Healing Bones, Mending Lives Globally at Annual UCSF International Trauma Course

International attendees in the Orthopaedic Trauma Institute surgical simulation lab learned about limb-salvaging reconstructive procedures.

Squealing tires. Screeching brakes. Crunching metal and shattering glass.

The sounds of a traffic collision are common anywhere motor vehicles is the preferred method of transportation. But caring for those who are injured is quite different in the United States compared to other parts of the world.

Just ask Dr. Lectary Lelei, a 53-year-old orthopaedic surgeon from MOI University School of Medicine in Eldoret, Kenya.

“We have many patients who come to our hospital from auto traffic accidents having exposed bones, especially their lower limbs,” Lelei said. “We don’t have any plastic surgeons in our health institutions, so it is very important for us to learn about (new procedures) and go back home to help our patients.”

Sign-in display for international attendees at the fifth annual UCSF Surgical Management and Reconstructive Training (SMART) Course.

Lelei was one of 51 surgeons from 18 developing countries who participated in the fifth annual UC San Francisco Surgical Management and Reconstructive Training (SMART) Course at San Francisco General Hospital and Trauma Center (SFGH). He was joined by fellow Kenyan countrymen Dr. Kiprono Koech from Tenwek Hospital in Bomet and resident Dr. Geoffrey Mwangi from AIC Kijabe Hospital in Kijabe.

Led by orthopaedic surgeons from UCSF, and plastic surgeons from UCSF and University of Southern California, the surgical skills course is sponsored by the Institute for Global Orthopaedics and Traumatology (IGOT) within the Orthopaedic Trauma Institute, a joint project of UCSF and SFGH. Done in collaboration with the SIGN (Surgical Implant Generation Network) Fracture Care International annual meeting in Richland, Wash., attendees learn about limb salvage and rotational flap procedures.

“Here at this course, we have surgeons from the front lines who have to try and figure out how to treat bad injuries, open fractures, horrible soft tissue problems from patients who sit in their hospital wards for months and months,” said R. Richard Coughlin, MD, MPH, UCSF orthopaedic surgeon and IGOT founder. “You walk through the wards every day looking, and you see the same patients. If they had the tool to do something, they could get the patient fixed and out of bed. And that’s what we do here. We actually give them the tools.”

Surgeons at the day-and-a-half course hailed from countries such as Nigeria, Tanzania, Burundi, Pakistan, Afghanistan, Myanmar, Haiti and Nepal. With West Africa represented amidst the current Ebola outbreak, there was brief discussion on how the attendees’ respective hospitals plan to manage the epidemic should it continue to spread.

Among the international course attendees were Kenyan orthopaedic surgeons, from left, Geoffrey Mwangi, Kiprono Koech and Lectary Lelei.

In severe trauma cases, surgeons use a flap – a piece of tissue partly detached from its place of origin to cover exposed bones or tendons – to save the damaged limb. UCSF surgeons at SFGH are among a handful in the United States who teach flap techniques to surgeons worldwide.

“In the last three months, our staff has talked about the need to be more active in terms of caring for patients with soft tissue injuries from trauma,” said Koech, 37. “This course is coming at just the right time. We have the right mindset now that we’ve got to do more. We can’t save them if we’re waiting for a plastic surgeon. We’ve got to do more ourselves.”

For training purposes, UCSF surgeons have developed a comprehensive course on a variety of flap techniques for upper and lower extremities, including didactics and cadaver tissue dissections. Training also is provided on basic clinical research methodology, and complex cases are reviewed through panel discussions.

“For me, it demystifies that flaps can actually be done by orthopaedic surgeons,” said Mwangi, 32. “We have a lot of problems with exposed bones and have to do amputations that would be unnecessary if we knew how to do these flaps to cover bone. The course has been very useful, enlightening and time well spent.”

The SMART Course was part of the IGOT International Summit, Sept. 7-9, which included a pre-course for regional residents and a research symposium for international orthopaedic surgeons interested in clinical research. About 40 residents in orthopaedic surgery, general surgery, plastic surgery, vascular surgery, podiatry, orthotics and prosthetics from UCSF, St. Mary’s Medical Center, Stanford University, UC Davis and Kaiser Permanente attended the half-day pre-course, which reviewed the principles of limb salvage and complex wound management in the extremities.

SFGH Building 9, location of the UCSF Surgical Management and Reconstructive Training (SMART) Course.

The need for institutions such as UCSF to share their expertise is tremendous. According to the Centers for Disease Control and Prevention, injuries and violence are a major public health issue worldwide, accounting for nearly 10 percent of deaths annually. Ninety percent of all injuries occur in developing countries, reports the World Health Organization, and injuries account for more death and disability than the top three infectious diseases – HIV/AIDS, tuberculosis and malaria – combined.

As a result, skills gained from this SMART Course have an immediate impact on the care of these injuries, saving both limbs and lives.

“The flap procedure really isn’t well understood in low and middle-income countries,” Coughlin said. “They’re finally starting to wrap their heads around these problems and say road traffic actually does affect the GNP (gross national product) of a country. These course attendees are well trained surgeons who have been given a good set of tools to make an immediate impact.”

In May, IGOT provided a similar course on fundamentals and practical application of trauma principles to more than 100 African orthopaedic surgeons gathered in Dar Es Salaam, Tanzania. Faculty worldwide took part in the orthopaedic trauma portion, with plastic surgeons from USC separately addressing soft tissue reconstruction.

Now, after making the 9,600-mile trip back to Kenya, Lelei, Koech and Mwangi will share their newly acquired knowledge on the flap technique, as will the other course attendees with their respective colleagues.

“It’s quite a useful part of my residency training, and I can share my knowledge with fellow residents, as well as tell them about this course,” Mwangi said. “Hopefully, in the future, with this interaction between UCSF and our country, we can look into how such a course can be incorporated so other residents can benefit.”

Photos by Scott Maier