E-newsletter Issue 51 | November 2006
Letter Home, Dr Nikki Blackwell, Australian anaesthesiologist In Amman
| Médecins Sans Frontières (MSF) left Iraq in November 2004 as targeted attacks on international aid organisations meant it was no longer possible to work there. This year it has begun to provide assistance again to Iraqis by partnering with the Red Crescent hospital in Amman, Jordan. This mission is focused mainly on surgical activities and is administered in close coordination with doctors working in Iraq. Dr Nikki Blackwell, an Australian anaesthesiologist from New Farm in Queensland, has been working on the Amman project since August 2006. This is Nikki's sixth mission with MSF having previously worked in Haiti, Ivory Coast, Pakistan, Liberia and Indonesia. Here she explains the specific features of the project, describing the difficulties involved as well as the new techniques employed and her initial grounds for satisfaction. |
What difficulties does your work in Amman involve?
In contrast to other missions I’ve worked on, at the beginning
of this project we are seeing a great many patients who need maxillo-facial
surgery, which calls for a highly sophisticated anaesthesia technique
that is difficult to apply but essential in these cases. This technique
requires the fibroscopic intubation of a patient whose facial anatomy
has been largely destroyed. To avoid losing the patient’s airway
during induction of the anaesthesia, we have to verify what we are doing
very carefully, while remaining ready to take action in case of suffocation.
Our only option in this case is to keep the patient awake in order to be able to check respiratory reflexes while performing the intubation. Otherwise we might cause suffocation without noticing it. We can only anaesthetise the patient after having completed the intubation. This is the first time MSF has used this fibroscopic intubation technique, and it may mark the beginning of a new era, though admittedly it is in a context that allows us to perform this type of surgical procedure.
Does this context allow us to improve some of our practices?
In keeping with the quality objective that we – principally my
colleagues here and in Paris – have set for surgical procedures,
we have an opportunity here to set up a peri-operative system designed
to cope with all possible contingencies, and thus to guard against the
risks inherent in surgical procedures.
To this end, we need first to rid ourselves of a number of myths affecting this quality objective. We need to fight against many mistaken beliefs, from the notion that only bad surgeons make mistakes to the idea that good supervision is sufficient to make good those mistakes. By introducing controls and strict, complete and specific procedures, we can deal with any contingency, including complications arising from our practices, from the pre-op stage until the patient leaves the hospital.
On a more technical note, we had been working to introduce thromboprophylaxis on missions. This is the first time we’ve administered this prophylaxis systematically to prevent pulmonary embolisms; eventually, we should be able to do so for all surgical missions.
We are also paying close attention to controlling infection. In this matter, we had already learned a great deal from the experience in Pakistan (see footnote 1), where orthopaedic surgery is concerned. Today, we are particularly vigilant concerning some patients’ resistance to antibiotics, and we have strict hygiene procedures after each operation to limit the risks of infectious transmission to other patients.
What about pain management?
This is one of the major points of satisfaction of this project. Pain
management is a priority on all surgical missions. Most of the patients
admitted in Amman suffer from sharp, stabbing pain, some of them for
months or years. It is generally chronic pain, including forms of neuropathic
pain which are so unbearable that some people commit suicide to put
an end to their suffering.
Fortunately, for a few years now we’ve had the right protocols, which let us check on patients’ condition. Surveillance by nurses is critical here because, unlike physicians and surgeons, nurses are in close contact with patients, which allows the latter to speak more freely. That’s why we ask the nurses systematically to question patients specifically about this point and to evaluate it on a pain scale. But we are also aware of the limitations of this programme; although it can fix up patients and relieve their pain, it says nothing about the psychological effects of war, which are indelibly marked on some of their faces.
1. During the MSF operation in October 2005, following the earthquake that hit the North-West province of Pakistan.
» More about this project - Given the targeted attacks on international aid organization, MSF cannot treat victims of the conflict directly in Iraq
» Project objectives - Head of mission Dr. Mego Terzian explains the goals of the project in Amman and describes the main difficulties encountered by the team and our partners in Iraq
» A health care system overwhelmed - Iraqi physician Dr. Bassam explains the current situation of the Iraqi health care system, and his collaboration with MSF
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