This was the second Hernia International mission to Assam, at the Makunda Christian General and Leprosy Hospital. The team met up at Kolkata airport and flew to Silchar, Assam. From there the 120km to the Hospital took over 5 hours on the worst roads in India!
Makunda Hospital is a mission hospital in a very rural and remote part of Assam, close to the border with Bangladesh and Tripura State. The nearest hospital with surgical services is over 5 hours away in Siclhar. Over the last 20 years the Hospital has gradually expanded and has a very busy maternity unit delivering over 5000 babies per year. The outpatients see over 500 patients per day; however it is still a single surgeon institution, although hopefully this should be changing in the near future.
We were accommodated at the home of the founding doctors, Dr Vijay Anand Ismavel and Dr Ann Miriam. As they were away for the initial part of our visit, in addition to the usual adult and paediatric hernias, hydroceles and orchidopexies; we were kept busy managing the acute surgical patients during the week of our visit. Given the remoteness of our location, and the advanced state the patients presented in, several life saving emergency operations were required during our visit.
As well as being accommodated in their family home, all our meals were provided for. The Hospital is essentially self sufficient, growing their own food on Hospital land, and feeding all the staff and patients. They have also developed a nursing school, and a primary and secondary school for the children of the staff and local community.
There were 3 theatre tables (in two operating theatres), however as one of the diathermy machines needed repair, we often shared with the Obstetric team. There was a continual stream of caesars occurring in the table adjacent in the same theatre, throughout our visit. We were all very impressed with the training and dedication of the theatre nurses, who willingly operated frequently late into the evening with no complaint. The frequent cups of sweet chai supplied by the kitchen kept everybody going with intermittent sugar rushes!
This part of rural Assam is certainly a beautiful part of India, with a mixture of Hindu and Muslim Bengali people (some from across the border from Bangladesh), Assamese and various tribal peoples who look ethnically similar to Nepalese, Chinese, Burmese, Tibetan, Bhutanese and Thai. This is a biodiversity hotspot of the world, with an interesting collection of giant multicoloured spiders visible on our walks to the Hospital, a giant (over 30cm) Tokay Gecko we shared our bedroom with, and the myriad of twinkling fireflies over the paddy fields at night.
This was certainly a very productive and fulfilling mission, and I would highly recommend it to anyone else who would like to visit this Hospital.
A team of 7 people: 3 general surgeons, a pediatric surgeon, an anesthesiologist, a surgical nurse and a professional photographer.
11 packages with a total of about 220kg of surgical material and medicines.
Departure from Madrid on Friday 22 and arrival in Madrid on Saturday 30 September.
Saturday 23/9: Evaluation of patients already preselected by Dr. George.
Sunday 24-Friday 29/9: Surgical interventions, from 8:00 a.m. to 6:00 p.m., in 3 operating rooms. Friday from 8:14 p.m.
b. ADULT PATIENTS:
91 procedures have been performed in adults. 36 in women and 56 in men.
Inguinal hernia: 62, procedures. In all but 2 Shouldice, anterior hernia repair was performed, type Lichtenstein, with mosquito mesh:
41 rights and 21 left.
Of these, 10 were bilateral inguinal hernias, in another patient an epigastric hernia was operated in addition to the inguinal hernia, and in one patient an appendectomy was associated, since the appendix was included in a large recurrent hernia.
35 were scrotal and 22 giants. 6 were recurrences of previous herniorrhaphy without mesh.
Crural hernia: 4 (Lichtenstein plug with mosquito mesh)
Epigastric and umbilical hernias: 16, one of them was recurrent. (4 raphys)
Other procedures: 3 hydroceles (giants), 1 cryptorchidism, 2 testicular tumors, 1 lipoma, 1 bilateral inguinal abscessed lymphadenopathys and 1 nail abscess.
c. PEDIATRIC PATIENTS:
61 procedures were performed in pediatric patients, 49 in children and 12 in girls, from 7 months to 14 years of age.
Inguinal hernia: (rafias)
27 right, 21 left. 3 of them bilateral.
Other procedures: 2 cryptorchidias (orchidopexy), 9 umbilical hernias and 2 hydrocele
Total procedures: 152
Total patients: 129, 103 males and 26 females.
d. COMPLICATIONS:
Until leaving Ganta City on Friday afternoon, all patients were discharged after one night of hospitalization, without complications, except for one patient with a recurrent epigastric hernia, who underwent a Rives retromuscular hernioplasty, which remained hospitalized for 2 days. Patients operated the same Friday, were admitted to waiting for discharge the next day. According to Dr. George’s later report, the only complication has been a surgical wound dehiscence.
2. MEMORY OF THE CAMPAIGN
a. THE PLACE
Liberia is a West African country bordering Sierra Leone, Guinea Konacri and Ivory Coast. It has an estimated population of about 4.2 million, of which 85% are estimated to live below the international poverty line, and ranks 6th among the world’s poorest countries, in the last annual report of the UN, with an annual per capita income of $ 518. He lived a moment of peace since 2003, with the first democratic elections in 2005. His social and economic recovery was seriously threatened by the Ebola epidemic of 2014, in which more than 4,500 people died. During the months of October and November this year the Liberians are called to the polls to elect their new president, among more than 50 candidates.
Ganta City is a town in Nimba County, Liberia’s largest and most populous city. It has a paved main street, which is the commercial center of the town, although most of the streets are dirt, and the vast majority of its population lives in very simple constructions. The access to this population is made by road, built by a Chinese company, in very good condition, and that crosses the whole country from Monrovia, from west to east, in a journey of about 4 hours from the airport.
E & J Medical Center is Ganta City Hospital, and its medical director is Dr. Peter George. The hospital has a very limited means of attending to the population, which the employees of the hospital, and expressly Dr. George as responsible, fill with an enormous capacity for work and ingenuity. They have a basic laboratory, a pharmacy, adult and pediatric hospitalization rooms, emergency room, delivery room, and two operating rooms. It was surprising to see that the hospital is kept in clean conditions more than acceptable. Among the serious shortcomings of such a hospital, it is clear to us that it is difficult to maintain adequate asepsis circuits of the surgical material, a subject to which we will deal later.
During our stay in the hospital, we used the two operating rooms full time, one exclusively for pediatric patients, and one for adults. In addition, we have enabled another room for a third operating room, which we have also used for adult patients.
b. THE TEAM
On 22 September, Friday afternoon, a team of 7 people left Madrid destination Monrovia:
-Carlos de la Torre Ramos, pediatric surgeon,
-Sebas Fernández Arias, general surgeon,
-Ana Gay Fernández, general surgeon,
-Bea Revuelta Alonso, anesthesiologist,
-Nuria Agulló Marín, a surgical nurse,
-Sergio Sánchez Agulló, photographer,
-David Fernández Luengas, general surgeon, leader of the campaigns.
This campaign was carried out by a team of the Surgeons in Action Foundation, in collaboration with the NGO Hernia International, following the agreement signed by the latter with Hospital E & J Medical Center. This is the second campaign to Ganta City, after the first of a team of Hernia International in July, which opened the way to what is likely to become one of the locations most appreciated by the organization, due to both the huge needs of the population and the willingness of all local hospital staff to collaborate and participate in the campaigns.
Together with the medical team, this time a professional photographer participated in the campaign, with the objective of collecting audiovisual material to carry out a documentary film on this place, its reality, its needs, and the task that the Foundation Surgeons in Action and Hernia International carry out here.
c. THE LOCAL PERSONNEL
In the hospital there are currently only two clinicians, including Dr. George, medical director and specialist in Gynecology and Obstetrics. In addition, they have a head of Anesthesia, who leads a team with 2 other anesthesia technicians. For our work, we had two assistants in each operating room, who worked as scrub nurses and circulating in the operating room. It is fair to acknowledge to all of them the enormous effort made and the joy with which they have shared the work with us. Their deficiencies in surgical training have been supplemented by their dedication and willingness to work. We were very pleased to note upon our arrival the cleaning of the facilities, which we were able to check as they were kept day after day by the cleaning staff.
It was very exciting the welcome ceremony, just after arriving at the hospital, and was even more the ceremony of farewell, with the central waiting room crowded, in which we deliver diplomas of participation to all the participating staff, made by Dr. George, and we were delivered to the whole team some beautiful gifts that we deeply appreciated.
Dr. George, as Medical Director, sets an example with a tremendous capacity for work, and conveys that involvement to all staff. We have always provided an anesthesia technician and two auxiliaries. All our belongings were guarded daily in Dr. George’s office, locked, and with the presence of a security guard at all times, although our feeling was that it was not necessary at all, given the tranquility that was lived inside the hospital . The management of the hospital has put at our disposal a 7-seater SUV, with its driver, who has transferred us daily from the hotel to the hospital, and back, at any time, and always with a smile. In addition, they took care of our transfer to and from Monrovia airport, in a journey that lasts about 4 hours.
d. THE EQUIPMENT
The hospital has very limited means. In terms of our work, each of the three operating rooms have anesthesia equipment, one of them quite modern, but absolutely useless since there is no oxygen or anesthetic gases. The operating tables are acceptable and the lights perfectly valid. The hospital has a relatively stable electricity network, from 8 am to 7 pm. There are oxygen concentrators and basic monitoring systems for blood pressure, heart rate and 02 saturation. There are several equipments of surgical instruments in acceptable conditions. Our team carried two sets of adult surgical instruments that did not need to be used, and two sets of pediatric instruments, which we divided into 4 and used constantly for pediatric patients. Regarding consumables and surgical clothing, the needs are enormous. We have used practically all the material we have carried, more than 200kg among gauzes, compresses, gloves, dressings, sterile disposable cloths, sterile disposable gowns, iv anesthetic medication, iv antibiotics for prophylaxis, mosquito meshes and antiseptics, among other things. Without this material, to raise a campaign of these characteristics to this place is impossible. The next teams should be very aware of the need to provide all this material. Each of the two surgical operating theaters have their electrocautery generator. For the third operating room that enabled us, we carry from Madrid a generator owned by the Foundation Surgeons in Action. It is fundamental to carry both the adhesive earthing plates and the electrocautery terminals, since there are practically none.
e. THE DAILY WORK:
Our day begins every day in the hospital at 8:00 a.m. We arrived there from the hotel in a vehicle provided by the hospital, which moves us every day. Except on Saturday, the day of our arrival at the hospital, that we were checking the prescheduled patients, about 50 adults and 20 children, the rest of the days from Sunday until Friday afternoon we dedicated all the time to operate, and Dr. George was in charge of selecting new patients. Before starting each day of surgery, we carried out the ward consultation of patients operated the day before. We operated every day in the three operating theaters, except for some interruption to attend emergencies, mainly cesareans. In an important part of pediatric patients, the pediatric surgeon has received assistance from one of our general surgeons. Also, in the vast majority of adult patients, a general surgeon of our team was assisted by local staff. During two days, we had the presence of a medical student from Monrovia, in his surgical rotation, who received a valuable surgical training for his profesional future, in which the surgical skills are very necessary. The days have become short, working with great intensity, well into the afternoon, sometimes beyond 19h. We paused to eat, a delicious “wrap” kebab style, which Dr. George entrusted us daily. It is important to emphasize, for new teams, that this food must be paid to Dr. George, as stated in the agreement signed with Hernia International, as well as the fuel of the vehicle. Our daily work, it is important to point out once again, it has been very well appreciated by all the local staff, who have always been willing to help us, collaborating at all times to make the whole process more agile. Undoubtedly, it is the campaign in which we have received better local support, all of which we have participated the various members of the team. Regarding the safety of the team, we must point out that at all times we have worn face masks and goggles, and we have used double gloves. We have taken antiretroviral medication with us for a possible accident that fortunately has not happened, and we have completed malaria prophylaxis according to international guidelines.
i.
ANESTHESIA
There are two fundamental considerations here. One, on equipment and anesthetic material. The other, about the personnel dedicated to anesthesia.
The anesthesiologist of our team, supported by our nurse, have devoted almost all their attention to pediatric anesthesia, which has been the most complicated. Taking into account the absence of supplemental oxygen and anesthetic gases and, therefore, the impossibility of performing general anesthesia with orotracheal intubation, she has been forced to handle pediatric patients by the general combination of ketamine , fentanyl, midazolam and atropine, with constant manual ventilation and basic monitoring. Obviously, her professionalism and problem-solving ability have made it possible to conclude all interventions without serious problems, but it is obvious to emphasize the need to improve in this regard for the next campaigns. For this, it is very necessary for the hospital to provide supplemental oxygen and anesthetic gases.
It is important to note that a significant part of the anesthetic medication has been provided by us.
With regard to the local team, once again we must emphasize their great willingness to work and its great effectiveness. The head of Anesthesia, Abenego, has been a great help to all, very well supported by his anesthesia technicians, Brendan and Jonsi, who have practically never failed in spinal anesthesia. Our congratulations and thanks to all of them.
ii. ASEPSIS AND SURGICAL MATERIAL
Undoubtedly this is the great weakness of this hospital. There is little to analyze. Basically, they have a “sterilization” room where they store the packages with the sterile material, and a patio where two autoclaves of the type “express pot” with a pressure gauge are placed on wood fire. The system itself is rudimentary, but effective to achieve sterilization of the material.
The big problem is the asepsis circuit. With very little material, the instrument sets are left open from one operation to another to distribute the material of each set between two or more interventions.
Surgical clothing is very scarce, with very few cotton gowns and resterilizable surgical cloths. For this reason, they usually use non-sterile paper gowns to dress the surgeon and the instrument table, and some very small sterilized cloths to dress the patient sparingly. We use a large amount of disposable cloths that we carry from Madrid, as well as disposable gowns. Unfortunately, the gowns were finished, and although we tried to force the constant resterilization of cotton gowns, having so few, we had to operate on many occasions with the non-sterile paper gowns. The local staff always wore these paper gowns, associated with their errors by the lack of knowledge of what a sterile field means, they made us constantly watch over them in order not to lose sterility.
We have been particularly concerned that all of our adult patients receive a dose of cefazolin 2gr iv in anesthetic induction, which we have taken.
Another problem arising from this situation was the reuse of the electrocautery terminals. Although we carried a large number of them, they were not enough for the 129 patients, so we had to devise a way to “resterilize” this material. As it is not possible to heat them in the autoclave, we arranged containers in which we submerged the terminals, once cleaned, in a solution of 2% alcoholic chlorhexidine.
These problems must be resolved urgently. We have explained to Dr. George the situation, and he has understood the need to provide the hospital with more stringent asepsis circuits and resterilizable surgical clothing.
Regarding the surgical material, the situation is equally bad, as it corresponds to the type of hospital that it is. We carried a lot of material that is essential for other missions to take equally, from gauze and compresses to sterile gloves, drainage, dressings, steri-streaps, sutures, elastic bandages, etc.
Of course, there are no meshes for performing hernioplasties. We have carried a large number of “mosquito” meshes, sterilized thanks to the work of Hernia International, which sterilizes, packs and labels individually, and from here we take the opportunity to thank. In addition, we have carried some larger polypropylene meshes (30x30cm, for large incisional hernias that we have not done in this campaign, but that are often done) and some double layer mesh to ensure some special needs.
Surgical instruments are acceptable. In fact, the two sets of adult instruments we had was not necessary to use them. We also carried two sets of pediatric instruments, which we converted into four, and which we use constantly.
f. OUR LIFE IN GANTA CITY
Our life in this place has been very simple. We have always felt very well treated and well accompanied. Apart from the hospital life, which occupied much of the day, our life was practically limited to seeing the town in every way from the car window, and to enjoy the hospitality of Jackie’s Guest House.
That is the name of our hotel. Probably the only hotel to which we can go in conditions of health and safety, and that other international organizations use aswell, with which we have meet there. It is not a luxury hotel, as it can be understood, and yet it is quite expensive given the situation of the country, probably because it is used by all foreigners, and for that the costs raise enormously. We paid $ 50 for each room per day, not including breakfast nor dinner, which we also made at the hotel.
The rooms are clean, with fridge and TV, and with a 1.35m bed. The bathroom is ok, although the water flow in some rooms was quite meager.
The food has been equally good, none of the team members has had gastrointestinal problems, and we have enjoyed some variety. Definitely the best thing about each day was being able to enjoy a large bottle of 75cc local beer called Club Beer, well cold, which was an absolute pleasure that none will easily forget.
The hotel has a wireless network that has allowed us to communicate with the outside, but with frequent interruptions.
Overall, Ganta City does not have much to do, and it is not overly recommendable to wander around the city either. The concept “tourism” is very far from this place.
We had the opportunity to spend a few hours in Monrovia, in the late night before boarding back, but also did not give us time to visit some of the most emblematic places of the city, so we can not tell much about this. From the rest of the country, what we could see during the road trips. Basically, leafy jungle, flat, and population nuclei of great poverty, with a lot of motorcycle traffic and very simple constructions.
3. CONCLUSION
In short, this campaign has been a success, both for the number of patients we have been able to operate, without complications, and for the satisfaction of the team for the great treatment received by the authorities and local staff.
Undoubtedly, this place has become, in its own right, an important goal for our organization. There is much to be done, and the people here are looking forward to help.
Strengths of this place:
– Dr. George, the hospital’s real engine.
– The hospital itself, a real luxury for this place, with a very needy population, plunged in poverty.
– The way they take care of foreign teams.
Objectives of improvement:
– Aseptic circuit and sterilization of material. An urgent need to expand the surgical material, currently very deficient, and improve the asepsis methods.
– Training of auxiliary staff in the operating room and in basic rules of asepsis and antisepsis.
– Anesthesia equipment with supplemental oxygen and anesthetic gases.
– Improve the available surgical instruments and surgical material.
4. BUDGET:
For information, and without going into too much detail, it must be said that the campaign to Liberia is comparatively more expensive than others. This is due to two fundamental reasons. One, the cost of the fligth, significantly more expensive than in other locations. Two, the costs of lodging and maintenance
On Saturday September 2nd I make an appointment with MaríaFanjul, children’s lady surgeon, in the Gregorio Marañón hospital to collect the generator for electrical scalpel and the mosquito meshes provided by Hernia International for our mission. We are going again together and to the same place, which gives us great joy, and we’ll be accompanied by Luis Rodriguez Bachiller and Laura Gomez Lanz, surgeons in the same hospital, Montse Sanchez Martín, nurse and companion in the Farafenni campaign (Gambia) in 2015, her sister MaríaJesús, medicine student, and Angel Revuelta who will act as reporter and helper in all our needs. MariamaBadji will accompany us and will be essential for drawing up lists of patients, for logistics and supplies, institutional contacts, shifting, etc., as she is always ready to help all of us. Without her we could not have managed.
Sunday 3rd we meet at 15 hours next to the machine that will pack all the material, that is sutures, instruments, electric scalpel terminals, operation theater linens, surgical gloves, sutures, meshes, dressings, caps, masks, toys for the children, medicines, etc.
We passed all controls without any trouble, waited to be fetched and made our acquaintance with new companions. We all feel that mutual relationship will be perfect, and so it was in spite of a few difficulties along the work. Good relationships are essential are essential for the success of a situation that met with difficulties at the beginning.
We arrive in Dakar at 20.40 local time (two hours less that Spain), and the night would be hard as, having no possibility to come out of the airport, we decided to try to sleep anyhow anywhere. Fortunately the Sanchez Martín family had given us food for the occasion. Thank you! New checking up at 7.30 with some problems with our bags and with the generator. Difficulties over, we take off at 9 and arrive at our destination at 9.45.
Two vehicles are waiting for us. We get ready for the two hours ride that will take us to Sédhiou. We agree to go first to the hotel to wash up and try to rest a while before going to the hospital to unpack and set in place all the material for the operation theaters. But in fact the adventure was just beginning.
Six of us boarded a jeep and a lorry meant for four people. The way is long and the road is full of military and police controlswhich we pass without difficulty. Difficulties begin 20 km before arrival when one of our lorries suffers a puncture in a back wheel. Without replacements, the jeep lends us its extra wheel which the drivers set up in the midst of the heat with all of us waiting at the ditch. We start again, and soon a van stops because of an electrical problem. Don’t ask me, but we repair it somehow we keep going till, at 8 km from Sédhiou it stops again, this time definitely. With the other vehicle we reach a nearby village where we get a rope and try to tow the lorry. The rope splits and we are all left helpless.
By this time we are all tired, sweating, hungry, desperate and only longing to reach the hotel to eat something and then going to the hospital to unload and order all the material. We finally get another lorry to come and fetch us, and so we reach Palmeraie.
It is 15 hours by now, but we eat something and go to our rooms. At 17.30 we go for the Centre Hospitalier. We are warmly received. Collaboration is perfet, but…
But Dr. Cámara appears and difficulties begin. Backed by his whole team (including the substitute for the director who is at present in China negotiating for a new hospital…) he gives us a lecture about mutual respect and obedience to the chief, that is to himself, and all that he may say. Quite a bad beginning.
Anyway, we do listen to him, and I just plead for mutual respect and that we, as always, are here to help and to operate upon poor patients without asking for anything.
The trouble is that, in spite of our having asked for a list of patients, there are only five ready for the next day. He effort not to get angry is great, but at least we get that while those few are operated, I may see the sick and so get more ready for operation. That first day we get 8 new cases.
We had come with the idea of working for three beds, but soon all our plans collapsed. Dr. Cámara, with plain gestures of disagreement, said no. The problem increased when we discovered that the Senegal surgeons who were going to collaborate in child surgery were in fact reduced to only one NGO (AMRAF) whom, just as in the 2016 campaign, the surgery chief has called to coincide with us.
Given this situation we had no other alternative than calling Dr. Amadou Yéri Camara, the new health chief for the Casamance region, so that he could act as mediator. He very kindly came to the hospital and took note of our requests, promising to transmit our request to another Camara who, as we foresaw, did not obey. It was a very difficult task to perform, and it got even worse when the members of the team began to show their disappointment and their annoyance. But we did not give up. I myself was astonished at my own patience. We had gone there for a campaign and we were going to carry it out, even if we knew it was not going to be as effective as the one we had planned.
Meanwhile we had established a pleasant relation with Prof. Gabriel and his team. It was not rare to see him watching our procedures. Talking together we reached the conclusion that it was essential to make the two missions coincide. I was surprised to know that the same thing had occurred the previous year… and now was repeated.
In short and without entering in further details, the mission was difficult, but it was carried out satisfactorily within the limits we were given. Comradeship was essential, as it also was the help given by the auxiliary staff of the hospital itself.
Xabier, the infirmary chief, invited us all on the 8th.We had a great time with beers, aperitifs and laughter. But heat, very high heat. Then we walked through the village and saw popular festivities taking photos of them.
Just as in previous times the Sédhiou community held for us in the local Casa de Cultura a warm farewell in which they gave us diplomas and a picture with local motives for the “Fundación Cirujanos en Acción”. There was music, dancing with the members of our team, and supper. As in the previous campaign a representative of the governor of the province, the mayor of the city and the Prefect were present. This time I had to say a few words of gratitude for the way we had been treated and had been trusted. It was not a moment for complaints but for diplomacy, as our work should certainly settle down there. There is a great necessity for it, but all conditions should be made clear. The obstacles experienced in our last two visits should not be repeated.
The last day of work was normal. We operated upon the last patients and we examined those of the previous day. Fortunately there was no complication. We collected prosthesis and sutures, even though Dr Camara did not like that. After all he never showed any interest in our work. He collaborated with the other NGO, with is alright with us, but he was not interested in knowing what we were doing and how.
There was no problem in our way back except long waiting in the airports and intense heat. In Dakar the family of Mariama (her brother and the daughter of our collaborator who was a student of technical engineering in the capital) were waiting for us and got for us some pizzas that helped us to spend the time. Some of us went collecting souvenirs although in previous days the girls had already collected gifts.
Mission accomplished. Exemplary team. Early morning farewell and recovering a peace of luggage which we had forgotten in the airport at our coming.
We’ll have to talk in order to correct mistakes so as to make future campaigns more and more effective. We’ll have time for that.
Dra.Laura Vega Lopez (surgeon) Dra,Libertad Martin Preto (surgeon Resident Dra.Marta Magaldi Mendaña ( anesthetist) Dr.Jose Miguel Moran Penco (pediatric surgeon) Miss.Sandra Rivas Losada (nurse)
Finally the day arrived, everyone met at the airport to start the adventure. 3 general surgeons, (1 last year resident), 1 pediatric surgeon, 1 nurse and 1 anaesthetist. We carried large bags for the campaign (full of drugs, toys, surgical material…). The trip was long, 16 hours, with a scale, final destination in Nairobi. It wasn`t easy to leave the airport, the drugs that we brought in the bags alerted the police and we were retained for 6 hours until they got “the permission of the President” (or that’s what they told us). Outside the airport was waiting for us the man who would be our faithful driver throughout the mission. He took us to Ruiru, where our hotel was. This was about 20-30 minutes from Gatundu, where we would be going to work. It was a level 4 hospital. China had cooperated and constructed a new building, with “modern” operating rooms and some hospitalization rooms.
We spent the first day in the consulting room, exploring and scheduling the patients who would be operated the following week, adults and children. As we were collaborating with Hernia International, most of the pathologies were hernias, inguinal and umbilical. Some hydroceles and testicular tumors were also scheduled. We also operated cryptorchids, and a thyroglossal cyst in children. As an exception, we operated an intestinal obstruction that required small bowel resection.
The following days followed always the same routine, we were picked up at the hotel at 07:00 – 07:15, arrived to the hospital at 07:30 – 07:45 and reviewed the patients operated the day before. We used to gift some toys to the children, make the complex cures and explain the recommendations to the discharged patients. Patients loved watching us, always smiling when they saw us coming, some of them even asked us for some photos. We began operating at 09:00-09:30. We had 2 operating rooms, quite modern, one for children and other for adults. About 11:00-12:00 the desired coffee arrived, accompanied by typical breakfast, sweet potato, and the “wase” (similar to the potato but softer, the reality was that its flavor didn`t convince any of the Group). Lunch was at 14.00-15:00. Always the stew beef with vegetables, coleslaw and corn bread, with a basket full of bananas for dessert. 7 to 10 patients by operating room per day. We used to finish rather late, so there was no time for sightseeing. When we arrived at the hotel after work we used to go straight to the dining room and order our deserved and desired “Tusker” (a typical beer there, was our favorite). We had to get used to the African rhythm, everything was made with a lot of calm, veeeery slow (this was applicable not only at meal time, but also in all aspects of the daily life). During dinner we talked, reviewed the anecdotes of the day and used to connect to the wifi.
Libertad Martin Preto
We worked hard, but the good company and the love for our profession made the experience worth it. We became friends, (between us and with the hospital staff who helped us in the operating room) we learned about each other, we laughed (that above all), we sweated and got tired. All this, added to the charm of Africa, discovering other cultures, other landscapes, made us returning back home with a big smile and unforgettable memories.
I will also say that the working week was followed by 4 days of a spectacular Masai Mara Safari. A new experience, unlike any other, which all of us enjoyed fully.
In September 2017, an eager group of doctors touched down in Entebbe, ready for another ‘hernia camp’ at the Bishop Asilli Hospital in Luwero. Three previous attendees (Tim Brown, Scott Caplin, David Hepburn), plus two new additions to the group (Guy Shingler, consultant surgeon and myself, Laura McClelland, ST7 in anaesthetics) under the care of Andy Pilcher (Care for Uganda) and his local staff. They ran as slick an operation as is possible and we were grateful for all of their hard work.
Most team members knew each other. I knew only one person but was sure that we would all be firm friends soon enough. Indeed, there is no greater breaker of ice and general leveller than when one is forced to dangle by the waist from the window of a Matatu taxi, violently vomiting for Britain, much to the hilarity of local Ugandans. When such things occur within two hours of landing, there can be no doubt that the rest of the trip will be just as eventful.
After a very welcome sleep in a guest house, we made our way to Luwero. The Matatu paint work bore no evidence of the Welsh vomit and it was like it had never happened. I would go as far as to say that I had a spring in my step as I skipped off into the dusty horizon. We drove through miles and miles of colour, dirt, poverty, pride, industry, farming, innovation, hope and helplessness. I felt incredibly privileged for all that I had ever had and was thankful for the fact that my children, by dint of where they were born, were dealt a far safer, healthier, easier hand than so many of the young lives that I observed playing at the roadside, lugging cans of water.
After arriving in Bbowa we visited the hospital for a pre-op clinic and visit to the theatre suite. The patients ranged from five months to seventy years in age. Some had travelled for days to get to the clinic. Others had been postponed from the previous year. All were shy in front of the pasty, white-faced doctors and the children made not a sound.
We identified the patients for the following day, delivered pre-op instructions through a mixture of broken English and sign language: possibly not fully understood. By the end of the clinic, we were explaining ‘tomorrow, no eat, no drink, needle in back’, finishing with a smile and a big ‘thumbs up’.
The next morning was my first experience of providing anaesthesia outside a UK teaching hospital. Dave talked me through his previous experience and we made plans for the general/regional anaesthesia cases. I made up a spinal trolley and an airway trolley in order to provide us with a degree of preparedness, familiarity and control in what I sensed would be a rather different working setup than I was used to. Drugs, kit, a draw-over vaporiser, an anaesthetic machine, some halothane and a large oxygen cylinder all checked and ready – it was time to start.
Our first patient was a five-month-old boy. This was nerve-wracking as such a case would be the preserve of the paediatric anaesthetist in ‘our’ world. A carefully thought out plan and rigorously prepared monitoring, equipment and drugs were all that we bring to the situation and so we just had to do the very best we could. All went well and we breathed a sigh of relief that our first challenge had been safely overcome.
During the week, we performed over 80 procedures on children and adults. The motivation of patients and staff enabled us to operate on a wide range of hernias under spinal block or local anaesthesia, with the occasional use of intravenous analgesia and sedation. The paediatric cases underwent general anaesthesia with or without caudal blocks. Interestingly, only one little girl cried at induction. We took them into the theatre ourselves with the parents trustfully sending them off with a clear warning to behave!
We did deviate from our ‘hernia’ mission on one occasion as we happened upon an extremely ill 28-year-old man on the ward. He had a perforated duodenal ulcer and was awaiting a review the following day. We explained to the patient and his family that an emergency laparotomy was his only chance of survival but his chance of death was high.
A mere seven hours into the work and we were about to anaesthetise a moribund, under-resuscitated, individual in an unfamiliar environment, among staff who spoke a different language, without standard monitoring or the normal drugs we would use. Nor was there an intensive care unit if we even got that far.
Was this appropriate? Were we interfering in the sociocultural ways of the Ugandan health system? We were present as volunteers and providing our care free of charge, but the post-operative care would be charged to the family. Would they be able to afford it? Were we potentially condemning them to a future of poverty? Their main breadwinner was very likely to die. Were we imposing our cultural values on them?
He made it through his surgery (6 litres of intra-peritoneal pus) and the night with strict post-operative instructions about fluids, analgesia, antibiotics, urine output and observations etc. He was still extremely sick the next day, but we continued to do what we could with improvised physiotherapy and oxygen via a concentrator, when power permitted.
On day two he was worse: pyrexial, hypoxic and tachycardic. All we could offer was the same with regular visits for coughing exercises, chest percussion and brief periods of sitting. On day three, he smiled and said the coughing was making him tired. On day four, he started to sip water and sat in a chair for five minutes. By day five, he was sipping mango juice and eating cake. He stood up, before collapsing back on his bed – we were thrilled.
We have received regular updates since leaving and he is now back home with his family and his cows. I don’t think we could hope for more. This was achieved without a financial burden on either him or his family.
Watching our young friend come through his ordeal with good attention to basic physiology, medicine and nursing care was one of the most valuable and rewarding experiences of my career to date. I will forever draw on the lessons it taught me.
At the end of the week, we had a special delivery – all the way from the Sancta Maria Hospital in Swansea. A donated ultrasound machine, shipped over to Uganda, had finally arrived in one piece. A great deal of time, money and effort had gone in to getting it to this final destination and the hospital were in desperate need of a functional machine – would it work?
With a mixture of euphoria, relief and concern, the machine was unloaded and manoeuvred into her new home. We all stood in silence, an audience full of anticipation and hope, praying that the Toshiba Aplio from Wales would do us proud. The radiographer happily wielded his probe on a ‘volunteer’, showing us all his model viscera. The machine continues to do great work for the local community but they can’t change the date format and so all scans will forever be dated December 2010!
Our work with a bunch of terrific, highly able local staff who had taught us much had sadly come to an end. We hope that we had taught them as much as they taught us. We had safely undertaken anaesthesia and surgery on a large number of people, allowing them a healthier, more comfortable future. And the ‘team ultrasound’ had worked well, justifying what had seemed like an impossible task during the planning phase.
The experience felt like it had gone by in a flash but similarly, I was often convinced that it had started in a different lifetime. It had shown me many things, some of which I noticed at the time and some which will no doubt continue to reveal themselves as time goes by. I am a better doctor and human for having been on that trip and feel fortunate for the opportunity to have done it.
My greatest joy, however, is that there was no public vomiting on the return journey.
Mission Report: Chittagong, Bangladesh (6-11th August 2017)
Group picture outside of Nurture General Hospital with local doctors and volunteers
Tucked away from the blaring horns of the main Chittagong roads, between paddy fields and an artillery camp lay Nurture General Hospital.
The 6-storey Nurture General Hospital
Nurture was founded as a charitable dispensary in 1995 by Mdm Nasreen Baqui. With the help of volunteers, well-wishers and organizations, it has since grown into a six-storied hospital for the disabled and a charitable school for destitute children.
After an overnight flight from Singapore to Chittagong with a layover in Dhaka, our team of 12 volunteers from Singapore returned for our second year of performing free hernia operations. In total, 50 operations were performed including 1 hydrocele repair and 49 inguinal hernia repairs. All operations were done under spinal anaesthesia unless contraindicated or deemed to be too high risk, in which case local anaesthesia was used. We arrived bright and early on the second day and started with screening patients and setting up of equipment. Our excellent anaesthesia team got to work immediately, administering spinal anaesthesia and pre-operative prophylactic antibiotics for the first round of patients.
Our anaesthesia team comprising of Dr Zheng Zhongxi, Dr Avinash and Dr Yeoh Chuen Jye (L to R)
Dr Avinash administering spinal anaesthesia
All inguinal hernia repairs were done using the Lichtenstein open mesh repair technique with pre-sterilised meshes kindly provided by Hernia International. We would run up to 5 operating tables at any one time and end the day with screening more patients for the next day. All patients were admitted overnight for monitoring and were reviewed the next day in a daily ward round and discharged to continue follow-up with their local doctors.
Dr Chok and Dr Ling at the daily ward round
“Our mission would like to give a loud shoutout of thanks to Sister Carol Reid from Omagh Hospital (UK) and Dr Aleksander Stanek for donating a diathermy machine for the mission’s use. This most definitely helped improve efficiency and operation performance!”
Dr Darren Chua (L) and Dr Lee Lip Seng (R) performing an open hernia repair
The assistance of Mdm Nasreen, her twin sons Yasmin and Yasir as well as their dedicated team of volunteers comprising of local doctors and medical students were invaluable in ensuring the success of this mission trip. The warmth and hospitality shown to us makes us look forward to returning again next year.
The team. From left to right. Front row: Dr Yvonne Ng, Dr Ling Xiao Shuang, Dr Teo Qi Tian, Dr James Ngu, Dr Goh Aik Wei, Dr Koh Ye Xin. 2nd row: Dr Lee Lip Seng, Dr Chok Aik Yong, Ms Wendy Lim, Dr Avinash, Dr Yeoh Chuen Jye. 3rd row: Dr Zheng Zhongxi, Dr Darren Chua
Takesure Mamvura. Operating Department Practitioner
THE HOST
Ganta City is a market town three hours’ drive (on a tarmacadam road recently built by a Chinese company) inland from the capital Monrovia, fairly close to the border with Guinea. The long-standing low level of health care provision in Liberia was made worse by the civil war 12 years ago, when many hospitals were taken over for military use, and then by the Ebola crisis of 2014, when many hospitals were closed. Both these events served to increase the sense of isolation experienced by Liberian doctors and rebuilding services following them has been slow.
Our host hospital, The E and J Medical Centre is an example of how some expansion of medical services is taking place. It was opened a year ago to provide mainly surgical and gynaecological services. Medical and surgical cover is provided by two doctors with support from a limited number of trainees. Anaesthetic cover is provided by two experienced anaesthetic nurse practioners, who work in both the E and J Hospital and a neighbouring hospital and a recently appointed anaesthetic practitioner working full time at The E and J.
OUR WORK
We had seven full days of work. We arrived in Ganta City late at night and spent our first day, attending a very impressive welcoming ceremony and then seeing patients in the Out Patient Department (OPD). There had been announcements of our mission on the local radio, informing that we were coming to provide hernia repairs free of charge. About two hundred and twenty people responded to the announcements, many more than could have been operated on during our limited stay. Each responder was given a number and then called in turn to be seen in the OPD. We spent all of the next two days in the Operating theatres and then had a further OPD session on our fourth morning. One more batch of patients were seen in the OPD by Dr George on the fifth morning.
We operated on 126 patients and repaired 135 herniae. 86 patients were adult men (18 years and over), 11 were adult women and 38 were children under 18 years. There were 73 adult inguinal herniae (25 were described as inguino-scrotal); 11 umbilical or other midline defects and 2 femoral herniae. The 38 children all of whom had inguinal hernia repairs (10 were bilateral) with an additional umbilical hernia repair performed in 4.
COMPLICATIONS
One man had a large scrotal haematoma the following morning which was drained through a scrotal incision. One man, who had a large femoral hernia repaired from below with some difficulty, due to dense scarring from previous surgery in the inguinal canal, had an obvious recurrence of the hernia by the next morning. A repeat repair was carried from above the inguinal ligament, with the pre-peritoneal space being entered through the posterior wall of the inguinal canal and the defect, along with the posterior wall, were then repaired with mesh. One man had a severe headache and neck stiffness on the morning after surgery. We were concerned about meningitis and recommended intravenous antibiotics. Two days later he had been sent home and it seems likely that this was a spinal headache. One infant developed laryngospasm shortly after returning to the ward. Respiratory support with a suitably-sized Ambu bag was required for a few minutes. This left the child with a very distended abdomen for the rest of the day, but his breathing gradually settled and he was back to normal the next day. One infant vomited during surgery and aspirated breastmilk. We learnt that he had breastfed an hour before his ketamine anaesthetic. He had a post-operative tachypnoea and some rib recession later that day but seemed back to normal by the following morning.
It is likely that more complications will develop during the days following surgery. Inevitably some of the patients with big scrotal herniae will develop scrotal oedema and haematomata, in spite of the seemingly very effective scrotal bandages which were applied by the anaesthetic practitioners. The later complication that worried us most was that of wound infection and chronic mesh infection. We had left the country before these problems would manifest themselves and, without a system of formal follow up, we will never know the actual incidence of septic complications. Dr George has said that he will keep us informed of any follow up information of which he becomes aware.
ASEPSIS AND ANTIBIOTICS
On leaving Liberia and reflecting on our six days of surgery, the aspect of our practice which concerned us most was the potential for surgical site sepsis. It was difficult to be confident that we were operating in an aseptic field during the course of any procedure. The skin was diligently prepared with antiseptic solution but there were many instances when asepsis could not be guaranteed. Our surgical gowns were thin, single use paper gowns as we might expect to wear in an isolation cubicle. They were clean, but not sterile. The drape isolating the surgical site was very often a single-use surgical gown in which a hole was cut to give access to the patient. This was sterile but not fixed in place. The scrub nurses clearly understood the theory of asepsis but sometimes the theory did not convert into practice. The sterilization of drapes and instruments was carried out in a pressure cooker type of container heated on a charcoal fire. When a live ant appeared from a drape as we unfolded it at the start of one case, one couldn’t help wondering how reliable this system was at achieving the required temperatures for sterilization.
We had not brought any antibiotics with us for routine use. Dr George had provided each adult patient with a three-day course of an antibiotic to take home. On reflection, we would have liked to be have been able to give all patients for mesh repair a single intravenous dose of broad spectrum antibiotic at the time of their spinal anaesthetic as a prophylactic against mesh infection. To do this a supply of the antibiotic would need to be brought by the mission team.
On considering the problem of asepsis, we were very fortunate to have an Operating Department Practitioner (ODP), Takesure Mamvura, as part of our team. Whereas the three surgeons were the workers of the mission, Takesure was the educator. He was able set an example on how to maintain asepsis during the procedures using simple suggestions such as covering the feet and lower legs with a drape and using small sterile towels, which seemed to be available in reasonable quantities, around the surgical site beneath the drape. He was also able to lead by example in other aspects of ODP technique, such as the benefits of maintaining a tidy and well-ordered instrument tray, instrument handling to prevent needle stick and scalpel blade injuries and the value of needle, swab and instrument counts.
PATIENT IDENTIFICATION AND MARKING
Another aspect of surgical practice that could be improved, following the experience of this visit, was that of patient identification and surgical site marking. All patients had a “chart”, which consisted of the two sheets of paper, one with the outpatient note and the other with the nursing note from the ward. Patients came to theatre with a chart usually, but not always, their own. Bringing the wrong chart seemed to occur more frequently with the young children. On one occasion the outpatient note stated “History of left scrotal swelling. No evidence of a hernia today in spite of crying ++. Not for surgery” and there on the table was an infant with a large right scrotal swelling. It would very helpful if every patient who was put on the list for surgery in the clinic was issued with a wrist band with identification details. Probably the name and proposed surgery would suffice. At the same time the surgical site could be marked. The wrist bands and surgical marking pens would need to be brought by the mission team.
ANAESTHETICS
One of the most remarkable aspects of our surgical experience in the E and J Hospital was the quality of the anaesthetic provision. Successful spinal anaesthetics were administered quickly and with great reliability so that additional anaesthesia, in the form of Ketamine or local infiltration, was only rarely required. The three anaesthetic practioners concerned, Abenego Yebakeh, Emmanuel Johson and Brenda Koly deserve great credit for this. In addition to giving the anaesthetic, they were also responsible for organising the operating lists and ensuring that the next patient was sitting waiting outside the theatre as the previous patient was wheeled out. The large number of cases that we operated on bears testimony to the way they worked. It enabled us to achieve a patient turnover rate which would be unthinkable in modern European practice.
One aspect of the anaesthetic practice with which we were not happy was the use of spinal anaesthetic in children. It seemed unrealistic to expect a young child to cooperate with the insertion of a spinal needle. It is true that some did manage, but others resisted and required Ketamine. We would have preferred to see Ketamine used as the first line anaesthetic for these children or at least a dose of Ketamine used prior to the insertion of the spinal needle.
EQUIPMENT
The mesh provided by Hernia International was perfectly satisfactory. We didn’t initially realise that some packets contained double sheets for bilateral hernia so there was some wastage. We also had with us some meshes donated by Braun Ltd which were very useful for large defects. We used the majority of the large number of sutures which we had taken with us. A good supply of surgical ties was very important, as most procedures were done without diathermy. We had brought some boxes of surgical gloves and extra were supplied by the hospital. Double gloving was regarded as the norm. Thomas Simon had been given several sets of surgical instruments by Braun Ltd. These proved very helpful and future missions would benefit from providing themselves with, if nothing else, suitable dissecting scissors. The hospital provided scalpel blades, but smaller ones for paediatric use would have been useful.
The operating lights provided good illumination but were sometimes difficult to manoeuvre. Also the electricity supply was erratic and a number of blackouts occurred. These were, thankfully, short-lived and hopefully will be less frequent when the planned solar / battery system is installed. Even so, we recommend that surgeons on future missions provide themselves with the reassurance of independent illumination from a good quality headlight.
One of our party sustained a significant needle stick injury during the course of a procedure. The spot test for HIV on the patient was negative. The surgeon concerned had brought a five day course of PEP (post exposure prophylaxis) with him and was reassured by being able to take it.
PAEDIATRIC SURGERY
A significant proportion of the surgery that we undertook was on children and we would strongly recommend that future missions include at least one surgeon who is familiar with groin surgery in children. We felt that the paediatric surgery that we did was potentially the most beneficial of all our work. If a simple herniotomy in childhood can prevent a large inguino-scrotal hernia, in which the vas is densely plastered to the sac (a very common scenario), in early adult life, then so much the better.
The infants who were bought for surgery all had bilateral, irreducible inguino-scrotal herniae. It seems likely that it was the recognition of the high risk of strangulation, with its very grave prognosis, which prompted the mothers to bring their babies for surgery. These were some of the most challenging cases that we were confronted with during our mission. The Ketamine provided no muscle relaxation and seemed (understandably) to be given fairly sparingly to the babies. A sudden flexion of the hip during the course of the dissection was not uncommon. Usually the inguinal canal had to be full opened before reduction could be achieved.
After we had spent our first day seeing patients in the clinic, we decided that we should put the children before the adults on the next days’ operating list and that, in line with our normal practice, we put the youngest children first. We realised, too late, that this meant that we had given ourselves the most challenging cases to do first in the unfamiliar operating theatre with unfamiliar staff. Subsequent missions may wish to pick some reasonably straight forward cases for their first morning.
The purpose of our mission was to provide the “free of charge” hernia repairs, which had been advertised on the radio, to as many patients as we could. This meant that we needed to do most of the operating ourselves, rather than spend time training the junior surgeons. Clearly, however, if we could train some of the local surgeons to do high quality hernia repairs, which in our case meant either a mesh repair or, in selected cases, a Shouldice repair, then we would leave behind a more sustainable surgical legacy. We had a particular incentive to do some training, as we knew that those patients who had presented following the radio announcement and whom we didn’t have time to operate on, were assured that they would have their hernia repaired as part of the “free of charge” deal by the local surgeons after we had gone. Two of the local surgeons, Dr Charles Manakpalah and Dr Charlie Kinpesa were very capable surgeons. They were taught to do both mesh and Shouldice repairs. We received a message subsequently from Dr Charles to say that they had successfully operated on the remaining patients.
Also assisting us were other surgical trainees of very variable experience. Some of them had not yet acquired basic surgical skills. They were advised to practise their knot-tying and suturing as much as possible before the next mission to the E and J Hospital in order to obtain maximum benefit as from the experience.
ACCOMMODATION AND SUBSISTENCE
We were provided with very comfortable accommodation at Jackie’s Guest House, where we had individual rooms with en-suite facilities, television and intermittent Wi-Fi. One of the pleasures of the week was sitting in the courtyard of the guesthouse in the evenings, drinking the local beer in the company of Peter George and his friends. The breakfasts and dinners provided by Jackie’s were much enjoyed. Food was not included in the $50 per night fee that had been negotiated for us by Dr George and future missions should be aware that subsistence expenses will contribute significantly to the cost of their mission.
There is no hospital restaurant in the E and J Hospital and special arrangements had to be made for lunch. We would advise future missions to discuss the provision of lunch with Dr George. During our week, Dr George usually arranged for food to be brought in from outside the hospital and we ate it in his office. (It is important not to forget to pay for this as otherwise Dr George would have to pay for it himself.). On two occasions we were taken into town in a hospital car and had lunch at Maggi’s Restaurant. This is something that we would recommend, both for the enjoyment of the lunch and for the welcome break it gives in the middle of a busy day. We also recommend that surgeons provide themselves with water to take to the operating theatres (or Coca-Cola if caffeine is required in addition to rehydration). We were aware that, in spite of the air conditioning in the theatres, we were often sweating freely during the long and sometimes demanding sessions.
CONCLUSION
We would like to pay tribute to the hard work undertaken by Dr George and his support team at The E and J Hospital in preparing for our visit. Missions such as ours require close co-operation between the host and the mission. The support we received at the E and J Hospital demonstrated that it was a very suitable host for such missions.
In the long term it is to be hoped that expansion of medical provision by the Liberian State will enable a service to develop which will begin to tackle the large number of people who would benefit from elective surgical care. For the time being, these people will have to rely upon charitable provision by external agencies. We hope that our mission has paved the way for successful missions in the future.
All four members of our team left Liberia with happy memories of the country, the town, the hospital, the people and the marvellous welcoming and farewell ceremonies that we found so moving. Our heartfelt thanks to all concerned for the hospitality that we received.
On July 29 2017 we eight volunteers started from Madrid, Brisbane, Cardiff and Mexico for Lima to carry out a Humanitarian Surgical Hernia Mission in the Ventanilla Hospital. This Campaign was undertaken by the Foundations “Cirujanos en Acción”, and Hernia International.
The Mission took place from July 31st to August 10th in the Hospital General of Ventanilla district. It is a Level II Hospital inaugurated in 2007 which has 100 beds and 5 operation theaters. It has 14 surgeons, 6 anaesthetists and 17 professional nurses. The Surgery Department carries out conventional surgery, abdominal wall laparoscopic surgery, biliar surgery and rectal surgery among others.
The Ventanilla District belongs to the El Callao Province and it is a densely populated community with about 375000 inhabitants, situated at two hours from Lima. The Ventanilla population is mainly poor, and part of the people live in settlements in the nearby hills with any number of huts and heavy environmental pollution owing perhaps to an excessive growing rhythm that has exceeded the capacity of the local resources. The “Ventanilla” name (small window) comes from innumerable caves and passages that looked like small windows from the sea and which pirates used to hide in them the treasures stolen from the forts and ships they attacked.
Voluntaries for the Ventanilla Mission 2017:
The Mission was made up by eight volunteers, four consulting surgeons, one consulting anaesthetist, one resident, one nurse and one in charge of Logistics, Communication and Documents.
Dr. Manuel Cires – General Surgeon – Navarra, Spain
Dr. Rafael Chaves – General Surgeon – Cardiff, England
Dr. Hugo Mc Gregor – General Surgeon – Brisbane, Australia
Lady Dr. Estefanía Villalobos – General Surgeon – Mexico City, Mexico
Lady Dr. María Remón Izquieta – Anaesthetist – Navarra, Spain
Lady Dr. Justine Etuláin – Resident 4, Anaesthetics – Madrid, Spain.
D.U.E. Lola García – Nurse – Madrid, Spain
María Orbe – Logistics, Communication and Documents – Navarra, Spain
The team was directed and coordinated by Dr Manuel Cires, with the co;;aboration of Dr Luis Bernaola, Chief of the surgery service of the Ventanilla Hospital.was directed and coordinated by Dr Manuel Cires, with the collaboration of Dr Luis Bernaola, chief of the surgery service of the Ventanilla Hospital.
We also had the valuable collaboration of all the enthusiastic staff at the hospital, including anaesthetists, general surgeons, nurses, helpers, cleaners, cooks, administrators and others.
Operating Theatres
The Hospital has five operation theaters in a single surgical area. Four of these were put at the disposal of the Campaign, leaving the other for urgencies in General Surgery and Obstetrics.
Of the four available operation theaters two are conventional and the other too are small, prefabricated and temporarily adjoined to the main building. They had the necessary resources for work, but the largest number of material, including surgical sutures, nets, electrical scalpels, antibiotics, analgesics, anaesthetic products among others were provided by the voluntaries themselves.
A system was established by which the majority of the patients were discharged in the afternoon and only a few with more complications were sent to the Short Stay Department.
The Patients
Patients were contacted before our arrival through announcements of our Campaign in the local media by surgeons there, as also through volunteers who visited poor areas in Ventanilla with our proposal for free interventions for all. Still, in some cases there was no discrimination made and people with greater resources were also treated.
The selected ones were previously evaluated by local surgeons and anaesthetists with a special study and reasoned consent, and they received due information on the whole procedure as well as instructions for their preparation including personal hygiene. As a result, all patients were properly prepared and at peace.
The way from our residence in the San Miguel area in Lima to the Hospital at about 40 km. distance took more than one hour on account of the heavy and irregular traffic of cars and lorries on the Panamerican road.
Our activity began at 7:45 hours with the introduction of the team of volunteers to the patients and their relatives in the hospital hall; then María Orbe, our expert in logistics and communication, gave them further information and answered their questions, thus informing the patients and their relatives and facilitating the team’s work.
The patients in the surgical area were first attended to by local doctors who collected the data for a proper control of the whole surgical activity; they were then questioned and reexamined by the surgeon and the anaesthesist in full detail.
The type of anaesthetic was in general local, although a good number of operations were performed under local anaesthetic and sedation, and a few under general anaesthetic.
In each operation theater the surgical team was made up by a Campaign surgeon assisted by resident doctor or surgeon, an anaesthetist, a nurse for the instruments, and a helping nurse.
We carried out the check list according to the OMS Manual for verification before and after each intervention, as this is the practice in the Ventanilla Hospital.
Distribution of inguinal hernias according to their classification as a help to fix the complexity of the operation.
– H1: (hernia inside the inguinal canal) n = 42
– H2: (hernia settled in the superficial ring) n = 27
– H3: (inguinoscrotal hernia) n = 10
Complications
7 cases:
1 Coming loose of suture in umbilical hernia when carrying out a new suture.
1 Slight inguinal pain of ingyuinal hernia treated with analgesics and antiinflamatories.
1 Seroma of incisional hernia treated with aspiration and ambulatory drainage.
2 Inguinal and inguinoscrotal hernia treated in a conservatory way.
2 Inguinal umbilical wound hernia and inguinal hernia treated with local cures and antibiotics.
Discussion of results
Of the 200 surgical procedures realized 7 complications were reported which did not need surgical intervention; the infection rate was 1%, a very low value, taking into account that the majority of the patients had not received any antibiotical profilaxis. The seroma was treated in ambulatory sessions with punction and drainage, and the hematoma was treated in a conservative way.
Observations
The personal at the hospital kept excellent asepsical measures during the whole campaign.
The nurses in charge of the instruments kept an excellent discipline and technique in the operation theatre.
– Washing of hands: with clorhexidina foam.
– Antiseptical preparation of the premises: they used clorhexidina soap to prepare the area.
Formation and Teaching:
An important teaching activity took place during the Campaign, so that the residents in surgery and anaesthesiology took an active part in diverse surgical and anaesthetical procedures under the supervision of voluntary surgeons and anaesthetists.
The last day of the Campaign we volunteers carried out an Academical Session with the following themes:
– Humanitarian Help: origin and actual state of the Hernia International and Surgeons in Action Foundations. Results of the 2917 Campaign in the Ventanilla Hospital, Dr. Manuel Cires.
– Surgery in the last century. Multidisciplinary handling of surgery in the last years. Dr. Rafael Chaves.
– Presurgery preparation in patients with giant ventral hernias: botulinica toxin, principles and technique; progressive and preoperative pneumoperitoneon. Dr. Estefanía Villalobos.
Surgical block. Standards and recommendations for the patient’s safety.
The Campaign ended on August 10th. Dr Wilber Espinoza, Director of the Hospital, addressed the voluntaries and gave thanks for the notable effort as well as for the high level of satisfaction of patients and relatives, and invited repetitions of new projects in the future. We were later given a diploma and were invited to a farewell supper in Lima.
ConclusionThe campaign has meant a great effort for all of us. It began several months before our trip to Lima with the creation of the voluntary group, unknown persons from different countries and cultures, who
The fifth mission of Hernia International to Brazil
The mission was carried out in collaboration with the Brazilian Hernia Society from July 23-29th, 2017. The regional focus of this mission was the state of Rio de Janeiro and was based out of the city of Rio de Janeiro as well. This included a one day conference on July 27th, bringing together faculty from the mission and healthcare providers from around the country. The team of 12 surgeons was lead by Dr Christiano Claus, along with local coordinators Heitor Santos, Luciana Guimaraes, and Marcio Cavaliere. The group also included myself and Arunkumar Baskara from the US. We repaired 125 hernias in over 100 patients at six different hospitals across the state, including: Laurenco Jorge Municipal Hospital, Iraja Hospital, Gaffre Guinle University Hospital, and Ipanema Hospital in Rio de Janeiro; Japuiba State Hospital in Angra dos Reis; and State Hospital Adao Periera Nunes in Saracuruna. The operations were aided by local volunteer surgical scrub techs and nurses, some of whom traveled with us from surrounding areas, as well as the residents from the local hospitals. Anesthesia coverage was provided by the hospitals. Traveling to the hospitals outside of the city provided a brief glimpse of the beauty of the state, as if the city doesn’t offer enough! Of course, there were plenty of social opportunities to get to know each other, including an awe-inspiring dinner at a famous Churrascaria in Rio de Janeiro.
MEMORY OF THE CAMPAIGN 16 June – 3 July IN THE HIPÓLITO UNANUE HOSPITAL, TACNA, PERÚ
After 4 months of preparation, the day came at last to start towards the Hipólito Unanue hospital in the Tacna region at the South of Perú. In the airport we all gathered with Teresa to prepare the bags with our equipment. This is always a great moment when the members of the team come to know each other in between chaos and nerves. We are 9 persons, 4 general surgeons, 1 paediatric surgeon, 2 anaesthetiologists and 2 nurses. For some of them this is their first mission, although most of us have had some previous experience
We land at Lima after a 112 hours flight, and there Dr. Herrera, who is coordinating all our Tacna mission, is expecting us. He takes us at once to the centre of Lima where we see the Main Square and the Cathedral.
We come back to the airport to catch our Tacna fight, where on arrival we are met by a great welcome committee headed by the Health Regional Director, Claudio Ramirez. They give us flowers and take us to our hotel.
We settle down in 10 minutes and proceed to the hospital with all our material. There are more than 70 patients waiting, and we begin, together with Dr. Chura, coordinator of the Tacna mission, and Dr. Carpio, to organize the program for the next days. Most of the patients have already gone through the proper preparation, and have been evaluated by cardiologists, anaesthetiologists and surgeons, what has meant quite an effort for the hospital staff.
The day after our arrival we start operations. With the help of the local surgeons we are able to operate upon 17 patients on that first day. We had 4 tables in 2 different rooms. Lady Dr. Pilar Murga, anaesthetiologist, together with nurse Almudena Ceballos in one room, and nurse Mercedes Contreras in the other. Paedriatic surgeon José Miguel Morán and general surgeons Lucía Catot, José Manuel Hernandez, Claudia Tinoco and myself went from one room to another according to need, always with the help of hospital surgeons, residents,students and nurses.
I want to underline the work of the nurses Almudena and Mercedes as well as Isaac, René and Delia who very efficiently organized the whole work.
In this way we began our daily work with Marathon timings with began at 7:30 h. with heavy work side by side with the hospital staff, so that by the end of the mission we had operated upon 170 patients with almost 200 procedures, with the greater part of patients being given leave on the same day. Those who had to be hospitalized were evaluated at the beginning of the next day. The operations were chiefly inguinal and umbilical hernias, some of them very large because of a long evolution, and incisional and epigastric hernias. Only a few children were operated upon, as there was little information and collaboration by locals.
In the midst of all this work there were always some moments to disconnect, particularly at the meals with the delicious traditionally Peruvian dishes prepared by Carmen and her daughter Vanesa, and also in our walks after work through the city of Tacna. One day Dr. Chura and Isaak took us to the seashore to admire the Pacific Ocean which many of us had never seen before.
Besides that daily work we also organized some teaching days where a workshop on operation theater work and experiences was carried out and three talks were given: “Inguinal hernia treatment through open hernioplastia mesh” (Lady Dr. Gay Fernandez); Inguinal hernia treatment by laparoscopic way. Tapp and TEP” (Dr Hernandez Gonzalez) and “Surgical calendar for children” (Dr. Morán Penco) with a large audience from hospital staff and students.
After 10 days of hard work came the farewell. They organized a function with the hospital director and the national health surgeon where they gave us a thanksgiving document from the Tacna community.
The mission in the Tacna Hipólito Unanue hospital, the first in the region, had been a success, and both the hospital staff and the patients are looking forward to new campaigns. All this has been possible thanks to good work relationships and to the outstanding persons of the team, together with the great persons who made up the team and the collaboration of the Hipólito Unanue hospital staff, chiefly Dr. Chura. Without of course forgetting Dr. Herrera and Martha Vasquez who helped us from Lima.
With the satisfaction of a work well done we started for Cuzco to see one of the marvels of the world before coming back to our usual routine.
