Journal of Humanitarian Medicine - vol. VIII - n. 3 -July/September 2008

There are many ways to extend humanitarian health assistance, and there are many countries where such action can be usefully applied. The Kind Cuts for Kids Foundation has been helping in providing pediatric surgical know-how in several developing countries, and the following concerns Gaza.

The Kind Cuts for Kids Foundation was established to assist Pediatric Surgeons in Australia and New Zealand to provide teaching and patient care in developing countries. The Foundation commenced on the back of an International Federation of Surgical Colleges initiative that recognized the “essentiality of essential surgery”, as William Gunn puts it, with the need for improving the care for surgical disease. The philosophy has been one of teaching the teachers and developing sustainable programs in developing countries. The Foundation has a principal focus of targeting projects that will produce a sustainable outcome through skill transfer. Involvement in several countries has resulted in more than 65 visits since 1993, and surgery on over 2,000 children, with the establishment of the specialty of Pediatric Surgery in Papua New Guinea and Mauritius, and the advancement of Pediatric Surgery and Anesthesia in places as diverse as Mongolia and Bangladesh. Not least of the unexpected outcomes has been the technical improvements that have come with the greater experience of those who are learning as they teach.

Overview

The fifth visit of the Kind Cuts for Kids team to the 50-bed not-for-profit, Al Awada non-government hospital in Gaza is covered in this report; a trip that has been a great success for many reasons and from many perspectives. Try as I may, it is not possible to put into words the impact of this project on the lives of children in Gaza, with over 190 patients with complex anomalies having had surgery and been part of the process of education for the surgical, anesthetic and nursing staff in Gaza. Readers should recognize that the greatest impact is not the surgical and education outcomes, but the recognition that while there are conflicts, war and privation, there are still people in the world who care for others, without any consideration of race, creed or colour – true humanitarian medicine.

The success for patients, now and in the future, is due to the combined efforts of individuals, and teams of people, particularly the Australian Palestinian community, the head nurse at the Al Awada Hospital, and the Kind Cuts for Kids Foundation Board. The teams of nursing staff and doctors in the theatre, outpatients and the ward at the Hospital are the backbone of the project; without their passion and hard work the program would not succeed. The trust of the children and their parents is also vital to enabling so many to be treated.

The mission has been successful for the large number of children treated, the education of the surgeons, junior doctors and nurses, but also for the education of the public about the care of children with urological disease, particularly the need for early presentation to help prevent the complications of congenital anomalies of the renal tract. Another measure of success was the involvement of more than five local pediatric surgeons and urologists who assisted with the surgery, referred cases for evaluation and enhanced the learning during a visit that conducted surgery 39 patients with 85 operations, which were performed during a total of 42 anesthetics; three patients returned for a second operation, one of which was due to a complication. The number of diagnoses is greater than the number of patients, as several of the patients had more than one abnormality.

Consultations

The differential diagnoses of 22 conditions indicate the predominance of urological cases, and the wide variety and severity of anomalies treated; fewer patients were operated on during this visit than previously; however, the pathology was, on average, more complex. Those cases with initially minor anomalies were often redo cases, and were selected for inclusion by the Gaza surgeons participating in the mission. Eighty-eight patients had 98 consultations; some had more than one diagnosis.

Surgical case examples

Case 1
Mohamed, an 11-year-old “boy”, presented with trouble passing urine from his penis. He was known to have XY chromosomes and thought to have normal male internal genital anatomy. He had previously had an operation to put his left “testis” in the scrotum and was found to have no right gonad; he had also had a number of operations on his penis to repair the associated hypospadias anomaly. During the 2008 procedure, to attend to the narrowing in his urethra, he was found to have a tubular structure into which the catheter preferentially went. Exploration via an abdominal operation was indicated, during which he was found to have a well-developed vagina and uterus. Given the gender or rearing and the age of the boy, as well as his chromosomal status, the internal female organs were removed.

Case 2
Baby Ahmad was one of the more than 11 children who had been born with an imperforate anus for which he had a temporary colostomy. In his case, the obstructed bowel was initially so huge that the formed stoma was likely to cause problems. Unfortunately, several attempts had not resolved the prolapse seen in the first of this gorgeous little boy’s pictures; a problem largely remedied by surgery in 2007. The proximal stoma continued to prolapse to a minor degree, and the boy was generally unwell, thus the major operation to repair his imperforate anus was not indicated. The end result of a further minor operation improved the colostomy. An operation by the visiting team demonstrated the cause of the problem, and brought a solution for this and future cases. Ahmad went home two days after his operation with an abdominal appearance his mother was much more able to cope with.

Case 3
Majid was born with bladder exstrophy, which has been the backbone of the service provided by the KCFK’s Foundation visits to Cuba, Ethiopia and Bangladesh. The boy had undergone previous surgery to close his pelvis and bladder, which had failed. On this occasion, despite the lack of resources, he made a good recovery. The next procedure for this boy will be the removal of the urinary catheters and investigation of his bladder, urethra and kidneys to ensure continence and renal preservation are maximized, education about which was an important focus of the teaching of the surgical team.

Teaching and future direction

This visit has added to the achievements of the earlier four, with a number of new techniques, and variations on procedures that were taught, reinforced and expanded upon.

The teaching included the daily ward rounds, the many outpatient sessions and ongoing discussions during the approximately 100 hours of operating, during which several Palestinian surgeons were present. Caudal anesthesia is now always performed by the anesthetic staff in the appropriate genitoperineal cases, and the fluid and catheter management in the ward is now much more reliable.

Various rescue techniques for hypospadias anomalies of the penis were demonstrated in patients requiring complex follow-up surgery, as well as repeat lessons on catheter elevation for early catheter removal, retrograde pyelography, guide-wire insertion of a Foley catheter, diathermy dissection, and catheterless ureteric reimplant. Other techniques shown included: l. Anterior anal sphincter plication. 2. Posterior anal sphincter plication. 3. Pena anorectoplasty – single stage. 4. Skin crease incision orchidopexy. Hypospadias rescue repair. 6. Lumbotomy nephrectomy. 7. Laparoscopy. 8. Ureterocystoplasty. 9. Transureteroureterostomy.

Nursing staff were given instruction on the care of the patients and how to better manage the post-operative care of the children. Information that was shared with the surgical team during the bedside discussions, included analgesia, antibiotic management, catheter management, charting of urine output, and treatment and prevention of bladder spasms, some of which reinforced the skills learned during previous visits.

Other features of the visit included areas that would be changed in the future such as: the use of powdered gloves; attention to the organization of the theatre instrument trolleys; poor use of sharps containers; the dangerous diathermy machine; donations of diathermy handles and diathermy tips were essential; instruments were often sterilized by soaking; instruments were of a poor quality; there was no pediatric cystoscope; sutures were far from adequate. All of these problems were overcome either by donations that had come with the team or by being inventive.

As previously stated, the hospital would also do well to instigate a theatre management committee and recruit a Pediatric Anesthetist, and to acquire a Pediatric Anaesthetic machine.

There are various aspects that limit both the ability of the visiting teams to provide service and the scope of practice by the locals (surgery under adverse conditions).

During this visit the lack of equipment, because of the military embargo, was most notable in the amount of rubbish that had collected in the streets, with the obvious health hazards associated with that. More directly affecting the patients was the difficulty of transferring to and from home on a donkey cart and the need for early discharge because of the lack of appropriate transport.

Equipment issues are highlighted by the poor quality of the instruments, the poor knowledge of handling of the kit of instruments and the poor state of the locally made product. Notable deficiencies are the poor quality of the diathermy machines and lack of a nuclear medicine facility.

Staff training continues to require attention with knowledge of standard safe procedure needing much attention, including the maintenance of the sterile field, and the need to prevent bloodstained stock from touching uncontaminated stock.