• 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.
    • A local replacement of tulle gras using palm oil-soaked gauze.

      Chan, P L; Mattru Hospital, Médecins sans Frontières, Sierra Leone. polchan@yahoo.com (2004-01)
    • Médecins Sans Frontières Experience in Orthopedic Surgery in Postearthquake Haiti in 2010

      Teicher, C L; Alberti, K; Porten, K; Elder, G; Baron, E; Herard, P (Cambridge University Press, 2014-01-15)
      Introduction During January 2010, a 7.0 magnitude earthquake struck Haiti, resulting in death and destruction for hundreds of thousands of people. This study describes the types of orthopedic procedures performed, the options for patient follow-up, and limitations in obtaining outcomes data in an emergency setting. Problem There is not a large body of data that describes larger orthopedic cohorts, especially those focusing on internal fixation surgeries in resource-poor settings in postdisaster regions. This article describes 248 injuries and over 300 procedures carried out in the Médecins Sans Frontières-Orthopedic Centre Paris orthopedic program.
    • Multidrug-Resistant Surgical Site Infections in a Humanitarian Surgery Project

      Murphy, RA; Okoli, O; Essien, I; Teicher, C; Elder, G; Pena, J; Ronat, JB; Bernabé, KJ (Cambridge University Press, 2016-08-11)
      The epidemiology of surgical site infections (SSIs) in surgical programmes in sub-Saharan Africa is inadequately described. We reviewed deep and organ-space SSIs occurring within a trauma project that had a high-quality microbiology partnership and active follow-up. Included patients underwent orthopaedic surgery in Teme Hospital (Port Harcourt, Nigeria) for trauma and subsequently developed a SSI requiring debridement and microbiological sampling. Data were collected from structured chart reviews and programmatic databases for 103 patients with suspected SSI [79% male, median age 30 years, interquartile range (IQR) 24-37]. SSIs were commonly detected post-discharge with 58% presenting >28 days after surgery. The most common pathogens were: Staphylococcus aureus (34%), Pseudomonas aeruginosa (16%) and Enterobacter cloacae (11%). Thirty-three (32%) of infections were caused by a multidrug-resistant (MDR) pathogen, including 15 patients with methicillin-resistant S. aureus. Antibiotics were initiated empirically for 43% of patients and after culture and sensitivity report in 32%. The median number of additional surgeries performed in patients with SSI was 5 (IQR 2-6), one patient died (1%), and amputation was performed or recommended in three patients. Our findings suggest the need for active long-term monitoring of SSIs, particularly those associated with MDR organisms, resulting in increased costs for readmission surgery and treatment with late-generation antibiotics.
    • Negative pressure wound therapy versus standard treatment in patients with acute conflict-related extremity wounds: a pragmatic, multisite, randomised controlled trial

      Älgå, A; Haweizy, R; Bashaireh, K; Wong, S; Lundgren, KC; von Schreeb, J; Malmstedt, J (Elsevier, 2020-03-01)
      Background: In armed conflict, injuries among civilians are usually complex and commonly affect the extremities. Negative pressure wound therapy (NPWT) is an alternative to standard treatment of acute conflict-related extremity wounds. We aimed to compare the safety and effectiveness of NPWT with that of standard treatment. Methods: In this pragmatic, randomised, controlled superiority trial done at two civilian hospitals in Jordan and Iraq, we recruited patients aged 18 years or older, presenting with a conflict-related extremity wound within 72 h after injury. Participants were assigned (1:1) to receive either NPWT or standard treatment. We used a predefined, computer-generated randomisation list with three block sizes. Participants and their treating physicians were not masked to treatment allocation. The primary endpoint was wound closure by day 5. The coprimary endpoint was net clinical benefit, defined as a composite of wound closure by day 5 and freedom from any bleeding, wound infection, sepsis, or amputation of the index limb. Analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT02444598, and is closed to accrual. Findings: Between June 9, 2015, and Oct 24, 2018, 174 patients were randomly assigned to either the NPWT group (n=88) or the standard treatment group (n=86). Five patients in the NPWT group and four in the standard treatment group were excluded from the intention-to-treat analysis. By day 5, 41 (49%) of 83 participants in the NPWT group and 49 (60%) of 82 participants in the standard treatment group had closed wounds, with an absolute difference of 10 percentage points (95% CI -5 to 25, p=0·212; risk ratio [RR] 0·83, 95% CI 0·62 to 1·09). Net clinical benefit was seen in 33 (41%) of 81 participants in the NPWT group and 34 (44%) of 78 participants in the standard treatment group, with an absolute difference of 3 percentage points (95% CI -12 to 18, p=0·750; RR 0·93, 95% CI 0·65 to 1·35). There was one in-hospital death in the standard treatment group and none in the NPWT group. The proportion of participants with sepsis, bleeding leading to blood transfusion, and limb amputation did not differ between groups. Interpretation: NPWT did not yield superior clinical outcomes compared with standard treatment for acute conflict-related extremity wounds. The results of this study not only question the use of NPWT, but also question the tendency for new and costly treatments to be introduced into resource-limited conflict settings without supporting evidence for their effectiveness. This study shows that high-quality, randomised trials in challenging settings are possible, and our findings support the call for further research that will generate context-specific evidence. Funding: The Stockholm County Council, the Swedish National Board of Health and Welfare, and Médecins Sans Frontières.
    • North American pediatric surgery fellows' preparedness for humanitarian surgery

      Traynor, MD; Trelles, M; Hernandez, MC; Dominguez, LB; Kushner, AL; Rivera, M; Zielinski, MD; Moir, CR (Elsevier, 2019-11-29)
      Introduction: The overwhelming burden of pediatric surgical need in humanitarian settings has prompted mutual interest between humanitarian organizations and pediatric surgeons. To assess adequate fit, we correlated pediatric surgery fellowship case mix and load with acute pediatric surgical relief efforts in conflict and disaster zones. Methods: We reviewed pediatric (age < 18) cases logged by the Médecins Sans Frontières Operational Centre Brussels (MSF-OCB) from a previously validated and published database spanning 2008-2014 and cases performed by American College of Graduate Medical Education (ACGME) pediatric surgery graduates from 2008 to 2018. Non-operative management for trauma, endoscopic procedures, and basic wound care were excluded as they were not tracked in either dataset. ACGME procedures were classified under 1 of 32 MSF pediatric surgery procedure categories and compared using chi-squared tests. Results: ACGME fellows performed procedures in 44% of tracked MSF-OCB categories. Major MSF-OCB pediatric cases were comprised of 62% general surgery, 23% orthopedic surgery, 9% obstetrical surgery, 3% plastic/reconstructive surgery, 2% urogynecologic surgery, and 1% specialty surgery. In comparison, fellows' cases were 95% general surgery, 0% orthopedic surgery, 0% obstetrical surgery, 5% urogynecologic surgery, and 1% specialty surgery. Fellows more frequently performed abdominal, thoracic, other general surgical, urology/gynecologic, and specialty procedures, but performed fewer wound and burn procedures (all p < 0.05). Fellows received no experience in Cesarean section or open fracture repair. Fellows performed a greater proportion of surgeries for congenital conditions (p < 0.05). Conclusion: While ACGME pediatric surgical trainees receive significant training in general and urogynecologic surgical techniques, they lack sufficient case load for orthopedic and obstetrical care - a common need among children in humanitarian settings. Trainees and program directors should evaluate the fellow's role and scope in a global surgery rotation or provide advanced preparation to fill these gaps. Upon graduation, pediatric surgeons interested in humanitarian missions should seek out additional orthopedic and obstetrical training, or select missions that do not require such skillsets.
    • Open letter to young surgeons interested in humanitarian surgery

      Chu, K; South African Medical Unit, Médecins Sans Frontières, South Africa (2010-02-01)
    • Operative mortality in resource-limited settings: the experience of Medecins Sans Frontieres in 13 countries.

      Chu, K M; Ford, N; Trelles, M; Medecines Sans Frontieres (2010-08)
      OBJECTIVE: To determine operative mortality in surgical programs from resource-limited settings. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of 17 surgical programs in 13 developing countries by 1 humanitarian organization, Médecins Sans Frontières, was performed between January 1, 2001, and December 31, 2008. Participants included patients undergoing surgical procedures. MAIN OUTCOME MEASURE: Operative mortality. Determinants of mortality were modeled using logistic regression. RESULTS: Between 2001 and 2008, 19,643 procedures were performed on 18,653 patients. Among these, 8329 procedures (42%) were emergent; 7933 (40%) were for obstetric-related pathology procedures and 2767 (14%) were trauma related. Operative mortality was 0.2% (31 deaths) and was associated with programs in conflict settings (adjusted odds ratio [AOR] = 4.6; P = .001), procedures performed under emergency conditions (AOR = 20.1; P = .004), abdominal surgical procedures (AOR = 3.4; P = .003), hysterectomy (AOR = 12.3; P = .001), and American Society of Anesthesiologists classifications of 3 to 5 (AOR = 20.2; P < .001). CONCLUSIONS: Surgical care can be provided safely in resource-limited settings with appropriate minimum standards and protocols. Studies on the burden of surgical disease in these populations are needed to improve service planning and delivery. Quality improvement programs are needed for the various stakeholders involved in surgical delivery in these settings.
    • Operative Procedures in the Elderly in Low-Resource Settings: A Review of Médecins Sans Frontières Facilities

      Wong, E G; Trelles, M; Dominguez, L; Mupenda Mwania, J; Kasonga Tshibangu, C; Haq Saqeb, S; Hazrati, K U R; Gupta, S; Burnham, G; Kushner, A L (SpringerLink, 2014-12-02)
      As the demographic transition occurs across developing countries, an increasing number of elderly individuals are affected by disasters and conflicts. This study aimed to evaluate the elderly population that underwent an operative procedure at MSF facilities.
    • Operative Procedures in the Elderly in Low-Resource Settings: A Review of Médecins Sans Frontières Facilities: Reply

      Wong, E G; Trelles, M; Dominguez, L; Mupenda Mwania, J; Kasonga Tshibangu, C; Saqeb, S H; Hazrati, K U R; Gupta, S; Burnham, G; Kushner, A L (SpringerLink, 2015-04-22)
    • Operative trauma in low-resource settings: The experience of Médecins Sans Frontières in environments of conflict, postconflict, and disaster

      Wong, Evan G; Dominguez, Lynette; Trelles, Miguel; Ayobi, Samir; Hazraty, Khalil Rahman; Kasonga, Cheride; Basimuoneye, Jean-Paul; Santiague, Lunick; Kamal, Mustafa; Rahmoun, Alaa; et al. (Elsevier - We regret that this article is behind a paywall., 2015-05)
      Conflicts and disasters remain prevalent in low- and middle-income countries, and injury remains a leading cause of death worldwide. The objective of this study was to describe the operative procedures performed for injury-related pathologies at facilities supported by Médecins Sans Frontières (MSF) to guide the planning of future responses.
    • [Orthopedic Surgery with Limited Resources After Mass Disasters and During Armed Conflicts : First International Guidelines for the Management of Limb Injuries and the Experience of Doctors Without Borders]

      Osmers, I (SpringerLink, 2017-08-29)
      Disasters and armed conflicts are often the unfortunate basis for aid projects run by Doctors Without Borders/Médecins Sans Frontières (MSF). The nature of war and disasters means that surgery is an integral part of this medical emergency aid. In these situations, resources are usually limited. As a result, surgical work in these contexts differs significantly from the daily routine of a surgeon working in a highly resourced hospital. The principles of surgery do not change but surgeons must adapt their tactical approach to the changed context otherwise there is a high risk of failing to improve the health of patients and potentially jeopardizing their prospects for recovery. Every experienced war surgeon has learned new skills the hard way. The Field Guide to Manage Limb Injury in Disaster and Conflict has been written to help new surgeons who may face the challenges of disaster and war surgery and to avoid unnecessary suffering for patients ( https://icrc.aoeducation.org ). Under the guidance of the International Committee of the Red Cross (ICRC), with participation of the World Health Organization (WHO), financed by the AO Foundation, and featuring the experiences of experts from different organizations (amongst them MSF), the book details techniques and guidelines for surgery in low resource settings. The following article provides a short summary of some of the surgical challenges when working with limited resources and reflects on a few specific recommendations for so-called war surgery.
    • Pain in traumatic upper limb amputees in Sierra Leone.

      Lacoux, P; Crombie, I K; Macrae, W A; Medecins Sans Frontieres, 8, Rue St Sabin, Paris XI, France. (2002-09)
      Data on 40 upper limb amputees (11 bilateral) with regard to stump pain, phantom sensation and phantom pain is presented. All the patients lost their limbs as a result of violent injuries intended to terrorise the population and were assessed 10-48 months after the injury. All amputees reported stump pain in the month prior to interview and ten of the 11 bilateral amputees had bilateral pain. Phantom sensation was common (92.5%), but phantom pain was only present in 32.5% of amputees. Problems in translation and explanation may have influenced the low incidence of phantom pain and high incidence of stump pain. In the bilateral amputees phantom sensation, phantom pain and telescoping all showed bilateral concordance, whereas stump pain and neuromas did not show concordance. About half the subjects (56%) had lost their limb at the time of injury (primary) while the remainder had an injury, then a subsequent amputation in hospital (secondary). There was no association between the incidence of phantom pain and amputation irrespective of being primary or secondary.
    • Providing Anesthesia Care in Resource-limited Settings: A 6-year Analysis of Anesthesia Services Provided at Médecins Sans Frontières Facilities

      Ariyo, P; Trelles, M; Helmand, R; Amir, Y; Hassani, G H; Mftavyanka, J; Nzeyimana, Z; Akemani, C; Ntawukiruwabo, I B; Charles, A; et al. (Lippincott Williams & Wilkins, 2016-03-01)
      Anesthesia is integral to improving surgical care in low-resource settings. Anesthesia providers who work in these areas should be familiar with the particularities associated with providing care in these settings, including the types and outcomes of commonly performed anesthetic procedures.