The Rewards and Dilemmas of Surgical Missions

Dr. Senders is professor and director of the cleft and craniofacial program in the department of otolaryngology at the University of California Davis Health System in Sacramento, Calif.

Q: How do you approach the issues of informed consent in a developing country?

Mark E. Boston, MD, FAAP: Here in the United States, only a minority of patients will say, “Okay, doctor, just do whatever you think you should do.” In other countries, the perception of physicians and health care are very different. Many patients understand only that they’re sick and that they could be better with surgery. They have no idea what I am telling them. As a surgeon, you don’t like to get “talked into” doing surgery, but there are a few cases where not operating would be worse than operating, so we will proceed, with the best understanding of the patient. You have to be very thorough in your explanations and make sure that the information is well translated and understood by the patient and the family.

Dr. Boston is a lieutenant colonel with the U.S. Air Force, a surgical services consultant and chief of the provision of medical care for the Air Force Medical Operations Agency, based at Lackland Air Force Base in San Antonio, Texas.

Difficult Cases

The patient prior to his mandible tumor surgery.

When Dr. Cordes and her team travel to Moi Teaching and Referral Hospital in Eldoret, Kenya, they try to balance straightforward cases such as cleft palate repair with one or two longer cases. One recent case was particularly troubling, however. Scheduled early in the week was a 25-year-old man with a large mandible tumor. It was a complicated case, requiring a parotidectomy, neck dissection and partial mandible resection with a pectoralis flap.

Typically, longer cases are scheduled early in the trip so that patients can be followed post-operatively by the visiting team. On the day of surgery, there were no ICU beds available, and the surgery was cancelled. The patient’s mother approached Dr. Cordes in the hallway, begging her to do the surgery and relieve her son’s pain. “The dilemma is that if we didn’t do the surgery, it wouldn’t get done,” said Dr. Cordes. “Sometimes we sit there with the patient and the Kenyan otolaryngologists who are telling us, ‘We want to get this procedure done while you’re here,’ and you know what they mean is, ‘we’re not comfortable doing it without you.’”

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