Aerial map of Guam
JAN 2015 BULLETIN American College of Surgeons
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,
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
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
DISPATCHES FROM RURAL SURGEONS