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)

 



 

Kids, Cats, and Collisions

14 June 2013

            We began the day by sitting in on a patient discussion. This is something Dr. Holtzhausen organizes every Friday to bring his professional staff of phisiotherapists together with the student phisiotherapists and biokineticists. The students present their cases that they have been working with, giving the background of the patients, their problems/diagnosis, and the methods of rehabilitation. Dr. Holtzhausen and his professionals then critique the students’ work, providing them with constructive criticism to become better at their professions. The main message that Dr. Holtzhausen wanted to get across during this discussion was that great medical professionals are not great because they know the most facts; rather, they are great because they know how to act in the best interests of their patients and can effectively communicate information between the other members of their team.   

            After the patient discussion, Jaclyn and I went with the kinder (children) kineticists to a nearby pre-school to play games with some adorable four year old girls. We had a variety of games to play to keep the kids interested. We set up relay races, played a version of duck-duck-goose, and had bean bag tosses. There was also a circle of square mats we set up and had the kids jump from mat to mat, alternating between landing on the mats with one foot and two feet. My favorite was something called “catch the puppy tail,” which consisted of hanging a flag off the back of your pants and running around taking everyone else’s flag. If your flag was taken then you had to sit down, so the last person with a flag was the champion. One girl, Madison, saw me as her only target and would run after my flag every round we played. Of course I let her get my flag, but we had a lot of fun chasing each other. The purpose of these games was to improve the children’s coordination, balance, and muscle mechanics. The games also encouraged kids to have healthy lifestyles by getting outside to play, rather than sitting inside staring at the TV or playing video games.

            That afternoon we went with our fisio friend, Marna, to the Cheetah Experience. For $10 you got to get up close and personal with full grown cheetahs, as well as some younger cheetahs and leopards. A part from the 22 cheetahs, there were also several male lions (including two white lions), leopards (including two black leopards), servals, and caracals. Our tour fell during feeding time so animals were very active, and we got to see those claws and teeth go to work!  One really cool moment occurred when we were checking out a 14 month-old male leopard named Zoro. I was crouched to get a good picture of his eyes and face as he was looking right at me. Just as I was about to take the picture, he started walking toward me and all I could say was, “Bring it in brother.” Zoro put his head right into my lap and we had us a little bonding moment.

            That night, we were helping with first aid on the sidelines of the university rugby game. We had two concussions, a sprained ankle, a sprained neck, and swollen eye brow. The guy with swollen eye brow looked like Rocky Balboa after 12 rounds with Apollo Creed. When he told me he had seen the movie I said, “Were going to have to cut you.” He just laughed and we bandaged him up so he could go play the second half.

If the Shoe Fits!

13 June 2013

            Shadowing Mr. Anton Kemp was a really cool experience because his profession is truly an art. Anton is a foot specialist who not only consults patients on issues with their gate and stance, but he also makes his own customized orthotics and prosthetics for is patients. He showed us around the workshop where he carved insoles and made prosthetics.



 

            If that weren’t cool enough, this guy is also a three-time conqueror of the Iron Man. He lives his profession and draws knowledge from personal experience; not just a textbook. He also has genuine care for his patients and has an incredible talent for talking so that his patients completely understand the causes and solutions for their problems. He is a great teacher, which separates the good health care providers from the legendary.

 



 



            Our first patient was a school teacher with diabetes who had been horribly neglected by previous podiatrists, causing her condition to worsen. Mainly, the metatarsals of the foot had become pinched together, causing pain, and needed to be spread out so as to provide a wider and more stable base. Anton created a casting of her foot and leg from the patellar tendon down. The boot will rest at the patellar tendon taking about 60% of the weight off the foot, easing the pain of the patient. Also, the boot will have an extractable inner sole that can be reconfigured to gradually correct the patient’s foot structure.



            The second patient had previous surgery on his left foot, causing his stance to change. This was causing pain, so Anton prepared a casting of the patient’s feet. As the plaster was drying, Anton was able to maneuver the metatarsals of the patient’s foot into a corrected position. The casts will then be used to make corrective insoles for the patient.



            We were also able to see several patients with gate issues. For each patient, Anton would have them walk down a hall and across a platform that had thousands of pressure sensors to detect the weight distribution across the patient’s feet. He would also film each patient as they walked, so as to analyze their gate.

 

 





(pressure sensing pad with camera at top of picture)

            During a break for lunch, Anton analyzed our running gates which revealed some interesting results. Most of my problems can be fixed by shortening my stride length and focusing more on landing mid-foot rather than striking the ground heel first. Anton also let us try on some sweet new kicks made by Newton. They are made to allow better flexing of the ankle and foot joints, as well as encourage you to land mid-foot while running. This gives you more spring in your gate, making you a more efficient and healthy runner.   

     



“I guess the geyser of saline solution shooting out of that dude’s shoulder is normal huh?”

12 June 2013

            I had the incredible opportunity to shadow Dr. Greef in the operating theater today, which took place at a private practice about a 15 minute drive off campus. Dr. Greef is an orthopedic surgeon and a leader in shoulder specialists. I was surprised at how rough shoulder surgery appeared when I walked into the operating room to see Dr. Greef pounding a pilot hole into the head of the humerus of our first patient with a hammer and punch. Also, the amount of saline solution being pumped into the shoulder was causing it to swell up to twice its normal size. This not only made you looked jacked, but also caused a fountain of liquid to come shooting out of your shoulder whenever a probe was inserted or extracted.

            The first patient had a partial tear of the rotator cuff which was mended easily enough with some screws and suturing. The second patient was a little more involved, suffering from impingement of the rotator cuff by the acromion (the outer end of the scapula attached to the collar bone) and a labral tear (labrum is cartilage found in the socket of the shoulder joint). The impingement of the rotator cuff was solved by cutting away the tip of the acromion. The labral tear was corrected by cutting the biceps tendon and reattaching it lower on the humerus with a screw. The third patient had a large tear in the rotator cuff. This was corrected by four screws and some extensive suturing. The biceps tendon was also cut and reattached lower on the humerus with suturing so that it would not be trapped underneath the repaired rotator cuff. Dr. Greef informed me that more severe rotator cuff tears can require cutting the humeral ligament to give an extra centimeter of slack, allowing the cuff to be more easily sutured back together. The fourth patient required acromioclavicular (AC) joint repair, which was a fairly quick operation. The fifth and final patient had a subscapularis tear, but unfortunately I was unable to observe the entire procedure as I had to catch my ride back to campus.

      

 

           

Humble Pie Anyone?

11 June 2013

            Today we shadowed Mr. Johan Steyl, an incredible man who has one the most heartbreaking stories I have ever heard. Through all his hardships, however, he maintains the most positive outlook on life I have ever seen, making him someone I truly aspire to live like. He showed us around the anatomy museum, explaining several of the dissections exhibited and the processes used to make them. He also gave us a detailed account of the fibula and skull. He showed us to the mortuary where they prepare the cadavers, dissections, and skeletons. Moreover, Johann taught us more life lessons in 7 hours than I have ever learned on my best days. Words alone cannot do justice to this man’s incredible character, so feel free to ask me about him when I get back.           

A Jam-Packed Day

10 June 2013

            Today we shadowed Dr. Labuschagne (Dr. L for simplicity), who is an opthomologist at the state hospital associated with campus. He also serves as the Head of the Clinical Simulation Unit and is a lecturer in the medical school. To start, he showed us the simulator dummies they have, which are ridiculously intricate. For example, “Sim-man” can blink, sweat, cry, foam at the mouth, convulse, bleed, and even talk! He has 19 microphones to give different heart sounds/murmurs, lung sounds, and bowel movements. Furthermore, he can tighten his jaw to constrict his airway, allowing for a tracheotomy to be performed by students. He will turn blue in the face if oxygen levels get too low! The coolest part is that he can respond to medicine. A label with an identifying microchip in it can be attached to a syringe which is then filled with water. “Sim-man” can identify the microchip and volume of water so as to ensure the student is giving the correct “medication” at the appropriate volume. Another dummy, “Sim-mom,” can actually give birth and can be set up for a C-section or other labor difficulties. There is also a “Sim-baby” that can cry and be used for various medical studies because the students are not allowed to interact with real infants. All dummies can change heart rate and breathing rate, as well as undergo defibrillation without shorting out.

            Dr. L showed us around the general medicine, pediatrics, ICU, and various wards of the campus associated state hospital. We also met some 5^th year medical students and we shared details about our different medical routes between the States and South Africa.

            Next, we went to the Central University of Technology (CUT) campus to observe an emergency responders exam for third year students. A simulation was set up where a dummy was lying on the ground in a shed on a farm. The victim had vomited, defecated, and was convulsing with copious amounts of saliva pouring out of his mouth. He was also sweating profusely. There was a smell of chemicals in the air with a table covered in bottles of various chemicals. He had lost his wife and two daughters in a fire a few months ago. Figured out the diagnosis yet? Ok I’ll give you a big hint, the main culprit was organic phosphate. If you’re like me you’re probably like, “Alright this guy obviously tried to end his life with internal poisoning, but how the heck do we keep him from dying?!” Then Dr. L mentioned the term SLUDGE, and a flash back to Dr. Henson’s Human System’s lecture about the nervous system came charging into the forefront of my memory. Atropine is the solution! SLUDGE is a mnemonic for salivation, lacrimation, urination, defecation, gastrointestinal upset, and emesis (fancy word for vomiting). Nerve gas and pesticides (like organic phosphate) can cause this pleasant array of sensory overload due to a massive discharge of the parasympathetic nervous system. The treatment is atropine, which acts to compete with the stimulated nerves to shut them down and bring the patient back toward stabilization.    

            Afterwards, Dr. L took us to National Hospital, another state hospital down the road. There he showed us the optometry and opthamology wards. He even let us observe each other’s iris with a split-lamp. He also showed us to the surgery theatres and HIV ward, sharing with us that 30% of South African’s have HIV. He also showed us some amazing statistics that South Africa is short in specialists by 8,000 doctors and short in general practitioners by 7,000 doctors. 

            Later that afternoon, we sat in on Dr. L’s lecture about diseases and tumors of the iris, choroid, and retina. I learned that brushfield spots are only found in Down syndrome patients and saw some pretty ridiculous pictures of tumors gone WAY wrong (especially with retinoblastoma: YIKES!!!).   

            I also got to join in a heart dissection class. They were dissecting pig hearts in correlation with a trans-esophageal echocardiogram. Each student had a heart and a square with a red dot at one end and green dot at the other. The square was used to orient their view of the pig heart with that of the human heart on the recorded sonar pictures. They dissected the tricuspid valve and mitral valves, orienting their pig hearts to with the views of the sonar so as to as to gain an understanding of how to navigate a probe to gain different views of the heart.

Beast Feast (South African Style)

Words to live by

Grilling up a storm

Pig Racing Contenders

Spitting Competition with Kudu Droppings