Guam surgeons face unique challenges

At the suggestion of Tyler Hughes, a member of the American College of Surgeons (ACS) Board of Governors, Fellows practicing in Guam recently sought to establish a chapter on the island. The ACS Board of Regents approved this request at its October 2014 meeting, thus allowing Guam for the first time to have representation on the ACS Board of Governors.

In our discussions leading up to the formation of the chapter, Dr. Hughes, a surgeon in McPherson, KS, and Chair of the ACS Advisory Council for Rural Surgery; my partner, Michael Cruz, MD, FACS; and I determined that surgeons in Guam face many similar yet unique challenges as rural surgeons on the U.S. mainland. By establishing an ACS chapter in Guam, we anticipate that surgeons on the island will be better positioned to receive the benefits of full participation in the ACS and the programs offered through the Advisory Council for Rural Surgery.

Geographic isolation

Guam is one of five U.S. territories and, at 212 square miles, the largest island in the Marianas chain.¹ Situated between 13 and 21 degrees north latitude, 144 and 146 degrees longitude, Guam arises from an extensive submerged mountain range, an arc-shaped archipelago called the Mariana Islands.¹ Weather is characterized as tropical marine with an average temperature ranging from a high of 86 degrees to a low of 76 degrees Fahrenheit. The population is approximately 165,100 and predominantly Asian/Pacific islander.² If “rural” is primarily defined on the basis of remoteness, then Guam’s strategic location in the Pacific, where “America’s day begins,” would certainly befit the description. The average distance between Guam and its nearest neighboring countries, including the Philippines, Japan, Korea, Hong Kong, China, and Australia, is approximately 2,287 miles. The closest country is the Philippines at approximately 1,597 miles or a flight time of three hours and 30 minutes, while the farthest is the U.S. Honolulu, HI, is approximately 3,801 miles away, with a flight time of seven hours. Between “us” and “them” is the vast Pacific Ocean. Therefore, any urgent transport for specialized care necessitates some type of air travel.

Health care system

The health care system is similar to that of the rest of the U.S. Patients are covered through Medicare, Medicaid, a local program (the Medically Indigent Program), and/or private insurers. Professional licensing also mirrors stateside regulations, requiring postgraduate training in a U.S. residency program and passing the U.S. Medical Licensing Examination.

Guam has two hospitals—the Naval Hospital, Agana Heights, and Guam Memorial Hospital Authority, Tamuning. The military hospital provides care to active duty military personnel and their beneficiaries. This institution also provides civilian humanitarian assistance for trauma patients or acute emergencies occurring in close proximity to the military hospital.

Guam Memorial Hospital Authority is a 200-bed acute and chronic care facility managed by the local government. It has been the only hospital to serve the entire civilian populace for many years. The facility has 10 critical care beds and four operating rooms (ORs); labor and delivery have two suites of their own.

Fortunately, a new hospital will be opening soon, which will increase the number of beds and health care providers, while also delivering subspecialty care to the residents of the island— a welcome relief for many patients. Three independent, privately owned ambulatory surgery centers round out the available surgical facilities.

Without taking the military surgeons into account, surgical care in Guam is provided by five general surgeons and one surgeon in each of the following specialties: hand surgery, neurosurgery, otolaryngology, plastic surgery, and urology. Two orthopaedic surgeons and 14 obstetric surgeons complete the surgical workforce for Guam. This ratio of approximately three general surgeons per 100,000 residents falls far below the reported general surgery workforce figures for rural America—six to seven per 100,000.³

Trauma call at Guam Memorial Hospital Authority is every fifth night, and patients present with a breadth of blunt and penetrating trauma. All of the general surgeons are in private practice, and there are no surgical hospitalists. Like most rural practices, those in Guam manage a broad spectrum of traditional general surgery cases, and general surgeons are expected to provide frequent call coverage and often experience professional isolation.

Rural surgical practice in Guam

My clinic, Island Surgical Center, is a two-surgeon collaborative with myself and Dr. Cruz. We are two local boys who returned to Guam at approximately the same time after stints in the military. What has bound us together for almost 20 years is the common goal of making a difference in the health care services provided on our island.

We have a broad spectrum of case mixes in our practice, beginning with endoscopy. Guam does not have a gastroenterologist, so general surgeons perform all endoscopic procedures. Between the two of us, Dr. Cruz and I average approximately 40 to 60 endoscopies a month, including upper and lower endoscopic screenings or therapeutic polypectomies, and bronchoscopies.

Complementing each other’s areas of interest, Dr. Cruz performs a large number of breast operations, whereas I focus largely on pediatrics and vascular surgery. Crossover occurs mainly with respect to laparoscopic cholecystectomies and some colorectal procedures. Because of how busy we are with our individual case loads, finding time to assist each other can sometimes be a challenge. Hence, we usually operate separately, aided by an OR technician.

What distinguishes surgery in Guam from most rural practices in the U.S. is that our geographic isolation often forces us to use rural solutions to address urban problems. For example, whereas severe traumatic injuries in level II or III urban hospitals are transported quickly, our distance to a level I hospital makes it nearly impossible to transport a critically ill patient. Therefore, using rural resources is frequently the only recourse available to save a patient’s life. Additionally, air ambulance transport for a critically ill patient who is on a ventilator is prohibitively expensive, nearing six figures. Generally, private insurers refuse to cover these services, and if alcohol is involved in the traumatic event, the claim will certainly be denied. Therefore, even most critically ill patients are not transported. Yet you can imagine how a severe cardiopulmonary and/or hepatic injury will consume a significant portion of the resources of the hospital and affect the surgeon’s ability to continue his or her daily practice.

Another example of what distinguishes surgery in Guam is the availability of specialized techniques like endovascular surgery to control bleeding, which is standard in most tertiary care centers. In Guam, a patient who remains unstable because of bleeding will receive an open exploratory laparotomy to control the bleeding.

Recently, I performed a splenectomy on a woman who was struck by an automobile. She remained unstable despite receiving four units of blood. Ideally, if a patient can be stabilized, some commercial airlines will provide medical transport, dedicating three seats to accommodate a stretcher. This avenue is less costly. We also have devised special bassinets to transport neonates commercially. In the last few years, we have finally received neurosurgical support, but burr holes or flaps to evacuate hematomas for neurotrauma were previously performed by the general surgeon on trauma call.

In many U.S. cities, a specialist in general surgery is frequently understood to be an intra-abdominal surgeon with laparoscopic skills or an acute care surgeon. The current definition of general surgery in the U.S. is in a state of flux as surgeons meet the challenges of regional restrictions, attitudes regarding subspecialization, and hospital privileging customs. For example, trauma and abdominal cases describe only a fraction of my practice. It is not unusual to see on my OR schedule the following assortment of operations: an endo-rectal pull-through for Hirschsprung disease, a carotid endarterectomy or an infra-inguinal bypass, thyroidectomy, lobectomy for a pulmonary lesion, adult and pediatric hernias, and even hemorrhoidectomies. Occasionally, it may even be necessary to ligate a patent ductus arteriosus that is unresponsive to medical therapy in a premature infant.

As I stated earlier in this article, I returned to Guam to make a difference in the health care system. Due to Guam’s geographic remoteness and the difficulty in transferring patients, I feel compelled to provide a broad range of surgical services. My practice is probably similar to the practice of our surgical forefathers, people that I would call “real general surgeons.”

This type of practice is not unlike the practice of many rural surgeons in the U.S. A total of 24 percent of Americans live in rural areas, but many people are unaware or do not appreciate the value of these rural surgical communities.⁴ Closer scrutiny will reveal the high-quality surgical care delivered in these non-urban settings.

Establishment of Guam Chapter

Because of the similarity of my practice to rural surgical practices in the mainland U.S., I have had the good fortune to meet Dr. Hughes. Dr. Hughes and the rural surgery community were instrumental in encouraging the surgeons of Guam to form an ACS chapter.

Most surgeons on the island never anticipated that the College would establish a chapter here. Indeed, until we received encouragement from Dr. Hughes and his colleagues, we felt like people walking on the sidewalk of a busy city street, invisible to the larger populace until someone calls out a name. By calling out our name, Dr. Hughes and the rural community in the ACS opened the lines of communication and our existence became a reality. An ACS chapter in Guam helps resolve our sense of professional isolation, provides us with a voice in the ACS, and identifies who we are. For the first time in the history of the College, Guam has a tangible presence and is now visible to the rest of the ACS.

I came back to Guam to come home. After many years of medical training, beginning at George Washington University School of Medicine, Washington, DC, and ending at Hartford Hospital/University of Connecticut, I looked forward to making a difference in my island home. The surgeons before me were “iron men” because, quite honestly, they were even fewer in number and worked longer hours, under worse conditions. They deserve our respect and gratitude.

I learned from my forebears the value of my profession, the satisfaction of a grateful patient, the courage to tackle difficult surgical problems, and the ability to lean on the basic surgical foundations taught during residency to perform a broad spectrum of surgical procedures. I have never regretted my decision to return to Guam. I appreciate the support from other rural surgeons in the U.S., and the members of the Guam Chapter of the ACS look forward to working closely with the College in the future.

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References

1. Guam. Wikipedia. http://en.wikipedia.org/wiki/Guam. Updated November 27, 2014. Accessed December 1, 2014.
2. Guam. The World Bank. http://data.worldbank.org/country/guam. Accessed December 1, 2014.
3. Lynge DC, Larson EH. Workforce issues in rural surgery. Surg Clin North Am. 2009;89(6):1285-1289.
4. Doty B, Zuckerman R. Rural surgery: Framing the issues. Surg Clin North Am. 2009;89(6):1279-1284.