Volunteers in Plastic Surgery Guidelines for Providing Surgical Care for Children in the Less Developed World: Part II. Ethical Considerations
Department of Pediatrics, University of California, San Francisco, San Francisco, California, United States Plastic and Reconstructive Surgery
(Impact Factor: 2.99).
09/2011; 128(3):216e-222e. DOI: 10.1097/PRS.0b013e31822213b4
Many international volunteer groups provide free reconstructive plastic surgery for the poor and underserved in developing countries. An essential issue in providing this care is that it meets consistent guidelines for both quality and safety-a topic that has been addressed previously. An equally important consideration is how to provide that care in an ethical manner. No literature presently addresses the various issues involved in making those decisions.
With these ethical considerations in mind, the Volunteers in Plastic Surgery Committee of the American Society of Plastic Surgeons/Plastic Surgery Foundation undertook a project to create a comprehensive set of guidelines for volunteer groups planning to provide this type of reconstructive plastic surgery in developing countries. The committee worked in conjunction with the Society for Pediatric Anesthesia on this project.
The Board of the American Society of Plastic Surgeons/Plastic Surgery Foundation has approved the ethical guidelines created for the delivery of care in developing countries. The guidelines address the variety of ethical decisions that may be faced by a team working in an underdeveloped country. These guidelines make it possible for a humanitarian effort to anticipate the types of ethical decisions that are often encountered and be prepared to deal with them appropriately.
Any group seeking to undertake an international mission trip in plastic surgery should be able to go to one source to find a detailed discussion of the perceived needs in providing ethical humanitarian care. This document was created to satisfy that need and is a companion to our original guidelines addressing safety and quality.
Available from: John G Meara
- "Follow-up rates have been correspondingly low: among medical mission groups that do provide postoperative care, rates range from 5% to 35% of patients . Cleft missions groups have made progress in monitoring surgical outcomes, for instance through the development of outcomes databases    . However, an increased focus on outcomes is needed. "
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ABSTRACT: Global cleft surgery missions have provided much-needed care to millions of poor patients worldwide. Still, surgical capacity in low- and middle-income countries is generally inadequate. Through surgical missions, global cleft care has largely ascribed to a vertical model of healthcare delivery, which is disease specific, and tends to deliver services parallel to, but not necessarily within, the local healthcare system. The vertical model has been used to address infectious diseases as well as humanitarian emergencies. By contrast, a horizontal model for healthcare delivery tends to focus on long-term investments in public health infrastructure and human capital and has less often been implemented by humanitarian groups for a variety of reasons. As surgical care is an integral component of basic healthcare, the plastic surgery community must challenge itself to address the burden of specific disease entities, such as cleft lip and palate, in a way that sustainably expands and enriches global surgical care as a whole. In this paper, we describe a diagonal care delivery model, whereby cleft missions can enrich surgical capacity through integration into sustainable, local care delivery systems. Furthermore, we examine the applications of diagonal development to cleft care specifically and global surgical care more broadly.
Available from: Kevin James Sykes
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ABSTRACT: To evaluate the safety of tonsillectomy in a short-term medical mission setting.
Retrospective chart review.
Catholic mission hospital in Guatemala.
During 7 consecutive annual mission trips from 2004 to 2010, patients received tonsillectomy and adenotonsillectomy. Established safety protocol requires candidates for tonsillectomy to agree to stay within 1 hour of the hospital for 10 days following the operation. This study includes all tonsillectomy patients regardless of age or indication for tonsillectomy. The primary outcome measures include posttonsillectomy hemorrhage, nasopharyngeal reflux, readmission for dehydration, and mortality. This is a novel study as the work performed by most short-term medical missions is unregulated and unevaluated.
Medical charts were available for 197 (96.6%) of the 204 patients receiving tonsillectomy in the 7-year period; this was the only inclusion criterion. Ninety-nine (50.3%) patients had tonsillectomy concomitantly with adenoidectomy. Patients ranged in age from 3 to 66 years. The mean (SD) age was 17.2 (14.0) years. The study team found documentation of postoperative complications in 3 (1.5%) patients; 2 experienced postoperative hemorrhage, 1 within the first postoperative hour and 1 at 96 hours. The final patient returned to the hospital within 24 hours symptomatic for dehydration.
The authors have evaluated a protocol for tonsillectomy patients in a specific setting and believe their data represent satisfactory outcomes for the reviewed patients. The generalizability of this information is uncertain, but safety protocols should be established on all short-term medical missions to prevent untoward complications.
Available from: Percy Rossell Perry
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The Peruvian health system is limited in providing specialized care for patients with clefts because there are an insufficient number of hospitals and few specially trained doctors in rural areas of the country. The most common model of care in these areas is the surgical mission wherein experienced cleft surgeons perform surgeries and teach local doctors. The purpose of this research was to identify the differences in outcome between the surgical mission trip and the referral center model of care provided by the same team.
A retrospective analysis (2002-2012) was performed on data from surgical outcomes provided by the Outreach Surgical Center Lima that utilized both models of care (surgical mission and referral center). A total of 935 procedures were performed in 680 patients with clefts who were treated by the Outreach Surgical Center Program Lima since 2002. Patients in both groups were identified from our records (medical records and screening-day registries). All patients underwent a physical examination, had photographs taken, and any unfavorable results and complications were documented. Comparison of categorical variables (including outcomes) between care models was performed using Pearson's χ (2) test or Fisher's exact test when appropriate. In all cases a two-tailed test was performed and the p value for rejecting the null hypothesis (no difference or no association) was set at 0.05.
We found significant differences between the two models of care with respect to unilateral cleft lip and cleft palate dehiscence (p = 0.02 and p = 0.04, respectively), palate postoperative hemorrhage (p < 0.01), and palatal fistula (p < 0.01) outcomes.
Differences in observed surgical outcomes between the two models might be attributed to the surgeon's performance and/or the patient's age, and these factors are also considered with respect to the model of care. Limitations in long-term medical evaluation at each site should be identified and strategies to improve surgical outcomes must be developed to ensure that patients served by surgical missions obtain the same results achieved at a referral center.
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