Scalpel's Edge

A surgeon's notes

Reflections on Global Surgery

Working in Tansen has given me a different perspective on surgery.  Although I was interested in global surgery prior to coming here, I never understood the difference in medical services.  It was a more academic interest – I liked the “idea” of supporting global surgery. Now, my experience is more immediate – problems with the access to surgery are real.

Watch this video for a summary of the problems of global surgery provision.

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The hospital that I work at is the equivalent of a major rural hospital.  People who live nearby have access to key life-saving procedures – caesarian section and laparotomy.  However, as I have discussed before there are more obstacles to people accessing hospital care than just the provision of that care.  In more remote areas, the issues grow.  At some of the hospitals we are associated with, the general doctors (GP’s) will put in a spinal before performing a caesar on the same patient.  At our hospital we don’t have medical anaesthetists (we have nurse anaesthetists) and it is common for smaller hospitals and health posts to have no separate anaesthetic services at all.  I heard of a nepali colleague who performed a laparotomy on a child because there was no option, despite the fact that he had never done one before.  He probably did the anaesthetic, too.

Here are some of the issues I have discovered working at my relatively well-equipped hospital that make best practise surgery difficult to deliver.

  • We have limited equipment.  In the west, hospitals are using more disposable equipment, which is expensive.  It is increasingly difficult to buy reusable equipment, meaning we are stuck relying on donations.  When we do purchase single use equipment it is resterilised and reused, prolonging its life.
  • It is not appropriate to try to model ourselves on western healthcare.  We train GPs to do simple surgery like appendicectomies and caesarian sections – life saving surgery.  If needed, they can perform these procedures in tiny hospitals, putting the spinal anaesthetic in themselves, before proceeding with surgery.  We have to teach them cheap, affordable techniques, or they will struggle. No laparoscopic appendicectomies!
  • Online resources like uptodate help us to make surgical decisions, but they are directed at “best practise.”  Many of the treatments and medications are unavailable to us, and prohibitively expensive for patients.  I looked up an antibiotic guideline last week and was advised to prescribe Piperacillin-tazobactam, Ticarcillin-clavulanate or meropenem.  Not so helpful.  It would be helpful to have a second line recommendation that included less expensive medications, but theres no similar resource for surgery in the less expensive world.
  • Equally, we need to treat some conditions in really poor people.  We can’t use adjuvant therapies and investigations because they are too expensive.  So we need to go back 50 years and find the evidence of best treatment without adjuvant therapy.  We know that mastectomy for breast cancer is equivalent to wide excision with adjuvant radiotherapy, but it is harder to find information on other diseases. Is is worth operating on large rectal cancers without adjuvant therapy? What are the indications for open fundoplication for gastro-oesophageal reflux without 24 hour pH monitoring?  In many conditions we return to best guess, previous surgical wisdom and inherited dogma, with little help from literature review.
  • Diseases that are common here, are not represented in the world literature.  So there is no best practise treatment of abdominal tuberculosis causing obstruction. Or relapsing cold (TB) abscess without microbiological diagnosis. Or strange liver abscesses with who knows what organism or parasite.  And we don’t know if there is something dietary or metabolic we could be doing to reduce the complications of renal stones that are at least twice as common as at home.
  • Research in this country is difficult to arrange, requiring forms and approval and time.  So the information is going to stay locked in the brain of the senior clinicians, who have learnt by experience.
  • The rest of the world, including the medical publishing world, believe that we are in an era of subspecialty surgery.  Textbooks are directed at people who have a surgical mentor to teach them a procedure.  So learning simple urological or ENT procedures, for example, is very difficult.  No one in my hospital has done a tonsillectomy recently, despite the fact that this common surgery was once firmly in the realm of general surgeons.  So we can’t learn or provide the surgery and have to send our patients to the expensive private hospital down the road.  And we know those guys aren’t necessarily better at the operation, they’re just more willing to do it out of a book!
  • Healthcare is a profit industry.  No hospital really cares if a doctor knows what he is doing, or cares if he gets it right, as long as he is registered.  Registration doesn’t really rely on competence, so unlike home.  Deaths and mistakes in healthcare are expected and not reviewed. How can patients even hope to know who to go to for help?
  • Power is intermittent and unpredictable.  Imagine surgery when the lights and diathermy machines turn off.  I have done more lap choles using scissor dissection than ever before (at our hospital the laparoscopic tower is protected by a UPS system that powers it by battery for 30 minutes after the power fails). 

This is my perspective from a  rural area.  It is certainly different in Kathmandu although some of the problems still exist.  Healthcare is still patient funded, and not everyone can afford the expensive procedures that are available.  Experienced doctors find it easier to get employment, but they are still working in a country with border blockade and petrol shortages.

In the western world we are so addicted to minimising risk and incrementally improving outcomes that we don’t realise how well-trained we are.  Surgeons in Nepal are registered as surgeons without ever having done a hernia repair, for example.  Yet in Australia, my colleagues are reluctant to work independently until they’ve had a few years under supervision. This is maybe appropriate in a western hospital with a huge oversupply of experienced and well-trained doctors.  It has the flow on effect that less people have confidence in their own ability and fewer surgeons feel equipped to mentor poorly trained third world surgeons. So in the expensive world, healthcare outcomes improve slowly and in the poor half of the world, doctors are left increasingly isolated, relying on their own resources to improve their own healthcare, despite all difficulty.

Surely the answer is to improve global surgery provision through funding and hard work, but the answer lies also in understanding the difference between Australia (or the US or England) and the rest of the world.  I think I used to imagine a rural nepali hospital as similar to a poorly funded Australian rural hospital, which is simply a ridiculous comparison.  My biggest wish to improve world healthcare is that we all step out of our shells and experience healthcare in the rest of the world. I hope one day we focus less on the 0.1% improvement we can make in the health of five suburban australians and start to notice what we can achieve in Bangladesh, and Nepal, and Cambodia, and all of the other broken countries nearby.  

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