Surgeons learn how to improvise in the field
During a continuing medical education course on international humanitarian surgery skills, physicians use beef shoulder bones to practice drilling burr holes for head injuries. The Stanford course, which emphasized the importance of being able to make do with the tools available, drew several dozen physicans.
The first time Sherry Wren, MD, knew she needed to channel her inner MacGyver — the '80s sitcom secret agent who could fix anything with a little duct tape and a Swiss Army knife — she was treating a patient with severe burns at a hospital in Chad.
Severe burns were common in that central African country, where she was volunteering, in 2006, with Doctors Without Borders. Families often cooked over open fires in their homes, accidents were common and, as a result, skin grafting was a routine procedure for physicians posted there.
"I asked, 'Do you have an electric dermatome?'" she recounted, hoping to use the surgical instrument commonly used in the United States to produce uniformly thin slices of skin for grafting. "They said, 'Yes,' and handed me a 12-inch-long knife."
Now a veteran of multiple humanitarian missions with Doctors Without Borders, Wren, a specialist in gastrointestinal cancer surgery and a general surgeon at Stanford Hospital & Clinics, called upon her field-tested medical ingenuity, such as how best to perform skin grafts with low-tech tools, to teach a course held earlier this month at Stanford.
From using papaya paste for wound dressing to hand drills for relieving brain bleeds, the new continuing medical education course on international humanitarian surgery skills drew about 30 surgeons and several ob/gyn doctors from across the country, plus a few physicians from overseas. The course emphasized the importance of being able to make do with the tools available.
Developing countries may not have well-stocked supply closets; there may be no blood bank nearby; anesthesia may be limited; sonograms may be nonexistent.
"We wanted to make physicians understand that it's all about somehow 'making it work,'" said Wren, a professor of surgery. "You survive on your wits, making do with what's on hand."
Wren organized medical experts from across various fields, the large majority from Stanford, to volunteer to teach different sections of the course. Some were extremely experienced in overseas work, such as Richard Gosselin, MD, co-director of the Institute for Global Orthopaedics and Traumatology at the University of California-San Francisco, who has worked in more than 40 developing countries. Others, such as Stephen Skirboll, MD, a Stanford neurosurgeon, hasn't worked on medical missions overseas but is an expert in how to do low-tech craniotomies. Six faculty in obstetrics and gynecology from Stanford led by Kay Daniels, MD, and Antonia Nicosia, MD, also volunteered teaching birth and delivery skills.
A surgeon practices dilation and curettage on a papaya. The procedure,which is often needed after an incomplete miscarriage, involves dilating the cervix and scraping the uterine wall to remove tissue.
Wren recruited a hand surgeon to teach the skills necessary to treat hand injuries such as machete cuts and festering thorn wounds. She recruited an orthopaedist to teach fracture and dislocation treatment for injuries common to people falling out of trees while picking fruit, or caused by massive motor vehicle accidents due to horrific road conditions.
The course itself was something of a lesson in MacGyver-like inventiveness. Students used pigs' feet to practice ligament repair. Breech births were simulated from sleeping bags. An orthopaedic company donated thousands of dollars worth of fake bones; hand drills ordered online were used for bone-drilling practice.
"You have no idea how physically hard it is to crank a six-millimeter pin into someone's femur with a hand drill," Wren said. "And I'm strong."
In addition to inventiveness, adaptability was stressed as another key asset to the successful medical mission physician. Wren taught about the need for general surgeons to be prepared to step into new roles as ob/gyn doctors to do C-sections or to develop the skill set necessary to become their own anesthesiologist.
"The scope of practice that was expected was phenomenally different than at home," Wren said about her overseas missions. "You have to go outside your specialty."
Wren, a professor of surgery and associate dean of faculty affairs at the School of Medicine, continually drew on her personal experience from medical missions to Chad, Congo and Ivory Coast to guide her course content. C-sections were a common operation for her in Africa, never before having done one prior to that.
"Oh god, no. In Palo Alto, a general surgeon doing a C-section? I really hadn't done them," she said. "Amputations, that's easy for me. But C-sections. It's just a skill that most general surgeons don't have."
Not to mention she had the added surprise of the occasional twins and triplets that came along without any advanced warning due to the lack of ultrasound tests.
In addition to C-section skills, Wren received on-the-job training in triage and neurosurgery. For example, Wren was the only surgeon to respond to a massive motor vehicle accident in Chad with 20 injured.
"It was the first time I had ever done any real triage," she said. "I determined who was dead, who was most critical and who could wait for treatment. Because I was the only surgeon, I had to pick out who went first."
Physicians practiced ligament repair on pigs' feet during the course held earlier this month.
Wren chose an unconscious 8-year-old girl with head trauma and operated on her skull fractures first. The child woke up five days later, Wren having saved her life.
Untold hours of preparation went into the course, Wren said. It required countless volunteer hours by multiple professionals. But she has received so much positive feedback from class participants, including both students and teachers, that she definitely plans to organize it again.
"We don't pay any of these people," she said. "It's obviously a labor of love."
The course was sponsored by the Stanford Center for Innovation in Global Health.
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