Navigating the Challenges in Setting Up a Sustainable Open-Heart Surgery Unit in a Resource-Constrained Environment in Northern Nigeria: Model and Strategies.

INTRODUCTION: Cardiac surgery requiring cardiopulmonary bypass had been unavailable in Northern Nigeria and the federal capital territory of Nigeria regularly. Several attempts in the past at setting up this service in a self-sustaining manner in Northern Nigeria had failed. This paper is a contrasting response to an earlier publication that emphasized the less-than-desirable role played by international cardiac surgery missions in the evolution of a sustainable open-heart surgery program in Nigeria. METHODS: The cardiothoracic unit of Federal Medical Centre, Abuja, was established on March 1, 2021, but could not conduct safe open-heart surgery. The model and strategies employed in commencing open-heart surgeries, including the choice of personnel training within the country and focused collaboration with foreign missions, are discussed. We also report the first seven patients to undergo cardiac surgery under cardiopulmonary bypass in our government-run hospital as well as the transition from foreign missions to local team operations. RESULTS: Seven patients were operated on within the first six months of setting up with high levels of skill transfer and local team participation, culminating in one of the operations entirely carried out by the local team of personnel. All outcomes were good at an average of one-year follow-up. CONCLUSION: In resource-constrained government-run hospitals, a functional, safe cardiac surgery unit can be set up by implementing well-planned strategies to mitigate encountered peculiar challenges. Furthermore, with properly harnessed foreign missions, a prior-trained local team of personnel can achieve independence and become a self-sustaining cardiac surgery unit within the shortest possible time.

Surgical outreach for the Americas: a self-sustainable model for partnership and education.

INTRODUCTION: It is estimated that up to 28% of global disease burden is surgical with hernias representing a unique challenge as the only definitive treatment is surgery. Surgical Outreach for the Americas (SOfA) is a nongovernmental organization focused primarily on alleviating the disease burden of inguinal and umbilical hernias in Central America. We present the experience of SOfA, a model focused on partnership and education. METHODS: SOfA was established in 2009 to help individuals recover from ailments that are obstacles to working and independent living. Over the past 15 years, SOfA has partnered with local healthcare providers in the Dominican Republic, El Salvador, Honduras, and Belize. The SOfA team consists of surgeons, surgery residents, triage physicians, an anesthesiologist, anesthetists, operating room nurses, recovery nurses, a pediatric critical care physician, sterile processing technicians, interpreters, and a team coordinator. Critical partnerships required include the CMO, internal medicine, general surgery, nursing, rural health coordinators and surgical training programs at public hospitals. RESULTS: SOfA has completed 24 trips, performing 2074 procedures on 1792 patients. 71.4% of procedures were hernia repairs. To enhance sustainability of healthcare delivery, SOfA has partnered with the local facilities through capital improvements to include OR tables, OR lights, anesthesia machines, monitors, hospital beds, stretchers, sterilizers, air conditioning units, and electrosurgical generators. A lecture series and curriculum on perioperative care, anesthesia, anatomy, and operative technique is delivered. Local surgery residents and medical students participated in patient care, learning alongside SOfA teammates. Recently, SOfA has partnered with SAGES Global Affairs Committee to implement a virtual Global Laparoscopic Advancement Program, a simulation-based laparoscopic training curriculum for surgeons in El Salvador. CONCLUSION: A sustainable partnership to facilitate surgical care in low resource settings requires longitudinal, collaborative relationships, and investments in capital improvements, education, and partnership with local healthcare providers, institutions, and training programs.

Local and Visiting Physician Perspectives on Short Term Surgical Missions in Guatemala: A Qualitative Study.

OBJECTIVE: To explore the impact of short-term surgical missions (STMs) on medical practice in Guatemala as perceived by Guatemalan and foreign physicians. SUMMARY BACKGROUND DATA: STMs send physicians from high-income countries to low and middle-income countries to address unmet surgical needs. Although participation among foreign surgeons has grown, little is known of the impact on the practice of foreign or local physicians. METHODS: Using snowball sampling, we interviewed 22 local Guatemalan and 13 visiting foreign physicians regarding their perceptions of the impact of Guatemalan STMs. Interviews were transcribed verbatim, iteratively coded, and analyzed to identify emergent themes. Findings were validated through triangulation and searching for disconfirming evidence. RESULTS: We identified 2 overarching domains. First, the delivery of surgical care by both Guatemalan and foreign physicians was affected by practice in the STM setting. Differences from usual practice manifested as occasionally inappropriate utilization of skills, management of postoperative complications, the practice of perioperative care versus "pure surgery," and the effect on patient-physician communication and trust. Second, both groups noted professional and financial implications of participation in the STM. CONCLUSIONS: While Guatemalan physicians reported a net benefit of STMs on their careers, they perceived STMs as an imperfect solution to unmet surgical needs. They described missed opportunities for developing local capacity, for example through education and optimal resource planning. Foreign physicians described costs that were manageable and high personal satisfaction with STM work. STMs could enhance their impact by strengthening working relationships with local physicians and prioritizing sustainable educational efforts.

Occupational Therapy in Haiti: A Pilot Study to Identify Intervention Methods Used during Short-Term Medical Missions.

Due to the shortage of occupational therapists (OTs) in Haiti and over 800,000 individuals with disabilities, most occupational therapy assessments and interventions are provided by OTs on short-term medical missions (STMMs). Learning which methods OT use to provide assessments and interventions during these STMMs is the first step to understanding how to facilitate follow-up and carry-over for clients and ensure longevity for STMMs in Haiti. This study used a cross-sectional, descriptive design to gather data on methods used by OTs. Thirty-three OTs, who travelled to Haiti on STMMs, completed a 16-question, online survey. The most common method provided by OTs was education to patients, caregivers, and local providers. Training of Haitian rehabilitation technicians was also prevalent. There was an association between the years of the OTs' clinical experience and the effort of OTs to train local providers, but this result was not statistically significant. Further research should be implemented on specific methods that can be used in the absence or shortage of Haitian OTs to ensure follow-up for Haitian clients. The sharing of data regarding OT methods on STMMs will promote evidence-based, client-centered, and cost-effective therapy to enhance effective client outcomes.

The Development of a Surgical Mission in the Peruvian Amazon: A 15-Year Expedition.

Musculoskeletal disorders and injuries represent a substantial proportion of the global burden of disease. This burden is particularly prevalent in low and middle-income countries that already have insufficient health-care resources. The purpose of this paper is to highlight the vision, the history, the implementation, and the challenges in establishing an orthopaedic surgical mission in a developing nation to help address the epidemic of musculoskeletal trauma.Scalpel At The Cross (SATC) is a nonprofit Christian orthopaedic surgical mission organization that sends teams of 10 to 20 members to Pucallpa, Peru, a rural town in the Amazon, to evaluate patients with musculoskeletal conditions, many that require surgery. The organization employs 4 full-time staff members and has included over 400 medical volunteers in 32 surgical campaigns since 2005. SATC has provided approximately 8.1 million U.S. dollars in total medical care, while investing approximately 2.2 million U.S. dollars in implementation and overhead.Given the projected increase in trauma in low and middle-income countries, the SATC model may be increasingly relevant as a possible blueprint for other medical professionals to take on similar endeavors. This paper also highlights the importance of continued research into the effectiveness of various organizational models to advance surgical services in these countries.

Creating arteriovenous fistulas for children in Guatemala.

OBJECTIVE: The Guatemalan Foundation for Children with Kidney Diseases was established in 2003 as the first and only comprehensive pediatric nephrology program and hemodialysis unit in Guatemala. Bridge of Life (BOL) is a not-for-profit charitable organization focused on chronic kidney disease and supplied equipment, training and support during formation of the hemodialysis unit. Pediatric permanent vascular access (VA) expertise had not been established and noncuffed dialysis catheters provided almost all VA, many through subclavian vein access sites. BOL assistance was requested for establishing a VA surgical program, resulting in recurring BOL surgical missions to create arteriovenous fistulas (AVF) in these children. This study analyzes the BOL pediatric VA missions to Guatemala. METHODS: Three surgical pediatric VA missions were conducted in Guatemala from 2015 to 2017. Each mission was led by two or three surgeons. All supplies and equipment (including ultrasound units) were taken as part of each mission. The BOL surgical VA mission teams work with local pediatric surgeons, pediatric nephrologists, and dialysis nurses to establish collegial relationships and foster teaching interactions. We retrospectively reviewed the patient demographic data, procedures, and outcomes for these missions. RESULTS: AVFs were created in 54 new pediatric patients. Ages were 8 to 19 years (13.4 ± 2.8 years) and 29 patients (54%) were male. Patient weights were 28 to 50 kg (30.8 ± 8.3 kg) with body mass indexes of 12 to 25 kg/m2 (17.9 ± 2.9 kg/m2). Radiocephalic AVFs were created in 21 children (39%), proximal radial artery AVFs in 12 (22%). and brachial artery inflow AVFs in 5 (9%). Sixteen patients (30%) required transpositions and one a translocation; two of these were femoral procedures. Primary and cumulative patency rates were 83% and 85% at 12 months and 62% and 85% at 36 months, respectively. The median follow-up was 17 months. Interventions with fistulagram and balloon angioplasty options were not available for AVF dysfunction or access salvage during the study period. However, six patients underwent an AVF revision and salvage during subsequent missions or by one of the Guatemalan surgeons (R.S.). Four individuals underwent successful transplantation during the study period. There were no operative deaths or major complications. CONCLUSIONS: Pediatric VA missions to Guatemala created safe and functional AVFs in concert with local pediatric surgeons and pediatric nephrologists. Three surgical missions included access operations in 54 new patients. Cumulative AVF patency was 85% at 36 months.

Optimizing the Use of a Precious Resource: The Role of Emergency Physicians in a Humanitarian Crisis.

Emergency physicians (EP) are uniquely suited to provide care in crises as a result of their broad training, ability to work quickly and effectively in high-pressure, austere settings, and their inherent flexibility. While emergency medicine training is helpful to support the needs of crisis-affected and displaced populations, it is not in itself sufficient. In this article we review what an EP should carefully consider prior to deployment.

Cooperación internacional ¿en qué estamos y hacia dónde vamos? / International cooperation. Where are we, and where are we heading to?

Unmet needs in global health are important issues, not yet solved by the international community. A variety of individuals, non-governmental organizations (NGO) and government institutions have tried to address this situation, developing multiple types of international cooperation (IC), such as humanitarian aid (HA), cooperation for development (CD) and medical missions (MM). In the last decades, we have witnessed an exponential growth in the creation and participation of these projects. Moreover, in the last 20 years, Chile has experimented a real paradigm switch, from a receiver to a provider of IC. Due to the recent surge in interest and relevance of the topic, we performed a narrative revision of the literature related with IC. In the present article, we characterize the different types of IC, with emphasis in MM: we address the risks, controversies and ethical problems associated with these activities. We finally propose some guidelines for the future development and promotion of MM.

Academic-Community Partnership for Medical Missions: Lessons Learned and Practical Guidance for Global Health Service-Learning Experiences.

To facilitate an academic-community partnership for sustainable medical mis-sions, a 12-step process was created for an interprofessional, global health educational, and service-learning experience for students and faculty in a school of pharmacy and health professions. Lessons learned and practical guidance are provided to implement similar global health opportunities.

Outcomes of an Immersion Proiect in the Dominican Republic Bateyes.

Faculty and nursing students from a southeastern college participated in a service-learning immersion in an intra-professional collaboration to treat migrant workers living in the bateyes (the name given to those communities that reside inside sugar plantations in the Dominican Republic that are comprised mainly of Haitians and Dominicans of Haitian descent) in the targeted Dominican Republic agricultural plantations. The mission team included physicians, nurse practitioners, registered nurses and nursing students These team members provided health assessment, screenings, and preventive health education to men, women, and children, and their families. The students were provided an in-depth orientation and briefed about what to expect during their visit to a foreign culture. Students were informed about local nursing care practices, beliefs of health-care practices, and the possibility of unexpected occurrences in the bateyes. The cultural and health issues of the Haitian migrant workers living in the bateyes were discussed prior to the trip, and upon arrival in the Dominican Republic. The immersion field experience had two primary aims, which included: 1. Exposing students to a field experience in another country that created avenues for developing a global perspective; and 2. Exposing students to methods of collecting and analyzing retrospective data to glean an understanding of the healthcare needs of individuals living in the Dominican Republic. The charts of 735 patients from the 1437 patients (51%) treated were analyzed with 49% not accounted for. Of those patients, 59% were females and 41% were males. The lower number of males in this retrospective study was probably due to restrictions of working with sugar cane; the males had difficulties leaving their work to be seen by the health-care professionals. The largest age group was the 12-21 age group (24%), with the next age groups 22-32 (18%), 6-11 (16%) and 33-43 (11%), 44-54(9%),0-5 (9%), 55-65 (7%), 66-76 (4%), and 77-87(2%). Many patients had multiple diagnoses in multiple diagnostic categories with the most frequent diagnosis, Gastrointestinal (24%), followed by Neurology (16%), Respiratory (14%), Genitourinary (11%), Musculoskeletal (10%), Dermatology (8%), Eyes, Ears, Nose & Throat (8%), Cardiology (7%), and Hematology (2%).

Establishing a surgical outreach program in the developing world: pediatric strabismus surgery in Guatemala City, Guatemala.

PURPOSE: To report our experince in establishing a sustainable pediatric surgical outreach mission to an underserved population in Guatemala for treatment of strabismic disorders. METHODS: A pediatric ophthalmic surgical outreach mission was established. Children were evaluated for surgical intervention by 3 pediatric ophthalmologists and 2 orthoptists. Surgical care was provided at the Moore Pediatric Surgery Center, Guatemala City, over 4 days. Postoperative care was facilitated by Guatemalan physicians during the second year. RESULTS: In year 1, patients 1-17 years of age were referred by local healthcare providers. In year 2, more than 60% of patients were prescreened by a local pediatric ophthalmologist. We screened 47% more patients in year 2 (132 vs 90). Diagnoses included congenital and acquired esotropia, consecutive and acquired exotropia, congenital nystagmus, Duane syndrome, Brown syndrome, cranial nerve palsy, dissociated vertical deviation, and oblique muscle dysfunction. Overall, 42% of the patients who were screened underwent surgery. We performed 21 more surgeries in our second year (58 vs 37), a 57% increase. There were no significant intra- or postoperative complications. CONCLUSIONS: Surgical outreach programs for children with strabismic disorders in the developing world can be established through international cooperation, a multidisciplinary team of healthcare providers, and medical equipment allocations. Coordinating care with local pediatric ophthalmologists and medical directors facilitates best practice management for sustainability.

The Challenges of Establishing and Sustaining an Overseas Enterprise: One Haitian NGO's Perspective.

This article describes the creation of Project Medishare for Haiti, Inc, a US 501(c)3 nonprofit organization and its counterpart in Haiti, Project Medishare in Haiti, a nongovernmental organization that provides health care resources and training and education in Haiti. It summarizes the strategy for fundraising and sustaining such an enterprise in a developing country and discusses the lessons learned and goals achieved during the last 20 years.

CIRPLAST: Cleft Lip and Palate Missions in Peru.

BACKGROUND: The author presents a 20-year experience leading cleft lip and palate surgical volunteer missions in Peru for CIRPLAST, a nonprofit volunteer plastic surgery goodwill program that has provided free surgery for patients with cleft lip and palate deformities in remote areas of Peru. Surgical procedures were performed by the author, together with a group of experienced plastic surgeons, under the auspices of the Peruvian Plastic Surgery Society, and local health authorities. METHODS: CIRPLAST missions are scheduled annually in different locations around Peru. Selected patients for surgery after adequate screening are photographed, and their cleft deformity is recorded. Scheduled patients or their parents, when they are minors, sign an informed consent form. Patients operated on in any given day are examined and photographed 1 day after surgery, before discharge. Between 30 and 35 patients are operated on at each mission site. About 2 weeks after the mission, patients are checked and photographed, and the outcome of surgery is recorded. Complications that may occur are recorded and treated by the CIRPLAST team as soon as possible. Almost all operations are performed under general endotracheal anesthesia coupled by local anesthesia containing a vasoconstrictor, to reduce bleeding and facilitate tissue dissection. All wounds of the lip and palate are closed with absorbable sutures, to avoid the need for suture removal. After cleft lip surgery, patients go to the recovery room for monitoring by nurses until they recover completely. RESULTS: A total of 6108 cleft lip and palate repairs, primary and secondary, were performed by CIRPLAST in 141 missions, between May 12, 1994, and October 15, 2014. The medical records of the 5162 patients (84.5%) who returned for follow-up (ranging from 12 days to 9 years) were reviewed retrospectively. Between 45% and 70% of the patients operated on a mission have returned for early follow-up and some the following year. There were 3176 males (51.9%) and 2932 females (48.1%). The incidence of isolated lip clefts was 1546 patients (25.3%); of isolated palate clefts, 2223 patients (36.4%); and combined defects, 2339 patients (38.3%). Of the 5162 patients who returned for follow-up, 377 patients (7.3%) had complications. Lip wound dehiscence was present in 58 patients (15.4). Palate fistula formation in 33 patients (8.8%): 24 (6.4%) after primary palate closure, and 9 (2.4%) after previous fistula closure. Infection occurred in 37 cleft lip patients (9.8%). Hypertrophic lip scars were seen in 56 patients (14.9%). Bleeding occurred in the recovery room after palatoplasty in 48 patients (12.7%), and in most cases, it was contained by applying pressure. No blood transfusions were used. Residual deformities of varying degree of the nose and/or lip occurred in 145 patients (38.5%). All required reoperation for correction. There were no intraoperative deaths in this series. CONCLUSIONS: During the past 20 years, the CIRPLAST team has offered free surgery with good outcomes and few complications, to more than 6000 cleft lip and/or palate patients in remote areas of Peru.

Cleft and Craniofacial Care During Military Pediatric Plastic Surgery Humanitarian Missions.

BACKGROUND: Military pediatric plastic surgery humanitarian missions in the Western Hemisphere have been initiated and developed since the early 1990 s using the Medical Readiness Education and Training Exercise (MEDRETE) concept. Despite its initial training mission status, the MEDRETE has developed into the most common and advanced low level medical mission platform currently in use. The objective of this study is to report cleft- and craniofacial-related patient outcomes after initiation and evolution of a standardized treatment protocol highlighting lessons learned which apply to civilian plastic surgery missions. METHODS: A review of the MEDRETE database for pediatric plastic surgery/cleft and craniofacial missions to the Dominican Republic from 2005 to 2009 was performed. A multidisciplinary team including a craniofacial surgeon evaluated all patients with a cleft/craniofacial and/or pediatric plastic condition. A standardized mission time line included predeployment site survey and predeployment checklist, operational brief, and postdeployment after action report. Deployment data collection, remote patient follow-up, and coordination with larger land/amphibious military operations was used to increase patient follow-up data. Data collected included sex, age, diagnosis, date and type of procedure, surgical outcomes including speech scores, surgical morbidity, and mortality. RESULTS: Five hundred ninety-four patients with cleft/craniofacial abnormalities were screened by a multidisciplinary team including craniofacial surgeons over 4 years. Two hundred twenty-three patients underwent 330 surgical procedures (cleft lip, 53; cleft palate, 73; revision cleft lip/nose, 73; rhinoplasty, 15; speech surgery, 24; orthognathic/distraction, 21; general pediatric plastic surgery, 58; fistula repair, 12). Average follow-up was 30 months (range, 1-60). The complication rate was 6% (n = 13) (palate fistula, lip revision, dental/alveolar loss, revision speech surgery rate). The average pre-surgical (Pittsburgh Weighted Speech Score) speech score was 12 (range, 6-24). The average postsurgical speech score was 6 (range, 0-21). Average hospital stay was 3 days for cleft surgery. There were no major complications or mortality, 1 reoperation for bleeding or infection, and 12 patients required secondary operations for palatal fistula, unsatisfactory aesthetic result, malocclusion, or velopharygeal dysfunction. CONCLUSIONS: Military pediatric plastic surgery humanitarian missions can be executed with similar home institution results after the initiation and evolution of a standardized approach to humanitarian missions. The incorporation of a dedicated logistics support unit, a dedicated operational specialist (senior noncommissioned officer), a speech language pathologist, remote internet follow up, an liaison officer (host nation liaison physician participation), host nation surgical resident participation, and support from the embassy, Military Advisory Attachment Group, and United States Aid and International Development facilitated patient accurate patient evaluation and posttreatment follow-up. Movement of the mission site from a remote more austere environment to a centralized better equipped facility with host nation support to transport patients to the site facilitated improved patient safety and outcomes despite increasing the complexity of surgery performed.