The Mobile Surgery Program

The Concept

At the beginning of the 21st Century, the world lives a tremendous contradiction. On one hand we have great scientific and technological progress, designed for the well being of mankind, and on the other, the everyday widening gap between a few who have more than what they need and the vast majority of people who do not have enough.

This contradiction is also evident in surgery. We are able to replace and transplant damaged organs. We can model the human figure to restore beauty that time has taken away, or to give beauty that nature has denied. Telesurgery allows us to operate in a remote geographical location. Yet, in spite of all of these advances, several mothers and children die, because they do not have access even to a simple Cesarean operation. Many people in the country or in the slums of the big cities die or are subjected to long periods of pain and incapacity due to a perforated appendix or a strangulated hernia, problems that could have been solved easily with a simple procedure performed in a timely manner.

Until now, we have not been able to apply our knowledge to benefit the communities. As surgeons and teachers, we have the duty to pursue excellence and strive for the progress and perfection of our science and art, but we believe that it is equally important, especially for surgeons in the developing countries, to search for new methods and systems to make that progress readily accessible to the common people.

With these principles in mind, the aim of our project was to take the operating room to the countryside and to the most disadvantaged neighborhoods of the cities. Progress in ambulatory surgery has made it possible to perform several types of operations and discharge the patient on the same day. The operating room is a limited space, relatively easy to equip and maintain. The areas required for patients preparation and postoperative recovery are also easy to arrange.

Contact with international medical missions such us Project Hope and Interplast, inspired the idea of taking medical care to underprivileged areas of the country. If foreign doctors and nurses were offering their services to our country, it is certainly a duty of Ecuadorian medical personnel to do the same for our own people.

There are mobile hospitals, some on water like the ship Hope; some on land, such as the Military Ambulatory Surgical Hospitals (MASH); and an ophthalmologic operating room has been installed on an airplane.

With these premises and examples,, the idea that an operating room could be set on a truck was born. A mobile surgical unit (image 1) was assembled and a new milestone in the history of mobile surgery began.

Program Description

Over the past sixteen and half years, THE CINTERANDES FOUNDATION, in cooperation with the University of Cuenca and University of Azuay (Ecuador) has introduced into the Andean mountains, Coastal region and Amazon jungle of Ecuador, this different and innovative method of surgical care, Mobile Surgery (MS).

Despite facing many hurdles and disadvantages, the project has been successful in providing specialized medical treatment to people that otherwise have had no option for attending their surgical needs. In many aspects, we believe that we not only met our expectations but that we have well surpassed them by integrating components that were not thought of when the program first spun its wheels.

On a 24-foot Isuzu van, an operating room and a preparation room were installed (image 1). We could have used more space, but a bigger vehicle is difficult to drive in the winding and narrow Andean roads. The operating room is equipped with an operating table and light, anesthesia machine and monitoring equipment, suction, electro surgical unit, a Mayo table and side table. Compartments for medicines and surgical supplies are built in the walls of the room (image 2). Lately, we have been able to equip our Mobile Surgical Unit (MSU) with laparoscopic equipment and low bandwidth telemedicine capabilities. The unit also contains a preparation room with a scrubbing sink, an autoclave and cabinets for supplies.

Rural doctors, contacted by our personnel, perform the first screening of patients with surgical problems. Initially they worked with children in local schools but later we had requests from adults, so we cover patients of almost all ages.

When the rural doctor has selected a group of patients, a surgeon and an anesthesiologist from the Cinterandes Foundation go to the area to make the preoperative consultation, in which a careful history and physical examination are carried out (image 3), the accuracy of the diagnosis is checked and laboratory and image exams are requested, when necessary. Based on numerous reports and our experience, we do not ask for routine laboratory or image tests.

Selection of patients is very important. We do not operate on individuals with additional pathology, patients of very advanced age or when we anticipate a complicated operation. Once patients have been selected we explain the operation and its risks, to them or their parents, as well as the risks of leaving the pathology unattended, we give the preoperative instructions and decide the day we are going to bring the MSU for surgery.

The day of the operation the MSU is properly cleaned and sterilized. It is parked next to a health center, school or community house where a preparation room and a recovery room are arranged. Sometimes we arrange these facilities in two or three tents (image 4).

The day of the operation, patients are again interviewed and examined to make sure they followed the preoperative instructions and did not develop any additional pathology such as respiratory or intestinal infections. According to the surgical procedure, different types of anesthesia are used.

The operation is carried out meticulously and according to a pre-established protocol (image 6). Patients are carefully controlled until they recover and sent or taken home when they fulfill a discharge criterion that has been determined, when there is no risk of anesthetic or immediate surgical complications.

They are left in charge of the local medical team but a surgeon and an anesthesiologist of CINTERANDES are continuously available by phone for consultation.

Sometimes we take the Mobile Unit by a Hospital. This is justified because in Ecuador there are several small hospitals that, in spite of having an operating room, do not have the adequate personnel and functioning equipment. Being next to a hospital we can use its operating room and the beds for hospitalization of patients who need it.

Results

At the end of the year 2010, after sixteen and half years of work with an excellent motivated and trained voluntary team and the growing support of our communities, we have performed 6,444 operations (pdf) in General, Urological, Gynecological, Reconstructive and Ophthalmologic surgery (Annex 1), at a much lower cost and with greater patients acceptance. We have operated in 17 of the 24 Ecuadorian provinces (pdf).

Advantages of Mobile Surgery

We believe that mobile surgery makes it possible to deliver high quality surgical care with excellent results and an acceptable rate of complications, similar to the most advanced centers in the world. Surgery is performed in an economical and, foremost of all, more humane way, since the patient is not separated from his or her own habitation. Children from the countryside are especially spared from the trauma of the separation from their family and environment.

Human interaction in this system is greatly enhanced. Doctors are freed from their busy city schedule, and a full day in the country gives them ample time for a more personal and peaceful relationship with their patients and families. This quiet environment is excellent also for teaching students and residents.

Doctors, nurses, and auxiliary staff experience real teamwork, responsibilities are shared equally, and everyone realizes that properly cleaning the operating room is as important as performing the operation safely; thus an “esprit de corps”” develops clearly in the benefit or patients and families.

Rural and local doctors move to another level of work. They leave their routine, and the contact with their former professors and the new responsibilities they face, gives them a higher motivation.

Patients and their relatives become closer by sharing the burden of the surgical experience through immediate postoperative care. Community contributions, with food for the surgical team and a small contribution of money based on their individual possibilities, show their gratitude and participation in the program.

With our experience, we have proven that it is possible to adapt ambulatory surgery to a mobile setting, transporting it to areas where the need for this type of health care is required, and to achieve successful results.