“Surgery is not mathematics”

Dr Chandrika Rao has been on numerous assignments with MSF since 2008 and is currently working as surgical advisor in Amsterdam. She speaks to DVL Padma Priya, Press Officer, MSF India, about the challenges faced by surgeons in the field, and why it’s difficult to match surgeons for MSF projects. 

What kind of surgical programmes does MSF have?

With MSF, surgery is one part of the larger picture. Only very few projects – Jordan comes to mind – are purely surgical. 90 per cent or more of our surgical projects are in association with the Ministry of Health (MoH) in the country the project is situated in. We focus on certain surgical activities, predominantly violence-related surgery. Burns are a major component because the countries or projects where we work are mostly in  remote places where there is a complete lack of awareness of safety measures. Other surgical activities are obstetrics and emergency life-saving caesarians and hysterectomies.

We do what we call secondary level surgery; that means obstetric, life-saving, trauma and other general surgery.

How long does a surgeon go to a mission for?

The average duration is 3 months but in the very busy projects it can be 8-10 weeks and sometimes surgeons gap-fill for 4-6 weeks. However, the rapid turnover has its own challenges because sometimes the surgeons may not be properly oriented themselves to the MSF dos and don’ts. For the national team it’s a great challenge that every 8-10 weeks there’s a new expat with a new way of managing patients.

Surgery is not mathematics. For example, you can remove the appendix in 8 or 10 ways; you can make cuts that look very different. A surgeon may inspect a patient’s wound on day 5 whereas another may want to see it on day 3. In India you may be trained in one way, in Australia in another way, in US another way. That’s the reason MSF has standardised guidelines and protocols that we insist be implemented in the field at all times.

Has there been any instance where a primary health project was converted into a surgical project because of conflict?

This happened in my own experience in 2011 in Malakal in South Sudan. Basically we had a team of four people there in a kala azar project and all of a sudden conflict broke out. So immediately they tried to assemble people who’d been to South Sudan before, and one of them was me. Within 48 hours, I flew in to Malakal and an operation theatre (OT) nurse flew in from Canada. This was in collaboration again with the MoH which was already based in Malakal and was doing certain surgeries but after they finished we’d do war wounded surgeries. It was quite a busy two weeks.

Sometimes the focus changes and other activities may take a backseat depending on the priorities. For instance, so many other medical activities have been deprioritised to provide care for malnutrition or kala azar. Similarly, when there’s a conflict, surgery might take priority.

What kind of dilemmas did you face when you were a field surgeon?

In some countries, the customs rules make it difficult for us to bring in surgical equipment. During my experience as a surgeon, there were certain instances where I had to use my skills, innovation, knowledge and common sense to save mothers who would have died otherwise. It was very tricky; these mothers came in with full-blown bellies but were not able to deliver and I could not do Caesarians because we didn’t have even a single set that could be used. So I had to do certain procedures that made deliveries easier to save mothers’ lives. I had never performed these life-saving procedures but had I not tried we would have lost two mothers and one baby.  

As surgical advisor, how do you prepare surgeons leaving for projects?

From my side I try to make the surgical team member’s life easier in the field by preparing him/her about what to expect in that particular OT. For instance, I don’t want surgeons to go to Sudan expecting laparoscopic surgery just because they trained in it; or demand equipment that’s difficult to maintain; or expect support always from the blood bank. These are things that could be unavailable in MSF’s surgical projects because of the remote context.

My role as surgery advisor is also to see how we can solve this issue of matching the right people and providing proper training and briefings so that they are ready for the specific field circumstances, which are so different from city-based practice.

Matching surgeons to various projects is a big challenge these days as many now have a more specialised background. There are less and less general surgeons that can do a wide variety of surgeries.  Most get trained in a narrow field of expertise. But in the field, a surgeon is expected to perform difficult and challenging operations keeping a smile intact on his/her face!