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Tropical Surgery Potpourri UMN / Mayo Global Health 2008 November 8

Tropical Surgery Potpourri UMN / Mayo Global Health 2008 November 8 Kenneth McMillan, MD General Surgery With CrossWorld in DRCongo (Zaire) & Minnesota African villager with one day of painful swelling in groin: Traditional healer lives within 20 km (13 mi)? Y N

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Tropical Surgery Potpourri UMN / Mayo Global Health 2008 November 8

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  1. Tropical Surgery PotpourriUMN / Mayo Global Health2008 November 8 Kenneth McMillan, MD General Surgery With CrossWorld in DRCongo (Zaire) & Minnesota

  2. African villager with one day of painful swelling in groin: Traditional healer lives within 20 km (13 mi)? Y N Have goat and healthy chicken to pay him? Y N Mission hospital (60 km) charges for emergencies? Y N Surgical nurse any good if doctor is not there? Y N Family lantern has kerosene ? Y N Afraid of rabid dogs along the path at night? Y N Surgical nurse afraid to wake new doctor after midnight ? Y N

  3. Young single surgeon with tropical medicine certificate and no school loans to pay off Willing to go to Africa for 4 years? Y N Willing to try hospital with no other doctor on staff? Y N Is afraid of rabid dogs on path to hospital after dark? Y N Willing to operate with kerosene lantern or flashlight? Y N Can do his own spinal anesthesia? Y N Can do small bowel anastomosis with 0 braided nylon? Y N Shocked to hear surgical nurse did strangulated hernia repair the night before? Y N

  4. I. Personal Background Born & raised in DRCongo (Zaire) Belgian public school in Kisangani (formerly Stanleyville) Fluent in French, Swahili and Lingala Hobby: taxidermy Familiar with malaria, hepatitis, amebiasis … Evacuated twice as a teenager … Returned to DRCongo as surgeon in 1982 Married, raised family at Rethy, in Ituri region of Northeast DRCongo, where traditional and modern societal forces made for an interesting life for both me and my patients:

  5. What is the orange substance in the pot? • Local fuel oil • Blood • Palm oil • Tomato paste

  6. Rethy.Bunia . Democratic Republic of Congo — Africa

  7. I. Personal Background (cont’) Early surgical experience (1984-1988) at Rethy Hospital and as Flying Doctor to 4 other rural hospitals without physicians: Total operative cases 1247, including 24 subtotal thyroidectomies (1 death) 8 cleft lip repairs 4 modified radical, 11 simple mastectomies 146 herniorrhaphies 36 prostatectomies 12 open reductions / internal fixations 115 hysterectomies 38 vessico-vaginal fistulae

  8. Personal Background (cont’) Surgical experience (1984-1988) at Rethy and as Flying Doctor to 4 other rural hospitals without physicians (cont’): Morbidity rate 2.6% (32/1247) Mortality rate 1.6% (20/1247) Records for other years are incomplete or lost, but numbers were similar, with many cases being done by surgical nurses in later years through 1996 Results of our training program: 6 surgical nurses, 3 national MDs and 1 missionary MD in surgical rotations of 1 to 6 months What rural surgical practice looked like in DRCongo before Civil War of 1996:

  9. II. Preparation for Surgical Practice in Developing Country Clarify personal/family motivation for serving in foreign location Get advice from veterans on how broad to train in medicine & surgery Bring out texts or CDs on wide variety of operations, especially pediatric surgery Plan on tropical medicine and public health courses Schedule time for language and culture studies Establish a relationship with supporting agency before leaving

  10. III. Adaptation of Medicine/Surgery to Poor Communities Evaluate status of healthcare before starting new medico-surgical interventions Carefully evaluate staff skills; retrain if necessary Observe use and effectiveness of existing operating room and equipment; enable correction of dangerous deficiencies The community has been there longer than you, and should be involved in making changes When prominent surgical diseases are identified, integrate them into the public health and education programs

  11. IV. Successful Practice of Surgery in Bush Hospitals Admit inadequacy, need for higher wisdom Acknowledge patient’s philosophy of health and wellness Involve patient’s family in decisions, care and payment for care Expect rural patients to have pathologic, physiologic and even anatomic variations from urban or developed populations Expect rural patients to present late in the course of a disease, eg, infection, trauma and cancer

  12. Which is the most common operation in African tropics? • Appendectomy • Herniorrhaphy • Mastectomy • Vessico-vaginal fistula

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