Revolutionizing Orthopedic Care in Low-Income Countries, Part 1 of 3
**Note - please excuse the typos. This transcript was automatically generated.**
Hetal Baman (00:00:39) - What happens when the breadwinner of a family living under the poverty line in a low or middle income country gets into an accident breaking bones and eliminating his or her ability to walk, eliminating their ability to go to work and make money for their family? What happens then with more than 50% of the world's population living on less than $5 and 50 cents per day, a disabled family member who cannot work may drag the entire family even further into poverty. Most hospitals in low and middle income countries are not equipped to deal with the rising epidemic of trauma injuries. They treat fractures with traction, which will explain in the episode or plaster casts, which force the patient to be immobilized for three months or more. And even so, we can't rely on the outcome because the bone may not heal properly. Untreated bone fractures can easily lead to lifelong pain and disability.
Hetal Baman (00:01:44) - As a biomedical engineer who has worked within trauma orthopedics, I've always asked my colleagues, what are we doing for patients who don't live in privilege? What are we doing for patients who don't have savings to spend on medical care? What about those patients who don't have medical insurance? Today, I introduce to you, Dr. Lewis Zirkle, president and founder of Sign Fracture Care. After graduating from medical school and beginning his orthopedic residency at Duke, Dr. Zirkle was drafted and served in the US Army as a commanding officer in Vietnam, during which time he was awarded the Bronze Star. The Vietnam War had a profound impact on Dr. Zirkle, and after establishing a thriving orthopedic practice, Dr. Zirkle was drawn back to Vietnam and Southeast Asia to donate his time to teach orthopedics to local surgeons. In 1986, at the bedside of a patient in Indonesia who had needlessly lane Intraction for three years, he had an epiphany that caused him to realize that in order to create sustainable orthopedic change education must be combined with appropriate implants.
Hetal Baman (00:02:59) - He made a promise to find a way to equip the local surgeons to treat the fractures of the injured poor in the developing world. Since that day, Dr. Zirkle has dedicated his life to the development and manufacturer of orthopedic implants and instrumentation that can be used in operating theaters in places that need it most. For Dr. Zirkle's full bio head over to the show notes linked in the description. This is part one of the sign fracture care series. So make sure to follow or subscribe if you wanna learn more about sign, how they successfully run their nonprofit and the unique way they manufacture and create their medical devices for the developing world. My name is Hetal Baman and this is the Global Health Pursuit. This is gonna be part one of the signed Fracture Care International podcast series featuring Dr. Urkel. I am really just so excited to have you back on the podcast cause I don't know if you remember, but you were on the podcast a couple of years ago during my first, my first go around and now I've relaunched in April and I just had to get you back on. It was just, your story is remarkable and I I just need people to hear it. The first thing I wanna ask you, I really, really want you to take us back to the very beginning, you know, cause your story is amazing. Where were you and what were you doing when you first realized that orthopedic care was a real issue in low and middle income countries?
Dr. Zirkle (00:04:38) - Well, I, I think, uh, when I was, uh, a resident at Duke, I was drafted by the Army and I was sent to Vietnam and I realized that they sent the Vietnamese civilians in and the American Army and Vietnamese army, and we were told to send the Vietnamese civilians to another hospital. And I went over to see that hospital and I didn't think it was very good. So I asked generals, Abrams and Westmoreland, if I could treat the patients at the 93rd of Act Hospital where I was stationed. And they gave me permission and I, I realized several things. First of all, I realized how terrible war is and I realized that people need care. If they don't have a choice, the nurses pitched in and spent extra time, anesthesia gave extra time so I could operate on them. And everybody along the evac chain sent us implants because in the US Army you could not put implants in, in the battlefield or the battlefield hospitals. But we had to do that here because we were the last resort. So I, I think, and I got to know them well, and, and you know, people are people and we have to do our best to help all the people we come in contact with.
Hetal Baman (00:06:13) - Your role was to be a surgeon?
Dr. Zirkle (00:06:15) - Right.
Hetal Baman (00:06:17) - You often talk about this story of this one person that you saw in the hospital in Vietnam. Can you paint a picture of what you saw in Vietnam from patients who have been in traumatic accidents? What's their standard of care?
Dr. Zirkle (00:06:31) - Well, I think it varied. I don't think it would've been good in this other hospital. I came away feeling that there are a lot of people in the world who don't have orthopedic care. And I went back to Vietnam after the war and I went to Indonesia and countries all around the world treating the poor. And it just grow, sign just grew.
Hetal Baman (00:06:56) - So according to the WHO, 93% of the world's fatalities on the roads occur in low and middle income countries. Even though these countries have approximately 60% of the world's vehicles, which is really interesting. Right? For those of you who haven't been to a country like Vietnam or Cambodia or you don't often see cars, you see motorcycles, you see rickshaws, autos, tuk-tuks. And this is often what causes road traffic accidents.
Dr. Zirkle (00:07:32) - There's a lot of, uh, motorcycles and Rick Shaws, Rick Shaws, especially in Bangladesh, and the motorcycles many times had as many as five people on 'em. They were often kids, but they were often adults. They could get three or four adults on a motorcycle and they were going with one hand on the, on the steering wheel, very nonchalant until they come to a wreck. The other, the other problem was the buses. We saw a lady after a bus accident and, and they, they drive very quickly. So they often get hurt with accidents. And then there's a lot of people walking at night on the side of the road who get hit. So we take care of them too.
Hetal Baman (00:08:24) - Let's take sign out of the picture. So if a patient gets hurt in a country like this from a road traffic accident, right? They're sent to a hospital that you saw, is there surgery? I feel like you've said this a lot in, in your talks where you'll see a patient in traction. Can you explain what traction is?
Dr. Zirkle (00:08:44) - Traction is a way. Uh, you put a, a pin through the tibia through the leg and you pull on that, put weights on to pull the fracture out, the, the fracture's like this and it gets pulled in by the muscles on either side of the fracture. So you need to pull it out. Traction is one way. Bone setters are another way. A lot of people go to bone setters if they have no funds.
Hetal Baman (00:09:12) - And why is that often not the best solution?
Dr. Zirkle (00:09:16) - Well, the bone setters no more than they understand. They treat the patient very positively, but they don't, they just don't treat 'em well.
Hetal Baman (00:09:25) - We were just talking about the patient themselves. Oftentimes we'll see when this patient is a breadwinner of the family and they're not able to go to work, what have you seen that would happen to these patients or their families, if not treated timely and properly?
Dr. Zirkle (00:09:46) - WHO studied this and the family spirals into poverty for three generations. If there's no breadwinner and that is so bad, the breadwinner is incapacitated laying in the bed and he becomes dependent and other people in the family have to go to work. Often it's the wife has to go to work and it's, it's a really difficult situation.
Hetal Baman (00:10:12) - Sometimes kids are pulled outta school.
Dr. Zirkle (00:10:15) - Yes. That often happens.
Hetal Baman (00:10:20) - So when you first thought about starting this organization, what was your first thought in terms of, okay, like what can we do about this? Cuz now you have a full on nonprofit that manufactures and designs implants and instrumentation for these specific scenarios. What was your first idea and how did you go about that?
Dr. Zirkle (00:10:42) - Well, uh, I, I tried to take it in steps. I recognize that a lot of the programs over there don't have C-arm. They don't have x-ray in the operating room, right? And so we had to find a way to put the screw through the hole without looking at it. And these, uh, once you get used to the, with good proprioception, proprioception means feeling is just as accurate as a c-arm and putting it in that way, in fact, we can do it faster. So that was our first challenge was how do we do that? And I hate to say this cause a lot of NGOs say they start in a garage, but we <laugh> we really did. We would buy butcher bone and experiment and try all these devices. And, uh, once we got that, that was our biggest hurdle. And then after all that, I realized we had to make 'em. So a man who was paraplegic, Richard came in and he ran the, uh, machinist program and a nearby town. He came in and he really helped us to set up our shop. Then we didn't have machines. So Randy Hubner, uh, who was the president at that time of Acumed, gave us some of their machines, which we used, and we've since replaced them. And so as we've gone through, I'm very humble about this because a lot of people have come to help us and they just show up when we need them.
Hetal Baman (00:12:32) - So even before deciding that you need to manufacture and design these implants, like were, were you talking to other medical device companies to say, Hey, can we do this? Like, can you start a program at your company? Like what, what was that? Because I feel like, you know, starting the, your own nonprofit and basically a medical device company as a nonprofit, which is really interesting because you don't often see that before thinking about, okay, now I have to start this, now I have to do this because nobody else is like, it's not working. What was that process like?
Dr. Zirkle (00:13:15) - Well, the process was sent talking about the relationship with the implant company. Mm.
Dr. Zirkle (00:13:20) - One implant company, the ceo Shiploads containers of in implants. But they didn't really fit into our device. Acumed gave us the, uh, machines to start with the Randy and gave us, Randy Hubner gave us a lot of help. Mm. And uh, so they arrived and Jean, whom you just talked with, came home from her job overseas and came in to help us. We are extremely lucky. Mm-hmm. But I've never gotten a lot of the implant companies. After this man retired at Cynthia's theses, I had a saying to myself, they never said no, but they never said yes. Mm mm-hmm. So we didn't get much. I realized then we had to make our own if we're gonna do it. And we had to make it because we had a specific technique and this one implant the nail and the screws, we then have plates and we've added more
Hetal Baman (00:14:32) - Why become a nonprofit medical device company versus for-profit medical device company. What was that decision like? Because I'm sure you thought about that.
Dr. Zirkle (00:14:44) - Well, I, I knew that we'd never get paid overseas. <laugh>. I mean, there's no reason to get frustrated. What we have is a system where they have the surgery, the poor, and then the surgeon reports the surgery including x-rays and then he reports follow up. And for each fracture that he reports, he reports the sizes. So we, we sent him the sizes that he's reported. So it's a, it works like that. They don't have the money to pay. I mean that would be a fruitless thing to try to get them to pay.
Hetal Baman (00:15:23) - Right. I mean that would be totally against what you're even trying to do cuz Right, because you're trying to provide surgeries for patients who can't pay <laugh>.
Dr. Zirkle (00:14:32) - Right. That's right.
Hetal Baman (00:15:34) - Now you just talked about the model of sign. When when you thought, okay, we're gonna have surgeons in each of these countries that we serve to do these surgeries and report back and all of that. Who were your first partners overseas?
Dr. Zirkle (00:15:50) - Well, the first partner was in Vietnam. When I went back to Vietnam, they were so enthusiastic and they helped us with designs and they, we, we had the best time operating and so, and interchanging our, our thoughts. Vietnam, then Indonesia, then Cambodia, Ethiopia, Tanzania, all of, pretty soon we're in 57 countries.
Hetal Baman (00:16:18) - And how does that relationship with each surgeon sustain itself? Because there's a lot of training that needs to be done, right. And then training of other doctors that are, that the science surgeons do.
Dr. Zirkle (00:16:32) - Well, first you're exactly right, they have to be trained. When we first started, I had to travel to those countries. I made about four to five trips a year. Often going to two or three countries. Always the good surgeons would kind of be attracted to this because they had trained to be surgeons and if they didn't have implants, they couldn't practice what they were trained to do. So this has gradually progressed now to the sign mobile program and these leaders, mentors now, we give them a set and they take it around to other hospitals and they're able to evaluate the nursing, the hospital, those aseptic conditions and everything. And if after three months they do good surgery and report 'em, we leave the set there. This is especially been good in Ethiopia and in Myanmar
Hetal Baman (00:17:41) - And in that sense you're able to repeat the process, scale the process,
Dr. Zirkle (00:17:46) - And we now have mentors reading the database. They give advice to the other surgeons and that works really well. They really like that. In fact, right before this I was reviewing the database and uh, surgeons from Pakistan asked if he could take over
Hetal Baman (00:18:05) - <laugh>. That's awesome. When I was speaking with Terry, he, he said that you look through every single x-ray that comes through.
Dr. Zirkle (00:18:15) - Yeah. Well it's important to know what you're doing and if you're doing it right and you, and it's a, a good way to teach cuz you offer advice. We've, we've got a, a good system to interchange.
Hetal Baman (00:18:28) - Tell me about the products that you have. Right now,
Dr. Zirkle (00:18:30) - Our major product is intramedullary nails. Those go down the middle of the bone, it's hold the fracture and then we have screws. I know you had a biomechanical <laugh>. I do
Hetal Baman (00:18:43) - <laugh>. I know.
Dr. Zirkle (00:18:46) - So we have screws, we've made slots, and then we have to have all the instruments, the, the target arm, et cetera. Then uh, we have a system for fractured hips where special screws that have different thread on both sides. So it compresses the fracture, which is new. Uh, we have pediatrics, which is new and we have discovered working with Cleveland Clinic that uh, we can treat kids by going up through the knee. When a fracture is very close to the knee, it's much more stable to go up through the knee. Now that is a sacred place because of the epiphysis, the growing center. But we found if it's done right, we don't cause growth disturbances, but we're following all the patients. Yeah,
Hetal Baman (00:19:39) - I feel like pediatrics is an interesting field within orthopedics because you'd think that you would have to follow up with these patients a number of times. And sometimes I've heard that these implants would have to be taken out just because of the growth of the child. That is really, really interesting. So moving forward, what are you most like excited about? What's your vision for the next like 10 years?
Dr. Zirkle (00:20:04) - I don't know if I can make it for 10 years, but I can make it <laugh>. For right now, we need to improve our, uh, treatment of hip fractures. That's really important. I think we do as good as any other company in the world. Commercial company treating long bone, femur, tibia, the leg bones, the arm bones. We do very well there. We're very happy with that though. We, and we're still devising the technique as I mentioned, so I'm happy with that. The other thing is, uh, in some fractures you need to have plates and we've developed a plate, which I, I think is biomechanically works well. So we're, we're working through those two things. We're also analyzing our data using metabase for some fractures, which also are long problems around the world. This what's called sub tro enteric, the ones that are high up in the femur. They, there's variable ways to treat them and we need to find out the best way.
Hetal Baman (00:21:18) - Well, Dr. Urkel, thank you so much for your time today. I think I learned so much and I hope that our listeners who are interested in this topic learn a lot more as well. I'm so grateful for your time and what you do. Thank you so much
Dr. Zirkle (00:21:32) - And thank you very much.
Hetal Baman (00:21:35) - Thank you for listening to this episode. If you'd like to learn more about today's topic and guest, head over to the show notes linked in the description of this episode. There you can get access to resources, links, and ways you can get involved in the pursuit for global health. And if you love this episode, don't forget to write me a review on Apple Podcasts and rate the podcast on Spotify. It helps me get in front of more people just like you and continues to elevate the causes we are so passionate about. I'll see you in the next one.