Training an Alternative to Bone Setters – Improving Orthopaedic Surgery in Ethiopia

Through a partnership between the University of Oxford and the College of Surgeons of East, Central and Southern Africa (COSECSA) orthopaedic surgical capacity was strengthened in the COSECSA region through the delivery of paediatric orthopaedic surgery and hip and knee surgery courses to 90 trainees in Kenya, Zambia, Ethiopia and Malawi. Many of these trainees also undertook fellowships at CURE hospitals across the region.

During a visit in June 2017, the Communications team met with Dr Biruk, Head of Orthopaedics at the Black Lion Hospital,  as well as two residents who had taken part in the training held in Ethiopia to find out more about the partnership and why their side of the training focused so heavily on road traffic accidents.

Ethiopia needs over 10, 000 orthopaedic surgeons but presently they have less than 500, serving a massive population of over 100 million people. This need is further exacerbated by the huge cost road traffic injuries put on surgical teams around the country. In total, every year, almost 5000 Ethiopians die from road traffic accidents.

Nowhere is this more apparent than at the Black Lion Hospital where trauma caused by traffic accidents is at the top of the list and is ‘always on the rise’. Currently, 70% of all trauma cases are due to traffic accidents. Most of these injuries are preventable.

“Ten Ethiopians die every day on average. Last year we lost between 4000-5000 Ethiopians due to car accidents.  We multiply it usually by twenty to estimate the number of injuries, so it is a huge amount and the number one enemy in the trauma section.

Two thirds of our patients who suffer accidents are men. This of course has further impacts, as they are often the main providers for their families aged between 20 to 60. Often they have their own farm in rural Ethiopia where of course the majority of Ethiopians live.  But during dry seasons they leave their villages for cities and engage in work that is likely to cause injury, working on busy roads or fast expanding construction sites across the city.”

More patients than beds

“Here we have 70 beds in orthopaedics but these are only the ones we count. We go to the emergency room and sometimes we have more patients than beds. The hospital has 1000 registered beds on but we can at a given time have between 1500 to 2000 patients.  We have 26 departments and on average each day we can see about 3000 patients.

In our department, on a bad day we may see over 20 emergencies but on average we tend to see 8 to 12 emergency patients every day and night. However we also have the non-emergency cases, like the fracture patients you see waiting outside and these can number up to up to 100 patients a day.”

Training through partnership

Nardos and Esmias, both final year Orthopaedic Surgery residents, spoke to us about the training they had received during the project:

“I was in two trainings, one focused on paediatrics and the other on tumour.  The special thing about the training was having experts from other countries come and share their learning and also being able to show them the techniques we use in Ethiopia.

We had lectures and were taught step by step.  Most theory was in the mornings and the practical elements were done in the afternoon.  It was a really thorough training. For the tumour cases in Ethiopia we usually do amputations here but instead they showed us how to do limb surgeries which was new for us and it was very helpful.”

Providing an alternative to traditional bone setters

As Dr Biruk explains, training programmes like this are so vital because they are helping to produce specially trained surgeons, providing alternatives to traditional bone setters.

“Through outreach and Health Extension Workers (HEWs) we have been able to work with bone setters to improve safe practices. Of course orthopaedics by the way is still a new concept but we are moving away from historical practices where traditional bone setters were common.  For now, we encourage simple teachings, asking them not to apply tight splints, and this is working. The wider problem we have is that most patients are shy and have a phobia of modern medicine. But training specialists in the hospitals is certainly having a positive impact as community leaders and patients return to their communities with success stories. We can only hope that this continues to alleviate the unnecessary suffering caused by traditional practices.”