• Before the Bombing: High Burden of Traumatic Injuries in Kunduz Trauma Center, Kunduz, Afghanistan

      Hemat, H; Shah, S; Isaakidis, P; Das, M; Kyaw, NTT; Zaheer, S; Qasemy, AQ; Zakir, M; Mahama, G; Van Overloop, C; et al. (Public Library of Science, 2017-03-10)
      Médecins Sans Frontières (MSF) has been providing healthcare in Afghanistan since 1981 including specialized health services for trauma patients in Kunduz Trauma Center (KTC) from 2011. On October 3rd, 2015, a US airstrike hit the KTC, killing 42 people including 14 MSF staff. This study aims to demonstrate the impact on healthcare provision, after hospital destruction, by assessing the extent of care provided for trauma and injuries by the MSF KTC and to report on treatment outcomes from January 2014 to June 2015, three months prior to the bombing.
    • The blast wounded of Raqqa, Syria: observational results from an MSF-supported district hospital.

      OKeeffe, J; Vernier, L; Cramond, V; Majeed, S; Carrion Martin, AI; Hoetjes, M; Amirtharajah, M (BioMed Central, 2019-06-20)
      BACKGROUND: In June 2017, the U.S.-backed Syrian Democratic Forces (SDF) launched a military operation to retake the city of Raqqa, Syria, from the so-called Islamic State. The city population incurred mass numbers of wounded. In the post-offensive period, the population returned to a city (Raqqa) contaminated with improvised explosive devices (IEDs) and explosive remnants of war (ERWs), resulting in a second wave of wounded patients. Médecins Sans Frontières (MSF) supported a hospital in Tal-Abyad (north of Raqqa) and scaled up operations in response to this crisis. We describe the cohort of blast-wounded cases admitted to this hospital in order help prepare future humanitarian responses. METHODS: We retrospectively extracted data from clinical charts in the MSF-supported hospital. We included all new admissions for blast-wounded patients with key data elements documented. We performed comparative analyses from the offensive period (June 6, 2017 to October 17, 2017) and the post-offensive period (October 18, 2017 to March 17, 2018). RESULTS: We included 322 blast related injuries. There were more than twice the number of cases with blast injuries in the post-offensive period as the offensive period (225 vs. 97, p = <.001). The offensive period saw a significantly higher proportion of female patients (32.0%, n = 31 vs. 11.1%, n = 25, p < 0.001) and paediatric patients (42.3%, n = 41 vs 24.9%, n = 56, p = 0.002). Blast-injured patients in the post-offensive period included more cases with multiple traumatic injuries (65.8%, n = 148 vs. 39.2%, n = 38, p < 0.001). The treatment of the blast-injured cases in the post-offensive period was more labor intensive with those patients having a higher median number of interventions (2 vs 1, p = <0.001) and higher median number of days in hospital (7 vs 4, p = < 0.001). CONCLUSIONS: In the wake of the Raqqa offensive, the MSF-supported district hospital received an unpredicted second, larger and more complex wave of blast-wounded cases as the population returned to a city strewn with IEDs and ERWs. These findings indicate the high risk of traumatic injury to the population even after warring factions have vacated conflict zones. Medical humanitarian actors should be prepared for a continued and scaled up response in areas known to be highly contaminated with explosive ordnance.
    • Burden of surgical disease: strategies to manage an existing public health emergency.

      McQueen, K A K; Parmar, P; Kene, M; Broaddus, S; Casey, K; Chu, K; Hyder, J A; Mihailovic, A; Semer, N; Sullivan, S R; et al. (2009-07)
      The World Health Organization estimates that the burden of surgical disease due to war, self-inflicted injuries, and road traffic incidents will rise dramatically by 2020. During the 2009 Harvard Humanitarian Initiative's Humanitarian Action Summit (HHI/HAS),members of the Burden of Surgical Disease Working Group met to review the state of surgical epidemiology, the unmet global surgical need, and the role international organizations play in filling the surgical gap during humanitarian crises, conflict, and war. An outline of the group's findings and recommendations is provided.
    • Cesarean Section Surgical Site Infections in Sub-Saharan Africa: A Multi-Country Study from Medecins Sans Frontieres

      Chu, K; Maine, R; Trelles, M (SpringerLink, 2014-10-31)
      Surgical site infections (SSI) are a significant cause of post-surgical morbidity and mortality and can be an indicator of surgical quality. The objectives of this study were to measure post-operative SSI after cesarean section (CS) at four sites in three sub-Saharan African countries and to describe the associated risk factors in order to improved quality of care in low and middle income surgical programs.
    • Comparative cost-effectiveness analysis of two MSF surgical trauma centers

      Gosselin, R A; Maldonado, A; Elder, G; School of Public Health, University of California Berkeley, Berkeley, CA, USA; Medecins Sans Frontieres, Paris, France (2010-09-22)
      INTRODUCTION: There is a dearth of data on cost-effectiveness of surgical care in resource-poor countries. Doctors Without Borders (Médecins Sans Frontières; MSF) is a nongovernmental organization (NGO) involved in the many facets of health care for underserved populations, including surgical care. METHODS: A cost-effectiveness analysis (CEA) was attempted at two of their surgical trauma hospitals: Teme Hospital in Nigeria and La Trinité Hospital in Haiti. CONCLUSION: At $172 and $223 per Disability-Adjusted Life-Year (DALY) averted, respectively, they are in line with other reported CEAs for surgical and nonsurgical activities in similar contexts.
    • Comparison of Operative Logbook Experience of Australian General Surgical Trainees With Surgeons Deployed on Humanitarian Missions: What Can Be Learnt for the Future?

      Coventry, CA; Dominguez, L; Read, DJ; Trelles, M; Ivers, RQ; Montazerolghaem, M; Holland, AJA (Elsevier, 2019-08-23)
      OBJECTIVE: General surgical training in Australia has undergone considerable change in recent years with less exposure to other areas of surgery. General surgeons from many high-income countries have played important roles in assisting with the provision of surgical care in low- and middle-income countries during sudden-onset disasters (SODs) as part of emergency medical teams (EMTs). It is not known if contemporary Australian general surgeons are receiving the broad surgical training required for work in EMTs. DESIGN: Logbook data on the surgical procedures performed by Australian general surgical trainees were obtained from General Surgeons Australia (GSA) for the time period February 2008 to February 2017. Surgical procedures performed by Médecins sans Frontières (MSF) surgeons during 5 projects in 3 SODs (the 2010 Haiti earthquake, the 2013 Philippines typhoon and the 2015 Nepal earthquake) were obtained from previously published data for 6 months following each disaster. SETTING AND PARTICIPANTS: This was carried out at the University of Sydney with input from MSF Operational Centre Brussels and GSA. RESULTS: Australian general surgical trainees performed a mean of 2107 surgical procedures (excluding endoscopy) during their training (10 6-month rotations). Common procedures included abdominal wall hernia repairs (268, 12.7%), cholecystectomies (247, 11.8%), and specialist colorectal procedures (242, 11.5%). MSF surgeons performed a total of 3542 surgical procedures across the 5 projects analyzed. Common procedures included Caesarean sections (443, 12.5%), wound debridement (1115, 31.5%), and other trauma-related procedures (472, 13.3%). CONCLUSIONS: Australian general surgical trainees receive exposure to both essential and advanced general surgery but lack exposure to specialty procedures including the obstetric and orthopedic procedures commonly performed by MSF surgeons after SODs. Further training in these areas would likely be beneficial for general surgeons prior to deployment with an EMT.
    • A Consensus Framework for the Humanitarian Surgical Response to Armed Conflict in 21st Century Warfare

      Wren, S; Wild, H; Gurney, J; Amirtharajah, M; Osmers, I; Pagano, H; Trelles, M; Brown, ZW; Burckle, FM (2019-11-13)
      Importance: Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols. Objective: To describe a consensus framework for surgical care designed to respond to this emerging need. Design, Setting, and Participants: An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision. Main Outcomes and Measures: The working group's method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018. Results: Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements. Conclusions and Relevance: Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.
    • Correction of Tuberous Nipple Areolar Complex Deformity in Gynecomastia: The Deformity That Can Get Forgotten.

      Godwin, Y (Lippincott, Williams & Wilkins, 2018-07-01)
      The desired end point of surgical reduction of gynecomastia is a masculine breast appearance and symmetry. This article concentrates on the tuberous deformity of the nipple areolar complex (NAC) that can present in gynecomastia and is sometimes overlooked at surgical correction.This deformity can be corrected at primary surgery if it is recognized preoperatively. If missed, or not adequately corrected, the postoperative result of primary reduction may be deemed incomplete by the patient and they will request revision.The deformity involves overprojection of the NAC in an anteroposterior direction, yet the base diameter may be close to normal. Correction involves reduction of the herniated breast bud, excision of excess areolar tissue, and careful radial scoring to flatten the NAC to a normal level of projection.For the NAC to have a masculine appearance, the areolae need to be symmetrical, of normal male size, and slightly oval in a transverse direction. The projection of both areola and nipple needs to be low, but present: not flattened. This article presents an operative technique to address primary or residual tuberous NAC deformity in the treatment of gynecomastia.
    • Design and Implementation of a Training Programme for General Practitioners in Emergency Surgery and Obstetrics in Precarious Situations in Ethiopia.

      Sohier, N; Fréjacques, L; Gagnayre, R; Training Department, Médecins Sans Frontières, Paris, France. office@paris.msf.org (Published by Royal College of Surgeons of England, 1999-11)
      Médecins Sans Frontières (MSF) has been implementing medical assistance programs in Ethiopia since 1994, including the rehabilitation of health structures and the supply of drugs and medical equipment. In 1995, the serious shortage of surgeons in Ethiopia prompted MSF to add a programme to train general practitioners to perform surgery in the Woldya region. The results of the relevant feasibility study were encouraging. The programme's design is based on recent educational data and MSF's experience with introducing transcultural training in countries where unstable conditions prevail. The training programme is currently being studied by the Ethiopian Health Ministry for use as a model for training general practitioners in surgery throughout the country.
    • Emergency Obstetric Care in a Rural District of Burundi: What Are the Surgical Needs?

      De Plecker, E; Zachariah, R; Kumar, A M V; Trelles, M; Caluwaerts, S; van den Boogaard, W; Manirampa, J; Tayler-Smith, K; Manzi, M; Nanan-N'zeth, K; et al. (Public Library of Science, 2017-02-07)
      In a rural district hospital in Burundi offering Emergency Obstetric care-(EmOC), we assessed the a) characteristics of women at risk of, or with an obstetric complication and their types b) the number and type of obstetric surgical procedures and anaesthesia performed c) human resource cadres who performed surgery and anaesthesia and d) hospital exit outcomes.
    • Fistulojejunostomy for Refractory Post-Traumatic Biliary Fistula in an Austere Environment: An Unusual, Time-Honored Procedure

      Kada, Fathalla; Abyad, Muhammad; Contini, Sandro; De Paoli, Laura; Mancini, Luisa (Elsevier - We regret that this article is behind a paywall., 2015-02-04)
    • Forensic Investigation Into a Death: Post-Traumatic Amnesia in a Worker with a Work-Related Head Injury Sustained in a Coal-Fired Thermal Power Plant in India

      Muralidhar, V (BMJ Publishing Group, 2017-03-15)
      This is the first reported case of a work-related head injury in a coal-fired thermal power plant in India. This case highlights the trend of not reporting work injuries due to fears of reprisal from the management team that may include the termination of employment. Post-traumatic amnesia in a worker presenting with head trauma must be recognised by coworkers, so the cause of injury can be elicited early and the victim gets timely medical help. There are few published studies on work-related traumatic brain injury, and they provide no information on either anatomical localisation or signs and symptoms. It is imperative that this under-researched area is studied, so detailed epidemiology and accurate national and global statistics are made available to address this dangerous yet preventable condition.
    • General surgeons: a dying breed?

      Chu, K; South African Medical Unit, Médecins Sans Frontières, 49 Jorissen St, Braamfontein 2017, Johannesburg, South Africa. kathryn.chu@joburg.msf.org (American Medical Association, 2009-06)
    • Humanitarian Surgery: A Call to Action for Anesthesiologists

      Marchbein, D (Lippincott Williams & Wilkins, 2013-11)
    • Improving Effective Surgical Delivery in Humanitarian Disasters: Lessons from Haiti

      Chu, K; Stokes, C; Trelles, M; Ford, N; Médecins sans Frontières, Cape Town, South Africa; Medecins sans Frontieres, Brussels, Belgium; Medecins sans Frontieres, Geneva, Switzerland (2011-04-26)
      Kathryn Chu and colleagues describe the experiences of Médecins sans Frontières after the 2010 Haiti earthquake, and discuss how to improve delivery of surgery in humanitarian disasters.
    • Introduction of a standardised protocol, including systematic use of tranexamic acid, for management of severe adult trauma patients in a low-resource setting: the MSF experience from Port-au-Prince, Haiti

      Jachetti, A; Massenat, RB; Edema, N; Woolley, SC; Benedetti, G; Van Den Bergh, R; Trelles, M (BioMed Central, 2019-10-18)
      Background Bleeding is an important cause of death in trauma victims. In 2010, the CRASH-2 study, a multicentre randomized control trial on the effect of tranexamic acid (TXA) administration to trauma patients with suspected significant bleeding, reported a decreased mortality in randomized patients compared to placebo. Currently, no evidence on the use of TXA in humanitarian, low-resource settings is available. We aimed to measure the hospital outcomes of adult patients with severe traumatic bleeding in the Médecins Sans Frontières Tabarre Trauma Centre in Port-au-Prince, Haiti, before and after the implementation of a Massive Haemorrhage protocol including systematic early administration of TXA. Methods Patients admitted over comparable periods of four months (December2015- March2016 and December2016 - March2017) before and after the implementation of the Massive Haemorrhage protocol were investigated. Included patients had blunt or penetrating trauma, a South Africa Triage Score ≥ 7, were aged 18–65 years and were admitted within 3 h from the traumatic event. Measured outcomes were hospital mortality and early mortality rates, in-hospital time to discharge and time to discharge from intensive care unit. Results One-hundred and sixteen patients met inclusion criteria. Patients treated after the introduction of the Massive Haemorrhage protocol had about 70% less chance of death during hospitalization compared to the group “before” (adjusted odds ratio 0.3, 95%confidence interval 0.1–0.8). They also had a significantly shorter hospital length of stay (p = 0.02). Conclusions Implementing a Massive Haemorrhage protocol including early administration of TXA was associated with the reduced mortality and hospital stay of severe adult blunt and penetrating trauma patients in a context with poor resources and limited availability of blood products.
    • Invasive Infection and Outcomes in a Humanitarian Surgical Burn Program in Haiti

      Murphy, RA; Nisenbaum, L; Labar, AS; Sheridan, RL; Ronat, JB; Dilworth, K; Pena, J; Kilborn, E; Teicher, C (SpringerLink - We regret that this article is behind a paywall., 2016-02-25)
      Compare to high-income settings, survival in burn units in low-income settings is lower with invasive infections one leading cause of death. Médecins Sans Frontières is involved in the treatment of large burns in adults and children in Haiti.
    • Laryngeal spasm after general anaesthesia due to Ascaris Lumbricoides

      Finsnes, K D; Kunduz Trauma Center, Médecins Sans Frontières, Kunduz, Afghanistan. k.finsnes@gmail.com (John Wiley & Sons Ltd, 2013-08)
      Postoperative upper airway obstruction during recovery from general anaesthesia may have several causes. This is a report of a young girl who developed laryngeal spasm as a result of an ectopic roundworm Ascaris lumbricoides.