Surgery In The Field

by RACHEL BECKER Credit: sxc.hu

BIO + MED

Surgery Two doctors relate their experiences

Professor Sherry Wren

“Saying ‘blood clot’ is not taught in most French classes,” said Professor Sherry Wren. Wren, a Professor of Surgery and Associate Dean of Faculty Affairs at the Stanford University School of Medicine, has spent three summers working with Doctors Without Borders in Africa. She learned how to say blood clot in French on her most recent mission in the Democratic Republic of the Congo.

“When I was there [in the Congo], I would hear gunfire at night, and then in the morning you would have to treat the gunshot victims. You would hear it, and then see it.” –Sherry Wren 18 www.stanfordscientific.org

“The nurse was trying to tell me that the patient had passed a clot, which I didn’t understand, so he had to flip through the dictionary until he found the word which turned out to be caillot,” Wren said. “This patient’s blood pressure was just crashing. You’re in the OR, the ‘blood bank’ is all the people in the hospital and I finally realized she [the patient] had all these blood clots between her legs, and I thought oh my god, this woman’s going to die. The blood technician came in, tested her blood type right then and there. Three o’clock in the morning I performed an emergency hysterectomy on her...She was fine.” Wren has been teaching and practicing medicine at the Stanford Medical School since 1997. She graduated with an MD from Loyola University in 1986, and then worked at the University of Southern California School of Medicine after completing her residency. “I decided to go to medical school during college, I’m not sure I really knew what it was. It wasn’t until I started to do the rotations on the different services and I did the general surgery rotation that I knew that surgery was what I wanted to do. And I still love it, I still would make that decision,” said Wren. Wren’s decision to balance her surgery practice at Stanford Hospital with practicing surgery at remote Doctors Without Borders

hospitals in Africa was not a sudden one. “I had wanted for a long time to work internationally. I tried after college in the Peace Corps but they didn’t think I had the requisite skills, so it took me awhile to get the skills I needed. Now, I’m at a point in time in my career and life where I could do something like that and spend a month to a month and a half a year away from my responsibilities here [at Stanford],” explained Wren of her decision to work with Doctors Without Borders. Doctors Without Borders was one of the few organizations that fulfilled Wren’s criteria of a nondenominational organization that focused on crisis management and allowed her to volunteer as a surgeon. Wren added that, “Another part of their mission that I really like is that you bear public witness to what you have seen. So not only do you provide aid, but you talk about what you’ve seen so you raise other people’s awareness.” In 1996, Wren filled out an online application, the first step in a process that ultimately led to practicing surgery in the Cote d’Ivoire, Chad, and the Democratic Republic of the Congo. Wren commented on the thoroughness of the application process, “I was impressed that it was a very in depth process by which they do their selection. They really truly contacted the people that I listed as references and they interviewed them for about thirty to forty minutes.” “I’ll never forget. I was at a meeting in Cincinnati, Ohio, of all places, and I was sitting in the airport and my cell phone rang and it was New York, saying hi, can you be in the Ivory Coast on such and such a day. And the first time it happened you’re kind of like, huh? What are you talking about? I’m more used to those phone calls now.” Since then, Wren has found herself facing linguistic and cultural barriers at Doctors Without Borders surgical missions. “The

in the Field

BIO + MED

with Médecins Sans Frontières

Medically, as well, Wren has been challenged on multiple occasions. “In the Cote d’Ivoire, and in the Congo, those were real conflict zones so you’re dealing with combat surgery, war injury surgery. In those cases we were only doing emergency cases so if you just came in routine elective general surgical cases we were not in a position provide that type of care…When I was there [in the Congo], I would hear gunfire at night, and then in the morning you would have to treat the gunshot victims. You would hear it, and then see it.” Wren added that, “The hardest things were the cancers. My life is cancer here, so not being able to effectively treat cancers was actually really hard for me. It’s not that you get used to it, but now I know it and I have learned to accept it.” Wren has worked through her own bouts of malaria, cholera, and amoebic dysentery. She has operated on wounds from AK-47 gunfire, mass casualty events, and high velocity military weapon wounds. However, according to Wren, the cultural differences were often among the hardest to reconcile. Wren said, “These cultures are very different than in the US. In the U.S., once you’re eighteen you can consent to any procedure you want done to your body. There, [in the African Continent] consent is familial and there are cultural prohibitions about certain types of practices. For example, in Chad

there was a pregnant woman with arrested labor who was not only going to die herself but in addition the baby was going to die if she didn’t get an emergency C-section. Unfortunately her husband refused to give consent to the procedure so you can’t do anything even if she consented. That was really difficult.” The rewards of working with Doctors Without Borders seem to have outweighed the difficulties for Wren, however, particularly working with the different national staffs. Despite the difficulties of keeping in touch with such conflict-torn areas, Wren will, “get these calls at 2 in the morning from the people I worked with in Chad saying, ‘It’s really pretty in November in Chad! Come back!’” Wren does see herself going back, particularly to the Congo, despite the fact that the Doctors Without Borders team has almost entirely been evacuated due to the escalation of local conflict -- except for the surgeon and anesthesia teams, who treat the conflict related injuries. Wren said, “The conflict there has been going on for over thirteen years, and it doesn’t seem like it will be ending soon. I’ll probably be going back.” Until then, however, Wren works on implementing the practices she learned abroad in her hospital operating room. “It’s hard when I come back, how much we waste. That’s what really gets me. I’ve worked with my OR staff about cutting back on waste, because we open materials that we don’t use and then it just gets thrown out. The amount of stuff that gets thrown out without being used just infuriates me. For example sutures are at a premium in Africa, so we would do a special kind of tie so that we would save more sutures, but here in the States we’d open up multiple packs and may only use two.”

Professor Sherry Wren

Credit: Sherry Wren

first time I was in West Africa, [I found] the French African accent is very different, so even the French people had problems understanding. But I was in the ER and I was listening to this man talking and I am paying so much attention, I’m trying to listen. And the guy finishes talking and I turn to the nurse and I said that I couldn’t understand one word of French that the guy said. The nurse laughed and said, ‘That wasn’t French.’ That was on my first trip to the Ivory Coast, I guess I just assumed they only spoke French there.”

volume VIII 19

I have believed in what we were doing. I think alone it is hard to say if I made a difference, but with MSF‘s approach to such situations and how to reach the poor of the poorest, I am sure it is making a difference.” - El-Khatib

Ziad El-Khatib Born in Lebanon to French and Arabic speaking parents, thirty-year-old Ziad ElKhatib has not faced quite the linguistic barriers that Professor Wren has endured during her stints with Doctors Without Borders, known internationally as Médecins Sans Frontières (MSF). El-Khatib is a PhD candidate in epidemiology and international health at the Karolinska Institute, Stockholm. While he calls Sweden home, El-Khatib has been living in South Africa since January 2007 for his field work. Professor David Katzenstein of the Stanford Medical School mentors El-Khatib’s PhD research there. El-Khatib’s PhD research was inspired by his volunteer work for MSF as a flying lab technician in Sudan. “When I was in south Sudan, I got interested with HIV areas. Using a satellite internet connection, I found the contact [information] of [Stanford] Professor David Katzenstein, so I had contact with him following the end of the Mission with MSF in August of 2005,” said El-Khatib. He is currently surveying the “database profile of 13 HIV treatment programs for the Southern African Treatment and Resistance Network and reviewing their medical records and setting up a mechanism to monitor them over twelve to eighteen months.” Though not working on any specific Médecins Sans Frontières missions now,

20 www.stanfordscientific.org

El-Khatib serves as a board member of the MSF-South Africa branch. “I liaise with them information about NICD [National Institute of Communicable Diseases] when they need contact persons et cetera: ”El-Khatib explained. He is also a member of the MSF-Sweden organization and attends their regular activities when in Stockholm. El-Khatib’s journey to MSF was circuitous. Earlier in his career, El-Khatib had applied to Heidelberg University in Germany to pursue a Masters degree, and had simultaneously applied for and was promised a scholarship to the Masters program. In the aftermath of the September 11, 2001 attacks in New York and Washington, DC, the scholarship was rescinded. “I had to rethink what I wanted to do,” said El-Khatib, “So I checked on the internet for public health informatics.” Eventually, he decided on MSF as an organization for which he could envisage working. Among the factors that drew El-Khatib to MSF were that they are an independent, neutral organization, “They don’t accept corporation money. They refuse this money because they want to stay independent. I had heard of MSF when I was in Lebanon. They’re kind of well known [there].” El-Khatib also appreciated the fact that one of the pillars of MSF volunteer is to bear public witness in addition to providing aid, “To witness what’s happening and to tell about fear. To go into these regions, we had to sign a secrecy contract from the government. But that’s what MSF is not about--you tell about what you’ve seen.” As with Professor Wren, MSF subjected El-Khatib to a stringent selection process. El-Khatib’s review involved three interviews, a one day written exam, and two assessment sessions – one of which was face to face, one written – all in addition to a phone interview with MSF-Holland.

Credit: sxc.hu

Credit: sxc.hu

BIO + MED

Credit: sxc.hu

Credit: sxc.hu

BIO + MED

“After they said yes, it took me awhile to get there [on a mission].” When he did, ElKhatib volunteered for six months, between February and August 2005, in the Sobbat corridor area in southern Sudan. There, he worked as a flying lab technician. ElKhatib described his job: “Flying laboratory technician, I can summarize the work in five main tasks: 1) setting up a laboratory at Nasir hospital; 2) quality assurance work between Nasir and Malakal labs; 3) testing dried blood spots (DBS) for malaria diagnoses; 4) three outreach programs and 5) helping the team with other tasks.” El-Khatib worked primarily in areas endemic with malaria, TB, and kala-azar which is also known as visceral leishmaniasis. Most were conflict-torn as well. He described the last week of his mission: “South was attacking the north, the army was killing southerners and both sides came to the hospital. One side would ask, ‘oh, why are you treating them?’ The other side would come and ask, ‘why are you treating them?’ It’s not about that, we are treating victims.” Not all of El-Khatib’s patient cases were caused by conflict or epidemic – some were more typical human situations such as pregnancy. El-Khatib described one of his “peak cases” -- a situation in which he was forced to do a remote examination of a pregnant woman by phone to find out if the baby was still alive. El-Khatib went by boat to bring the woman to the hospital, which was normally a journey of four to five hours. The boat went down, so it took eight hours to arrive. “By the time we got back to the hospital, we were praying the baby was still alive. In the end, the mother delivered and the baby was alive. This was one of the peak moments for me, that we took this responsibility.”

El-Khatib counts another success as particularly rewarding: a simple excel spreadsheet. El-Khatib explained that in order to get supplies, the MSF clinic needed to place an advance order for 3 months’ supplies. El-Khatib developed an Excel spreadsheet to predict the amount of test reagents that they needed, based on temperature among a variety of additional environmental factors, plus the estimated number of patients. He used previous statistics on numbers of patients at the clinic, and then used it to extrapolate a trend that would help him estimate the number of patients at any given time. El-Khatib said, “Where you play your role is sharing the statistics. I can only say what [I] have seen, I can’t advocate beyond that.”

Médecins Sans Frontières Doctors Without Borders/ Médecins Sans Frontières is an international aid organization that was conceived of in France in 1971. MSF-USA was founded in New York in 1990, and today the organization has offices based in 19 countries. It is an independent, neutral organization that provides aid in 60 countries. MSF won the Nobel Peace Prize in 1999.

For El-Khatib, the experience of working for MSF has not solely been a series of such successes. “When you’re working with MSF, you sacrifice a lot as a person. There are no financial rewards. When you are in the field, you lose contact with your friends, families, relationships, and that’s where it becomes tough to work with MSF long term. Once you have done your first mission, you know whether this is what you really have a passion for.” El-Khatib concluded, “I know I have believed in what we were doing. I think alone it is hard to say if I made a difference, but with MSF‘s approach to such situations and how to reach the poor of the poorest, I am sure it is making a difference.”

To Learn More

For more information, visit MSF website at www.doctorswithoutborders.org

volume VIII 21