An enthusiasm to improvise: A Journal club with Dr. Tamara N Fitzgerald
Smrithi Sriram, aspiring surgeon at St. George’s University of London
Conor Boylan, medical student at the University of Birmingham hoping to pursue a career in orthopaedic or plastic surgery, while also staying involved with academic medicine (teaching and research). Conor loves global surgery and would like to spend some time working in lower income countries later in life.
Gastroschisis and Uganda
Gastroschisis is a congenital disorder that has been increasing in prevalence in recent years, now affecting 1 in 2000 babies . Children with this condition are born with a weak abdominal wall that predisposes the formation of holes near the belly button causing their intestines to spill out . With the right treatment some of these babies can be saved, as seen in the 10% mortality rate in high-income countries . However, the mortality rate remains alarmingly high in high-income countries – 35-80% . The large discrepancy in the mortality rates suggests that though gastroschisis is fatal, death can be prevented in some cases.
The resources available in high-income countries, for example the United Kingdom, greatly reduces the mortality rate. Great Ormond Street Hospital in the UK suggests that the exposed intestines are wrapped in a silo and a ready-made mesh sac is used to cover the intestines while it is returned back to the abdomen . However, in Uganda silos are too expensive and thus unavailable . Additionally, there is no access to intravenous nutrition (TPN) for the affected babies . Furthermore, sub-Saharan Africa only has 45 pediatric surgeons with 4 in Uganda , compared to 388 pediatric surgeons in the UK .
This huge setback for Uganda has made some surgeons lose hope for treating these babies. However, Dr. Tamara N Fitzgerald (a surgeon in Duke University Hospital, North Carolina) and Dr. Anne Shikanda Wesonga (a pediatric surgeon in Uganda) in Mbarara Regional Hospital, Uganda together decided that “they wanted to start somewhere” and try to help these babies, despite the challenging circumstance .
Figure 1 Dr Tamara N Fitzgerald (left) and Dr Anne S Wesonga (right)
Dr. Tamara et al.’s research
An observational study: “Gastroschisis in Uganda: Opportunities for improved survival” by first author Dr. Anne S Wesonga and co-author Dr. Tamara N Fitzgerald et al. talks about setbacks in Uganda that contributed to a high mortality rate. They highlighted that improved prenatal diagnosis and postnatal care could improve the outcome to this condition .
Prenatal check-ups such as ultrasounds scans are very common in high income countries whereas in Uganda poverty-stricken families do not consider it as an option during pregnancy. In the UK routine prenatal ultrasounds scans at or after 12 weeks of pregnancy are able to detect gastroschisis . A treatment plan is then drawn out for the pregnant mother and her child, ensuring a safe birth and reducing mortality. Unfortunately, in Uganda this is a difficult thing to achieve due to financial constraints faced by families who often compromise prenatal checkup for other expenses. Nevertheless, Dr. Fitzgerald and Dr. Wesonga decided to change the attitudes of how this condition was perceived.
A happy ending
Both the doctors decided to be resourceful and found a way to feed infants without intravenous nutrition and made use of surgical gloves instead of expensive plastic silos to cover the babies’ intestines. After the first baby survived, an attitude of resilience replaced that of hopelessness. This led to the next 10 out of 17 babies with Gastroschisis being saved! .
An important lesson
Dr. Fitzgerald claims that she has learned how to be more resourceful from the Ugandan surgeons. She said that they would often do smaller procedures at the bedside, re-sterilize things like cautery pencils, endotracheal tubes etc. and create less trash during surgeries . This suggests that a low resource setting though challenging is not enough to give up hope. This is summarized by John Sekabira (another doctor and co-author on Dr Fitzgerald’s research) in his quote – “It takes the enthusiasm of an individual to improvise so that a patient can survive” .
Special thanks to Dr. Fitzgerald for her contribution to our journal club (August 14, 2020)
 Cincinnati Children’s (2020) Gastroschisis. Available at: https://www.cincinnatichildrens.org/health/g/gastroschisis
 Centers for Disease Control and Prevention (2019) Birth defects (Gastroschisis). Available at: https://www.cdc.gov/ncbddd/birthdefects/gastroschisis.html
 Stevens P, Muller E, Becker P. (2016) Gastroschisis in a developing country: poor resuscitation is a more significant predictor of mortality than postnasal transfer time. S Afr J Surg., 54(1), pp. 4-9.
 Great Ormond Street Hospital for Children, NHS (2016) Conditions we treat (Gastroschisis). Available at: https://www.gosh.nhs.uk/conditions-and-treatments/conditions-we-treat/gastroschisis
 Brookland, J (2019) “We have a solution for it”. Available at: https://globalhealth.duke.edu/news/we-have-solution-it (Accessed: 5 August 2020)
 Duke global health institute (2018) “Changing our lens on global surgery”. 12 January. Available at: https://www.youtube.com/watch?v=vPDMQZWaXTM&fbclid=IwAR1_wtvTJNK9pcudZzCX9zXCExYknGl31mtksXISOp6396MkFbqE18elbdc (Accessed: 4 August 2020)
 Royal College of Surgeons of England (2020) Pediatric surgery. Available at: https://www.rcseng.ac.uk/news-and-events/media-centre/media-background-briefings-and-statistics/paediatric-surgery/
 Fitzgerald et al., 2016. “Gastroschisis in Uganda: Opportunities for improved survival”, National Centre of Biotechnology Information, 51(11), pp. 1772-1777. doi: 10.1016/j.jpedsurg.2016.07.011