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Surgery in the time of Ebola

By Dr. Sherry M. Wren And Dr. Adam Kushner

San Jose Mercury News

Daily reports and statistics on the worsening Ebola crisis no longer shock us. An Ebola patient dies in Dallas and a nurse who treated the patient is infected there, too. Cuban physicians and U.S. military personnel arrive in West Africa. Infected international aid workers evacuated and local health care workers die. These are the headlines of the Ebola crisis, but one word is not among the headlines: Surgery.

But why should anyone care about surgery and Ebola? Ebola is a virus.

The health systems in Sierra Leone, Liberia and Guinea failed. Now the emphasis is on building Ebola isolation wards. Yet routine medical emergencies still occur. Car accidents happen. Difficult deliveries and obstructed labor occur. Children fall from trees and break bones or need stitches. As surgeons with more than 30 combined years working in developing countries, we recognize the need for surgery. But as World Bank President Jim Kim first stated over six years ago, surgery is still the neglected stepchild of global health.

Sierra Leone surgeons are willing to operate, but patients with a fever or vomiting, common with surgical emergencies, are often first sent to the Ebola evaluation and isolation wards. Forced to wait days for a negative test for Ebola, many die before getting needed operations.

At a Sierra Leone district hospital, one doctor recently performed a cesarean section on a woman with Ebola. She was at risk of dying from Ebola, but without the operation, her child would die. She too would be at risk. With supportive medical care, patients may survive an Ebola infection. Without surgery for severe trauma, obstructed labor, a strangulated hernia, or a perforated ulcer, some patients may die. How does one operate on a patient infected with Ebola, yet at the same time protect the surgical staff?

The issues with surgery and Ebola are reminiscent of discussions and shunning of patients in the early days of AIDS. In the mid-1980s AIDS was often a fatal diagnosis. Operating room personnel and physicians often declined to treat infected patients. Training, protocols and personal protective supplies helped remove the stigma and allow for safe treatment. Last week we wrote an Ebola surgery protocol and sent it to the largest surgical organization in the United States. Within a day the guideline went worldwide.

The management of Ebola is new to many clinicians in the United States and elsewhere. We hope to see more training, protocols and personal protective supplies to lower risks to surgical staff and patients. Just as surgery is a necessary part of a functioning health system, surgery must be part of the discussion during this time of Ebola.

Dr. Sherry M. Wren is a professor of surgery and director of the Global Health at Stanford University. Dr. Adam Kushner is a surgeon at the Johns Hopkins School of Public Health.

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