Telesurgery in Humanitarian Settings

Mohana Amirtharajah

Surgery Advisor

Operational Centre, Amsterdam

About MSF

Médecins Sans Frontières (MSF) is an

international, independent, medical

humanitarian organisation that

delivers emergency aid to people

affected by armed conflict, epidemics,

healthcare exclusion and natural or

man-made disasters, irrespective of

race, religion, gender or political

affiliation.

International network

Structure- Operational Centre (Headquarters)

General Director

Operations

Director

Operations

Desks/Cells

Public Health

Department

Medical Director

Surgical advisor(s)

Projects worldwide

The Operating Theatres

Yemen

Jordan

Central African Republic

South Sudan

Why do we need

telesurgery?

1. Specialisation

Jack of all Trades…

Basic general surgery and obstetric

“Bush Surgery”

Wounds and infection

Obstetric: C-sections (midwives)

Laparotomy, appendectomy, incarcerated

hernia

Trauma, Orthopaedic

Specialised surgery projects

Trauma, Obstetrics, Burns, Reconstructive

No more “general” surgeons

General surgery= abdominal

surgery

No training in bone surgery

No training obstetric surgery

Rise of laparoscopy

Telesurgery- remote consultation

Send More Surgeons?

Money

Volume of cases

Send more surgeons?

“Evacuable” staff

Why do we need

telesurgery?

2. Remote Supervision

All Our Surgery is Remote Supervision

Need a surgeon judge skills of another

surgeon

“Transitive” judgement of skills

Remote Supervision + Consultation

Use of qualified national staff

Aid worker ≠ Expat

Without Borders ≠ Without Restrictions

Why do we need

telesurgery?

3. Confidentiality

All Our Phones Are HIPAA Disasters

All Our Phones Are Disasters…..

But in our home countries they

probably won’t get us…

Detained

Interrogated

Persecuted

Killed

Dangerous for Doctors…

2014-2015 WHO’s “Attacks on Health

Care”

594 attacks

959 deaths and 1,561 injuries

19 countries experiencing emergencies

Physician’s for Human Rights: Syria

March 2011-June 2016

382 attacks on 269 facilities

757 deaths medical personnel

International Humanitarian Law

Rule 110. The wounded, sick and

shipwrecked must receive…the

medical care and attention required by

their condition. No distinction may be

made among them founded on any

grounds other than medical ones.

Injured combatants = non-combatant

Phones As Evidence?

National Staff Carry the Burden

What are our telesurgery

requirements?

1. Encryption/confidentiality

What are our telesurgery

requirements?

2. Simple/ Intuitive

Audio and Visual

1-way visual, 2-way audio

Easy to use in multiple contexts

Variation comfort with tech

We are busy/cranky

Added features not necessary

E-health/EMR

Overlay of images

X-ray/US images

What are our telesurgery

requirements?

3. Hardware- “simple”

Hardware Considerations

“Attrition of Equipment”

Things we don’t have

Laparoscopes

Microscopes

Head cameras

Ceiling light cameras

The MSF-OCA Telesurgery

Experience

N=1

Strategy

Early 2016- MSF Sweden Innovation Unit

Is it a good

idea?....

yes Technology mapping

Evaluate hardware

Trial in the field by the end of

the year (no commitment)

Testing

Platforms

Hardware

Bandwidth

Which System?

Technology mapping

Met with few companies

Platform

Which Hardware?

Courtesy REACTS

Which Hardware

Audio?

Camcorder

Logitech

The Hardware

174.93 €

Where?

Where am I going already?

What’s in Sokoto

Noma: necrotising infection of

the face

Multifactorial, Preventable

Surgical reconstructive project

Why was it a decent choice?

Non-emergency,

non-trauma program

Availability of internet

Context

Preparation

Is there wifi in the

hospital?

Is there wifi in the

operating

theatre?

Is there wifi in the OT?

The Test!

N=1

Hmm…..

OT’s are Loud!

Issue?

Bandwidth

No other users

Wireless and cable

Contract 2 Mbps

Sweden 76 Mbps

Next Steps

Maximise bandwidth

VSat connections

Compression?

Next Steps

Identify trial site

Invest in IT Infrastructure- maximise

bandwidth

Additional logistic HR support

Upgrade hardware

Thank you!!!!