Dear Lew - I recently had the opportunity to work in Abbottabad in Pakistani Kashmir, where you had been earlier. I was based at the Ayub Medical Complex, which combines a medical school and a teaching hospital with close to a thousand beds. The head of the orthopedic department is Dr. Sohail Sahibzada, a delightful and generous host, who has spent many years in the U.K., as have his two assistants, Drs Schoaib and Ayaz. They oversee the academic activities of a dozen residents headed by Dr. Alam Zeb Khan, a very knowledgeable and skillful chief resident. Teaching is done at all levels: the Casualty Ward, the morning trauma conference, the ward rounds, the OPD and the operating theaters. The morning trauma conference lasts one hour, and new admissions are reviewed. It is quite dynamic, and I was impressed at the level of theoretical knowledge of the residents. I gave 2 presentations, on pelvic ring fractures and acetabular fractures. These appeared to be well received, and I later assisted Dr. Ayaz in an ORIF of a fresh posterior wall acetabular fracture with hip dislocation.

At the time of the earthquake in October, the entire system was overwhelmed. The hospital itself sustained some structural damage that forced its closure for a few days. A field hospital was quickly erected on the hospital grounds, but lack of personnel, equipment and supplies forced the transfer of many patients to more central hospitals. Still Dr. Sahibzada estimates that approximately 8,000 patients were treated within the first week of disaster.

By the time I got there, around 8 weeks later, the department had resumed its routine operation. The 60 or so orthopedic beds were all occupied with a turnover of 5 or 6 patients a day. Between 150 and 200 patients are seen daily in the OPD, and between 6 and 8 cases are done each day in the two operating theaters dedicated to orthopedics. Almost all the in-patients were earthquake survivors with either old, untreated injuries or who had already had initial treatment earlier and presented a complication such as hardware failure, wound problems and/or infection. I was surprised to see how many patients fell in the second category, as I saw at least a dozen patients treated elsewhere, with failed hardware. This has not been my previous experience in other similar circumstances, and should be analyzed appropriately. There were also a few fresh injuries, either from road traffic accidents, or as a consequence of a more recent earthquake that occurred a few days after my arrival.

Patients are scheduled during ward rounds for surgery the next day. Practically, The OT starts around 9am and does not run past 2pm, because of lack of personnel and anesthetists. There is one fracture table, old and decrepit, but still able to provide traction. We did a number of percutaneous pinnings and DHSs, as there is also a good image intensifier, most of the time operated by one junior resident. There are one or two circulators that provide equipment and supplies on an as-needed basis, but no scrub nurses. Again this task is performed by students. Drapes and gowns are old and frayed, gloves are re-used, and the lighting is precarious (only 4 out of 12 light bulbs were working in the ceiling light), but suction and electocautery are functional. Overall the sterility is very poor, with dozens of breeches per case and, by our standards, one would expect all these patients to get infected, which is fortunately not the case. In fact, I saw surprisingly few iatrogenic infections during ward rounds.

I had no opportunity to visit other facilities in the city, so comparisons are impossible. Fortunately, a SIGN surgeon from Dhaka, Dr. Faruque Quasem, was also there, dividing his work amongst different centers. He was present for most of the cases of SIGN nailing done while I was there: 5 in total, 3 femurs, 1 tibia and 1 humerus, and we all benefited from his vast experience. All fractures, except for one femur, were from the time of the earthquake and were technically challenging. Except for the long drill bits which were all broken, the SIGN instrumentation was complete and in good order. They are running short of interlocking screws. The newly arrived fracture distractor had already been used a couple of times, and everybody was raving about how well it worked. Attendings and senior residents seem all quite proficient with the surgical technique, and can do relatively difficult cases fairly quickly. I was satisfied with the surgical results in all cases.

I also had the opportunity to visit Balakot, one of the cities at the epicenter of the cataclysm. The magnitude of the destruction is hard to imagine, much less describe. The entire city was leveled, as if by an atomic device. No structure was left intact in this otherwise very scenic area. And I already saw some small infants showing signs of frostbite to face or feet, not a good sign as winter is barely beginning.

Overall, I had a very satisfying experience. The SIGN system is definitely put to good use, by technically proficient hands, and at no cost to the patient. Attendings and residents are, like in every developing country, limited by lack of means and materials, not knowledge and enthusiasm. The collaboration between the Ayub orthopedic department and SIGN is a good example of success, and in my opinion, should be supported for the foreseeable future.