MGH Global OB-GYN Newsletter

From Academics to Advocacy and Action
 

May 2019

Massachusetts General Hospital                    Vincent Program in Global OB/GYN

 


How Do We Heal Ourselves When Surrounded By So Much Pain?
Annekathryn Goodman, MD, MPH


As the world enters its sixth month of a COVID pandemic, all eyes and energies are turned to survival from the physical, social and economic ravages of this virus. The medical world has struggled with inadequate supplies and moral dilemmas of how to choose which patient receives the finite medical resources available and which healthcare provider gets the limited personal protective equipment. In this issue of our Global OB-GYN newsletter, Dr. Kaafarani, an experienced trauma surgeon and humanitarian worker, reminds us of the devastating medical consequences of conflict and violence against women and men. Despite COVID and perhaps in some cases amplified by it, violence and the consequent medical and surgical needs continue to increase worldwide. Dr. Kaafarani challenges us to consider how we would act when need surpasses the scope of practice, and how to choose when there is not enough to go around and the person not receiving care will die as a consequence.

The moral distress of bearing witness and selecting between terrible choices can harm us deeply. We risk becoming secondary victims as we help those suffering and dying from COVID and those harmed by the ongoing brutality of humankind. Medical workers are vulnerable to illness, despair, and death. As Dr. Kaafarani teaches, we must discuss these horrific experiences with our communities, to learn and heal. 


Please be advised that the cases described by Dr. Kaafarani that follow are graphic and very disturbing.

Notes from the Field

The Ethics of Conflict Area Surgery: 3 Cases from the Field
by Haytham Kaafarani, MD, MPH, FACS





 
As an active surgeon with Médecins Sans Frontières (MSF), the ethical challenges I faced daily were often more distressing than the clinical challenges. I have no pearls of wisdom to share and no advice to give. I share three selected cases to get us to think about them and hopefully help mentally prepare us for future situations. On purpose, I will not offer solutions or answers, just questions.
 
Case #1: Working Beyond Your Comfort Zone
It’s 2012. You just arrived to your first mission with MSF. You traveled for two days by plane and eight hours in the back of a truck going off-road to reach this remote area near the borders of Chad and the Central African Republic. As soon as you get out of the truck, you get asked: “Tu es le Chirurgien?” (Are you the surgeon?). You nod. They take you to the OR suite. In addition to the gunshot wound that needed immediate surgery to stop the hemorrhage, two young women have arrested labor and need c-sections. A third woman looks septic and needs a dilatation and curettage (D&C) procedure. As a trauma surgeon, you have never done a c-section or a D&C before. You feel really uncomfortable and outside your comfort expert zone, especially with the D&C. It is not clear whether anyone else around can provide this kind of care for these patients. What would you do?
 
Case #2: Staring At Human Behavior At Its Worst
It’s 2015. You are the MSF surgeon in the war-torn area of North Kivu, in the Democratic Republic of the Congo. You receive a critically ill young woman. She has been raped by a gang of militiamen, mutilated by multiple machete strikes all over her body, and then shot by an AK-47 in her vagina. You feel nauseated as you hear the story and examine her. You feel her pain and suffering, and know that, even if you fix her physical injuries, she will be scarred mentally forever. As you realize that your conflict-area zone hospital does not have the expertise nor the capacity to provide the mental care she will need, the idea crosses your mind: should I even operate on her, or is death a better outcome?
 
Case #3: Triaging The Hard Way
It’s 2016. You are in Bangui, the capital of the Central African Republic, on yet another MSF mission. You receive a clearly septic young woman with a ruptured ectopic pregnancy and festering multiple intra-abdominal abscesses. You take her immediately to the OR, obtain infection source control with good washout and exploration. It’s an effective surgery. As you place the last stitch closing her skin, the anesthesia colleague looks distressed. He cannot extubate the patient as she is in pulmonary edema. Since you have source control, you predict that with 2-3 days on the ventilator, she could probably recover. You administer most of the Lasix supplies available to you in the hope of improving her respiratory status, but the ED team comes to inform you that several trauma and surgery patients arrived. They need to be operated on in a timely fashion. This is your only ventilator and the only OR in the hospital. Should you extubate her to give the ventilator to the next patients?
 
I share with you these real cases, three out of many, not looking for answers. There probably are none. Perhaps having the courage to discuss them not only prepares you for such difficult situations but also helps me heal from them.

Author's biography:

Haytham Kaafarani, MD, MPH is an Associate Professor of Surgery at Harvard Medical School and a Trauma Surgeon at the Massachusetts General Hospital (MGH). He currently serves as the Medical Director of the Center for Outcomes & Patient Safety in Surgery (COMPASS) and the TESSCC Director of Research. He is a leading surgeon-scientist recognized nationally and internationally with more than 200 published textbook chapters and scientific manuscripts focused on improving surgical outcomes, patient safety and quality benchmarking of surgical care. He is the creator of ESS, the Emergency Surgery Score, POTTER, the Artificial Intelligence emergency surgery risk calculator, as well as the intraoperative adverse events Severity Classification Scale. He currently serves as the Chair of the Scientific Studies Committee of the Surgical Infection Society and the Vice-Chair of the International Fellowship Committee of the American College of Surgeons. He is also an active conflict-area surgeon with Médecins Sans Frontières (Doctors without Borders) and has served on multiple missions in Central Africa.
Interesting fact
 
One of the oldest binding documents in history, the Oath written by Hippocrates is still held sacred by physicians. How does the modern-day Hippocratic Oath compare to its original version? 
https://www.medicinenet.com/script/main/art.asp?articlekey=20909
Paperchase

Fair Allocation of Scarce Medical Resources in the Time of Covid19: 
https://www.nejm.org/doi/full/10.1056/NEJMsb2005114

The Challenge of Allocating Scarce Medical Resources During a Disaster in a Low Income Country: A Case Study from the 2010 Haitian Earthquake:
https://openventio.org/Volume1-Issue1/The-Challenge-of-Allocating-Scarce-Medical-Resources-during-a-Disaster-in-a-Low-Income-Country-A-Case-Study-from-the-2010-Haitian-Earthquake-PMHCOJ-1-105.pdf

Health Policy Approaches to Measuring and Valuing Human Life: Conceptual and Ethical Issues: https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.85.10.1356


Hospital ethics reflection groups: a learning and development resource for clinical practice: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6813973/
News Bulletin
 
Who Should Doctors Save? Inside the Debate About How to Ration Coronavirus Care: https://www.newsweek.com/2020/04/24/who-should-doctors-save-inside-debate-about-how-ration-coronavirus-care-1495892.html

A lottery for ventilators? Hospitals prepare for ethical conundrums: https://www.politico.com/news/2020/03/27/venitilators-coronavirus-lottery-152574


U.S. Civil Rights Office Rejects Rationing Medical Care Based on Disability, Age:
https://www.nytimes.com/2020/03/28/us/coronavirus-disabilities-rationing-ventilators-triage.html

In Memoriam: We honor our beloved colleague, Dr. Lorna Breen, and mourn her loss.
E.R. Doctor Who Treated Virus Patients Dies by Suicide: 
https://www.nytimes.com/2020/04/27/nyregion/new-york-city-doctor-suicide-coronavirus.html
Safety
 
PhysicianOne Urgent Care in Medford, MA is offering COVID-19 testing to all essential workers, even those without symptoms. Essential workers include healthcare workers, first responders, postal workers, pharmacy workers, food and agriculture workers, grocery employees, and other infrastructure employees. Schedule a virtual visit to be evaluated for testing: 
https://physicianoneurgentcare.com/coronavirus2019


The Partners Employee Assistance Program is available to help you get through stressful and uncertain times:
https://eap.partners.org/
1-866-724-4EAP
Announcements and Events
 
Our program, Strength & Serenity- MGH Global Initiative to End Gender-Based Violence has compiled a list of resources for survivors and care providers to mitigate potential upsurge in gender-based violence during COVID. To access the list or to contribute, please visit:
https://drive.google.com/drive/folders/14mFmYvdVBRxol35r5pfEx0lmish3phUl

Strength & Serenity MGH Global Initiative to End Gender-Based Violence's logo has been finalized:








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