Congo, 2014 - University of Virginia School of Medicine surgeon…C sxs... meaning of obstructed...
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Transcript of Congo, 2014 - University of Virginia School of Medicine surgeon…C sxs... meaning of obstructed...
University of Virginia Surgical Critical Care Division
“En Attendant Godot“ What We Do as We Wait
Rudolph Rustin MD FACS FACRS
University of Virginia Surgical Critical Care Division
no financial disclosures
Young girl and woman brick workers DRC
“En Attendant Godot”
http://www.andrewalexanderwriter.com/2013/08/05/60-years-and-still-waiting/
“World premiere production of Waiting for Godot 5 January 1953 at the Théâtre de Babylone in Paris.”
University of Virginia Surgical Critical Care Division
Let me begin with a story…
MSF Triage Tent, 2016
University of Virginia Surgical Critical Care Division
Colorectal surgeon…C sxs... meaning of ‘obstructed labor’
University of Virginia Surgical Critical Care Division
Sun had set…no electricity...enormous trees... sounds of nature...emotions palpable
America Tylenol Gabapentin Dilaudid, Fentanyl, Codeine Alvimopan Spinal GA - Ventilator AbThera Angio CT NPO NGT Ostomy Staplers Ostomy Supplies Blood Transfusions Plethora of Labs Consultants Ambulation (limited)
CAR – MSF O2 6l/min max Ketamine Tourniquet Tramadol Ambulation Ceftriaxone/Cipro/Flagyl/Augmentin Limited suture Early Feeding regular diet Local blood donors rare
University of Virginia Surgical Critical Care Division
“African ERAS…”
same procedure postop recovery less interference
University of Virginia Surgical Critical Care Division
All victims of violence, regardless of race or faith… have families
Rwanda The Catholic Church sent Flemish
Priests to proselytize the word of God
in Rwanda.
The Flemish priests, belonging to a
lower heirarchial status within the
European church, identified with the
Hutu class of Rwandans
. Although the Hutu
comprised the majority, the Tutsi ruled
Rwanda due to their Physical attributes
ascribed by the Germans, giving them more
western features (nose, cheeks, height, eyes).
1990 Kagame “Invades”
Rwanda but is defeated by
French Commandos in Kigali.
He retreats to Virunga
Mountains and re-organizes.
July 1993 Hate Radio
April 6, 1994President Plane
Shot Down
April 7-July 15, 1994Genocide
Genocide Consequences • Indisputable Storyline
• Silence / Lack of Dissent
• Stages of Tolerance
• 80% Population under 20 years of age
(Ben Curtis/AP) #
There is no “freedom of
speech” in Rwanda
today. There is no freedom
of press. There is no
freedom to organize. There
is no freedom of
assembly. The Kagame
regime continues to
assassinate and disappear
critics, journalists, former
business associates,
former military and former
government officials.”
http://www.consciousbeingalliance.com/2012/04/pe
ntagon-reveals-satelitte-photos-of-1994-rwanda-
genocide
University of Virginia Surgical Critical Care Division
Surgeons ability to ‘improvize’
rectal prolapse and cow’s milk
University of Virginia Surgical Critical Care Division
Abcesses …anywhere and everywhere neck hand septic myositis
University of Virginia Surgical Critical Care Division
From the operating theatre to the ‘improv’ theatre empyema femur fx tubing, gravity, bottle tape + stones
University of Virginia Surgical Critical Care Division
burns and fractures amazingly common
huge impact on inabilty to work
1/5 global deaths 2 surg disease/trauma
G IIIB Ex Fix
University of Virginia Surgical Critical Care Division
Chronic Advanced Disease
Kaposi Chronic Osteomyelitis
Ten Commandments of Working in Low Resource
Settings I.
Concentrate on the youth, for
they are the most likely to
listen, learn, and implement
institutional reforms necessary
on a grand scale. Have faith.
Faith outperforms hope.
II.
It is not about you! However
the most valuable asset you
have is your ability to
positively affect others with
your talents. Your impact on
others will far outlast your
possessions that will all rot
with time.
IV.
Understand that priorities are not set by you, but by tho
se with whom you are working. Low expectations rule
the day.
V.
Time is on no one’s side. The impact of any work done
may not become observed or palpable for years. You
will likely leave no fingerprints. Never abandon
yourself.
VI.
Sometimes the most
formidable obstacles to
change are those in
power with their own cultural
and institutional imprinting.
Expect change to be minimal.
VII.
Develop as many personal
and institutional relationships
as possible –networking
groups and forming coalitions
is critical to
success.
X.
Always consider the
road not taken as an alternative in achieving
whatever goals you set. Consider the arts as a means
to free yourself from the concerns of the day.
University of Virginia Surgical Critical Care Division
US Armed Forces field manual Tourniquet Ketamine
‘Scoop and Run’ vs ‘Lie and Die’ ‘Special K’
Nurse at Hospital
Fever / Arthralgia
Vesicular Rash / Lymphadenopathy
Transmission from mother nurse
University of Virginia Surgical Critical Care Division
Ebola, now Zika, monkey pox risk of global pandemics
Bioterrorism
Total 8 patients No Internet x 3 weeks Meetings? - Plan of Action? Confidentiality? Situational Awareness Week 2, Expatriot Pediatrician with fever, malaise, vesicular lesions Expat vs National Infection Chain of Command Obligation of Camp / Intl Travel Leadership at all levels
University of Virginia Surgical Critical Care Division
Global surgery experience Possibility to return to our roots
May 1, 2016 University of Virginia Surgical Critical Care Division
How did we get to this? • Imed X 20
• Vent
• CRRT
• EMRs
• 68k ICD-10s
• CPTs
• HMOs
• ACA
• Lawsuits
MD BURNOUT
University of Virginia Surgical Critical Care Division
Chance to rediscover our ‘raison d’etre’ ‘renew our vows’
University of Virginia Surgical Critical Care Division
Very profitable experience you receive much more than you give
University of Virginia Surgical Critical Care Division
CAR Water Supply CAR Infirmiere
Moving forward… Each of us has a path to choose
May 1, 2016 University of Virginia Surgical Critical Care Division
Bibliography
1. Zganjer M et al. Treatment of rectal prolapse in children with cow milk injection sclerotherapy: 30-year experience. World J Gastroenterol. 2008 Feb 7;14(5):737-40.
2. Bernier-Jean A et al. The Diagnostic and Therapeutic Impact of Point-of-Care Ultrasonography in the Intensive Care Unit. J Intensive Care Med. 2015 Sep 30. pii: 0885066615606682. [Epub ahead of print]
3. Bulger EM, et al. An evidence-based prehospital guideline for external hemorrhage control: American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014 Apr-Jun;18(2):163-73. doi: 10.3109/10903127.2014.896962.
4. Mawhinney AC ,Kirk SJ. A systematic review of the use of tourniquets and topical haemostatic agents in conflicts in Afghanistan and Iraq. J R Nav Med Serv. 2015;101(2):147-54.
5. McCollum AM et alHuman Monkeypox in the Kivus, a Conflict Region of the Democratic Republic of the Congo. Am J Trop Med Hyg. 2015 Oct;93(4):718-21. doi: 10.4269/ajtmh.15-0095. Epub 2015 Aug 17.
6. Christopher J.L. Murray, M.D., D.Phil., and Julio Frenk, M.D., Ph.D., M.P.H. Ranking 37th — Measuring the Performance of the U.S. Health Care System N Engl J Med 2010; 362:98-99.
Bibliography
8. Monkeypox, 2003 Outbreakhttps://www.cdc.gov/poxvirus/monkeypox/outbreak.html
9. Monkeypox. https://www.cdc.gov/poxvirus/monkeypox/index.html
12. Prevalence and risk factors associated with tungiasis in Mayuge district, Eastern
Uganda https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5012786/
13.Monkeypox Isolation Guidelines.
https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.htl
14. Update: Multistate Outbreak of Monkeypox --- Illinois, Indiana, Kansas, Missouri,
Ohio, and Wisconsin, 2003
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5224a1.htm