Hip Dislocation Far From Home

                                               by Robert H. Gelber, M.D.                         

It happened on a summer dive vacation with my college freshman son. The place was one of the world’s premier dive sites, Bunaken National Park, Menado, North Sulawesi, Indonesia. Three dives per day without problem: incredible walls, brilliant multicolored soft and hard corals, yellow and blue nudibranchs, and a vast abundance and array of tropical fish. On the fifth day I nonchalantly put on my weight belt for the first dive, internally rotated my thigh to pull on my swim fin and felt a snap and pain in my left hip. At first, I tried to persuade myself that I had pulled a muscle or had a cramp, but I knew better.

Weight bearing was impossible and associated with agonizing pain. I had been warned this could happen–the weight belt, the position, the maneuver. I had not known hip pain like this in the three years since my left hip had been replaced. The surgery had been enormously successful. I could hike and even backpack without even mild discomfort. I had essentially forgotten it wasn’t original equipment and had also forgotten my "hip precautions." I had indeed dislocated my prosthetic hip far from home.

The other divers were gracious as the boat turned around and returned to shore in 45 minutes. Things were okay if I didn’t move, but when I did, the pain was excruciating. I was carried to a pickup truck and off to the hospital. Unfortunately, it was payday, and the only x-ray technician was gone, probably already drinking his wages. After two hours of uncertainty, I was again back in the truck and off to the other small hospital on the island.

Getting me on the x-ray table and in position for a film was daunting and agonizing. I am an infectious disease internist with a particular interest in Hansen’s disease. Before replacing my hip, Alan Zacharia had performed many successful tendon transfers and other procedures on my leprosy patients and was a good friend. Luckily there were cell phones available, and we contacted my orthopaedic surgeon, Dr. Zacharia, a diver himself.

Because of the time difference, it was something like 2:00 a.m. in California, yet he seemed fully awake upon answering the phone and immediately grasped the situation.

I wanted to know whether I should get myself to Singapore or have my prosthetic hip put back in North Sulawesi. Alan asked me questions about my symptoms and nerve function.

Long Distance Consultation

At 5:00 p.m. local time, the local surgeon showed up and had several prolonged broken English conversations with Dr. Zacharia on the cell phone. The man had never reduced a total hip prosthesis, but he had seen the operation once and had dealt with a natural hip dislocation. Another call to Dr. Zacharia, who tested this surgeon’s knowledge of the anatomy and mechanics of the hip and his experience in this situation. Eventually Alan was convinced that the surgeon was competent and that I was probably better off having it done there than suffering the prolonged delay of trying to get transport to Jakarta and then to Singapore. Alan coached the surgeon on the least traumatic reduction technique and he planned to put the hip back in the socket the next morning when the local person who could do spinal anesthesia was available. I pleaded with him to make it happen immediately, but to no avail. Besides it was dinnertime.

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The hospital charged me something like four times what they would a normal patient

       and would accept only cash. Luckily, the dive resort, owned by an American married

to an Indonesian, assisted me.

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I was put in a hospital bed with my head elevated and my son on a nearby cot. No history or physical exam was done. In fact, no one even checked my blood pressure or pulse. A large bottle of water was placed at my bedside, and I saw no one until dawn. The mattress had a plastic cover; obviously there was no air-conditioning, and I lay in a pool of sweat. I spent most of the night trying to pull myself up in bed, each time with enormous pain. In the morning, I was moved onto a gurney and brought to a preop room. After an IV was placed, I saw several large rats running on the floor and then the Valium took hold. Next thing I knew, I awoke and the pain was gone.

The hospital charged me something like four times what they would a normal patient and would accept only cash. Luckily, the dive resort, owned by an American married to an Indonesian, assisted me. Somehow they borrowed a cane, and I was gone, able to walk gingerly. Another call to Dr. Zacharia to see whether I should fly straight home, and he told me to continue my itinerary, absent the diving. Fortunately, I had travel insurance, but to change tickets to Singapore required money. My Visa credit card was routinely rejected because my wife had been using the same account at the same time in San Francisco. I have had this problem subsequently more than once when traveling in the third world. Fortunately, I had enough in traveler’s checks to meet the fare.

For a few days, I holed up in Singapore and managed a first-class "seat/bed" home to San Francisco. Having lived and worked on a leprosarium in Malaysia for two years in the 1970s, what occurred was not entirely unfamiliar.

The outcome was fine, and four years later I have no hip pain, hike, and dive–only now I remain quite cognizant of my hip precautions, especially when I put on my swim fins.

Dr. Gelber has an infectious disease practice in Marin County.