Critical Support for the Underserved: Surgery in the Land of Horseman and the Eternal Blue Sky
20 October 2017
On a normal workday, Daniella Blinder heads the orthognathic surgery unit at the Sheba Medical Center in Tel Aviv, Israel. This past May, the CMF specialist traveled to the capital of Mongolia, to fulfill a request from the Virtue Foundation for support from an orthognathic surgeon. This was her first surgical teaching mission.
A high incidence of injury
Every day, about 20 patients with different facial fractures or other pathology, along with their family members, congregate at the door of Dr Davaadorj Purevsuren’s office in Ulaanbaatar. Trained in Novosibirsik, Russia, the young doctor heads the OMS Department at one of only two hospitals in the country of three million that treats oral maxillofacial pathologies.
“In a typical case, the injury is already one week old, and was inflicted by a horse,” Blinder shares. In Mongolia, horses outnumber people, and run wild through the vast, rugged countryside.
“Mongolia has one of the largest nomadic populations in the world. Many of these patients live in distant, remote parts of the country, and have to travel extensive distances, requiring many hours, and even days, in order to reach the hospital,” Blinder elucidates.
“Often, when they arrive at Puresvuren’s office, a large number of the fractures or lesions are infected,” Blinder shares. “The pathology—which ranges from fractures of the midface and mandible, large cystic lesions, ameloblastoma, and severe infections including abcesses, faceitis, and osteomyelitis of the jaws due to fractures, dental infection, or lesions—are often compounded due to the length of time that has lapsed since the injury occurred,” she adds.
The doctor quickly checks the patients’ injuries and provides a date for surgery. Minimum explanation is given. Despite their discomfort, the patients remain smiling.
“The patients are not exigent and accept every decision,” Blinder reflects. “In this country, where the average lifespan is 65 years, those who are suffering are very grateful to receive any form of modern treatment,” she adds.
Providing surgical care with limited resources
When admitted, the patients stay in a room with five others and make their bed with sheets they have brought along with them.
“One patient, aged 47, traveled alone from the Gobi Desert in the south of Mongolia to visit the hospital,” recalls Blinder. “The woman, who lived a subsistence lifestyle, complained of pain and swelling in the right maxilla and on both sides of the mandible,” she explains. About one-fifth of Mongolia’s population lives in extreme poverty on USD 01.1 per day.
“The X-ray showed a very large, multilocular lesion of the whole right maxilla, and the right and left body, angle, and ramus of the mandible. The skull X-ray revealed multiple opaque lesions in the brain,” she says. “Normally, we would perform incisional biopsies, and eventually marsupialization, to reduce the lesions, but the woman’s socio-economical condition did not permit this possibility,” Blinder conveys.
In an operation theater lacking basic surgical devices, nasal tubes for intubation, saws, osteotomy micromotors, and infusion possibilities, the patient underwent enucleation and curettage of all lesions with mutilation of the jaws,” Blinder explains.
“I was surprised to see patients, like this one, who were operated on in the morning, walking into the surgeon’s office for the post-operative examination later on in the evening full of gratitude and without complaints, even when the surgery was aggressive,” shares Blinder.
In this case, the pathology results showed the lesions to be Keratocyst, and the associated lesions of the brain showed that the patient suffered from the rare Gorlin Goltz Syndrome, due to a mutation of the PTCH1 gene. The patient was released in good condition, and upon departure for the long trip back home, promised to return in one year for a check-up.
Raising the standard of patient care
In urban Ulaanbaatar, the health care system is improving, while a dire need for access to medical treatment remains in other parts of the country. Medical aid helps to raise the standard of care in the country, where patients do not have to pay for orthognathic surgery or genioplasty.
A part of Blinder’s mission served to provide local surgeons and healthcare professionals with knowledge and skills about the AO Principles. To educate, Blinder gave lectures over two days on orthognathic surgery, covering clinical examination, X-rays, different analyses, diagnosis, treatment, and the need of orthodontic treatment. "Dr Purevsuren completed a short fellowship in Japan, where he learned to reduce and fixate fractures according to the AO Principles. The major problem is that he does not have the instruments that will permit him to apply the AO principles," Blinder explains.
On the surgical front, all of the orthognathic cases Blinder checked during her visit were not ready for surgery. “Due to a lack of knowledge and devices, I was only able to perform a sliding genioplasty, and the shaving down of a malar bone during my visit,” she explains. To ramp up expertise, Blinder contacted an Israeli orthodontist. “We aim to start working together, by having the doctors in Mongolia send us the clinical photographs, X-rays, and models, so that we can help to prepare the patients,” she offers.
On sharing her overall experience, Blinder conveys: “The people of Mongolia are kind, and I found Dr Purevsuren to be a nice, intelligent, hard-working, and sympathetic person who wants to alleviate suffering. Dr Purevsuren has great potential to develop and raise the level of healthcare in Mongolia. With two years of oral and maxillofacial surgery training already, he quickly applied what I taught him, which he practiced with enthusiasm. Every day, he reduced and fixated a number fractures, and showed great manual skill in surgery,” she adds.
“With the right continuing medical education—through a fellowship and surgical training courses—as well as funding for devices, Dr Purevsuren could really improve the standard of care, and also provide treatments including TMJ and orthognathic surgery in the future,” she concludes.
Creating a brighter future by leaving no one behind
Blinder’s efforts follow the 2030 Agenda for Sustainable Development’s pledge to leave no one behind. One way to achieve this is by strengthening health systems so that all people can get the quality health services they need, starting with those furthest behind.
Through Blinder’s efforts, in this land with 250 days of sunshine a year, brighter times lie ahead. Answering the call to help, she plans to return to Mongolia in 2018.
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