Feature Articles Articles

Reproductive Healthcare in Latin America: Perspectives from a Guatemalan Elective

If medicine is to fulfill her great task, then she must enter the political and social life.

—Rudolf Virchow, founder of modern pathology

An overseas elective is a time to experience medicine in another setting, and it is as much about the setting as it is about the medicine. While gunshot wounds in Johannesburg, and tropical diseases in East Timor, are the often the draw cards when we are planning an elective, it is witnessing the social conditions that lead to those health problems that really change our outlook. Rudolph Virchow was right about many things, but this dictum seems to go unheeded in much of our medical education. Perhaps that is best; there doesn’t seem to be much space in the curriculum for a quick course on East Asian history, Latin American politics or economic development. It does mean, however, that for many of us, our elective becomes a crash course on the political and social life we aren’t taught about in medical school.

After some deliberation, I decided on a women’s health elective in Guatemala. It seemed like a good chance to spend some time learning about a single public health issue in more depth, and at the time I was interested in how cervical cancer, a disease so preventable in our own country, could be such a significant killer of women in the developing world. Some quick research led me to believe Guatemala was no different. Once I arrived, however, I discovered that most of the women in that area of Guatemala, Antigua, a wealthy area popular with tourists, were already engaged by cervical cancer screening programs. While the hospital I was working at openly encouraged women to be screened for cervical cancer, there was an issue that no one seemed to be talking about. An issue that inextricably links medicine to the political and social lives of women. Contraception.

In the first week I went out on a few visits with the social worker to the villages surrounding Antigua where most of the patients lived. As we walked farther from the edge of town the roads diminished to dirt tracks, the cinder block houses became tin shacks. We spoke mostly to women and many of their stories were similar; they worried when their husbands would next get regular work, whether there would be enough money for food, whether they could continue to afford to send their children to school. It also seemed as if every family had upwards of five or six children, many of them only a year or two apart. The doctors at the hospital had said they did not discuss family planning with the women because it was a cultural issue, and they did not want to alienate the community. Although the hospital was run by a Christian non-profit based in the United States (US), the director stated the practices at the hospital were not guided by religious belief. The doctors and health workers at the hospital would not raise the issue of contraception with patients. If women requested contraception the hospital would refer them to another US-based non-governmental organization (NGO), WINGS, that dealt with family planning amongst other reproductive health issues, and had limited funding and scope. Walking through those tin shacks and dirt lanes family planning seemed much more than a cultural issue, it seemed to be about gender, politics, economics, education, religion and history too.

Guatemala has one of the highest fertility rates in Latin America of four children per woman. [1] Amongst Indigenous women that rate is 6.8, and in some rural areas is reported to be as high as 10 per woman. Indeed the Indigenous population, mostly Maya, make up approximately 50% of Guatemala’s population, of which 80% live rurally. [2] As is true almost universally for Indigenous populations, they suffer from significantly poorer health parameters, which can be traced back to a brutal colonial history followed by a 36-year civil war, and the ongoing economic and educational disparities related to this.

On a quest to find out more about contraceptive use, I decided to spend the remainder of my elective with another NGO, Maya Gift, doing village clinics in the Lago de Atitlan region of the Guatemalan highlands, where the population is largely Indigenous and the fertility rates are highest. Maternal mortality rate (MMR) in this region is up to 534 per 100 000, compared to 120 per 100 000 in Guatemala as a whole, or 7 per 100 000 in Australia. [3] Most births are not attended by a skilled midwife, but by a comadrona, a traditional birth attendant. In Guatemala, 59% of births are attended by a traditional birth attendant only, in rural areas this percentage is thought to be much higher. [4] The high fertility rates, combined with high maternal mortality rates, result in a 1 in 20 lifetime chance of dying in childbirth in the highlands surrounding Atitlan. [5] That is significantly higher than the 1 in 190 lifetime risk in Guatemala as a whole, or the 1 in 8100 lifetime risk of dying in childbirth in Australia. [3]

Given the incredible impact of pregnancy on women’s lives in this part of the world it seemed strange for health organizations to not actively discuss the issue, or to consider it as purely cultural. It seemed like these women were missing out on a basic element of healthcare, but were they really? What does contraceptive use mean to the individual and the society they live in.

A revolutionary pill

Family planning may date back to the fertility goddesses of ancient Egypt, but modern family planning methods started in the 1960s with the contraceptive pill. The availability of effective contraception had far reaching consequences for role of women in society, particularly in terms of marriage and the workforce. [6]

It was not long before family planning entered the domain of public health. Amid concerns about rapid population growth, international family planning programs in the 1960s and 70s were framed with population policies, with the focus on reaching demographic and fertility targets. In this context some nations adopted coercive population control policies that violated human rights and often targeted sections of the population based on race and socioeconomic status. [7] This sort of practice is completely at odds with the family planning efforts of the majority of governments and public health organizations today.

Family planning in 2012

The marked shift in the basis of family planning policy from population control to human rights was clearly demarcated in 1994 by the Program of Action of International Conference on Population and Development in Cairo. [8] Here, 179 countries signed on to a Program of Action that framed family planning as a women’s health issue rather than a purely demographic issue. For the first time, universal access to contraceptives was set as the goal, rather than the population targets set in the past. From this conference onwards the focus has been on autonomy, choice and improving access.

With this approach in mind, the benefits of family planning programs in developing countries have been marked. In development terms family planning provides one of the best returns for investment of any public health measure. [9] When women are given access to modern family planning methods they have fewer children and those children go on to be better educated and healthier, suffering significantly less from malnutrition. The most well known cases are perhaps in South East Asia, where countries like Thailand dropped their fertility rate from 6.3 in 1967 to 1.7 in 2003. [10] In this setting the decrease in fertility was associated with an explosion in economic growth, leading to a phenomenon known as the ‘demographic dividend’. [11] This phenomenon occurs in countries with high fertility rates, where an increased investment in family planning results in a significant fertility drop across one generation. [12] As a greater proportion of the population are at working age relative to dependants, there may be more funds to spend on health and education. This raises the ‘human capital’ of the population, as those children who have grown up an environment with increased access to health and education become more economically productive than their predecessors.

Despite the knowledge of the profound effect of family planning on economic development, funding for programs was slowly eroded from the 1980s onwards. [13] This was in part due to the redirection of funds to fight the AIDS epidemic, and in part due to the political rise of the Christian right in US politics. The Christian right lobbied to block US funding to the United Nations Population Fund (UNFPA), a key reproductive health body, and prevented the United States Agency for International Development (USAID) funding any organisations that were linked with abortion. Many of those organisations were also key providers of less controversial aspects of family planning, including the contraceptive pill and injectable contraceptives. [14]

In 2012, however, family planning was placed back on top of the development agenda, when Melinda Gates, of the Bill and Melinda Gates Foundation, the largest philanthropic organization in the world, decided to make family planning her signature issue, investing several billion dollars in the cause. Gates highlighted the key issues in her first public speech on the topic: accessibility, education and above all, removing the taboo surrounding contraception. [15] At the landmark London Summit on Family Planning in July 2012, organized by the Gates Foundation, world leaders gathered to orchestrate a plan to address the enormous unmet need for contraceptives. It is estimated that 222 million women who would like to use contraception do not have access to it. Of the 210 million pregnancies each year, 80 million are estimated to be unintended. Furthermore, there are 22 million unsafe abortions occurring each year, resulting in 47,000 deaths. [13]

There is, of course, another reason family planning has been put back on the agenda: climate change. Uncontrolled population growth has been touted as one of the most significant contributors to carbon emissions. [16] A 2011 UN report on the predicted population of the world in 2050 outlined the variability in our global future. [17] The report released three variants of estimated population, a smaller, medium and large variant, 8.1 billion, 9.3 billion and 10.6 billion, respectively. The medium variant, largely held to be the most likely, relies on fertility rates in high fertility countries dropping from an average of 4.9 children per woman to 2.8. Family planning services in high fertility countries in Africa and Asia will need to be expanded if they are to meet this need. Alarmingly, Africa, which struggles to provide food and water to its inhabitants today, could see its population more than triple, from 1 billion today to 3.6 billion by 2100. [18]

The global, the local

For the women of the Lago de Atitlan region of Guatemala these global issues are largely esoteric. The inaccessibility of contraception at the local level is made up of a different set of factors, albeit related to these global issues. After talking with these women for a few weeks it seemed that the barriers to contraceptive use could be broadly broken down into economic, educational, cultural, historical and geographical obstacles.

In this area of Guatemala, generally only the males worked for a paid wage, which for a campesino (rural labourer) was US$150 per month. [19] Speaking with the campesinos who came to the clinic, it seemed this wage would often need to support families with six or more children and dependant grandparents. An average workday involved 12 hours of backbreaking labour, carrying 60kg sacks of coffee back and forth. Speaking with the women it was clear they worked just as hard: labouring, preparing meals and selling food in the bigger towns. In this environment it seemed there was rarely a free morning, or spare funds, to go and get an injection of depot contraceptive at the clinic in the next town. Contraception would have to be cheaper, or free, and more accessible if they were to use it consistently.

Inextricably linked to the economic disadvantage of rural Guatemala was the educational disadvantage. Many families could not afford to send their children to school, which although free, required purchasing shoes, uniforms, books and supplies. The average amount of schooling is 4.28 years per person. [20] Illiteracy rates are amongst the highest in Latin America; 21.8% for men and 39.8% for women. [21] It is estimated that two million children of school age are not attending school. The majority of these are Indigenous girls living in rural areas, the very demographic that go on to experience poor reproductive health and the highest fertility rates. [22] These educational disparities are apparent in every aspect of health and particularly in reproductive health. Myths of contraceptive side effects abound in such an environment. Some I commonly heard were that contraceptives can give you cancer, can cause irreversible infertility, or can cause menstrual blood to collect in the uterus and make a woman sick.

Perhaps the most commonly referred to barriers to contraception are culture and religion. In fact, it was the reason the doctors in Antigua gave me for not discussing contraception with their patients. Certainly the Guatemalans are very religious people, 55-60% are Catholic and 40% are Evangelical Christian. [23] There is also a strong machismo culture, as in much of Latin America, and virility is associated with manhood. Culture, however, has proven to be exquisitely sensitive to change when it comes to contraception. In historically strong Catholic countries like Ireland and Italy contraceptive use rates have grown to mirror other developed countries. In 2010, 94% of sexually active adults trying to avoid pregnancy in Ireland had used contraception in the previous year. [24] Similarly, 85% of Catholics in the United States no longer believe that the use of contraception is immoral. I think this signifies that when people are educated and have access to contraception, they are willing to integrate different forms of knowledge into their own belief systems and practices. Attributing the low rate of contraceptive use as religious in origin seems overly simplistic, given members of the same religion in another cultural and economic environment make different decisions.

Lastly, nothing can be discussed in relation to Guatemala without mentioning history and geography. The Indigenous Guatemalans bore the brunt of a brutal 36-year civil war, which only ended in 1996. Assumed to have sided with the left wing guerrillas, who supported more populist policies, the Indigenous were targeted by the right wing military government. [25] Some of the towns in the Lago de Atitlan region were the sites of acts of genocide by the government. It goes without saying that public health, and family planning, for these people was not a priority for the Government. Aside from small NGOs that carried out work in the Atitlan region throughout the violence, the health system of the region has been developed from scratch since 1996 and remains grossly underfunded. The Atitlan region remains one of the poorest in a country with one of the most unequal distributions of wealth in the world. Contributing further to the disadvantaged health status of these people is the difficulty of accessing services in larger towns. Seemingly regular natural disasters have severely damaged what little infrastructure there was connecting small mountain villages. Even the shortest of distances can take hours to travel, and poor roads and lack of transport are yet another barrier to delivering effective healthcare.

Xocomil: wind of change

Despite all these barriers to accessing contraception, it seems there is real hope. Many of the Guatemalans I met believed the end of the Mayan calendar on winter solstice 2012 would bring change, a new world, and an end to the old world of inequality and injustice. Thinking of the immense change contraception brought to many countries, and the very real possibility that this will soon be available to women in developing countries, I found myself sharing in the optimism.

But optimism should never breed complacence, and the struggle to make contraception universally available to women continues. Continued progress towards this goal raises new obstacles. After all, it was only recently in the United States, where contraception has been available since the 1960s, that there was a push to remove the requirement for health insurers to cover contraception from the Affordable Care Act.  We cannot afford to forget Virchow’s words now. In order to fulfil our tasks as future medical professionals, we must not forget the political and social life of the world we live in.

The Xocomil is the midday wind that crosses Lake Atitlan. The local Mayan people believe the wind carries away sin and the souls of lives lost in the lake. It is famous in the region and is a symbol of change and vitality.


Lyle and Andree at Maya Gift for giving me the opportunity to travel to villages as part of my elective.

Conflict of interest

None declared.


C McHugh:


[1] UNICEF. At a glance: Guatemala. 2012; Available from:

[2] Metz B. Politics, population and family planning in Guatemala: Ch’orti’ Maya experiences. Human Organization. 2001;60(3).

[3] Organization WH, UNICEF, UNFPA, Bank TW. Trends in maternal mortality: 1990 to 2010 2012.

[4] Walsh L. Beliefs and Rituals in Traditional Birth Attendant Practice in Guatemala. Journal of Transcultural Nursing. 2006;17(2):148-54.

[5] Pfeiffer E. Guatemala. Minnesota Curamericas Guatemala; 2010 [cited 2013]; Available from:

[6] Goldin C, Katz L. The Power of the Pill: Oral Contraceptives and Women’s Career and Marriage Decisions. Journal of Political Economy. 2002;110(4):730-70.

[7] Santhya K. Changing Family Planning in India: An Overview of Recent Evidence. New Delhi: Population Council, 2003.

[8] Greene M, Joshi O, Robles O. By Choice, Not By Chance: Family Planning, Human Rights and Development. New York: 2012.

[9] Singh S, Darroch JE. Adding It Up: Costs and Benefits of Contraceptive Services. Estimates for 2012. New York: Guttmacher Institute; 2012 [cited 2013 July 6]; Available from:

[10]  SEARO. Thailand and Family Planning: An Overview. New Delhi: World Health Organization; 2003.

[11] Atinc TM. Realizing the Demographic Dividend: Challenges and Opportunities for Ministers of Finance and Development. Word Bank Live2011 Available from:

[12] Bloom DE, Canning D, Sevilla J. The Demographic Dividend: A New Perspective on the Economic Consequences of Population Change. RAND Corporation 2003.

[13] Family Planning: An Overview. The Bill and Melinda Gates Foundation; 2012; Available from:

[14] Douglas E. USAID Halts Supply of Contraceptives to Marie Stopes in Six African Countries. RH Reality Check. 2008.

[15] Gates M. Let’s put birth control back on the agenda: TED; 2012.

[16] Simmons A. 7 challenges for 7 billion. ABC News; 2011 [cited July 6 2013]; Available from:

[17] World Population Prospects: The 2010 Revision, Highlights and 2011.

[18] Gillis J, Dugger C. UN forecasts 10.1 billion by Century’s End. 2011 [cited 2013 July 6]; Available from:

[19] Schieber B. Guatemala: 60 percent of workers earn less than minimum wage. The Guatemala Times. 2011 Wednesday 16th November

[20] Edwards J. Education and Poverty in Guatemala. World Bank, 2002.

[21] Literacy: Guatemala. 2012 [cited 2013 July 6]; Available from:

[22] Hallman K, Peracca S. Indigenous Girls in Guatemala: Poverty and Location. In: Lewis M, Lockheed M, editors. Exclusion, Gender and Education: Case Studies from the Developing World. Washington: Centre for Global Development; 2007.

[23] International Religious Freedom Report: Guatemala. Washington US Department of State; 2006 [cited July 6 2013]; Available from:

[24] McBride O, Morgan K, McGee H. Irish Contraception and Crisis Pregnancy Study. Health Service Executive, 2010.

[25] Manz B. Refugees of a Hidden War: The Aftermath of the Counterinsurgency in Guatemala. Albany, New York: State University of New York; 1988.

Case Reports Articles

Mobile segment of the hamulus causing dynamic compression of the motor ulnar nerve branch in the hand

This paper is the first to document the mechanism of how a mobile segment of the hook of hamate can dynamically compress the motor branch of the ulnar nerve. Presented is the case of a professional golfer who experienced pain on the ulnar aspect of his right hand that he attributed to weakness and inability to control his hand. Imaging revealed the rare condition of os hamulus proprius causing a dynamic compression of the ulnar nerve when in power grip.  Provided is a review of wrist anatomy with particular focus on the peculiar case of the bipartite hamulus.


Anatomy of the wrist

The wrist comprises a proximal and distal carpal row. The distal carpal row consists of the trapezium, trapezoid, capitate and hamate and acts as a base for the metacarpals. The proximal carpal row consists of the scaphoid, lunate, triquetrum and pisiform bone. These function as an intercalated segment, balancing the hand on the radius and ulna. [13]

Hamate anatomy and function

The hamate articulates with the triquetrum proximally and the bases of the 4th and 5th finger metacarpals distally. The hook of the hamate is an important structure in the hand.  Protruding from the volar surface of the hamate, it anchors the distal transverse carpal ligament, acting as a pulley for the ulnar flexor tendons and protecting the motor branch of the ulnar nerve. This branch of the ulnar nerve courses dorsally and distally around the hook of the hamate to supply nearly all the intrinsic muscles of the hand. [14]

Guyons Canal and the Ulnar Nerve

Felix Guyon described a potential space [15], which is a fibro-osseous tunnel, protecting the ulnar nerve and artery and veins as they enter the hand. The boundaries of Guyon’s canal are the pisiform bone, the tip of the hook of the hamate, the piso-hamate ligament and the transverse carpal ligament.

Os Hamulus proprium

The os hamulus ossifies from a primary ossification center in the body of the hamate; however, occasionally a secondary ossification center in the hook of the hamate is also present. [1] Rarely, the secondary ossification center in the hook of the hamate does not unite with the primary ossification center in the body of the hamate. [2] When the tip of the hook of the hamate does not fuse with the body of the hamate the result is a separate ossicle known as the os hamulus proprium or a bipartite hamulus. Whilst an os hamulus proprium or bipartite hamulus is often congenital a similar appearance can sometimes be the result of a non-union of a fracture of the hook of the hamate. [3]

Ossification of the hamate is not complete until the early teenage years. [4] Bone growth and maturation usually takes place via a single ossification center. However, a secondary ossification center independent from associated underling bone occasionally develops giving rise to an accessory ossicle. [9] This lack of fusion has been observed involving the hamulus and the hamate and is known as either os hamulus proprium or bipartite hamulus. Such cases are often congenital in nature; however, depending on the patient’s history, trauma or degenerative etiology should be considered. [10]

A study [5] conducted in 2005 on 3,218 hand radiographs revealed that variations are more prevalent than previously thought. 96 participants were found to have variations of the hook of hamate of which 42 patients had a bipartite hook, 50 had a hypoplastic hook and 4 had an aplastic hook. Furthermore, 93 of these cases presented with carpal tunnel syndrome symptoms.

In 1981, Greene et al. [6] identified a single case of bipartite hamulus with ulnar tunnel syndrome. However, since then there have been no other accounts of the os hamulus proprius, associated with dynamic ulnar neuropathy.

Case Study


The patient was a 37 year old professional right handed golfer with an unremarkable medical record.

He presented with an eight-week history of pain in the ulnar side of the right hand with loss of fine motor control requiring the use of his contralateral left hand to perform activities of daily living. The patient reported no other neurological symptoms at the time.

Physical examination revealed wasting of the intrinsic muscles of the right hand, most pronounced in the first dorsal interosseous muscles with weak intrinsic movements when comparison to the left side. Following initial examination a series of investigation and imaging was conducted:

It is not uncommon for golfers to fracture the hook of hamate based on the type of grip and dynamics of the golf swing. Furthermore, they can develop stress fractures of the hook of the hamate, which subsequently do not unite. [11,12]

Whilst this may have been the mechanism for the development of injury, an alternative explanation implicates a congenital anomaly where the primary ossification center the hamate fails to unite with the hook of the hamate giving rise to a bipartite bone (os hamulus proprius). [3]


This patient had a well-established long-standing asymptomatic non-union of the hamate or an os hamuli proprius, which subsequently became symptomatic following a motor vehicle accident in January 2005 resulting in an acute eight-week history of fine motor control deficit in the right hand.

Surgical intervention

A mobile segment of the hook of the hamate was identified.  Pressure over the mobile segment of the hook of the hamate compressed the motor branch of the median nerve as it traversed around the ulnar and distal hook of the hook of the hamate. The motor branch of the median nerve was swollen proximal to the point where the mobile segment of the hook of the hamate dynamically impacted on the nerve. This had the appearance of a ‘neuroma in continuity’ commonly seen from failure of regenerating nerve growth cone to reach peripheral targets.

The ulnar nerve was released in Guyon’s Canal. The motor branch of the ulnar nerve was identified and dissected as it coursed around the hook of the hamate. The hook of the hamate was very mobile and unstable. Manipulation of the mobile hook of the hamate demonstrated how it impacted and compressed the motor branch of the median nerve distal to the swollen segment of the motor branch of the median nerve. This was surgically excised.

The patient noticed a marked improvement of symptoms within two days post-operatively commenting on a return of ‘power and movement’. Following rehabilitation through daily grip strength exercises; this was further demonstrated on clinical examination at eighteen days confirming a return of intrinsic muscle power in the right hand.

The following five images describe the surgical repair of Os Hamulus Proprius as performed in this case.


The hook of the hamate is an important structure providing mechanical stability on the ulnar aspect and protecting the motor branch of the ulnar nerve as it traverses deep into the hand from Guyon’s canal. It is also an important structure for insertion of the flexor retinaculum and as a result the muscles on the ulnar side of the hand. [16]

It is very likely that this abnormality of the hook of the hamate was present prior to his injury. The most likely explanation is that it is a secondary ossification center of the hook of the hamate (os hamulus proprius) which went on to unite. However, it is not possible to completely rule out that this represents a long standing non-union of the hook of the hamate and at some stage in the past he may have sustained a stress fracture which resulted in a non-union. [1,3,6,8,11,17]

Clinical examination plays a crucial role in isolating cases of os hamulus proprius. Patients will often present with clinical signs suggesting ulnar neuropathy such as intrinsic muscle weakness and altered sensation of the hand. In differentiating a case of bipartite hamulus, there will also be marked local tenderness over the hook of hamate with symptomatic pain due to dynamic compression such as when performing a power grip. Further hand and upper limb evaluation can compliment the diagnosis by quantifying and comparing loss of strength in the hand. [17]

The patient had marked motor (intrinsic hand muscles) weakness and some minor impairment of sensation in the ulnar distribution, which is consistent with the electrophysiological abnormalities in the hand. Surgery to remove the mobile segment of hamulus resulted in major improvement – particularly in terms of the level of his symptoms and restoration of normal power to the intrinsic muscles of the hand. Excision of the mobile os hamulus proprius has restored control and sensation of his left hand and enabled him to resume his career as a professional golfer.

Ulnar nerve compression in the hand could be due to a multitude of factors, including a tumour, a ganglion cyst, a fracture of either the pisiform or the hamate, compression in Guyon’s Canal, and an aneurysm of the ulnar artery. [18] To discriminate between a congenital bipartite hamulus or a non union of the hook of the hamate five criteria [17] have been described:

  • Bilaterally similar bipartite hamulus
  • Absence of history or signs of previous trauma
  • Equal size and uniform signal intensity of each part on imaging
  • Absence of progressive degenerative changes between the two components of the hamate or elsewhere in the wrist
  • Smooth well corticated and rounded margins of the hamate and mobile separate hook


There are a limited number of options to treat a mobile hamulus segment causing ulnar nerve compression. [8] Initial splinting of the hand can be trialed to prevent dynamic compression of the nerve in the hope that pain and weakness resolve. [5] Furthermore, avoidance of sports relying on grip strength may provide symptomatic relief. If these interventions do not result in the resolution of symptoms, then there is the option of surgically excising the accessory ossification center on the tip of the hook of the hamate with subsequent decompression and release of the ulnar nerve such as presented in this case.

Consent declaration

Informed consent was obtained from the patient for publication of this case report and accompanying figures. IMAGE ONE is taken from This image is in the public domain because its copyright has expired. This applies worldwide.


This paper was written under the supervision of Jeff Ecker from the Western Orthopaedic Clinic in Perth, WA.

Conflict of interest

None declared.


S Moniz:


[1] Andress M, Peckar V. Fracture of the hook of the hamate. British Journal of Radiology. 1970;43(506):141-143.

[2] Blum AG, Zabel J-P, Kohlmann R, Batch T, Barbara K, Zhu X, et al. Pathologic Conditions of the Hypothenar Eminence: Evaluation with Multidetector CT and MR Imaging1. Radiographics. 2006;26(4):1021-1044.

[3] Bianchi S, Abdelwahab I, Federici E. Unilateral os hamuli proprium simulating a fracture of the hook of the hamate: a case report. Bulletin of the Hospital for Joint Diseases Orthopaedic Institute. 1990;50(2):205.

[4] Grave K, Brown T. Skeletal ossification and the adolescent growth spurt. American journal of orthodontics. 1976;69(6):611-619.

[5] Chow JC, Weiss MA, Gu Y. Anatomic variations of the hook of hamate and the relationship to carpal tunnel syndrome. The Journal of hand surgery. 2005;30(6):1242-1247.

[6] Greene M, Hadied A. Bipartite hamulus with ulnar tunnel syndrome–case report and literature review. The Journal of hand surgery. 1981;6(6):605.

[7] O’Driscoll SW, Horii E, Carmichael SW, Morrey BF. The cubital tunnel and ulnar neuropathy. Journal of Bone & Joint Surgery, British Volume. 1991;73(4):613-617.

[8] Pierre-Jerome C, Roug I. MRI of bilateral bipartite hamulus: a case report. Surgical and Radiologic Anatomy. 1998;20(4):299-302.

[9] Garzón-Alvarado D, García-Aznar J, Doblaré M. Appearance and location of secondary ossification centres may be explained by a reaction–diffusion mechanism. Computers in biology and medicine. 2009;39(6):554-561.

[10] Freyschmidt J, Brossmann J. Koehler/Zimmer’s Borderlands of Normal and Early Pathological Findings in Skeletal Radiography. TIS; 2003.

[11] Koskinen SK, Mattila KT, Alanen AM, Aro HT. Stress fracture of the ulnar diaphysis in a recreational golfer. Clinical Journal of Sport Medicine. 1997;7(1):63.

[12] Torisu T. Fracture of the hook of the hamate by a golfswing. Clinical orthopaedics and related research. 1972;83:91-94.

[13] Viegas SF, Patterson RM, Hokanson JA, Davis J. Wrist anatomy: incidence, distribution, and correlation of anatomic variations, tears, and arthrosis. The Journal of hand surgery. 1993;18(3):463-475.

[14] Berger R, Garcia-Elias M. General anatomy of the wrist. In: Biomechanics of the wrist joint: Springer; 1991.

[15] SHEA JD, McCLAIN EJ. Ulnar-nerve compression syndromes at and below the wrist. The Journal of Bone & Joint Surgery. 1969;51(6):1095-1103.

[16] LaStayo P, Michlovitz S, Lee M. Wrist and hand. Physical Therapies in Sport and Exercise. 2007:338.

[17] Evans MW, Gilbert ML, Norton S. Case report of right hamate hook fracture in a patient with previous fracture history of left hamate hook: is it hamate bipartite? Chiropractic & osteopathy. 2006;14(1):1-7.

[18] Zeiss J, Jakab E, Khimji T, Imbriglia J. The ulnar tunnel at the wrist (Guyon’s canal): normal MR anatomy and variants. AJR. American journal of roentgenology. 1992;158(5):1081-1085.

Letters Articles

Lessons learned from internship

Many medical students this year have asked me about what it is like to become an intern. The truth is, nothing you learn at medical school can fully prepare you for the transition to internship. In fact, 42% of newly qualified doctors feel their medical training does not adequately prepare them for starting work. [1] However, it’s not all drama and chaos as shows like House would make you believe. Most internship work is spent on paperwork, requesting investigations and simple procedures like inserting cannulas and taking bloods.

From day one, interns are often rostered for after-hours work, something medical students often have very little exposure to. All of a sudden, new interns may find themselves looking after several wards overnight. Even though some, like me, are interested in critical care medicine, it can still be a challenging thought that over a hundred patients’ lives are entrusted to your care. My first after-hours shift will always stick in my mind, having given me many valuable lessons that I have taken through internship. This is that night in my life:

It is 5pm and most of the doctors have already left. I turn on my pager, secretly hoping it will not beep. Two minutes into the shift, the pager sounds and anxiety kicks in. The nurse on the other side of the phone requests, “Doctor, can you please dose this patient’s warfarin?” It feels strange to not have any other doctors nearby, and my first thought is to ‘phone a friend’. However, I hold off, remembering that the answer lies in the hospital protocol for warfarin, found on all the computers. It reminds me that there is always an abundance of resources and guidance available to us as medical students and interns – if we are willing to ask and look for them.

For the next hour, the tasks are manageable. I re-chart medication charts and get a request to insert a cannula into an elderly lady for intravenous fluids. The team struggled to put the last one in, and her newest one has fallen out during a shower. The lady is thin with fragile veins, and after three painful attempts, the cannula still isn’t in. She is tired of being poked and prodded, and I’m feeling frustrated. I decide to take a break and come back later.

The nurses then page urgently for a doctor. A patient has slipped and knocked his head, and now lies on the floor with a pool of blood beside him. When I arrive at the ward, I find a nurse beside the patient saying, “Everything’s going to be OK, the doctor’s here now,” as if a miracle is about to happen. I do not feel like anyone’s miracle worker, but as one of the first responders and because more senior help had not arrived yet, the nurses look to me for further instructions. My mind freezes, but kickstarts to life again when the basics of ‘ABC’ spring to mind. I feel incredibly grateful for the medical school hammering the ABC approach for such situations. I begin to assess and treat the patient. His airway is patent, cervical spine protected, breathing and circulation maintained. We apply pressure to the wound and perform an ECG and glucose. The few minutes waiting for help to arrive seem to last forever. When more help arrives, we give a huge sigh of relief. I notice that all this time, the patient’s wife has been waiting outside and has been growing extremely worried. As the appropriate members are treating the patient, I take the opportunity to go to her, explain what is happening, and reassure her that her husband is being cared for. One of my consultants once told me that as a junior doctor, one of the best things to do in such situations is to communicate with the patient’s family.

Just when I think that there has been all the excitement I’d need in one night, the pager beeps again. A patient is spiking a high fever, and the nurse is requesting antibiotics. I check through the patients notes first and note that she has been spiking fevers in the last few days, cultures are negative, and the treating team thinks it may be viral. A septic screen has been done, and it was previously decided paracetamol should be sufficient  I reassess her and decide that she does not look too ill at this stage. She has been stable over the last few days.  I choose to leave her without antibiotics, as it does not seem likely that they will be beneficial. The next day, I will check on the patient and be relieved to see that the treating team did not decide to prescribe any antibiotics either.

Before the end of the shift, I go back to visit the elderly lady who still needs a cannula. If I fail, I’ll need to call the duty anaesthetist, and I feel bad because it is getting pretty late in the night. I discuss with the patient, and she agrees for me to have one last opportunity to try. I aim for a small vein in her left hand, and by some stroke of luck, the cannula goes in and flushes smoothly. I breathe a sigh of relief and thankfulness. It reinforces to me that sometimes, just when we are feeling down and tired from trying, we can come back to the task and succeed.

Every day in the hospital, you learn something new. After completing my internship, I am able to reflect back on how much I have learnt in the past year. Completing medical school makes you a doctor, but that is far from the end of the journey. If I may offer some advice, it would be to stay calm in unfamiliar situations, stick with what you have been taught, and never be afraid to ask for help.

Conflict of interest

None declared.


[1] Cave J, Woolf K, Jones A, Dacre J. Easing the transition from student to doctor: how can medical schools help prepare their graduates for starting work? Med Teach. 2009 May;31(5):403-8.

Feature Articles

Up the creek without a paddle: An Australian take on disaster medicine

Figure 1. Participants are assessed in water rescue from a previous module during a water rafting exercise. Here, participants begin to resuscitate an unconscious patient during a disaster simulation.

Disaster medicine is a subject category that invokes thoughts of emergency medicine on a much grander scale; one that involves all levels of healthcare governance. But in reality, it is an area of medicine that is often neglected in Australia, despite its pertinence in this land of extremes. This has been shown to be currently so with the education of Australian medical students, where it is perceived as being too “young a branch on the old tree of medicine.” [1] But what exactly is disaster medicine, and why is there a lack of discussion of this field in a country so often threatened by disasters, natural and man-made? This was recently investigated by a delegation of medical students across Australia during a summer course in disaster medicine and management. They were amongst the 41 students, across five continents, that converged upon Gadjah Mada University in Yogyakarta, Indonesia under the auspices of the World Health Organisation and the Indonesian Ministry of Health. The following article explores the nature of disaster medicine. It then outlines the experiences of students undertaking the summer course run in Indonesia in this area. Finally, it provides an insight into the potential value of incorporating disaster medicine training into the Australian medical education curriculum.


Imagine you are on placement in a rural location in the middle of summer enjoying your free time when wildfires rapidly surround and engulf the town you are based in. Local gas explosions rock the area, as you see dozens of patients with severe burns or in critical conditions lying on the ground. Some are conscious, screaming or clutching their abdomens, while others are unconscious and there is word of hundreds more streaming into the local hospital to escape the fires. All desperately need your help. Hysteria erupts and communication lines are down due to the catastrophe that has suddenly occurred. With nothing in hand, what do you do with no one else on the scene? Who do you save and how do you deal with streams of panicking individuals?

The term ‘disaster medicine’ is difficult to define, and over the years numerous definitions have been proposed as the discipline began to flourish. The World Health Organisation (WHO) defines ‘disaster’ as an occurrence where normal conditions of existence are disrupted and the level of suffering exceeds the capacity of the hazard-affected community to respond to it. [2] The distinct difference between disaster and emergency…

Feature Articles

Delays in adoption of statins on the Pharmaceutical Benefits Scheme: Reflections of a John Snow Scholar

This article is sponsored by the Royal Australasian College of Physicians

The evidence for using statins in diabetic patients with normal cholesterol levels to prevent myocardial infarction or stroke was firmly established in 2002 with the publication of the Heart Protection Study. This large, prospective controlled trial found a relative risk reduction attributable to statins of around 25% in this and other population groups. [1] Statins were not subsidised for this indication in Australia until 2006. [2] I conducted a research project that sought to quantify the effect of this delay in terms of the number of cardiovascular events that might otherwise have been prevented if the subsidy for statins had occurred in 2002, when the evidence for this indication became available.

Completion of the project provided me with a more complete understanding of the use of the breadth of data sources available to synthesise an answer to the research question: what was the impact of the delay in subsidising statin drugs for diabetics with normal cholesterol from 2002 to 2006, in terms of cardiovascular outcomes? It also gave me valuable insights into the public health implications of the decisions of Medicare Australia relating to the funding of drugs, such as those for lowering cholesterol for the primary or secondary prevention of cardiovascular disease.

As an unusual research question, for which I could find little precedent in the published literature, it posed a challenge in terms of designing some means of answering it and required a creative approach. I used baseline cardiovascular risk data from the United Kingdom Prospective Diabetes Study, [3] statin-related risk reduction data from the Heart Protection Study, [1] and epidemiological data from the Australian Bureau of Statistics’ National Health Survey. [4] For one part of the study I also referred to unpublished data from the Perth Risk Factor Survey.

In order to integrate these data to provide an answer to my research question, I had to learn statistical methods and familiarise myself with software that I had never previously used, which was also very challenging and at times frustrating, although good supervision helped to somewhat offset this! I have no doubt that the skills learned will be of use in the future. I then had to present my research methodology and findings in the format of a journal article.

The project allowed me to learn about access to pharmaceuticals in Australia and how the decision-making process is conducted for subsidising medicines for particular patient groups. I gained…