District Hospitals should have facilities, manpower to conduct emergency and essential procedures

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 Aga Khan University’s 4th Annual Surgical Conference
District Hospitals should have facilities, manpower to conduct emergency and essential procedures
Lifesaving caesarean sections, orthopedic surgeries and even simple procedures can dramatically enhance quality of life

By Mubarak Ali

KARACHI: Experts speaking at the 4th annual surgical conference of Aga Khan University held from 1-4th February 2019 has emphasized that all district hospitals in the country should have the facilities, processes, systems and manpower to conduct forty four emergency and essential procedures noted in the World Health Organization’s Disease Control Priorities Edition-3. If a hospital is able to perform three procedures i.e. emergency exploration of the abdomen, caesarean section and treatment of open bone fractures then it will have the capability to conduct twenty eight emergency surgeries. Once these facilities are available, hospitals can then focus on the remaining sixteen essential procedures that have the greatest impact on reducing the morbidity and mortality. This will also go a long way in reducing the backlog of surgeries for which the patient have to wait for long.

Dr. Sadaf Khan, conference chair speaking on the occasion said that Pakistan suffers from widespread disparities in surgical care caused by geographic, socioeconomic and political dynamics. These intricate and interlinked challenges are key contributors to the annual backlog of surgical procedures and call for researchers, practitioners, academics and policymakers to come together to develop interdisciplinary, innovative solutions. Dr. Sadaf Khan also stated that the health-related Sustainable Development Goals call for specific measures to reduce maternal deaths as well as casualties caused by road traffic accidents. These targets cannot be met without enhancing access to quality surgical and anesthesia care.

Syed Ather Enam, Chair Department of Surgery at AKU said that in South Asia, economic factor is the major problem besides inability to judge the graveness of the situation. Women appear to face great difficulty in accessing healthcare. Dr. Lubna Samad, Consultant Pediatric Surgeon, at Indus Hospital, Karachi explained how NSOAP can help get us to the goal of ensuring safe surgical care for 80% of humanity by 2030. Surgeons in the country, she stated are not enough to tackle the issue. Indus Hospital started in 2007 now has twelve centers all over the country. Work Force is the major problem, we are not able to strengthening the systems. Private sector is very strong and about 70% care is provided by private sector hospitals. Rural population is at the major risk of surgical inequity, she added.

Andrian Gelib talking about Anesthesia and Global surgery said that China is leading in provision of Anesthesia care. Pakistan needs ten thousand Anesthetists at least. If you do not have safety, you will never have trust and without trust in Doctor and Hospital, you can’t be successful. Global surgery encompasses anesthesia, all surgical specialties including trauma surgery, general surgery, pain management and palliative care, rehabilitation, nursing and other health professions involved in the care of the surgical patients. Global surgery is defined as an area of study, research, practice, and advocacy that seeks to improve health outcome and achieve health equality for all people who requires surgical care, with a special emphasis on underserved population and population in crisis.

Continuing Andrian Gelib said that Anesthesiologists want from the surgeon to acknowledge safe surgery by a trained, competent, and dedicated surgeon, must be accompanied by appropriately trained competent and dedicated anesthesia provider. Accepting anything less devalues the patients we care for together. To encourage, facilitate and support appropriate training of providers even when this results in short term provider shortages while training takes place.

Dr. Rahat Qureshi talking about Obs/Gyn and global surgery said that we see more and more patients of morbidity. There is special need for maternal care, Nutritional depletion and prevalence of anemia in pregnant women is a major problem. Talking about needs at present she said that approximately one million obstetric cases require surgical procedure per year and majority of these are in South Asia, Sub-Saharan and Africa and similar countries. Task must be shifting to allow continuity and sustainability of projects. Integration with other programs to improve maternal health, reduce fertility rates thereby reducing women’s need for emergency obstetric procedures and improving their chances of survival. Strategies for reducing global rates of C Section and promoting early referral to reduce risk of complication i.e. morbidity adherent placenta and fistulas. There is need to develop benchmarks to allow quality to be monitored and improved at secondary level facilities in LMIC.

Mark Holterman talked about low cost surgical innovations for the developing Word and stated that preterm is a global burden with an average is of 12% and preterm birth accounts for almost half of women. In Acute hemorrhage, every minute of delay in replacing lost blood increases mortality by 5%. Acute hemorrhage is the leading cause of preventable deaths after trauma. Red blood cell substitute is needed when RBCs are not available.

Lynette Dominguez talking about Trauma and Disaster care said that response In trauma violence is very important. The importance of continual gradual influx and peaks of arrivals, importance of a triage system, provision of treatment of medical and non-surgical emergencies was emphasized. The closer to the front line will result in more emergency cases secondary to violent trauma. Younger age group of patients must be given priority. To work in humanitarian context needs to be prepared, physically and mentally for frustrations fatigue and long working hours. The adverse conditions put the safety of patients and medical personnel at risk. Triage system should be implemented and a multiple causality incident plan should be prepared. Surgical skill needed in response to disaster and conflict situations include a broader level of surgical skills that are standard ones for a general surgeon , damage control surgery, war related surgery, obstetrics skills, basic orthopedics, notions of vascular and neurosurgery.

Damage control surgery she stated should always be considered and consider use of auto transfusion. It is possible to perform surgery with good outcomes in disaster or violent settings in LMICs. Good outcome can be ensured through a rigorous set up. Implementation and monitoring of minimum standards and unambiguous standard operating procedures is important. In order to perform quality surgical care, minimal and adequate pre-requisites should be settled from the beginning.

Rozina Karmaliani addressing the participants aid that nurses and midwives are the backbone of health services. We are struggling to deliver by midwives because of the underutilization of nurses and allied health workers. The existing nurse-patient ratio is approximately 1:50 whereas the ratio prescribed by the Pakistan Nursing Council is 1:10 in general areas and 2:3 in specialized areas. Training and quality is very important, we should train nurses of rural areas, BLS & ACLS / Basic Health Care. Change in Policy and scope of practice, mandatory licensing exam, global volunteerism, mission trips by surgeons and anesthetists, regional and country specific interventions besides devolution of skills and expertise can help to motivate nurses and will result in improvement in the standard of care, she added.

Inaugural Session

Mr. Firoz Rasul, President and Chief Executive Officer, Aga Khan University was the chief guest In the inaugural session. Syed Ather Enam, Chair Department of Surgery at AKU welcomed the guests. Mr. Carl Amrhein, Provost & Vice President, Academic AKU in his remarks said that Non Communicable Diseases are the leading cause of death all over the World. It is not only the disease of under developed but also in developed countries. Dr. Adil Haider, Professor & Dean Medical College AKU said that team efforts are the need of the hour. Surgery is a team approach, we need support of the government, public sector and we have to train people in rural surgery. The new center of excellence being established at AKU will develop, disseminate and deliver new knowledge.

Prof. Zulfiqar Bhutta, Director of Research Centre for Global Child Health, The Hospital for Sick Children, Canada stated that Millennium Development goal is to reduce child mortality rate by two thirds, between 1990 and 2015, but we in Pakistan are very slow to achieve the targets. Inappropriate healthcare to mothers are the cause of maternal deaths. Pakistan has produced lot of physicians during the last few years, spent on LHVs, but not spent on nurses and midwives. Eighty five percent of physicians practice in major town but very few are in rural areas. Baluchistan has very low facilities for caesarean section. Delay in recognition of diseases leads to delay in decision making, delay in transportation and delay to get appropriate care form providers. A convergence in MDG health conditions is possible by 2035 if we intensify efforts. Three dimensions to consider when moving towards universal coverage includes evidenced based cost effective coverage, task sharing/task shifting and community engagement.

Our primary focus Prof. Zulfiqar Bhutta stated should be to control iniquities. Get engaged and become a part of the solution, by recognizing the business as usual will not take us to the MDG targets for Maternal & child survival and health. Address equitable access & receipt of affordable health services as a fundamental human right. Develop the evidence based interventions at scale across the continuum of care (linked primary, secondary and tertiary care). Address maternal, newborn and child health and survival through community engagement, outreach, promoting women empowerment and gender equity. Advocate to make maternal & child health and survival a global development priority, a moral imperative and collective responsibility. Increase the resource allocation and financial protection for universal health coverage. Build collaborations and partnership across the regions we serve to reduce the equity gap in maternal and child survival. Build the political will to reduce inequity and address the social determinants of health for which the sustainable development goals stand.

Speakers at the event pointed out that country’s National Health Vision 2016-2025 recognizes the need to address inequalities and inequities in access to healthcare, the strategy doesn’t mention the role of surgery and anesthesia in achieving the country’s public health goals. This is surprising since the burden of four out of seven of Pakistan’s leading causes of death – cardiovascular diseases, injuries, cancer and diabetes – can be reduced through access to timely, safe and affordable surgeries at different points of a person’s life. Yet, most hospitals outside the country’s major cities lack the infrastructure, trained surgeons and anesthetists, and systems to treat these common diseases and conditions.

Referring to the Lancet Commission on Global Surgery’s recommendation it was pointed out that it is essential to ensure ‘two-hour access’ or the availability of a hospital that can conduct emergency surgeries within two hours. This is particularly important in the case of cardiac illnesses, or cases of life-threatening bleeding often caused by road traffic accidents. Speakers noted that while ensuring timely access to care is vital, capacity constraints also need to be addressed. While there may be a hospital nearby, it may not have a trained surgeon or an experienced anesthesiologist available. This results in delays in receiving care and leads to a patient and his attendants having to restart the search for a hospital.

The conference included a policy debate on Pakistan’s challenges which saw researchers, academics and policy experts highlight the need for the country to expedite development of its first-ever National Surgical, Obstetric, and Anaesthesia Plan. Speakers noted that many developing countries had developed and implemented such plans which highlight existing strengths and weaknesses, and enable stakeholders to prioritize steps that can raise the overall performance of the health system.

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