Tropical Surgery Potpourri

UMN / Mayo Global Health2008 November 8

Kenneth McMillan, MDGeneral SurgeryWith CrossWorld in DRCongo (Zaire) & Minnesota

African villager with one day of painful swelling in groin:

Traditional healer lives within 20 km (13 mi)? Y NHave goat and healthy chicken to pay him? Y N Mission hospital (60 km) charges for emergencies? Y NSurgical nurse any good if doctor is not there? Y NFamily lantern has kerosene ? Y N Afraid of rabid dogs along the path at night? Y NSurgical nurse afraid to wake new doctor after midnight ? Y N

Young single surgeon with tropical medicine certificate and no school loans to pay off

Willing to go to Africa for 4 years? Y NWilling to try hospital with no other doctor on staff? Y N

Willing to operate with kerosene lantern or flashlight? Y NCan do his own spinal anesthesia? Y N

Is afraid of rabid dogs on path to hospital after dark? Y N

Can do small bowel anastomosis with 0 braided nylon? Y NShocked to hear surgical nurse did strangulated hernia repair the night before? Y N

I. Personal Background

A. Born & raised in DRCongo (Zaire)B. Belgian public school in Kisangani (formerly

Stanleyville)C. Fluent in French, Swahili and Lingala D. Hobby: taxidermy E. Familiar with malaria, hepatitis, amebiasis …F. Evacuated twice as a teenager …G. Returned to DRCongo as surgeon in 1982H. Married, raised family at Rethy, in Ituri region of

Northeast DRCongo, where traditional and modern societal forces made for an interesting life for both me and my patients:

What is the orange substance in the pot?

A. B. C. D.

24%

8%

39%

29%A. Local fuel oilB. BloodC. Palm oilD. Tomato paste

Democratic Republic of Congo — Africa

Rethy.

Bunia .

I. Personal Background (cont’)

A. Early surgical experience (1984-1988) at Rethy Hospital and as Flying Doctor to 4 other rural hospitals without physicians:

1. Total operative cases 1247, including a. 24 subtotal thyroidectomies (1 death)b. 8 cleft lip repairsc. 4 modified radical, 11 simple mastectomiesd. 146 herniorrhaphiese. 36 prostatectomiesf. 12 open reductions / internal fixationsg. 115 hysterectomiesh. 38 vessico-vaginal fistulae

I. Personal Background (cont’)

A. Surgical experience (1984-1988) at Rethy and as Flying Doctor to 4 other rural hospitals without physicians (cont’):

1. Morbidity rate 2.6% (32/1247)2. Mortality rate 1.6% (20/1247)3. Records for other years are incomplete or lost, but numbers

were similar, with many cases being done by surgical nurses in later years through 1996

B. Results of our training program: 6 surgical nurses, 3 national MDs and 1 missionary MD in surgical rotations of 1 to 6 months

C. What rural surgical practice looked like in DRCongo before Civil War of 1996:

II. Preparation for Surgical Practice in Developing Country

A. Clarify personal/family motivation for serving in foreign location

B. Get advice from veterans on how broad to train in medicine & surgery

C. Bring out texts or CDs on wide variety of operations, especially pediatric surgery

D. Plan on tropical medicine and public health courses

E. Schedule time for language and culture studiesF. Establish a relationship with supporting agency

before leaving

III. Adaptation of Medicine/Surgery to Poor Communities

A. Evaluate status of healthcare before starting new medico-surgical interventions

B. Carefully evaluate staff skills; retrain if necessaryC. Observe use and effectiveness of existing operating

room and equipment; enable correction of dangerous deficiencies

D. The community has been there longer than you, and should be involved in making changes

E. When prominent surgical diseases are identified, integrate them into the public health and education programs

IV. Successful Practice of Surgery in Bush Hospitals A. Admit inadequacy, need for higher wisdomB. Acknowledge patient’s philosophy of health and

wellness C. Involve patient’s family in decisions, care and

payment for careD. Expect rural patients to have pathologic,

physiologic and even anatomic variations from urban or developed populations

E. Expect rural patients to present late in the course of a disease, eg, infection, trauma and cancer

Which is the most common operation in African tropics?

A. B. C. D.

10%

27%

2%

62%A. Appendectomy B. HerniorrhaphyC. Mastectomy D. Vessico-vaginal

fistula

IV. Successful Practice of Surgery in Bush Hospitals (continued)

A. Use readily available supplies, eg, fine nylon string for suturesB. Recycle gloves, needles, syringes, catheters, etc in order to

have continuous supply of materials. Heat sterilization and/or antiviral solution is used.

C. Use distilled water from autoclave for local production of IV fluid.

D. Have relatives or other donors ready to give fresh typed and cross matched blood if necessary

E. Treat pre/intra/post op fevers with anti-malarials

IV. Successful Practice of Surgery in Bush Hospitals (continued)

A. Allow family to pray with patient before operationB. Use universal precautions with all body fluids and double glove

for bone exposure and oral operationsC. If staff are competent at starting IVs, hold off use of IV until

needed for meds, stabilizationD. Rural major surgery can be done without oxygen, oxymetry,

electronic monitors or electrocauteryE. Anesthesia can be adequate using local, regional/spinal, ether

or ketamine (pediatric cases)

IV. Successful Practice of Surgery in Bush Hospitals (continued)

A. Variations for certain operations are safer and/or more affordable in a rural setting:

1. Primary anastomosis for emergency sigmoid volvulus

IV. Successful Practice of Surgery in Bush Hospitals (continued)

A. Variations for certain operations are safer and/or more affordable in a rural setting:

1. Primary anastomosis for emergency sigmoid volvulus

2. Non-operative treatment of most fractures, including long bones of leg; exception for open, ankle, forearm

3. Suprapubic transvessical prostatectomy for prostatic hypertrophy

4. Vessico-vaginal fistula repair may need re-operation, but majority can be closed

5. Total rather than radical excisions when biopsy results are not available and lesion appears malignant

IV. Successful Practice of Surgery in Bush Hospitals (continued)

A. Other suggestions for performing surgery satisfactorily in rural settings:

– Consult textbooks and distant generalists/specialists

– For preventable surgical illnesses, eg, iodine-deficient goiters, involve non-surgical staff in programs that allow patient to avoid operation

When was the last time you saw a 2 kg thyroid gland?

This was the las t one I saw.

IV. Successful Practice of Surgery in Bush Hospitals (continued)

A. Other suggestions for performing surgery satisfactorily in rural settings:

1. Consult textbooks and distant generalists/specialists2. For preventable surgical illnesses, eg, iodine-deficient goiters,

involve non-surgical staff in programs that allow patient to avoid operation

3. Train nurses and surgical assistants to perform common surgical emergencies--C-section, strangulated hernia, etc

4. Keep price of major operation affordable--equivalent to month’s income for individual

5. Consider a rotating fund to help poor families6. Accept operating on your own family!

V. Future of Surgery in Rural (Bush) Communities

A. Applying the above guidelines will certainly depend on which country or community one is serving

B. Current rural surgeons in DRCongo report no improvement in “bush” surgery methodology in their locations (eastern Congo)

C. War-time hospital experience is difficult to analyze due to lack/loss of records, displaced staff

D. A period of peace more than a few months is needed to evaluate rural communities for surgical as well as public health/medical outcomes

V. Future of Surgery in Rural (Bush) Communities (continued)

A. Present approach is to continue all of the above as valid methods while awaiting peacetime outcome studies specific to bush surgery

B. Consider more interaction with outside world, now that internet and satellite phones are available, especially for treatment of rare cases, staff training and visits by specialists

C. Strive for STEEEP, the six quality components recommended by the Institute of Medicine

D. Pray for peace and prosperity for countries populated by rural people

I. Conclusions

A. Successful, quality surgery in isolated poor communities is feasible

B. Until outcome studies show otherwise, we recommend a simple, clinical approach tailored to community characteristics and resources

C. Training non-physicians in surgery is justified in rural settings in some countries

I. Challenge

S ome body ne e ds to write the book Whe re The re Is One Doctor.

I’m too busy to comple te mine !

References

CDC (www.cdc.gov)

CIA World Fact Book (www.cia.gov)

Institute of Medicine (www.iom.edu)

Tropical Medicine (Dion Bell)

United Nations Integrated Regional Information Networks (www.irinnews.org)

Wall Street Journal (www.wsj.com/health)

World Health Organization (www.who.org) …