Patients in rural and developing locales often have difficulty accessing health care and undergoing surgical interventions. Interest in global surgery has grown significantly in recent years due in part to all of the following EXCEPT:
Although much of the world remains with limited access to surgery, this is changing. Patients who have been denied surgical care previously due to concerns about cost and access are no longer being ignored. Over time, it has become apparent that the patients in need of surgical care are those who have the greatest socioeconomic impact on society (ie, young, otherwise healthy and productive members of society). Offering a potential cure via surgery allows the patient to return to normal function and contribute to society in a meaningful way; improving the infrastructure of the country. Many trained physicians, especially surgeons, who planned to return to areas of need find that the lack of resources and infrastructure hamper their opportunity for development. Therefore, fully trained surgeons tend to remain in larger, more developed areas. While this is seen across the globe, migration of practitioners to economically and culturally favorable locales impacts Low and Middle Income Countries (LMICs) more, as they have a higher burden of diseased patients with fewer health care workers and a steeper gradient from developed to developing areas of their country.
A 24-year-old man in Tanzania is traveling without helmet on the back of a motorbike sideswipes a large truck. He is brought in to the hospital and found to have rib fractures, a femur fracture, and a traumatic brain injury. If one wanted to calculate the impact of this injury on his life, one could calculate a Disability Adjusted Life Year (DALY) score. What components make up this score?
The Disability Adjusted Life Year (DALY) score is a measure of overall disease burden expressed as the number of years lost due to ill-health, disability, or early death. The DALY has become commonly used in public health in dealing with the Health Impact Assessment. DALYs deal with potential life years lost due to premature death or disability. This combines morbidity and mortality into a single metric. Health liabilities are typically measured in Years of Life Lost (YLL). However, YLL does not take into account disability, often expressed as Years Lived with Disability (YLD). DALYs are calculated by taking the sum of these two components. A valuation of the "severity" of the disability must be made to accurately account for the degree of patient disability.
DALY = YLL + YLD
The DALY reflects chronic illness and amount of time a person remains affected. One DALY is equal to 1 year of healthy life lost. DALY can be applied to a multitude of conditions including physical, psychiatric, and neurologic conditions.
After you establish an advanced surgical department in a foreign country, a 55-year-old woman presents with right upper quadrant pain of 3 months occurring after every meal. An ultrasound shows a thickened gallbladder wall and peri cholecystic fluid and a diagnosis of cholecystitis is made. The patient undergoes a laparoscopic cholecystectomy. The World Health Organization's (WHO) 10 basic and essential objectives for safe surgical practice focus on all of the following EXCEPT:
Surgeons strive to constantly improve morbidity and mortality of their patients. In resource-limited areas access to certain pre and postop interventions or monitoring may be limited and in order to minimize complications, the World Health Organization (WHO) enacted the Safe Surgery Saves Lives Initiative. This campaign targeted preventable injuries and was found to have a 50% decrease in mortality. The 10 objectives for safe surgery include: identifying the correct patient and site, prevention of harm and pain, preparing for life-threatening airway compromise, preparing for high-risk blood loss, avoiding allergic reactions or reactions to drugs, minimizing surgicalsite infections, preventing retained sponges, identifying all surgical specimens, effective han d-offs of patient information, and routine patient surveillance (Table below).
Ten basic and essential objectives for safe surgery (WHO*):
*Data from WHO Guidelines for Safe Surgery 2009. http://whqlibdoc.who.int/publications/ 2009/9789241 598552_eng.pdf
A 50-year-old man presents to a clinic in Cameroon with abdominal pain. On further questioning, you learn that he lives 60 miles from the nearest hospital and has not seen a physician in years. The patient is counseled regarding screening colonoscopy, which he undergoes and multiple polyps are noted. The patient is referred to for surgery. Factors which must be considered that impact surgical services include:
Three factors, among many others, that must be considered when planning surgical care in low-resource settings are listed above. It is important for surgeons to understand and acknowledge their patients circumstances and customs while considering the physical and human resources of their environment. Safe and effective surgical care in low-resource setting requires careful attention to several fields traditionally outside of surgical training-such as logistics, business, public policy, engineering, and public health.
A 55-year-old East African woman presents with a palpable mass in her right breast that has been present for several years. You are concerned for cancer and know her case fatality rate is significantly higher than a similar patient in North America. Why?
Patients in LMICs bear a substantial proportion of the global burden of cancer morbidity and mortality. In the year 2030, the proportion of new cancer cases from LMICs is expected to be at least 70% with nearly two-thirds of global cancer deaths in LMICs. Cancer mortality is inversely associated with the strength of a country's health system, which is reflected in patient access to screening and treatment as well as the ease with which patient can access medical care.
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