Mass casualty incident training in a resource-limited environment

Background

A mass casualty incident (MCI) occurs when a disaster involves a large number of injured people, overwhelming the capacity of local emergency medical services. This article describes the planning and execution of a MCI workshop created for use in Sierra Leone, a low-income country.

Methods

Surgeons OverSeas (SOS), an international non-governmental organization, partnered with the Sierra Leone Office of National Security and Connaught Hospital to develop a 2-day MCI workshop designed to meet needs specific to their resource-limited environment. Pre- and post-course questionnaires were completed. Day 1 consisted of didactic teaching focused on triage principles, resource deployment, communication/operations and tabletop drills. On day 2 a mock MCI with performance assessments by independent observers was staged, followed by post-event debriefing.

Results

Pre-course questionnaires identified the following deficits: lack of triage training (29 per cent), and transportation (19 per cent) and communication (17 per cent) shortfalls. Only 11 per cent could define MCI. During the drill, on-scene and hospital triage was accurate in 28 (93 per cent) and 23 (77 per cent) of 30 casualties respectively. Systematic deficiencies identified included: transport issues, no accurate system for tracking victims, and undersized triage areas. Participants identified interagency coordination (63 of 136 responses; 46·3 per cent) and triage (32 of 136; 23·5 per cent) as the most valuable lessons learned.

Conclusion

Pre-existing MCI programmes based on first-world logistics do not account for challenges encountered when caring for casualties in resource-constrained settings. Logistical training, rather than medical skills or knowledge, was identified as the educational priority.

Self-expanding metal stents (SEMS) for patients with advanced esophageal cancer in Malawi: an effective palliative treatment

BACKGROUND AND OBJECTIVES

Esophageal cancer is common in Malawi and most patients are inoperable at time of diagnosis. The aim of this study was to prospectively evaluate palliative treatment with self-expanding metal stents (SEMS) in Malawi, a low-income country with limited medical resources.

METHODS

Data of patients with advanced inoperable esophageal cancer were prospectively collected. Tumor and patient specifics, risk factors, dysphagia scores, complications, and survival were assessed. Follow-up data for 1 year or until death were collected from 118/143 patients (83%) during clinic visits, home visits, or via cell phone.

RESULTS

One hundred forty-three patients were treated with 154 SEMS. Median survival was 210 days (95% CI: 150-262 days). Fourteen of 118 patients with complete follow-up (11.9%) survived more than 1 year with longest documented survival of 406 days. The median dysphagia score improved from 3 at the time of presentation to 0 at the time of death. Early complications occurred in 4.2% (6/143), late complications in 11.9% of patients (14/118). The procedure related mortality was 2.1% (3/143).

CONCLUSIONS

SEMS is an appropriate palliative treatment in a resource-limited environment. For the vast majority of patients a single intervention provides lasting improvement of dysphagia.

High-grade dysplasia of the cystic duct margin in the absence of malignancy after cholecystectomy

BACKGROUND

A total of 750,000 cholecystectomies are performed annually in the USA. No data exist on patients with microscopic high-grade dysplasia at the cystic duct margin and the associated incidence of cholangiocarcinoma.

METHODS

Pathology reports for 1992-2010 were reviewed for patients with high-grade dysplasia of the cystic duct margin in the absence of invasive gallbladder cancer. Clinical data were obtained from chart review.

RESULTS

Five patients with high-grade dysplasia at the cystic duct margin without evidence of malignancy were identified. Radiologic imaging was abnormal in two patients. The cystic duct stump was abnormally dilated in both patients and one patient had an enlarged portacaval lymph node. All five patients underwent exploration and resection of either the cystic duct stump or the bile duct. Specimens in four of the patients showed no evidence of malignancy or dysplasia. One patient was found to have a node-positive adenocarcinoma of the cystic duct.

CONCLUSIONS

High-grade dysplasia at the cystic duct margin without evidence of invasive gallbladder cancer is rare. Patients with this finding should undergo cross-sectional imaging and a diagnosis of an underlying cholangiocarcinoma should be considered, especially if imaging reveals any abnormalities.

Scarcity of healthcare worker protection in eight low- and middle-income countries: surgery and the risk of HIV and other bloodborne pathogens

OBJECTIVE

In view of the substantial incidence of bloodborne diseases and risk to surgical healthcare workers in low- and middle-income countries (LMICs), we evaluated the availability of eye protection, aprons, sterile gloves, sterilizers and suction pumps.

METHODS

Review of studies using the WHO Tool for the Situational Analysis of Access to Emergency and Essential Surgical Care.

RESULTS

Eight papers documented data from 164 hospitals: Afghanistan (17), Gambia (18), Ghana (17), Liberia (16), Mongolia (44), Sierra Leone (12), Solomon Islands (9) and Sri Lanka (31). No country had a 100% supply of any item. Eye protection was available in only one hospital in Sri Lanka (4%) and most abundant in Liberia (56%). The availability of sterile gloves ranged from 24% in Afghanistan to 94% in Ghana.

CONCLUSION

Substantial deficiencies of basic protective supplies exist in low- and middle-income countries.

Teaching emergency and essential surgical care in Sierra Leone: a model for low income countries

BACKGROUND

Surgeons OverSeas (SOS), a New York-based organization with a mission to save lives in developing countries, conducted a surgical needs assessment in Sierra Leone in 2008 which identified a large gap in surgical knowledge. We hypothesized that knowledge transfer could be improved by conducting workshops with significant local faculty participation.

DESIGN

Description of emergency and essential surgical care workshops (EESC) workshops and follow-up.

SETTING

Freetown and Bo, Sierra Leone.

PARTICIPANTS

International and local health providers in Sierra Leone.

METHODS

SOS organized EESC workshops in collaboration with significant local surgeons' support. Data on subsequent workshops were recorded.

RESULTS

Fifteen instructors were identified and assisted with teaching. Nine of the instructors were specialists from Sierra Leone. Each workshop lasted 3 days. Feedback was gathered after these workshops Subsequent to the SOS workshops, 8 other workshops were undertaken by local surgeons in Sierra Leone, 5 of which were organized and taught solely by local surgeons working for the Sierra Leone Ministry of Health and Sanitation. Three other workshops were organized with external support.

CONCLUSIONS

EESC workshops organized with significant local input are useful for knowledge transfer and empower local surgeons to conduct subsequent workshops on their own.

The role of laparoscopic staging in patients with incidental gallbladder cancer

BACKGROUND

The role of staging laparoscopy (SL) in patients with incidental gallbladder cancer (IGBC) is ill defined. This study evaluates the utility of SL with the aim of identifying variables associated with disseminated disease (DD).

METHODS

Consecutive patients with IGBC who underwent re-exploration between 1998 and 2009 were identified from a prospective database. The yield and accuracy of SL were calculated. Demographics, tumour- and treatment-related variables were correlated with findings of DD.

RESULTS

Of the 136 patients submitted to re-exploration for possible definitive resection, 19 (14.0%) had DD. Staging laparoscopy was carried out in 46 (33.8%) patients, of whom 10 (21.8%) had DD (peritoneal disease [n = 6], liver metastases [n = 3], retroperitoneal disease [n = 1]). Disseminated disease was identified by SL in two patients (yield = 4.3%), whereas eight were diagnosed after conversion to laparotomy (accuracy = 20.0%). The likelihood of DD correlated closely with T-stage (T1b, n = 0; T2, n = 5 [7.0%], T3, n = 14 [26.0%]; P = 0.004). A positive margin at initial cholecystectomy (odds ratio [OR] 5.44, 95% confidence interval [CI] 1.51-24.37; P = 0.004) and tumour differentiation (OR 7.64, 95% CI 1.1-NA; P= 0.006) were independent predictors of DD on multivariate analysis.

DISCUSSION

Disseminated disease is relatively uncommon in patients with IGBC and SL provides a very low yield. However, patients with poorly differentiated, T3 or positive-margin gallbladder tumours are at high risk for DD and targeting these patients may increase the yield of SL.

Obstructive jaundice expands intrahepatic regulatory T cells, which impair liver T lymphocyte function but modulate liver cholestasis and fibrosis

Although obstructive jaundice has been associated with a predisposition toward infections, the effects of bile duct ligation (BDL) on bulk intrahepatic T cells have not been clearly defined. The aim of this study was to determine the consequences of BDL on liver T cell phenotype and function. After BDL in mice, we found that bulk liver T cells were less responsive to allogeneic or syngeneic Ag-loaded dendritic cells. Spleen T cell function was not affected, and the viability of liver T cells was preserved. BDL expanded the number of CD4(+)CD25(+)Foxp3(+) regulatory T cells (Treg), which were anergic to direct CD3 stimulation and mediated T cell suppression in vitro. Adoptively transferred CD4(+)CD25(-) T cells were converted into Treg within the liver after BDL. In vivo depletion of Treg after BDL restored bulk liver T cell function but exacerbated the degrees of inflammatory cytokine production, cholestasis, and hepatic fibrosis. Thus, BDL expands liver Treg, which reduce the function of bulk intrahepatic T cells yet limit liver injury.

Role of intra-arterial hepatic chemotherapy in the treatment of colorectal cancer metastases

Hepatic metastases are common with colorectal cancer. The primary blood supply to hepatic metastases is the hepatic artery. Regional chemotherapy utilizing the hepatic artery is one treatment option for liver metastases. The advantage of hepatic arterial chemotherapy is that high concentrations of the therapeutic drug are obtained in the liver with minimal systemic toxicity. Recently, systemic chemotherapy regimens have been added to hepatic arterial infusional chemotherapy to treat hepatic metastases. Due to the high response rates in the liver, resection rates are increasing in patients originally thought to have unresectable liver disease. Hepatic arterial chemotherapy has also been used in the adjuvant setting after resection of all liver metastases in order to minimize hepatic recurrences. The role of hepatic arterial infusional therapy in treating hepatic colorectal metastases includes treating patients with both resectable and unresectable metastases in the adjuvant, neoadjuvant, or palliative settings.

Percentage of cesarean sections among total surgical procedures in sub-Saharan Africa: possible indicator of the overall adequacy of surgical care

The aim of this study was to assess emergency and essential surgical care in low-income countries, review of the literature to obtain data on the number of cesarean sections, and compare the results with the total number of all operations. This cesarean section/total operations ratio was much higher for low-income countries than for high-income countries. We recommend more research into the validity of this tool for use as a possible proxy indicator for overall adequacy of emergency and essential surgical care.

Improving access to surgery in a developing country: experience from a surgical collaboration in Sierra Leone

BACKGROUND

Although surgery is increasingly recognized as an essential component of primary health care, there has been little documentation of surgical programs in low- and middle-income countries. Surgeons OverSeas (SOS) is a New York-based organization with a mission to save lives in developing countries by improving surgical care. This article highlights the surgical program in Sierra Leone as a possible model to improve access to surgery.

METHODS

An SOS team conducted a needs assessment of surgical capacity in Sierra Leone in February 2008. Interventions were then developed and programs were implemented. A follow-up assessment was conducted in December 2009, which included interviews of key Sierra Leone hospital personnel and a review of operating room log books.

RESULTS

Based on an initial needs assessment, a program was developed that included training, salary support, and the provision of surgical supplies and equipment. Two 3-day workshops were conducted for a total of 44 health workers, salary support given to over 100 staff, and 2 containers of supplies and equipment were donated. Access to surgery, as measured by the number of major operations at Connaught Hospital, increased from 460 cases in 2007 to 768 cases in 2009.

CONCLUSIONS

The SOS program in Sierra Leone highlights a method for improving access to surgery that incorporates an initial needs assessment with minimal external support and local staff collaboration. The program functions as a catalyst by providing training, salary support, and supplies. The beneficial results of the program can then be used to advocate for additional resources for surgery from policy makers. This model could be beneficial in other resource-poor countries in which improved access to surgery is desired.

Outcome of patients with a positive sentinel lymph node who do not undergo completion lymphadenectomy

BACKGROUND

Completion lymph node dissection (CLND), although considered a standard approach for patients with melanoma and a positive sentinel lymph node (SLN), is not performed in as many as 50% of indicated cases. This study evaluates the outcome of patients who had a positive SLN but did not undergo CLND at Memorial Sloan-Kettering Cancer Center.

METHODS

A prospective database was used to identify all patients with a positive SLN from 1992 to 2008. Patient and tumor characteristics, number of positive SLNs, recurrence pattern, reason for not performing a CLND, and current status were evaluated.

RESULTS

There were 2269 patients who underwent SLN biopsy. Three hundred thirteen had a positive SLN, of whom 271 (87%) had a CLND and 42 (13%) did not. Patients in the no-CLND group were older (median age 70 vs. 56 years, P < .01), and had a trend toward thicker melanomas (3.5 vs. 2.8 mm, P < .06). A significantly higher percentage of no- CLND patients had lower-extremity melanomas (40% vs. 13% CLND; P < .01). The most common reason for not performing a CLND was patient refusal (45%). There were similar rates and patterns of recurrence between the two groups. Recurrence-free survival and disease-specific survival were also similar between the groups.

CONCLUSIONS

It remains unclear whether CLND must be performed in all melanoma patients with a positive SLN. For selected informed patients who choose not to participate in the Multicenter Selective Lymphadenectomy Trial II trial, or in centers where the trial is not available, nodal observation may be an acceptable option.

Global surgery: thoughts on an emerging surgical subspecialty for students and residents

Interest is growing in global health among surgical residents and medical students. This article explores the newly developing concept of "global surgery." Providing surgical care to resource-limited populations, often found in low- and middle-income countries, has numerous professional and personal developmental benefits. A significant interest is found among most general surgical residents; however, it is necessary to formalize more exchange programs and fellowships like some institutions have done. Medical schools also should establish similar global clinical electives to channel the exuberance of students, develop properly their global health interests, and expose them early to the realities and health needs of the global population. Current opportunities for medical students and residents are reviewed along with the relevant literature.

Randomized clinical trials in melanoma

The incidence of melanoma is increasing and it is estimated that, in the United States, the lifetime risk of developing melanoma is 1 in 55. There have been many randomized trials that have refined the treatment and minimized the morbidity of the intervention of this prevalent disease. From 1975 to 2000, there were 154 prospective randomized trials on the treatment of local, regional, and metastatic melanoma. Between 2001 and the end of 2008, there were 52 randomized controlled trials relating to the treatment of patients with malignant melanoma. This article reviews the results of the major studies included in the prior article, and provides a detailed description of selected randomized controlled trials performed from 2001 to 2008.

Surgery and refugee populations

Although infectious diseases, malnutrition and diarrhea account for the vast majority of deaths in many crisis situations, many individuals also suffer from traumatic injuries and other surgically treatable conditions. Understanding the determinants involved in surgical interventions is facilitated by defining baseline, emergent and chronic phases for refugees and internally displaced populations. International aid organizations often expend vast resources on surgical interventions. More detailed assessments and further study may help provide insight into optimizing the success and minimizing the cost of such interventions. This article is a review of the surgical and disaster literature and defines issues for further study.

Multidisciplinary treatment of gastrointestinal stromal tumors

Gastrointestinal stromal tumor (GIST) has been recognized as a unique tumor only in the last decade. Although rare as a clinical entity, there is much interest in the pathology and treatment because the KIT protooncogene mutation common to most GISTs can be inhibited by imatinib mesylate. Diagnosing and treating GIST requires a multidisciplinary approach, given the combination of pathologic and radiographic evaluation, surgical treatment, and oncologic care required to successfully treat patients with GIST.

Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care

HYPOTHESIS

Lack of access to surgical care is a public health crisis in developing countries. There are few data that describe a nation's ability to provide surgical care. This study combines information quantifying the infrastructure, human resources, interventions (ie, procedures), emergency equipment and supplies for resuscitation, and surgical procedures offered at many government hospitals in Sierra Leone.

SETTING

Site visits were performed in 2008 at 10 of the 17 government civilian hospitals in Sierra Leone.

MAIN OUTCOME MEASURES

The World Health Organization's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was used to assess surgical capacity.

RESULTS

There was a paucity of electricity, running water, oxygen, and fuel at the government hospitals in Sierra Leone. There were only 10 Sierra Leonean surgeons practicing in the surveyed government hospitals. Many procedures performed at most of the hospitals were cesarean sections, hernia repairs, and appendectomies. There were few supplies at any of the hospitals, forcing patients to provide their own. There was a disparity between conditions at the government hospitals and those at the private and mission hospitals.

CONCLUSION

There are severe shortages in all aspects of infrastructure, personnel, and supplies required for delivering surgical care in Sierra Leone. While it will be difficult to improve the infrastructure of government hospitals, training additional personnel to deliver safe surgical care is possible. The situational analysis tool is a valuable mechanism to quantify a nation's surgical capacity. It provides the background data that have been lacking in the discussion of surgery as a public health problem and will assist in gauging the effectiveness of interventions to improve surgical infrastructure and care.

Management and spectrum of complications in patients undergoing surgical debridement for pancreatic necrosis

Patients who undergo pancreatic necrosectomy frequently develop complications and often have high mortality rates. These patients are best cared for at specialized centers to minimize morbidity, manage complex complications, and reduce mortality. We present a review of our experience and describe the spectrum of complications encountered in managing of these difficult patients. A registry of patients undergoing pancreatic necrosectomy during a 7-year period was analyzed for preoperative clinical scoring systems (Acute Physiology and Chronic Health Evaluation [APACHE] II and APACHE III scores), patient characteristics related to necrosectomy, and morbidity and mortality. Twenty-nine patients underwent necrosectomy. Indications for surgery were consistent with those previously described. There were 27 complications in 22 patients. Sixteen complications were early (less than 3 weeks after surgery) and 14 were late. The mortality rate was 14 per cent. All deaths were in patients transferred from outside institutions, some after extended time periods. Temporary percutaneous catheter drainage of abscesses before transfer and definitive surgery appeared to reduce mortality in transferred patients. There was a statistically significant correlation between mean maximal preoperative APACHE III score, but not APACHE II score, and the number of postoperative intensive care unit days (rho = 0.52, P = 0.004). We describe our experience managing patients with infected pancreatic necrosis that required operative necrosectomy. We found that more severely ill patients (higher APACHE III scores) had longer intensive care unit stays, but the initial severity of their illness did not increase mortality. If patients with infected pancreatic necrosis are referred to specialized centers, preoperative pretransfer percutaneous drainage may serve to temporarily control sepsis.

Management and Spectrum of Complications in Patients Undergoing Surgical Debridement for Pancreatic Necrosis

Patients who undergo pancreatic necrosectomy frequently develop complications and often have high mortality rates. These patients are best cared for at specialized centers to minimize morbidity, manage complex complications, and reduce mortality. We present a review of our experience and describe the spectrum of complications encountered in managing of these difficult patients. A registry of patients undergoing pancreatic necrosectomy during a 7-year period was analyzed for preoperative clinical scoring systems (Acute Physiology and Chronic Health Evaluation [APACHE] II and APACHE III scores), patient characteristics related to necrosectomy, and morbidity and mortality. Twenty-nine patients underwent necrosectomy. Indications for surgery were consistent with those previously described. There were 27 complications in 22 patients. Sixteen complications were early (less than 3 weeks after surgery) and 14 were late. The mortality rate was 14 per cent. All deaths were in patients transferred from outside institutions, some after extended time periods. Temporary percutaneous catheter drainage of abscesses before transfer and definitive surgery appeared to reduce mortality in transferred patients. There was a statistically significant correlation between mean maximal preoperative APACHE III score, but not APACHE II score, and the number of postoperative intensive care unit days (rho = 0.52, P = 0.004). We describe our experience managing patients with infected pancreatic necrosis that required operative necrosectomy. We found that more severely ill patients (higher APACHE III scores) had longer intensive care unit stays, but the initial severity of their illness did not increase mortality. If patients with infected pancreatic necrosis are referred to specialized centers, preoperative pre-transfer percutaneous drainage may serve to temporarily control sepsis.

NK dendritic cells expanded in IL-15 exhibit antitumor responses in vivo

NK dendritic cells (NKDC) are a novel subtype of DC with NK cell properties. IL-15 is a pleiotropic cytokine that plays an obligate role in the proliferation and survival of NK cells. We hypothesized that IL-15 is also essential for NKDC development. NKDC were nearly absent in IL-15(-/-) mice, but restored by administration of exogenous IL-15. Treatment of wild-type mice with IL-15 caused a 2- to 3-fold expansion of both NK cells and NKDC. After 7 days of culture with IL-15, sorted splenic NKDC expanded 10-fold while NK cells increased 5-fold. NKDC expanded in IL-15 retained their cytolytic capacity but lost the ability to stimulate naive T cells. Meanwhile, NKDC expanded in IL-15 produced 10 times more IFN-gamma as fresh NKDC and conferred protection in a tumor prevention model. Thus, IL-15 is essential to the proliferation and survival of NKDC and IL-15 expanded NKDC possess antitumor properties.