Tropical surgery potpourri umn mayo global health 2008 november 8
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Tropical Surgery Potpourri UMN / Mayo Global Health 2008 November 8 Kenneth McMillan, MD General Surgery With CrossWorld in DRCongo (Zaire) & Minnesota African villager with one day of painful swelling in groin: Traditional healer lives within 20 km (13 mi)? Y N

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Tropical Surgery PotpourriUMN / Mayo Global Health2008 November 8

Kenneth McMillan, MD

General Surgery

With CrossWorld in DRCongo (Zaire) & Minnesota


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African villager with one day of painful swelling in groin:

Traditional healer lives within 20 km (13 mi)? Y N

Have goat and healthy chicken to pay him? Y N

Mission hospital (60 km) charges for emergencies? Y N

Surgical nurse any good if doctor is not there? Y N

Family lantern has kerosene ? Y N

Afraid of rabid dogs along the path at night? Y N

Surgical nurse afraid to wake new doctor after midnight ? Y N


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

Willing to go to Africa for 4 years? Y N

Willing to try hospital with no other doctor on staff? Y N

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

Willing to operate with kerosene lantern or flashlight? Y N

Can do his own spinal anesthesia? Y N

Can do small bowel anastomosis with 0 braided nylon? Y N

Shocked to hear surgical nurse did strangulated hernia repair the night before? Y N


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I. Personal Background no school loans to pay off

Born & raised in DRCongo (Zaire)

Belgian public school in Kisangani (formerly Stanleyville)

Fluent in French, Swahili and Lingala

Hobby: taxidermy

Familiar with malaria, hepatitis, amebiasis …

Evacuated twice as a teenager …

Returned to DRCongo as surgeon in 1982

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:


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What is the orange substance in the pot? no school loans to pay off

  • Local fuel oil

  • Blood

  • Palm oil

  • Tomato paste


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Rethy. no school loans to pay offBunia .

Democratic Republic of Congo — Africa


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I. Personal Background (cont’) no school loans to pay off

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

Total operative cases 1247, including

24 subtotal thyroidectomies (1 death)

8 cleft lip repairs

4 modified radical, 11 simple mastectomies

146 herniorrhaphies

36 prostatectomies

12 open reductions / internal fixations

115 hysterectomies

38 vessico-vaginal fistulae


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Personal Background (cont’) no school loans to pay off

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

Morbidity rate 2.6% (32/1247)

Mortality rate 1.6% (20/1247)

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

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

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


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II. Preparation for Surgical Practice in Developing Country no school loans to pay off

Clarify personal/family motivation for serving in foreign location

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

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

Plan on tropical medicine and public health courses

Schedule time for language and culture studies

Establish a relationship with supporting agency before leaving


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III. Adaptation of Medicine/Surgery to Poor Communities no school loans to pay off

Evaluate status of healthcare before starting new medico-surgical interventions

Carefully evaluate staff skills; retrain if necessary

Observe use and effectiveness of existing operating room and equipment; enable correction of dangerous deficiencies

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

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


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IV. Successful Practice of Surgery in Bush Hospitals no school loans to pay off

Admit inadequacy, need for higher wisdom

Acknowledge patient’s philosophy of health and wellness

Involve patient’s family in decisions, care and payment for care

Expect rural patients to have pathologic, physiologic and even anatomic variations from urban or developed populations

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


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Which is the most common operation in African tropics? no school loans to pay off

  • Appendectomy

  • Herniorrhaphy

  • Mastectomy

  • Vessico-vaginal fistula


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

Use readily available supplies, eg, fine nylon string for sutures

Recycle gloves, needles, syringes, catheters, etc in order to have continuous supply of materials. Heat sterilization and/or antiviral solution is used.

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

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

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


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

Allow family to pray with patient before operation

Use universal precautions with all body fluids and double glove for bone exposure and oral operations

If staff are competent at starting IVs, hold off use of IV until needed for meds, stabilization

Rural major surgery can be done without oxygen, oxymetry, electronic monitors or electrocautery

Anesthesia can be adequate using local, regional/spinal, ether or ketamine (pediatric cases)


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

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

Primary anastomosis for emergency sigmoid volvulus


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

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

Primary anastomosis for emergency sigmoid volvulus

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

Suprapubic transvessical prostatectomy for prostatic hypertrophy

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

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


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

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


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

This was the last one I saw.


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

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

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

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

Consider a rotating fund to help poor families

Accept operating on your own family!


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

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

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

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

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


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

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

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

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

Pray for peace and prosperity for countries populated by rural people


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Conclusions (continued)

Successful, quality surgery in isolated poor communities is feasible

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

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


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Challenge (continued)

Somebody needs to write the book

Where There Is One Doctor.

I’m too busy to complete mine!


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References (continued)

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) …


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