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My Journey to Hand Surgery

My Journey to Hand Surgery

By Jerone T. Landström, MD, FACS

I would pursue a broad based surgical specialty or become a medical genetic researcher.  Both of these vocations would benefit society, especially the former in areas of the world where surgical care is inadequate.  I would certainly stay in the field of medicine and would preferably remain a hand surgeon and continue to inspire and motivate others to do the same. 

Through the privilege of practicing as a general practitioner and surgeon over thirty years, my greatest satisfaction and enjoyment has been that of a hand surgeon.  Yes, it was exciting and at times gratifying to do trauma surgery to the head, chest and abdomen by saving lives from our societies and our persistent genetic violent tendencies to each other outside our tribe and at times within our tribe.  Yet, there always was this over hanging displeasure and sadness like a hang over after the episodes of high adrenalin trauma surgical intervention of what we are capable of doing to each other.  In contrast, the specialty of hand surgery has provided the means to apply a broad spectrum of surgical skills to remote, isolated, impoverished areas that have no hand surgeon care to treat congenital and acquired functional deficiencies to let people peacefully carry on with their lives.  However, entering the field of hand surgery was not achieved without a serpentine,  diverse and arduous medical educational process that is atypical in our current medical education system.

So, when and how was the realization that general and hand surgery were critical aspects of health care?  This epiphany was not planned nor anticipated and did not occur until after completion of my general surgical internship in Detroit, Michigan.  Due to a medical school Public Health Service scholarship, I was obligated to work as a primary care physician in a health care shortage area. To my disappointment, I was not able to remain in my general surgery program without violating my scholarship obligation. 

The selected duty location was voluntary for my multiyear service obligation in a health care shortage area and in retrospect this fortunately allowed maximal continued exposure to surgical health care while working as a primary care doctor.  As I slowly spun a desk top globe from east to west of the U.S. and its territories, I found a duty station with a vacancy located halfway around the planet that I never knew existed. It was a surprise to find this duty station was part of the U.S. and only visible as a tiny dot near the equator in the far west pacific ocean known as the Trust Territory of the Pacific Islands (TTPI).  This geographic location was mainly ocean speckled with coral atolls and volcanic Islands that spanned an area as large as the continental U.S. and was closer to the Philippines than to U.S. Hawaiian Islands. This Public Health duty station was with an unfilled position ever since it was created and was located in Truk (Chuuk) State of the TTPI due to enhanced rumors of the violent tribal nature of the service community.  I thought to myself, this could not be any worse than Detroit, Michigan the murder capital of America at the time of my medical school and surgical internship.

The Public Health Service allowed funded my interview travel to Chuuk from Detroit Michigan and there I was interviewed by the local physician medical director.  He was excited and keen to recruit another physician and to seal the deal he told me that I could practice the full spectrum of health care due to severe critical shortage of physicians and no availability of specialists.  I signed up and returned to Chuuk after completing my surgical internship.

What a shock to my accustomed urban setting life, but also that of a cultural perspective in a subsistence society and from the attempted application of modern medicine with communications based on word of mouth and radios, marginal infrastructure, and no specialty support.  Here a physician shouldered patient care without the background support enjoyed Stateside.  

Upon arrival to Chuuk after 22 hours of island hopping flights for refueling, the half cargo and half passenger 727 plane had to perform a low flybys over the coral runway to alert the locals on the runway to clear.  It was common at that time for locals to relax and enjoy the cool ocean breeze coming across the runway with others scattered around the break wall of concrete tetrahedral ocean barriers fishing for their evening meal.  As the runway cleared of villagers by the second flyby, the plane came down hard and fast with immediate engagement of reverse thrusters kicking up a blinding cloud of white coral dust and debris obscuring the view from passenger windows as the roaring jet engines and wheel brakes settled the plane abruptly just before overshooting the runway and ending up in the ocean.  Later on, discussions with pilots that flew this route had stories of frequent aborted landings, ruined engines and planes that had ended up in the water was a little disconcerting as this means of transport was the only way to get back to modern civilizations.  As the plane taxied back to the single storied open terminal building, I was able to see from the plane’s windows lush island jungle and pristine blue to emerald green lagoon water. I thought I had landed in paradise and it was the most beautiful place on the planet, and it was in stark contrast to inner city Detroit, Michigan where I lived during medical school and surgical internship. 

Stepping of the plane, I was greeted with a smiling welcoming party from Truk State Hospital and curious local onlookers that always came to see the rare arrival of a plane.  For them it was an amazing site and would be the same as if we were to witness a UFO landing next to us.  After retrieving my baggage, I could hardly move through the tightly packed people trying to get a view of the newly arrived passengers.  The Truk hospital greeting party placed several Marmars on my head which are similar to the crown leis of Hawaii followed by their local version of leis around my neck until I could barely see from under the fragrant natural gifts of flowers. I noted that the Marmars and the leis cooled my head and body and that they had strong delicious scent from a local flower I had never previously experienced creating a surrealistic view of locals with smiling faces with exuberant excitement.  Walking through the onlookers, I scanned over the people I would soon serve as their physician and there were lots of runny nosed half naked to naked children, topless women in brightly colored dresses from waist to the top of their bare feet, men from the outer Islands of Chuuk wearing loin cloths varying from white, red and blue colors to identify their caste and others barefoot or with flip flops wearing typical western clothes that either had a shirt or pants but not typically both.  It was hot but not miserable due to the breeze coming from the ocean blowing through the crowd dispersing the smells of sweat, coconut oil, tropical fruits and fragrant flowers that was almost overwhelming.  As I made my way out of the throng of tightly packed people, I was met and led by the local Truk hospital staff with the Marmars and the leis making me strangely relaxed and sleepy.  Suddenly, I was rattled out of my bliss when I was told to sit inside the hospital pickup truck so I wouldn’t have a stone possibly thrown at my head during the drive to my temporary lodging.  I asked why I was not able to be taken to the designated open screen housing for hospital employees and was informed that there were still unauthorized squatters living in the quarters. 

Because of this problem, I was taken to temporary hotel lodging far from the hospital on the northwest tip of the Island.  We drove on an unpaved pot holed coral road away from the administrative center of government on the Island with scenery changing from American government concrete buildings to typical structures made of palm leaves and local wood products without windows to shelter families from rain as we drove deep into the jungle.  Because of there was no plumbing, fresh water supply, electricity or sewage systems outside the small central administrative government area of the Island, residents outside of this area lived similarly to their tribal ancestors.  Shelters, kitchens and areas to wash in were all made from the surrounding environment from palm fronds, wood branches, hibiscus bark, pandanus leaves, volcanic stones and coral based sand.  Since there was no indoor plumbing or a government administered sewage system, their small out houses known as benjos from the Japanese occupation during world war II were built over the lagoon for human waste.  Although this arrangement was a food feast for the fish, mollusks and crabs living in the ocean water below the benjos, this would end up with creation of the first recorded cholera epidemic in Micronesia.  Fresh rain water would be gathered  from their palm roofs or from mountain streams running down from the central elevated areas channeled by bamboo pipes to containers.  This water was used for communal drinking from a large container dipped into without any hand hygiene, used for bathing, and cooking.  Chickens, dogs and pigs roamed freely through the living, bathing and cooking areas with the pigs and chickens eating the dropped over ripe bread fruits splattered on the ground that attracted swarms of flies. 

Within a week I was moved into the hospital housing that had screens around the entire house without any glass windows that was a two minute walk to the hospital.  Of course, this housing situation allowed the patients to walk down the hill to my residence 24/7.  No matter the time or day the patient or family would arouse me from sleep or other activity respectfully and quietly through the screen window they could see me for medical assistance since often the health aid or doctor on duty at the hospital could not be found.  There were limited telephone service between the hospital and my quarters and the surrounding government administrative buildings, but it was usually not working due to the routine rain storms and monsoons.  Thus, when I was needed at the hospital off or on duty a nurse or a patient family member would come and get me personally from across the street. 

This experience did not take me long to appreciate our 20th and now 21st century societies advanced administrative, technical and health care systems.  Looking back at this period of service to those in need was a privilege spanning four years of experience in a health care shortage area in a society where survival is based on day to day subsistence highlighting the importance of our hands for survival.  Without functional hands in this type of society, one would not be able to shelter or feed self or a family as there was no place to get your shelter, daily nourishment except from the ocean and the Island you lived on. 

In this isolated physician shortage health care setting that often would leave a single physician to care for an approximate population of 50,000 people 24/7, the system was always at the margin of collapse.  This was frustrating since all physicians strive to give the best possible care within our training and experience but rarely have most physicians in our society truly experienced the added burden of care created by inadequate supplies, medications, diagnostics, and infrastructure.  From this experience, one really learns to appreciate the essential need for a team effort to administer and achieve the best possible care and outcome of our patients.  It takes a society such as ours with all members contributing to achieve our current standard of health care.  Otherwise, basic treatable health problems result in mortality or morbidity that affects all of us. 

This Public Health Service experience was illuminating and led to my realization and conceptional reinforcement of the essential need of general surgery and hand surgery care in all health care systems to mitigate pain and suffering in all.  This is where I became fascinated by hand anatomy, function and biomechanics.  I wanted to be able to treat all general surgical problems and have the skill set augmented by a hand surgery fellowship in order to provide the full spectrum of care to this society on my return to Chuuk from the States.  Despite my plans of returning the Chuuk after completion of all my training, it never happened due to local Island tribal politics, bias, and not being a blood relative.  But it has allowed application of these skills to health care systems of the Mariana Islands, Philippine’s, Afghanistan and of other areas in Micronesian.  

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