BMJ 2014;348:g1995 doi: 10.1136/bmj.g1995 (Published 10 March 2014)
Page 1 of 3
Feature
FEATURE BMJ AWARDS 2014
Karen Woo Surgical Team Award: making a difference in the UK and abroad The award honours a UK based surgical team that has measurably improved surgical care for patients or had an effect on a wider population basis. Anne Gulland looks at this year’s candidates Anne Gulland freelance journalist London, UK
This award is inspired by the life of Karen Woo, a British surgeon who was killed while working on an aid mission in Afghanistan in 2010. Woo had a masters in surgical education and she was particularly interested in the psychology of communication and information transfer.
Operation Hernia
About 10 years ago consultant surgeon Andrew Kingsnorth attended a conference where a speaker described setting up a field hospital in the middle of the Amazonian rainforest for the treatment of hernia. This set Kingsnorth wondering if he could do something similar.
A colleague helped him make contacts in Takoradi, Ghana, and in 2005 a surgical team ran its first hernia repair mission in the city. Since then, Operation Hernia has spread to 16 countries, its teams have performed around 12 000 operations, and volunteer surgeons and anaesthetists hail from all over the world. “Hernia repair is the commonest, treatable surgical procedure, but in Africa it is rarely performed,” says Kingsnorth. He believes Operation Hernia is plugging a gap: hernia disproportionately affects men, who are not traditional aid recipients, and surgery is rarely targeted by aid agencies.
“The millennium development goals don’t touch on surgery at all, and in Africa there is just one surgeon for every 250 000 people,” he says. The teams operate in hospitals that have at least one operating theatre and basic equipment and where follow-up can be provided by teams of community health workers. Operation Hernia teams also train local doctors and nurses.
The project has pioneered the use of mosquito net mesh, first used in India, to replace expensive hospital grade mesh. About $10 worth of mosquito net can be used to treat 3000 patients, whereas commercial mesh costs around $30-40 per patient.
After conducting an economic analysis with the Johns Hopkins Medical School and bacterial adherence studies, Kingsnorth introduced it to the programme.
“We’ve done about 5000 mosquito net repairs so we have made the operations more affordable as well as being safe,” he says.
Peritoneal Malignancy Institute The Peritoneal Malignancy Institute at Basingstoke and North Hampshire Hospital is the world’s largest treatment centre for pseudomyxoma peritonei (PMP)—a condition arising from a ruptured appendiceal tumour. The condition is rare—just two to three cases per million people every year—and without treatment patients face a grim prognosis: death by starvation.
Previously, treatment involved repeated debulking to relieve symptoms and long term survival rates were poor: just 50% at five years and 30% at 10 years.
The service is led by surgeon Brendan Moran, who had already developed an expertise in low rectal cancers before operating on his first patient with PMP in 1994. The institute officially became a national centre for PMP in 2000, and in the past 20 years has seen 1300 patients. The treatment involves a 10 hour operation known as the Sugarbaker technique, in which the peritoneum and affected organs are removed before an hour of hyperthermic intraperitoneal chemotherapy.
The team now performs around 200 operations a year and five year survival rates stand at 83%. The technique has also shown promising results in the treatment of patients with peritoneal metastases from colorectal cancer—a far more common condition. Patients are referred from all over the UK and Ireland, and Moran has trained surgeons who have gone on to set up their own centres in Japan, the Republic of Ireland, Denmark, and Sweden.
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1995 doi: 10.1136/bmj.g1995 (Published 10 March 2014)
Page 2 of 3
FEATURE
“The centre is a great NHS success story and an example of how the NHS can do something that other healthcare systems can’t. Somewhere like Australia would have trouble setting this up because a large part of its healthcare is privately funded and run and there’s no central control,” says Moran.
Microvascular surgery in Lahore, Pakistan UK plastic surgeon Umraz Khan was providing humanitarian relief in Pakistan after the country’s 2005 earthquake when he was approached by local doctors for his opinion on patients who had had tumours removed. Khan specialises in free tissue or free flap transfer surgical reconstruction using the patient’s own tissue after trauma or removal of a tumour. “These patients were considered inoperable, but that to me was a tragedy,” says Khan. “If you can give surgeons the skills and confidence to undertake these operations then you can offer hope.” Free tissue or flap transfer is still a relatively new treatment, but the need for it in countries like Pakistan, where the injury rate is far higher than in the West and where there is no social safety net, is even greater.
A new burns centre was being built in Lahore so Khan, a consultant at Frenchay Hospital in Bristol, teamed up with the Alama Iqbal Medical School in the city to provide an annual week-long microvascular course. Every year since 2006 Khan has put together a UK team of specialists in head and neck cancer reconstruction, limb reconstruction, and burns, alongside three to four trainees, to run an intensive week of clinics, lectures, and surgery, training 40 to 50 local doctors each time. To maximise the number of surgeons able to take part in the training a camera and a two-way microphone have been set up in the operating theatre so that doctors can watch the operation in an auditorium and ask questions.
Khan and his team have operated on 80 patients in the eight years the course has been running, but he says hundreds of others have benefited from local surgeons’ new knowledge. Free flap has also spread to other parts of Pakistan in what Khan describes as a “domino effect.” “This is low tech, high skill surgery. But it is also a team effort and it needs to be done in a big teaching hospital,” says Khan.
Surgical telementoring in Tanzania When Liam Horgan, consultant surgeon at Northumbria Healthcare NHS Trust, was first approached about teaching laparoscopic surgical techniques to colleagues at Kilimanjaro Christian Medical Centre in Tanzania, he was doubtful of the success of the venture.
But the more he thought about the advantages of laparoscopy over conventional surgery the more he was convinced of its applicability in a resource poor setting: hospital stays are shorter than for conventional surgery; infection risks are lower; the surgery is less invasive; and there is less need for anaesthesia and pain relief. After two years of intensive training Tanzania’s first (and only) laparoscopic service began in 2005, and within a few years patients were coming from all over the country for hernia repair and removal of gall bladder or appendix.
Tanzania has a severe lack of specialists, with just two consultant surgeons at the Kilimanjaro hospital to serve a population of 13 to 15 million people. Luckily, the two surgeons trained initially have remained at the hospital and now perform For personal use only: See rights and reprints http://www.bmj.com/permissions
as many laparoscopic procedures as surgeons in the UK, says Horgan.
Audit has been an important part of the project. “Their results are better than those of some surgeons in the UK,” says Horgan, who visits Tanzania once a year.
At the beginning of the partnership the surgeons were comfortable performing laparoscopic procedures when the team from Northumbria were present, but on their own they lost their confidence. To combat this, a secure telemedicine link was set up between the two hospitals. The link is now used as a training tool for students in Tanzania, and the team is considering extending it to other hospitals in Tanzania if the Kilimanjaro hospital is established as the country’s first laparoscopic training centre. “All the surgeons needed was an extra bit of encouragement and an opportunity to discuss the cases. Within a year they were fully confident to operate on their own,” says Horgan.
Paediatric acute surgical service—patient and family centred care Joanne Minford, paediatric surgeon at Alder Hey Children’s Hospital in Liverpool, admits that staff were complacent about the care they offered to patients. They were doing well on surgical outcomes, but while working with the King’s Fund on a patient focused care project they realised some patients had a worse experience than others. Children with abdominal pain were getting a particularly raw deal, she says. They were waiting a long time in emergency departments, were not getting the pain relief they needed, and they and their families felt that communication was poor.
Surgeons were also located at the other end of the hospital from the emergency department—at the end of what is reportedly the longest hospital corridor in Europe, clocking in at half a mile (800 km)—so rarely saw patients who were waiting.
A four bedded ward was set up half way between the emergency department and theatre. Called the surgical decision unit, it is led by an advanced paediatric nurse practitioner who clinically assesses patients, orders the required investigations, and manages their pain. “That patient would have pitched up in accident and emergency and would just have waited there. That was a very bad experience,” says Minford.
Other measures introduced by the team include nurse led discharge and ward based pharmacy. Minor surgical procedures that in the past would have required theatre are now done with local anaesthetic, sedation, and analgesia where appropriate. Hospital stays for acute surgical patients have reduced from an average of five days to three as patients progress through the system more quickly.
Next year the hospital will move into a brand new building and Minford hopes the patient focused care will go from strength to strength.
“We’re looking at how we keep this teamwork going in the new hospital and how we make it viable and sustainable in the long term,” she says. Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare. The Karen Woo Surgical Team Award is sponsored by BUPA and the BMJ Awards are sponsored by MDDUS. The awards ceremony will take
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1995 doi: 10.1136/bmj.g1995 (Published 10 March 2014)
Page 3 of 3
FEATURE
place on 8 May at the Park Plaza Hotel, Westminster. To find out more go to http://thebmjawards.bmj.com.
Cite this as: BMJ 2014;348:g1995 © BMJ Publishing Group Ltd 2014
Provenance and peer review: Commissioned; not externally peer reviewed.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Page 1 of 3
Feature
FEATURE BMJ AWARDS 2014
Karen Woo Surgical Team Award: making a difference in the UK and abroad The award honours a UK based surgical team that has measurably improved surgical care for patients or had an effect on a wider population basis. Anne Gulland looks at this year’s candidates Anne Gulland freelance journalist London, UK
This award is inspired by the life of Karen Woo, a British surgeon who was killed while working on an aid mission in Afghanistan in 2010. Woo had a masters in surgical education and she was particularly interested in the psychology of communication and information transfer.
Operation Hernia
About 10 years ago consultant surgeon Andrew Kingsnorth attended a conference where a speaker described setting up a field hospital in the middle of the Amazonian rainforest for the treatment of hernia. This set Kingsnorth wondering if he could do something similar.
A colleague helped him make contacts in Takoradi, Ghana, and in 2005 a surgical team ran its first hernia repair mission in the city. Since then, Operation Hernia has spread to 16 countries, its teams have performed around 12 000 operations, and volunteer surgeons and anaesthetists hail from all over the world. “Hernia repair is the commonest, treatable surgical procedure, but in Africa it is rarely performed,” says Kingsnorth. He believes Operation Hernia is plugging a gap: hernia disproportionately affects men, who are not traditional aid recipients, and surgery is rarely targeted by aid agencies.
“The millennium development goals don’t touch on surgery at all, and in Africa there is just one surgeon for every 250 000 people,” he says. The teams operate in hospitals that have at least one operating theatre and basic equipment and where follow-up can be provided by teams of community health workers. Operation Hernia teams also train local doctors and nurses.
The project has pioneered the use of mosquito net mesh, first used in India, to replace expensive hospital grade mesh. About $10 worth of mosquito net can be used to treat 3000 patients, whereas commercial mesh costs around $30-40 per patient.
After conducting an economic analysis with the Johns Hopkins Medical School and bacterial adherence studies, Kingsnorth introduced it to the programme.
“We’ve done about 5000 mosquito net repairs so we have made the operations more affordable as well as being safe,” he says.
Peritoneal Malignancy Institute The Peritoneal Malignancy Institute at Basingstoke and North Hampshire Hospital is the world’s largest treatment centre for pseudomyxoma peritonei (PMP)—a condition arising from a ruptured appendiceal tumour. The condition is rare—just two to three cases per million people every year—and without treatment patients face a grim prognosis: death by starvation.
Previously, treatment involved repeated debulking to relieve symptoms and long term survival rates were poor: just 50% at five years and 30% at 10 years.
The service is led by surgeon Brendan Moran, who had already developed an expertise in low rectal cancers before operating on his first patient with PMP in 1994. The institute officially became a national centre for PMP in 2000, and in the past 20 years has seen 1300 patients. The treatment involves a 10 hour operation known as the Sugarbaker technique, in which the peritoneum and affected organs are removed before an hour of hyperthermic intraperitoneal chemotherapy.
The team now performs around 200 operations a year and five year survival rates stand at 83%. The technique has also shown promising results in the treatment of patients with peritoneal metastases from colorectal cancer—a far more common condition. Patients are referred from all over the UK and Ireland, and Moran has trained surgeons who have gone on to set up their own centres in Japan, the Republic of Ireland, Denmark, and Sweden.
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1995 doi: 10.1136/bmj.g1995 (Published 10 March 2014)
Page 2 of 3
FEATURE
“The centre is a great NHS success story and an example of how the NHS can do something that other healthcare systems can’t. Somewhere like Australia would have trouble setting this up because a large part of its healthcare is privately funded and run and there’s no central control,” says Moran.
Microvascular surgery in Lahore, Pakistan UK plastic surgeon Umraz Khan was providing humanitarian relief in Pakistan after the country’s 2005 earthquake when he was approached by local doctors for his opinion on patients who had had tumours removed. Khan specialises in free tissue or free flap transfer surgical reconstruction using the patient’s own tissue after trauma or removal of a tumour. “These patients were considered inoperable, but that to me was a tragedy,” says Khan. “If you can give surgeons the skills and confidence to undertake these operations then you can offer hope.” Free tissue or flap transfer is still a relatively new treatment, but the need for it in countries like Pakistan, where the injury rate is far higher than in the West and where there is no social safety net, is even greater.
A new burns centre was being built in Lahore so Khan, a consultant at Frenchay Hospital in Bristol, teamed up with the Alama Iqbal Medical School in the city to provide an annual week-long microvascular course. Every year since 2006 Khan has put together a UK team of specialists in head and neck cancer reconstruction, limb reconstruction, and burns, alongside three to four trainees, to run an intensive week of clinics, lectures, and surgery, training 40 to 50 local doctors each time. To maximise the number of surgeons able to take part in the training a camera and a two-way microphone have been set up in the operating theatre so that doctors can watch the operation in an auditorium and ask questions.
Khan and his team have operated on 80 patients in the eight years the course has been running, but he says hundreds of others have benefited from local surgeons’ new knowledge. Free flap has also spread to other parts of Pakistan in what Khan describes as a “domino effect.” “This is low tech, high skill surgery. But it is also a team effort and it needs to be done in a big teaching hospital,” says Khan.
Surgical telementoring in Tanzania When Liam Horgan, consultant surgeon at Northumbria Healthcare NHS Trust, was first approached about teaching laparoscopic surgical techniques to colleagues at Kilimanjaro Christian Medical Centre in Tanzania, he was doubtful of the success of the venture.
But the more he thought about the advantages of laparoscopy over conventional surgery the more he was convinced of its applicability in a resource poor setting: hospital stays are shorter than for conventional surgery; infection risks are lower; the surgery is less invasive; and there is less need for anaesthesia and pain relief. After two years of intensive training Tanzania’s first (and only) laparoscopic service began in 2005, and within a few years patients were coming from all over the country for hernia repair and removal of gall bladder or appendix.
Tanzania has a severe lack of specialists, with just two consultant surgeons at the Kilimanjaro hospital to serve a population of 13 to 15 million people. Luckily, the two surgeons trained initially have remained at the hospital and now perform For personal use only: See rights and reprints http://www.bmj.com/permissions
as many laparoscopic procedures as surgeons in the UK, says Horgan.
Audit has been an important part of the project. “Their results are better than those of some surgeons in the UK,” says Horgan, who visits Tanzania once a year.
At the beginning of the partnership the surgeons were comfortable performing laparoscopic procedures when the team from Northumbria were present, but on their own they lost their confidence. To combat this, a secure telemedicine link was set up between the two hospitals. The link is now used as a training tool for students in Tanzania, and the team is considering extending it to other hospitals in Tanzania if the Kilimanjaro hospital is established as the country’s first laparoscopic training centre. “All the surgeons needed was an extra bit of encouragement and an opportunity to discuss the cases. Within a year they were fully confident to operate on their own,” says Horgan.
Paediatric acute surgical service—patient and family centred care Joanne Minford, paediatric surgeon at Alder Hey Children’s Hospital in Liverpool, admits that staff were complacent about the care they offered to patients. They were doing well on surgical outcomes, but while working with the King’s Fund on a patient focused care project they realised some patients had a worse experience than others. Children with abdominal pain were getting a particularly raw deal, she says. They were waiting a long time in emergency departments, were not getting the pain relief they needed, and they and their families felt that communication was poor.
Surgeons were also located at the other end of the hospital from the emergency department—at the end of what is reportedly the longest hospital corridor in Europe, clocking in at half a mile (800 km)—so rarely saw patients who were waiting.
A four bedded ward was set up half way between the emergency department and theatre. Called the surgical decision unit, it is led by an advanced paediatric nurse practitioner who clinically assesses patients, orders the required investigations, and manages their pain. “That patient would have pitched up in accident and emergency and would just have waited there. That was a very bad experience,” says Minford.
Other measures introduced by the team include nurse led discharge and ward based pharmacy. Minor surgical procedures that in the past would have required theatre are now done with local anaesthetic, sedation, and analgesia where appropriate. Hospital stays for acute surgical patients have reduced from an average of five days to three as patients progress through the system more quickly.
Next year the hospital will move into a brand new building and Minford hopes the patient focused care will go from strength to strength.
“We’re looking at how we keep this teamwork going in the new hospital and how we make it viable and sustainable in the long term,” she says. Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare. The Karen Woo Surgical Team Award is sponsored by BUPA and the BMJ Awards are sponsored by MDDUS. The awards ceremony will take
Subscribe: http://www.bmj.com/subscribe
BMJ 2014;348:g1995 doi: 10.1136/bmj.g1995 (Published 10 March 2014)
Page 3 of 3
FEATURE
place on 8 May at the Park Plaza Hotel, Westminster. To find out more go to http://thebmjawards.bmj.com.
Cite this as: BMJ 2014;348:g1995 © BMJ Publishing Group Ltd 2014
Provenance and peer review: Commissioned; not externally peer reviewed.
For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
