthopaedic problems, but the suffering is compounded by the lack of access, due to poverty and the lack of orthopaedic surgeons in the country. You could choose to say the situation is hopeless, and the suffering is overwhelming. Or you could say that this remarkable group of men and women is doing something about it, and tomorrow will see a little less suffering. I can’t tell you how privileged I feel to be a part of this team.