Second visit by Australian team

 

Benin 2018 Report

Mission report, Dangbo, Benin July 2018

 

The team this year consisted of 3 surgeons, Christine Russell, Richard Turner (both from Australia) and Thorbjorn Somers from Denmark + Anaesthetist Philip Gribble with critical care nurse Amy McLennan. This was our second trip to Dangbo in southern Benin; the mission in 2017 had demonstrated multiple, impressively large hernias and the workload was significant

 

The Hopital Auberge de L’Armour Redempteur is run by the local catholic nuns and only operates with visiting international teams; there are several visits a year from Spanish teams who clearly provide a broad & regular service. Mme Opportune is the leader of the nuns and a doctor to boot, though was not available to assist with the surgery. The operating conditions were basic but clean, the single operating room having two beds to work with [and is air conditioned]. The anaesthetic equipment was basic, the monitoring largely non-existent, and the Oxygen supply being one large cylinder and only in theatre.

 

We arrived in the Saturday prior to operating on the Monday. Sunday, we were presented with over 60 people to evaluate and many came for review with non-hernia issues [enlarged thyroids, metastatic disease, multiple unusual skin lumps, a 7month old with cleft palate, a 15yo inter-sex pateint]. Preparatory assessment had been done locally but was a little variable; 3 patients were cancelled as having uncontrolled HT [>210] and one had severe LVF.  Whilst we were there to focus on hernias, we were able to include several hydrocoeles, a couple of haemorrhoidectomies as well as keloid & lipoma removals in to our operating list. Of the 41 operations, 25 were hernia repairs.

 

Despite basic conditions, we were wonderfully looked after by the nuns, picking us up from the airport 90 min drive away; accommodation and food [and the evening beers] was all provided for us. The accommodation was spartan, but air conditioned, and the showers hot. There are no local facilities to access ‘extras’ though we really didn’t need anything; we did, take some theatre snacks which was a nice comfort. There is no reliable wifi service and phone contact was patchy to existent.

 

The weather in July/August was also noted to be far more pleasant than in April when we last visited; then it had been hot and humid building to the wet season, this time mid-20’s and far more comfortable.

 

From Australia, we had been supported by 2 local service groups [Rotary & Lions] to pre-purchase medications locally [especially Ketamine and Morphine], as well as bringing 2 pre-used diathermy machines from Australia to supplement their local equipment, all of which was very gratefully received.

 

One of the nuns, Sr Ruffina, performed the task of operating room manager and worked extremely hard, both before and after our work day, as well as Gabin Hounnou , the sole, post-op nurse. The aftercare was limited as it was a communal ward [in a separate building] with up to 10 people, but Gabin managed to perform admirably with limited equipment.

 

All operations were performed under either LA + sedation, or spinal; all hernia operations were planned TAP block under U/S guidance + infiltration. No GA was made available due to the lack of post-op care and the absence of a recovery area].The memorable morning of 2 patients singing a call & response duet at high volume (under the influence of the Ketamine) was a clear - and very

funny - highlight.

 

All the surgeons noted the difficult and ‘stuck down’ nature of the Beninoise hernia, so even apparently small examples provided a surgical challenge. The clear gratitude was also a delight and privilege; possibly the most rewarding post-op round one could have.

 

Suggestions for a future visit

# Prior liaison with Fr Martin of the Dangbo diocese allowed us to get him to order medications locally; we gave him 4 months warning and he was obliging to trust us to bring the money when we arrived. This worked very well we were guaranteed of critical supplies without having to transport it from Australia.

# The monitoring is basic to non-existent; we took 3 finger oximetry probes and left them there but  self-supply may be sensible. Capnography would have to be imported as well; ECG’s can be done but only if the patient is sent to the capitol, 2 hours drive away.

# Language was an issue for us, with only 1 fluent French speaker. Many patients do not speak French, only the local Fon, which makes communication even more challenging. The local support was ever present, though no interpreters were available. Without fluent french, there are clear difficulties.

 - one suggestion may be to bring a French vocabulary list for common medical terms as an adjunct

# The issue of duplicate medications and equipment was noted. The resident, residual supply of medications is large and somewhat eclectic & most of what we arranged was additional to requirements [though given the unreliability of storage in Dangbo, we ended up using mostly our own, ‘fresh’ supplies]. Whilst it may be difficult in Dangbo, information of what is present prior to a team visiting would be very helpful to direct resources to what is needed. This may be tricky, due to difficulty in email communication and limited local resources, though any prior information would certainly give a better service

# One specific suggestion for a next time would be to bring wrist bands for identification. The combination of the language barrier, unfamiliar names & difficulty in recognising patients clearly opens the door for error. A simple name + operation would significantly improve patient safety and surgical flow.

# Surgical practices [eg fasting times, post op care, routine preparation] have advanced in western practice compared to Dangbo and providing standardised information at the beginning would be helpful.

# Bring simple cleaning equipment [alcohol wipes, hand gel].

# We noted minimal supply of N Saline for mixing drugs; possibly bring a few 250ml bags of NS for this, eg 1 a day.

# Dr Gribble brought a hand held U/S machine for TAP blocks that was very useful and improved post-op analgaesia significantly; this was also utilised in pre-op assessments to aid in diagnosis.

# An Ampoule breaker would have been very handy; the local glass ampoules frequently shattered &/or were very difficult to crack

The local instruments vary widely in quality and we did leave several self-retaining retractors [for example] that were needed.

Whilst our visit this year did not have the same challenges as 2017, certainly the appreciation from both the patients and the nuns was obvious. Dangbo is a small unit but the HI mission provides surgical access to a group of people who have otherwise minimal opportunity. We left with the clear message that they would like us back.