Could you tell us about your role within MSF?
I am now retired from the NHS but worked initially as a general surgeon with an interest in transplantation, performing kidney and liver transplants. The liver transplant case numbers escalated, and this also led to more hepatobiliary and pancreatic surgery so the “general surgery” aspect progressively reduced. Obviously for my work as an MSF surgeon I have reverted to a very broad general surgery practice. What led you to this role? As a medical student I did an elective in Ibadan, Nigeria in 1971 (the year after the Biafran war had ended). For me that was a life-changing experience, opening my eyes to the rest of the world. I always wanted to go back and work in Africa, so I took early retirement and Médecins Sans Frontières / Doctors Without Borders (MSF) was the obvious NGO to choose. I have chosen to work mainly in Africa and of my 13 MSF assignments so far, 12 have been in sub-Saharan Africa, the other being in Haiti. Describe a typical day in your life as a surgeon with MSF One of the exciting things about working with MSF is that you never know what is going to come next. The range of cases is very broad, anything from a neglected abscess that needs draining to a snake bite threatening the circulation of a limb or causing major skin necrosis that ultimately will need a skin graft. Mornings start with a staff meeting to discuss problems that might have arisen over night. A ward round follows, and then the theatre list. Cases are booked in a theatre diary and many require repeated procedures such as wound debridement for gunshot cases or dressing changes under sedation or anaesthetic for burns. Night times can be quiet as new cases are unlikely to travel at night due to security issues, though Caesareans can arise at any time. How intensive is your work schedule? All my assignments have kept me busy. On one of my postings we had over 300 gunshot wound cases transferred over eight days though that was exceptional. Working single-handed means no days or nights off which is why the postings for surgeons are much shorter than for other staff. Favourite things about your job? As in all surgical practice, my favourite part of the job is seeing a patient recover and go home. Most challenging aspects of your job? Inevitably there are cases for whom surgery would be possible in the UK, but for whom in the field our surgical options are limited. Another frustrating aspect is when patients are taken out of the hospital by the family to be managed by traditional healers. Anything you wished you had known before starting you career in MSF? While the majority of MSF projects do not have surgical services, there are many other vital roles such as child and infant nutrition and dealing with epidemics. The majority of MSF projects with surgery are staffed by a single surgeon. That has two major implications. Firstly, as the only surgeon you will need to cope with a wide spectrum of surgical conditions. This means abdominal emergencies; trauma, including both penetrating and blunt injuries, as well as the common fractures; burns; and obstetric cases. Before my first assignment I sought out training in Caesareans, as well as external fixation for fractures, and burn care. The second implication is that the work can be very intense and tiring, as there is no time off. I mentioned that surgeons tend do much shorter postings than the other staff: I have always done six-week assignments whereas staff in most other roles do six months or longer. Any advice for medical students interested in surgery in the humanitarian sector? Surgery in the humanitarian sector can be very rewarding and I have found it just as satisfying as my transplant work. You are likely to be treating people who have no other medical care available, so the work is greatly valued. One disadvantage of the way surgery has progressed is that specialisation, and even super-specialisation, is now the norm. This means that training tends to be more focussed and gaining a broad experience sufficient to cope with a wide range of conditions can be a challenge. However, getting experience in other fields should not be too difficult for a motivated trainee. Realistically however, this means surgeons are likely to have the skills needed to work with MSF later in their careers than physicians. What attributes are best suited to a surgeon working for MSF? The most important attribute for working as a surgeon with MSF is being adaptable. As well as the environment being challenging (climate, perhaps security issues, possibly food,) you will see cases you have never seen before. It is worth emphasising that there are likely to relatively few diagnostic tests. There are limited blood tests, there is ultrasound that is vital for the obstetric cases, but not usually any X-rays. This means that a careful history needs to be taken and a meticulous examination performed. For me keeping my clinical skills honed is a great attraction, no chance of saying “well, let’s get a CT”! How is surgery on the front line different from the NHS? MSF generally places its surgical services in areas of armed conflict, so trauma cases are well represented. In regions where there are a lot of internally displaced people there tend to be a lot of burns in children, as cooking on open fires in the camps where people are housed carries risks. There is little elective surgery and in fact little demand for it. Perhaps the most obvious difference is the broad range of cases you would be doing on a single operating list. It can range from setting a fracture, a laparotomy for a typhoid perforation, a Caesarean section, a burn dressing, incision, and drainage of an abscess, all the way through to removing a tooth. The theatres are equipped with a limited selection of instruments, but these are adequate for the work needed. Help is always available, albeit through reference books (I always take the two Primary Surgery volumes edited by Maurice King), advice from your medical colleagues at the project (tropical surgery conditions can be puzzling), email to the MSF surgical adviser or to specialist colleagues back home. I have used all three over the years. You need to be unpretentious and ask advice if you are not coping, remember not even surgeons know everything! And of course, it is humbling to see the bravery and courage of the patients who often face barriers in accessing care until very late with their illnesses, sometimes even having walked for days to reach the hospital. What are some of your most memorable moments working as a surgeon for MSF? On every assignment there have been very memorable cases. On my most recent posting in South Sudan I was able to help with a patient I had treated a full year earlier. So, around a year ago, a 10-year-old boy had presented at an MSF facility. The facility didn’t have a surgical service, but he had a suspected diagnosis of perforated typhoid disease. He was transferred to the MSF facility I was working at by plane, but that took time to arrange, and at surgery he had advanced peritonitis due to perforated typhoid. That was repaired, but unfortunately, he developed a small bowel fistula with wound breakdown. He was not eating and was wasting away. I took a photo of his chest for teaching purposes, to show his ribs standing out as his body cannibalised his muscles. I left the project and my successor let me know that he was being transferred back to the referral centre for palliative care. I then met a surgeon at an MSF ultrasound training course who was at the project much later. He had been sent a photo showing a healthy-looking boy doing a Mandela style salute, despite still having a small volume fistula. It made my week! I was back at the project soon after and we transferred him in, repaired the fistula and gratifyingly he made a swift recovery. John Buckels CBE MD FRCS ESSS thanks Professor John Buckels for writing this article.
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AuthorsArticles are written by Edinburgh-based students and doctors, for the benefit of those interested in surgery. Archives
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