Silkroad Surgery For Children is a U.K.-based charity that is planning their 2nd annual trip to Mandalay, Myanmar from September 15-21, 2018.
The group includes healthcare team members (representing intra- and post-operative nursing, surgical subspecialties, and anesthesia) as well as other administrative volunteers. Members are traveling from the U.K. and U.S.
Unlike many surgical mission trips which focus on completing as many procedures as possible, Silkroad Surgery has a unique focus on teaching. Our team works alongside local physicians and surgeons to share evidence-based practices that optimize patient outcomes, and create a shared mental model with regards to patient safety measures.
In 2017, the group visited Mandalay's Hospital and met the dedicated medical staff there for the first time. We provided peri-operative care for a dozen patients with orthopedic surgery indications, including congenital uncorrected clubfoot (e.g. severe twisting of the foot since birth). Routine tele-follow-ups indicate good outcomes for the patients and continued interest for the partnership between Silkroad Surgery and Mandalay Children's Hospital.
We will return this September with a bigger team to continue to provide patient care and education at Mandalay Children's Hospital.
The population we are serving is indigenous to Myanmar, pediatric patients ( < 18 years of age) who have long-standing or congenital orthopedic conditions (i.e. clubfoot, varus and valgus abnormalities of the lower extremities). For our second trip, we will additionally be working with general surgery team for common cases such as appendectomies and soft tissue mass excisions.
Our group is focused on pediatric patients, similar to the missions of many other global health groups. Pediatric patients are growing and changing with respect to their physiology, and certain conditions become much more difficult to treat is care is delayed until an older age. This is especially true of clubfoot, which can permanently affect the ability to walk (and thus enjoy, interact, and keep up with family and friends).
Furthermore, I am fellowship-trained in pediatric anesthesia and see this as an opportunity to maintain my skillset while learning to be flexible in an a environment with limited supplies and a challenge to teach across a language barrier.
Based on our pioneering trip, we completed 10 surgeries in which we worked alongside local surgeons and anesthetists, and all patients had successful follow-ups that were facilitated between our group and the local healthcare team. We expect to double the number of procedures done during this visit, with a similar follow-up program in place.
Our teaching program had some initial impact which we would like to expand upon this time. For example, we taught the local surgery teams the indications and techniques for administering local anesthetics into the incision as part of their post-operative pain control therapy. This was not routinely done before.
We instituted some quality improvement techniques (including LEAN and Six Sigma) which will be instrumental in helping the local teams train their junior trainees.
Cultural norms often downplay the pain that our patients feel, and this had a great impact on our own team during our first visit. We learned that pain is often downplayed much more than countries like the U.S.
Furthermore, we learned about the perils of instituting a curriculum or technique without adequate followup and understanding of the consequences and long-term effects of these interventions. For example, when morphine ran out at the hospital, we strategized about how to procure a continuous supply for the local hospital after we left. However, we realized that the hospital did not carry naloxone (Narcan) to reverse the effects of these medications, causing the potential of a local "opioid crisis."
We plan to create an online, interactive, distance-learning program to provide dissemination of knowledge and evidence-based practices between the U.S. / U.K. and a local hospital in Mandalay after this trip
We completed our 2nd trip to Mandalay, Myanmar with London-based Silkroad Surgery for Children. While our first year was focused on learning about the hospital, staffing structure, and inventory versus use of equipment and medications, we spent much time during the visit targeting workflow and focusing on orthopedic surgeries (hands and feet), specifically teaching local doctors and nurses techniques regarding perioperative care for patients with congenital orthopedic disorders.
*Our team mentored through and completed 8 procedures ranging from hand deformities such as syndactyly (fused fingers), to clubfoot and other lower leg deformities. Our major take-home lesson learned is the same as the lesson taught: it takes a team to understand and address the issues commonplace to the operating room. A few pearls:
*ICU care is staffed at 17 patients : 3 nurses, and mothers are trained to bag ventilate their intubated children.
*Access to health care is a real issue, where simple injuries can lead to threatened hands and feet (i.e. at risk for loss) if not quickly addressed.
*Don’t introduce a medication without an antidote, or a technique without adequate measures for follow-up after surgery.
*Drug availability, especially antibiotics, are tailored to endemic diseases and disorders that may trump medications that are used
*Turnover is a major issue everywhere, especially with a steadily increasing case volume. So much to the point that the recovery room was converted to another operating room.
*More attention is needed for child and family interaction prior to surgery, in order to ease anxiety and facilitate the transition to the operating room when it is time for surgery.
The challenge lies in whether or not this wonderful team can continue to expand their comfort zone and continue to provide these novel surgeries - with best practices - in Myanmar. I’m looking forward to seeing the effects next year.