• 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.
    • Providing surgical care in Somalia: A model of task shifting.

      Chu, K M; Ford, N P; Trelles, M; Médecins sans Frontières, 49 Jorrisen St, Braamfontein 2017, Johannesburg, South Africa. kathryn_chu@yahoo.com. (2011-07)
      ABSTRACT:
    • Quality of Care in Humanitarian Surgery

      Chu, K M; Trelles, M; Ford, N P; Médecins Sans Frontières-South Africa, Johannesburg, South Africa; Department of Surgery, Johns Hopkins University, Baltimore, MD, USA; Médecins Sans Frontières–Belgium, Brussels, Belgium (2011-04-13)
      Humanitarian surgical programs are set up de novo, within days or hours in emergency or disaster settings. In such circumstances, insuring quality of care is extremely challenging. Basic structural inputs such as a safe structure, electricity, clean water, a blood bank, sterilization equipment, a post-anesthesia recovery unit, appropriate medications should be established. Currently, no specific credentials are needed for surgeons to operate in a humanitarian setting; the training of more humanitarian surgeons is desperately needed. Standard perioperative protocols for the humanitarian setting after common procedures such as Cesarean section, burn care, open fractures, and amputations and antibiotic prophylaxis, and post-operative pain management must be developed. Outcome data, especially long-term outcomes, are difficult to collect as patients often do not return for follow-up and may be difficult to trace; standard databases for post-operative infections and mortality rates should be established. Checklists have recently received significant attention as an instrument to support the improvement of surgical quality; knowing which items are most applicable to humanitarian settings remains unknown. In conclusion, the quality of surgical services in humanitarian settings must be regulated. Many other core medical activities of humanitarian organizations such as therapeutic feeding, mass vaccination, and the treatment of infectious diseases, such as tuberculosis and human immunodeficiency virus, are subject to rigorous reporting of quality indicators. There is no reason why surgery should be exempted from quality oversight. The surgical humanitarian community should pull together before the next disaster strikes.
    • "Reality rarely looks like the guidelines": a qualitative study of the challenges hospital-based physicians encounter in war wound management

      Älgå, A; Karlow Herzog, K; Alrawashdeh, M; Wong, S; Khankeh, H; Stålsby Lundborg, C (BioMed Central, 2018-06-27)
      Globally, armed conflict is a major contributor to mortality and morbidity. The treatment of war-associated injuries is largely experience-based. Evidence is weak due to difficulty in conducting medical research in war settings. A qualitative method could provide insight into the specific challenges associated with providing health care to injured civilians. The aim of this study was to explore the challenges hospital-based physicians encounter in war wound management, focusing on surgical intervention and antibiotic use.
    • Reconstruction of Nonunion Tibial Fractures in War-Wounded Iraqi Civilians, 2006-2008: Better Late Than Never

      Fakri, R M; Al Ani, A M K; Rose, A M C; Alras, M S; Daumas, L; Baron, E; Khaddaj, S; Hérard, P; Médecins sans Frontières, Paris, France; Chronic Disease Research Centre, University of the West Indies, Bridgetown, Barbados; Epicentre, Paris, France; Women and Health Alliance (WAHA) International, Paris, France (Lippincott Williams & Wilkins, 2012-01-10)
      OBJECTIVE
    • Reconstruction of Residual Mandibular Defects by Iliac Crest Bone Graft in War-wounded Iraqi civilians, 2006-2011

      Guerrier, G; Alaqeeli, A; Al Jawadi, A; Foote, N; Baron, E; Albustanji, A; Epicentre, 8 rue Saint Sabin, 75011 Paris, France. Electronic address: guerriergilles@gmail.com. (2012-06-28)
      Our aim was to assess the long-term results, complications, and factors associated with failure of mandibular reconstructions among wounded Iraqi civilians with mandibular defects. Success was measured by the quality of bony union, and assessed radiographically and by physical examination. Failures were defined as loss of most or all of the bone graft, or inability to control infection. During the 6-year period (2006-2011), 35 Iraqi patients (30 men and 5 women, mean age 33 years, range 15-57) had residual mandibular defects reconstructed by iliac crest bone grafts. The causes were bullets (n=29), blasts (n=3), and shrapnel (n=3). The size of the defect was more than 5cm in 19 cases. Along the mandible the defect was lateral (n=14), central/lateral (n=5), lateral/central/lateral in continuity (n=6), and central in continuity (n=10). The mean time from injury to operation was 548 days (range 45-3814). All but 2 patients had infected lesions on admission. Bony fixation was ensured by locking reconstruction plates (n=27), non-locking reconstruction plates (n=6), and miniplates (n=2). Complications were associated with the reconstruction plate in 2 cases, and donor-site morbidity in 5. After a mean follow-up of 17 months (range 6-54), bony union was achieved in 28 (80%). The quality of the bone was adequate for dental implants in 23 cases (66%). Our results suggest that war-related mandibular defects can be reconstructed with non-vascularised bone grafts by multistage procedures with good results, provided that the soft tissues are in good condition, infection is controlled, and the method of fixation is appropriate. Further studies are needed to assess the role of vascularised free flaps in similar conditions.
    • Regional Anesthesia for Painful Injuries after Disasters (RAPID): Study Protocol For A Randomized Controlled Trial

      Levine, AC; Teicher, C; Aluisio, AR; Wiskel, T; Valles, P; Trelles, M; Glavis-Bloom, J; Grais, RFF (BioMed Central, 2016-11-14)
      Lower extremity trauma during earthquakes accounts for the largest burden of disaster-related injuries. Insufficient pain management is common in resource-limited disaster settings, and regional anesthesia (RA) may reduce pain in injured patients beyond current standards of care. To date, no controlled trials have been conducted to evaluate the use of RA for pain management in a disaster setting.
    • Rethinking surgical care in conflict.

      Chu, K; Trelles, M; Ford, N; Médecins Sans Frontières, Braamfontein 2017, Johannesburg, Gauteng, South Africa. (2010-01-23)
    • Saving life and limb: limb salvage using external fixation, a multi-centre review of orthopaedic surgical activities in Médecins Sans Frontières

      Bertol, M J; Van den Bergh, R; Trelles Centurion, M; Kenslor Ralph D, H; Basimuoneye Kahutsi, J-P; Qayeum Qasemy, A; Jean, J; Majuste, A; Kubuya Hangi, T; Safi, S (Springer Berlin Heidelberg, 2014-07-20)
      While the orthopaedic management of open fractures has been well-documented in developed settings, limited evidence exists on the surgical outcomes of open fractures in terms of limb salvage in low- and middle-income countries. We therefore reviewed the Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB) orthopaedic surgical activities in the aftermath of the 2010 Haiti earthquake and in three non-emergency projects to assess the limb salvage rates in humanitarian contexts in relation to surgical staff skills.
    • The short musculoskeletal functional assessment (SMFA) score amongst surgical patients with reconstructive lower limb injuries in war wounded civilians

      Teicher, C; Foote, N L; Al Ani, A M K; Alras, M S; Alqassab, S I; Baron, E; Ahmed, K; Herard, P; Fakhri, R M (Elsevier, 2014-10-24)
      The MSF programme in Jordan provides specialized reconstructive surgical care to war-wounded civilians in the region. The short musculoskeletal functional assessment score (SMFA) provides a method for quantitatively assessing functional status following orthopaedic trauma. In June 2010 the Amman team established SMFA as the standard for measuring patients' functional status. The objective of this retrospective study is to evaluate whether the SMFA scores can be useful for patients with chronic war injuries.
    • Sniper-induced sciatic nerve injury.

      Mathieu, L; Algassab, S; Fakhi, RM (BMJ Publishing Group, 2019-07-29)
    • South African General Surgeon Preparedness for Humanitarian Disasters

      Chu, KM; Karjiker, P; Naidu, P; Kruger, D; Taylor, A; Trelles, M; Dominguez, L; Rayne, S (Springer, 2018-12-06)
      Background Humanitarian medical organizations provide surgical care for a broad range of conditions including general surgical (GS), obstetric and gynecologic (OBGYN), orthopedic (ORTHO), and urologic (URO) conditions in unstable contexts. The most common humanitarian operation is cesarean section. The objective of this study was to identify the proportion of South African general surgeons who had operative experience and current competency in GS, OBGYN, ORTHO, and URO humanitarian operations in order to evaluate their potential for working in humanitarian disasters. Methods This was a cross-sectional online survey of South African general surgeons administered from November 2017–July 2018. Rotations in OBGYN, ORTHO, and URO were quantified. Experience and competency in eighteen humanitarian operations were queried. Results There were 154 SA general surgeon participants. Prior to starting general surgery (GS) residency, 129 (83%) had OBGYN, 125 (81%) ORTHO, and 84 (54%) URO experience. Experience and competency in humanitarian procedures by specialty included: 96% experience and 95% competency for GS, 71% experience and 51% com- petency for OBGYN, 77% experience and 66% competency for ORTHO, and 86% experience and 81% competency for URO. 82% reported training, and 51% competency in cesarean section. Conclusions SA general surgeons are potentially well suited for humanitarian surgery. This study has shown that most SA general surgeons received training in OBGYN, ORTHO, and URO prior to residency and many maintain competence in the corresponding humanitarian operations. Other low- to middle-income countries may also have broad-based surgery training, and the potential for their surgeons to offer humanitarian assistance should be further investigated.
    • Surgeons Without Borders: A Brief History of Surgery at Médecins Sans Frontières.

      Chu, K; Rosseel, P; Trelles, M; Gielis, P; Médecins Sans Frontières, 49 Jorrisen St., Braamfontein 2017, Johannesburg, South Africa, kathryn.chu@joburg.msf.org. (2009-08-12)
      Médecins Sans Frontières (MSF) is a humanitarian organization that performs emergency and elective surgical services in both conflict and non-conflict settings in over 70 countries. In 2006 MSF surgeons departed on approximately 125 missions, and over 64,000 surgical interventions were carried out in some 20 countries worldwide. Historically, the majority of MSF surgical projects began in response to conflicts or natural disasters. During an emergency response, MSF has resources to set up major operating facilities within 48 h in remote areas. One of MSF strengths is its supply chain. Large pre-packaged surgical kits, veritable "operating theatres to go," can be readied in enormous crates and quickly loaded onto planes. In more stable contexts, MSF has also strengthened the delivery of surgical services within a country's public health system. The MSF surgeon is the generalist in the broadest sense and performs vascular, obstetrical, orthopaedic, and other specialized surgical procedures. The organization aims to provide surgical services only temporarily. When there is a decrease in acute needs a program will be closed, or more importantly, turned over to the Ministry of Health or another non-governmental organization. The long-term solution to alleviating the global burden of surgical disease lies in building up a domestic surgical workforce capable of responding to the major causes of surgery-related morbidity and mortality. However, given that even countries with the resources of the United States suffer from an insufficiency of surgeons, the need for international emergency organizations to provide surgical assistance during acute emergencies will remain for the foreseeable future.
    • Surgery for Conditions of Infectious Etiology in Resource-Limited Countries Affected by Crisis: The Médecins Sans Frontières Operations Centre Brussels Experience

      Sharma, Davina; Hayman, Kate; Stewart, Barclay T; Dominguez, Lynette; Trelles, Miguel; Saqeb, Sanaulhaq; Kasonga, Cheride; Hangi, Theophile Kubuya; Mupenda, Jerome; Naseer, Aamer; et al. (Mary Ann Liebert, Inc., 2015-07-31)
      Surgery for infection represents a substantial, although undefined, disease burden in low- and middle-income countries (LMICs). Médecins Sans Frontières-Operations Centre Brussels (MSF-OCB) provides surgical care in LMICs and collects data useful for describing operative epidemiology of surgical need otherwise unmet by national health services. This study aimed to describe the experience of MSF-OCB operations for infections in LMICs. By doing so, the results might aid effective resource allocation and preparation of future humanitarian staff.
    • Surgery in low-income countries during crisis: experience at Médecins Sans Frontières facilities in 20 countries between 2008 and 2014

      Trelles, M; Dominguez, L; Stewart, B (Wiley-Blackwell, 2015-04-16)
      The global burden of trauma and surgical conditions fall disproportionately on low- and middle-income countries (LMICs).(1, 2) Inopportunely, developing countries are least equipped to provide essential surgical care.(3) Consequently, LMICs have a significant burden of unmet surgical needs.(4) When these fragile health systems are disrupted by conflict, a natural disaster or an epidemic the volume and quality of surgical care decreases even further. This article is protected by copyright. All rights reserved.
    • Surgery with Limited Resources in Natural Disasters: What Is the Minimum Standard of Care?

      Trelles Centurion, M; Crestani, R; Dominguez, L; Caluwaerts, A; Benedetti, G (Springer International Publishing, 2018)
      In a challenging scenario, such as in the aftermath of a natural disaster, minimum standards of care must be in place from the moment surgical care activities are launched.