(COLLABORATION: SURGEONS-in-ACTION and HERNIA INTERNATIONAL)
Team leader: T. Butrón
Team:
General surgeons: Teresa Butrón, Sebastián Fernández Arias, Francesc Marsal, Sol Villar.
Anaesthetist: Beatriz Revuelta, Blanca de Prada
Nurse: Manuela Dorado
After a year of uncertainty and cancellation of the mission, on the month of October, with Hernia International in Sodo (Ethiopia), Cirujanos en Acción together with Hernia International organizes the first mission for Kamuturu (Uganda).
The references of the hospital where we are going to work imply that it is a rural center under construction, with a project for extension, about which the director provides information, situated at the North-East of the country and, according to the information given by Sister Clare Nantandwe, in charge of the centre, is about 4 hours by road from the Entebbe airport.
The seven members of the group, 4 surgeons, two anaesthetists and one nurse, planned out in a short time the trip to Uganda. Finally for several reasons we decided to travel with the company Emirates via Dubai till the Entebbe airport, situated at about 40 km from Kampala, capital of Uganda. The Emirates company told us that the total weight accepted without pay would be 30 kg per person, so that we reduced our luggage to 210 kg without any extra kilograms.
On December 1st the group started from Spain with a short stop in Dubai till Entebbe, to Entebbe, Uganda’s international airport. More than 11 hours flight.
Customs were not more complicated than those in other African countries, and our having our visa in advance, having got it through Internet, facilitated our way without any complication, with all our luggage book out previously.
In the airport we were received by the driver who took us to our destination. Our surprise, after our long trip to Uganda, begins with the slowness in traffic, as we had to cross Kampala, the capital of the country, on Saturday evening and from West to East, without any round way that would avoid the heavy traffic in the city. Getting out of the capital took us more than two hours of heavy traffic till we got to the road that links Kampala to Mbale more than 300km ahead. Since in Uganda night comes at 06:30 pm our journey took place mostly at night, through a very poor road with too much traffic and through cities where speed should be diminished, but the Uganda drivers never did that. This gave us, Europeans, a very bad impression.
After more than 8 hours travelling, with the last part of the way (about 40km) through a rural path, our driver decides not to go ahead because of the bad state of the road, so that we had to finish our way walking with our luggage in hand and with lights on our foreheads. The whole team took the situation as part of our adventure, and finally about 01:00 am on Sunday December 3rd we arrived at our destination. Moses and his helpers shifted all the material in our trips on a motorcycle without any problem.
After settling down in our rooms, which were comfortable African shacks with beds, sheets and mosquito nets, we took the supper the Sisters had prepared for us.
On Sunday December 3rd we woke up at 06:00, and after an African shower and breakfast we began to organize the operation theatre where we were going to work, unpacking the more than 200kg of luggage identified as “Cirujanos en Acción”. At the same time two members of our team examined the patients to be treated. Given that the center has not a sufficient infrastructure, particularly from the anaesthetical point of view, we did not operate upon children, so that all our patients were adults.
The provisional operation theatre of the Holy Innocents Health Center, is found in one of the pavilions in which a room was made into an operation theater. Two table-stretchers in a place that was meant for other uses would be our operation theatre where we began our work at once. The first two patients, under local anaesthetics, were operated upon for two subcutaneous lipomas, and later we went on to operate upon a total of 14 patients, where the most complex case of an intraumbilical eventration required a Stoppa reparation.
On the whole we operated upon 46 patients in five days, with the further complication that one of the members of our team had to return home for a serious family problem. We decided to go back to the airport, given the difficulties of the journey, on Thursday evening so as to make sure of our arrival with sufficient time for the return flight to Europe.
The Holy Innocents Health, a general hospital of 57 beds with an 80% occupation of beds, situated in a very remote zone to the East of Uganda, with rural centers of difficult access, started about a year ago with the idea to cater to a poor population in remote places towards the East in Uganda. Its director and founder, Moses Aisia together with his wife Sister Clare Nantandwe, administrator of the centre, manage the centre. Two family doctors control the patients for infectious sicknesses together with maternity and labour since the main aim of the founders is the reduce the number of child mortality, attack VIH/SIDA and malaria. In the staff there are also four nurses, three midwifes, two technical laboratory helpers, as well as maintenance, cleaning and security staff.
As Moses Aisia says, with the improvement in basic sanitary attention through education, formation and information, the changes will become permanent and deeper with a great impact in future generations. The patients came mainly from Bukedea (53,2%), Sironco and part of the Balubuli districts. Children under 5 years represent 30% of the patients, and approximately 64,7% are women. Moses informs that 89% of the mothers in the community give birth in the centre. It is important to mention that Bukedea was the centre of the civil was in Uganda from 1980 to 1993.
The mission that we in “Cirujanos en Acción” and “Hernia International” carry out had, among other aims, to initiate surgical assistance with the starting of an operation theatre and the postoperation control of our patients by part of staff in the centre with the idea to start new cooperation missions in Kamuturu.
We could observe that there are new pavilions being built for the new operation theater, which with the recommendations of our team and the monetary help they hope to get, could have a better infrastructure and material more complete and in a better condition if possible. The lack of ceiling lamp, plugs for connexions and respirator with oxygen concentrator, make it impossible for now to have some type of interventions and to attend to some kind of patients. Still, our team carried out with good results all the interventions that were programmed after the selection of patients.
In later conversations with Moses we have seen hoy our proposals have been carried out. First, we proposed the possibility of shifting from Entebbe to an airport close to the hospital centre so that we diminished the hours of our way by road, which according to Moses would be possible with local flights with important discounts as it was a cooperation humanitarian mission. Installation of running water in the surgical pavilion is another of the improvements foreseen by the direction of the centre in the new pavilions under construction.
In conclusion, the experience of our camp in Kamuturu, Uganda, has been very positive. The centre and the needs of its extensive population to which it reaches (more than 101.999 persons) can benefit from future missions by surgical groups or voluntaries who may like to live for some months in the hospital centre and, as its director Moses Aisia says, through a process of strategic planning they can attend to all those who may need it at their homes or in the hospital.
Mission report ICS Training team, Okpoga, Nigeria,
November 2017
From November 4th to 17th the first mission by a training team of the Swiss section of the International College of Surgeons (ICS) was undertaken to St. Mary’s Hospital in Okpoga, Nigeria. Previously the missions were carried out by Swiss Surgical Teams, but this organisation decided to abort the project after 6 years. This years team included two surgeons (Peter Nussbaumer & Florian Oehme), an anaesthetist (Thomas Stoinski) and gynaecologist (Katrin Ochs) and a scrub nurse (Sanne van Rijn).
After an uneventful flight from Zurich to London and Abuja the first challenge was Nigerian Immigration. Thanks to our partners from the hospital and a very helpful note verbal by the Swiss Embassy in Abuja our passing through Immigration and Customs was smooth, despite the multiple boxes filled with medical equipment and consumables. Various medical companies in Switzerland donated the material.
Immediately we continued our journey by minibus. On the road we passed cities, marketplaces, cattle and landscapes with a few huts, some made of stone some made of clay. Due to the bad condition of the usual route we had to take the long road through Lafia. After 8 hours and 450 km of pothole ridden driving we arrived at St. Mary’s hospital just before dusk. There the staff with singing and dancing warmly welcomed us.
To ensure an early start the next morning we decided to unpack our boxes and set up the theatre the same evening. This activity was interrupted by the first emergency case, a 7-year-old girl with a perforated typhoid ulcer. After a successful operation the patient was discharged a week later.
The next morning we started with a lecture* in the meeting hall. About 40 staff joined and participated in the discussion. Afterwards there was a ward round together and then work in theatre started. 60 patients were ready for screening and confirmation of the diagnosis. Some were operated on the same day, others planned for the following days. Everybody agreed to have a short list on Sunday, so we could schedule patients for 10 days. Soon we had adjusted to our day -to-day routine, the only interruption being the many emergency cases. With 6 cases of typhoid perforations we could put a focal point on teaching the concept of emergency laparotomies including staged procedures and the equally important postop care.
Sunday was the only day with some recreation, first by visiting the catholic mass in the village and later in the afternoon the get-together with traditional dancing, singing, speeches and traditional clothes for each team member.
Unfortunately one of our diathermy machines, necessary for haemostasis during surgery, was blown. The second one mal-functioned and so we were left with only one functioning machine. This slowed down work considerably and the operations went on late into the night. Never the less we were able to treat 130 patients and perform 143 operations; including 24 children aged 3 to 7 years. Despite very limited recourses and without the accustomed standard equipment our anaesthetist contributed significantly to the successful outcome of these interventions.
Once again the hospitality of the Matron Sister Christiane and her team was overwhelming. They went out of their way to make our stay relaxed and convenient.
Time flies by and already we had to say farewell. Altogether the team spent an amazing, extraordinary and unforgettable time in St. Mary’s Hospital, and we thank everyone involved for their help and support.
*The following topics were covered during the lectures:
Hernia International: Korogwe, Tanzania November 2017 Report
This mission was the 10th Hernia International team to visit Korogwe and the welcome and support that we received from Sister Avelina (lead surgeon) and all the staff was heart-warming. The team comprised Katharina (anaesthetist and excellent team leader from Switzerland), Michael (medical engineer from Switzerland), Margaret (RN from Great Britain), and the surgeons Christoph (from Switzerland), Stefan and Nico (from Germany). Most of the team had previously worked together on another mission so there was a nice feeling of ‘re-union’.
The custom check at Tanzania airport is quite strict especially for the (X-Ray-dense) surgical equipment.It was very helpful that Christoph was able to show the invitation letter from the ministry of health.
Coming from different destinations we met at the Trinity Airport Hotel and spend our first night there, and at 8am the following morning our transport arrived accompanied by Justin our escort (Korogwe dentist). The Land rover roof was packed high with our luggage and supplies and secured with a much needed tarpaulin to cover. There had been heavy rains the day of our arrival and the rain continued for most of our 7 hour journey to Korgowe (Michael likened it to a cloud hernia!). The traffic was pretty dense for the first hour until we hit the outskirts of Dar es Salaam, and the rains hampered our progress somewhat but we eventually arrived at the hospital at 4pm.
We were greeted by Sister Avelina and her team and without much delay taken to the ward where 30 patients waited patiently for review and assessment for surgery. The Korogwe staff had worked hard with their preparations and recruiting of hernia patients, and were very well organised. The next day’s operating schedule was agreed and we then unpacked our supplies and set up the 3 operating rooms ready for work the next day.
Our operating days started at 8am and usually finished by 6pm. We had superb hospital staff to work with, and the efficiency of the sterilising team was amazing – keeping up with supplying a stream of instruments and gowns throughout the day was constant work.
We completed 85 hernia procedures on 72 patients (19 female, 53 male). There were 18 children under 12 years (all had general anaesthesia). Most patients had inguinal or umbilical hernias, we operated 10 epigastric/incisional hernias, mainly in women. 7 adults had general anaesthesia. 27 adults had spinal anaesthesia and 21 had local anaesthesia. There were 6 particularly large/complicated hernias – one of which comprised a mini laparotomy and could be regarded as bordering on major surgery.
There were occasions during the week that we had to stand aside and make available the operating rooms for local emergency surgery that occurred. And it was impressive to observe quite complex surgery and clinical decisions being undertaken with such limited equipment and resources. The learning was endless, along with adapting to new ways of working
– but it has to be said that the connections with the people deepened the whole experience and made it so meaningful. Sister Avelina had invited a junior doctor in surgical training and we are happy to have taught her some hernia operation techniques for further benefit.
Michael, our medical engineer, worked unrelentingly alongside the local engineer/technician. His knowledge, expertise and educational input was invaluable. Infusion and syringe pumps were cleaned and resurrected; anaesthetic machines checked and repaired; theatre tables adjusted; diathermy machines repaired; the steam steriliser serviced and repaired; and fridges in the mortuary attended to………….. and much, much more. Michael was a real asset. If the option was available, every mission could do with having a medical engineer!
Mid-week we changed our accommodation to the `Magnificent Korogwe Hotel (due to ongoing building work and noise at the “White Parrot” Hotel). The title probably does not capture accurately how delightfully quiet it was on an unsealed road, providing comfortable rooms and open court yards in which to relax in the evenings – all a 15 minute walk away from the hospital. The morning and evening walk to and from the hospital on a path through the villages gave insight into daily living – free roaming chickens and goats, small plantations/crops, and children going to school in immaculate uniforms. The hotel provided good food and we would recommend this accommodation for future missions.
All too quickly the week came to an end, but it was not before experiencing (on our last afternoon) the hospitality of Sister Avelina and other nuns at the St Joseph’s convent, a 45 minute drive from Korogwe. It was a most serene setting of landscaped buildings and gardens. On our arrival the local choir was practising under the trees – and it was quite atmospheric to hear the beautiful African harmonies wafting in the evening breeze. Before we left we enjoyed lovely afternoon drinks and food, along with interesting conversations with the nuns about spiritual life in the convent, and education opportunities for the novices in local universities and colleges.
Huge thanks goes to Sister Avelina and all the staff – we have left with great memories and unforgettable experiences that live on and influence our professional practices.
Three experienced surgeons, Jane from UK, Fernando from Spain and me, Leo from Austria, arrived on 18. November 2017 in Banjul and were picked up at the airport. We were taken to a hotel (woodpecker) where we stayed overnight. On Sunday, 19. November 2017 we arrived in Farafenni early in the afternoon having been welcomed by the medical director Dr. Wandifa Samateh and the hospital staff. We became acquainted with the building and especially with the theatre.
Then we checked in in Eddies hotel which was very low standard except for the garden where we spent our evenings “under the mango trees”.
On Monday we started working and operated on 78 patients until Friday night. Our working days were usually from 8:30 a.m. until 8 or 9 p.m. We did not just operate on grown-ups but also on many children, who even came from Senegal.
The anesthesia for our youngest patients was a challenge but perfectly done.
Apart from our medical work we could experience the hospitality and friendliness of our hosts. I am sure we would not have succeeded that much if the hospital staff had not collaborated with us in such a wonderful way.
After our mission was finished we returned to Banjul on Sunday, where my colleagues flew home and I stayed another three days in the capital city.
Our stay in Gambia was a chance to experience medical treatment from another point of view.
The team: Fernando from Spain Jane from UK, Leo from Austria.
Jane screens patients
Every child received a soft toy as a present
Patients staying overnight, waiting for getting screened
On 29th October a team built by Professor Campanelli reached the “Hopital la Croix” in Zinvie, a compound managed by Fathers Camilliani. Over the past years, the efforts of Professor Campanelli have addressed the problem of the treatment of abdominal wall defects in under-developed countries and on this special occasion, with the help of Day Surgery Onlus Foundation and Gruppo San Donato.
For the very first time, the group was nearly all composed of Italian professionals, with only an American nurse. Three general surgeons, two anesthetists, one resident in general surgery, two scrub nurses, four nurses and one medical student compose the team.
The arrival of the team had been announced during the previous days so that every patient complaining of symptoms regarding the abdominal wall had been visited and successfully treated. From 30th October to 3rd November, 45 patientes, both adults and children had been operated on. Not only open inguinal and umbilical hernia repair had been pergormed, but also complex incisional hernia repair and pediatric hernia repair under general anesthesia.
The team was warmly welcomed by Padre Mario, who with his constant support and sensibility made the work possible and rewarding. The entire team was well integrated thanks to the local staff which made easy the perioperative management of the patients. The well-known continuous research for improvements in abdominal wall surgery of Professor Campanelli, perfectly matched with professionalism of the team, reaching nearly the same results as performed in Italy.
Padre Mario made the team’s stay possible and comfortable; a apartment was offered and there was a place for the surgeons to relax and enjoy the local culture and dishes at the end of the day’s work. That made the team stronger and involved in their work.
The unique experience will last for years in the heart of the surgical team and the patients who were able to benefit from such expert surgeons. On the other hand, the work for the surgeon had been widely rewarded by the patient’s simple smiles and enthusiasm.
A very special thank to whom made this experience possible
2nd Slovenian “Hernia International Foundation” Expedition
Ghanta City, November 11th – 19 th 2017
This year’s planned charity mission led the Slovenian national team to Liberia, to Ghanta City and to Ghanta’s “Esther and Jereline Koung Medical Centre” (E&J MC).Our team consisted of 10 members: 3 surgeons, 3 assistants, 2 anaesthesiologists, 1 radiologist and 1 nurse.
We travelled to Monrovia with the dutch airline KLM via Munich and Amsterdam, with a short stop in Freetown. In the capital, Dr. George’s team picked us up in the middle of the night with a couple of powerful 4-wheel-drive vehicles. There were two reasons for a one hour delay at the airport in Monrovia: 1 piece of lost bagagge and a missing customs’ approval for importing the goods into the country. When the person authorized to “approve” the import of medical equipment to Liberia was finally reached over the telephone, we hit the road. The good thing about the 4 hour drive to Ghanta at night was the reasonable traffic conditions. On the way back we needed more than 5 hours. The road, built recently by Chinese, was a very good one and made travelling much easier.
The weather during the week was quite good: partly cloudy with frequent afternoon/night showers that we only heard because of the thin metal rooftops. The temperature of 30°C felt like 35°C and morebecause of the humidity. Accomodation at Jackies Guest House was a good decision (privacy, airconditioning, WiFi with some interruptions, a restaurant with reliable food and a minishop with all the essentials that one needs, even in the case of lost luggage). Some members decided to share a room to minimize the costs, which exceeded the costs of some airport hotels in Europe (USD 50, dinner about USD 20, breakfast about USD 10). Jackies Guest house was built and first owned by a local politician Mr. Koung and has now a new owner.
After some hours rest upon arrival, the welcoming ceremony in the hospital started with a prayer and speeches by Dr. Peter Mathew George and the hospital director. The hospital was constructed in July 2016 and was built by Mr. Koung.
All the patients for the week gathered in a big hall. The decision for the mission to start the next day was well accepted among all team members, although it was Sunday.
Short instructions to well educated local team
Ultrasound is allways welcome
All OT’s (0perating theatres) in the hospital were airconditioned. We had to use head lamps in just one of them, the other OT lamps functioned well. The tables were adjustable for height, which was not expected. 2 OT’s were close to each other, which made any interventions easier, especially for anasthesia. Two diathermies were working properly, there had been some trouble with the one that we brought with us. Before it is finally donated to the E&J hospital, it will be rechecked in Europe. Many thanks to Sister McDermot from South West Acute Hospital in Enniskillen, for this donation.
For the first three days, the work in all three operation theatres (OTs) ran smoothly. A special thanks goes to Dr. George, who selected the patients personally. On day four, a huge number of patients who had been waiting for surgery (almost 200) forced Dr. George to start operating himself in OT Nr. 4. This was not a very good idea from the organizational point of view as his hospital colleagues were (not yet) fully capable of recruiting and diagnosing patients for 3 or 4 OTs. Our radiologist with the ultrasound was a great help, excluding some patients (with enlarged lymph nodes, other swellings, etc.), who initially expected to be operated on.
On day four we stopped operating on children, as one of them had aspirated just recently breastfed milk during an anaesthesia induction (it took some time for the mother to understand that milk is considered as a food and not just a simple liquid). Our anaesthesiologists and the nurse managed to solve the situation skilfully with emergency drugs, an improvised aspirator and an oxygen concentrator. Under self-built intensive care, supplying antibiotics and oxygen over the following days, the aspiration pneumonia was managed and the child was saved. After this event, Dr. George took over the patient recruitment again and the mission continued smoothly. Dr. George, MD, PhD is basically an obstetrician and gynaecologist with the good skills of a general physician and is capable of performing hernia surgery, including Lichtenstein mesh repair. And of course, with organizational talent. One of his reliable co-workers, Dr. Charles might also be an important link for future missions. Emanuel, an anaesthesiology assistant, showed a lot of readiness to upgrade his anaesthesiological skills. In the absence of HI teams, the whole anaesthesia issues in the hospital depend on him
»Talking« to pediatric patients before surgery
During narcosis induction
We worked daily from 9am to 7pm, sometimes even longer. The local staff were always ready to work, even late into the evening. Lunch break (chicken gyros sandwicheslike doner kebabs, sometimes French fries with fish) was also an opportunity for briefing the morning patients and planning the rest of the day.
The good thing of having a self sufficient team (surgeons, assistants, anaesthesia,..) was to work with people that one knew from hospitals at home and that were used to working as a team. Anyway, we educated the local staff as well, among them were many very motivated volunteers who applied to work for free during the week and helped so that the mission could succeed.
As we did not have enough gloves to fully suport all the teams in 4 operation theatres in the sense of double gloving (as a Spanish team had done some months earlier), we used single gloves because of the expectation that all patients were HIV and Hepatitis B tested. As this was only possible for 2 days from the side of the hospital and further on against additional payment, we paid for the tests for the rest of the patients ourselves. It was not realistic to expect that the patients should cover these costs as they expected that the management would be free of charge. Covering some minimal costs from the side of the patients (or the hospital) is an issue that can be discussed in the future.
Anyway, the best surgical infection prophylaxis is a considerate and careful operating technique.
A good decision was to bring along over 300 disposable sterile gowns and sterile hole-drapes to ensure the sterility of the operative field. With additional education of the scrub-teams, we were more and more satisfied with the preparation of the operative field. One of the suggestions to the new hospital director Mr. Victor W. Kpaiseh (the general directors of the hospital had changed during our mission) was providing cloth gowns at least for the scrub personnel. This would demand improving the sterilization capacities (buying the second charcoal-run autoclave pot), which are one of the bottle-necks of the process. This idea is probably not immediately applicable, but might be solved in the future.
One of the incisional hernias with praeperitoneal repair
In 6 working days (4 full days, 2 half days) we performed 103 procedures on 86 patients (14 female, 72 male). The average age of the patients was 36.5 years. The oldest patient was 89 years, the youngest 1 year. The majority of patients had inguinal and large inguinoscrotal hernias (71).
Predominantly we repaired inguinals using the Lichtenstein (>95%) and sometimes the Shouldice technque with young patients (<5%). In 14 pediatric patients with inguinal hernia, the Mitchell Banks and Ferguson techniques were used. We performed 2 incisional repairs (retromuscular), 17 umbilical repairs, 2 undescended testicle repairs, 1 femoral hernia repair and 1 hemorrhoids operation (acute). We performed 2 revisions, 1 due to a postoperative haemathoma, 1 for a suspicious haemathoma (negative revision). As we had a reliable anaesthesia team, the anaesthesia was predominantly spinal (72), general (13) and local in only 2 cases.
The presence of a radiologist on such a mission was a very good idea: 70 performed ultrasound diagnostic checks preoperatively, 3 postoperative ultrasound checks, 12 pregnant women with ultrasound (education of midwives), 16 emergency ultrasounds.
Our team with the medical director of »E&J MEDICAL CENTRE«
Dr. Peter Mathew George
At the end of the team work, we agreed with Dr. George, that it was a good mission. The farewell ceremony was much more a cultural event than just saying thanks and we were thankful to be able to be in Ghanta City, Liberia, together with the local hospital staff for their patients.
All this would not be possible without a skilled, experienced and enthusiastic team:
– Tomaž Benedik (consultant, surgeon, 2nd mission)
– Maria Greiner (consultant, surgeon, 1st mission)
– Marija Jekovec (consultant, radiologist, 1st mission)
– Irena Urbancic (consultant, anaesthesiologist, 1st mission)
– Katarina Primožic (registrar, anaesthesiology, 1st mission)
– Katja Carli (registrar, surgery, 1st mission)
– Luka Kovac (registrar, gynaecology and obstetrics, 2nd mission)
– Selena Benedik (medical student, 2nd mission)
– Mateja Selic (scrub nurse, acted as an anaesthesiological nurse, Hernia International mesh sterilizing support)
– Jurij Gorjanc (consultant, surgeon, team leader, 7th mission)
Dr. Petr Bystricky, General Surgeon (Czech Republic)
Dr. Stepan Matoska, General Surgeon (Czech Republic)
Dr. Paulina Mysliwy, Anesthesiologist (Poland)
Dr. Parafull Bohra, General Surgeon (U.K.)
Dr. Usha Bohra, Anesthesiologist (U.K.)
Dr. Meena Agrawl, Pediatric Surgeon (U.K.)
Dr. Scott Leckman, General Surgeon, Team Leader (U.S.A.)
We operated for eight straight days, 20-27 November, at the Nuture General Hospital. During this time, we did the following:
Total patients operated: 83
Including 15 Pediatric patients
Total procedures on 83 patients: 94
Special thanks goes to Nasreen Baqui and her team of volunteers. The hospitality shown to us was extraordinary. Contributing greatly to the mission were the many volunteers including Bangladeshi medical students and residents.
The vast majority of cases were inguinal or inguinal-scrotal hernias, unilateral or bilateral. In addition to these, there were hydroceles, lipomas, umbilical hernias, an epididymal cyst, inclusion cyst of the scalp and one of the scrotum and an abscess of the scrotum. After three weeks, complications noted were three cases of post-operative urinary retention requiring catheterization after bilateral hernia repairs and one case of a deep surgical site infection treated non-operatively.
MEMORY OF THE “SURGEONS IN ACTION” and “HERNIA INTERNATIONAL” MISSION IN THE GUSTAVO DOMINGO RODRIGUEZ ZAMBRANA HOSPITAL OF SANTO DOMINGO DE LOS COLORADOS (ECUADOR)
After several months organizing everything by mail, and having had to change some members of the original team (almost up to 59%) that left at the last moment, the date to start for Ecuador came at last. The team was made up finally by 7 members: Cesar Ramirez (surgeon and team coordinator), Antonio Satorras (surgeon), Ana Belén Fajardo (surgeon) Alejandro Unda (paediatric surgeon), Paco Gomez (nurse), Isabel Moreno (anaesthetist) and Yolanda Cabrero (anaesthetist).
Except for Alejandro, who is from Ecuador and had been there for some time visiting his family and working in other missions as he does every year, and for Yolanda Cabrero who was on guard duty and came a day later, all the other team members met to get acquainted with each other on Friday 29th September in Terminal 4 of Barajas in order to book our luggage in our Madrid-Quito flight at 12.35 p.m. After the first awkwardness in our introductions everything went very well so that with the help of Paloma Gonzalez (of the “Mano a Mano” NGO who works with Iberia) we had not to pay for any extra luggage and we could book without any problem our own bags and the almost 120 kg of medical and surgical material we were bringing for our mission. For Antonio, Ana Belén and Isabel this was their first mission with “Cirujanos en Acción” with this kind of collaboration, as we all the others had already being in previous campaigns.
After an 11 hours flight Madrid-Quito flight we landed without problems (at 16.35 p.m. local tme) and passed through customs without any problem. At the terminal Dr. Kathia Tinizaray, who is the second director of the Hospital Gustavo Dominguez Zambrana of Santo Domingo de los Tsáchilas, the centre where we were going to carry out our mission. Kathia is a faithful coworker of the “Cirujanos en Acción” campaigns (or rather their very soul) and is always seeing to it that we are as comfortable as possible from the start. She placed all our luggage in a van and took us to our hotels in the colonial centre of Quito. Just as last year, I decided we would spend the weekend in Quito so as to start for Santo Domingo the day before the mission in order to share walks, meals and suppers those two days so as to be able to meet and get acquainted for the 10 days of intense work waiting for us.
We used the weekend to visit in detail the center of Quito and all its wonderful churches (there is no capital in the world with so many churches so great and beautiful, in such a small place, particularly the churches of the Society of Jesus, the one of St Francis, Carmen Alto, and the spectacular and gothic “Basílica del Voto Nacional”), and the “Virgen del Panecillo” who from its height contemplates, guides and cares for the whole city of Quito. On Sunday October 1st,and after a tiring 4 hours journey by van to Santo Domingo, we arrived at our hotel (the modest Hotel Santander in the outer city neighbourhood) where Dr Kathia Tinizaray and Dr Lenin Falcones, who is Medical Director of the Hospital and surgery chief who has been our most constant and important logistic help during these two weeks in Ecuador.
The same Sunday night we went to the Hospital, we unpacked and placed all the material in the operation theater that had been us for our work and, besides, we revised the operation theatre programation that Dr Falcones has prepared for our two weeks. The Gustavo Dominguez Zambrana is a relatively new hospital, but it suffers from the miseries of a health system which is deficient and very badly run from the central administration, so that there are no resources to operate the patients (no laparascopy, and the patients have to buy for themselves even the most basic material to be operated upon,the famous “insumos”, they have no meshes, neither any suture material of the lowest quality) and the waiting lists for the most basic processes lengthen to eternity.
In the morning of October 2nd we were able to begin operating thanks to the great effort of DrFalcones and Francisco, the Anaesthetics coordinator of the Hospital, who had taken care that all patients were programmed with their pre-operatory examination carried out and with the approval for surgery. Every day the patients were given an appointment for 7 in the morning in a room next to the operation theater where part of our team carried out a quick evaluation of all the cases so as to be able to begin operations as soon as possible. We are grateful for the excellent organization at this level, thanks to which many patients have been operated upon easily.
Thus on the first day we operated upon 19 patients, which can be taken as a great success and which shows how well organized everything was. On the whole we have operated upon 119 patients with 149 processes, which means that up to 25% of the patients have been operated upon for more than one process in the same act. All the cases in CMA regime were discharged without problems or post-operation complications immediately noticed. Since in “Cirujanos en Acción” we consider that our missions also help formation,
I organized with Dr Falcones a programme of clinical sessions each morning from 10 a.m. to 10.30 a.m. for the whole staff connected with the Surgery Service and the Surgical Block; we also collaborated in cases of a special difficulty and complex abdominal wall, so that we carried out 11 giant eventrations (two associated with right colectomy), one coledoco-duodenostomy and 8 colecistectomies by laparoscopic way, all successful except for one patient with a deep infection which was treated in a conservative way without any difficulty. At each moment we have had exact information as to how the patients were doing, so that we visited them at their places on admission and each day whether any patient operated by us under CMA regime or visited in Urgencies; when this has happened it has been due to minor complications.
If there is something I have learned in these 3 missions is the key role of the infirmary. The all out work of Paco, who places the material or takes out the patient or works as surgical helper, and I don’t want to leave out the roll of the licensed Marlene and Liliana, and of all their students who have worked with us all this time and have been essential for the operation of so many patients.
In order to get the most from our work the time for meals was 30-45 minutes in some of the small bars around or in the “shopping” in front of the Hospital. We also operated on Friday October 6th in the evening and on Saturday October 7th in the morning. The moment to relax each day was always theend of the work, never before 20-21 p.m., which allowed us in some of the multiple “burger pubs” of Santo Domingo to share with the whole team gossip, laughter and refreshments (local beers chiefly) often accompanied by Dr Falcones and our local anaesthetists, the popular Francisco and Raúl Castillo.
Sunday October 8 was really our only full rest day, and we went to see the community of Red Indians (or Tsáchilas) who have lived historically in that zone, and who since a few years form part of the social and political activities. The last night was special as we decided to invite for supper all the directors of the Hospital, the infirmary staff and the surgeons from the Hospital Surgery Service, so that we all enjoyed ourselves in a very good way. We enjoyed local gastronomy and the ceviches, meats, “guata”, and other typical dishes from Ecuador.
To say goodbye, and coinciding with some acts commemorating the 40 anniversary of the creation of the hospital, Dr. Kathia Tinizaray on behalf of the hospital Gustavo Domínguez Zambrana gave us this plaque-trophy recognition of our work that we Honor and finish giving full meaning to the work that we have done there.
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
