Surgery

Please post any surgery questions, discussions etc. in this space.

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  • Just saying hello.  The Dr, Brender American Surgical Clinic  is up and running at the Khmer Soviet Friendship Hospital (KSFH) in Phnom Penh, Cambodia.  We have 3 surgeons, a full time senior supervisor, a rotating senior surgeon, and R5, R4, & R3 surgical residents from UCI, UCLA, USC, & Cedars Sinai.  We do not charge for our services.  We have provided the hospital 2 laparoscopic towers & laparoscopic instruments.  We pioneered laparoscopic surgery at KSFH.

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    • Elliott Brender MD Thanks for joining the new forum Dr. Brender! Do you perform pediatric surgeries at KSFH? If so, I may be in communication. I'm the Medical Liaison for an NPO called Destiny Rescue in Cambodia (Phnom Penh, Kampong Cham and Siem Reap). I work with adolescent girls primarily between 14-18 years of age that have been rescued from sexual exploitation and slavery. Some have infants. Would be great to learn more about your services, as we have surgical needs that arise. Happy to send you an email to connect further.   

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  • Yes we do pediatric surgery.   Hernia, appendectomy, IHSS (pyloric stenosis), most of the routine pediatric needs.  We do not do complex procedures.  We are happy to evaluate everything & we do not charge for the evaluation.

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    • Elliott Brender MD Great, thanks Dr. Brender. I'll be in communication via email. 

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  • I came across a great article and resources by Harvard Medical School published 10/31/2018 titled "Help Wanted". Click here to read the article. Would love to hear from more members about your surgical work i.e., where you are working, types of surgeries, greatest challenges etc.  

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  • Just returned from my 11th trip to Cambodia.  We have a clinic at the Khmer Soviet Friendship Hospital.  We put on a presentation of what we have done over over the past 11 years.  We are responsible for bringing the hospital into the 21st century by supplying 2 laparoscopic towers & enough equipment to perform laparoscopic surgery.  Did a live laparoscopic cholecystectomy that was transmitted into the classroom for everyone to watch.  I had our local surgeons select the case.  Would up doing a very difficult acute cholecystitis, lots of inflammation, successfully.  Our clinic will be expanding from one to two days a week now.  Invited the American Embassy personnel, the Phnom Penh Rotary club & other sponsors to watch & see how we have been spending their money.  They were very pleased.  I have an ongoing crew of one permanent supervisor, one rotating supervisor, & one surgical resident.  We have 4 schools providing residents, UCI, UCLA, USC, & Cedars Sinai.  What are our most difficult issues - a lack of infrastructure, broken & worn out equipment.  We make do  - this is the interesting part.  I  just bought them a neurosurgical operating microscope.  The neurosurgeon then did a difficult brain stem tumor successfully with no neurologic damage and a full recovery.

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    • Elliott Brender MD Thank you for sharing! It is wonderful what you are doing in Cambodia! Glad this past trip was successful for you and your team! Yes, a lack of infrastructure, broken and worn out equipment must be a great challenge. I'm wondering if the nonprofit organization THET may be a resource and potential partnership for you... Biomedical Equipment / Health Technology Management https://www.thet.org/our-work/bme/. Although they are not currently operating in Cambodia, their website states "We are always looking to develop new partnerships and are interested in being contacted by any prospective partners who share our vision." If I come across anything else, I'll be sure to pass along information, if you're interested. Curious how other surgical members deal with this issue? We'd love to hear from you! All the best Dr. Brender and thank you.

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    • Valerie Colgate, MSGH, CCTSS  I wrote to them.   They appear to be for Brits only but I'll see if they respond.

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    • Elliott Brender MD . Hi Dr. Brender, I'd be interested in learning more about the presentation of your work at Khmer Soviet Friendship Hospital and the evolution of the program you have developed there. If you have any key resources to share, I am sure there are forum members who would find your experience highly useful. 

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    •  What would you like to know?  We have been operational  for a year & a  half now.  We have our own surgical clinic at the Khmer Soviet Friendship Hospital (KSFH).   We have recently expanded to twice a week.  This was no easy accomplishment.  For US surgical residents to get approval i.e. credit for the experience this needed to be approved by the American Board of Surgery, the American College of Surgeons, the residency review committee, approval by the Cambodian government, & Cambodian medical licensure.  11 years of   missions, donations of supplies & equipment & teaching of our latest techniques got the Cambodian surgeon surgeons to trust us enough to get this to work.    Trust is something that is learned & takes time.   And you have to be good.  Your results - spectacular.

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    • Elliott Brender MD Where do we get our patients from?   We know in advance the hospitals we plan to cover.  A letter (or e-mail) is written to the  director of the hospital & the chief of surgery introducing who we are. and the type of cases we do.  They then round up potential cases.  When we arrive we meet with everybody, give the hospital donations base on what the hospitals needs might be i.e., suture, mesh, instruments, etc.,  & then  screen the patients they arrange for us to see.  On confirmation of a  surgical problem we can fix, they are scheduled. & done.  We do see them the next day postop but they are then followed by the  local surgeons.

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    • Elliott Brender MD : Thank you Dr. Brender. It sounds like you have put a lot of work into the program and took the necessary time and effort to establish a good rapport among your local colleagues and within the community. This is such an important step for a long-lasting and sustainable program. 

      Thank you for also sharing your process for recruiting and following patients.  It's great that you have access to local follow-up. It would be nice to hear from others as well in regards to pre-screen and recruitment of patients, as there are some forum members who are working on setting up surgical programs. Obviously each place is going to be different depending on if it is permanent program or a short-term surgical mission, what type  of setting, type of surgeries, etc.  I know several groups doing short-term surgical trips in Haiti who do similar to your program--word is spread among NGOs/community of date/type of surgical, usually first 1-2 days of outreach is pre-screening process and pre-surgical education, surgeries take place the next several days, the last few days are post-op visits and arranging referral or local follow-up pathways. 

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    • Micaela Theisen Local trust is incredibly important.   I have been going to Cambodia for 11 years now.  I am known.  I have an excellent reputation.  I can get things done often when my colleagues can't.  Why? - Trust.  And trust takes time.  It must be earned.  One thing I did luck out with.  Early on one of my volunteers asked if he could work full-time?  The answer was yes even thought I was going to cost me more .  I pay airfare & accommodations.  But it was so worth it.    He is competent & affable, a great combination.

      A word about the prescreen.  All surgeons must ALWAYS examine their patients pre-operatively.  Case if fact. An ER Dr, from our local community hospital calls meat 1am.  He has a patient in extreme pain with an incarcerated hernia.   So  not to waste time sitting around for the crew to arrive I have them called in.  After all, an incarcerated  is a surgical emergency.  So I arrive, examine the patient, & surprise, there is a huge hernia, reducible, NOT incarcerated and not painful.  But when I move his leg he screams in pain.   Surprise , no incarcerated hernia,; his problem is a fx femur. The ortho would not come in at 1am but since I called in the crew, I fixed his hernia.   BUT  - until you personally examine the patient what his problem is , is only hearsay.

      Another point - never cut anything until you are sure of what you are cutting.  A 4 y.o. Cambodian boy couldn't straighten his penis.  There appears to be a "cord" that is restricting his ability to straighten his penis.  My Cambodian colleague says its a  chordae.  Just cut it.  I say no, I need to know where the urethra is first.  Guess what - it was the urethra.  I placed a catheter first to identify the urethra.  If I had just cut it - MAJOR problem.  1 - it is short and the ends would have sprung away.  Sewing it back together (if recognized) is under tension & likely to fail.   Not recognizing the injury perineal sepsis, possibly death. 

      Screen, sort out your cases, what are you capable of.  Some diseases are far advanced and will not be able to be treated.  But MANY can & quite successfully.

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  • Great resource excerpted from Global Health NOW published February 15th: 

    Setting the Standard for Surgery

    Safe surgery and anesthesia are increasingly recognized as a crucial element of universal health care in low- and middle-income countries.

    Improving surgical care for children, in particular, is a clear asset toward achieving the SDGs. To that end, the Global Initiative for Children’s Surgery—a consortium spanning 13 pediatric specialties—has drawn up adaptable guidelines for essential surgical care for children in LMICs.

    The guidelines—reflecting the needs as determined by LMIC surgeons themselves—aim to help LMICs advocate for more resources, offer a template to support surgery at all levels of the health system and establish a minimum standard of care.

    Please see attachment for guidelines. Would love to hear your feedback regarding these minimum standards in relation to the country where you work. Are these standards currently implemented? If so, how? If not, are they feasible? Biggest challenge(s)?

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  • World Tuberculosis Day March 24, 2019

    Any providers addressing TB in LMICs? Would love to hear more about your work.

    Article published March 25, 2019 by John Hopkins Bloomberg School of Public Health Global Health NOW: How Surgery Could Help End Tuberculosis (Click title to read.)

    In summary, the author discusses how surgery "might be the only alternative for a group of patients who can no longer be helped by medical management", and the great challenges it presents in LMICs.  

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  • For the forum members who do surgical outreach missions, could you let us know your process for patient access (how do they know about your services, know to access them, etc) and pre-screening/patient selection process? This question has come up among forum members who are  hoping to set up or streamline their surgical outreach abroad and I have found few useful open-access resources to share.  

    I do want to share the WHO Surgical Safety Checklist, which is available in a number of different languages and can be a simple intervention to implement at your sites to improve surgical safety. It is available at: https://www.who.int/patientsafety/safesurgery/checklist/en/

    I have also attached an informative article from Lancet:  "Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development." There are a few key images from the article posted here. 

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  • The Medical Outreach Program offers pulse oximeters through our Safe Surgery Initiative. For teams performing surgeries, I encourage you to partner with us in Safe Surgery! We will provide the pulse oximeters, you take the units to your in-country partner facility, train the local staff on its use and leave the devices behind. Let's chip away at that staggering statistic stating that there are more than 5 billion people around the world who lack access to safe surgical and anesthesia care! BTW...,.if you state via your application (when applying for a donation of free medicines and supplies to support your important work) we will offer you Surgical Safety checklists in English, French and Spanish. Based on partner feedback, teams seem to like that we laminated them, added velcro for easy mounting in the operating and recovery rooms and even provide a white board marker so that you can customize the checklist for each patient.  To find out more about our Safe Surgery Initiative, visit our site. https://medicaloutreach.americares.org/en/initiatives/safe-surgery-initiative/

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    • Tricia Gordon I think my team has distributed 77  (? maybe more)  pulse oximeters throughout Cambodia.  And we saved a life which I wrote up for you before  4 1/2 year old boy with a cleft palate.  The surgeon untapped the tube for better access to the cleft.  Except he unknowingly dislodged the tube.  The alarm sounded.  we saw the displaced tube & reinserted it.  What would have happened without a pulse oximeter?   Successful surgery - patient is brain dead.

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