I visited Banda Aceh, Indonesia for two weeks in May and June 2006, just one week after graduating from medical school at the University of Calgary. With 6 weeks before the start of my rural family medicine residency at the University of Alberta, I was able to set up an independent elective in Banda Aceh with the help of Dr. Lewis Zirkle and SIGN.

I was met at the airport by Dr. Azharuddin, the only staff orthopedic surgeon in Banda Aceh, his wife, Dr. Dina Lidadari, and a visiting senior orthopedic resident from Java, Dr. Agus Dwi Sasongko. It was dark when I arrived, so it wasn't until the following day when Dr. Azharuddin and his family took me on a day trip to a neighboring island that I was able to have a good look at the city. It has been a year and a half since the tsunami, and I alternated between feeling amazed at how much had already been rebuilt, and overwhelmed by the thought of how much still remains to be done. Near the port of Uleh Leh, the effects of the tsunami are still very much in evidence: half-collapsed buildings, rubble, tents and fishing boats driven inland by the tsunami are visible as far as the eye can see. A simple memorial has been built near Uleh Leh to remember those who died in the tsunami.

Zainoel Abidin General Hospital in Banda Aceh has received a considerable amount of foreign aid since the tsunami and reconstruction efforts are ongoing. The hospital now has a CT scanner, and also has a brand-new NICU, labour and delivery ward, and emergency room. However, there are still shortages in terms of equipment and supplies. Prior to my arrival, Dr. Azharuddin sent me an email telling me that their only orthopedic drill was broken and by fundraising at my medical school, I was able to purchase a heavily subsidized drill from Stryker. The surgical wards do not have proper traction beds, which led us to improvise for the treatment of a young girl with a femoral fracture. Because of a lack of conventional external fixators, Dr. Azharuddin uses an acrylic substance to make fixators of varying sizes and shapes. Another need which several doctors expressed to me is the lack of textbooks, particularly ones which would be appropriate for medical students and residents.

While in Banda Aceh, I stayed at a government house across the street from Zainoel Abidin General Hospital with Dr. Azharuddin and his family. Dr. Dina cooked delicious food for us everyday, and Dr. Azharuddin's niece, a medical student, showed me around the university and the city. A typical day for me would start at 8 AM with a general assembly in front of the hospital with most of the doctors and the director of the hospital in attendance, following which we would round on the patients and then go to the operating theatre. We had a maximum of 4 cases per day, ranging from fresh trauma to spinal surgery to neglected malunions and non-unions to tuberculous spondylitis. Several of the surgeries we performed used the SIGN interlocking nail. On Tuesdays and Thursdays, we had outpatient clinics in the afternoons, and Dr. Azharuddin also had private outpatient clinics every weekday evening. Occasionally, I joined Dr. Azharuddin for operations at the nearby military hospital. I had free time most evenings and on weekends to visit the sights in Banda Aceh such as the market and the Grand Mosque, and some of the fishing villages and beaches nearby.

A good proportion of our cases were neglected cases, including at least two cases which were left over from the tsunami: a posterior hip dislocation, and femoral fracture malunion. Most of the patients we saw with malunions or non-unions had visited traditional bonesetters prior to seeking medical attention. According to Dr. Azharuddin, some people choose to go to bonesetters because of constraints such as money and access to facilities. Others are scared of surgery, and often assume incorrectly that a visit to the hospital automatically means surgical treatment. Unfortunately, the results are often sub-optimal and in addition to malunions and non-unions, gangrene and necrosis are common. One particularly memorable case involved a young girl with a severe flexion contracture of the hip. Her mother had taken her to 11 traditional bonesetters before finally coming to the hospital. On the same day, we also saw another girl who had visited a bonesetter and developed chronic osteomyelitis of the radius. On my last day in Banda Aceh, we saw a young boy with a fracture of the radius and ulna who had visited a bonesetter immediately prior to coming to the hospital. His arm was tightly wrapped with cloth and splinted with wood strips, and his skin had been covered with a paste made of duck eggs and herbs. Dr. Azharuddin told me that he often sees allergic reactions or even chemical burns as a result of this paste. With some difficulty, we scrubbed off the very sticky paste and applied an above elbow cast.

In addition to my experiences in orthopedics, I had the opportunity to attend clinic with Dr. Dina, a dermatologist, during which I saw a case of Stevens-Johnson syndrome, as well as a case of bullous pemphigus vulgaris. I spent some time on the wards and reviewing chest X-rays with Dr. Mulyadi, a pulmonologist, which was a great chance to learn about tuberculosis, a disease which we very rarely encounter at my hospital in Canada. As a brand-new family medicine resident, perhaps the most surprising thing for me was that family medicine in Indonesia does not appear to be recognized as a distinct discipline in itself. Patients generally go directly to the specialist of their choosing, which is often inefficient.

Although my time in Banda Aceh was short, I felt that Dr. Azharuddin and the other doctors I worked with did an excellent job of tailoring his teaching to my needs as a general practitioner rather than a specialist. I especially appreciate learning about principles of fracture reduction and casting. I am very grateful to Dr. Azharuddin, Dr. Dina, Dr. Agus and the staff at Zainoel Abidin General Hospital for their kindness and hospitality. This is the second elective which I have arranged through Dr. Lewis Zirkle and SIGN, and I remain convinced of the value of international experiences. I look forward to many more such experiences during the next two years of residency!