Professor and surgeon leads medical mission to Nicaragua with Hand Help
This story also appears in the Yale Medicine alumni magazine.
“Yes, he was born with the little finger,” answers Jenifer, a pretty young woman with a high, bouncy ponytail, in Spanish when asked about the wriggling baby sitting in her lap. His name is Matias. His chubby arms and legs stick out of a onesie decorated with cars and trucks, and his big brown eyes stare, rarely blinking, at the doctors and nurses crowding around him. He turns six months old today, but is big enough to pass for 10 or 11 months.
Jenifer shows Matias’ right hand to the group: growing alongside his thumb is a second thumb, slightly smaller than the first. A doctor inspects the dedito (“little finger”) while a nurse coos at Matias.
This is the second time that Jenifer has brought Matias to Hospital Alemán in central Managua to inquire about the possibility of removing the extra thumb. If it stays, it will hinder the full development of the main thumb and subject Matias to social stigma once he starts school. The first time Jenifer brought him, however, the doctors told her she must wait until he is six months old and, besides, none of the surgeons specialize in this type of surgery, especially on such tiny hands.
91 surgeries in 5 days
The hospital is located a few turns up narrow cobblestone roads from the main highway in Managua, Nicaragua's capital city. It took Jenifer and Matias more than an hour to get there on the city's packed buses. Still, she made the trip once again, pinning her hopes on a rumor she heard that a visiting group of medical professionals from the United States might be able to help.
That group is Hand Help. Founded in 2006 by Grant Thomson, plastic surgeon and professor of surgery at Yale School of Medicine, the group today includes around 30 people: surgeons, anesthesiologists, pediatricians, occupational therapists, nurses, residents, medical students, and interpreters, over half of whom are affiliated with Yale. Once a year, the group travels to Central America to provide highly specialized surgeries that are difficult or impossible to obtain in under-developed countries.
“When we live in the U.S., we don't understand that … at least a fifth of the world's population doesn't have access to modern healthcare, that if they have a need for surgery, they can't get it,” Thomson said. This is evident at Hospital Alemán, where staff lack access to the training or equipment needed to handle complex surgeries. Hand Help seeks to address that need: this year, in just five days, they performed 91 surgeries.
Three of the most common surgeries they conduct are removal of ganglion cysts, fluid-filled sacs typically found on wrists, which are unsightly and often painful; release of “trigger” fingers that are stuck in a bent position; and treatment of carpal tunnel syndrome, a condition in which a pinched nerve in the wrist can cause numbness and weakness. Each of these procedures typically lasts less than 30 minutes, and one of Hand Help's four surgical teams can perform six or seven per day.
The overall impact on patient outcome, however, is life-changing. Nine-year-old Brigit will be able to return to school after withdrawing for a year because the ganglion cysts on her wrists made holding a pencil too painful, 5-year old Isabel will be able to play and communicate like other kids after the release of her two trigger fingers, and the many older patients will be able to care for their children or return to work when they are relieved of the pain of carpal tunnel syndrome.
“It’s very important for the patients in Nicaragua to have access to good hand care because a lot of their livelihoods are based on their ability to use their hands,” explained Felicity Fishman, orthopedic surgeon and assistant professor of orthopedic and hand surgery at the Yale School of Medicine. “It’s a matter of getting them back to everything they need to do to survive.”
Changing the art of surgery
When the Hand Help team boards the buses taking them to the hospital each morning, most of them have bottles of Fuente Pura, a local bottled water brand, stowed in their bags. Tap water in Nicaragua isn’t potable for visitors, so plastic water bottles abound. Veteran Hand Help volunteers instruct newcomers not to dispose of the empty bottles because, at the end of each day, a Nicaraguan nurse collects them and whisks them away to the pathology department, where they'll be used to transport samples of bodily fluids for testing.
“Resources that we take for granted at home — suture, drapes, extra gloves, things like that, things at which we don't even bat an eye — we have to think twice about here,” said Regina Meis, an orthopedic surgeon who works with Thomson as the Hand and Microsurgery Fellow at Yale.
Hospital Alemán, the only hospital in Managua's Xolotlán district that serves patients for free, cares for an estimated 520,000 people every year, 90% of whom live under the poverty line. It used to receive funding from East Germany (‘Alemán’ means ‘German’ in Spanish), which founded the hospital in 1985 as Hospital Karl Marx during the Nicaraguan civil war. At first a series of tents, the hospital slowly evolved into the sprawling compound of colorful buildings and cobblestone courtyards that it is today. After German reunification, however, Germany slowly backed away from funding until the Nicaraguan Ministry of Health took over in 1998.
Today, Nicaragua has .9 physicians and .9 hospital beds per 1,000 people and a GDP per capita of $5,300. By comparison, the United States has 2.45 physicians and 2.9 beds per 1,000 people and a GDP per capita of $54,800.
“The hospital is always willing to solve, as far as we can, the population’s health problems. But because of financial matters, we don’t have the medical supplies, and without those, it's as if we can't do anything,” said Dr. Fernando Aguilar, coordinator of the orthopedics and trauma department at Hospital Alemán.
For Dr. Aguilar and his coworkers, this is routine. For Hand Help, it's a lesson in the art of medicine. Keeping the tight surgery schedule flowing smoothly requires adaptation akin to saving water bottles for fluid samples. Before one surgery, for instance, the Hand Help team noticed that the arm board was significantly lower than the stretcher, meaning a patient’s arm would dangle insecurely off the bed. To rectify this, a Hand Help nurse grabbed two bottles of iodine, stacked them on top of the board, and taped them in place.
“What’s critical to making this trip successful is … the patience to persevere through the lack of resources — troubleshoot, work through the challenges, and keep moving forward,” Meis said. “It changes the whole art of being a surgeon … and it makes you a better surgeon.”
Minimizing (and maximizing) impact
To minimize the impact they have on Hospital Alemán’s resources, Hand Help collects donations — many from its own volunteers — to purchase all of its supplies, from bandages to scissors to a machine that sterilizes equipment. For months leading up to the trip, John Tangredi, Hand Help’s secretary, painstakingly anticipates the types of surgeries Hand Help will perform and the equipment they’ll need, then packs it all into crates at a storage unit near the Yale School of Medicine.
“We had to calculate everything we’d need from start to finish,” said Tangredi, who can list what each crate contains from memory. “We brought 24 crates this year because … we never know what they’ll have here.”
Each member of the Hand Help team checks one of the crates as part of his or her luggage. This makes for chaotic and exhausting scenes at airports — explaining endoscopic carpal tunnel surgical equipment in Spanish to skeptical customs’ agents, for instance — but it’s work that is necessary to avoid straining Hospital Alemán’s already-limited resources.
Tangredi oversees the organization and distribution of Hand Help’s equipment at Hospital Alemán from his small room in the middle of the operating suite, which he nicknamed “the kitchen.” Nurses stop by to get equipment from the bags that line the walls while Tangredi packages tools for the day’s surgeries and instructs one of the surgeon’s teenage daughters in how to use the equipment sterilizer.
“Our mission is to recreate a surgical environment like we have in the United States,” explained Marc Walker, a fifth-year plastic surgery resident and organizer for Hand Help. “While it’d be easy to cut corners, we find that we don’t have to and we pride ourselves … because we’re able to do that. I think everyone is committed to that concept, and I think the patients benefit from it.”
“If we do the surgery and don’t have the dressing for post-op, the patient suffers,” Tangredi said about why he devotes so much time and effort to Hand Help’s logistics.
Cross-cultural efficacy and efficiency
It’s March 17, the last day of surgeries. Nicaraguan and U.S. staff alike zip around the halls as usual. They’ve fallen into a rhythm over the previous four days, but today is St. Patrick’s Day, so everyone is sporting a green bowler hat or a plastic four-leaf clover necklace, stick-on mustache in the color of the Irish flag, oversized green sunglasses, or a combination of holiday kitsch. This is thanks to Tangredi, a driving force behind the establishment of cross-cultural group cohesion.
“It breaks the ice and opens up avenues of ‘Hey, this person is friendly; we know who to contact when we need something,’” Tangredi said.
A team of interpreters and the few members of the Hand Help team who are fluent in Spanish are also key to establishing relationships between the two staffs.
“It’s nice to be able to interact with the patients — to make jokes in their language so they feel more empathy and more comfortable in that environment,” said Jack Kanouzi, a postdoctoral fellow from Spain. Kanouzi and a few other Hand Help members worked double-duty as medical professionals and interpreters, from initial patient intake to the operating room. “We really want them to feel comfortable and happy, and I think knowing their language is really important for … overcoming sociocultural barriers.”
Still, the language barrier can lead to misunderstandings, said Meis, whose Spanish parents taught her the language from birth.
This became clear on the first day, when hundreds of potential patients came to Hospital Alemán’s clinic to be evaluated and scheduled for care. “This woman had a small deformity on her finger that was painful, and through the explanation of what we were going to do, it somehow got lost in translation and she thought we were going to amputate her finger,” Meis recalled of one patient. “Because I speak Spanish … I said ‘no, no!’ and she looked so relieved and started crying. We were able to really help her — she got to keep her finger and we took away the pain she was having.”
Most of the Hand Help staff, however, relies on broken Spanish, past interactions, and a shared sense of purpose to develop relationships with the staff of Hospital Alemán.
“We are back in Nicaragua for the fourth year now. We know the head of the hospital. We know the orthopedic surgeons. We know the nurses. And they know us by name,” said Walker. He, like many repeat Hand Help volunteers, has picked up a little Spanish over the years. The bulk of the bonding between staffs happens in the long hours during which they toil together in the operating room — quiet concentration when the anesthesiologists intubate a patient, for instance, or spontaneous dance breaks between surgeries to whatever pop music plays over a nearby Bluetooth speaker (especially to Shakira, which nine-year old Brigit requested for her pre-surgery tunes).
“It’s true that we speak different languages, but we can identify with each other anyway,” said Marta Hernández Ortega, a specialist nurse and chief of the surgical technicians. Ortega and her team work closely with Hand Help all week, with one surgical technician coming to work anyway on her day off. “Although they can’t understand me, we’ve gotten along, we’ve worked together, and we’ve done things the best we could to help my country.”
This camaraderie extends past the operating suite. Elsewhere on the compound, Hand Help’s occupational therapist, Virginia Ells, works long days with one of Hospital Alemán’s physiotherapists, Nubia Mayorga. Neither speaks the other’s language, but they manage to deliver care anyway, making splints and teaching patients exercises with hand gestures, sharing knowledge of their craft, and a lighthearted willingness to persevere through miscommunications.
“It’s true I can’t speak English, but I can communicate with a person,” Mayorga said. She’s more than a foot shorter than Ells, and her bald head is covered with a pink knitted cap that she made herself. Mayorga was diagnosed with breast cancer in October, but she came back to work with Ells and the Hand Help team.
“I’ve been working with the brigade [the hospital staff’s nickname for the US contingent] for three years,” Mayorga said. “When the brigade is here, I’m here.”
This close teamwork is crucial for success both during Hand Help’s hectic surgery schedule and after the team leaves, when patients need follow-up and postoperative care. In choosing a site, Thomson looks for teams of doctors and nurses who want to make an active commitment to both of these phases.
“It's not just a matter of doing our surgery then taking off,” Thomson said. “Patients need follow-up. That's one of the most important factors — having a host that can provide support services while we're here and also after we leave.”
Making missions “last forever”
“In the late 1990s and early 2000s, there was controversy about whether people should be doing these missions at all. There were questions of outcomes and concerns of being paternalistic,” Thomson said. “I realized Hand Help had to be different.”
Thomson uses a dual approach to avoid these pitfalls: educating local hospital staff on new procedures and studying the long-term results of Hand Help’s surgeries.
On Friday, the last full day of Hand Help’s mission, Thomson gave a lecture on endoscopic carpal tunnel release (ECTR) to a crowded auditorium of doctors, students, and residents. In this surgery, doctors insert a tiny camera attached to a thin tube into a small incision in the wrist and locate and cut the transverse carpal ligament, thereby relieving pressure on the median nerve. This method is growing in popularity due to its minimal invasion and faster recovery times as compared to earlier methods.
The Hand Help team brought an ECTR machine, so a few staff members at Hospital Alemán had seen the surgery in action throughout the week: Thomson looking at the video screen to navigate his tools through the small incision, chatting with the still-conscious patient, and sewing the incision closed, all in under half an hour. At the lecture, however, he brought the technique to the rest of the hospital community.
While there are five orthopedic surgeons at the hospital, Thomson guessed that this was the first time this surgical technique had been done at Hospital Alemán, and perhaps in all of Nicaragua. Because of a critical lack of trained medical professionals, most doctors gravitate towards more general specialties, leaving too few people to cover specialties such as hand surgery.
“It’s not like medicine here is different. They’re practicing advanced medicine … but the things that we bring augment that,” explained Walker, who, after completing a surgery, often answers questions from curious residents who came to watch that particular surgical technique. “That knowledge-sharing component is how we can make the mission last forever.”
Additionally, in Hand Help’s early years, Thomson took pains to determine how helpful Hand Help actually is. He recruited medical students to return and examine patients four and six months after surgery for two consecutive years. In addition to finding a few ways to improve outcomes, they ultimately discovered that Hand Help’s missions improve both hand function and overall quality of life for the patients they treat in the long term.
“It does turn out that the way we do things is helping people,” Thomson said. He is currently in the process of publishing his research, which is the first of its kind.
“Are you happy?”
Sohel Islam, one of four Hand Help surgeons, and Robert Golenbock, the group's pediatrician, enter the room where Jenifer and Matias wait, accompanied by a doctor and nurse who work at the hospital. They greet Jenifer in halting Spanish and coo over Matias, inspecting his thumbs and discussing in English when to squeeze him into the busy surgery schedule. Golenbock blows a raspberry at Matias, who promptly slaps the doctor's face — his tiny, smooth hand with its little finger momentarily contrasted against the five-o-clock shadow on Golenbock's cheek.
“Are you happy?” the cameraman asks Jenifer after the doctors leave. They've scheduled Matias — now bouncing on his mother's lap — for surgery the next morning. She smiles.
“Yes, I’m happy,” she responds.
Hand Help is currently preparing for their next trip to Peru in spring 2018.