Dr. Kent Saltonstall M.D., orthopedic surgeon, volunteered his valuable time

 

Dr. Kent Saltonstall M.D., orthopedic surgeon, volunteered his valuable time on Christmas Island earlier this year.

Dr. Kent Saltonstall M.D., orthopedic surgeon, volunteered his valuable time on Christmas Island earlier this year.

This report describes my medical service with PIMA at London Hospital on Christmas Island, Line and Phoenix Group, Republic of Kiribati, central Pacific Ocean, May 17-24, 2011.

I was extremely well received the entire time by Doctors John Tekanene and Teraira Bangao, and the friendly hospital staff. Every effort was made to assist me in my work as consulting Orthopedic Surgeon.

My work began with an inventory of operating room equipment. I found a large quantity of donated used Synthes high-technology instrumentation, consisting of three separate small fragment sets, the basic large fragment fracture instruments, and tools for the Dynamic Hip Screw, all including plenty of bone screws but no fracture repair plates. This equipment is of little use in the present island environment. At the same time, there is a severe inventory shortage of basic supplies such as Steinman pins (there is one bent one), Kirshner wires (none), traction bows, pulleys, rope, and the like. Plaster of Paris inventory is limited to a few rolls, and there is some older fiberglass casting material starting to harden in the packages. Webril and stockinette are needed, four and six inch sizes. There are only a few well-used metal splints. I have suggested an equipment swap with other Kiribati hospitals, Synthes stuff for casting materials, splints of all sizes, etc.

I saw a dozen or more patients each day for Orthopedic consultation, some selected by MD referral, and many self-referred, especially after I was announced on the local radio. My time was best utilized by MD referrals, and the injured from the international fishing fleet. I felt particularly useful to a 20 year old Vietnamese fisherman with a displaced both bones forearm fracture, and we were able to send him home nicely reduced and casted, together with his x-rays and a letter of instruction. I believe the hospital will bill the boat owner for my services. One nice feature of this practice was that our international patients were billeted with me at Captain Cook Hotel, so I lived among them: Ngoc in his new cast, the Spaniards with supposed appendicitis eating with gusto in the old British officer’s mess, and our psychiatric patient Elvis from the Philippines, already much improved. Elvis had been behaving strangely on the tuna longline boat, sleepless, wandering about babbling in his language, fighting, but he straightened out nicely with medication from Dr. John and tourist accomodations on the beach. Also I was able to advise several patients about their arthritic joints and malunited fractures, and speak to parents about their crippled children, including cases of old polio and severe clubfoot. I saw spine deformities from old tuberculosis, and one active case. I made one recommendation for possible elective reconstructive surgery off-island, a 29 year old tattoo artist with a 90 degrees malrotation of his proximal femur and end-stage hip avascular necrosis following a childhood electrical injury.

On Sunday we went around the island by truck to the small clinic at Poland, where I saw 27 patients (about ten per cent of the village population), and everybody said I was the first Orthopedist ever to visit there. We tried to bring several to London the next day for x-rays, but there was not transportation. Perhaps next time. The Poland clinic has some basic sanitation needs such as screens to keep out flies, and handwashing facilities.

I worked closely with Ordman the xray technician, and was able to share some tips about positioning of patients. The scope of her work has been limited by the lack of different x-ray film sizes and the dimensions of her drying rack, so that her day grinds to a halt when the rack is full.

I did no surgery on the island, and would not attempt clean orthopedic cases there under the present circumstances. Emergency surgery such as drainage of infection and debridement of open fractures is feasable, they have the knives and Dr. Bangao who is a very capable anesthesiologist. It would be good to get a donation of some bone plates for emergencies, new or used.

The biggest impact I forsee would be to somehow improve the almost non-existant fracture referral on the island. Island culture seems to be that extremity injuries are treated by the traditional massage practitioner, and the doctors are not seeing many, so are not getting the experience. My first priority for the hospital is for basic sanitation such as hand washing, and elimination of flies indoors using fly traps and screens.

I had a very fine experience at London Hospital and I look forward to more.

Respectfully submitted,

by Kent Saltonstall MD, Associate Clinical Professor of Orthopedic Surgery Emeritus, University of Washington Medical School, Seattle, Washington, USA.

Diabetes Specialist Leads Christmas Island Study; More Than 500 Islanders Surveyed

Team Tackles Diabetes: The Christmas Island diabetes team has done its homework and is ready to go to work in each village on the island. Clockwise from left are Kiribati nurses Taairi Iete and Tekoriri Kiauea, Dr. Elizabeth Beale, USC masters of public health students Alexandra (Nikki) Anderson and Brooke Lejeune-Chanman, and Christmas Island nurses Nana Teboko,Tarannang Iaramako and Ira Matang Tekanane.

Team Tackles Diabetes: The Christmas Island diabetes team has done its homework and is ready to go to work in each village on the island. Clockwise from left are Kiribati nurses Taairi Iete and Tekoriri Kiauea, Dr. Elizabeth Beale, USC masters of public health students Alexandra (Nikki) Anderson and Brooke Lejeune-Chanman, and Christmas Island nurses Nana Teboko,Tarannang Iaramako and Ira Matang Tekanane.

In early August I was very fortunate to make my second trip to Kiritimati (Christmas Island) with PIMA, this time accompanied by 2 Masters of Public Health students from the Institute of Global Health of the University of Southern California: Alexandra (Nikki) Anderson and Brooke Lejeune-Chanman. Our goal was to obtain a better understanding of the prevalence of non-communicable disease on the island in order to help plan further medical aid, and also to assess factors that might explain the very high prevalence of type 2 diabetes in Kiribati.

In 2 weeks we surveyed over 500 islanders. We conducted in-depth questionnaires, body measurements and fasting blood glucose. In a subgroup of nearly 200 participants we also conducted a detailed dietary recall, measured a full fasting lipid panel and took buccal swabs for genetic analysis.

It will take us several months to enter and analyze the data but we look forward to being able to share our findings by the end of the year. In the meantime I would like to take this opportunity to highlight some of the many people who contributed to this trip and to thank them for their assistance. Sincere thanks goes to each person and group who participated for their generous and enthusiastic support.

  1. To our colleagues and friends in the medical community of Kiritimati: Dr Teraira Bangao and Dr John Tekanene and all the nurses and staff who helped us including Tarannang, Nana, Maria, Tekoriri, Tamato, Taiiri, Ira, Kuta, Nunkay, Ruta, Julia, Tebikea and Kiaman (and of course Taaren). We appreciated your willingness to do all the translating we needed, for helping with the recruitment and the consent process and your hard work in collecting data. We are particularly proud of the fact that so many team members obtained the CITI Human Subjects certification course online prior to our arrival which enabled us to carry out the survey according to the high ethical standards that are appropriate as well as required by USC. This would not have been possible without the internet capabilities now available in the new Ronton Hospital Annex and installed by PIMA. Now that the team has Human Subjects certification future studies will be much easier to organize. Thank you too for our warm welcome, your hospitality during our stay and for our wonderful send-off.
  1. To the Institute of Global Health and Department of Preventive Medicine at the University of Southern California: thanks for choosing 2 outstanding students to help develop the project and to come along and share the work and fun, as well as for the financial support provided for this project. Both Brooke and Nikki have said they want to return and continue with the work and keep in touch with their new friends. Special thanks to Ivette Flores who helped guide the project through the early planning stages and for making sure it became a reality.
  1. To Linda Chan PhD friend and colleague and statistician par-excellence at LA County, who is always available with expert help when needed despite an incredibly busy schedule.
  1. To Dr Jaimie Davis and Amanda Vanni for assistance with the design of the project and for teaching us how to conduct the dietary recalls.
  1. To Dr Hooman Allayee: for adding the genetic analysis side of the study. We look forward to hearing about your findings.
  1. To the IRB of USC: especially Marie Reyes and Dr Darcy Spicer for their conscientious and careful assistance with this project (the first international study I had attempted) and especially for helping us to get approval “under the wire” to start on time in Kiritimati.
  1. To my colleagues in the Division of Endocrinology and Diabetes at USC: especially Dr Anne Peters who first put me in touch with PIMA and has continued to support my involvement, and Dr Tom Buchanan for giving his approval for my participation.
  1. To the team at Abaxis: Ron Blasig, Rick Betts, Jeanne Blake and Ruby Baniaga. We appreciate your loan of the Piccolo Xpress labs through your Philanthropic Loaner Agreement. Without the Piccolo’s we would not have been able to do the first-ever assessment of lipids in this part of the world. The labs were put through their paces for over 2 weeks: in equatorial temperatures and running off a car battery in the tiny clinic at Poland and 3 different maneabas (meeting centers) in Banana …and did a great job.
  1. Preparing for Research: PIMA volunteer endocrinologist Dr. Elizabeth Beale, flanked by USC masters of public health students Alexandra (Nikki) Anderson, on her left, and Brooke Lejeue-Chanman, begin the first of several study sessions with nurses and the doctor on Christmas Island in preparation of surveying more than 500 islanders in their anti-diabetes campaign.

    Preparing for Research: PIMA volunteer endocrinologist Dr. Elizabeth Beale, flanked by USC masters of public health students Alexandra (Nikki) Anderson, on her left, and Brooke Lejeue-Chanman, begin the first of several study sessions with nurses and the doctor on Christmas Island in preparation of surveying more than 500 islanders in their anti-diabetes campaign.

    To Erin Bonovetz and the Perrigo Company: thank you for your generous donation of 1,500 of the most accurate fingersticks and glucometers currently available. We used them every day and they served as the backbone for assessment of glucose in the study and we believe will significantly contribute to the value of our findings.

  1. Of course last and not least I have to thank PIMA for initiating and coordinating the trip, for making sure we had everything we needed to do our project and for working to make the trip as enjoyable as possible: nothing seemed to be too much to ask…well maybe one thing: as Carlton and I scrambled between immigration and tight flights in Honolulu with 4 month old Baby Inga and his suitcase lovingly packed by his Mom in Banana, 2 precious Piccolo Labs, our own carry on luggage with laptops, four large suitcases packed with sea shells, gifts from our colleagues on Kiritimati, 500 data forms and 200 mouth swabs not to mention passports, visas, health documents and boarding cards, I suggested it might be nice to take a dozen or so Hawaiian pineapples home with us as gifts. Just for a second I thought Carlton might have thought this was a bit much to ask and I thought that I might just have blown my chance of being invited back again. But we all know he WOULD have let me buy them. Thank you Carlton. It was the trip of a lifetime. For those of you who didn’t get a pineapple: now you know why.

by Elizabeth Beale MD

Assistant Professor in Clinical Medicine

Division of Endocrinology and Diabetes

Keck School of Medicine

University of Southern California