Surgical Care of Pediatric Patients in the Humanitarian Setting: The Médecins Sans Frontières Experience, 2012-2013.

IMPORTANCE: Little is known about the scope of practice and outcomes in pediatric surgery performed by humanitarian organizations in resource-poor settings and conflict zones. This study provides the largest report to date detailing such data for a major nongovernmental organization providing humanitarian surgical relief support in these settings. OBJECTIVE: To characterize pediatric surgical care provision by a major nongovernmental organization in specialized humanitarian settings and conflict zones. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted from August 15, 2014, to March 9, 2015, of 59,928 surgical interventions carried out from January 1, 2012, to December 31, 2013, by the Médecins Sans Frontières Operational Centre Paris (MSF-OCP) program in 20 locations, including South Sudan, Yemen, Syria, Gaza, Pakistan, Nigeria, Central African Republic, Democratic Republic of Congo, and the Philippines. Surgical interventions were primarily for general surgical, traumatic, and obstetric emergencies and were categorized by mechanism, type of intervention, American Society of Anesthesia risk classification, and urgency of intervention. MAIN OUTCOMES AND MEASURES: Operative indications, type of intervention, and operative case mortality. RESULTS: Among all age groups, 59,928 surgical interventions were performed in dedicated trauma, obstetric, and reconstructive centers for 2 years. Nearly one-third of interventions (18,040 [30.1%]) involved preteen patients (aged <13 years) and 4571 (7.6%) involved teenaged patients (aged 13-17 years). The proportion of violence-related injuries in the preteen group was significantly lower than in the teenage group (4.8% vs 17.5%; P < .001). Burns (50.1%), other accidental injuries (16.4%), and infections (23.4%) composed the bulk of indications in the preteen group. Interventions in the teenage group were principally caused by trauma-related injuries (burns, 22.9%; traffic accidents, 10.1%; gunshot wounds, 8.0%). Crude perioperative case mortality rates were 0.07% in the preteen group, 0.15% in the teenage group, and 0.22% in the adult group (>17 years) (P = .001). One-third of the cases (33.4%) were deemed urgent, while most of the remaining cases (57.7%) were deemed semielective (surgical intervention to be performed within 48 hours). CONCLUSIONS AND RELEVANCE: When examining surgical interventions in a population of pediatric patients cared for in the specialized setting of humanitarian aid and conflict zones, burns, other accidental injuries, and infection composed the bulk of indications in the preteen group; interventions in the teenage group were principally caused by trauma-related injuries. Crude perioperative case mortality rates in the preteen group were significantly lower than in the adult group. Further work is needed to examine long-term outcomes of pediatric operations in these settings and to guide context-specific surgical program development.

Field research in humanitarian medical programmes. Treatment of neuropathic pain in Sierra Leone.

A pilot study was carried out among 223 war wounded and amputees in Sierra Leone in 2001 to investigate whether an intervention using proven medication for clinically diagnosed neuropathic pain would work in a developing country with limited health services. Compliance with medication was assessed in 79 patients and their pain and mood scores were assessed by questionnaire before medication and 6-10 months later. The pain and mood scores of 33 patients who stopped taking medication were compared for the initial and follow-up assessments indicating that, although the scores showed an improvement at follow-up, there was no significant improvement. Compliance was reasonable in 46 patients who continued with their medication, with 86.5% of possible doses collected although many had difficulty understanding how to take the drugs properly. Their pain and mood scores showed significant improvement at reassessment indicating that pain will be reduced with a longer duration of treatment. This study showed that it is possible to run an effective intervention for neuropathic pain in Sierra Leone with intermittent expert involvement and MSF have been able to develop a protocol for the assessment and treatment of neuropathic pain that may be useful in other difficult settings in which they work.

Assessing pain and mood in a poorly resourced country in a post-conflict setting.

CONTEXT: Accurate pain assessment is important but presents problems in poorly resourced countries. A civil war in Sierra Leone resulted in civilian casualties with pain from deliberate amputation and other injuries. OBJECTIVES: To examine the quality of simple pain and mood scales. METHODS: Within a pain treatment project, pain was assessed using numerical and verbal descriptor scales, and mood using visual analogue and verbal descriptor scales. The relationships between these scales (translated where necessary) were examined by comparison of pairs of measures. RESULTS: The overwhelming majority (99%) used the scales consistently. The verbal pain scale showed substantial discrimination between the pain words mild/small, moderate/half and half, and severe/serious (F=41.80, P<0.001). Numerical and verbal pain scales were related at a modest level (Kendall's tau-b=0.39, P<0.001, n=272) and not dependent on the level of education. A smaller sample (n=30) provided pain data across three assessment occasions, and both pain scales appeared sensitive to change. The 5-point verbal mood scale collapsed into three categories, with reasonable distinction between mood words (F=14.75, P<0.001). The visual analogue scale proved difficult to explain to civilian casualties in this setting. CONCLUSION: Verbal pain and mood scales and numerical pain scales appeared to yield useful information in a post-conflict situation. This suggests that adapting these established rating scales for pain, and for mood, was useful to clinicians and acceptable to patients.