Cheers

28 June 2013

            They say you only cry twice in Bloemfontein. Once when you first arrive and see how pitifully mundane the city and surrounding landscape look compared to the grandeur of Cape Town or Johannesburg, or the scenic views of the mountains and coast. Then you cry again when you leave after having laughed, danced, and shared life stories with the people you met during your stay. After my four week experience, I have to say “they” were absolutely right.

            The theme of this trip was ambiguity. When I first arrived, I had no idea what my accommodations would be like or even what I would be doing for my Sports Medicine Internship. Every week was a mystery in that we had no idea what was scheduled for us until we walked into the Sports Medicine building on Monday and were handed a freshly printed copy of our schedule for the week. Also, how to go about making friends and getting around the city to experience things off campus were a bit puzzling. Most students were away on holiday leave, and we had no car and were told that walking around the city was not the safest option. At first I was uneasy and frustrated with all this lack of detail, but time and time again everything worked out perfectly.

            We first met Tracey, who was an absolute angel and life saver. She is a wonderful friend and would give us a ride wherever we needed to go. Through her we met Lisa, another great friend and the life of the party. There was never a dull moment with Lisa. She and her family showed us boundless generosity when they had us stay at their house and showed us the natural beauty of the Drakensberg Mountains.

            The program itself even introduced us to new friends. For example, Marna, a student phisio, took us to experience the South African game cuisine at the WildsKOSFees. She also took us to the Cheetah Experience to interact with the big cats of Africa. Additionally, the program introduced us to Christine, the phisio for the Cheetah’s Rugby team, who invited us to her church, Every Nation in Bloem, where we gained a South African church family. We were also able to meet Brandon and Antoi, and several other medical students, while shadowing doctors at the University Hospital. They invited us to watch our first rugby game at the Brazen Head Pub and kept my social agenda full for the remainder of my stay.

            The program was superb, giving me opportunities and experiences that I would have never seen in the States. In addition to working alongside some of the most talented and honored professionals in their respective fields, it was incredible to be in a hospital setting to observe the similarities and differences between medical care in South Africa and the United States. It was great that the program gave us the opportunity to see the broader spectrum of medicine in South Africa outside of sports medicine specialists. The private practices that I saw were exactly the same as what I have observed in the States. The public hospitals do not receive enough funding; therefore, the buildings are old and rundown, the equipment is not state of the art, and sometimes the staff is not as qualified or hard working as you would like them to be. Also, the shortage in medical staff means medical care is not readily available to everyone, so doctors are overwhelmed by the numbers of patients.  Regardless, you have to work with what you have, and for what the doctors in the state hospitals have they are doing an incredible job providing medical care to their patients. They work diligently and efficiently to attend to as many patients as possible.       

 

            I would like to thank the staff in the Sports Medicine Department at the University of the Free State, as well as Dr. Jones and the faculty at Appalachian State University for providing me with this incredible experience. I would also like to thank the medical professionals for their generosity in welcoming us to work with them, as well as their exceptional job in serving as teachers for us. Most of all, I want to thank all the friends among the students, faculty, and medical professionals that made this experience one to remember. It is rare to find a place in our world where foreigners are accepted so immediately with smiling faces and welcoming handshakes. It was incredible how nearly everyone we met was instantly willing to set aside their personal agendas to make sure we felt comfortable and that our needs were satisfied. It was as if everyone wanted to be your new best friend after saying “hello” to one another for the first time. Although it can be numbingly cold at times, Bloemfontein is the warmest place I’ve ever been.     

Hey Arnold!

25 June 2013

            Today we were with Arnold Volk, who is a biokineticist. We were not always with Arnold, so we bounced around to see whole spectrum of what the facilities had to offer. For example, we started out at 8AM in an intermediate Pilates class. We participated in the class and had a lot of fun with it, but that was no joke. I was the only male in the class so I felt a little out of place, especially when the instructor kept saying, “now curl over your bra strap.” I was getting a good laugh out of it, so I just played along. Next we went to the pool where there was a hydrotherapy class taking place. I had every intention of joining the class, which was again all female, until I realized I would have brought the average age of the class down to about 65. So I took my place on the side wall to observe and hand out flotation noodles when needed.  

            After hydrotherapy finished, we went over to the gym where we observed Arnold working with a patient. The patient was a cyclist who suffered a brain injury in an accident. The patient had progressed to the point in therapy where he was now focusing on strength training. The exercises Arnold was having the patient do were designed to integrate several muscle groups at once. For example, the patient would stand on an instability pad and balance on one foot while throwing or bouncing a medicine ball. This would work the muscles of the leg and core for balance while working the arms to throw the medicine ball.

            Arnold took us to the “lab” later that afternoon to show us how each patient is first analyzed and a customized rehabilitation program is prepared based on their results. The lab had all kinds of fancy machines, such as treadmills with pressure sensing tracks to analyze stance and gate. There are also electrodes that are attached to the patient to test neuromuscular function. After crunching the numbers from the evaluation, each patient is given a specific rehabilitation plan that has four categories of focus: mobility, flexibility, sensitivity, and strength.     

Nothing Like a Good Handshake for First Impressions

21 June 2013

            Today I went solo and shadowed Dr. Vom, who is an orthopedic surgeon and works in the same group as Dr. Pelser. Dr. Vom was performing a latarjet procedure. I had heard the term several times over the past few weeks and had a basic idea about what the procedure was all about, so I was excited to see the procedure first hand. Little did I know how up close and personal my learning experience was going to be.

             My first hint should have been when Dr. Vom told me to scrub up with him. My previous experience of going into the operating theatre has consisted of me putting on scrubs, mask, and hair net only to watch at a distance. So when I was asked to “scrub up,” I was completely lost. Thankfully, the nurse (they are called “sisters” in South Africa) was willing to coach me through the process. After tying on my hair net and mask, tightening my protective glasses, washing my arms and hands (a much more thorough process than it sounds), dawning a sterile gown, and putting on two layers of gloves, I was finally fit to take my stand at the operating table.

            The latarjet procedure is performed when a shoulder has been dislocated and a piece of the glenoid (part of the scapula that forms the socket of the shoulder joint) was chipped off during the dislocation. When the glenoid is chipped the socket does not appropriately cup the head of the humerus in the shoulder joint; therefore, the integrity of the shoulder joint is compromised, making the joint more susceptible to future dislocations. In the latarjet procedure, a bone graft is performed to fill the chip in the glenoid, so as to reestablish the structural integrity of the socket of the shoulder joint. In our procedure, the graft was taken from the coracoid process (extends forward from top, outer edge of scapula to stabilize shoulder joint).

            When I got up to the operation table, Dr. Vom had already cut down to the shoulder joint between the deltoid and pectoral muscles. This exposed the coracoid process. OK so thus far, I’ve just been watching, then Dr. Vom says, “Here hold this” and puts the patients arm in my hand. Then he breaks out the bone saw and tells me to pull on the arm to open the shoulder so he can get a good position on the coracoid. So there I am pulling on the patient’s arm, thinking, “No way is this happening.” Then Dr. Vom starts up the saw and goes to work, all the while I’m trying to hang on to this arm so it doesn’t move and Dr. Vom goes sawing on something he shouldn’t. Liability issue? “Ain’t nobody got time fo dat!” It was awesomely terrifying holding on that arm, feeling the tremors from the saw reverberating down its entire length and into my hands. That was probably one of the most intense moments of my life.

            The coracoid was cut free from the scapula, but it still had muscle attached to it. Dr. Vom then cleaned the surface of the coracoid to prepare it for grafting. Then he took it between the fibers of the subscapularis tendon and screwed it into the glenoid where it had chipped. In this way, the muscles left attached to the coracoid stabilize the shoulder joint, and the supscapularis tendon further stabilizes the joint by acting like a sling.      

Hands on Education

20 June 2013

            Jaclyn and I were back shadowing Dr. Pelser today, except this time we scrubbed up and went to the operating room! We were at Pelonomi Hospital, which is another state hospital located about a 15 minute drive from campus. Before I get to the surgery, I wanted to give an update on the young boy with the deformed index finger. Dr. Pelser is going to wait for an MRI to get back to him before making a decision because he is not sure if the defect is congenital. As for now, Dr. Pelser believes that the boy’s hand will function better if the finger is amputated.

            Alright now on to the cool stuff. Our first patient had a fractured ring finger on his right hand that was completely displaced. The fracture occurred at the first phalanx (finger bone between the knuckle and first joint). A metal plate was screwed into the bone on either side of the fracture, bringing the fragments together in their proper alignment. This immobilizes the bone so that it can heal while still allowing the joints of the finger to move, so no stiffness occurs in the finger. The patient can begin moving his finger as early as tomorrow, but I got a feeling it’s going to be a little sore for that.

            We saw an interesting case in the operating theatre next door to us. A boy of about five years old had a severely deformed right leg and foot. The foot itself was angled to the left almost 90 degrees from normal. In looking at previous x-rays, the boy was born with loss of bone from his right tibia. In a previous operation, a bone graft from his left fibula was performed to fill the hole in his tibia. The x-rays also showed the bones of his ankle to be deformed and some were fused together. During today’s operation, the boy was undergoing a muscle and skin graft for the inside area of his deformed right ankle. Specifically, a piece of his gastrocnemius (calf) muscle and skin was taken from his left leg to be used for the graft. The operation was successful and after he heals, then the doctors will perform another operation to reconstruct his ankle so that he can walk.

            Our second patient had a combo order. He had a scaphoid (bone in the wrist) fracture, as well as a fracture on the neck of the radial head. Apparently the rule about the scaphoid is that if you can easily see the fracture on an x-ray, then surgery is advised. It was an easy fix in which a guide wire was first inserted into the fracture, and then a compression screw was used to bring the scaphoid together so it could heal. The fracture on the neck of the radial head was a bit more involved. The fracture caused the radial head to fall out of perpendicular alignment with the humerus in the elbow joint. A plate was screwed across the fracture to correct the alignment of the radial head. At first, Dr. Pelser attempted to move the radial head in the joint and you heard a terrible popping sound and it appeared as if the elbow was dislocating. After some minor readjustments, the elbow was in proper working order and the patient was on his way to recovery.

            Our third and final patient had a fractured fourth metacarpal (bone in the back of your hand attached to the knuckle of your ring finger) on his left hand. Unfortunately the patient did not present the fracture to a medical professional until three months after it originally occurred; therefore, the bone had healed incorrectly. The bone had healed at an angle so that it looked like he had an extra knuckle poking out the back of his left hand. In order to correctly realign the bone, a wedge was chiseled out where the bone had healed at an angle. A plate was then screwed across the fracture, bringing the fragments together in their proper alignment. The space between the fragments was filled with pieces of bone from the wedge that was taken out, allowing the bone to heal more effectively.     

Play Ball! (or something like that)

19 June 2013

            Today we were with Shaun who works on Dr. Holtzhausen’s staff and is also the team physiotherapist for the Knights, which is the provincial cricket team. Cricket has some similarities to baseball, but is a much different game once you get into the details of it. We went with Shaun to Chevrolet Stadium (Home of the Knights) and he let us tour the field and locker rooms. Afterwards, the head coach, athletic trainer, and three players arrived for some conditioning practice. One of the players was just now getting to where he could run comfortably on his left ankle, which he severely injured six months ago when sliding for the wickets. He was sliding like you see in baseball where the player has one leg extended and the other curled under it. His left foot was under his extended right leg when his left foot caught in the dirt, tearing ligaments and tendons in his ankle so that his toes were able to touch his fibula (YIKES!).

            Basically, Jaclyn and I were given free field passes to watch the conditioning practice and learn a little about cricket. No water breaks were given throughout the entire hour and a half practice. They started out with a 200 meter warm up jog, and then they got to work with suicides. First, they had to do eight repetitions of 30 meter suicide sprints, going from the 10m mark to the 20m mark and finishing with the 30m mark. Next, they ramped it up to 80 meter suicides, beginning with a run to the 80m mark and working each suicide down from the 60m mark, to the 40m mark, and finished with the 20m mark. Afterwards, the players worked on field exercises, chasing down balls and accurately throwing them to the head coach who acted as the “Wicket Keeper” (equivalent to a catcher).

            Then we moved to the indoor facilities where the players worked on catching and toughing up their hands. Only the Wicket Keeper has gloves on the field, while everyone else catches with bear hands; therefore, tough hands are crucial in cricket. The head coach would bat balls, which were like tennis balls with a solid core (softer than the leather coated cricket balls they will catch later), at each player and have them catch four balls before rotating out. After about five rotations, it was time for batting practice.

            After the conditioning practiced finished, Shaun took us back to the clinic on campus where the cricket player with the recovering ankle came in have his tibialis anterior muscle (along the shin) needled and relaxed.             

Arm Bone Connected to the... Hand Bone

18 June 2013

            Jaclyn and I were at National Hospital to shadow Dr. Pelser during his office visits. Dr. Pelser is an orthopedic surgeon who specializes with the hand and wrist. The majority of the office visits were concerning minor issues. Most issues were mended with some corticosteroid injections and time for healing.

            One of the most interesting things we saw was an X-ray of a wrist replacement. It worked by using a ball and socket joint mechanism. One end of the wrist was screwed into the radius and the other was screwed into the middle metacarpal, positioning the ball and socket joint in the center of the wrist. Both screws were coated with calcium so they would fuse with the patient’s bones to give more stability. Also, the replacement left the majority of the bones in the wrist intact, maintaining the structural integrity of the wrist.

            Another interesting case was a young man who had a deformity in the index finger of his left hand, causing his finger to be at least an inch shorter than normal.  He was born with the deformity and has never been able to bend his index finger. Now the deformity was causing him pain and swelling as the bones around it continued to grow. From the X-ray, the index finger looked normal to me, except that it was smaller. Dr. Pelser pointed out that there were some deformities of the bones and joints at the knuckles of the index and middle fingers. I'll get you an updated prognosis when we see Dr. Pelser again this Thursday.

Big Cats

 

 

 

 

 

 

 

 

 

 

(Zoro)