Dr. Nikki Blackwell, an anesthesiologist on the Amman program, explains the specific features of this surgical project, describing the difficulties involved as well as the new techniques employed and her initial grounds for satisfaction.

What difficulties does your work in Amman involve?

An Iraqi patient after a maxillo-facial surgical operation. Photo © Olivier Falhun / MSF

In contrast to other missions I've worked on, at the beginning of this project we are seeing a great many patients who need maxillo-facial surgery, which calls for a highly sophisticated anesthesia technique that is difficult to apply but essential in these cases. This technique requires the fibroscopic intubation of a patient whose facial anatomy has been largely destroyed. To avoid losing the patient's airway during induction of the anesthesia, we have to verify what we are doing very carefully, while remaining ready to take action in case of suffocation. Our only option in this case is to keep the patient awake in order to be able to check respiratory reflexes while performing the intubation. Otherwise we might cause suffocation without noticing it. We can only anesthetize the patient after having completed the intubation. This is the first time MSF has used this fibroscopic intubation technique, and it may mark the beginning of a new era, though admittedly it is in a context that allows us to perform this type of surgical procedure.

Does this context allow us to improve some of our practices?

In keeping with the quality objective that we — principally my colleagues here and in Paris — have set for surgical procedures, we have an opportunity here to set up a peri-operative system designed to cope with all possible contingencies, and thus to guard against the risks inherent in surgical procedures. To this end, we need first to rid ourselves of a number of myths affecting this quality objective. We need to fight against many mistaken beliefs, from the notion that only bad surgeons make mistakes to the idea that good supervision is sufficient to make good those mistakes. By introducing controls and strict, complete and specific procedures, we can deal with any contingency, including complications arising from our practices, from the pre-op stage until the patient leaves the hospital.

On a more technical note, we had been working to introduce thromboprophylaxis in projects. This is the first time we've administered this prophylaxis systematically to prevent pulmonary embolisms; eventually, we should be able to do so for all surgical missions.

We are also paying close attention to controlling infection. In this matter, we had already learned a great deal from the experience in Pakistan¹ , where orthopedic surgery is concerned. Today, we are particularly vigilant concerning some patients' resistance to antibiotics, and we have strict hygiene procedures after each operation to limit the risks of infectious transmission to other patients.

What about pain management?

This is one of the major points of satisfaction of this project. Pain management is a priority on all surgical missions. Most of the patients admitted in Amman suffer from sharp, stabbing pain, some of them for months or years. It is generally chronic pain, including forms of neuropathic pain which are so unbearable that some people commit suicide to put an end to their suffering. Fortunately, for a few years now we've had the right protocols, which let us check on patients' condition. Surveillance by nurses is critical here because, unlike physicians and surgeons, nurses are in close contact with patients, which allows the latter to speak more freely. That's why we ask the nurses systematically to question patients specifically about this point and to evaluate it on a pain scale. But we are also aware of the limitations of this program; although it can fix up patients and relieve their pain, it says nothing about the psychological effects of war, which are indelibly marked on some of their faces.

¹ During the MSF operation in October 2005, following the earthquake that hit the North-West province of Pakistan