Dr. Brendan Campbell, surgeon at Connecticut Children’s Medical Center, speaks to his clinical colleagues about his most recent trip to Haiti and the challenges and opportunities that present themselves.
The poverty, pathology and ethical dilemmas you collide with in Haiti force you to think creatively about clinical problems because the options for establishing a diagnosis, providing treatment and dealing with complications are limited. Surgical volunteerism at Hopital Sacre Coeur in Milot makes you think differently about what providing high quality surgical care means and puts your troubles back home in clearer perspective.
One of the hardest things to appreciate before you try and perform a surgical procedure in Haiti are the challenges of putting the infrastructure in place that allow it to happen. The CRUDEM organization which runs Hopital Sacre Coeur does a remarkable job making sure that these basic requirements are met (i.e., electricity, running water, security, and hospital staff), so that the medical and surgical teams that visit for one week at a time can focus on providing clinical care and teaching. For us this means sorting out which pediatric surgical cases exceed the capabilities of the local surgeons, and how we can best help the surgeons there while providing pragmatic education. The Lancet Commission on Surgery proposed a group of 3 bellwether procedures (i.e., Caesarian section, laparotomy, and treatment of open fractures) to identify hospital systems operating at a significant level of complexity that would allow them to do most other surgical procedures. Hopital Sacre Coeur meets this standard, but it’s not clear how accurately this standard can be extrapolated to pediatric surgical cases. The emerging field of “global pediatric surgery” in low and middle income countries is largely uncharted territory about which we still have a lot to learn.
The unique thing about trying to provide safe and responsible pediatric surgical care in Haiti is that you have to get comfortable feeling really uncomfortable. If you are easily frustrated, prone to temper tantrums in stressful situations and are unable to adapt to changing circumstances – Haiti’s austere clinical environment isn’t for you. Cancellation of scheduled cases for spurious reasons (without speaking with us), poor quality basic surgical instruments and scrub techs unfamiliar with pediatric surgical customs and priorities are a few of the challenges we encountered this past week.
In Northern Haiti, we have identified an opportunity to help the local surgeons manage patients with anorectal malformations. While we don’t yet have a “mega-team” (i.e., fully staffed/equipped anesthesia and OR team) geared toward a single congenital anomaly (e.g., cleft palate surgery, cardiac surgery) that some groups have developed, we’re making some progress in that direction. Simple things that we take for granted back home can be a real impediment to getting these fairly complex reconstructive cases done efficiently and safely in Haiti. A few examples include not having equipment to optimally position the patient (we’re used to doing these operations on babies, many Haitian patients are older/larger), poor quality surgical instruments that won’t handle small needles and substandard lighting in the operating room.
Virtually all the kids we see who were born with anorectal malformations, survived beyond the neonatal period because Haitian general surgeons gave them colostomies when they were newborns (i.e., relieving the intestinal obstruction and allowing them to feed and grow). This is lifesaving for the patient and allows the definitive procedure to be delayed indefinitely. The challenge for the surgeon is that with the more complicated anomalies there is no option for a pressure-augmented distal colostogram and no equipment to perform vaginoscopy/cystoscopy for the purpose of surgical planning…
So, at the end of our third short-term surgical trip to Hopital Sacre Coeur I think we’re getting a little better. We understand that these trips should not occur in isolation. Having an unflappable pediatric anesthesiologist (Rich Kuntz) makes the anesthesia part safe. We have a spreadsheet to track our anorectal malformation cases, monitor our results objectively and to try and plan our case list ahead of time. Our team led by Dr. Rob Freishtat (Children’s National) included nurses, a pediatrician, a pediatric ER doc, physician’s assistant, a respiratory therapist and two child life specialists and they all did an amazing job and were a lot of fun to spend time with. Next year we hope to bring a scrub tech from Connecticut Children’s and Drs. Hight and Kuntz both want to return.
Visiting the same hospital and building relationships with the local surgeons and staff is mutually beneficial. To quote another surgeon, “It is much better to pick one country and serve it well, than to hopscotch all over Africa, going everywhere and truly getting nowhere.” (World J Surg 2010;34:466-470). We still have a lot to learn about providing pediatric surgical care in Haiti, but hopefully we’re getting somewhere, and making the lives of a handful of Haitian children a little better along the way.