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Developing Pediatric Hand Surgery in Nicaragua 

Dr. Michelle James, pediatric hand surgeon and chief of orthopaedics at Shriners Children’s Sacramento, had always wanted to volunteer but felt she needed to wait for her kids to be grown and out of the house. When her daughter took her own volunteer trip to Central America and loved the experience, Dr. James realized there was no reason to wait. Her daughter inspired her to take the leap.

After traveling to Honduras through HVO with a colleague, she assumed she would travel with them to Honduras for subsequent trips. However, just before she was ready to return, the country underwent a coup, and her trip was cancelled. Nancy Kelly, HVO’s Executive Director at the time, suggested Dr. James join an established adult hand team going to Nicaragua with the goal of starting a new pediatric hand rotation in Managua, and Dr. James quickly signed on.

It would be the first of seventeen trips in only ten years. Dr. James kept returning to Velez Paiz Hospital and La Mascota Children’s Hospital with pediatric hand surgery colleagues from the U.S. and Spain, forming several lifelong friendships with Nicaraguan colleagues. She traveled to Nicaragua nearly every six months, heading a small team, to provide pediatric hand surgery care and training. Each team included an occupational therapist, two hand pediatric hand surgeons, and residents, fellows, or medical students, all handpicked by Dr. James. Her daughter, her colleague’s children, and even former patients, also accompanied her on several trips.

Such a diverse team was able to provide well-rounded and holistic training. Dr. James felt modeling the partnership between occupational therapy (which did not exist in Nicaragua before the team began providing training) and hand surgery was important. The occupational therapist on the team taught their Nicaraguan physical therapist colleagues some of the principles of occupational therapy, working with them on splint fabrication, activities of daily living, helping patients and their families determine which activities were most important to them, and addressing treatment and practices specific to those activities. Pauline Ng OTR CHT initiated the local OT training. Mary Ellen Brown, OTR and Ginny Gibson, OTR, CHT each traveled on multiple occasions to provide and train this valuable skill set.

From the start, Dr. James worked closely with Dr. Jairo Rios, a promising young orthopaedic surgeon, who was being encouraged to study hand surgery by the leadership in his department. Dr. Rios began medical school at only fifteen years old and always knew he wanted to be a surgeon. He decided to pursue a residency in orthopaedics and trauma, which he completed in 2008. In 2009, he met Dr. James and her team and began his training with them in pediatric hand surgery. Dr. Rios and Dr. James’ team, nicknamed La Brigada de las Manos, organized a clinic on each of their trips where they saw approximately 100 patients and operated on twenty to thirty patients with various congenital differences.

In 2011, Dr. Rios had the opportunity to travel to Sacramento, CA to present at the Pediatric Hand Study Group (PHSG) meeting. Between 2011 and 2017, he traveled nearly every year to learn from PHSG conferences and develop his knowledge of hand related congenital defects in children.

Dr. Rios now has fourteen years of experience working in pediatric orthopaedics and thirteen years of experience with congenital hand surgery. He says, “I am very happy now to be able to help so many children thanks to the collaboration and training of all my volunteer friends from HVO.”

In 2017, he, Dr. James, and two other colleagues published a paper entitled “Pediatric Hand Surgery Training in Nicaragua: A Sustainable Model of Surgical Education in a Resource-Poor Environment.” In the paper, they describe their experiences implementing their pediatric hand surgery training program. They discuss their collaborative efforts, the differences in training between Nicaragua and the U.S., and look at their results and ways further efforts might be improved. A second paper, “Assessment of Health Needs in Children with Congenital Upper Limb Differences in Nicaragua: Community Case Study,” which they also published in 2017 with two other colleagues, presents their findings on the needs of pediatric patients with congenital upper limb differences at La Mascota Hospital in the hopes that this research will inform possible new programs and pathways to better care.

Dr. Rios is the only congenital hand surgeon in all of Nicaragua. He therefore has a very busy schedule and a long wait list. Due to continued political unrest in Nicaragua, HVO recently made the difficult decision to close all projects in the country for the safety of our volunteers. Dr. James made her last trip just three weeks before the start of the unrest. Dr. Rios, while understanding, is disappointed.  “I wish with all my heart that help from all my friends from HVO would return and to be able to work together again for Nicaraguan children,” says Dr. Rios. “It would be a huge help to have more HVO volunteer collaboration to train more colleagues in pediatric hand surgery as all other hand surgeons in the country only operate on adults.”

While the project is currently closed, the relationships that came of it continue to thrive. Dr. James and colleague Dr. Marybeth Ezaki, a hand surgeon who accompanied La Brigada de las Manos on nine trips, are sponsoring Dr. Rios, to attend the World Congenital Hand Symposium in Minneapolis next year. HVO is hopeful that at some point in the future there will be an opportunity to re-establish programming in Nicaragua so that more pediatric hand surgeons can be trained to help Dr. Rios provide care to the young and vulnerable in Nicaragua.