So thanks very much for having me here. It's an honor to speak to you and an honor to share the stage with this distinguished group of panelists. In addition to working here at home at the Harvard Combined Orthopedic Residency, I'm the orthopedic advisor for Partners in Health in Boston, and it's work like this which I'm going to talk about today. So I want to tell you just one case, which I think illustrates both some of what we can do, but also some of the hazards and some of the really necessary preconditions to succeed in the kind of cases that may present. So I'm going to tell you about Leonard, who was 19 years old when I met him. He's an auto mechanic, and he still is an auto mechanic. He was burned on the job as an auto mechanic 12 years prior, which means he was seven years old if you do the math. His injuries included extensive skin loss, loss of his ulnar digits, a 180-degree burn contracture across his wrist inflection, and then an opposite 90-degree extension contracture across his thumb IP, and then ankylosis of all of his fingers. So his first reconstructive operation, and I'll send you some images and show you some images in a moment, also illustrates something very important, which is that it was performed early in 2014 in Haiti by a Haitian surgeon whom I know, which to me illustrates the importance of not underestimating the immense talent of the host surgeons who we go to visit. That surgeon performed a wrist release and covered the resulting defect with a groin flap, but he did not treat the fingers or the thumb. And so while this was a really terrific operation, it was an incomplete reconstructive process for this man and left him severely limited. So this was the product of an amazing referral to us. So I was there together with Scott as part of the Touching Hands projects to the Adventist Hospital in Haiti, and a hand therapist named Kate Corrigan, who's a long-term volunteer for years and years with a group called Global Therapy Group Haiti, spends seven weeks there every summer. And she is a former student of one of our team members, Rebecca Vonderheide, who arranged for us to see this patient, and then most importantly, for us to know that when we left, the patient would have excellent follow-up and follow-on care. So this is Leonard. Big smile. Always had a big smile. Always has those headphones. And here's his hand. So you can see that glossy skin on the back and almost no motion. Here's another view showing the loss of the ulnar digits, and you can see that his fingers are stuck, mannequin-like, without the ability to oppose. You can see in the top corner there the triangular shape or diamond shape resulting from the wrist release and the groin flap. And here's another view. Shows the groin flap a little better, but also shows the thumb, which is stuck in about 90 degrees of hyperextension. The thumb IP joint was also very unstable. And this is a video that just shows him trying to pinch. And you can actually see, if you look carefully, so the thumb is pretty mobile. Thumb's not bad. And you can see the fingers trying to move, and you could feel on exam that his flexors were present and functioning and would actually have pulled through except for the bony ankylosis of his joints. So the surgical plan was built around the goal, which was to restore him functional pinch, and the steps were to manipulate all of the joints that were ankylosed, to ablate the thumbnail, because the thumb had taken on such a funny look, to perform z-plasties to free the thumb so that it could get into position opposite the fingers, and then to fuse the IP, which was unstable anyway. And so step one was the manipulation, which was really a workout, you can see there, but achieved really remarkable results. So after just a few minutes of manipulation, we were able to get him to a full passive flexion under anesthesia, but you can still see the thumb there. So then step two was to treat the thumb, so opened it, fused it, shortened it just a little bit, and thereafter the nail was ablated and the contractures were released dorsally is how it looked intraoperatively. But that's really the beginning part, and honestly my role and my surgery were the preamble to the real story. So this, and I've printed the whole thing, this is a copy from Becky's email to her friend Kate, and it not only demonstrates how great the handoff was, it actually could probably teach all of us a thing or two about how to really explain something to your therapist. So this is how therapists address each other when they really want to communicate what to do. But that led to a just terrific series of things. So there's Kate and there's Leonard, he's still got the headphones, different ones, and that's our post-op cast. And she saw him within a day or two after our surgery and began getting him both to continue his passive motion, but also to have him try and pull through with those tendons. So here's more pictures of Kate working with him. This is after the cast came off, I had put pins into the MP joints just to hold them in a good position of flexion. But you can see already the thumb is where it needs to be, it's opposite the other digits. And this is Kate training Leonard to use his thumb. And this is the most recent follow-up picture I have. There are other ones on the way and they didn't arrive in time for this talk. But he is still being followed by a chain of therapists who have passed him person to person for the last now three months. So this to me illustrates one of the most important things, and if I can leave you with just this one piece of advice about international mission work, it's that although the upsides are tremendous and it's remarkably rewarding for us, and we have the opportunity to do some real good, there are also some things that can go wrong. And I really like this article, and I'll just leave you with it, because it illustrates in a very succinct way seven things that can go wrong. So doing something that leaves a mess behind. So if I had done that operation to Leonard and there was no follow-up plan, it's easy to imagine a pin site infection, a problem with the cast, he just wouldn't understand what to do with it. Doing something that's too complex for the local ability to follow it up. I'll skip the military help, although that's really more in a disaster situation. But to not have a follow-up plan to allow something else, some other agenda to trump the purpose of service. So although we love the opportunity to use these service trips to expand the training of our trainees, I try never to lose focus on the training of the surgeons who were there to visit. Going where you're not wanted, where you're not needed, or just being a bad guest, or doing the right thing for the wrong reason. So thank you very much.

gratitude

Harvard Combined Orthopedic Residency

orthopedic advisor

burn injuries

surgical interventions