Chapter 133

2174 PART 6 ■ Specific Considerations
quantity of surgeries to expect. The administration can make clear
the goals of the trip and the rules of team conduct.
Sexual harassment, either physical or verbal, is not to be
tolerated and may result in a team member being sent home for
engaging in these activities. Romantic liaisons with a team member
or a local person may threaten the present trip and future trips
to that site. Logistic details such as living arrangements, costs to
the team (meals and other expenses) should be made clear. Team
members should be told approximately how much money they
will require for expenses. One member of the team should be
designated as the “team physician”; the most appropriate person
for this role is the pediatrician/general practitioner, if there is one
as part of the team. This person should be made aware of health
problems of team members (e.g., diabetes, asthma) before the trip
begins (not during the phone call, for reasons of confidentiality).
If infectious diseases such as avian flu are prevalent at the trip site,
the team should be told how sick team members will be treated
medically and how they will be evacuated home. Team members
who have previously been to the site can address local customs
and dress code. Drugs, tobacco, and alcohol use can be discussed
and the rules made clear by the organization’s leaders. Giving
individual gifts or money to patients or their families often causes
problems, because one group may perceive that they received a
lesser gift than another. The organization can indicate during the
phone call that the organization will give the same gift to each
patient/family and avoid these problems. Often the hosts at a site
give small gifts to team members. It is difficult to refuse these gifts
without seeming rude.
TEAM LEADERSHIP
Each trip should have a team leader who is responsible for the dayto-day
running of the trip and for solving problems. Each specialty
group (anesthesiologists, surgeons, nurses, etc) should have a
leader who deals with the day-to-day details of the trip related to
their specialty. Trips function better when there are frequent
discussions between the leaders and the team members. Having
team meetings at breakfast or dinner, when everyone is together,
is one way to accomplish this. Cases for the day or any problems
that occurred with the surgery schedule can be discussed. Before
the first surgery takes place, it is helpful to have a team meeting
to orient team members to the site and let them know where the
fire extinguisher, emergency oxygen tanks, emergency drugs, defibrillator,
and so on are located. During this meeting, team
members can be told how to contact the pediatrician/general
practitioner during the day and how emergencies will be handled,
especially if a patient must return to surgery for any reason. If a
patient requires intensive care, some organizations put the patient
in the hospital’s intensive care unit (ICU) and others have an
anesthesiologist and a postanesthesia care unit (PACU) nurse care
for the patient in the PACU. If an anesthesiologist and nurse are up
all night caring for a patient, they may be tired and not function
well the following day. This may necessitate canceling some
surgery. Canceling cases may be difficult, but if it is safer for
patients it must be done. A surgeon, anesthesiologist, nurse, and
translator should make rounds after dinner and see all patients
operated upon that day to determine whether there are any
problems and if the patients have adequate pain relief. The same
group can take night call that night. The hospital must be able to
contact the team leader at all times, including night and weekends.
CHOOSING AND EVALUATING SITES
Although different organizations use different models for site
selection, it is generally considered best if organizations are invited
to provide surgery in a country by physicians, governments (local
or federal), or service groups (Rotary clubs, Lions clubs, etc). If
local medical professionals are not involved in the invitation, they
may feel the trip was forced on them and refuse to work or
cooperate with the team. Government officials also must be aware
of the invitation. Without the government’s cooperation, the team
may be denied entrance to the country and may be prevented from
doing surgery. After all, it is the government that allows team
members to practice medicine in their country without a license.
Most countries allow us to practice medicine, nursing, and so on
in-country without having a license to do so, for the time we are
there. Malpractice insurance is seldom available for this type of
work. To date, there have been no lawsuits for such care. Host
physicians are responsible for all interactions with the team and
the parent organization. The host must be able to communicate
with the organization’s offices by e-mail or by telephone.
When an organization considers performing surgery in a
country, a letter asking certain questions should be sent to whoever
it was that proffered the invitation, such as questions regarding the
stability of the government and whether bribes are expected to
permit teams to work in the country are important. It is illegal for
Americans to take or give bribes in this situation, according to the
Foreign Corrupt Practices Act (http://www.justice.gov/criminal/
fraud/fcpa). Whether it is safe for foreigners to be in the country
must be addressed.
Are there sufficient patients who require the type of surgery
that can be provided? If there are, how will they be recruited? Will
newspaper, television, and radio advertisements be used? Who
will place the advertisements, when will they be placed, and who
will pay for them? Are similar surgical groups working in the area
and when were they last there? If other teams have been in the area
recently or recruiting was inadequate, insufficient patients may be
available to make the trip cost-effective or satisfying for the team
members.
The parent organization and CMO must make clear to the host
what type of surgery the team can and will do. Orthopedic
surgeons will not repair cleft lips and plastic surgeons will not do
pelvic osteotomies. It is then up to the host physician(s) to find
appropriate candidates for surgery. The host(s) must be willing
and able to provide needed follow-up care for the patients after
the team leaves. Ideally, this person should be a surgeon who will
be the focus of teaching during a trip and who has the potential to
lead her/his own team and provide the same type of surgery for
poor patients in the future. For burn patients in particular, the
personnel and the facilities must be available for postoperative
care, including splinting and physical therapy if required.
Who will help with customs, transport of the team and
equipment from the airport to the hotel, and from the hotel to the
hospital? Will someone be available every day to help solve
problems? If the team’s equipment is confiscated or delayed by
customs, as it sometimes is, how will this problem be resolved? Is
there a locked, safe room in which to store equipment and drugs?
Who will have access to this area at night? How will the team
access this room at night if they must provide emergency surgery?
Is the operating environment adequate? Are there sufficient
rooms in which to perform surgery without compromising patient
safety or the ability of local surgeons to care for their patients?
How many operating rooms will be available to the team? Placing