Daniel’s Drive: Training Ethiopian Surgeons

 

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Dr. Daniel Getachew, left, and Dr. Per Hall, right, evaluate a patient's X-ray with Dr. Yonas Exchetu at Jimma University Specialized Hospital in March 2015. Photo: Jasmin Shah.

How did one surgeon’s sleepless night become another’s dream come true?

When the vision of the former, Dr. Per Hall of the United Kingdom, fuelled the relentless drive of the latter, Dr. Daniel Getachew of Ethiopia.

At Operation Smile’s 2018 NEXT Medical Conference, the reconstructive plastic surgeons shared their perspectives on the successes and challenges of the surgical training rotations hosted by Operation Smile at Ethiopia’s Jimma University Specialized Hospital (JUSH).

The commitment of Daniel and his staff cemented the establishment of a 28-bed reconstructive plastic surgery ward in JUSH’s newly constructed hospital. The unit officially opened on Jan. 1, 2018, just days after Daniel returned to Jimma after completing a three-year training program in Taiwan.

His graduation made him the first general surgeon to earn accreditation as a reconstructive plastic surgeon through an Operation Smile surgical training rotation.

“It’s just like a dream come true,” Daniel said. “I couldn’t wait for that day to come.”

While Daniel’s accreditation and his new ward are significant milestones for both JUSH and Operation Smile, there is still much work to be done for the unit to become self-sustaining.

Daniel and Per emphasized this in their presentation at NEXT, making impassioned appeals to the Operation Smile medical community gathered in Norfolk, Virginia, on May 10, 2018.

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Daniel, left, and Per present an update on the Jimma, Ethiopia, surgical training rotations at the 2018 Operation Smile NEXT Medical Conference in Norfolk, Virgina, on May 10, 2018. Photo: Marc Ascher.

“This is actually just the beginning of a better future that I’m hoping to see,” Daniel said in front of a crowd of more than 250 of his fellow volunteers from around the world. “So anyone who is interested in coming to teach us and help the patients is very much welcome to come.”

Daniel didn’t know it at that time, but his unit would get another major boost of visibility later in the conference. The day after their presentation, Per was selected as the Operation Smile’s volunteer of the year in honour of his leadership of the Jimma rotations.

Today, as Daniel emerges as the leading plastic surgeon at JUSH, Operation Smile is working with key partners to develop the next layers of training to support the growth of the new plastics unit.

“Carefully crafting programs to locally grow general surgeons and anaesthetists in cleft and plastic surgery skills is key to the success and long-term sustainability of the unit,” said Libby Durnwald, Operation Smile’s associate program officer of education.  “It will take the effort, creativity and passion of dedicated volunteers alongside local providers to design a program that lasts for years to come. The next cohort of plastic surgery trainees will be fortunate to have Daniel as a role model, teacher and leader as they work to develop their skill sets.”

 

Spearheaded by Dr. David Orr of Ireland and Per, the rotations have been conducted twice per year since 2012. The two-week training courses for Ethiopian surgeons, anaesthetists and nurses have revolutionised how patients receive surgical care at JUSH, the only hospital serving the 15 million-plus people living in Ethiopia’s southwestern region.

The focus of the rotations isn’t only on cleft surgery, but also teaching general surgeons a wide range of techniques to better heal burn, trauma and surgical wounds, which represent the bulk of the hospital’s need for plastic surgery.

“When you go somewhere like Jimma, where they have such a huge workload, cleft lip and palate are actually a really small (portion of the overall need),” Per said. “Every day, you have people with intestinal obstructions, machete injuries, people falling from trees, road traffic accidents, burns – they come in and they have to be dealt with immediately.”

When scheduled cases are delayed by emergencies, the backlog builds. This reveals the immense need for increased staff and training to handle both immediate and elective surgical care in Jimma.

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Daniel performs surgery under the guidance of Dr. David Orr during the November 2014 Operation Smile surgical training rotation in Jimma, Ethiopia. Photo: Jörgen Hildebrandt.

The goal is to close this critical gap between the amount of reconstructive plastic surgeons and the people they serve, especially in the country’s more remote areas like those surrounding Jimma. In Ethiopia, there are little more than a dozen reconstructive plastic surgeons serving 105 million people, and most of them are cantered in and around Addis Ababa, the capital city.

Operation Smile Chief Medical Officer Dr. Ruben Ayala said: “I believe that the genius of individuals like David Orr and Per Hall – who believed in the power of training the local professionals way before Operation Smile looked beyond (medical missions) – is that they saw a need that was tangible; it was really in their faces and they couldn’t turn away from it.

“They also saw the opportunity in what Operation Smile could and should offer. They paved the way for us, as an organization, to start thinking about the impact that we could have on the lives of children and on the lives of entire communities.”

So, back to Per’s sleepless night.

After years of serving on medical missions in Ethiopia, David and Per stepped into uncharted territory when they brought Operation Smile’s first surgical training rotation to JUSH in 2012. Per said that while he knew that the hospital’s general surgeons were skilled, he didn’t know what to expect from their initial attempts at performing cleft lip surgery.

At that time, Daniel was the hospital’s general surgery consultant, the equivalent of an attending physician in the U.S., and two of his residents were the rotation’s surgical trainees, including Dr. Yonas Yilma Metaferia, who assisted Per on the first surgery of the day.

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Per evaluates a patient in need of reconstructive plastic surgery with surgical training rotation student Dr. Yonas Yilma Metaferia in March 2016. Photo: Jörgen Hildebrandt.

“When the second patient was on the table, I asked Yonas if he would like to put the marks on the lip. He did, and I looked, and I thought, ‘Well that’s perfect,’” Per recalled. “I gave him the scalpel and asked him if he’d like to carry on. He then did 85 percent of the second cleft lip he had ever seen in his life.

“And that night I could not sleep. Because I just thought, ‘Wow, we’re starting at such a high level,’ and there was almost an arrogance that we didn’t realize that. These guys had enormous hours of surgery under their belts. By the time they are consultants or attendings, their flying hours are in the hundreds of thousands compared to U.K. and U.S. trainees, and they’re using very limited resources very ingeniously.”

After the first rotation, Per gathered the surgical results of his mentees to be analysed by Operation Smile’s medical oversight team. They affirmed what Per already knew: The results were fantastic and the need to invest in the training of these general surgeons was solidified.

“We can take general surgeons like Daniel and use (the rotations) as a test case to show that you can teach cleft lip surgery to very able people and get results that are comparable or better than some of the outcomes I have seen on other Operation Smile missions. That’s why I couldn’t sleep,” said Per, who acknowledged the further complexities of and training required to perform cleft palate surgery.

Per added: “It wouldn’t have worked without Daniel’s drive, because he is so motivated to make this happen, so we are very, very lucky in this project and we need to support him. We need Daniel to train his own surgeons internally and we need to support the supply chain, the consumables and equipment. There is such a lot of stuff that they need.”

Despite the challenges ahead, Daniel is optimistic that the future of his unit is bright.

“I have already established the plastic surgery unit, and a lot of people are getting help from it, so you can see how it’s going to exponentially change the service that we can deliver,” Daniel said. “We can sustain that for a much longer time and we can provide service for the rest of our region.”

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Daniel, left, and Per present an update on the Jimma, Ethiopia, surgical training rotations at the 2018 Operation Smile NEXT Medical Conference in Norfolk, Virgina, on May 10, 2018. Photo: Marc Ascher.

 

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“Every child that has a facial deformity is our responsibility. If we don’t take care of that child, there’s no guarantee that anyone else will.”

- Kathy Magee, Operation Smile Co-founder and President