Twenty-six percent of us volunteer to mentor youth, raise funds, distribute food or offer our professional skills. Two states lead the country in this regard—Minnesota with 37% of its citizens volunteering (#1) and Utah where each volunteer gives 54.5 hours of their time annually (#1).
Then there are orthopedic surgeons.
Since we started writing OTW, we’ve had the pleasure and honor to tell the stories of close to a hundred individual physicians, surgeons, nurses and techs who deliver volunteer surgical and other musculoskeletal care. No matter how complex the problem or rudimentary the operating theater, we’ve learned that hundreds of your colleagues have answered the call. Orthopedists will be there.
The percentage of orthopedists who volunteer their skills, we’re certain, is higher than the national volunteerism average. At the University of Pennsylvania, for example, of the many surgeons we know, more than half volunteer routinely, quietly and profoundly.
Like Dr. Vincent Arlet, Chief of Orthopaedic Spine Services at the University of Pennsylvania.
Two or three times a year Dr. Arlet leaves Philadelphia to go to the 59-year-old Princess Elizabeth Center for Handicapped Children in Port of Spain, Trinidad. There he joins Dr. David Toby, an orthopedic surgeon from Trinidad who’s been heading up the scoliosis program for the past 25 years. “When he asked me to get involved, I jumped at the chance, and have been working ever since in association with the Foundation of Orthopaedics and Complex Spine (F.O.C.O.S).” For free. As a volunteer.
The most exciting thing, says Dr. Arlet, is that he can make a concrete and lasting difference in the lives of these patients.
The scoliosis curve I see in Trinidad is so severe that I know that if I don’t go, they will have no one to take care of them. Dr. Toby does his best, but he is the only spinal deformity surgeon on the island, and as such he gets referrals from all over the West Indies. These deformities are primarily kyphoscoliosis with a Cobb angle measure of 90 degrees or more…and they require two surgeons in the operating room.
Dr. Arlet, who is committed to this project for life, describes the logistics: “We spend about six days there, four of which are in the OR. Trip dates are decided during the preceding visit to make sure that all members of the team will be available; we select patients for the next surgeries during the clinic preceding the next visit. It is challenging to prioritize the patients and surgeries… getting patients ready for the surgery is another issue that must be dealt with efficiently.”
Prepping for these massive operations requires the talents of other skilled specialists. “Dr. Rodney Benjamin, our anesthesiologist, is trained in total intravenous anesthesia, which is necessary during such complex spinal deformities in order to achieve perfect spinal cord monitoring. We also have an electrophysiology technician and OR nurses. One of these nurses—Geeta Pollard—traveled to the U.S. three years ago and spent six weeks with us at The University of Virginia (UVA) to observe nursing and OR techniques involved in complex spine surgery.”
Courtesy Andrew Huth
So what is it like to do surgery without all of the bells and whistles of a U.S. operating room? Dr. Arlet notes, “As there is no ICU bed available in the center, we have to be very careful during the surgery that there will not be any need for this type of equipment. To decrease the blood requirement, we do an extremely meticulous dissection of the spine, use a cell saver, and plan our surgery such that we have a minimum of blood loss.”
And sometimes, just when Dr. Arlet nearly had the rod in…surprise…water. “The OR has been flooded several times in the last few years. As a consequence, the c-arm fluoroscopy unit broke down, making it unreliable. This means that the majority of our scoliosis surgeries are done without a C-arm. Also challenging is that the overhead lights in the OR are relics from the 1950s. On two occasions we operated on 90 degree curves with only our personal head lamp. Every time we go there are improvements in terms of patient care, but we have setbacks because of local conditions. For example, we had a brand new Jackson spine table, but the flooding ruined it and we are left using a regular OR table.”
But the team knows that being organized can cut down on the chaos. “We schedule our most complex surgery for the first day; that way, if there are any issues postop we are there to take care of them. The surgeries are pretty grueling, and last anywhere from five to ten hours. The girl in the photo below underwent an 11 hour procedure; during her surgery we lost electricity and had to use our head lamps—not ideal because it gives us a limited field of vision…and there are lots of shadows ‘flying around.’”
After the patient emerges from the OR, he or she does have postop care. “Following surgery, patients go to the recovery room, where a well trained nurse cares for their pain and monitors their vital signs. Typically a patient will spend three or four days on the Stryker frame and will be mobilized after this time; adult patients are mobilized earlier. One of the advantages of the Stryker frame—something that we no longer use in the U.S.—is that it helps to mobilize the patient’s lungs.”
To make all of this possible, locals help themselves and caring individuals from abroad step up as well. Dr. Arlet: “We have relied on the support of a local (Trinidadian) charity to fund a portion of these trips. They assist us with logistics, provide lodging, transportation, and meals, and raise money for patient care. Outside Trinidad, we receive support from F.O.C.O.S. (Foundation of Orthopedics and Complex Spine) for both transportation and the implants. F.O.C.O.S. is a 501c3, so people can donate and get a tax deduction. Several friends in industry have generously provided us with full support by giving the implants for free—this is especially important because it means that no expenses are incurred by the patient.”
In an ideal world, says Dr. Arlet, every institution would have an outreach spinal deformity program. “More and more, universities are encouraging their residents and/or fellows to rotate overseas…even for a short period of time. When I was at the University of Virginia, I got this program approved through the school’s graduate medical education office and it became part of the training. Typically, I bring along a resident or fellow who is interested in spine. They usually come back reinvigorated…and saying to their peers: ‘Just go there. It is amazing.’”
To date, Drs. Arlet and Toby have performed 50 complex spine surgeries. “These are huge operations, with the average Cobb angle of these curves being 95 degrees. The correction rate has been 60%. Unfortunately, we have had a few complications: two infections that required local debridement, two transfers of our patients to the Port of Spain General Hospital where there is an ICU, and one cerebrospinal fluid leak that required a lumbar drain. We did not observe any neurologic complications. However, we lost the motor evoked potentials during the surgery on several occasions. None of the complications carried any long term sequellae.”
Dr. Arlet states,
I am extremely grateful for the whole team at Princess Elizabeth Hospital. The establishment of a complex spine surgery program has been for me an invaluable experience. Without the help of an exceptional team in Trinidad nothing would have been possible.
We are grateful to Dr. Arlet and the thousands of other volunteer surgeons, nurses, technicians and companies who donate instruments, equipment and pharmaceutical products every year without fanfare or pay.
For more information about F.O.C.O.S. go to http://www.orthofocos.org/
Click here for more information about volunteering your skills.
