David R. Welling

Seven Sins of Humanitarian Medicine

The need for humanitarian assistance throughout the world is almost unlimited. Surgeons who go on humanitarian missions are definitely engaged in a noble cause. However, not infrequently, despite the best of intentions, errors are made in attempting to help others. The following are seven areas of concern: 1. Leaving a mess behind. 2. Failing to match technology to local needs and abilities. 3. Failing of non-governmental organizations (NGO’s) to cooperate and help each other, and and accept help from military organizations. 4. Failing to have a follow-up plan. 5. Allowing politics, training, or other distracting goals to trump service, while representing the mission as “service”. 6. Going where we are not wanted, or needed and/or being poor guests. 7. Doing the right thing for the wrong reason. The goal of this report is to discuss these potential problems, with ideas presented about how we might do humanitarian missions more effectively.

Stomas and trauma.

The current dogma about the treatment of penetrating colon injuries is reviewed, both from the civilian and the military perspective. This discussion is still evolving, and the time-honored methods of diversion, including colostomy and ileostomy, are still appropriate for the most severe and devastating sorts of wounds, especially in the military context. For the vast majority of penetrating wounds, primary repair works well and should be practiced. For the few patients who have primary repair that fails and leaks, mortality rates are high. The art of surgery involves knowing when to divert and when to repair.

Diversion defended - Military colon trauma

Primary repair of traumatic colon injuries has become more common in the civilian trauma setting. Although the advantages of colon diversion have been well documented in the distant past, during the last 20 years or so the surgical literature has indicated a changing philosophy. Civilian surgeons have become increasingly adept at primary repair, reporting excellent results when compared with those obtained by diversion. One particularly provocative editorial, by Nance and Nance (1995), extolled the virtues of primary repair, and was entitled “A stake through the heart of colostomy”. The authors promote the concept that colostomy diversion is outdated, and should no longer be considered for colon trauma. The authors end their editorial with this statement, which summarizes how they felt about the issue: “In our view, a surgeon using colostomy in the management of penetrating colon injury should be required to justify the continuation of this obsolete and discredited practice”. The Cochrane Collaboration reviewed six studies, which addressed this question, and concluded the following: “Metaanalysis of currently published randomized controlled trials favors primary repair over fecal diversion for penetrating colon injuries”. The authors also stated that primary repair was favored over diversion when one looked at “. . total complications, total infectious complications, abdominal infections including dehiscence, abdominal infections excluding dehiscence, wound complications including dehiscence, and wound complications excluding dehiscence”. No attempt was made to differentiate civilian versus military wounds. A prospective randomized study, by Sasaki et al., concluded their summary with this statement: “. . primary repair or resection with anastomosis is the method of choice of treatment of all penetrating colon injuries in the civilian population despite any associated risk factors for adverse outcomes”. Current teaching and surgical training now emphasize primary repair of colon injuries rather than diversion and colostomy. It is, therefore, not surprising to find that a number of wounded soldiers, in the current conflict, who have suffered colon injuries, are receiving primary repairs. This is to be expected, because a large number of our combat surgeons are mobilized reservists and National Guard personnel. They have been activated out of civilian practices, and are practicing combat surgery with training from their civilian backgrounds. The purpose of this article is to revisit the “primary repair versus diversion and colostomy” issue with regard to the strategy of the proper care of battlefield colon wounds.

Is poor performance on NBME clinical subject examinations associated with a failing score on the USMLE step 3 examination

Purpose To investigate the association between poor performance on National Board of Medical Examiners clinical subject examinations across six core clerkships and performance on the United States Medical Licensing Examination Step 3 examination. Method In 2012, the authors studied matriculants from the Uniformed Services University of the Health Sciences with available Step 3 scores and subject exam scores on all six clerkships (Classes of 2007–2011, N = 654). Poor performance on subject exams was defined as scoring one standard deviation (SD) or more below the mean using the national norms of the corresponding test year. The association between poor performance on the subject exams and the probability of passing or failing Step 3 was tested using contingency table analyses and logistic regression modeling. Results Students performing poorly on one subject exam were significantly more likely to fail Step 3 (OR 14.23 [95% CI 1.7–119.3]) compared with students with no subject exam scores that were 1 SD below the mean. Poor performance on more than one subject exam further increased the chances of failing (OR 33.41 [95% CI 4.4–254.2]). This latter group represented 27% of the entire cohort, yet contained 70% of the students who failed Step 3. Conclusions These findings suggest that individual schools could benefit from a review of subject exam performance to develop and validate their own criteria for identifying students at risk for failing Step 3.

Medical treatment of diverticular disease.

The medical treatment of diverticulitis is discussed, including its incidence, stages, and presentation, as are the antibiotic and dietary therapies currently recommended for this disease. Because diverticulitis can be a challenge to treat, several pitfalls are listed in this discussion, including diverticulitis in the immunocompromised, in the young, and in patients who do not have true diverticulitis but who present with some signs and symptoms of the disease.

One Example of a Model Humanitarian Mission

This paper describes a model humanitarian mission to Guyana; it illustrates the value of excellent ongoing care in collaboration with local physicians and surgeons, cooperation with local government and medical officials, and frequent periodic follow-up missions (always to the same hospital, working with the same staff). This effort has largely avoided the so-called “Seven Sins of Humanitarian Medicine”.

A model for a medical school surgery interest group.

The purpose of this report is to record some of the recent accomplishments of the Surgery Interest Group (SIG) at the Uniformed Services University of the Health Sciences, and to provide a framework for others to follow, with the goal of encouraging students to become interested in the exciting field of surgery. We will outline some of the events that our SIG planned and carried out in order to provide a quality experience to its members.

Historical Perspectives on Colorectal Trauma Management

Abstract The authors discuss the history and evolution of management of traumatic wounds to the colon and rectum, summarizing early management parallel with the history of armed conflict followed by the increase in research and management interest by civilian centers in the post‐Vietnam era. They explore the strong opinions of the early thought‐leaders such as DeBakey and Ogilvie, detailing factors that may have impacted their views. The current literature on optimal management of both colon and rectal trauma is reviewed, including the contentious debate over which patients may benefit from diversion. Current organ injury staging and clinical practice guidelines are also reviewed, as well as lessons learned by the U.S. military in recent conflicts in Iraq and Afghanistan. Understanding of the evolution of colon and rectal trauma management, as well as the current literature, will help surgeons in their decision‐making and management of these challenging injuries.

Hemorrhoid veins, the forgotten realm of the vascular surgeon

Hemorrhoids have been a part of the human anatomy since the beginning of humankind. Interestingly, although hemorrhoids are inherently “vascular” structures, and can be enlarged because of vascular disease (portal hypertension, for example), it appears that vascular surgeons have always avoided this part of the body. Hemorrhoidal veins, by definition, are venous structures. In looking through several vascular surgery texts, it is striking to note that there is no mention of hemorrhoids in the typical vascular surgeon’s library. Several recent texts specifically written about venous disorders fail to even mention hemorrhoids. One text, Surgical Management of Venous Disease by Raju and Villavicencio, simply states this about hemorrhoids, when describing patients with vulvar varicosities: “Hemorrhoids were present in 87% of our patients.” Older vascular surgery texts, like Vascular Surgery by de Takats, in 1959, mention that hemorrhoids and vaginal varices often follow vena caval occlusion. Rutherford, in 1984, in his extensive Vascular Surgery text, simply mentions that hemorrhoids can be associated with portal hypertension. Apparently, hemorrhoid veins might be considered the “Rodney Dangerfield” of the vascular system, getting no respect. When one of the early vascular surgery fellowships was started in 1966 at Walter Reed General Hospital (later named Walter Reed Army Medical Center), there was considerable discussion among involved general surgeons and cardiovascular surgeons about the relatively new area of interest in peripheral vascular surgery, setting it apart from cardiovascular surgery. An early

Dominique Jean Larrey and the Russian Campaign of 1812

Two hundred years ago, 1812, was a year of conflict throughout many of the “civilized” countries of the world. In the United States of America, still a very young country, the War of 1812 was an early test of resolve and trial, and cost much blood and treasure with little longterm benefit. The War of 1812 is perhaps best known for our national anthem, which mentions “. . . bombs bursting in air . . .,” referring to the invention of Henry Shrapnel, who devised cannonballs that would explode in mid-air. These weapons were used over Fort McHenry in Maryland. The cannon fire was observed by Francis Scott Key and inspired him to pen “Defence of Fort McHenry,” which became known as “The StarSpangled Banner” and is our national anthem. In the meantime, on the European Continent, Napoleon was cobbling together a mighty army of more than 400,000 men, who were not informed about who they would be fighting or where they would be going until very late in the year. The French did not have the supposed advantage of Shrapnel’s shells in 1812. Napoleon chose wisely when he called on Dominique Jean Larrey to be the Chief Surgeon of this Grande Armée 5 (Fig. 1). This report is about the amazing efforts of Larrey during this difficult conflict. As we observe the 200 anniversary of the Russian Campaign, we should pause and reflect on Larrey, who did demonstrate those “. . . most ennobling