Introduction
In 2017, a team of 34 individuals traveled to Managua, Nicaragua as a part of a week-long surgical mission trip to provide care for individuals in developing nations with upper extremity disease. This team of surgeons, anesthesiologists, nurses, students, therapists, and interpreters was organized by Hand Help, Inc., a nonprofit organization founded in 2005 by Dr. Grant Thomson, Professor of Plastic Surgery and Director of the Yale Hand and Comprehensive Microsurgery Center. Since its founding, Hand Help has treated more than 1,800 patients in developing countries with congenital and traumatic diseases of the upper extremity. In 2017, the group performed 91 cases, ranging from wrist cyst excisions to complex tendon and peripheral nerve transfers in children and adults.
The Problem
Having adequate hand function is crucial for our daily living. Our hands allow us to interact with the world and society. In lower-resource countries, many individuals critically rely on the use of their hands for the ability to work. Eighty percent of the population in Nicaragua are engaged in manual labor including agriculture and factory work. For children with congenital hand deformities, many parents worry that their children will have no future. Operative interventions need not be overly complex or time-consuming to make a world of difference in the lives of these patients. It is important to recognize that resource-poor populations also suffer from disease common to resource-abundant populations. One common pathology that we observed during this mission was carpal tunnel syndrome, which can seriously impair an individual’s ability to work or perform day-to-day life activities. In a matter of minutes, a carpal tunnel release can provide almost immediate resolution of symptoms with minimal risk of complications or postoperative management.
Logistics
Members of the Hand Help team began planning for several months prior to the mission. Each trip costs approximately $30,000-35,000. Fundraising campaigns are typically launched online and take place at local charity events. Aside from the monetary costs, all medical supplies were donated from hospitals and manufacturers, and all trip participants volunteer their time every year. In the process of sharing our cause with the New Haven community, several local businesses supported our cause, including CandiTopia (located at 1022 Chapel Street, New Haven CT), which donated $4,000 to last year’s mission.
This past year, Hand Help partnered with Hospital Alemán Nicaragüense (HAN), located in Managua. While this is a large 300-bed hospital that is staffed by several attending surgeons and surgical residents, there are still limited resources and patients typically wait for months to be treated.
The Hand Help team arrived in Managua on a Saturday, and Sunday was then spent in our intake clinic, triaging patients at HAN. Often, these were patients who had traveled from outside Managua to be seen by the Hand Help team. On Sunday night, the attending surgeons met to develop an operative schedule for the week, which balanced the limited personnel, instrument sets, disease acuity, and need for postoperative monitoring.
New Technology
This year, the Hand Help team demonstrated the efficacy of using minimally-invasive endoscopic carpal tunnel release in the global surgery setting. For this procedure, the team brought an endoscope donated by the manufacturer and the accompanying monitor and tower. Introducing new technology was not without its hurdles, as our team quickly discovered that the autoclave method we were using was not compatible with the scope, and instead relied on other sterilization methods.
One of the patients, Renata, presented to the Hand Help mission three years prior for an open carpal tunnel release. In 2017, she returned for her contralateral hand, and was very satisfied that she was able to receive the endoscopic procedure. Throughout the week, Nicaraguan surgeons and residents would stop in the endoscopy room to observe as Dr. Thomson performed these endoscopic carpal tunnel releases. On our final day, we had the opportunity to provide educational lectures to HAN staff and students, and Dr. Thomson gave a lecture on endoscopic carpal tunnel release.
Hand Help Model
The Hand Help model is one that differs from many other global surgery organizations. Of the team that embarks on the trip every year, there is a diverse group of expertise, including plastic and orthopaedic surgeons, pediatric anesthesiologists, pediatricians, interpreters, hand therapists, residents and students. Many of the individuals who participate in the trip trained at Yale under Dr. Thomson or have some ties to the university.
Through this diversity of expertise, the team provides a continuum of care from screening, perioperative care, and discharge counseling for hand therapy. This effort would not be possible without the partner hospital, HAN, which provides the facilities for our work, and whose staff assist as administrative, nursing, and support personnel, and also follow-up care after the team leaves. As a result, this is a replicable model that can be achieved in many settings, since it is one that does not place the burden of providing equipment and supplies on the host. In the coming year, Hand Help will travel to Peru to continue their mission of providing surgery care for the hand and upper extremity as well as rehabilitating lives in these communities.
Marc E. Walker, MD, MBA
Chief Resident, Plastic & Reconstructive Surgery
Alex Sun, BS
Medical Student, Yale University School of Medicine
Cyril Gary, BA
Medical Student, Yale University School of Medicine
Jack Kanouzi, MD
Postdoctoral Research Fellow, Plastic Surgery