Making an impact overseas

Bamako, Mali, September 2010. Awa Konandji is a 14 year old girl, who dreams of one day becoming a banker. This might be a little difficult for a number of reasons: she lives in Bamako, Mali, one of the 25 poorest countries on earth  and a couple of weeks before we meet, she accidentally touched a live cable and, although she survived, both hands and both feet are badly damaged; burnt.

She is an in-patient in the hospital I am visiting with the American ReSurge International for two weeks. We concentrate on hand surgery and cleft, lip and palate (CLP) surgery. I don’t operate on CLP in the UK, so I don’t do it here either. A very experienced American plastic surgeon, who specialises in CLP is on the team, so I get all the hand patients. There are many. Health and safety would have a field day: there are live cables everywhere on what passes for the pavement. I am not putting the cables to the test, but there are many, many children and adults with untreated burns and subsequent contractures from touching live wires

Awa’s left hand has burns in the palm and at the wrist, the tendons are exposed and there is clearly no function in the hand - it is stiff, she can’t move the fingers because the tendons have been burnt away. The wrist burn sits right over the median nerve, which supplies the sensation to the thumb, index, middle and some of the ring finger and the power to some of the small muscles in the hand, especially the thumb.

Awa’s right hand is also burnt in the palm, her right foot has a couple of clearly dead toes hanging on and the left foot has a superficial burn.

It is important that she gets treatment, there are no plastic surgeons in Mali, so our visit is necessary. ReSurge International provides one trip a year to Bamako, the capital of Mali. A young surgeon from Cote D’Ivoire is visiting to get as much training as possible in the two weeks we are here. Other surgeons from the hospital, but mostly medical students come to watch, work and learn.

Awa gets her burns debrided and dressed at the first operation. The next one is a little more involved - the raw areas are covered with skin grafts and she gets a pedicled groin flap for the left hand so that later, maybe the following year, we can perhaps reconstruct nerves and tendons.  The local surgeon is going to divide the flap later, once we have left, once it is time.

Her dress has to be cut off at the end of the operation, so I go out and buy her a new one. A pretty pink dress.

She tolerates having her hand attached to her groin very well, she doesn’t complain when her dressings are changed, we try to give her as many painkillers as is possible. Antibiotics are scarce, painkillers too. We brought a lot, but we have used them up.  I leave Awa and all the other patients in the care of Pam, the Hand Therapist from San Francisco, who is staying behind for another week, to change dressings, make splints and avert disasters.

I am not able to go back in 2011, but Pam does and she sends me pictures of Awa, who came bounding into the consultation room. Her hands are stiff, but she uses the left as a scoop, to hold things. She walks and skips on her foot and a half. An opponens-plasty, to bring her thumb into a better position is planned, but she needs to get a little mobility in the hand, before that is possible. Therapy and splinting is again initiated, but she needs the operation and the next visit from ReSurge is a year away. A couple of people from the 2010 trip have maintained contact with Awa, and I am trying to get her treated in Sierra Leone. UK Hand Surgery teams visit a small hospital in the middle of the country, in Makeni, but it is difficult. There are elections, no money and it is far away. I am not sure I will succeed, but I am trying. Continuing care is what makes the difference.

Barbara Jemec
Chair, BAPRAS Overseas Service & Training Committee