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Surgery_Schwartz. Opioids should not be stopped abruptly, even if the patient becomes nonresponsive, because sudden withdrawal can cause severe distress.49,50Cognitive failure at the end of life is manifested in most patients by increasing somnolence and delirium. Gradually increasing somnolence can be accompanied by periods of dis-orientation and mild confusion, and it may respond to the reas-suring presence of loved ones and caregivers with minimal need for medications. A more distressing form of delirium also can distress, pain, and cognitive failure. General principles that are applicable to symptom management in the last days of life include (a) anticipating symptoms before they develop; (b) minimizing technologic interventions (usually manage symp-toms with medications); and (c) planning alternative routes for medications in case the oral route fails. It may be possible to cautiously reduce the dose of opioids and other medications as renal clearance decreases near the end of life, but it is


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Surgery_Schwartz. routes for medications in case the oral route fails. It may be possible to cautiously reduce the dose of opioids and other medications as renal clearance decreases near the end of life, but it is important to remember that increased somnolence and decreasing respira-tions are prominent features of the dying process independent of medication side effects. Sudden cessation of opioid analgesics near the end of life could precipitate withdrawal symptoms, and therefore medications should not be stopped for increasing som-nolence or slowed respirations.The principles of pharmacotherapy for pain and non-pain symptoms in the palliative care setting are outlined in Table 48-4. The World Health Organization,35 the United States Agency for Healthcare Policy and Research,47 the Academy of Hospice and Palliative Medicine,48 and many other agencies have endorsed a “step ladder” approach to cancer pain man-agement that can predictably result in satisfactory pain control in most patients (Table


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Surgery_Schwartz. and Palliative Medicine,48 and many other agencies have endorsed a “step ladder” approach to cancer pain man-agement that can predictably result in satisfactory pain control in most patients (Table 48-5). More refractory pain problems require additional expertise, and occasionally, more invasive approaches (Tables 48-6 and 48-7).Brunicardi_Ch48_p2061-p2076.indd 206919/02/19 1:49 PM 2070SPECIFIC CONSIDERATIONSPART IITable 48-6Analgesics for persistent painDRUGINITIAL DOSING (ADULT, >60 kg)COMMENTSMild persistent pain, visual analogue scale (VAS) 1–3 Acetaminophen (Tylenol)325–650 mg PO four times a day Maximum = 3200 mg/24 hUse <2400 mg if other potentially hepatotoxic drugs taken. Acetaminophen contained in concurrent nonprescription medications can easily exceed maximum daily allowable dose. Aspirin600–1500 mg PO four times a dayGastric bleeding, platelet dysfunction Choline magnesium trisalicylate (Trilisate)750–1500 mg PO twice a dayUseful for avoiding platelet


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Surgery_Schwartz. daily allowable dose. Aspirin600–1500 mg PO four times a dayGastric bleeding, platelet dysfunction Choline magnesium trisalicylate (Trilisate)750–1500 mg PO twice a dayUseful for avoiding platelet dysfunction Ibuprofen (Advil, Motrin)200–400 mg PO four times a day Maximum = 3200 mg/24 hGastropathy, nephropathy, decreased platelet aggregation Naproxen (Naprosyn)250 mg PO twice a day Maximum = 1300 mg/24 hAvailable as a transcutaneous gelModerate persistent pain, VAS 4–6 Hydrocodone (Vicodin, Lortab)5–7.5 mg PO every 4 hoursMost prescribed drug in the United StatesAcetaminophen in compounded drug limits use to moderate pain Oxycodone5 mg PO every 4 hoursSold as single agent or compounded with aspirin or acetaminophenSlow release form available (Oxycontin)Severe persistent pain, VAS 7–10 Morphine10 mg PO every 2–4 hours 2–4 mg IV, SC every 1–2 hoursStandard drug for comparison to alternative opioids. Avoid or caution when giving to older adults, patients with diminished glomerular


Surgery_Schwartz

Surgery_Schwartz. mg PO every 2–4 hours 2–4 mg IV, SC every 1–2 hoursStandard drug for comparison to alternative opioids. Avoid or caution when giving to older adults, patients with diminished glomerular filtration rate, or liver disease. Slow release PO form available (MS Contin). Hydromorphone1–3 mg PO, PR every 4 hours 1 mg IV, SC every 1–2 hoursSuppository form availableOral dose forms limited to 4 mg maximum Fentanyl, transdermal12 μg/h patch every 72 hoursNot for acute pain management. Do not use on opioid-naive patients. Absorption unpredictable in cachectic patients. MethadoneConsultation with pain management, clinical pharmacists, or palliative care/hospice services skilled in methadone use is recommended for those inexperienced in prescribing methadone.Not a first-line agent, although very effective, especially for pain with a neuropathic componentVery inexpensiveCan be given PO, IV, SC, PR, sublingually, and vaginallyIts long half-life makes dosing more difficult than alternative opioids and


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Surgery_Schwartz. especially for pain with a neuropathic componentVery inexpensiveCan be given PO, IV, SC, PR, sublingually, and vaginallyIts long half-life makes dosing more difficult than alternative opioids and close monitoring is required when initiating.Numerous medications, alcohol, and cigarette smoking can alter its serum levels.Physicians who write methadone prescriptions for pain should specify this indication. Methadone use for drug withdrawal treatment requires special licensure.Risk factors for NSAID-induced nephropathy include: advanced age, decreased glomerular filtration rate, congestive heart failure, hypovolemia, pressors, hepatic dysfunction, concomitant nephrotoxic agents. Dose reduction and hydration reduce risk.Opioids compounded with aspirin or acetaminophen are limited to treatment of moderate persistent pain because of dose-limiting toxicities of acetaminophen and aspirin.Slow-release preparations of morphine and oxycodone may be given rectally.Timed-release tablets or patches


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Surgery_Schwartz. of moderate persistent pain because of dose-limiting toxicities of acetaminophen and aspirin.Slow-release preparations of morphine and oxycodone may be given rectally.Timed-release tablets or patches should never be crushed or cut.Opioid analgesics are the agents of choice for severe cancer-related pain. Sedation is a common side effect when initiating opioid therapy. Tolerance to this usually develops within a few days. If sedation persists beyond a few days, a stimulant (methylphenidate 2.5–5 mg PO twice a day) can be given.Initiate bowel stimulant prophylaxis for constipation when prescribing opioids unless contraindicated.Adjuvant or coanalgesic agents are drugs that enhance analgesic efficacy of opioids, treat concurrent symptoms that exacerbate pain, or provide independent analgesia for specific types of pain (e.g., a tricyclic antidepressant for treatment of neuropathic pain). Coanalgesics can be initiated for persistent pain at any visual analogue scale level. Gabapentin is


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Surgery_Schwartz. for specific types of pain (e.g., a tricyclic antidepressant for treatment of neuropathic pain). Coanalgesics can be initiated for persistent pain at any visual analogue scale level. Gabapentin is commonly used as an initial agent for neuropathic pain.No place for meperidine (Demerol), propoxyphene (Darvon, Darvocet, or mixed agonist-antagonist agents [Stadol, Talwin]) in management of persistent pain.Always consider alternative approaches (axial analgesia, operative approaches, etc.) when managing severe persistent pain.Note: These are not recommendations for specific patients. The interand intraindividual variability to opioids requires individualizing dosing and titration to effect.Adapted with permission from Cameron JL: Current Surgical Therapy, 9th ed. Philadelphia, PA: Elsevier; 2008.Brunicardi_Ch48_p2061-p2076.indd 207019/02/19 1:49 PM 2071ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48Table 48-7Examples of adjuvant medications for treatment of neuropathic,


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Surgery_Schwartz. 207019/02/19 1:49 PM 2071ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48Table 48-7Examples of adjuvant medications for treatment of neuropathic, visceral, and bone painaDRUG CLASSINITIAL DOSING (ADULT, >60 kg)COMMENTSTricyclic antidepressants Best for continuous burning or tingling pain and allodynia Efficacy for pain not due to antidepressant effectAmitriptyline 10–25 mg PO before bedNortriptyline 10–25 mg PO one per daySedating properties may be useful for relief of other concurrent symptoms. Side effects may precede benefit. Avoid in older adult patients due to anticholinergic side effects. Dose generally less than that required for antidepressant effectDoxepin 10–25 mg PO before bedLess anticholinergic effect Dose titrated up every few days until effect. Pain may respond to alternative antidepressants if no response to initial agent.Imipramine 10–25 mg PO one per day Anticonvulsants For shooting, stabbing painGabapentin 100–1200 mg PO three times a day.


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Surgery_Schwartz. may respond to alternative antidepressants if no response to initial agent.Imipramine 10–25 mg PO one per day Anticonvulsants For shooting, stabbing painGabapentin 100–1200 mg PO three times a day. Titrate up rapidly as needed. Max: 3600 mg daily in divided dosesCommonly used first-line agent. Generally well tolerated. Does not require blood level monitoring. Carbamazepine 200 mg PO every 12 hoursPregabalin starting dose 25–50 mg PO three times a dayEffective. Well studied. Requires blood monitoring.Does not require blood monitoring. Valproic acid 250 mg PO three times a day Local anesthetics Systemic use requires monitoring. Nebulized local anesthetics (lidocaine, bupivacaine) can be used for severe, refractory cough.Lidocaine transdermal patch 5%. Apply to painful areas. Max: 3 simultaneous patches over 12 hours (each patch contains 700 mg lidocaine).Lidocaine/prilocaine topical. Apply to painful areas.Systemic toxicity can result from applying more than recommended number per


Surgery_Schwartz

Surgery_Schwartz. patches over 12 hours (each patch contains 700 mg lidocaine).Lidocaine/prilocaine topical. Apply to painful areas.Systemic toxicity can result from applying more than recommended number per unit time and in patients with liver failure. Effective for postherpetic neuralgia.MiscellaneousBisphosphonates (pamidronate, zoledronic acid)For bone pain and reduced incidence of skeletal complications secondary to malignancy—best results in myeloma and breast cancer. Contraindicated in renal failure. Calcitonin nasal sprayRefractory bone pain DexamethasoneFor bone pain, acute nerve compression, visceral pain secondary to tumor infiltration or luminal obstruction by reducing inflammatory component of tumor Radionuclides (Sr-89)For malignant bone pain secondary to osteoclastic activity. 4–6 wk delay in benefit. Requires adequate bone marrow reserve. For prognosis of more than 3 mo. OctreotideReduces GI secretions that contribute to visceral painaRecommendations are based on experience of


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Surgery_Schwartz. delay in benefit. Requires adequate bone marrow reserve. For prognosis of more than 3 mo. OctreotideReduces GI secretions that contribute to visceral painaRecommendations are based on experience of practitioners of hospice and palliative medicine and in some instances do not reflect current clinical trials.Brunicardi_Ch48_p2061-p2076.indd 207119/02/19 1:49 PM 2072SPECIFIC CONSIDERATIONSPART IIdevelop, manifested by increasing agitation that may require the use of neuroleptic medications. Increasing amounts of opioids and/or benzodiazepines may exacerbate the delirium (especially in the elderly).Pronouncing Death51If the body is hypothermic or has been hypothermic, such as a drowning victim pulled from the water in the winter, the phy-sician should not declare death until warming attempts have been made. In the hospital, hospice, or home setting, the dec-laration of death becomes part of the medical or legal record of the event. There are a number of physical signs of death a


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Surgery_Schwartz. attempts have been made. In the hospital, hospice, or home setting, the dec-laration of death becomes part of the medical or legal record of the event. There are a number of physical signs of death a physician should look for in confirming the patient’s demise: complete lack of responsiveness to verbal or tactile stimuli, absence of heart beat and respirations, fixed pupils, skin color change to a waxen hue as blood settles, gradual poikilothermia, and sphincter relaxation with loss of urine and feces. For deaths in the home with patients who have been enrolled in hospice, the hospice nurse on call should be contacted immediately. In some states, deaths at home may require a brief police investiga-tion and report. For deaths in the hospital, the family must be notified (in person, if possible). A coroner or medical examiner may need to be contacted under specific circumstances (e.g., deaths in the operating room), but most deaths do not require their services. The pronouncing


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Surgery_Schwartz. if possible). A coroner or medical examiner may need to be contacted under specific circumstances (e.g., deaths in the operating room), but most deaths do not require their services. The pronouncing physician will need to complete a death certificate according to local regulations. Survivors may also be approached, if appropriate, regarding potential autopsy and organ donation. Finally, it is important to accommodate religious rituals that may be important to the dying patient or the family. Bereavement is the experience of loss by death of a person to whom one is attached. Mourning is the process of adapting to such a loss in the thoughts, feelings, and behaviors that one experiences after the loss.52 Although grief and mourn-ing are accentuated in the immediate period around death, it is important to note that patients and families may have begun the process of bereavement well before the time of death as patients and families grieve incremental losses of independence, vitality, and


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Surgery_Schwartz. important to note that patients and families may have begun the process of bereavement well before the time of death as patients and families grieve incremental losses of independence, vitality, and control. In addition to the surviving loved ones, it is impor-tant to acknowledge that caregivers also experience grief for the loss of their patients.53,54Aid in DyingFive European countries, Canada, and six U.S. states have legal-ized physician-assisted suicide, medical assistance in dying, or aid-in-dying, in some form, ranging from hospital-based pro-grams to provision of fatal doses of medications for home self-administration.55-57 Medical assistance in dying is a complex ethical and legal issues with divergent opinions among the pub-lic and healthcare providers.58,59 While aid-in-dying laws passed in the United States vary somewhat, these laws essentially all allow physicians to prescribe a lethal dose of medication to men-tally, competent, terminally ill adult patients for the


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Surgery_Schwartz. laws passed in the United States vary somewhat, these laws essentially all allow physicians to prescribe a lethal dose of medication to men-tally, competent, terminally ill adult patients for the purpose of achieving the end of life.60,61 Key areas of ethical consideration in this area include the benefit and harm of death; the relation-ship between passive euthanasia, active euthanasia, withholding treatment, and withdrawing treatment; the morality of physician and nursing participation in deliberately causing death; and the management of conscientious objection.60,62 Although surgeons outside of the critical care arena may only infrequently be asked to participate in aid-in-dying, it is important to be familiar with local legislation so that appropriate information can be provided to patients who request it.PROFESSIONAL ETHICS: CONFLICT OF INTEREST, RESEARCH, AND CLINICAL ETHICSConflict of InterestConflicts of interest for surgeons can arise in many situations in which the potential


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Surgery_Schwartz. who request it.PROFESSIONAL ETHICS: CONFLICT OF INTEREST, RESEARCH, AND CLINICAL ETHICSConflict of InterestConflicts of interest for surgeons can arise in many situations in which the potential benefits or gains to be realized by the surgeon are, or are perceived to be, in conflict with the respon-sibility to put the patient’s interests before the surgeon’s own. Conflicts of interest for the surgeon can involve actual or per-ceived situations in which the individual stands to gain mon-etarily by his or her role as a physician or investigator. In the academic community, monetary gain may not be the primary factor. Instead, motivators such as power, tenure, or authorship on a publication may serve as potential sources of conflict of interest. For example, the accrual of subjects in research studies or patients in surgical series may ensure surgeons better author-ship or more financial gains. The dual-role of the surgeon-scien-tist therefore needs to be considered because the duty as


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Surgery_Schwartz. studies or patients in surgical series may ensure surgeons better author-ship or more financial gains. The dual-role of the surgeon-scien-tist therefore needs to be considered because the duty as surgeon can conflict with the role of scientist or clinical researcher.Research EthicsOver the last three decades in the United States, the ethical requirements for the conduct of human subject research have been formalized and widely accepted. Although detailed informed consent is a necessary condition for the conduct of ethically good human subject research, other factors also deter-mine whether research is designed and conducted ethically. Emanuel and colleagues63 described seven requirements for all clinical research studies to be ethically sound: (a) value—enhancement(s) of health or knowledge must be derived from the research; (b) scientific validity—the research must be methodologically rigorous; (c) fair subject selection—scientific objectives, not vulnerability or privilege, and the


Surgery_Schwartz

Surgery_Schwartz. must be derived from the research; (b) scientific validity—the research must be methodologically rigorous; (c) fair subject selection—scientific objectives, not vulnerability or privilege, and the potential for and distribution of risks and benefits, should deter-mine communities selected as study sites and the inclusion cri-teria for individual subjects; (d) favorable risk-benefit ratio—within the context of standard clinical practice and the research protocol, risks must be minimized, potential benefits enhanced, and the potential benefits to individuals and knowl-edge gained for society must outweigh the risks; (e) independent review—unaffiliated individuals must review the research and approve, amend, or terminate it; (f) informed consent—individuals should be informed about the research and pro-vide their voluntary consent; and (g) respect for enrolled subjects—subjects should have their privacy protected, the opportunity to withdraw, and their well-being monitored.63Special


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Surgery_Schwartz. and pro-vide their voluntary consent; and (g) respect for enrolled subjects—subjects should have their privacy protected, the opportunity to withdraw, and their well-being monitored.63Special Concerns in Surgical ResearchA significant issue for clinical surgical research is that many surgical studies are retrospective in nature and are not com-monly undertaken in a prospective, double-blind, randomized fashion. For a randomized trial to be undertaken, the researchers should be in a state of equipoise—that is, there must be a state of genuine uncertainty on the part of the clinical investigator or the expert medical community regarding the comparative thera-peutic merits of each arm in a trial.64 To randomize subjects to receive two different treatments, a researcher must believe that the existing data are not sufficient to conclude that one treat-ment strategy is better than another. In designing surgical trials, surgeons usually have biases that one treatment is better than another


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Surgery_Schwartz. existing data are not sufficient to conclude that one treat-ment strategy is better than another. In designing surgical trials, surgeons usually have biases that one treatment is better than another and often have difficulty maintaining the state of equi-poise. As such, it is frequently difficult to demonstrate that a 77Brunicardi_Ch48_p2061-p2076.indd 207219/02/19 1:49 PM 2073ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48Table 48-8ICMJE criteria for authorshipAccording to ICMJE best practices recommendations, authors should fulfill each of the following four criteria67:1. Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work2. Drafting the work or revising it critically for important intellectual content3. Final approval of the version to be published4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part


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Surgery_Schwartz. content3. Final approval of the version to be published4. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolvedContributors who do not fulfill all four criteria should be named in the manuscript in the acknowledgment section.Adapted with permission from Cameron JL: Current Surgical Therapy, 9th ed. Philadelphia, PA: Elsevier; 2008.randomized trial is necessary or feasible, and treatment options that question the validity of clinical tenets are difficult to accept. Meakins has suggested that a slightly different hierarchy of evi-dence applies to evidence-based surgery.65A second major issue for surgical trials is whether it is ethically acceptable to have a placebo-controlled surgical trial. Some commentators have argued that sham surgery is always wrong because, unlike a placebo medication that is harmless, every surgical procedure carries some risk.66


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Surgery_Schwartz. placebo-controlled surgical trial. Some commentators have argued that sham surgery is always wrong because, unlike a placebo medication that is harmless, every surgical procedure carries some risk.66 Others have argued that sham operations are essential to the design of a valid ran-domized clinical trial because, without a sham operation, it is not possible to know if the surgical intervention is the cause of improvement in patient symptoms or whether the improve-ment is due to the effect of having surgery.67,68 Most surgeons readily agree that designing an appropriately low-risk sham sur-gical procedure would create problems for the surgeon-patient relationship in that the surgeon would need to keep the sham a secret.69 In this sense, a sham surgical arm of a trial is very different from a placebo medication in that there cannot be blinding of the surgeon as to which procedure was undertaken. As a result, to have a sham surgery arm in a clinical trial, the interactions between the


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Surgery_Schwartz. a placebo medication in that there cannot be blinding of the surgeon as to which procedure was undertaken. As a result, to have a sham surgery arm in a clinical trial, the interactions between the surgeon and the subject must be lim-ited, and the surgeon performing the procedure should not be the researcher who follows the subject during the trial. Despite difficulties with designing a surgical trial in which the surgeon could ethically perform a sham operation, there are specific cir-cumstances that allow for placebo operations to be conducted, so long as certain criteria are met and are analyzed on a case by case basis.70,71Surgical InnovationAn important issue is whether surgical innovation should be treated as research or as standard of care. Throughout history, many advances in surgical techniques and technologies have resulted from innovations of individual surgeons crafted dur-ing the course of challenging operations—such innovations and technologies have served to move the


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Surgery_Schwartz. techniques and technologies have resulted from innovations of individual surgeons crafted dur-ing the course of challenging operations—such innovations and technologies have served to move the field of surgery forward.72 In the Korean and Vietnam wars, military guidelines for treat-ment of vascular injuries recommended ligation and amputation rather than interposition grafting of vascular injuries. Individual surgeons chose to ignore those guidelines and subsequently demonstrated the value of the reconstructive techniques that ultimately became the standard of care. It is debated whether modifications to an accepted surgical technique in an individual patient based on their circumstances and within the skill and judg-ment of an individual surgeon should require the same type of prior approval that enrollment in a clinical trial would warrant.73 However, if a surgeon decides to use a new technique on sev-eral occasions and to study the outcomes, Institutional Review Board approval and


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Surgery_Schwartz. that enrollment in a clinical trial would warrant.73 However, if a surgeon decides to use a new technique on sev-eral occasions and to study the outcomes, Institutional Review Board approval and all other ethical requirements for research are necessary. These situations require strict oversight as well as explicit consent by the patient.74 In particular, when developing new and innovative techniques, the surgeon should work in close consultation with his or her senior colleagues, including the chairperson of the department. Frequently, more senior individuals can provide sage ethical advice regarding what constitutes minor innovative changes in a technique vs. true novel research.Compared to the formalized process for new drug approval by the Food and Drug Administration, the process for a surgeon developing an innovative operation can be relatively unregu-lated and unsupervised.The Ethics of AuthorshipAuthorship specifies who is responsible for published research. It confers both


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Surgery_Schwartz. a surgeon developing an innovative operation can be relatively unregu-lated and unsupervised.The Ethics of AuthorshipAuthorship specifies who is responsible for published research. It confers both recognition for academic achievement as well as responsibility for the academic integrity of the published con-tent. Authorship is the stock in trade of productivity for aca-demic surgeons, and it plays a significant role in promotion and tenure. It can also be commodified in the form of intellectual property and patents in which the author and the author’s insti-tution have vested interests. Yet it can also become a liability if a given piece of work becomes embroiled in accusations of plagiarism, data fabrication, or other academic misconduct.In the past, criteria for authorship were unspecified: Those submitting manuscripts simply listed the authors with little or no need to substantiate their contribution to the work. Unfortu-nately, this informal process led to confusion and even abuse.


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Surgery_Schwartz. Those submitting manuscripts simply listed the authors with little or no need to substantiate their contribution to the work. Unfortu-nately, this informal process led to confusion and even abuse. For example, there has been a long tradition of awarding author-ship to the investigator who supervised or obtained funding for research, regardless of that person’s specific contribution to the manuscript. However, current recommendations specify that supervision and funding, by themselves, are insufficient criteria for authorship, and thus such individuals should only be included as authors if they make direct contributions to the work.75,76 A more disturbing example is the practice of “ghost writing” by which senior investigators publish industry-written research under their own name to bolster their productivity while providing a luster of academic integrity to industry.To address these conflicts of interest and to provide guid-ance to investigators, the International Committee of


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Surgery_Schwartz. bolster their productivity while providing a luster of academic integrity to industry.To address these conflicts of interest and to provide guid-ance to investigators, the International Committee of Medical Journal Editors (ICMJE) provides recommendations on criteria for authorship so that individuals who contributed to the intel-lectual content of a work get appropriate credit and that all those listed as authors take responsibility and are accountable for the published work. The ICMJE recommendations for authorship can be found in Table 48-8.75 Furthermore, the ICMJE recom-mends that each author should be able to identify the contribu-tion that each other author made to the work and be confident regarding the integrity of their co-authors. The ICMJE also recommends that individuals who do not meet these criteria be acknowledged in the manuscript, providing appropriate pro-cedures for such acknowledgement. Additionally, the ICMJE Brunicardi_Ch48_p2061-p2076.indd 207319/02/19 1:49


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Surgery_Schwartz. not meet these criteria be acknowledged in the manuscript, providing appropriate pro-cedures for such acknowledgement. Additionally, the ICMJE Brunicardi_Ch48_p2061-p2076.indd 207319/02/19 1:49 PM 2074SPECIFIC CONSIDERATIONSPART IIspecifically excludes certain types of contributions including acquisition of funding, general supervision of a research group, administrative support, writing assistance, technical editing, language editing, and proofreading.75Many journals have adopted these criteria, operational-izing them at the time of submission by having each author specify his or her contributions. These contributions are then disclosed in the published manuscript to further specify how credit and responsibility is shared.77 This approach has been shown to provide valuable information and has proved feasible in several journals, including The Lancet.78As research becomes increasingly interdisciplinary with ever-expanding teams of contributors, it can be difficult to determine


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Surgery_Schwartz. and has proved feasible in several journals, including The Lancet.78As research becomes increasingly interdisciplinary with ever-expanding teams of contributors, it can be difficult to determine which contributions warrant full authorship rather than simple acknowledgement. Individuals working together on research endeavors should have clear discussions early in the planning process about authorship, and those discus-sions should be continued throughout the project or study.Clinical Ethics: Disclosure of ErrorsDisclosure of error—either in medical or research matters—is important, but often difficult (see Chapter 12). Errors of judg-ment, errors in technique, and system errors are responsible for most errors that result in complications and deaths. Hospitals are evaluated based on the number of complications and deaths that occur in surgical patients, and surgeons traditionally review their complications and deaths in a formal exercise known as the mortality and morbidity conference,


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Surgery_Schwartz. of complications and deaths that occur in surgical patients, and surgeons traditionally review their complications and deaths in a formal exercise known as the mortality and morbidity conference, or M&M. The exercise places importance on the attending surgeon’s responsibility for errors made, whether he or she made them themselves, and the value of the exercise is related to the effect of “peer pressure”— the entire department knows about the case—on reducing repeated occurrences of such an error. Although a time-honored ritual in surgery, the M&M conference is nonetheless a poor method for analyzing causes of error and for developing methods to prevent them. Moreover, the proceedings of the M&M con-ference are protected from disclosure by the privilege of “peer review,” and the details are thus rarely shared with patients or those outside the department.A report from the United States Institute of Medicine titled “To Err Is Human” highlighted the large number of medi-cal errors that


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Surgery_Schwartz. thus rarely shared with patients or those outside the department.A report from the United States Institute of Medicine titled “To Err Is Human” highlighted the large number of medi-cal errors that occur and encouraged efforts to prevent patient harm.79 Medical errors are generally considered to be “prevent-able adverse medical events.”80 Medical errors occur with some frequency, and the question is what and how should patients be informed that a medical error has occurred.81Disclosure of error is consistent with the ethical virtue of candor (e.g., transparency and openness) and the ethical prin-ciple of respect for persons by involving patients in their care. In contrast, failing to disclose errors to patients under-mines public trust in medicine and potentially compro-mises adequate treatment of the consequences of errors and effective intervention to prevent future errors. In addition, fail-ure to self-disclose medical errors can be construed as a breach of professional ethics, as


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Surgery_Schwartz. of the consequences of errors and effective intervention to prevent future errors. In addition, fail-ure to self-disclose medical errors can be construed as a breach of professional ethics, as it is a failure to act in the patient’s best interests. Information regarding a medical error may be needed so that patients can make independent and well-informed deci-sions about future aspects of their care. The principles of auton-omy and justice dictate that surgeons need to respect individuals by being fair in providing accurate information about all aspects of their care—even when an error has occurred.Disclosing one’s own errors is therefore part of the ethi-cal standard of honesty and putting the patient’s interests above one’s own. Disclosing the errors of others is more complicated and may require careful consideration and consultation. Sur-geons sometimes discover that a prior operation has included an apparent error; an injured bile duct or a stenotic anastomosis may lead to the


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Surgery_Schwartz. may require careful consideration and consultation. Sur-geons sometimes discover that a prior operation has included an apparent error; an injured bile duct or a stenotic anastomosis may lead to the condition for which the surgeon is now treating the patient. Declaring a finding as an “error” may be inaccurate, however, and a nonjudgmental assessment of the situation is usually advisable. When clear evidence of a mistake is at hand, the surgeon’s responsibility is defined by his or her obligation to act as the patient’s agent.REFERENCESEntries highlighted in bright blue are key references. 1. Aristotle. Nichomachean Ethics, Book VI. In Ackrill J, ed. A New Aristotle Reader. Princeton, NJ: Princeton University Press; 1987:416. 2. Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 3rd ed. New York: Oxford University Press; 1989. 3. Bosk C. Forgive and Remember, 2nd ed. Chicago, University of Chicago Press, 2003 (1979). 4. McCullough LB, Jones JW, Brody BA, eds. Surgical


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Surgery_Schwartz. 3rd ed. New York: Oxford University Press; 1989. 3. Bosk C. Forgive and Remember, 2nd ed. Chicago, University of Chicago Press, 2003 (1979). 4. McCullough LB, Jones JW, Brody BA, eds. Surgical Ethics. New York: Oxford University Press; 1998. 5. Faden RR, Beauchamp TL. A History and Theory of Informed Consent. New York: Oxford University Press; 1986. 6. Bernat JL, Peterson LM. Patient-centered informed consent in surgical practice. Arch Surg. 2006;141:86-92. 7. Schneider CE. The Practice of Autonomy: Patients, Doctors, and Medical Decisions. New York: Oxford University Press; 1998. 8. Robb A, Etchells E, Cusimano MD, et al. A randomized trial of teaching bioethics to surgical residents. Am J Surg. 2005;189:453-457. 9. Steinemann S, Furoy D, Yost F, et al. Marriage of professional and technical tasks: a strategy to improve obtaining informed consent. Am J Surg. 2006;191:696-700. 10. Guadagnoli E, Soumerai SB, Gurwitz JH, et al. Improving dis-cussion of surgical treatment options for


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Surgery_Schwartz. tasks: a strategy to improve obtaining informed consent. Am J Surg. 2006;191:696-700. 10. Guadagnoli E, Soumerai SB, Gurwitz JH, et al. Improving dis-cussion of surgical treatment options for patients with breast cancer: local medical opinion leaders versus audit and perfor-mance feedback. Breast Cancer Res Treat. 2000;61:171-175. 11. Braddock CH III, Edwards KA, Hasenberg NM, et al. Informed decision making in outpatient practice: time to get back to basics. JAMA. 1999;282:2313-2320. 12. Leeper-Majors K, Veale JR, Westbrook TS, et al. The effect of standardized patient feedback in teaching surgical resi-dents informed consent: results of a pilot study. Curr Surg. 2003;60:615-622. 13. Courtney MJ. Information about surgery: what does the public want to know? ANZ J Surg. 2001;71:24-26. 14. Newton-Howes PA, Dobbs B, Frizelle F. Informed con-sent: what do patients want to know? N Z Med J. 1998;111: 340-342. 15. Streat S. Clinical review: moral assumptions and the pro-cess of organ


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Surgery_Schwartz. PA, Dobbs B, Frizelle F. Informed con-sent: what do patients want to know? N Z Med J. 1998;111: 340-342. 15. Streat S. Clinical review: moral assumptions and the pro-cess of organ donation in the intensive care unit. Crit Care. 2004;8:382-388. 16. Williams MA, Lipsett PA, Rushton CH, et al. The physician’s role in discussing organ donation with families. Crit Care Med. 2003;31:1568-1573. 17. Pearson IY, Zurynski Y. A survey of personal and professional attitudes of intensivists to organ donation and transplantation. Anaesth Intensive Care. 1995;23:68-74. 18. Sulmasy DP, Lehmann LS, Levine DM, et al. Patients’ percep-tions of the quality of informed consent for common medical procedures. J Clin Ethics. 1994;5:189-194. 19. Ubel PA, Loewenstein G, Jepson C. Whose quality of life? A commentary exploring discrepancies between health state 8899Brunicardi_Ch48_p2061-p2076.indd 207419/02/19 1:49 PM 2075ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48evaluations of patients


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Surgery_Schwartz. exploring discrepancies between health state 8899Brunicardi_Ch48_p2061-p2076.indd 207419/02/19 1:49 PM 2075ETHICS, PALLIATIVE CARE, AND CARE AT THE END OF LIFECHAPTER 48evaluations of patients and the general public. Qual Life Res. 2003;12:599-607. 20. Schneider CE. After autonomy. Wake Forest Law Review. 2006;41:411. 21. Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med. 2006;166(5): 493-497. 22. Sulmasy DP, Hughes MT, Thompson RE, et al. How would terminally ill patients have others make decisions for them in the event of decisional incapacity? A longitudinal study. J Am Geriatr Soc. 2007;55:1981-1988. 23. SUPPORT Principle Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The study to under-stand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274:1591-1598. 24. Pawlik TM. Withholding and


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Surgery_Schwartz. The study to under-stand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA. 1995;274:1591-1598. 24. Pawlik TM. Withholding and withdrawing life-sustain-ing treatment: a surgeon’s perspective. J Am Coll Surg. 2006;202:990-994. 25. In re Quinlan. 355 A2d 647 (JN). Vol 429 US 9221976. 26. Cruzan vs. Director, Missouri Dept of Health, 497(1990). 27. Annas GJ. Nancy Cruzan and the right to die. N Engl J Med. 1990;323:670-673. 28. Sykes N, Thorns A. The use of opioids and sedatives at the end of life. Lancet Oncol. 2003;4:312-318. 29. Trotter JF, Adam R, Lo CM, Kenison J. Documented deaths of hepatic lobe donors for living donor liver transplantation. Liver Transpl. 2006;12(10):1485-1488. 30. Singer PA, Siegler M, Whitington PF, et al. Ethics of liver transplantation with living donors. N Engl J Med. 1989;321(9):620-622. 31. Fournier V, Foureur N, Rari E. The ethics of living donation for liver transplant: beyond donor


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Surgery_Schwartz. PF, et al. Ethics of liver transplantation with living donors. N Engl J Med. 1989;321(9):620-622. 31. Fournier V, Foureur N, Rari E. The ethics of living donation for liver transplant: beyond donor autonomy. Med Healthcare Philos. 2013;16(1):45-54. 32. Shapiro RS, Adams M. Ethical issues surrounding adult-to-adult living donor liver transplantation. Liver Transpl. 2000; 6(6 suppl 2):S77-S80. 33. Kleinman A. The Illness Narratives. Suffering, Healing & the Human Condition. New York: Basic Books; 1988. 34. Nelson KA, Walsh D, Behrens C, et al. The dying cancer patient. Semin Oncol. 2000;27:84. 35. WHO. Definition of palliative care, 2008. World Health Orga-nization. Available at: http://www.who.int/cancer/palliative/definition/en/. Accessed August 29, 2018. 36. Dunn G. Surgical palliative care. In: Mosby, ed. Current Surgical Therapy, 9th ed. Philadelphia: Elsevier; 2008. 37. Saunders C. The challenge of terminal care. In: Symington T, Carter R, eds. Scientific Foundations of Oncology.


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Surgery_Schwartz. In: Mosby, ed. Current Surgical Therapy, 9th ed. Philadelphia: Elsevier; 2008. 37. Saunders C. The challenge of terminal care. In: Symington T, Carter R, eds. Scientific Foundations of Oncology. London: Heineman; 1976:673. 38. International Association for the Study of Pain, Subcommittee on Taxonomy. Part II. Pain Terms: a current list with definitions and notes on usage. Pain. 1979;6:249. 39. Byock IR, Merriman MP. Measuring quality of life for patients with terminal illness: the Missoula-VITAS quality of life index. Palliat Med. 1998;12:231-244. 40. Christakis NA, Lamont EB. Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. BMJ. 2000;320:469-472. 41. Anderson F, Downing GM, Hill J, et al. Palliative performance scale (PPS): a new tool. J Palliat Care. 1996;12:5-11. 42. Morita T, Tsunoda J, Inoue S, et al. Validity of the palliative performance scale from a survival perspective. J Pain Symptom Manage.


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Surgery_Schwartz. scale (PPS): a new tool. J Palliat Care. 1996;12:5-11. 42. Morita T, Tsunoda J, Inoue S, et al. Validity of the palliative performance scale from a survival perspective. J Pain Symptom Manage. 1999;18:2-3. 43. Buckman R. How to Break Bad News. A Guide for Healthcare Professionals. Baltimore: Johns Hopkins University Press; 1992. 44. Kubler-Ross E. On Death and Dying. London: Routledge; 1973. 45. Twycross R, Lichter I. The terminal phase. In: Doyle D, Hanks G, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York: Oxford University Press; 1998:977. 46. Hinshaw DB. Spiritual issues in surgical palliative care. Surg Clin North Am. 2005;85:257-272. 47. Jacox A, Carr D, Payne R, et al. Management of cancer pain. AHCPR Publication No. 94-052: Clinical Practice Guideline No. 9. Rockville: US Department of Health and Human Services, Public Health Service; 1994. 48. Storey P, Knight C. UNIPAC Three: Assessment and Treat-ment of Pain in the Terminally Ill. 2nd ed. New York: Mary


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Surgery_Schwartz. US Department of Health and Human Services, Public Health Service; 1994. 48. Storey P, Knight C. UNIPAC Three: Assessment and Treat-ment of Pain in the Terminally Ill. 2nd ed. New York: Mary Ann Liebert Inc; 2003. 49. Rubenfeld GD, Crawford SW. Principles and practice of with-drawing life-sustaining treatment in the ICU. In: Curtis JR, Rubenfeld GD, eds. Managing Death in the Intensive Care Unit. New York: Oxford University Press; 2001. 50. Rousseau P. Existential distress and palliative sedation. Anesth Analg. 2005;101:611-612, 51. The EPEC-O Project, Educating Physicians in End-of-Life Care-Oncology: Module 6: Last Hours of Living. Bethesda: National Cancer Institute; 2007. 52. Worden J. Bereavement Care. Philadelphia: Lippincott Williams and Wilkins; 2002. 53. Bishop JP, Rosemann PW, Schmidt FW. Fides ancilla medici-nae: on the ersatz liturgy of death in biopsychosociospiritual medicine. Heythrop J. 2008;49:20. 54. Schroeder-Sheker T. Transitus: A Blessed Death in the Modern World.


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Surgery_Schwartz. FW. Fides ancilla medici-nae: on the ersatz liturgy of death in biopsychosociospiritual medicine. Heythrop J. 2008;49:20. 54. Schroeder-Sheker T. Transitus: A Blessed Death in the Modern World. Mt. Angel: St. Dunstan’s Press; 2001. 55. Li M, Watt S, Escaf M, et al. Medical assistance in dying—implementing a hospital-based program in Canada. N Engl J Med. 2017;376(21):2082-2088. 56. Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316:79-90. 57. Trice Loggers E, Starks H, Shannon-Dudley M, Back AL, Appelbaum FR, Stewart FM. Implementing a Death with Dignity program at a comprehensive cancer center. N Engl J Med. 2013;368:1417-1424. 58. Rhee JY, Callaghan KA, Stahl A, et al. Physician-assisted sui-cide and euthanasia is incompatible with medicine: a response from medical students. Crit Care Med. 2017;45(6):e626-e627. doi:


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Surgery_Schwartz. JY, Callaghan KA, Stahl A, et al. Physician-assisted sui-cide and euthanasia is incompatible with medicine: a response from medical students. Crit Care Med. 2017;45(6):e626-e627. doi: 10.1097/CCM.0000000000002354. 59. Vogelstein E. Evaluating the American Nurses Associa-tion’s arguments against nurse participation in assisted suicide. Nurs Ethics. 2017;969733017694619. doi: 10.1177/0969733017694619. 60. Sharpe JT. Is there a significant moral distinction between active and passive euthanasia? Critique. 2011;5:11-16. 61. Buchbinder M. Aid-in-dying laws and the physician’s duty to inform. J Med Ethics. 2017;43(10):666-669. doi: 10.1136/medethics-2016-103936. 62. Goligher EC, Ely EW, Sulmasy DP, et al. Physician-assisted suicide and euthanasia in the ICU: a dialogue on core ethi-cal issues. Crit Care Med. 2017;45(2):149-155. doi: 10.1097/CCM.0000000000001818. 63. Emmanuel EJ, Wendler D, Grady C. What makes clinical research ethical? JAMA. 2000;283:2701-2711. 64. Freedman B. Equipoise and


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Surgery_Schwartz. Care Med. 2017;45(2):149-155. doi: 10.1097/CCM.0000000000001818. 63. Emmanuel EJ, Wendler D, Grady C. What makes clinical research ethical? JAMA. 2000;283:2701-2711. 64. Freedman B. Equipoise and the ethics of clinical research. N Engl J Med. 1987;317:141-145. 65. Meakins J. Innovation in surgery. The rules of evidence. Am J Surg. 2002;183:399-405. 66. Lefering R, Neugebauer E. Problems of randomized controlled trials in surgery. Paper presented at: Nonrandomized Compara-tive Clinical Studies. Heidelberg, 1997. 67. Flum DR. Interpreting surgical trials with subjective out-comes: avoiding UnSPORTsmanlike conduct. JAMA. 2006;296:2483-2485.Brunicardi_Ch48_p2061-p2076.indd 207519/02/19 1:49 PM 2076SPECIFIC CONSIDERATIONSPART II 68. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81. Summary for patients in: J Fam Pract. 2002;51:813. 69. Angelos PA. Sham surgery in research: a surgeon’s view.


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Surgery_Schwartz. trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81. Summary for patients in: J Fam Pract. 2002;51:813. 69. Angelos PA. Sham surgery in research: a surgeon’s view. Am J Bioeth. 2003;3:65-66. 70. Miller FG. Sham surgery: an ethical analysis. Sci Eng Ethics. 2004;10:157-166. 71. Angelos P. Sham surgery in clinical trials. JAMA. 2007;297:1545-1546, author reply 1546. 72. Riskin DJ, Longaker MT, Gertner M, et al. Innovation in sur-gery: a historical perspective. Ann Surg. 2006;244:686-693. 73. Biffl WL, Spain DA, Reitsma AM, et al. Responsible develop-ment and application of surgical innovations: a position state-ment of the Society of University Surgeons. J Am Coll Surg. 2008;206(6):1204-1209. 74. McKneally MF, Daar AS. Introducing new technologies: pro-tecting subjects of surgical innovation and research. World J Surg. 2003;27:930-934. 75. International Committee of Medical Journal Editors. Defin-ing the role of authors and contributors. Available at:


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Surgery_Schwartz. subjects of surgical innovation and research. World J Surg. 2003;27:930-934. 75. International Committee of Medical Journal Editors. Defin-ing the role of authors and contributors. Available at: http://www.icmje.org/recommendations/browse/roles-and-respon-sibilities/defining-the-role-of-authors-and-contributors.html> Accessed August 29, 2018. 76. Eggert LD. Best practices for allocating appropriate credit and responsibility to authors of multi-authored articles. Front Psychol. 2011;2:196. 77. Rennie D, Yank V, Emanuel L. When authorship fails. A proposal to make contributors accountable. JAMA. 1997;278(7):579-585. 78. Yank V, Rennie D. Disclosure of researcher contributions: a study of original research articles in The Lancet. Ann Intern Med. 1999;130(8):661-670. 79. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington: National Academy Press; 2000. 80. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in


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Surgery_Schwartz. JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington: National Academy Press; 2000. 80. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370-376. 81. Hebert PC, Levin AV, Robertson G. Bioethics for clinicians: 23. Disclosure of medical error. CMAJ. 2001;164:509-513.Brunicardi_Ch48_p2061-p2076.indd 207619/02/19 1:49 PM


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Surgery_Schwartz. Global SurgeryKatherine E. Smiley, Haile T. Debas, Catherine R. deVries, and Raymond R. Price 49chapterINTRODUCTIONModern surgery can save lives, help expand economies, and offer hope to individuals and communities. Prior to the accep-tance and availability of aseptic technique to prevent or decrease infections, and improved anesthesia for controlling pain, sur-gery as a specialty was held in very low esteem by medical doc-tors and the general public. Over the last 100 years, surgery has developed into a highly regarded discipline that not only pro-vides opportunities for curing certain diseases but also fulfills a special role in preventing and mitigating disability.Yet, surgery is currently unavailable to most people world-wide. The vast majority—90%—of the world’s population receives only 10% of the surgical care delivered. Said another way, 90% of surgical resources are consumed by the most privi-leged 10% of the world’s population. More than 5 billion people lack access to safe,


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Surgery_Schwartz. 10% of the surgical care delivered. Said another way, 90% of surgical resources are consumed by the most privi-leged 10% of the world’s population. More than 5 billion people lack access to safe, timely, and affordable surgical care.1 Very few surgical procedures occur in countries spending less than U.S. $100 per person on health care per year compared to coun-tries spending greater than U.S. $1000 per person (Fig. 49-1).2Examples of disparities abound. In many countries, including the wealthiest, islands of poverty coexist within cities replete with material resources. Tertiary level hospitals operate within eyesight of slums whose inhabitants have no access to even basic care. Most of the people without access—people in rural areas and in countries with poor infrastructure—are the very people most at risk for death or disability due to lack of surgical care. Often the poor accept and endure many painful and potentially correctable fatal conditions as a fact of life.3-6 Care for


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Surgery_Schwartz. people most at risk for death or disability due to lack of surgical care. Often the poor accept and endure many painful and potentially correctable fatal conditions as a fact of life.3-6 Care for trauma and obstetrical emergencies is considered a basic surgical need but is absent in many rural regions. Other chronic conditions—often equally debilitating—progress to death or serious disability due to lack of available, safe surgery and anesthesia.Many factors contribute to the disparity in access to surgi-cal care. Poverty, a primary risk factor for all types of diseases, is a major obstacle hindering access to surgery. Healthcare pro-fessionals, including surgeons, migrate from areas of need due to a lack of infrastructure (hospitals, roadways, and stable elec-trical sources), limited supplies and equipment, lack of human resources, few opportunities for professional development, and concerns for personal safety. Until recently, there has been a significant lack of information


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Surgery_Schwartz. supplies and equipment, lack of human resources, few opportunities for professional development, and concerns for personal safety. Until recently, there has been a significant lack of information regarding the burden of surgical disease and surgery’s positive impact on communities. Current research substantiates that investment in surgical care improves economies and is an integral and necessary component of global health.7,8Disparities in care and outcomes are multidimensional, and no simple solution exists to improve access to appro-priate and affordable surgical care. Yet, five major forces are reshaping priorities and strategies leading the charge for the globalization of surgical care.1. The epidemiologic transition of diseases from primarily in-fectious to more chronic conditions2. The mobile nature of the world’s populations, allowing peo-ple to move freely between more isolated areas of the world, leading to a more integrated global community3. Ubiquitous information access


Surgery_Schwartz

Surgery_Schwartz. mobile nature of the world’s populations, allowing peo-ple to move freely between more isolated areas of the world, leading to a more integrated global community3. Ubiquitous information access exponentially enabling wide-spread participation in understanding and designing innova-tive opportunities for high-quality surgical care4. A revolution for equity and human rights where the world’s poor are demanding benefits to surgical care similar to those found in high-income countries (HICs)5. Recognition of the cost-effectiveness of surgical care and its potential to build economies, demonstrating the value of in-cluding surgery in global health strategies9-12The greatest burden of disease occurs in areas where human resources—physicians, nurses, pharmacists, and other healthcare workers—are scarce (Fig. 49-2).13 The proportion of physicians is low both in high-population areas and in areas where the population is growing most rapidly (Fig. 49-3).14,15 Fully trained surgeons and


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Surgery_Schwartz. scarce (Fig. 49-2).13 The proportion of physicians is low both in high-population areas and in areas where the population is growing most rapidly (Fig. 49-3).14,15 Fully trained surgeons and anesthesiologists comprise only a small proportion of the total number of the Human Resources in Health (HRH), and efforts to meet the 12Introduction 2077Defining Global Surgery 2079Global Surgery Ecosystem / 2079Human Resources / 2081Burden of Surgical Disease / 2081Strategies for Development 2086Essential Surgery: Current and Evolving Concepts / 2086Outreach and Engagement / 2087International Organizations / 2088Global Surgery and Public Health / 2091Cancer Initiatives / 2098Integrating Value into Global Surgery / 2102Advanced Surgical Care for Resource-Poor Areas / 2102Academic Global Surgery / 2103Ethics / 2105Innovation in Global Surgery / 2106The Future for Global Surgery 2106Brunicardi_Ch49_p2077-p2112.indd 207713/02/19 5:53 PM 2078surgical needs are now embracing a multifaceted


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Surgery_Schwartz. / 2103Ethics / 2105Innovation in Global Surgery / 2106The Future for Global Surgery 2106Brunicardi_Ch49_p2077-p2112.indd 207713/02/19 5:53 PM 2078surgical needs are now embracing a multifaceted approach, including advanced care practitioners. The Lancet Commission on Global Surgery estimates that an additional 143 million sur-gical procedures are needed each year in LMICs to prevent death and disability caused by lack of care.16The potential benefits of surgical care for economic pro-ductivity are astounding. Considering that the annual eco-nomic loss from road traffic injuries alone exceeds U.S. $500 billion globally, a panel of expert economists at the Copenhagen Consensus of 2012, including four Nobel prize lau-reates, prioritized strengthening surgical capacity as the eighth most cost-effective investment for addressing the world’s most pressing problems. The Consensus reconvened in 2015, syn-chronizing their recommendations to the United Nations’ Sus-tainable Development


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Surgery_Schwartz. cost-effective investment for addressing the world’s most pressing problems. The Consensus reconvened in 2015, syn-chronizing their recommendations to the United Nations’ Sus-tainable Development Goals, and reaffirmed that surgery-related initiatives (i.e., circumcision and skilled obstetrical support), offer the best “value-for-money” in terms of alleviating world poverty.17-19 The Lancet Commission on Global Surgery, a research and advisory working group with contributors from 110 nations, echoed these sentiments. Surgery should be viewed as an investment rather than a cost.16,20Much of the economic modeling and strengthening of political will related to surgical and anesthesia care has been carried out by collaborative groups and consortia including aca-demic, nongovernmental, and other organizations. The efforts of these groups truly coalesced in 2015, when several major consensus statements from governmental organizations, such as the World Bank and the World Health Assembly,


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Surgery_Schwartz. organizations. The efforts of these groups truly coalesced in 2015, when several major consensus statements from governmental organizations, such as the World Bank and the World Health Assembly, recognized the importance of surgery in public health for the first time. 3$100$101-400$401-1000> $100012,00010,00080006000400020000Number of procedures/100,000 populationUS dollars/person healthcare/yearFigure 49-1. Worldwide distribution of surgical procedures. (Data from Weiser TG, Regenbogen SE, Thompson KD, et al. An estima-tion of the global volume of surgery: a modelling strategy based on available data, Lancet. 2008 Jul 12;372(9633):139-144.)Key Points1 There are five major forces reshaping priorities and strate-gies for the globalization of surgical care:a. The epidemiologic transition of diseasesb. The mobile nature of the world’s populationsc. Ubiquitous information accessd. A revolution for equity and human rightse. Recognition of the cost-effectiveness of surgical care for


Surgery_Schwartz

Surgery_Schwartz. of diseasesb. The mobile nature of the world’s populationsc. Ubiquitous information accessd. A revolution for equity and human rightse. Recognition of the cost-effectiveness of surgical care for treatment and prevention of disease2 The burden of disease is greatest in areas where human resources—physicians, nurses, pharmacists, and other healthcare workers—are the least.3 Surgery should be viewed as an investment rather than a cost.4 The key components of the global surgery ecosystem include technology, education, community, healthcare, business, and multidisciplinary engagement between a variety of disciplines.5 Understanding and addressing the necessary communica-tion, energy, and transportation technologies along with the underlying cultural context represent the foundation critical to implementing sustainable infrastructure for appropriate surgical care.6 There has been a significant shift from communicable, maternal, neonatal, and nutritional causes of disease to noncommunicable


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Surgery_Schwartz. implementing sustainable infrastructure for appropriate surgical care.6 There has been a significant shift from communicable, maternal, neonatal, and nutritional causes of disease to noncommunicable causes, many of which require surgi-cal care.7 Patients and their communities in lowand middle-income countries (LMICs) bear a much greater share of the burden of cancer than high-income countries (HICs).8 Globally, trauma has become a leading cause of death and disability; 90% of trauma deaths occur in LMICs.9 Essential surgical services should be integrated into com-prehensive health care delivery, with the potential to avert 1.5 million deaths per year in LMICs.10 Surgery is gaining an increasingly recognized role for improving public health, having a role in prevention as well as treatment.11 The cost-effectiveness of surgical care has been demon-strated, and its value as a public health investment is increasingly understood by policymakers.12 Developing capabilities for surgical care


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Surgery_Schwartz. cost-effectiveness of surgical care has been demon-strated, and its value as a public health investment is increasingly understood by policymakers.12 Developing capabilities for surgical care has the ability to promote system-strengthening in resource-poor countries and to mitigate migration of health professionals at all levels.13 Academic global surgery provides a unique environment to study health systems, identify solutions and implement them collaboratively, fulfilling many institutions’ mis-sions to strengthen multidisciplinary training, advocacy, and research.14 Surgical innovations that bring value by balancing cost with quality designed for challenging energy environ-ments will foster equity in surgical care for LMICs.Brunicardi_Ch49_p2077-p2112.indd 207813/02/19 5:53 PM 2079GLOBAL SURGERYCHAPTER 49The third edition of World Bank’s Disease Control Priorities (DCP3) and the World Health Assembly’s Resolution 68.15 both specifically discuss the vital nature of surgical care


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Surgery_Schwartz. SURGERYCHAPTER 49The third edition of World Bank’s Disease Control Priorities (DCP3) and the World Health Assembly’s Resolution 68.15 both specifically discuss the vital nature of surgical care as part of any health system.7,21 Such resolutions represent a sea change in terms of how the global policy community views surgical care for LMICs and, indeed, the entire world.This chapter examines the ongoing need to expand and strengthen surgical care globally, explores some of the signifi-cant challenges of global surgery, and presents potential guid-ing concepts along with examples of successful strategies for sustainable surgical development.DEFINING GLOBAL SURGERYGlobal Surgery EcosystemTo understand how surgery fits into healthcare systems and to understand its unique needs, it is helpful to consider global surgery as an ecosystem. The emerging field of global surgery considers surgical care to be a fundamental component of global health. As a system with both local and international


Surgery_Schwartz

Surgery_Schwartz. to consider global surgery as an ecosystem. The emerging field of global surgery considers surgical care to be a fundamental component of global health. As a system with both local and international scope, global surgery encompasses not just the medical and technical aspects of surgical care, but also the societal and environmental context in which surgery is per-formed. Global surgery also refers to a worldwide lens through which we view challenges collaboratively; thus, global sur-geons may focus on resource-limited areas where needs are profound, but the ultimate goal should be to make surgical care equitable, accessible, and affordable for every human being.22 Surgery as an ecosystem considers the diverse but interrelated systems that must be functional for quality surgical care to be delivered. Only part of these systems falls within the tradi-tional training of surgeons. Yet, modern surgical care requires these systems to work in a coordinated fashion to support three priorities


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Surgery_Schwartz. delivered. Only part of these systems falls within the tradi-tional training of surgeons. Yet, modern surgical care requires these systems to work in a coordinated fashion to support three priorities critical for expanding surgery globally—accessibility, affordability, and innovation (Fig. 49-4). Global surgery is a way to consider a “systems-based practice” beyond a single hospital or community, for the benefit of people worldwide. Many interrelated components of this surgical ecosystem orig-inate outside the hospital.Disparities in surgical care have geographical, socioeco-nomic, and cultural components. Most people who live in major cities in the northern and western hemispheres take for granted a functioning energy grid. The development of energy beyond major cities has enabled wealthier communities to imagine, and indeed, to expect healthcare to be available at all times and affordable. Yet, a lack of reliable energy sources is a major limiting factor. Communication and


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Surgery_Schwartz. wealthier communities to imagine, and indeed, to expect healthcare to be available at all times and affordable. Yet, a lack of reliable energy sources is a major limiting factor. Communication and transportation technologies, for example, the mobile phone and air and ground travel, have dramatically progressed in highand middle-income countries but are still rudimentary in poor countries. Many of the current disparities in health care, particularly surgical care, are due to the lack of penetration of these technologies. Under-standing and addressing the necessary communication, energy, and transportation deficits as well as the underlying cultural nuances are necessary to support the sustainable development of surgical care.Electricity is necessary for all modern surgery. Anesthe-sia monitoring, operating room lighting, cautery, suction, and patient warming devices all require sources of electricity that are stable, without huge electrical surges. Only in the last 50 years or so could


Surgery_Schwartz

Surgery_Schwartz. operating room lighting, cautery, suction, and patient warming devices all require sources of electricity that are stable, without huge electrical surges. Only in the last 50 years or so could stable electricity be expected in most wealthy cities. However, in rural areas of even wealthy countries, electricity remains unpredictable (Fig. 49-5).23In poorer countries, the cost and availability of electric-ity is frequently the limiting factor for more advanced diagnos-tic and therapeutic technology—from laboratories that require refrigeration to radiology in all of its various branches. Modern design for surgical devices has, for the most part, not taken into account the wide range of energy environments where surgery is practiced. Fragile instruments and monitors that cannot survive the rigors of the real working environment limit the types of surgery that can be provided.4535302520151050Percent of global disease burdenPercent of global


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Surgery_Schwartz. and monitors that cannot survive the rigors of the real working environment limit the types of surgery that can be provided.4535302520151050Percent of global disease burdenPercent of global workforceAmericasEuropeWesternPacificSouth-EastAsiaAfricaEasternMediterranean* Even with grants and loans from abroad.054045303520251015Africa suffers from 24% of the global burden of disease but has access to only 3% of health workers and less than 1% of the world's financial resources.*Figure 49-2. Distribution of healthcare workers by burden of disease in WHO regions. (Reproduced with permission from Intermountain Healthcare.)Brunicardi_Ch49_p2077-p2112.indd 207913/02/19 5:53 PM 2080SPECIFIC CONSIDERATIONSPART IIComponents of the Global Surgery Ecosystem. Improve-ments in energy, transportation, and communication are criti-cal to support the growth of surgical care.9 Building capacity for surgical care requires interaction between the various com-ponents that create a functioning,


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Surgery_Schwartz. and communication are criti-cal to support the growth of surgical care.9 Building capacity for surgical care requires interaction between the various com-ponents that create a functioning, sustainable system. When surgeons think of surgery, they usually think in terms of science and hands-on technical expertise. However, global surgery requires a broader understanding of systems in other disciplines. Surgeons must work collaboratively with engineers and busi-ness leaders to develop technology that can function in lower 0–1717–3434–50Physicians (per 10,000 population)2005–201050–67200,000,000–600,000,0000–200,000,000600,000,000–1,400,000,000Population20120.48%–1.96%1.96%–3.45%3.45%–4.93%Population growth rate2012–1.01%– –0.48%Figure 49-3. Number of physicians, world populations, and world population growth rates. (Reproduced with permission from World Health Organization, 2018 (Density of Physicians [total number per 1000 population]); 2013 World Population Data Sheet Interactive Map;


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Surgery_Schwartz. population growth rates. (Reproduced with permission from World Health Organization, 2018 (Density of Physicians [total number per 1000 population]); 2013 World Population Data Sheet Interactive Map; World Bank, population growth (annual %) map.)Brunicardi_Ch49_p2077-p2112.indd 208013/02/19 5:53 PM 2081GLOBAL SURGERYCHAPTER 49resource environments. These innovations can provide a source of economic growth for the community, which in turn supports better health care (Fig. 49-6).No sustainable surgical system in the modern age can function without specialists in bioengineering, sterile process, supply chain, hospital safety, and waste management. These often unappreciated colleagues make possible the daily practice of surgery. Similarly, specialists in anesthesia, nursing, and the diagnostic specialties of radiology, pathology, and laboratory services are fundamental to a fully functional surgical service.Human ResourcesPrimary care physicians, nurses, midwives, or advanced care


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Surgery_Schwartz. specialties of radiology, pathology, and laboratory services are fundamental to a fully functional surgical service.Human ResourcesPrimary care physicians, nurses, midwives, or advanced care practitioners (ACPs) provide much of the basic surgical and anesthetic care in LMICs. Where regulations allow, “task sharing,” or training ACPs to deliver surgery and anesthesia services previously allowed only under the purview of fully trained specialists, can provide expanded access to care.24-26 Non-MD practitioners, known as assistant medical officers (AMOs) or “tecnicos de cirurgia” in Mozambique, often have extensive operative experience, including obstetrical care, and are the pri-mary surgical providers in some regions.27-29 Task sharing with ACPs also occurs in the United States and other countries where they fill a need otherwise unmet by specialists even in major tertiary care centers.30 However, concerns about the quality of care, lack of adequate supervision, and the effect on


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Surgery_Schwartz. countries where they fill a need otherwise unmet by specialists even in major tertiary care centers.30 However, concerns about the quality of care, lack of adequate supervision, and the effect on prestige and professional development for specialists and ACPs, continue to be topics for debate.31,32Migration of practitioners to economically and culturally favorable locales is universal and not restricted to low-resource countries.33,34 However, the net impact on poor countries is greater. In a 2004 study, more than 23% of U.S. physicians received their medical training from other countries; of these 64% were from low-income countries.35 Using 2013 data, another study showed annual emigration rates of sub-Saharan physicians to the United States are increasing, despite a World Health Organization Global Code of Practice in 2010 aimed at LMIC workforce retention.36 Investments in training greater numbers of doctors in these countries, including surgical spe-cialists, have been only


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Surgery_Schwartz. Global Code of Practice in 2010 aimed at LMIC workforce retention.36 Investments in training greater numbers of doctors in these countries, including surgical spe-cialists, have been only partially successful in meeting demand in poor countries. Until economic conditions improve or oppor-tunities for professional development increase, and incentives enticing migration of health care workers to high-income countries abate, it is unlikely that the most skilled practitio-ners will remain in resource-poor areas beyond their immediate obligations.37-41Burden of Surgical DiseaseEpidemiologic Transition of Disease. The population on Earth currently stands at more than 7 billion. While the rate of growth has slowed in recent years, projections estimate that AccessibilityAffordabilityInnovationGLOBALSURGERYFigure 49-4. Global surgery priorities. (Reproduced with permission from University of Utah Center for Global Surgery and Intermountain Healthcare.)Figure 49-5. Map of world electrification.


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Surgery_Schwartz. 49-4. Global surgery priorities. (Reproduced with permission from University of Utah Center for Global Surgery and Intermountain Healthcare.)Figure 49-5. Map of world electrification. (Reproduced with permission from NASA, Visible Earth, Available at: http://visibleearth.nasa.gov/view.php?id=79765.)Brunicardi_Ch49_p2077-p2112.indd 208113/02/19 5:53 PM 2082SPECIFIC CONSIDERATIONSPART IIthe population will continue to grow to 9 billion by 2050.42 Population characteristics are changing rapidly. According to United Nations’ estimates, the entire world is aging even in low-income countries, and by 2050, 2 billion people will be over the age of 60. Currently, Asia is home to 55% of the world’s population over the age of 60.43 Just before the year 2020, the percentage of the world’s population over age 65 years is predicted to surpass the percentage of children under age 5 years, on an unprecedented reversal of trajectories for both age demographics. While this represents a victory for


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Surgery_Schwartz. over age 65 years is predicted to surpass the percentage of children under age 5 years, on an unprecedented reversal of trajectories for both age demographics. While this represents a victory for infectious disease control, the dramatic increase in longevity will present new challenges in terms of treating noncommu-nicable disease in the older adult population.44 At the same time, Sub-Saharan Africa’s population is experiencing a much different trend: a current “baby boom” will lead the region to quadruple its population, from 960 million to 4 billion, by the year 2100.45Until recently, infectious diseases dominated public health strategy. Now with major scourges like polio isolated to rela-tively small regions of the world, and HIV and malaria decreas-ing in their relative impact worldwide, chronic diseases and their complications, as well as the effects of aging, are gaining dominance in health care needs. Many of these chronic diseases are best approached by surgery.The lack of


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Surgery_Schwartz. chronic diseases and their complications, as well as the effects of aging, are gaining dominance in health care needs. Many of these chronic diseases are best approached by surgery.The lack of metrics and paucity of data identifying the unmet burden of surgical need in many countries have been obstacles facing global surgery initiatives. The 2010 Global Burden of Disease Study was the first worldwide comprehensive burden of disease evaluation since the initial 1990 epidemiologic study. Using the disability-adjusted life year (DALY), a metric that captures both premature mortality and the prevalence and severity of illnesses, disease burdens were calculated for 291 causes in 21 regions of the world (including 187 countries) for 1990, 2005, and 2010 to enable identification of significant trends over time.46 While the global DALYs remained stable from 1990 to 2010, the study identified a significant shift from communicable, maternal, neonatal, and nutritional causes of disease to


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Surgery_Schwartz. trends over time.46 While the global DALYs remained stable from 1990 to 2010, the study identified a significant shift from communicable, maternal, neonatal, and nutritional causes of disease to noncommuni-cable causes (Fig. 49-7).47In 2015, the previous estimate by the second edition of Disease Control Priorities in 2006 of an 11% global surgical dis-ease burden was updated to 30%, obtained from provider-based survey data from the Lancet Commission.1,10 Using country-wide population surveys (the Surgeons OverSeas Assessment of Surgical Need Survey [SOSAS]) in Sierra Leone, Rwanda, and Nepal, the overall presence of surgically treatable condi-tions was 11.2%, with 25.6% of deaths potentially avoidable had surgical care been available. Applying these percentages to the 48 low-income countries, as defined by the World Bank, suggests that there are 288.2 million people currently living with surgically treatable conditions; providing improved access to surgical care could prevent 5.6


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Surgery_Schwartz. as defined by the World Bank, suggests that there are 288.2 million people currently living with surgically treatable conditions; providing improved access to surgical care could prevent 5.6 million deaths per year.48-50 Untreated acute and chronic surgical conditions represent a sig-nificant unmet burden of disease that has major impact on the economies of these nations.7,16,51Cancer. Patients and their communities in LMICs bear a much greater share of the burden of cancer than HICs. The dramatic increase in the proportion of reported cancer cases in LMICs is a result of population growth, aging populations, and decreased mortality from infectious diseases. In 1970, only 15% of newly reported cancer cases worldwide were from the developing world; by 2008, this proportion rose dramatically to 58% and is expected to grow to 70% by 2030.52 Since 2013, the second leading cause of death world-wide has been cancer, and an estimated 20% of all global surgery is now cancer-related.53


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Surgery_Schwartz. to 58% and is expected to grow to 70% by 2030.52 Since 2013, the second leading cause of death world-wide has been cancer, and an estimated 20% of all global surgery is now cancer-related.53 Previously thought to be a 67ElectricityLaundrySupply chainKnowledgeCultureHealthcareFamily supportGeographyPatientRoad/travel infrastructurePre-hospital careSpiritualityExpectationsLaboratory servicesHospital safetyAdministrationBusinessHealthcarePublic healthInsurersRegulatory agenciesTechnologyPublic policyEducationSURGICALECOSYSTEMBioengineeringWaste managementSterile processingAnesthesiologyRadiologyNursingPharmacyPathologyRESOURCESCOMMUNITYMULTIDISCIPLINARY ENGAGEMENTSURGICAL CARE INFRASTRUCTUREValue-driven outcomesPatient-centered careFigure 49-6. The global surgery ecosystem requires broad integration of many fields in a multidisciplinary context. (Reproduced with permission from Intermountain Healthcare.)Brunicardi_Ch49_p2077-p2112.indd 208213/02/19 5:53 PM 2083GLOBAL SURGERYCHAPTER


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Surgery_Schwartz. of many fields in a multidisciplinary context. (Reproduced with permission from Intermountain Healthcare.)Brunicardi_Ch49_p2077-p2112.indd 208213/02/19 5:53 PM 2083GLOBAL SURGERYCHAPTER 49disease almost exclusive to high-income countries, nearly two-thirds of the 7.6 million cancer deaths worldwide occur in LMICs. Mortality from cancer correlates inversely with a country’s economy for certain treatable cancers, including breast, testicular, and cervical cancer—LMICs have higher case fatality rates than HICs (Fig. 49-8).52,54For example, breast cancer case fatality rates illustrate the great disparity in outcomes between regions. Case fatality rates in East Africa reach an unacceptable 59% compared to 19% in the United States.54 In LMICs, patients have very lim-ited access to screening. They present for care with much later stages of cancer. In Haiti, after the great earthquake in 2010, with its initial onslaught of orthopedic injuries, many aid orga-nizations found themselves


Surgery_Schwartz

Surgery_Schwartz. They present for care with much later stages of cancer. In Haiti, after the great earthquake in 2010, with its initial onslaught of orthopedic injuries, many aid orga-nizations found themselves faced with the unmet underlying burden of disease, including late-stage breast cancer and other tumors (Fig. 49-9). The DCP3 has devoted an entire chapter to cancer screening in LMICs, emphasizing the importance of proper infrastructure for screening and treatment, as well as considering cost-effectiveness and ethical concerns related to screening and subsequent treatment of detected cancers.55 The number and quality of training programs in surgical oncology is also inversely related to a country’s income, leaving LMICs with few adequately trained providers. Collaborative training programs between HIC and LMIC centers, as well as tele-teaching and mobile consultation, may address this shortage in a relatively low-cost, high-impact way.56Trauma. Trauma has become a leading cause of death (5.8


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Surgery_Schwartz. HIC and LMIC centers, as well as tele-teaching and mobile consultation, may address this shortage in a relatively low-cost, high-impact way.56Trauma. Trauma has become a leading cause of death (5.8 million people per year) and disability around the world; 90% of trauma deaths occur in LMICs.57 Approximately 32% more people die as a result of injuries than from malaria, tuberculosis, and HIV/AIDS combined, representing 10% of the world’s deaths (Fig. 49-10).58,59 The major causes of death from injuries are road traffic accidents (RTAs), suicides, homicides, falls, drownings, and burns; in every category except burns, almost twice as many men die compared to women.60847354354101119902010% Worldwide DALYsCommunicable, maternal, neonatal, nutritionalNoncommunicableInjuriesFigure 49-7. Shift in disease burden 1990–2010. (Reproduced with permission from Intermountain Healthcare.)ThyroidHighHigh-middleLow-middleLow0.80.60.40.20.0Ratio of mortality to incidenceIncome


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Surgery_Schwartz. 49-7. Shift in disease burden 1990–2010. (Reproduced with permission from Intermountain Healthcare.)ThyroidHighHigh-middleLow-middleLow0.80.60.40.20.0Ratio of mortality to incidenceIncome classBreastCervicalTesticularProstateColorectalFigure 49-8. Ratio of mortality to incidence by solid tumor type and country income (2008). (Reproduced with permission from Intermountain Healthcare.)Brunicardi_Ch49_p2077-p2112.indd 208313/02/19 5:53 PM 2084SPECIFIC CONSIDERATIONSPART IIOver 1.25 million people die from RTAs, causing LMICs to lose 3% of their GDP; 50 million more people incur nonfatal injuries, many with resulting lifelong disabilities.61 Globally, RTAs are the main cause of death for young people between the ages of 15 and 29. Forty-nine percent of all traffic deaths are among pedestrians, cyclists, and motorcycles.62 In the United States, a patient presenting with an injury in a rural community has a higher mortality than those from an urban setting.63 This disparity is much more


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Surgery_Schwartz. cyclists, and motorcycles.62 In the United States, a patient presenting with an injury in a rural community has a higher mortality than those from an urban setting.63 This disparity is much more pronounced in eco-nomically disadvantaged societies, where seriously injured patients from road traffic accidents are twice as likely to die compared to similarly injured patients in a high-income set-ting (Fig. 49-11).58,64 Additionally, death is much more likely to occur in the prehospital settings for injured patients from low-income countries. The lack of integrated communication and emergency transportation systems contribute to prehospital risk, while the lack of infrastructure, supplies, and personnel contribute to inhospital mortality.The number of deaths from RTAs has remained the same between 2007 and 2013. The predicted increase in mortality from RTAs, expected from the increase in population and global motorization, did not materialize, suggesting that interventions to improve


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Surgery_Schwartz. between 2007 and 2013. The predicted increase in mortality from RTAs, expected from the increase in population and global motorization, did not materialize, suggesting that interventions to improve global road safety (i.e., The Decade of Action for Road Safety 2011–2020) may be having some success in pre-venting deaths from RTAs.62Burns. The World Health Organization estimates that 265,000 people die of burn injuries each year, mostly (95%) from LMICs; the vast majority never present for medical care.65 Scalds and electrical burns represent another significant source of death and disability. Women and children in LMICs are most likely to be burned in domestic kitchens; men are more likely to be burned in the workplace. The economic and social impact from long hospitalizations and from the resulting disfigurement provides a significant negative stigma causing ostracism and rejection.Of all the forms of trauma worldwide, burns are the only type that predominantly afflict women and


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Surgery_Schwartz. the resulting disfigurement provides a significant negative stigma causing ostracism and rejection.Of all the forms of trauma worldwide, burns are the only type that predominantly afflict women and children. Southeast Asia accounts for 27% of burn-related deaths worldwide; 70% of people dying from burns in this region are women.66 Cooking on wood, charcoal, or low kerosene stoves also puts children at risk, particularly from scalding (Fig. 49-12). Small children in the WHO African region have triple the number of burn deaths as children worldwide. Con-trast this with the United States, where more burns and burn deaths affect men.People living in rural areas suffer disproportionately because there are fewer facilities capable of managing the acute and chronic aspects of burns and because the population is gen-erally poorer. Surgical grafting and management of contractures is often best done in specialized burn centers, but these are rare in LMICs. Telemedicine has been shown to be


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Surgery_Schwartz. the population is gen-erally poorer. Surgical grafting and management of contractures is often best done in specialized burn centers, but these are rare in LMICs. Telemedicine has been shown to be effective in man-aging burns and preventing complications, and now, in the era of high resolution mobile phones, it can effectively diagnose and triage many burn patients appropriately.67 Telemedicine can also be useful in providing much-needed education of rural providers in basic burn care (Box: Telemedicine and Tele-education at the University of Utah).6801234567Deaths per year (millions)InjuryHIV/AIDS, TB, and malariaInjuries and violence:the scale of the problemFigure 49-10. Injuries and violence: the scale of the problem. (Reproduced with permission from World Health Organization, Geneva. Injuries and violence: the facts. http://www.who.int/ violence_injury_prevention/key_facts/VIP_key_fact_1.pdf.)Figure 49-9. Underlying unmet cancer burden in Haiti (2010). (Reproduced with permission


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Surgery_Schwartz. Injuries and violence: the facts. http://www.who.int/ violence_injury_prevention/key_facts/VIP_key_fact_1.pdf.)Figure 49-9. Underlying unmet cancer burden in Haiti (2010). (Reproduced with permission from Intermountain Healthcare. Photo contributor: R. Dirk Noyes, MD.)Brunicardi_Ch49_p2077-p2112.indd 208413/02/19 5:54 PM 2085GLOBAL SURGERYCHAPTER 49Figure 49-11. Change in traffic fatality risk (deaths per 10,000 persons, 1975–1998). (Reproduced with permission from Intermountain Healthcare.)Telemedicine and Tele-education at the University of UtahThe University of Utah’s Burn Center has utilized Project ECHO (Extension for Community Healthcare Outcomes), an HIPAA-compliant tele-education platform developed at the University of New Mexico. Project ECHO provides live, free, interactive educational materials to rural physicians, nurses, and EMTs in eight surrounding states.69 This model has been expanded internationally through the University of New Mexico to 21 countries, with the


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Surgery_Schwartz. educational materials to rural physicians, nurses, and EMTs in eight surrounding states.69 This model has been expanded internationally through the University of New Mexico to 21 countries, with the potential to drastically improve the knowledge base of providers in many resource-limited settings.70Direct patient care has also been achieved at the University of Utah’s Burn Center, through their Telemedicine outreach program. “TeleBurn” currently provides approximately 400 video consultations per year, serving 80 sites in five surrounding states that lack specialized burn care. For a region like the Intermountain West, where travel can be limited by inclement weather and long distances, the TeleBurn program provides better access to specialty care, at lower costs to patients.71Figure 49-12. Domestic kitchen: risk factor for burns in women and children in LMICs. (Used with permission from James H. Kenney, Jr.)CanadaAustriaFranceIndiaChinaUnited


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Surgery_Schwartz. at lower costs to patients.71Figure 49-12. Domestic kitchen: risk factor for burns in women and children in LMICs. (Used with permission from James H. Kenney, Jr.)CanadaAustriaFranceIndiaChinaUnited StatesColumbiaBotswana400350250200150100500–50–100High income countriesLow income countriesHigh income countriesLow income countriesPercentage changeBrunicardi_Ch49_p2077-p2112.indd 208513/02/19 5:54 PM 2086SPECIFIC CONSIDERATIONSPART IISTRATEGIES FOR DEVELOPMENTEssential Surgery: Current and Evolving ConceptsDr. Jim Yong Kim, President of the World Bank, aptly stated that surgery is an “indivisible, indispensable part of health care.”72 The wisdom of this statement has been supported by the findings of two landmark publications in 2015: Disease Control Priorities, third edition (DCP3), and the Lancet Com-mission on Global Surgery 2030 (LCGS).7,16 According to the DCP3, “the provision of essential surgical procedures would avert 1.5 million deaths a year or 6.7% of all avertable deaths


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Surgery_Schwartz. the Lancet Com-mission on Global Surgery 2030 (LCGS).7,16 According to the DCP3, “the provision of essential surgical procedures would avert 1.5 million deaths a year or 6.7% of all avertable deaths in LMICs,” and according to the Lancet Commission, 5 billion people do not have access to safe, affordable surgical and anes-thesia care when needed. Taken together, these and other find-ings suggest that without the provision of accessible, affordable essential surgical care in all LMICs, the lofty goal of another Lancet Commission report, Global Health 2035: A World Con-verging Within a Generation, would be unachievable.73 This earlier Lancet Commission believes that, with adequate invest-ment in global health, all countries could reduce their infectious, maternal, and childhood mortality rates down to those currently seen in the best-performing middle-income countries (e.g., the 4C countries: Chile, China, Costa Rica, and Cuba) within a gen-eration by 2035. They also make the


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Surgery_Schwartz. rates down to those currently seen in the best-performing middle-income countries (e.g., the 4C countries: Chile, China, Costa Rica, and Cuba) within a gen-eration by 2035. They also make the interesting observation that the LMICs can use their own resources for much of the funding needed.The critical role of essential surgical and anesthesia ser-vices in global health, in general, and in saving lives and disabil-ities in LMICs, in particular, has been established by fact-based evidence and analysis provided by the two landmark publica-tions of 2015, DCP3 and LCGS. Table 49-1 summarizes the key findings and recommendations of the two publications.The DCP3 adopted a working definition of essential sur-gical conditions as those that (a) are primarily or extensively treated by surgery; (b) have a large health burden; and (c) can be successfully treated by a surgical procedure that is cost-effective and feasible to promote globally. Using this def-inition, the DCP3 identified 44 essential


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Surgery_Schwartz. a large health burden; and (c) can be successfully treated by a surgical procedure that is cost-effective and feasible to promote globally. Using this def-inition, the DCP3 identified 44 essential procedures, most of which can be performed in first-level hospitals (Table 49-2).74 The first-level (district) hospital is the appropriate platform to provide essential surgical service. These procedures rank among the most cost-effective of all interventions and include those that treat injuries, obstetric complications (including fistulas), abdominal emergencies, cataracts, and congenital anomalies.The LCGS Report, based on extensive research and analy-sis of factual evidence, provides recommendations to improve access to safe, affordable anesthesia and surgical care in LMICs. Essential surgical services should be integrated into a compre-hensive platform of healthcare delivery. At the core of delivery of essential surgery is the first (district) hospital, which must be capable of


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Surgery_Schwartz. surgical services should be integrated into a compre-hensive platform of healthcare delivery. At the core of delivery of essential surgery is the first (district) hospital, which must be capable of delivering three bellwether essential surgery pro-cedures (hysterectomy, laparotomy, and treatment of an open fracture). A hospital that can provide these three procedures safely is presumed to have the necessary expertise in general and orthopedic surgery, obstetrics, and anesthesia to perform all essential surgical procedures.The cost of untreated surgical conditions is huge and, until now, not recognized. At the present time, some 33 million individuals face catastrophic health expenditure for surgical and anesthesia care in LMICs. The LCGS estimates that it would cost U.S. $420 billion to scale up the surgical workforce 9Table 49-1Key findings and recommendations from the Disease Control Priorities (DCP3) and the Lancet Commission for Global Surgery (LCGS)DCP3LCGSProvision of essential


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Surgery_Schwartz. up the surgical workforce 9Table 49-1Key findings and recommendations from the Disease Control Priorities (DCP3) and the Lancet Commission for Global Surgery (LCGS)DCP3LCGSProvision of essential surgery in LMICs would prevent 1.5 million deaths, or 6.7% of all avertable deaths5 billion people lack access to safe, affordable surgical and anesthesia care when neededEssential surgical procedures rank among the most cost-effective of all health interventions143 million more operations are needed in LMICs, where only 6% of all worldwide procedures are now doneEffective and affordable measures (such as task-sharing) increase access to surgical care33 million face catastrophic health expenditure from surgery and anesthesia care each yearInvestments must be made to expand capacity buildingWithout urgent investment, LMICs will lose US $12.3 trillion in economic productivity between 2015 and 2030Substantial disparities exist between countries in safety of surgical and anesthetic care. Feasible


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Surgery_Schwartz. urgent investment, LMICs will lose US $12.3 trillion in economic productivity between 2015 and 2030Substantial disparities exist between countries in safety of surgical and anesthetic care. Feasible and affordable measures (e.g., surgical safety checklist) improve safety and qualitySurgery is an indivisible, indispensable part of health care. Surgical care should be part of the National Health Care System, and should be “available, accessible, safe, timely, and affordable.”Universal coverage of essential surgery should be publicly financed early on the path to universal health coverage LMIC = Low and Middle Income CountryTable 49-2Essential surgical procedures that can be performed in first level (District) hospitals (DCP3)Obstetric Complications Severe postpartum hemorrhage, obstructed labor, prolonged labor, eclampsia, prolapsed cord, fetal distress, tubal pregnancy, postabortion endometritis/myometritis, postabortion sepsis, intrauterine fetal deathTrauma and Violence Major limb


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Surgery_Schwartz. labor, prolonged labor, eclampsia, prolapsed cord, fetal distress, tubal pregnancy, postabortion endometritis/myometritis, postabortion sepsis, intrauterine fetal deathTrauma and Violence Major limb fracture/injury, joint dislocation, major soft tissue injury, pneumo/hemothorax, ruptured spleenAcute Surgical Emergencies Strangulated hernia, intestinal obstruction, intestinal perforation, appendicitis, liver abscess, major wound infection, osteomyelitis/septic arthritisNonacute Surgical Conditions Congenital hernia, hernia, breast cancer, chronic osteomyelitis, hydrocele, urethral stricture, prostatic hypertrophy, cataract, eye injuryBrunicardi_Ch49_p2077-p2112.indd 208613/02/19 5:54 PM 2087GLOBAL SURGERYCHAPTER 49to have 20 surgical, anesthetic, and obstetric providers (SAOPs) per 100,000 population in LMICs by 2030. This figure must be compared to the U.S. $20.7 trillion loss in global economy that surgical conditions would be responsible for.Recent studies have shown that