CHAPTER 32

MEDICAL MISSIONS: The Mechanics

Stepben J. Miller, DPM

Our world is filled with people who haveinsurmountable obstacles to freeing them from thegrip of poverty and destitution, not the least ofwhich is access to healthcare. Reliance on EJovern-ments to institute soir-rtions to the problems of thepoor is fraught with obstacles such as lack ofresollrces, indifference by the ruling regime, graftand corruption and sometimes frank politicalobstruction. Devastating human misery can remainwithor:t relief as governments poncler something as

mundane as a definition.'Medical missions collectively comprise one

method of helping to alleviate poverty andsuffering. Their goal is to bring skilled people whocare into contact with people who need.Nevefiheless, there are critics who feel that medicaimissions provicle substandard care and squandermillions of dollars that could be put to better useby 1oca1 authorities.' Sti1l others argue that only thebest trained specialists should provide such care inthe third wor1d.3 To counter these arguments, if wewere to wait until such utopian conditions cotiid beestablished, thousands of people would continlreto suffer unaided. When a team clramaticallychanges the life of even one chi1d, one individual,then the members have collectively contributed toa better worlcl. It is seen in the smiles of gratitudefrom the recipients and their families obsetwed onevery mission. Just like the "starfish story."

VOLUNTEERS

People volunteer to pafiicipate in medical missionsfor a variety of reasons, the most common being toexpress their compassion for the less fofir-rnate. Ittakes courage and a sense of commitment tovolunteer. It not only costs time and money but itinvolves exposure to the raw side of poverty as

well as various leve1s of risk. On the positive side,seruing on a medical mission team leaves eachvolunteer with a profound sense of accomplish-ment and the gratification of having made a smalldifference in the lives of a few unfofiunate fellou,'human Lreings. There is an indelible bond betweenthe team members as a result of a unique

experience together, an experience that involvedgenerosity, hardship, camaraderie, teamwork andinsight into another culture.

Desirable characteristics have been listed tohelp recruit reliable volunteers to achieve successfulmedical missions (Tab1e 1). A volunteer mustdemonstrate the right commitment.i Unfortunately,not all people volunteer for the most altruistic ofreasons. Selfish motives of any individual can

threaten any operation, but they can devastate a

medical mission.

THE INMITATION

Although a medical mission can be offerecl toattend to any needy people, it real1y must end upbeing a response to an invitation. It should neverbe foisted upon another people, no matter howdestituie. Their dignity should always be respected.

Ideally, one or more ofganizers can make an

advance scouting trip to the host collntry to assess

the needs and resources available. This type ofon-site contact is invaluable as it can firm up an

invitation and provide valuable information for thepretrip preparation.

There are many sponsoring organizalions thatfunction as logistics coordinators, communicationcenters and combined resources for information,

Table I

a

a

a

a

a

a

a

a

VALUES TTIAT MOTTVATESTAFF AND VOLUNTEERS FOR

HEALING THE CHILDREN

love of childrenfespect for peopleapplication of best medical and ltusiness practices

people working together in teamscollaboration with other organizationshope, optimism and faith in Godthe ability of one person to make a differencethe passionate commitment to take action.

162 CHAPTER 32

contacts and coordination. They are invah-rable forthe support that they can provide. A sponsoringorganization is impofiant for logistics and funnelingfinancial support, as well as a resource ofexperience and volunteer training. It can be anyone of the many nonprofit organizations set up toorgantze and implement medical missions and tobring nationals from the host country stateside forspecialized treatment. Representative examples ofsuch organizations are seen in Table 2. They mayalso be service clubs such as Rotary, Kiwanis orSoroptomists, church entities or other NGO's.

II{E TEAM

A medical mission consists of a team of healthcare volunteers traveling usually to another collntryto provide medical services to the indigent at theinvitation of the host entity in that country. Beinginvited is essential to the acceptance of the good willintended by the proposed mission. The variousentities that may invite and be integratecl into thecoordination and implementation of the projectinclude local foundations, hospitals, clinics,orphanages, relip;ious organizations, and govern-ment agencies.

A successfi-il medical mission requires a

reliable sponsoring organization, meticulousplanning, a mutually supportive team of dedicatedvolunteers. a strong team leader and responsiveteam administrator, continuing coordination with

Table2

the host entity, and endless communication andcooperation amongst the organizations supportingthe mission ancl those involved in carrying it out. Ateam may vary from an individual doctor or dentistor other provider and an assistant who incorporatelocal resources5 (e.g., brigada) to a completeentourage of surgeons and support personnel whotranspofi all their equipment and supplies. (Table 3)

THE MISSION

The main purpose of the medical mission is toprovide specialized serwices to the needy notavailable in their country or due to their circum-stances, withor-rt charge. The second goal iseducation of the local rnedical ancl social supportpersonnel. Involving nurses and doctors in as muchof the evaluations, surgery and tfeatment as

possible extends the benefits of the mission andensLlres follow-up care, besides engenderinggood-will. Arranging aclequate postoperative careis essential. The third oblective of the mission is toexpose the team to the loca1 culture and customsand, at the same time, deliver supplies, equipmentand other gifts to improve care delivered locally.

The duration of a medical mission varies fromone week to one or more months to theestalrlishment of a more durable mission thatprovides the core set-up to cycle volunteer providerson a regular basis. One week is popular because itfits into the usual western work/vacation scheduleancl is the most affordable for most volunteers.

It is thought to be icleal for a medical mission

Thble 3

A TYPICAL FOOT SURGERYMEDICAL MISSION TEAM*

1 Team T.eacler

1 Team Adminstrator2-4 Surlaeon(s)2-4 Anesthesiologists/Nurse Anesthetists7-2 Pediatricians/Family Practitioners2 Scrub Nurses,/Surgical Scn-rb Techniciens2 Circr-rlating Nurses2 PACU Nurses1 Logistics Coordinator1 IT Processor1-4 Translators

a

a

a

a

a

a

a

a

a

a

a

a

a

SPONSORING VOLUNTEERORGANIZATIONS

Heaiing the Children (HTC)EsperangaInterplastRotaplast InternationalOrthopedics Overseas (AAOS)Health Volunteers OverseasOutreach & Education Funcl (AOFAS)

Operation Condor - PeruDoctors of the VorldDoc'tors for the PoorCentral Asia Institute\X/isdom in ActionNorthwest Medical Teams

t'Assumes ctccess to at leotst two operating totbles

CHAPTER 32 t63

to go back to the same location regularly so as toprovide some measure of care continuity.However, a greater impact is rcalized whenmeclical volunteers commit to a year or more in thesame area.i

Achieving a successful mission also involvesthe cooperation of many suppofi organizatictns andother entities: government agencies, other NGO's,nonprofit organizations in the host country, serviceorganizations n'ith international branches, andcorporate donors. As long as one is not toointrusive or presLlmptuous in his or her approachcorporate donors can be surprisingly generous.This valuable relationship should never be abused.It takes many people from the donor country anclthe host country working together to organize aviable medical mission.

A pretrip meetinla or two of as many teammembers as possible is highly recomrnended. Itset.lres as a time to focus on the goals of themission, rer.iew everyone's ro1es, check off supplyand equipment lists, pack them and get a previewof the cuiture of the host country. Each part of theteam: anesthesia, sllrgery, surgical assistants andmedical are responsible for assembling theirneeded sr-rpplies and equipment (Table 4). Greatcare must be taken to keep the bags and boxeswithin the airiine weight and dimension guiclelines.It is important for every team member to carry/ theirshare both to and from the mission.

TYPICAL ONE-WEEK MISSION

After months of organrzation and assemtrly ofeqr-ripment and supplies, a medicai mission ideallyassembles at one US exit airport to fly together toa destination airport near where the medicalmission is to take place. On zrrrival, it is essentialthat all documentation is in order to clear localirnmigration ancl customs. The more cletailed theorganization, the less likely that there will bepeople and luggage detained by the authorities.Having lists of the contents of each bag or boxinside, outside and in a separate folder can helpdecrease the need for officials to search them.

Once all team mernbers have clearedimmigration and cllstoms, prearranged grouncl-transportation takes people and baggage to theiraccommodation. This may be fbr the mission itselfor fbr an overnight stay so as to be transported to a

more clistant location for the mission the next dav.

Saturday is a good time for the team to assemble inthe evening for dinner to get zrcquainted andsocialize and hopefully meet some of the hostcountry personnel. Perhaps, there is even timeto tour some of the facilities that are being madeavailable.

Sunday is usually the day when the potentialpatients preselected by the hosts are screened by thesurlleons and then by the cloctot's responsible formedical management and anesthesia. Preoperativescreening for anesthesizr is important as it helps min-imize the potential complications for the chiidren.6This is a very demanding session that can be quitehectic. So, it takes detailed organization anclcoordination. Records and diagnostic films from thehosts are made available and kept with the recordfbr each patient. Translators need to be readily

Table 4

EQUIPMENT AND SUPPLIESFOR A MEDICAL MISSION

Anesthesia mach-inesAneslhesia monitiorsAnesthesia supplies and drugsSurgical gowns (pre-sterilized)Drape and starter packsMasks, gloves, shoe covers, capsSurgical instrument setsAntiseptics and prep sets

Miscellaneous surgical instruments (to supplementthe sets)

Single instrumentsInternal fixation instruments and implantsExternal fixation equipment (optional)

Power instrument sets and attachmentsCautery units and handpiecesPortable suctionTourniquetsPACU monitors and equipmentDrugs for analgesia, antibiotics,

anti-inflammatories, anti-emeticsSr-rtures

Dressing materialsCasting materialsCast cutterFirst aid kitToys and gifts

164 CHAPTER 32

available to all stations involved in this screeningand information assembly process.

An information record is establishecl for eachchild selected for surgery, preferably with the aid ofa laptop computer. A Polaroid or digital photoshould be taken of the patient and attached to therecord. Information forms and history and physicalforms as well as preoperative and postoperativeinstructions shoulcl be prepared in both Englishand the local language prior to the mission. Havinga computer printer along is invaluable for makinglast minute forms, printing photos and makingsigns. The computer can store c1ata, forms, Iists andphotos. It can also be used for internet activity.

While the doctors are screening the patientsthe OR crew is taken to the operzrting facility to setup the operatin5l rooms, organize the supplies andmeet the local medical staff. They must quicklyassess the resources available and arrange how theteam's resource's can be used to compliment thoseavailable 1ocally.

At the end of the screening, the doctors andother team members meet to establish the surgeryschedule for the week. The computer is a greatresource for this but it can be done on paper ifnecessary. The team leader is responsible forassigning the surgeons and other supportinp4 teammembers to the individual patient's treatment.Sometimes, non-surgical care is prescribed, such as

casting or-rt a flexible clubfoot deformity, and theloca1 medical personnel are involved.

Surgery to correct the children's deformities is

usually performed Monday through Friday. Eachday starts with rounds in the morning on theprevlous day's surgical cases and preparing thechildren for the schedule of the day. This requiresa lot of coordination, especially first thing in themorning and cluring case turnovers. It is notunusual for two operzrting tables to be active in thesame operating theater. A good PACU staff isanother essential. The children usually stay one ortwo nights before being discharged with writteninstructions, medication and an appointment forfollow-up care.

It is important to invite the local mediczrl staffto pafiicipate in the erraluations, surgical andhospital care and prepare them for postoperativemanagement. Even before any invitation to send a

medical mission team, a loca1 orthopedic slrrgeonor trained physician must be identified as agreeingto provide the care postoperatively.

On Saturday morning, the final hospital roundsare completed with care for the remaining patientsbeing transferred to the 1ocal staff. Then the teamheads either directly home or to an area town orvillage of interest for a clay and a night to unwindbefore flying Lrack to each member's country.

LOWER EXTREMITY PATHOLOGY

The range and variety of pathology encounterecl onmeclical missions draws on every oLlnce of one'straining ancl experience as well as creativity ancl

resourcefulness. Many congenital deformities,neurological deficits and inherited disorders areroutinely encounterecl as well as the sequellae frominjuries due to mines, burns and trauma. A list oftypical deformities and disorders encolrnterecl onmedical missions is seen in Table 5. Deformityrepairs, revisions ancl reconstrllctions entail a

variety of releases, arthrodeses, osteotomies,tendon transfers, ancl amputations, ol revisions(Figures 7-72). They often require teamconsultation, decision-making and surgeryparticipation. Blinging one or two referencetextbooks can be extremeiy heipful but certainlyadcls to the luggage weight.

EPILOGUE

Team members must be forewarned abor-it theretlrrn home. Even after a short week away. theintensity of lengthy travel, working in adr.erseconditions immersed in poverty and experiencingIimited resources) a person's emotional andphysical capacity can be fairly exhausted. There is

quite a culture shock with the return home and atwinge of guilt can set in when confronted with theabundance. However, the f'eeling of accomplish-ment that naturally permeates one's whole beingfollowing a mission far outweighs the feelings ofinadequacy at not being able to solve all theproblems. Contributing to improving so much as

one child's life brings a sense of joy and fi-r1fillmentthat is more than enough reward for committing tothe medical mission.''o

CHAPTER 32 t65

Thble 5

TYPICAI PATHOLOGY ANDPROCEDURES ENCOUNTERED

ON MEDICAL MISSIONS

Clr-rbfootCongenitrI MrlfonnationsVertical TalusArtl-rrogryphosisCerebr'.rl PalsyPost Polio\erLrologit al DelicitsAmpLltations/RevisionsFracture Mgt/RevisionBurn Scar Revision

Figure 2. Po11.6lx61u1u post sr.l1'!ijcal reduction

Figurc 1. Polydact,vlv fcct

|igrire I. Anlpllt:ltion slutnp clcfbrmitv preventing ttse of prosthesis.

:unplrt:rtiorl sturnp rcv jsiot-lFigr-rre 5. Post polio c:rvoeqr:inrts clefbrn'ritv

166 CHAPTER 32

Figure 6. Post-polio flaccicl parai.vsis.

Figule 8. Posrsurgic:rl release ol Achillcs aml hantstring conrracrlires.

Figure 10. lncisiotr markccl fbr posteromeclial releasc of clubfirotclefirrrifr'.

Trigule !. Rcsistant clubfbot in 9-month olcl nrlant

Figure 7. Cerebral palsyCONtfACtLII'CS,

paticnt n,ith

CHAPTER 32 167

Figurc 11. Post surgical reduction of clr.rbfbot cleformitv

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pe\^te. N Eng J ller:l. 2004357:745 7 .

Cranrner HH. Volunteer r'vork-logistics first. N Eng J lled2005:353:7511-4.

Figure 12. Neglectecl clubfbot dcformity

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\(io1flrerg AJ. Yolunteering ovcrseas-lcssons from surgicallrrigades. N ErtgJ Med 2006;3541443-5.Fishcr QA, Nichols D. Stewart FC, et :r1. Assessing pecliatric

anesthesia practices for voluntecr medical sen'ices abroad.

Anestb esioktg.y 200 I ;95 :7375 22.

Scranton PE, Gonclring W-. Shields NN, et al. Special Repot: The20OJ Orthopaed:ic Education Foundation's o\rerseas missiorl toVietnam. Foot Ankle Intl 2004;25:772-9.Scrzlnton PE, Veith RG, Thom:rs, R, et al. Special rcport: the 200'1

Orthopaedic Eclucation Founclation's ovcrseas rnission toVietnam. Foot Ankle Intl2001;25:903-1 .

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