Diary of a Mission: Project Hope Belize — Part One

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By Rob Kistenberg, MPH, CPO, FAAOP

This July the summer prosthetic mission trip to Belize, Central America, marked the ten-year anniversary of Sonrie Inc. and Project Hope Belize providing prostheses in Belize. The following is a diary of the mission trip recounting my ten-day experience.

Day 1: Thursday, July 13, 2006

I arrived on Thursday evening, July 13, and was met at the airport by Adrian Camara-the clinic manager, technician, and a congenital bilateral transfemoral amputee. Don Pfau, RTPO, the next team member, will arrive on Saturday, July 15. Adrian has done a fine job with scheduling patients for evaluations; six patients for tomorrow, Friday, and another six on Sunday.

One very long transtibial amputation.
One very long transtibial amputation.

The trip to Belize was uneventful. No problems with the 120 lb. of materials and supplies getting through the airport. When I arrived in Belize, it was hot and muggy. On the hour-and-a-half ride to Orange Walk Town, Adrian and I caught up with each other. There was standing water alongside the highway which is unusual for this time of year. He noted that there has been a lot of rain. It always has an effect on the resin and laminations.

After dinner at Mr. Lee's Chinese Restaurant, I checked into the St. Christopher's hotel and was trying to do some reading when the power went out. So, I just went to bed early.

Day 2: Friday, July 14, 2006

We met at 7:00 AM for breakfast at a new restaurant, Marvia's Diner, to conduct strategic planning for the day. We had six patients on the schedule for evaluation. On the way to the clinic, the radio announced a warning to those in low-lying areas that a tropical storm was coming in on Sunday morning and that flooding was possible. That may affect whether our patients for Sunday can come in or not. For now, it is time to start making legs.

At the clinic by 8:00, we performed the morning ritual of opening windows and turning on the fans and lights. It is always good to be back in Belize. The clinic was spotless.

The First Three Patients

Deodato, Francis, and Farrid had transtibial amputations secondary to diabetes at ages 54, 69, and 74 respectively. Each had had diabetes for some time before they were made aware of it. Each had some small injury or insult on a toe that ultimately and quickly led to transtibial amputations. It is a very familiar story down here. They all also came in with shoes that were inappropriate for diabetic feet. The surgeries also were less than optimal. As prosthetists, we work with what people present with, and revision in Belize is really not an option. Each patient was evaluated and cast. We will be using gel liners and pelite as interfaces with mostly cuff suspensions.

A not-too-unusual presentation from one of the first three patients. His residual limb was swollen and the scar had adhered to the distal end.
A not-too-unusual presentation from one of the first three patients. His residual limb was swollen and the scar had adhered to the distal end.

Unfortunately, his 'sound side' was actively undergoing changes as a result of Charcot Foot
Unfortunately, his 'sound side' was actively undergoing changes as a result of Charcot Foot



The Next Two Patients: Juan Carlos and Barry

Juan Carlos had an amputation above the knee when he was 14 years old secondary to an accident with a machete. Shortly thereafter he received his first prosthesis from a group that brought him to the US for a few months in order to make his prosthesis. He has been wearing the same leg ever since. He is 35 now. His adductor roll is larger than his existing socket and he walks in pain with every step. The trim line of his existing leg has permanently scarred his residual limb. This is the result of receiving legs with no provision for follow-up and continued care. Was it worth him getting his first leg to leave him like this? It's hard to say.

We are going to try to make a new leg for him, but nothing is assured. He lives many hours away and will be staying in Orange Walk Town until we are finished.

The next patient, Barry, weighed approximately 360 lb. and had a left transtibial amputation secondary to elephantitis. It was truly a challenge finding any bony anatomy or identifying what I could feel. He is 35 years old and works as a taxi driver. His wife reported that he has been brokenhearted since the amputation because he cannot get out of his cab to assist with luggage and to open the car door for his fares. We were able to get a liner on him, but I am not certain if we can make a prosthesis for him. At this point, we only promised that we would try. He is ready for us to work our "magic."

Here I had, back-to-back, the two most challenging residual limbs for prosthetic fitting I had ever encountered in Belize or the US, and it wasn't even lunchtime on the first day. Bienvenidos a Belize.

A Busy Afternoon

Barry's left transtibial amputation in full extension.
Barry's left transtibial amputation in full extension.

We broke for a quick lunch at 1:30 at the Hong Kong Restaurant. After we returned to the clinic, the last patient of the day was cast while the first round of casts was filled. It was back to the Hong Kong (there are limited restaurant options) for dinner at 8:00 after modifying four of the six casts.

Juan Carlos is staying in town for the fitting, and calling his residual limb a "challenging fit" would be an understatement. We decided to go with a plaster diagnostic socket because we can make it quickly and assess the fit to see if we are even close. This way we can get a trial fitting on him tomorrow. After that We will finish modifying the remaining casts and then it's off to the airport to pick up Don.

Day 3: Saturday, July 15, 2006

Breakfast back at Marvia's, and a stop to fill up the mission van (It cost US $85--Gas is US $5.50/gallon) and pick up some phone cards and newspapers. We were at the clinic by 9:00 AM and began fabricating the plaster diagnostic socket for Juan Carlos. Adrian tried to call him on his cell phone but could only leave a message. He is staying at one of the small villages around Orange Walk Town (OWT), and they do not always get cell reception. Since we cannot contact him, we modified the last two casts.

We tried Mr. Lee's for lunch but it is getting a bit expensive as they have raised the prices again in response to a new tax from the government. A plate of chow mein is going for US $8.50.

Sugar Cane Season

We had some time before heading off to the airport so we took a small detour to the city bypass. Sugar is the main agricultural product for this part of the country, which means that during sugar cane season (NovemberJune), the large trucks loaded with cane clog the main streets of the city. Accidents between cars, bicycles, pedestrians, and these large trucks are common as they come barreling through the center of town. As a result, the government created a bypass that runs east of the city through the jungle which was completed in 2005. It is mostly "da bush" (jungle) with a small shack or two. The monotony of lush jungle was broken up by a family trying to catch fish in one of the streams running towards the New River.

Don Arrives

We picked up Don Pfau at the airport and headed back to Orange Walk. After a brief stop at the clinic for unloading of the supplies he brought, we headed over to Hong Kong for dinner and back to the hotel so he could get checked in.

Day 4: Sunday, July 16, 2006, 7:55 AM

It is a warm and cloudy morning but not yet raining. Since the hotel is on a high point of town, I can see the storms in the distance. It was pleasant to wake up to some peaceful bird songs and yoga. Adrian picked us up at 7:00 AM. Since no restaurants are open on Sundays, we went to the gas station and picked up some juice and bread. One lady was selling chicken tacos across the street, so Adrian picked up a few. We were at the clinic by 7:30. Still no patients and no rain. Perhaps the weather reports were wrong.

Day 5: Monday, July 17, 2006 8:45 AM

Juan Carlos

Juan Carlos in a plaster diagnostic socket.
Juan Carlos in a plaster diagnostic socket.

The rain did start falling yesterday but not the torrential downpour as predicted. Of the patients scheduled, four showed up and another three were walk-ins. We started with Juan Carlos' plaster diagnostic socket fitting. It went surprisingly well. He fit with a three-ply and even took a few steps with it. It helped to get the alignment, and he already reported being more comfortable on this socket than his current leg, which isn't saying much. After some minor modifications, we will move to laminate him.

Two More Patients and Rain

The next two patients both had transfemoral amputations, one secondary to complications of diabetes, the other secondary to poor circulation. The first, Manville, age 64, arrived with five family members. The second, Brijido, age 59, arrived with ten. Both men worked up until their amputations and both need to get back to work. Brijido's family came from four hours south, and they reported that the rains were pretty severe for their entire journey up here. This is notable because most of the family rode in the bed of a pickup truck holding a tarp. It is legal to ride in the back of a pickup truck as long as everyone is sitting on the bed.

Both men were evaluated and cast for prostheses. The challenge will be to modify them and try to fit them without the benefit of any diagnostic sockets.

The Manville Contingent.
The Manville Contingent.

Team Brijido.
Team Brijido.


Ms. Joyce Arrives

Fernando never left the house after his amputation at age five. Since being fit with a leg he has a job, a bike, and a girlfriend.
Fernando never left the house after his amputation at age five. Since being fit with a leg he has a job, a bike, and a girlfriend.

The last scheduled patient, Ms. Joyce, age 65, has had bilateral transtibial amputations for the last three years. She has spent most of that time in her wheelchair and as a result, she has severe hip and knee contractures and is not really a candidate. We explained the need for her to be able to straighten out her legs and that perhaps she could get physical therapy to help with the stretching. Her family agreed to look into it. She will be scheduled for the next mission in November.

Return Patients Come By

The other three patients were returns from previous missions. Fernando, a 14-year-old boy with a transfemoral amputation secondary to a car accident when he was five, appeared on his bike to say that he was doing fine. Deodoro came to get a replacement cuff strap and just to say hello. He was first fit in 1998 and again in 2003. Isabel, whose right transtibial amputation was fit two years ago, has had a transfemoral amputation on his left side now and needs a leg made for that one. He will be put on the schedule for the return trip in November. It was a strange reunion when Manville saw Isabel in the waiting area. They went to grade school together and now both were having amputations as a result of "da sugar" (diabetes).

Lunch was again at the Hong Kong and then it was back to the lab for fabrication. Don had been in back working feverishly all morning. I modified the remaining sockets and made a plaster test socket for Barry. I still am not certain what we are going to do for him. By the time we broke for dinner at 7:30, we had made two pelite liners and laminated three sockets. All in all, it was a smooth day. Days like this make me a bit nervous about the days to come. We usually need a good snag or crisis before I begin to feel like things are going well.

Robert Kistenberg, MPH, CP, FAAOP, is the prosthetics coordinator at the Georgia Tech Master of Science Program in Prosthetics and Orthotics. He is also a clinical coordinator for LIVINGSKIN by Aesthetic Concerns Prosthetics. In addition to teaching and clinical work, Rob does mission prosthetics in Belize and is serving as chair for the US Member Society of ISPO. Last year Rob completed his masters degree in Public Health with a focus on program evaluation and international health.

EDITOR's NOTE: Look for Part Two of Rob Kistenberg's Diary of a Mission in the November issue of The O&P EDGE.