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Building Relationships and Improving Orthopaedic Healthcare in Tanzania

Dr. Robert Erdin made his first trip to Moshi, Tanzania with the HVO orthopaedic project at Kilimanjaro Christian Medical Center (KCMC) in January of 2020. He had been looking for volunteer opportunities for orthopaedists, and he learned of HVO through the American Orthopaedic Foot & Ankle Society. He felt it was a good fit and took his family along with him.  

The trip was a success, but, shortly after, international borders closed and operations shut down due to the COVID-19 pandemic. As HVO embraced a virtual education model, Dr. Erdin remained an involved volunteer. He and Matthew Braswell, a third-year resident with some overseas volunteer experience and an interest in building stronger relationships, explored online possibilities for themselves and partners at KCMC. The first step they took was using Zoom to include KCMC providers in their grand rounds at Dr. Erdin’s institution, the Atrium Health Foundation. This evolved into monthly Zoom meetings that ranged in discussion topics. KCMC residents had a particular interest in consulting with pediatric orthopaedists, as there are no subspecialists there with this expertise. Some of the many topics covered in these online meetings include pediatric upper extremity fractures, total joint periprosthetic infections, emergency management of pelvic fractures, foot and ankle fractures, and basics of knee arthroscopy. 

When Atrium Health merged with Wake Forest Baptist Health, the Wake Forest residency director and trauma specialist, Dr. Jason Halvorson, expressed enthusiasm and became involved as well. When Dr. Erdin decided to make a second trip in 2023, Dr. Braswell and Dr. Halvorson signed on. They also recruited Dr. Virginia Casey, a pediatric orthopedist, and Dr. Natalie Marenghi, a chief resident.  

Dr. Erdin was excited to return in person to KCMC. “By far, in person work is a more effective learning tool for surgery. Teaching with hands, even just gestures is so much easier in person,” he said. But he also expressed how important virtual opportunities were during the pandemic and in times when travel is not possible.“Zoom feeds have helped us establish relationships and gain some buy-in and trust from the residents…The most important thing about Zoom is the ability to provide a continuous presence which builds the relationship making our ‘on the ground’ time more efficient and kick starting that process.” 

The orthopaedics department at KCMC was equally excited to receive in-person volunteers once again. They expressed eagerness to have HVO volunteers return to the hospital to provide continued arthroscopy training, although unfortunately at the time of Dr. Erdin’s trip the equipment necessary for this training needed repair. The pandemic shutdowns made a noticeable difference at KCMC to Dr. Erdin, who says, “Unfortunately, the pandemic has hit the area hard.  Implant availability has been limited, residency size has increased which limits personal OR time, and fewer in-person volunteers has limited exposure to certain specialty areas within orthopedics…We roughly calculated that each resident is getting maybe 300 cases per residency time, which is very low. US residents usually participate in roughly 2000 cases. As a result, surgical skills are behind per training year compared to pre-pandemic. Returning volunteers will likely help improve technical skills.”  

On this trip, Dr. Erdin and his team covered a wide variety of topics. 

“We discussed foot and ankle trauma with interactive lectures, pediatric trauma and congenital deformity, and ended with nailing techniques, damage control orthopedics, and acetabular fracture identification/classification. While we had PowerPoint presentations for most talks, we quickly moved to more round table discussions which led to more active learning and less tired eyes in the afternoon heat. The PowerPoint slides provide some graphical reinforcement, but the talks were clearly more effective when everyone was talking and involved.  

We developed a deep vein thrombosis (DVT) prophylaxis protocol with the KCMC residency. Recent literature advocating aspirin as an alternative treatment is a game-changer compared to the expense of low molecular weight heparins and heparin prophylaxis. There were two deaths early on in our visit, likely due to DVT and pulmonary embolism (PE). A formal prophylaxis protocol was not in place. If implemented, I think this would be our biggest mutual achievement as a tangible improvement in healthcare standardization with the resources available to the hospital and patients.” 

Over the course of monthly Zoom meetings and his four week in-person visit, Dr. Erdin has established friendships he hopes will last years into the future. He also feels that the visit encouraged KCMC staff interest in future partnerships with himself and his team.  

This year’s visit may be completed, but Dr. Erdin’s work is not finished. “We hope to continue involvement with KCMC and the two North Carolina residency programs…With [KCMC staff] support, we hope to establish a consistent presence both online and on the ground with a rotation of sub-specialists to help provide a well-rounded exposure of all aspects of orthopedic fields. We plan to resume Zoom meetings [in March]. With KCMC staff help, we hope to build a case load for sub-specialist work to improve the opportunity of hands-on teaching when the different fields make trips to KCMC so the time with the residents there can be maximized.”