Two surgeons from the National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR) met me at the Dhaka airport and immediately took me to their hospital where I demonstrated the SIGN equipment. When we tried operating the next day, however, we discovered that the bone of the Bangladesh people was exceptionally hard. This appears to be due to genetic as well as to physical reasons (they do harder physical labor). Therefore, our SIGN technique had to be altered. Several instruments developed by SIGN staff (especially the new slot finder) proved to be very useful and, in fact, made the completion of cases there possible.

We spent the following days operating, making rounds, and participating in conferences. Approximately 200 people attended the conferences, where we had excellent discussions about orthopaedic surgery and philosophy as we discussed the injuries of patients who had been admitted the night before.

NITOR has 500 beds, does 16,000 cases per year, and has six operating rooms. Four more operating rooms have been built, but, lacking furnishings, cannot be used. They have many needs.

The operating rooms at NITOR were about the size of those in US hospitals, but, after the first day, since I had brought two SIGN instrument sets with me and they wanted to do as many cases as possible, we operated on two patients simultaneously. I did the first case and then insisted that they begin operating themselves. The surgeons in Bangladesh proved to be excellent. There were many obstacles to overcome but we persisted and, fortunately, all of the cases we did had good results. The (portable) x-ray in the operating room, however, had no cone down tube; this resulted in considerable radiation exposure to the surgeons, staff, and patients . . . a problem that must be corrected.

The helping spirit of the people in Bangladesh is evident. The doctors were great advocates for their patients and proposed SIGN nails for many difficult cases. The cases became increasingly difficult but, as they gained experience, the surgeons there became increasingly skillful. There were often many visitors in the operating room, some coming from other hospitals that would also like to start SIGN programs. The surgeons and I quickly became good friends.

Preparation for surgery in Bangladesh was different than in the US in that we used bar soap and had no brushes. I use Microcide to prep the patients, and, on follow-up, found no infections. Between cases we had many discussions about the origin of the people of Bangladesh and many other topics. I am very grateful to be able to help the patients and to work with these doctors.

My second day in Bangladesh was a "Hartal" (a political-religious strike), which meant that no motorized transport was allowed between 6 a.m. and 6 p.m. Accordingly, I was transported to the hospital by rickshaw, a human-powered three-wheeled bicycle. Four rickshaw drivers were killed during the strike.

I stayed at the Baptist Guest House near where the rickshaw drivers lived. As I looked out and watched them bathing in, and cooking with, the same canal water, I felt especially grateful for their transporting me back and forth to the hospital. It was a signal event for me as I remembered the book City of Joy, and realized that I could as well have been born to be a rickshaw driver in Bangladesh as a surgeon in the United States. I pledged to help the rickshaw drivers and decided that my first step should be to buy NITOR a fluoroscan so that SIGN surgeons there can safely x-ray their work while still in the operating room.

After 6 p.m. one night, when the heavy traffic had begun and I was being taken back to the Guest House in the dust and fumes of Dhaka traffic, taxis and other vehicles seemed to nudge us at every stop. My rickshaw driver, loyal to his passenger, was soon in the street, fighting another taxi driver.

As I left Bangladesh, I felt a deep gratitude to God for the opportunity to work with these people. They agreed to be a center for SIGN training and expressed the wish to train not only the surgeons in Bangladesh, but also those in Nepal; there is a great deal of interchange between the two countries. I enjoyed the camaraderie I experienced with the surgeons in Dhaka as well as my communication with the people of Bangladesh.

The people of Bangladesh have a way of staring that seems to communicate their thoughts. In this land of 120 million people, fifty percent of the population is below the poverty line, and 10 percent of the people are starving. A fracture under these circumstances is devastating, especially when the patients are family breadwinners. The entire family suffers from the trauma. I believe SIGN can, and will, make a difference in Bangladesh.