Outreach not Over-Reach
Dr Justin Curtin, Clinical Assistant Professor in Oral and Maxillofacial Surgery, writes about the challenges one needs to cope with in the delivery of cleft services while on a humanitarian mission.
“Cleft lip and palate surgery is a life changing event. In many regards the surgery itself is relatively straightforward without major physiological consequences and the opportunity of making an impact for little risk is highly attractive. Medical missions offer the framework for medical personnel to deliver their skills in a location where need outstrips supply, and it all seems a perfect fit. However, despite good intentions, medical teams visiting foreign lands to provide services can end in disappointment or even disaster for all concerned. This article aims to provide some background, and ‘food for thought’ to enhance the likelihood that the experience will be enjoyable and beneficial for all concerned – a ‘stay out of trouble guide’.
Outreach surgical care can be delivered either by fitting into an existing hospital framework or temporary platforms of variable independence. The latter essentially creates a field hospital that is able to deliver care to areas of need that are beyond access to local services. Such an environment is by its nature limited in the services it can safely provide, a fact that can impact upon the outcome quality despite the capabilities of the surgeon – this is an important issue to accept. Temporary surgical facilities are by far the most common in the delivery of cleft services in low income countries.
We need to accept the fact that temporary surgical facilities are by far the most common in the delivery of cleft services in low income countries. One of the questions most commonly asked is “What shall I bring?” The answer to this question is both simple and complex: bring the essentials as well as bring all you have, including those tangible items needed to handle unexpected complications, such as in cases of bleeding and airway issues. Other intangible essentials include factors that impact quality of care, ethics and respect for the local culture and expertise.
Screening assessment looms large in determining safe delivery of care, given that places where humanitarian aid is required are also areas where poor living standards, underlying cardiac and respiratory diseases as well as nutritional deficiencies may be prevalent, factors of which played an important part in making prudent decisions in the selection of patients.
As a surgeon, focus is almost habitually on delivery of care, however a significant amount of this preparation is undertaken months prior to the mission. It can be a deflating experience to turn up, full of enthusiasm and willingness to help (after all that is the nature of most healthcare providers) to find oneself almost impotent because of lack of planning and consideration of facilities; those things that most of us take for granted in both our daily lives and our working lives – facilities without which we cannot move into action.
For healthcare to be sustainable teaching and learning must be continual and part of the framework that includes local and visiting team members, and it is at the same time essential to acknowledge local expertise, which is often of high calibre despite their having little public recognition. One should be reminded to avoid committing the Seven Sins of Humanitarian Medicine pointed out by Welling: Leaving a mess behind/Failing to match services to local needs and facilities/Failing to co-operate with other organisations, including local colleagues and authorities/Failing to have plans for patient transfer in case of unforeseen medical emergency, and failure to have a follow-up plan/Being distracted by politics, training or other issues in the delivery of medical care/Going where the services is not needed, not wanted or being poor guests/Doing the right thing for the wrong reason.
Challenging case – Expect the Unexpected
During one case, having spent the best part of an hour battling ongoing ooze from a routine cleft lip repair, while wondering what the anaesthetist was doing to make my life so hard, I was relieved to be finished. Midway through the next case, the recovering room nurse came to inform us that our last patient was breathing strangely, and there was a lot of blood coming from the wounds. Upon review, the patient had stridor and was covered in blood. The lip was inordinately swollen, and even the needle marks from the nerve blocks were purpuric. It turned out that the child had been declined surgery by other surgical teams on the basis of her proclivity to bleeding and bruising. Realising this was an issue, the parents withheld that information. The diagnosis? Vocal cord haematoma due to an unknown bleeding diathesis. It could have been disaster, and probably would have been if the surgery had been palatoplasty.
Article first appeared in PMFA News 2015;3(1):6-10. Reprinted with kind permission of Pinpoint Scotland Ltd – www.pmfanews.com