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What Borders for MSF Surgery?
Caroline Veldhuis, International Editor
The idea of humanitarian field surgery, for many, conjures scenes of tv-show doctors performing crude operations, in chaotic environments at the front lines of war. While MSF’s 30-year surgical history is inarguably illustrated with such images, surgical aid continues to evolve, adapting to new field realities and incorporating higher standards of medical practice. the only appropriate response to certain medical needs, surgery has become an inextricable component of MSF’s medical aid. In 2006, surgeons departed on approximately 125 missions and over 64,000 surgical interventions were carried out in some 20 countries worldwide.
MSF continues to perform surgery in areas of conflict where humanitarian space can be obtained, with teams working in volatile places such as Democratic Republic of Congo and Somalia. Posted at a new project opened in Kismayo, southern Somalia in 2007, British surgeon Dr. Paul McMaster describes his work,“We see lots of gunshot wounds in the abdomen, I just saw someone whose arm was shattered with a kalashnikov. The busiest day so far, I was working on a skin graft for a burned child, when a bomb went off. There were about 15 casualties. It took an hour and a half to get people triaged and stabilized and I worked into the evening on various operations from serious facial wounds to sutures.”
In war settings, it is documented that as many as 96 percent of deaths from trauma occur within four hours, so proximity to patients is essential for doctors to perform lifesaving acts. Dr. Ritsuro Usui, surgeon and president of MSF Japan, emphasizes the importance of this proximity, explaining that the type of injuries surgical teams see is a function of time and distance from conflict. “Twenty-four hours after trauma has been sustained,” he says, “mainly limb injuries are seen, because most people with chest and abdomen trauma will have already died.” Massive needs for surgical care have led MSF to establish trauma centers in hospitals in Port Harcourt, Nigeria and Port-au-Prince, Haiti, both epicenters of violence, where over 3,000 surgeries were performed in 2006, many for gunshot and knife wounds, beatings, road accidents, and burns. These well-equipped trauma centers have developed rehabilitative services including physiotherapy, psychological counseling, and prosthesis referrals. In a context such as Iraq, however, soldiers may have access to good medical and surgical care and quick evacuations, but obtaining the proximity for medical-humanitarian organizations to save injured civilians is extremely difficult. Blurred front lines present enormous security risks in some areas, transportation is hazardous and health infrastructure is increasingly destroyed.
When proximity is impossible, operations can be performed to help patients unable to receive proper care at time of injury. MSF’s initial surgical response for people wounded in Iraq has been a reconstructive plastics, maxillofacial, and orthopedic project at the Red Crescent Hospital in Amman, Jordan. Here people are treated for severe facial disfigurement, bone, and wound infections. Procedures take place in a well-equipped hospital with modern equipment, permitting MSF to use advanced techniques such as internal fixation and fibreoptic intubation, necessary to administer anesthesia when a patient’s facial anatomy is destroyed.
The doctors in Amman see patients such as Zeinab, 36, who in 2004 was traveling to the holy city of Najaf with a vanload of people that was caught in crossfire. The vehicle crashed, killing everyone but Zeinab, who not only lost her two-year-old son and unborn child, but she also sustained two broken legs, a fractured arm, and jaw. She received internal fixations in her broken legs from surgeons in Iraq, but the plate in her right leg later broke because of a serious bone infection. In 2007, she was transported to Amman, where doctors treated her infection and re-set her internal fixations so she will be able to walk again. A reconstructive program was also established in 2005 for people with severe war wounds in Chechnya, some of them like Zeinab, having received the best possible, though insufficient, surgery and medical care when injured. Here, as in all settings, MSF’s contribution also consisted of general measures to reduce risk of infection and implement safer surgery, including the supply of an oxygen concentrator to replace the unstable industrial oxygen previously employed.
In addition to these ongoing projects, surgery on an itinerant basis has been provided for people with war wounds. Extensive violence inflicted, not with bombs or bullets but machetes, left victims in Uganda with facial mutilation including loss of noses, ears, and lips. MSF in 2005 and 2006 coordinated with the surgical group Interplast Holland, to provide reconstructive surgery for 24 people with war-related injuries, burns, and cleft lip and palate conditions in Kitgum.
Treating the effects of obstetric complications
Obstetric emergencies account for roughly one-third of MSF’s volume of surgery, even in some conflict contexts. Reconstructive procedures are now increasingly offered to women suffering the consequences of poor prenatal care and/or not having access to medically indicated Cesarean sections.
Utero-vaginal prolapse (UVP) and obstetric fistulas are two possible conditions resulting from obstetrical trauma, characterized not only by physiological damage and pain but also by social ostracism. Both UVP and fistulas may result in incontinence, with some fistulas causing women to experience continuous leaking of feces, and consequent rejection by their husbands, families, and communities. Dr. McMaster says he sees many women with fistulas. “We have a woman on the ward, she came in two weeks ago in obstructed labor, with a ruptured uterus. The baby died, and we had to remove her uterus to save her life. Then we noticed she was losing urine because of a big hole in her bladder. This has been going on this for four years, since she had her first child. She leaks urine, stinks, and has been confined to home.” Rare in more developed countries, fistulas require a specialized surgery that must be learned in Africa. Several MSF surgeons have now mastered the techniques and train others through MSF. Fistula repair has been provided in numerous countries including Liberia, Republic of Congo, Ivory Coast, and Chad, and interventions are now being considered for other locations. In Nepal, where there has been a special focus on women’s health needs in a project in Khotang, MSF in 2007 partnered with a Nepalese surgical NGO to help women with UVP, organizing and managing a “uterine prolapse camp.” Eighty-two women received the operations they needed and a future collaboration is planned for 2008.
“The surgery went well, but the patient died”
Concomitant with the growth of surgery as a medical-humanitarian response is careful attention to the factors that complement surgical skills and will afford the best possible outcome for patients in any setting. Higher standards and updated protocols are increasingly implemented in projects to achieve better hygiene and more sterile environments, assure a range of drugs and proper equipment, and supply and/or train necessary human resources, such as nurse anesthetists. In keeping with western medical practice, for example, MSF has been improving patient care through individualized anesthesia and pain management. Dr. Matthew Mackenzie, an anesthetist who has worked in Ivory Coast and Central African Republic, explains pain is more tolerated and perhaps undertreated in the African hospitals where he has worked, remarking that people never make a fuss when it is obvious they would be in excruciating pain. MSF is placing an increased emphasis on the awareness of pain and its treatment, and many projects have now implemented the use of pain scales, where nurses regularly check in with patients and adjust their drugs as necessary.
An essential part of surgical teams in developed countries, anesthetists and nurse-anesthetists have gained greater recognition on MSF surgical teams, whereas some early projects may have functioned without a dedicated anesthetist. In addition to determining which type of anesthetic is safest and most appropriate for a given patient and operation, these specialists are highly trained in airway management and intravenous lines, and can be indispensable beyond the OR. MSF trains local nurses in anesthesia in some projects.
A widening skill gap
Outside the specialized and itinerant surgical missions, in many field settings the operations required in a district hospital – a fairly typical structure for many MSF projects – are broad and basic. Dr. Gary Myers, one of a handful of MSF headquarters’ surgical referents, estimates that in a surgical inpatient hospital for a neglected population, “out of every 100 patients, 50 will be suffering from soft-tissue injuries that are a consequence of trauma and/or infection; 25 the complications of pregnancy or childbirth; 12 will have a variety of bone injuries or fractures and the remainder will need major surgery for conditions such as burns or sepsis or require laparotomies.” The skills required to address this spectrum of needs fits well with the traditional general surgeon who has some facility in orthopedic, obstetric, and visceral interventions. The emerging generation of surgeons in developed countries, however, is trained with new technology and is increasingly compartmentalized in their skills. A growing gap is foreseen between surgical needs in remote field settings and the abilities of new surgeons schooled in a wealthier infrastructure to provide relevant assistance. Although they may be well-versed in endoscopic techniques and able to work in very specific projects, “In ten years,” says Dr. Nathalie Civet, surgical referent for MSF’s Belgian-run programs, “we are going to have problems finding a surgeon who knows how to open an abdomen.” Organizations such as MSF will thus face an additional challenge in attempting to fill human resource gaps in countries with a dearth of skilled medical professionals.
Where to draw the line?
Particularly in conflict zones, the needs for medical and surgical care are extensive and demanding, and the question of what is and is not possible in field-based operating room is a daily one. Location and context are the all important factors. Sophisticated techniques such as internal fixation, for example, can be implemented in some locations, but the numerous requirements to implement this procedure safely and effectively means it may not be available in others. Yet MSF continues to push forward. On a logistical level, inflatable tent hospitals, developed and first launched after the 2005 earthquake in Kashmir, have been modified to include adequate surgical capacity and are being tested. Gigantic surgical kits, veritable “operating theaters to go,” can be readied in enormous crates and quickly loaded onto planes . These kits comprise beds, rolling trays, respirators – in short, all the equipment and medicines required to provide effective lifesaving surgery. The difficult prerequisite is the humanitarian space in which to function.
Meanwhile, as poor access to health care in many parts of the world continues, so will the need for surgery to treat complications. Late presentation combined with the lack of drugs and diagnostics for buruli ulcer, a “neglected disease,” leads to severe osteomyelitis requiring a teenager in Cameroon to undergo a leg amputation. Lack of obstetric care in Sudan produces a fistula that finds a woman living alone and isolated, rejected from her community. And these are but two of many examples. Vigorous debates will continue to inform MSF surgical programming choices that attempt to balance the allocation of resources with what must be a select alleviation of suffering – in itself, a most difficult form of triage.