I traveled to Banda Aceh, North Sumatra, Indonesia for one month in September 2005 as a senior resident (Year 4) from the University of British Columbia on elective, affiliated with and greatly assisted by SIGN and Dr. Zirkle. I am very thankful for his help, without it this trip would not have happened, and I certainly hope to continue to help with SIGN projects in the future.

It was overall an excellent experience both culturally and operatively. I felt very welcome, and the people were exceptionally hospitable and warm. Even as a stranger walking down the street people would greet me and smile at me. I worked mainly at Dr. Zainoel Abidin General Hospital, a large public hospital, and did just a couple cases at a private hospital.

Banda Aceh at that time was around 9 months after the tsunami, and still very much a reconstructive work in progress. Of all the areas hit by the tsunami, it was the most destroyed with a huge loss of life. Around 200,000 people died out of around 550,000 in the area. One person I met had lost 24 members of his family.

Dr. Azharuddin who I worked with is the only orthopedic surgeon for Banda Aceh city as well as a large surrounding area, so has lots to do! To help him there was a senior Indonesian orthopedic resident there for two weeks while I was there, and then a just-graduated orthopedic surgeon. Generally our day started at 0800 with ward rounds, then to the OR for 0900 where we would do 2-3 elective orthopedic cases or any emergencies. The maximum of cases we ever did in a day was 4. They are still short of personnel and in the reconstructive phase in the hospital, but around 5 out of 10 ORs were running. 150 nurses out of 800 died in the tsunami, as well as 20 doctors, and they are still flying in nurses from Jakarta every two weeks to keep their staffing sufficient. We were generally done by the late afternoon and often earlier. Dr. Azhar also runs a private clinic in the late afternoon into the evening, and as mentioned on the odd occasion I helped him with private operative cases. The physicians here for the government portion of their salary are paid about $200 US per month, so the private portion of their practice is fairly crucial to them economically.

We did a very interesting mix of fresh trauma (lots of open fractures), neglected trauma with horrific non-unions and malunions, and some spinal surgery as well as three clubfeet. We did about one case per week of non-union or malunion still left over from the tsunami. Overall in one month we did around 35 cases, of those I was the principle operator for around 25. I missed some cases on two weekends that I was away visiting a neighbouring island.

Our operative cases were high on the spectrum of orthopedic complexity. People here still tend to go to the traditional healer/bonesetter as their first treatment, so we saw very few bread and butter orthopedic cases like ankle fractures, hip fractures, or distal radius fractures. Even one patient with three open fractures refused surgery and went to the bonesetter! Needless to say, this led to a heavy load of elective attempts to correct neglected trauma, difficult and time-consuming. For example we did several femoral non-unions, several complex tibial nonunions, two both bones forearm non-unions, a non-union of the femoral neck, and a Barton’s fracture with completely dislocated carpus that was 6 months old! I also repaired an injury to all the flexor tendons to the ring and little finger that was 20 years old, hoping to get improved function at least through the tenodesis effect. It was a challenge dealing with shortened soft tissues and scarred in nerves and vessels, and trying to restore normal anatomy with limited equipment. We jokingly called our operating “high on creativity, low on technology.” The SIGN nail was a great tool, although has to be used with great care in non-unions due to the severe disuse osteopenia. In one segmental tibial non-union I managed to put the nail through into the ankle joint although I placed it by hand gently. Without fluoroscopy we didn’t figure it out till the next day, and had to revise it. They did have one fluoroscopy machine that worked, but was often in use in the other ORs, so we never actually used it while I was there.

With the shortage of OR time and personnel, open fractures often have to wait. We actually started a study on open fractures while I was there, and enrolled 10 patients during my stay. We hope to look at the incidence of infection both short and long term in the delayed treatment of open fractures, and the safety of primary closure. Some patients waited two days till we got to them, for a variety of reasons, usually transport time or resources. We had only one post-op infection while I was there, of a Chopart amputation for squamous cell carcinoma.

Generally the operative experience was excellent, but not for the faint of heart. As I was there to help, Dr. Azhar was actually doing other things most days, and so I operated with the Indonesian resident and then the visiting surgeon. I did a number of cases alone assisted by the nurses, fortunately that was around two weeks in and I had learned the names of the instruments in Indonesian by then. One day the other surgeon was doing emergency cases in one room, I had the other room, and Dr. Azhar was running the clinic. We had some interesting equipment challenges, we didn’t have a good converter for the donated drill for the first two weeks, and so used a semi-sterile 6V Black and Decker drill, whose battery ran out at the beginning of a case once with no replacement, so we scrubbed down the charging cord with iodine and alcohol and plugged the drill in! I would then drill a hole and wait 2-3 minutes for the next one so the battery could build up juice.

Overall I was very impressed with their surgical skill and the difficult problems that they routinely have to deal with. As far as other things went, for accommodations I stayed with Dr. Azhar and his wife in a house which is right across the street from the hospital. It is a government house, and had up to 8 other doctors in it as well at any given time. His own house is still being rebuilt. All doctors in Indonesia have to do government work for up to three years post-grad, so many are sent to Aceh from elsewhere to do their service, and have to spend months away from their family at a time. The atmosphere in the house was very collegial, we would eat together and plan outings together, as all of us were generally away from our families and not from the Aceh area. The food was very good, probably better and healthier than what I usually eat! Dr. Azhar’s wife is a dermatologist but also a fabulous cook! There was power and water, and air conditioning in the bedrooms.

Two of the weekends I went away to a nearby island, where there was a nice beach area with beautiful swimming, snorkeling, and scuba-diving. Banda Aceh itself is definitely not a tourist destination, but I did also go swimming there quite often outside the city. I was generally swimming alone as very few locals swim there, so many people died in the water that they are worried about ghosts. For transport I drove with Dr. Azhar, the other doctors in a ambulance that wasn’t on duty (for Sunday trips to the beach), and rented a scooter for the last two weeks (although the traffic is a little crazy). The city itself is still very much in reconstruction phase, with many people still living in tents.

The political situation in Aceh province is quite good right now. The Free Aceh Movement rebels that had been causing trouble for 29 years have now signed a peace treaty. Two soldiers were killed farther away in the province while I was there as a last gasp attempt I think, but I felt very safe in the city. Many countries still have travel advisories against Indonesia, and another bomb did go off in Bali just after I left, but I think Aceh province is no problem. There was no hostility towards me as a foreigner at all, rather I felt more welcome than I do in my home country! I had no trouble with customs even though I was bringing in some surgical equipment, and the visa was easy to obtain in Canada, or can even be obtained on landing.

Food and everything else is very cheap by our standards, the minimum or poverty level wage is only around $20 US a month. I spent very little money on food, and didn’t have to pay rent at the government house. I did try to help pay for the food and household expenses, but “Mama Dina”, Dr. Azhar’s wife, refused. I did promise her royal treatment on any visit to Canada though…

The climate is hot and humid, usually in the mid 30s Celsius (not sure what that is in Fahrenheit), and I had to tie an extra wrap around my head sometimes so that I wouldn’t sweat into the sterile field. The OR did have air conditioning, but still got quite warm. There were five small earthquakes while I was there, as the area is relatively seismologically active. They had no other effect beyond minor shaking, and I slept through two of them.

Overall, it was a great experience. Certainly I learned a lot and did a lot surgically, and hopefully was of some help. I really enjoyed the relationships with the people I met, and would gladly return. As there was no night duty for me and no call, it was even quite restful compared to my schedule at home! I certainly would recommend this experience to other senior residents or qualified surgeons, and know Dr. Azhar is happy to have the help.