SICOT e-Newsletter

World Orthopaedic Concern Newsletter Summaries from Nos. 126, 127, & 128

Michael Laurence
SICOT Emeritus Member - London, United Kingdom

The following are selected notes relating to current WOC activities (full scripts are available through www.worldortho.com and www.wocuk.org. Contributing membership obtainable through National branches).

Regular monthly editions will be sent to individual e-mail addresses, on request, from laurence.woc@gmail.com.

   
Global Frontiers in Surgery

This was the subject of an all day meeting at the Royal College of Surgeons (Eng) in London, on 16 January 2013. A busy, packed program covered opportunities for surgeons of every specialty to arrange teaching and training visits to areas with limited (or even absent) resources, with two principle objects; firstly, to reawaken the long-ago-learned art of managing without packaged and polished equipment; and secondly, to teach and train those who have to manage under those circumstances. Such visits are educational, but it is a two-way process – for the trainee from the West and for the established Consultant. Both will find themselves to have learned much.

Introducing the subject, R.C.S.Council member Martin Bircher spoke about the attention given to the subject by the Council with collaboration between the other Royal Surgical Colleges.

Recently retired Consultants attended the meeting in great numbers (N=242), with Registrars in training and senior students, together with abundant NGO societies (dozens) keen to prove their credentials and offer to fund volunteers. Prominent among the presenters were the Royal Colleges of England and Ireland, MSF, VSO, THET, WOC, COSECSA, CURE, Merlin; also many individual local organisations, all devoted to preaching a fundamental faith – to manage without Management. In a slot titled “Lightening Presentations” every organisation was given a strictly limited period of three minutes to convey the core of their message; and afterwards each had a stall in the main room for follow-up questions. All were extremely busy.

The general themes that emerged from the day included the following:

1. that there is an appalling world-wide imbalance in medical care;
2. there is more to medicine than iatropathic disease;
3. that shortage or lack of equipment does not mean impossibility to treat;
4. that a complete undergraduate program in the UK does not cover the most pressing of the World’s epidemics;
5. that time spent engaged in S-S A (= countries as poor as Sub-Saharan Africa) is a positive item on a trainee’s or a student’s CV.

The economics of care with limited resources was honestly analysed; the domestic problems of uprooting families during training, the place for clinical research, the responsibility for consultant cover and a reappraisal of surgical priorities, dominated the discussion. Nor were anaesthesia, prosthetics and rehabilitation ignored. There was a general air of optimism and adventure.

The organisers, Prof Chris Lavy and Mr Martin Bircher, are to be congratulated on a constructive meeting, reviving a real interest in positive medicine rather than defensive damage limitation.

   
Afghanistan

The history of the Sandy Gall Afghan Initiative is an interesting example of the many and varied enterprises that offer medical support where facilities are in pathetically short supply. In Newsletter No. 126 we made an attempt to categorise the modes by which orthopaedic assistance was most usefully arranged. A little more thought leads one to the conclusion that every area, country, village and town is different from every other; and the nature of everyone who has been drawn to their help is also different. This is a classic example of how inappropriate any guidelines for the subject are, and how unusual situations lead to a common outcome.

Sandy Gall, now an octogenarian, was a high profile Newscaster for British Television and an award winning foreign journalist. His work took him all over the world until finally he came to rest in Afghanistan in the “nineteen seventies”. As a war correspondent he watched and wrote about the struggle between the independent tribes and the occupying Russian army, and saw the impotence of military might to take and hold an unfamiliar terrain. He has written much about that war and its atrocities, both in his journalism and several books about the conflict. Like many correspondents, he was drawn to the under-dog, then the Mugahadeen. Most of the required surgery had been life-saving amputation. No prosthetic replacement service existed. Sandy arranged for one of the charismatic rebel leaders, who continued to hop about, literally, to be fitted out from Roehampton with a “leg”. Quite soon, swathes of the male population, similarly disabled, crowded the clinic. Sandy Gall set up a clinic for amputees, with the generosity of German “Limb” Manufactures, with the surgical support of Peter Styles from Guildford, who had in his training, worked in the leading vascular unit in London.

Out of this particular epidemic, flowed a need for precision in the performance of amputation – no longer to save a life, but to fit a prosthesis, for which much surgical revision was required. By the time Peter had a heart attack and was obliged to pack up, a wide variety of totally different problem cases followed in the footsteps of their fathers and brothers. John Fixsen joined the team with paediatric expertise, but he also had had considerable experience in adult amputation. By now, clubfoot, DDH and polio had joined the queue. They were fortunate that, as the politics of the situation in Afghanistan became complex, the interest of the Swedish Embassy in Kabul was enlisted, and continues its philanthropy to this day. John makes two or three three-week visits to Kabul each year and guides the development and provision of orthoses, prostheses and wheelchairs – the largest such unit in the country, still beset by mines.

It always takes time for an unsophisticated population to become convinced that “foreign unbelievers” are to be trusted. The prosthetic work was the catalyst for a clinic now performing a wide variety of elective procedures, both adult and paediatric, and has provided the means by which they might be enabled to return to peaceful and gainful employment. Time has elevated Sandy Gall into the affection of the population, and with him the doctors who have worked in his clinic. His problem is how to perpetuate the work and support it financially, when the time comes when he or his family no longer can. There is no doubt about the need for it. Too many such enterprises, with such an established reputation, have foundered on domestic difficulties, beyond outside understanding or assistance.

   
India

The Association of Rural Surgeons of India (ARSI) is to combine with the International Federation of Rural Surgery (IFRS) in organising a three-day Conference, to be held at the Shri Vigad Welfare Hospital in Bhachau, Kutch, Gujarat, in North Western India, 22-24 November 2013. This meeting has much support from the Times of India’s Welfare Trust.

It will be the 21st such conference for ARSI, and the 5th for the International Federation (IFRS). A broad faculty includes representatives form Germany, Holland and Nigeria.

According to the announcement by Dr Ram Prabhoo, the scientific programme will cover clinical and research papers with emphasis on what is ingenious, inexpensive and essentially effective and safe. (The words “minor surgery” do not appear in the title - there is no such thing! Only minor surgeons! Ed). Vigorous discussion will be encouraged by an open forum system of presentation, with practical videotape displays of technique.

To build upon a solid base of the common and established treatments is a wise principle.

  
Philippines

From Louis Deliss, with reference to the untimely death of Jose Antonio Socrates in Palawan. “Soc had tried with mixed success in his attempts to train local Hilots (the Filipino traditional healers). Their firm belief that vigorous massage was essential to bone healing was difficult to break! But we continue to train the village health workers. Each village has a health worker paid by the village to look after the sick and disabled whilst the family goes to work. This training has been very successful. I am also exploring the possibility of a senior Orthopaedic trainee from the Philippine Orthopaedic Center in Manila to visit on a regular basis. This would help us and be a great addition to their training.

We do not expect to "replace" Soc, as all Orthopaedic surgeons are now trained to believe that fractures will not heal unless internally fixed. I will however continue to teach them the fundamental non-operative treatment methods, upon which all else in traumatology is built.”

Louis Deliss
, Chairman British Palawan Trust, 
www.britishpalawantrust.org.uk