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In October, 2000, I had the opportunity to fly to
Guatemala City on a humanitarian and educational tour. For
the past six months, a program has been implemented for
orthopaedic surgeons from Latin America and South America to
spend time with us, observing our surgery and learning more
of the nuances of total joint arthroplasty involving the hip
and knee.
 My
surgical team and I flew to Guatemala City. With a
population of 2 million, this is a city of contrast. Less
than 10 percent of the population is enrolled in private
health care insurances, and 90 percent of the population is
dependent upon the national health care insurance program.
This program provides access to medical care including
hospitalization. A unique situation we observed involves
total joint replacement. While the patient has access to
medical care, they must purchase their own implant at the
time of surgery. Since the average income in Guatemala City
is between $600 and $800 per year and the average cost of an
implant ranges from $1,000 for a low demand generic
prosthesis to $3,500 for a quality total hip or total knee,
this surgery is affordable to very few Guatemalans.
Ironically, the $3,500 prosthesis available to Guatemalans
patients would be considered a middle-of-the-road prothesis
to the America populace. So therein lies our dilemma. For
the Guatemalan patient to afford the appropriate joint
replacement requires the patient and family to pool their
resources for at least one to two years. The end result is
that by the time the patient can afford the necessary
surgery, deterioration of the joint is most pronounced.
When we arrived in Guatemala, we were
greeted by very grateful orthopaedic surgeons and their
supporting staff. We were presented medical cases that had
been scheduled well in advance and posed inherent
difficulties to the Guatemalan orthopaedic surgeons. Our
cases included physician's family members, physician's
office members, and others that were deemed beyond the
expertise of the local surgeons. When we were taken to the
clinic for what was to be a review of x-rays of the upcoming
surgeries, it became apparent that this experience would
impact us all at an emotional level. Walking down the
corridor into the clinic, we observed benches filled with
both patients and family members. As the Guatemalan
orthopaedic surgeons presented x-rays and the history behind
individual cases, we were asked if we would like to examine
the patients. One particular patient illustrates the
challenges we faced.
A very pleasant 40 year old female walked
into our room smiling and greeting us. She used two crutches
and was probably dressed in the best dress that she owned.
It was obvious that her one extremity was 2 inches shorter
than her other and the Guatemalan doctors explained that she
had multiple prior operations on her hip. She never
complained of pain while we examined her hip, but her facial
expressions and the look in her eyes told us the true story.
In reviewing the x-rays it became apparent that the
destruction of her hip from all the prior surgeries was so
massive, and the resources that were available to us were so
inadequate, that we could not reconstruct her hip. As the
Guatemalan doctors explained this to her, we could see the
heartbreaking disappointment on her face. She looked at us
and in broken English said, "Thank you". Nevertheless, it
was time to proceed with those patients that we could help.
Before finishing in the clinic I turned to the Guatemalan
physicians and told them, "One day we will be back and we
will reconstruct this lady's hip".
From this point on, we began to educate
and treat those patients that were deemed eligible for
surgery. We operated out of three facilities, two of which
could be called a hospital, the third was most likely a
renovated house referred to as an outpatient clinic. Two of
the facilities' temperatures exceeded 95( despite the fact
that they were considered ultra sterile rooms. The windows
were painted black so that the sun could not heat the rooms
any further. At one facility, due to the lack of
instrumentation, the Guatemalan orthopaedic surgeon in
charge purchased a Black and Decker drill to perform our
surgery. The drill was sterilized in a gas chamber so that
we had some power equipment to perform our surgery. Despite
the abysmal circumstances presented to us, all the patients
that were operated on were sitting up on the day of surgery,
out of bed the next day, walking and expressing their thanks
to us. Each night x-rays were brought back to our hotel for
our review by the Guatemalan orthopaedic surgeons who were
ecstatic with the progress of their patients and the
appearance of the x-rays. While the team, including my
nurse, Liz, and members of Osteonics, Inc. (Larry and Kevin)
reviewed the x-rays, we could only wonder if we could have
done the operation a little bit better. This baffled the
local physicians who felt that our surgeries were
spectacular.
By the time we completed our work, we
were exhausted with the rigorous schedule and the
heart-wrenching decisions that had to be made regarding who
could and could not undergo surgery. As we left the country,
I voiced my opinion to my cohorts, "While the rewards were
great, the stress was probably too much to bear". The
response from my support group was swift and concise, "So
where do we go next?".
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