The Concept

At the beginning of the 21st Century, the world lives a tremendous contradiction. On one side 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. Tele-surgery 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.

Fig.1. The Mobile Surgical Unit crossing the treacherous Andean roads en route to rural communities.

Until now, we have not been able to apply our knowledge to benefit the masses. 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 neediest neighborhoods of the cities. Progress in ambulatory surgery has made it possible to perform several types of operation 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.

Program Description

Over the past eleven years THE CINTERANDES FOUNDATION in cooperation with the Medical School of 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 (fig.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( fig.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 (fig.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, a school or a community house where a preparation room and a recovery room are arranged. Sometimes we arrange these facilities in two tents (fig.4). 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. Children are sedated with 0.4 Midazolam/Kg. per os, and given general anesthesia plus local or troncular infiltration of Bupivacaine to control postoperative pain. Most of the time, adults are operated on under epidural or local anesthesia and some times under general anesthesia.



The operation is carried out meticulously and according to a pre-established protocol (fig.5). 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.



Teaching

Besides serving rural and suburban communities, we have a teaching program for medical and nursing students and surgical and anesthesiologist residents. We were affiliated to the University of Cuenca-Ecuador and now we are affiliated to University of Azuay-Ecuador. We have received visiting students from several universities of North, Central and South America, Europe, Australia and New Zealand.

Besides teaching them the art and science of surgery and anesthesia we try to give them a human experience and the principles of solidarity and compassion for our fellow men and women.

Research

We are always conducting some research programs comparing the mobile system with the standard hospital care, regarding to complications, costs and patient acceptance. We also study alternative surgical and anesthesia procedures, looking for excellence in our health delivery system.