Helping Hands: A Yale Surgery Team Repairs Lives in Nicaragua

Hand Help is dedicated to treating people in developing nations who have serious hand and arm problems.

Why Yale Medicine?
  • We have one of the most comprehensive programs in the region. Orthopaedic surgeons and plastic surgeons collaborate to determine the best approach for each patient.
  • We use the most advanced techniques for diagnosis and treatment. If nerve problems are suspected, the nerves may be stimulated with electricity to evaluate their ability to react properly.
  • We treat work injuries, including pain and injury related to repetitive tasks. After carpal tunnel surgery, patients often go home the same day with just a light bandage on their wrist.​

On a plastic lawn chair screwed to a metal wheelchair frame, tiny Isabel, 5, is wheeled into a dim, noisy hospital hallway. The paint on the concrete walls and floors is scraped and cracked. Patients wearing green hospital gowns watch from broken wooden benches, awaiting their turn. The man pushing Isabel’s makeshift wheelchair is dressed completely in blue, including over his hair and face.

Isabel wears only a thin hospital gown. Her gangly legs poke out into the chilled air. The man stops pushing, and four caregivers, also in blue, swarm around Isabel as she clings to the plastic arm, exuding worry and fear.

“Hola,” says one, as she kneels next to the chair. Isabel turns to look at her, frightened but alert. The woman has kind, sparkling eyes. “Can I see your hand?” asks Felicity Fishman, MD, gently in Spanish. Slowly and carefully, Isabel holds out her right hand, where the middle finger has been stuck, curled inward and sideways, since birth. Dr. Fishman touches her hand softly, looking at the finger. “We’re going to make it a little bit better for you,” she says.

Isabel smiles a tiny smile and wiggles her fingers.

Felicity Fishman, MD, with patient Isabel

Felicity Fishman, MD, cheers up Isabel before her hand surgery.

Dr. Fishman was caring for Isabel as part of a week-long medical mission to Nicaragua, organized by Hand Help, a nonprofit organization dedicated to helping people in developing nations who have serious hand and arm problems. J. Grant Thomson, MD, a Yale Medicine plastic surgeon who leads Hand Help, first participated in such a mission 20 years ago; two years later, he started leading them. Hand Help, which he established in 2005, has performed surgeries for more than 1,800 people—first in Honduras and now in Nicaragua. “We've created a better situation for a lot of people,” says Dr. Thomson.

The 2017 mission was a true labor of love for the 34 surgeons, anesthesiologists, nurses, interpreters, an occupational therapist, and others who traveled thousands of miles and used vacation time to care for people who don't typically have access to specialized health care. The organization conducted 91 surgeries, ranging from removal of simple cysts to complex bone plating and skin grafting.

Grant Thomson, MD speaks in the hallway

Hand Help founder, J. Grant Thomson, MD, (left) takes a break from surgeries with Jack Kanouzi, MD.

The team arrived on a Saturday and spent Sunday evaluating patients. They met that evening for a planning session to match surgeons with patients and create the schedule for about 20 surgeries per day. On Monday, they began to operate. The team started early and worked into the evening. The hallways and operating rooms were a swirl of constant activity. After each operation, the surgery kits had to be cleaned, sterilized and put in order for the next operation—several times a day for many of the kits. The team members were exhausted at the end of each day.

But the work is deeply gratifying. “I never imagined my baby would open her hands like normal,” Isabel’s mother said after the surgery. Then she burst into tears. “I’m very grateful to everyone here, and the doctors, for caring so much about my baby.”

The team’s work was also appreciated by the staff of Hospital Alemán Nicaragüense, located in Managua, Nicaragua's capital. “We welcome and need them. People might otherwise have to wait years or never have surgery at all,” said Fernando Aguilar, MD, a surgeon and the coordinator for orthopedics and trauma.

People in need

In Nicaragua, a person’s hands are critical to their ability to work and get by in society. Eighty percent of the workforce performs manual labor. Nearly half are farmers, often using hand tools and oxen-drawn plows. Others are industrial workers, many in food-processing plants. For children with serious hand deformities, there is fear is that they will never work, marry or have children of their own. Even for a child with partial handicaps, such as an extra digit or fingers fused together, the future can look bleak.

“This community requires their hands every day to function,” said Tracey Kelly, RN, head nurse for the mission and a specialty nurse coordinator at Yale New Haven Hospital.

Speaking to patients.

On each weeklong annual mission, Hand Help caregivers see hundreds of people and perform about 100 surgeries. 

The hospital was originally built in 1985 by East Germany. At first, there were just tents, replaced over the years with small buildings. To get from surgery to pediatrics, a person must walk outside in the 95-degree heat. Families swelter as they wait outdoors for news of their loved ones.

Nicaragua has socialized medicine, so people have access to health care, but the resources are limited and the needs are great. Almost half of the population lives below the poverty line. Though Hospital Alemán Nicaragüense is a 300-bed teaching facility with 900 employees, it is the only medical facility serving 700,000 residents of the section of Managua where it is located. The wait time for care can be many months. Those who come from outside the city face transportation costs and lost income, which can be debilitating. “We see people who should have surgeries within 72 hours of their injury, but because of our resources and backlog, they have to wait a month or two, and, by the time they come back, the disease has had an exponential effect on their lives,” said Dr. Aguilar.

Isabel was lucky that she lives in the city and her mother was able to take two days off work when the Hand Help surgeons were in town. Isabel was born with both middle fingers curled into her palms. As a result of the Hand Help surgery, her fingers would move more freely for the first time.

A common problem in Nicaragua is carpal tunnel syndrome, a painful condition of the wrist and hand that often results from stressful repetitive motions. People's hands go numb at work and they often can’t sleep at night. All week, Dr. Thomson performed carpal tunnel surgeries—a total of 13. He made small incisions at the base of the hand and cut the ligament that had been putting pressure on the nerves.  “We perform a five-minute operation, and their symptoms go away immediately and they can get back to using their hands,” Dr. Thomson explained. “Even though it’s a small operation, carpal tunnel surgery has the highest satisfaction of any of the operations that we do.”

A different approach to helping

Hand Help differs from many other medical missions because the organization brings with it all of the equipment and staff needed to perform the surgeries and provide follow-up care. Hand Help’s team includes experts in both plastic and orthopaedic surgery, making possible complex surgeries such as nerve transfers, which are still considered cutting-edge medicine in the United States. The team even includes a specialized hand occupational therapist. The hospital provides the space where the team does its work, and the hospital staff participates in nursing, physical therapy, administrative and follow-up medical care for the patients.

Wonder Woman Surgery 2

Kevin Tomany, MD, vice president of Hand Help, and Regina Meis, MD, focus intently on repair surgery for a complex bone fracture.

Hand Help has collected a large amount of data over the years, using it to improve processes and patient satisfaction. A goal is to share their learning with other medical groups interested in doing missions of their own. “It is a replicable model that makes it less taxing on the host than missions that use local staff, supplies, and equipment—and everyone can focus on helping the patients,” said Dr. Thomson.

The volunteers who travel with Hand Help each year were introduced to the work by Dr. Thomson and inspired by his passion. Many work at Yale or have some past tie to the university. Two of the founding members are Kevin Tomany, MD, vice president of Hand Help and an orthopaedic surgeon at Lowell General Hospital, who trained with Dr. Thomson at Yale, and John Tangredi, RN, a retired operating room nurse supervisor at Yale New Haven Hospital, who has organized equipment for more than 50 missions similar to this one.

Embrace

Brenda Hunt, RN, the circulating nurse comforts a frightened child.

Newer participants are just as motivated. “This is an opportunity to help people who really, fundamentally need it,” said Regina Meis, MD, a Yale School of Medicine hand and microsurgery fellow. “I look into their eyes and can see they are breathing a sigh of relief that someone understands, and is going to do something to help.” It was her first trip of this kind, but she says nothing will keep her from returning.

Hand Help runs on a tight budget. The total cost for the trip is just $30,000 each year, with travel and lodging the main expenses. The participants are all volunteers, and supplies are donated from hospitals, including Yale New Haven Hospital. This year, the team brought 24 50-kilogram crates of equipment, plus 10 extra duffel bags of wraps, tape and equipment. Still, they ran out of gauze dressings and bandages.

Several of the volunteers work throughout the year to gather donations, such as batteries for equipment, and toys and candy for the kids. “If we had a one-time gift of $700,000, we could fund this mission in perpetuity. That is what I would like to see happen,” said Marc E. Walker, MD, MBA, the chief plastic surgery resident at Yale.

Difficult working conditions

In Nicaragua, the working conditions were less than ideal. In the operating rooms, many of the chairs and operating stools were broken. Monitoring equipment was outdated or only partially functional. Some tools were simply not available. The Yale surgeons had to rely on intuition and experience. “One thing I’ve learned on these trips is that you can do a lot with very little,” said Dr. Thomson. “You realize that the surgeons here don’t have the things we’re used to, but they can still get good results with much less.”

shoulder

An X-ray of a broken humerus. Hand Help surgeons repair injuries that were not properly treated earlier.

Because of the limited resources, the surgeons on the Hand Help missions do not perform complex operations for which recovery may be long or especially challenging. One of their patients had a broken leg and severed nerves in his shoulder from a motorcycle accident. The surgeons performed a nerve transfer procedure (called brachial plexus surgery) for his shoulder, but they didn’t attempt to address the complex leg fracture. “If we had more resources here, there is so much more we could do,” said Dr. Meis, the surgery fellow.

This year, for the first time, Hand Help brought endoscopy equipment, which enables surgeons to perform surgeries with far smaller incisions. As a result, recovery is easier and there is a lower risk of complications. Tangredi, the retired nurse, held his breath while the endoscopy equipment was being assembled. Luckily, it worked; the Nicaraguan surgeons and residents later crowded into an operating room to see Dr. Thomson perform the endoscopic procedure. On the last day of the trip, Dr. Thomson gave a lecture about endoscopic carpal tunnel surgery to the local surgeons and staff. “We have to share knowledge,” he said.

The mission volunteers learned important lessons, as well. In the operating room, medical students and residents felt freer than they would be in the United States to ask questions of the surgeons. And even the surgeons learned from dealing with medical conditions that are rare back home—such as injuries that have not been treated for months. “There is learning at all levels,” said Dr. Walker, the surgery resident.

Exchanging gifts and good wishes

During quiet moments, the U.S. and Nicaraguan medical staff members exchanged gifts to show their appreciation for one another. Tangredi got everyone on the mission to sign a soccer ball and presented it to their hosts. “I always leave them with a present that’s just about this team,” he said.

Exchanging gifts.

Hand Help volunteers John Tangredi, RN, and Elena Bukanova, MD, sign a soccer ball. They later presented it to their hosts as a souvenir of their visit.

Dr. Tomany gave Noel Lopez Vaca, MD, a Nicaraguan orthopaedic surgeon, several pieces of orthopaedic and trauma surgical equipment. Victor Muños, a member of the hospital staff, presented Tangredi with a branch of the Jocote tree, laden with sweet and sour fruit that resembles olives.The chaos of the OR seemed to freeze as these two, who did not share a language, dipped the fruit in salt and savored its flavors.

Later in the day, Dr. Tomany brought Dr. Vaca the true prize: a brand new, completely adjustable, padded operating room stool. Dr. Vaca’s eyes opened wide and the room erupted in laughter.

Toward the end, the mission’s volunteers became emotional as they recalled their experiences. Their own lives had been enriched by helping others in need. “I reflect a lot on what it means to be human,” said Kelly, the head nurse, who had put in 12-hour days managing the nurses and the patient flow. “In our hectic world, I do this because it’s back to the roots of why I became a nurse. It makes me a better person to take care of others.”

To contribute, visit the Hand Help website.

The views expressed in this article and video are those of the individuals appearing herein; they are not the official positions, statements of advice, nor opinions of Yale University and should not be viewed as an endorsement by Yale University of any product or service.