Author: akingsnorth

KAMUTUR CAMPAIGN. BUKEDEA DISTRICT.

UGANDA. SEPTEMBER 2018

SURGEONS IN ACTION FOUNDATION

1.      TECHNICAL REPORT:

a.      DATES:

A team of 8 people: 3 general surgeons, one pediatric surgeon, one anesthesiologist, two surgical nurses and one professional photographer.

8 packages with a total of about 240kg of surgical material and medicines.

Departure from Madrid on Friday 9/14 at night and arrival in Madrid on Tuesday 9/25 in the morning.

Saturday 14th: Very long car ride from 9:30 am in a typical Ugandan taxivan from Entebbe, crossing Kampala, with a technical stop to pick up two oxygen bullets, which will travel all the way with us, until arriving at Kamutur, a village in a rural setting in the Bukedea district, at 19:30h in the evening. We crossed roads of all kinds, fortunately during the dry season, we enjoyed the Ugandan landscape, we stopped to eat typical chicken legs and fried livers on skewers, and we even had time to change a wheel for a blowout.

Sunday 15th to Friday 20th: Surgical interventions, from 8:00 am to 8:00 pm, in 2 simultaneous operating theaters.

b.      ADULT PATIENTS:

95 procedures performed in 83 adults, 34 in women and 49 in men.

As a summary, it can be highlighted:

-36 inguinal hernias, 5 bilateral. Mosquito mesh provided by Hernia International and PLP meshes contributed by the volunteers have been used.

-2 infraumbilical laparotomies for two right ovarian masses resections, one 7cm and one 20cm, previously diagnosed by ultrasound provided by the patient.

-3 large incisional hernias with PLP retromuscular mesh (Rives)

-14 hydroceles, including 3 scrotal masses of doubtful diagnosis that required orchiectomy.

-1 breast tumor, quadrantectomy.

-30 soft tissue procedures, including keloid scars, some very complex, and several tumors up to 15cm in diameter.diámetro.

c.      PEDIATRIC PATIENTS:

14 procedures were performed in pediatric patients, 7 in boys and 4 in girls, from 2 to 17 years of age.

Inguinal hernias: (raphias) 4 rights, 1 left. 3 of them associated with hydrocele.

Other procedures: 3 soft tissue tumors, 1 cord cyst, and 1 ganglion and 1 hydrocele.

It is important to point out that, even though we had a pediatric surgeon with us, and we advised it to the hospital with sufficient time, there has not been a recruitment campaign for pediatric patients, fearing that they were not finally operated. Unfortunately, in the two campaigns prior to ours it was not possible to operate on this type of patients, and that has meant that the influx has been very low. Hopefully, this trend will be broken as of our campaign, and a more constant pediatric care will be consolidated in the next ones.

Total procedures: 109

Total patients: 94, 56 men and 38 women.

d.      COMPLICATIONS:

Until the time of leaving Kamutur on Friday evening, all patients were discharged on the same day or after a night of hospitalization, with no complications, except for patients with laparotomies or with drains after eventroplasties, which remained for up to 3 days, or patients with a long distance from the hospital, who stayed for up to two days. According to a subsequent report by Moses Aisia, head of the Hospital, and Dr. David Oikia, physician in charge, there have been no complications in any patient.

2.      CAMPAING REPORT

a.      THE PLACE

Uganda is a country in East Africa, bordering Kenya, South Sudan, Congo, Rwanda and Tanzania. It is an independent country, belonging to the Commonwealth, since 1962. It has had a very convulsive recent past, and currently maintains a relative socio-political calm, with a presidential regime led by Museweni, which has governed since 1986. It is divided into 111 districts and a capital city, Kampala. More than 80% of the population is Christian. Each woman has an average of more than 6 children. Life expectancy is estimated around 52 years. The district of Bukedea, where Kamutur is located, is a district with about 120,000 inhabitants, in a rural environment, and with 80% of its population below the poverty line.

The Holly Innocents Health Center (HIHC), is a private hospital center, created from nothing,  thanks to the enormous work of Moses Aisia, a social worker, who began to build the center after a terrible personal story, and is getting basic health care to an entire region of the district. The entire project, which is fully structured and planned, will turn it into a Hospital with all the basic services, although at the present time there is still much work to be done and a large investment of money, personal and material resources is necessary. At present, it gives attention to gestation and delivery, it has a hospitalization area, laboratory with basic diagnostic tests, and a surgical pavilion in the process of construction, very advanced. Among the health personnel, hospital nurses, midwives and surgical nurses stand out, with a great capacity for work that we have been able to confirm, and a doctor paid for by the center itself, Dr. David Oikia, who carries out commendable work with scarce media, and who stays in the hospital from Wednesday to Sunday, alternating his activity with that of university professor in Mbale, in a government post, on Mondays and Tuesdays. Recently, the center has been certified as Level 4, which in the Ugandan health system corresponds to what we know, saving distances, such as Community Hospital.

The hospital center is clean and tidy, and our fundamental workplace, the surgical pavilion, although still unfinished, has allowed us to work in two operating theaters with enough fluidity, understanding the circumstances in which the surgical campaigns of our Foundation normally take place, quite far from European standards applied to an operating room. In any case, we have maintained a circuit of asepsia-antisepsia more than acceptable, using a pressure autoclave and organizing the instruments in small kits, helped with all the sterilized single-use material that we carry with us. Although we did not have surgical lighting, still without acquiring, we have been able to work with “alternative” lighting with sufficient security. We have organized a circuit for transferring patients from the hospitalization block to the operating room. We have enabled a pre-surgical waiting area and a postanesthetic recovery area with two beds inside the pavilion. We have been able to work with 3 local nurses very efficient and willing, to which we thank their great capacity and joy.

b.      THE TEAM

On September 14th, Friday night, we started from Madrid a team of 8 people:

-Carlos de la Torre Ramos, pediatric surgeon,

-Rocío Fernández Sánchez, general surgeon,

-Ana Gay Fernández, general surgeon,

-Beatriz Revuelta Alonso, anesthesiologist,

-Nuria Agulló Marín, nurse,

-Gustavo Sánchez Bravo, nurse,

-Sergio Sánchez Agulló, photographer,

-David Fernández Luengas, general surgeon.

This campaign has been carried out by a team from the Surgeons in Action Foundation. This is the second campaign in the HIHC of the Foundation, after the first of a team held in December, still without having the surgical pavilion. In addition, in April there was a campaign of Hernia International, an organization that initially contacted the HIHC, but they had very poor results, for various reasons that it is not time to analyze, but differ a lot from what our team experienced. This location of the HIHC is likely to become one of the locations most valued by our organization, due to the enormous needs of the population, the great willingness of all the local hospital staff to collaborate and participate in the campaigns, and the improvement of the facilities projected or in the execution phase, very advanced taking into account how it is all in Africa.

Together with the medical team, this time a professional photographer participated in the campaign, with the aim of collecting audiovisual material to make a documentary film about this place, its reality, its needs, and the task that the Surgeons in Action Foundation has out here.

c.      LOCAL STAFF

In the hospital there is only one doctor, Dr. David Oikia. For our work, we counted on 2 nurses in the operating room (Florence and Esther Norah), who did circulating work together with our nurses, and cleaning and sterilization. In addition, we work with two hospitalization nurses (Karoline and Emmanuel). In addition, two guards performed all the work of circulating patients. 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. His deficiencies in surgical training have been replaced with his dedication and willingness to work. We were very pleased to note upon our arrival the cleanliness of the facilities, which we were able to verify how it was maintained day after day by the cleaning team.

It was very exciting the party-ceremony of welcome to the team, in the back garden of the hospital, where there were speeches, gifts, dinner … and many dances, in a demonstration of gratitude that we deeply appreciated.

Moses Aisia, director of the center, sets an example with an enormous capacity for work, and transmits that implication to all the staff. He is the real engine of the hospital, the one that deals with getting financing to finish the project, designed by him, and was always with us pending of anything that we needed.

We have lived in the hospital center, in 3 rooms with very basic resources.

d.      EQUIPMENT

The hospital has very limited means. Focusing on the surgical pavilion, it is worth mentioning:

-The pavilion is unfinished, so it still can not be used at full capacity according to its projected structure. The exterior construction and the partition of the different rooms is finished. Only some rooms are paddled on floors and walls. There is still no running water and electricity. Therefore, there is no light of any kind installed yet.

– At present the projected operating rooms (3) are not yet operational, since the work is not finished. In this campaign we have used two rooms that are projected as offices when the pavillion will be finished. In those locations we have achieved the basic conditions to turn them into an operating room. In addition, we were able to use a large main room already finished as a warehouse and as a waiting room, another unfinished room as a sterilization room, and another room as a postanesthetic recovery room.

-With regard to the equipment:

Two electrocautery generators are available. One of the two, we were not able to make it work, and it’s going to be sent to repair. Instead we used one that we brought, happily. It is essential to carry both the adhesive grounding plates and the scalpel terminals, since there are practically none there.

They have just acquired an anesthesia machine, which is not yet operational because it is necessary for the company to send a technician to finish checking it and put it into operation, an appointment that is planned immediately, so that it is operative for the next team that goes to operate there.

Currently there are two complete oxygen bullets, which we ourselves collected from Kampala.

We have used an oxygen concentrator that we have transported from Spain, and that we have left there, thanks to the donation of the company Oximesa, managed by our pediatric surgeon Carlos de la Torre.

We have used a diesel engine por electric power that the hospital has, and that has worked correctly for the use of these equipment.

The light for the operating room has been provided by the frontal lights that we all carry from Spain, and which have been essential at some moments.

The two main actions to be carried out in the pavilion, well known by Moses, are the electrical installation, through solar panels, and the piped water.

Regarding the surgical instruments, there is a basic reserve of surgical instruments in the hospital, but we have taken surgical instruments to make about 6 basic kits, which have allowed us to work with fluidity, supported by the cleaning and sterilization in the autoclave by the local nurses.

Regarding fungible material and surgical clothing, the needs are enormous.

We have used much of the material we have worn, including gauze, compresses, gloves, dressings, disposable sterile drapes, sterile disposable gowns, iv anesthetic medication, IV antibiotics for prophylaxis, mosquito mesh and antiseptics for surgical scrubbing, among other things. Without this material, to propose a campaign of these characteristics to this place is impossible. The next teams must bear in mind the need to provide all this material.

e.      ANESTHESIA, ASEPSIA AND SURGICAL EQUPMENT

All adult patients have undergone surgery under spinal anesthesia, supported according to the cases with more or less deep sedation. In soft tissue tumors, as a general rule, local anesthesia has been performed with sedation.

In children, surgical procedures have been performed by general anesthesia in spontaneous ventilation, with the oxygen concentrator, and no doubt thanks to the experience and professionalism of our anesthesiologist.

We have transported all the necessary medication from Spain. There we found a small assortment of medicines from other previous missions, or acquired by the hospital, but, without a doubt, it is very important that any campaign that is organized, at least for now, has the need to ensure its own anesthetic medication.

Basically, they have a “sterilization” room where they keep the packages with the sterile material, and where an autoclave of type “express pot” is put on a wood fire, with a pressure gauge. The system itself is rudimentary, but effective to achieve sterilization of the material.

Surgical clothing is very scarce, with few cotton cloths. We use a large amount of disposable cloths that we carry from Spain, as well as disposable gowns.

All of our adult patients with mesh implants receive a dose of cefazolin 2g iv in the anesthetic induction, which we have taken.

Regarding the surgical material, the situation is equally bad, as it corresponds to the type of hospital it is. We carried a lot of material that is essential that other missions also carry, from gauzes and compresses to sterile gloves, drains, dressings, steri-streaps, sutures, elastic bandages, etc.

Of course, there are no meshes for performing hernioplasty. We have taken a large quantity of meshes “mosquito”, sterilized thanks to the work of Hernia International, which sterilizes, packages and labels individually, and from here we take this opportunity to thank. In addition, we have taken some polypropylene meshes with a larger surface area and some double-layer mesh to ensure a special need that has not been met.

The surgical instruments are very scarce. We have used our own instruments divided into small kits.

f.       OUR LIFE AT KAMUTUR

The alarm clock sounds at 7:00 a.m. It’s time to get up, take a big bucket and go to the hospital well, in the middle of the central square to fill it with water. There is a lot of hustle and bustle at that time, and you always find a child in the well who gladly applies it to the crank of the well to fill the bucket. Then you have to go through the kitchens to add enough hot water, to your taste, and approach our “shower”: a stay with walls of approx. 1,5m high, outdoors, where we could improve the technique of the “shower cube”. The mornings are fresh, about 20º max. After (or before, according to tastes and needs) we enjoyed a wonderful communal latrine, which I do not intend to describe here, but which is far from what any of us understands as a bathroom.

All meals were made in a nice covered terrace, with a menu basically the same every day, clean, cooked there, and enough to feed, without great difficulties. Practically all the members of the team have suffered, to a greater or lesser extent, a gastrointestinal disorder, which in no case has been serious, nor has it prevented our daily work. If anything, it has deepened our knowledge about the operation, cleaning schedules and presence of native fauna in communal latrines.

Our life in this place has been very simple. We have always felt very well treated and very accompanied. Apart from the hospital life, which occupied a large part of the day, our social life was limited to conversations around the table. Especially at night, when, after dinner, we enjoyed one (or two) wonderful bottles (75cl) of Nile beer, some days even something “cold”, with an entertaining conversation. Some confessions about anecdotes of our lives that I will never reveal will remain for the secret of our team.

Our rooms, one for the 3 boys, one for the three girls, and one for Nuria and me, were quite basic, with the beds as only furniture, but clean and comfortable enough to spend a week. There is a bathroom with shower-sink and toilet bowl finished, but still without pipe water, so it is useless, for now.

We have paid $ 70 each for the room and the food, for the whole week. .

Communication with the outside world can only be done through the Ugandan telephone network, through SMS or international tariff calls.kits.

The concept “tourism” is very far from this place. Kamutur is in the middle of nowhere, in a rural environment where families still live in traditional huts in the countryside, without any basic services, and dedicated to a subsistence economy based on agriculture and livestock. There is a primary school, which we were able to visit, that serves the children of this community, with very basic resources.

Regarding the rest of the country, we have been able to complete an in-depth learning about the road network and the landscape of a large part of its territory, since we have made some 1600km in less than 3 days, in a taxi-van whose amenities I will not describe, to visit, at the end of the trip, the famous Bwindi Imprenetrable Forest, and its no less famous mountain gorillas. An unrepeatable experience, in every way.

CONCLUSION

In short, we consider that 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 deal received by the authorities and local staff. Moreover, if possible, after the bad experience of the previous team of Hernia International that was in April. This report aims to serve to demonstrate that, with obvious improvements that need to be undertaken by the hospital management, it is perfectly feasible to carry out surgical campaigns safely in this center.

I believe that this place should be an important work goal for our organization. There is a lot to do, and the people here are eager to receive help.

Strengths of this place:

– Moses Aisia, true engine of the hospital. His ability to start, from nothing, this center, is incredible.

– The hospital itself, a true center of hope for this place, with a very needy population, immersed in poverty.

– The treatment we have received and the willingness of the staff to work with us.

Improvement objectives:

– Complete the surgical pavilion. This task is fundamental, and should be carried out as soon as possible. Includes complete work, equipment, and communication corridors with the rest of the hospital. In addition, as planned, it is convenient to carry out the surgical hospitalization building next to the pavilion.

– Medical material: To date, any campaign must have the need, already explained, to carry with it necessary medical material. It would be highly advisable to progress in supplying the hospital with this material, by the center’s management.

– Hosting of team members. A space must be adapted for the correct rest and basic hygiene.

Budget: For information purposes, and without going into too much detail, it must be said that the campaign in Kamutur is more affordable for the surgical team than other locations. This is due to two fundamental reasons. One, the cost of the flight, not especially expensive. The other, the costs of accommodation and maintenance, which have been almost non-existent ($ 70 for the entire 6-day stay), in addition to road transport, about $ 450 round-trip all the equipment. In the budget has not accounted for the cost of all the material we have contributed, in total about 240kg.

COST (ONE PERSON): Aprox. 900€

TOTAL COST: Aprox5.600€

Fdo: David Fernández Luengas

Campaign leader

Surgeons in Action

Report on hernia mission Brazil July 2018- Dominique Robert

 Brazil is a bit far away from Australia but worth the trip, lovely people, good surgical setting and competent surgical teams. Joao Pessoa is a big town, 1,800,000 inhabitants mainly living in blocks of flats around 30 levels. There are food outlets and fruit and vegie shops everywhere. Their beer is light and their Caïpirinas are absolutely delicious.

Day one was at teaching hospital Santa Isabel, 5 operating theatres well equipped, day 2 at Itabaiana, a rural local hospital one hour out of town, day 3 at Mamanguape, another rural hospital, one hour out of town but very active, day 4 hospital Santa Isabel, day 5 hospital Universario a very big teaching unit with everything available, day 6 at Santa Isabel. There are long working days because of the time spent in transportations around. Recruitment of patients does not seem to be an issue as the cities are big. I did or assisted for 23 hernias on 22 patients. There was no hernia done under local anaesthesia as the Brazilians Anaesthetists are in favour of spinal analgesia which they master very well, no problem on my side and it seems easier for their recovery units.

We were very well treated and fed in every hospital, the Juniors have an active role and are very keen on learning, ask questions and do not hesitate to challenge our techniques. I was a bit surprised we did not have to operate on more children. I think this was worthwile both for them and us. There was good companionship during all these days and I am quite keen on returning next year After time was very good too with plenty more restaurants, drinks and good food, quite often with the surgeons we worked with during the day.Excellent ambiance.

Thanks to Christiano and Christiano, Pericles the local surgeon organiser and all the Junior and senior surgeons Brazilian or from overseas we worked with, Andrew, Leo and Gail accomplished anaesthetist and Whatsapp Champion.

Benin 2018 Report

Mission report, Dangbo, Benin July 2018

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

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

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

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

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

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

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

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

funny – highlight.

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

Suggestions for a future visit

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

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

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

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

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

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

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

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

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

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

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

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

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

Campaign Hernia surgery, Ventanilla June 2018

The campaign of Hernia International and Cirujanos en Acción took place in the public hospital of the Ventanilla neighbourhood in Lima, Peru, from 11^th 21^th last June. 8 days of full work.

Team: General Surgeons: Jose Mª Perez Alfranca (CA), Nicola Clemente (HI), Juan Porta Medina (CA), Irene Miron (R4), Laia Torrent (R3), María Pitarch Martínez (R4)             Anaesthesists: Beatriz Fort Pelay (CA),   Javier Mora Burbano (CA), Guadalupe Sedeño(CA).

The group arrived in Lima on the 9^th and 10^th last June and lodged in the Miraflores neighbourhood at about 20 km from the hospital.

The Ventanilla public hospital is 11 years old, it has about 10 royal beds for the surgical service, with 14 surgeons, 6 anaesthetists and 17 nurses. They are very well prepared at their level (level II), and very specially the one of the infirmary with excellent collaborators. We would like to express here our appreciation for such professionals. 

The social and financial traits of the neighborhood are rather low, being in the periphery of the area controlled by the Barrio del Callao with its tendency for independence, self-control and closeness to the harbor and the airport.

The daily trip from our quarters to the hospital through a thick traffic took between 30 and 45 minutes. We reached the Centre before 8 a.m. and started our work at once. We dealt with 20 to 25 patients, and we finished at 4 or 5 p.m. Between 2 and 3 we had lunch. We want to express our thanks for the menu as well as to the staff.

The surgical staff deserves special mention, particularly Doctor Bernaola.

The operation theater has 5 rooms. We operated in 3 of them, and occasionally in 4 with the collaboration of local surgeons. The 5^th was reserved urgencies which, as is usually the case, were gynecological urgencies.

The patients were listed in a waiting list which had been prepared through an “Informative Campaign” through local media of the Callao Regional Government which insisted on the gratuity of our work. This gratuity did not reach the intervention as such and the anaesthetic and surgical material which the patient usually has to pay from his pocket in spite of it being a public hospital.

The list included local patients who had been previously examined the surgeons from the Department in their pathology and preoperatory. Both were seen by our group who approved them all except for two cases in which the previous pathology was not found.

About 170 patients from about 150 (as recorded in another document) were treated. The group contributed anaesthetic material, medicines and sutures. We used the instruments of the Centre.

The results of the campaign are recorded in a separate document.

As a commentary on procedures we must say that they were chiefly ambulatory and relatively simple, against what one expected to find in such a depressed zone. Factors like the difficulties to remain hospitalized postoperationally 24-48 h. made it impossible to treat other pathologies as we would have wanted.

With due protocol we were welcomed and given farewell by the Direction and Head of service in two official meetings, and we treated to night supper on the 21^st.

We end by saying that our group of voluntaries has shone an excellent technical level and a human quality which have made of those days a fantastic experience.

My personal greeting for all of them. They have been fantastic companions.

Dr. José María Pérez Alfranca

Team Leader

Hernia International Mission:

Bewal, Pakistan, April 2018

 If you were to choose an ideal location for a Hernia International Mission, it is unlikely that Pakistan would come to mind. Since 2014, however, the Bewal International Hospital in the Pothohar region of Pakistan has successfully hosted such a mission with a tally of 293 hernia procedures completed.

Pakistan-Kashmir Border

Officially the Islamic Republic of Pakistan, created in 1947, this beautiful country is home to diverse landscapes ranging from hilly and mountainous regions through ancient and historical monuments and finishing in bustling, crowded cities. Perhaps most notorious and very evident is the hospitality and generosity of its inhabitants.

Many people in Pakistan, particularly those in rural areas, are affected by both poor access to healthcare and the variable quality of these services. Bewal itself is a small town approximately 50 miles from Islamabad on the east border of Tehsil Gujar Khan in the Rawalpindi district. The Bewal International Hospital, which opened in 2010 serving a population of approximately 300,000, is a modern facility that aims to provide quality healthcare services for those in need, regardless of ability to pay.

Bewal International Hospital

 The hospital has 2 operating theatres which were ready and waiting for our 4 days of operating from the 2^nd to the 5^th April. Patients had identified in the weeks leading up to the mission and were ready and waiting for our arrival on the Monday. Our team consisted of Atiq-Ur Rehman, who alongside other ex-patriot Pakistanis’ had designed, fundraised for and overseen the building and running of the hospital and its’ previous missions, Dr Sajed Mohammed, a consultant anaesthetist based at Russells Hall Hospital, Mr Hakan Gök, a consultant surgeon specializing in hernia surgery from Turkey and myself. Mr Khaleeq-Ur Rehman, a maxillofacial surgeon and a founding member of the hospital was also on hand to assist and arrange much of the logistics of the mission.

The Team outside the Operating Department

Operating

 Over the 4 days we performed 71 hernia repairs, including inguinal, umbilical and epigastric herniae as well as a couple of incisional hernia. The vast majority of these were performed under spinal anaesthesia. Paediatric hernia repairs were also performed under general anaesthesia which provided its own unique challenges given the age of the anaesthetic machine and the difference in monitoring that is accustomed in England. To provide some variety, an open cholecystectomy and 3 excisions of lumps were included in the mix.

We were supported by an incredibly hard-working team from the hospital, without whom the mission would not have been possible. In particular we would not have been able to accomplish the number of operations we did without the work of the local ODP who not only performed a large number of spinal anaesthetics, but also acted as runner and assistant on a number of occasions. In addition to this, surgical residents from nearby hospitals attended each day which was a high help.

Having worked hard over 4 days we allowed some time to see some of Pakistan and spent a day sight-seeing around Islamabad. Islamabad is a new city, surrounded by beautiful scenery including the Margalla Hills which provides views over the entire city. Other sights included Faisal Mosque, one of Asia’s largest mosques which is said to hold around 100,000 people and is a mix of both traditional and modern architecture, and the Pakistan Monument which highlighted the unique history of this country.

Margalla Hills

The Pakistan Monument at dusk

During the week we were fortunate to be housed in a beautiful (and new) family house in Bewal with the added luxury of an excellent chef. Numerous family members and friends visited providing support (and more food), making us feel welcome and at home in their country.

The week spent in Pakistan was an amazing experience. Having the opportunity to visit this beautiful country and be welcomed into the community was an immense privilege. The ability to provide surgical care to members of the community was an added bonus. I would encourage anyone looking for a challenge to consider a Hernia International mission and contemplate the captivating country of Pakistan as your destination.    

 Emma Upchurch

Surgical Registrar, Gloucester Royal Hospital

MEMORY OF THE MISSION CARRIED OUT FROM 19 TO 28 APRIL 2018 BY “CIRUJANOS EN ACCIÓN” IN THE “ESTHER & JERELINE MEDICAL CENTER”OF GANTA CITY (LIBERIA)

The Ganta City (Liberia) mission was proposed several months in advance, and from the start it was a wonderful challenge: for the majority of the members of the team (except the lady anaesthetists) that was our first visit to Africa. The team was finally made up by 9 members:

César Ramírez (surgeon and team coordinator), Javier Moreno (surgeon), Elena González (surgeon in residence, 5^th year), José Pradillos (paedriatric surgeon), Inma Giménez (anaesthetist), Ana López (anaesthetist) plus Paco Gomez, Sara Corredera and Verónica Fernandez. On April 19 we started each from his or her city (Málaga, León, Valencia and Murcia) and we met in the Casablanca airport to take our Air Maroc flight and its 23 hours to Monrovia. Then after a 4 hours flight in a commercial plane with unbearable heat, we reached Monrovia at 2.25 a.m.

We found waiting for us the Medical Director of the Esther and Jereline (E&J) Medical Center and alma mater of the local mission, Dr. George, and the highest authorities of that center. The Monrovia airport is small, all up-and-down, and lacking even the minimal conveniences of safety and luggage control, with a single customs with works with utter laziness. In this mission we’ve had no problem with our luggage (10 bags 30 Kg each, including a generator for electrical scalpel) thanks to the help we got at the Málaga airport from an Air Europa pilot, Nacho Ballesteros, personal friend of Dr. Javier Moreno, who worked hard to get everything properly done. For Verónica, Sara and Elena this was their first mission with “Cirujanos en acción“; the rest of us had already taken part in previous campaigns.

The way from Monrovia to Ganta City takes almost 4’30 hours along a rudimentary commercial road, and we occupied 3 local lorries that Dr. George books for us for all our stay in Liberia. Our lodgings in Ganta City are in a small guesthouse called Jackie’s Guest House where we have been able to choose either individual or shared room; that is the best available in the city and we have hot water, air-condition and a “tex-mex” meal, more than acceptable, which does for breakfast and supper “in situ”, and is taken along to the E&J Medical Center at lunch time.

There is absolutely nothing worth seen in Ganta City and no possibility for any excursion to touristic places, so that our days had been intense and very repetitive. Every morning we met at 7.30 a.m for breakfast, and half an hour later they took us to the Medical Center. On arrival we found a group of patients (children and adults) who had been called by the local doctors so that we would evaluate them.

Daily one of the surgeons of our team and the paedriatic surgeon had a small room in which we saw the patients, examined them selected them for surgery. No pre-operation information has been asked by us, and the patients (children and adults) have been operated after the surgical evaluation.

The E&J-MC is something similar to what in Spain could be a small ambulatory with two operation theaters whose sterility conditions are just basic, and then a small room for patients had been arranged for a third operation theater. We have practically no material as it is a medical center in which only caesarians are performed, and now they are just beginning to carry out some caesarians as acute appendicitis.

Though there are respirators in the operation rooms they cannot be used because there is no oxygen; thus when general anaesthetic with breading help is required for some patient, this has to be ventilated by hand by the anaesthesist.

We had brought 3 whole sets of surgical material to operate hernias and one for paediatric surgery which we donated to the E&J-MC when the mission was over. We have fully utilized the more than the 300 Kg of surgical material we had brought with us, as they hardly have any gloves, gauze, antiseptics, sterilized gowns, sterilized fields, dressings (in fact since our coming, they have made use of our material for their surgical needs). Similarly we have taken their and the donated to them more than 200 boxes of omeprazole, paracetamol and analgesics for their use in Ganta City.

During the mission a total of 175 patients have been operated upon (83 children and 112 adults) with 249 surgical interventions. In 74 patients (almost a 40%) several 2 or 3 processes have been carried out. We have been struck by the amount of patients with inguinal hernia who associated umbilical hernias of at least 1.5-2 cm, and all the more as the majority were young, thin and with apparently good mussels. We have utilized 80 mosquito net gauzes donated by Hernia International and about 100 large opening and low molecular wait which had been donated by BBraun; we had enough and to spare. The patients remained for a night (the hospital has some common rooms for 3-4 patients and then one large common hall for men and another for women, were at least 20 patients could be accommodated. They were revised by us early each day to be able to release them and realize that there was no problem. A patient operated upon for an epigastric hernia had to be operated again for an important hematoma on the first day after the operations, and 4 patients have presented minor postoperation scrota hematomas which have needed no intervention. For a personal petition of Dr George we operated upon two young women with evident symptoms, who otherwise they wound have never been healed.

The medical and administrative authorities of the E&J Medical Centre have been most help from the start. We have received all kind of help, and all have tried to make us happy. On our arrival and farewell we were received with local songs and prayers by the local people, and as a special thanksgiving they have gifted us clothes with local motives which we’ll keep with all love. They have repeatedly asked us to come again as soon as possible because they are very much in need, and we surely will do it as it has been an unforgettable mission.

TANZANIA    2 0 1 8

1^st Austrian “Hernia International Foundation” Mission

Korogwe, February 24^th – March 3^rd 2018

Our group was the 10^th Hernia International team to Korogwe. It consisted of 6 members: 2 surgeons, 2 anaesthesiologists, 1 radiologist and 1 nurse anaesthetist.

Before our travel, we did not all know each other. Through common friends, a team was assembled , which later showed to be a good one. We travelled separately. Unfortunately, the intended plan to host the first African surgeon on Hernia International Mission (Dr. Peter George from Liberia), had to be abandoned due to problems during his flight. The team met in Triniti Hotel close to Dar es Salaam airport. After breakfast, we travelled to Korogwe on mainly good, but busy roads for the next 6 hours. During this trip, and later on in the hospital, an observation was made that after being here in 2015, Tanzania has been making progress in every sense (roads, traffic rules, infrastructure,…). In Korogwe hospital, we were warmly welcomed by the hospital’s medical director and Dr. Avelina Temba as the 10^th Hernia International team, after starting in 2013.

        

 Warm welcome in front of the Korogwe hospital

Immediately after that, we visited the patients and arranged the surgical programme for the first day. We nearly managed to retain all of our equipment with just 1 piece of lost luggage missing. We bought sutures from a local pharmacy. Operations were planned parallel on 3 tables, however this had to be reduced due to the unpredicted absence of 1 surgeon. However, our host, Dr. Temba was willing to operate on table 3 on almost all days. Operations started with 3-4 paediatric cases on table 1, these patients got general anaesthesia and caudal blockage, then we continued with adults, mostly also in general anaesthesia due to large hernias. On table 2, mainly large inguinoscrotals, up to H420 cm-(Kingsnorth classification) were performed mainly in spinal anaesthesia. On table 3, Dr. Temba performed diverse procedures, mostly in local anaesthesia, partly in spinal as well. Table 1 and 3 were sometimes occupied by local surgeons performing emergency procedures. A very well organised, local team was of big help to us. Also, there was a big interest from local surgeons to learn modern hernia procedures.                                                   

   1 OT was well air-conditioned, the other partly (AC was out of order on the second day) so Maria and Marija showed a lot of bravery, working at 37 ^oC while wearing surgical coats. Strong headlights were a good idea to take with us. Although lighting were working in 2 theatres properly, they were not very bright. The diathermies were working well, despite regular power cuts.

 Maria and Dr Agripina during surgery

 Jurij during teaching retrorectal Rives-Stoppa

In the first three days, the work in all three operating theatres (OTs) ran smoothly from 8 am to 9 pm or even later. Arranging the surgical programme for the following day was the last task every evening. On day 3, after a good dinner in a local grill restaurant on Korogwe main road, we decided to reduce the working hours for next 2 days. This was done partly allowing teambuilding and to enable the local staff to relax and tidy up in the evenings. On the next day, after finishing surgery, we were honoured by visiting the monastery and private hospital of The Sisters of Usumbaya (a catholic order of sisters, to whom surgeons Dr. Avelina, Dr. Archangela and Dr. Dativa belong). Around their monastery various tropic trees with diverse fruits were growing, and considering the peaceful atmosphere of people praying, we almost had the impression of being in the garden of Eden. The private St. Joseph Hospital close to the monastery has just been expanded with a new maternity ward. In this building, a donated ultrasound machine, a gift from Dr. Michael Wutte from Austria, which we brought to Tansania,  will be installed.

On the last day, after finishing surgery, we visited a local market acompanied by surgeon Dr. Ahmad and were in awe of the diversity of groceries and other articles sold by the locals. The final evening party, organised by ourselves and hospital staff in our guest house (Magnificent Korogwe Resort), consisted of speeches thanking the work that had been done, a buffet dinner and some dancing.

Special thanks were given to local surgeons, who performed the early morning rounds every day for all of the patients. This was a big time saving for us, allowing us to start with surgery immediately after arriving to the hospital. The Korogwe hospital has about 15 doctors and 100 beds, making this organisationally possible. We personally checked dressings and removed drainages in incisionals and some large inguinoscrotal hernias Korogwe hospital has about 100 beds, around 15 doctors are working there.

 Michael, Hannes and Sarah during education, which was an important part of our mission   

Ultrasound procedures were very useful not just for our patients (undescended testicles, hernias, …), but also for emergencies. Unfortunately, regular power cuts limited the number of ultrasound checks we could carry out. When Marija, our radiologist, was not busy in X-ray department, she assisted Maria in OT2. Women are capable of multitasking! This proof came also from Sarah, the anaesthesia nurse, who helped everybody, besides being a great support to our skilled anaesthesiologists Michael and Hannes.

Lunch break and refreshments were always welcome. The kitchen lady Scholastica took abundant care of us (rice, vegetables, some local specialities, chicken, water, coffee, peanuts).

Staying in Magnificen Korogwe Hotel was a good suggestion, given to us by Dr. Katharina Wentkowski from Switzerland. It is much closer to the hospital than other Korogwe guest houses. 20 USD/night was reasonable, but there was no WIFI available This was solved by our radiologist, who bought a local Tanzanian SIM card and offered us to use the hotspot.                  

In 5 working days we performed 72 procedures on 66 patients (16 female, 50 male) on 2, sometimes 3 tables. Our anaesthesia team performed two additional long-term general anaesthesia’s for emergencies. The average age of the patients was 44,4 years. The oldest patient was 100 years old (no official confirmation), the youngest 1 year and 2 months. The majority of patients had large inguinoscrotal hernias (34).

We repaired inguinals using the Lichtenstein (33 patients) and the Shouldice technique with one young patient. In 15 paediatric patients with inguinal hernia, the Mitchell Banks and Ferguson techniques were used. We performed 4 incisional repairs (2 sublay – retromuscular Rives Stoppa and 2 onlays), 11 direct umbilical repairs, 2 undescended testicle repairs (orchidopexies). We were blessed having no complications. The anaesthesia was predominantly spinal with 43 cases, 22 patients had a general anaesthesia, local anaesthesia was done in just 11 cases.

A lot of above mentioned procedures were partly or fully performed by local staff (surgeons, anaesthesiologists, nurses).

For the second time, the presence of a radiologist on our mission confirmed to be a good idea: 12 performed ultrasound diagnostic checks preoperatively, 12 other outpatient ultrasounds, 2 emergency ultrasounds and 18 sonography checks on pregnant women (altogether 44, including education).         

Special thanks go to  the well coordinated work between anaesthesia and surgery and of course, with local experts. We did not need to talk much to find right solutions in situations that needed to be discussed. The comment of Dr. Avelina was very appropriate: » It was a calm and blessed mission«.

Although we travelled as the 1^st Hernia International team from Austria, our skill, experience and enthusiasm originates from different countries and hospitals. The anaesthesia team comes from large clinic (Feldkirch in Vorarlberg) in the west of Austria and surgical team comes from Carinthia (south Austria). The radiologist, whose task was performing preoperative ultrasounds and introducing the donated ultrasound machine to local doctors, came from Ljubljana clinical centre (Slovenia).

–         Michael Wirnsperger (consultant, anaesthesiologist, 1^st mission)

–         Hannes Lienhart (consultant, anaesthesiologist, 1^st mission)

–         Sarah Bertsch (anaesthesia nurse, 1^st mission)

–         Marija Jekovec (consultant, radiologist, 2^nd mission)

–         Maria Greiner (consultant, surgeon, 2^nd mission)

–         Jurij Gorjanc (consultant, surgeon, team coordinator, 8^th mission)

 To view a short film about the mission, click on the following link:

https://drive.google.com/file/d/1ybgCiGFt-re7jdts3lpVskLRhiBWy61e/view

FARAFENNI GENERAL HOSPITAL

 REPORT ON HERNIA INTERNATIONAL MISSION

 (SPANISH GROUP) TO THE GAMBIA

12^th – 16^th MARCH 2018

Compiled By

Farafenni General Hospital Management

Farafenni

North Bank Region

The Gambia

20^th March 2018

BACKGROUND

The Hernia International Organization a multi – European Humanitarian group started partnership with Farafenni General Hospital in 2007 marking the beginning of the organization’s first Hernia Camp in the Gambia.

Preparations for the March 2018 Mission began in December 2017 with the submission of a letter of intent to Dr Andrew Kingsnorth coordinator for Hernia International from the Spanish team leader Dr. Antonio Satorras a General Surgeon. The team includes; 1 General Surgeon; 2 paediatric Surgeons; 1 Anesthetist and 2 Theatre Nurses.

OBJECTIVES

The objective of the 2018 mission were;

1.      To offer surgical services mainly hernia but not limited to hernia alone to patients needing surgical care including children.

2.      To reduce the backlog of patients on waiting list for surgery at Farafenni and other facilities in the Gambia.

PREPARATION

Following clearance for the mission obtained from the Office of the Director of Health Services, Ministry of Health & Social Welfare dated 2^nd February 2018, the Hospital Management established a local support team including a Doctor; Anesthetist Technicians; Theatre Nurses; General Nurses and other support staff to work with the mission. From the success registered in the last Hernia Misssion, the local team were encouraged to work with the vistiong team hence the establishment 3 key task-forces.

1.      Clinical: assigned with the responsibility of screening and booking (including contact details) of all hernias and related cases seen at the clinic.

2.      Communication: responsible for sensitizing the general public including health facilities using the local radio and influential community members.

3.      Logistics: Identifying and mobilizing the required resources needed for the mission and these includes; medical supplies, drugs and personnel.

The units that were fully involved in the preparation process included Administration; Nursing Department; Operating theatre; Laundry; DRF Unit; Security; Generator Unit and Catering Unit.

SUPPORT FROM MANAGEMENT

To achieve success in this mission, Management ensured that;

1.      The visiting team’s movement was well coordinated with support from the office of the Director of Health Services by providing transportation from the Airport to Farafenni and back to the Coast after the completion of the mission.

2.      The visiting Doctors and Nurses were cleared through the Ministry of Health.

3.      Drugs and supplies needed for the camp were made available.

4.      Staff identified (local team) were available at all time (8AM – 9PM daily) during the course of the surgery.

5.      Food and water was available to avoid interruption of services by providing lunch for the local staff while a hospital cook prepared meals for the visiting team.

OUTCOME

The 2018 Spanish Hernia Mission operated on 51 patients with varied surgical conditions. Of the total cases performed, hernia represents 72.5%; Lipoma 7.8%; hydrocele 15.6%; and Keloid 3.9%. Of the total patients operated on 46 (90.1%) were males and 5 (9.8%) were females. Gambians represents 84.3% of patients and non-Gambians accounted for 15.6%. Children under the age 5 represents 15.6% of all patients operated on.

SEX	NATIONALITY	CONDITIONS	AGE DISTRIBUTION
M	F	Gam	Non-Gam	Hernia	Lipoma	Hydrocele	Keloid	< 5yrs	> 5yrs
46	5	43	8	37	4	8	2	8	43
90.1%	9.8%	84.3%	15.6%	72.5%	7.8%	15.6%	3.9%	15.6%	84.3%

Table above shows summary statistics of the 2018 Spanish Hernia Mission  

CONCLUSION

The Mission was a success despite the feeling among the team that more could have been done. However, given that it was only 3 months ago when we had a camp that operated on 78 patients, registering 51 for this mission is a significant milestone. I must also acknowledged the transfer of skills between the visiting team and the local team.

The Hospital Management would like to register appreciation to the Spanish Mission and by extension to Hernia International ably coordinated by Dr. Adrew Kingsnorth. The local staff must be commended for their dedication and commitment. We also register gratitude to the Ministry of Health for the technical support and encouragement through out the process.

Wandifa Samateh(MSc,RM,RN)
Chief Executive Officer
Farafenni General Hospital
Ministry of Health and Social Welfare
Banjul, The Gambia

REPORT SHINYANGA. TANZANIA 2018

We began our journey to Tanzania at the Barajas airport on 9^th March 2018. We met a few hours before to pack the material and get to know the whole team. For some of us it´s the first experience as cooperators, others with some previous experience, but all with the same illusion that this type of missions entails. We invoice without problems 9 packages of 23Kg each one. A long trip awaits us, from Madrid to Addis Ababa (with a stop in Rome) and from there to Dar es-Salam, where we have to spend a night before leaving for our final destination, Shinyanga. At the airport we obtain the visa for entry into the country without problems, although after a long wait. We passed the customs with all the material without problems thanks to Dr Chacha, pediatrician in Shinyanga hospital, who comes to pick us up at the airport with all the necessary permits. We have more than 24h of travel, so we went to the hotel to leave all the luggage and go out to explore the city. The driver of the hotel takes us for a walk around the city, to a market of local crafts and finally to enjoy a pleasant dinner in a restaurant with terrace by the sea. The next day we know the fishing port and the market, where there is a frenetic activity with people cleaning and selling fish or cooking to eat there. There are also multiple stalls where they sell starfish, all kinds of shells of all shapes and colors imaginable. We also visit the national museum, a good place to get to know the culture and history of the country we visited. To finish our short stay in Dar es-Salam we went to the beach to taste the warm waters of the Indian Ocean, unknown to many of us.

We return to the airport to catch our internal flight to Mwanza, where we landed at 9:30 p.m. on 11^th March. There, our hosts pick us up with a bus to transport us to Shinyanga, where we arrived after 2 p.m. The hotel they have chosen for our stay is very pleasant, with spacious and comfortable rooms, bungalow type, with air conditioning and WiFi connection (although it started to work on the thirdday of our arrival). There are a garden area and terrace for outdoor dining, which allowed us to have very nice dinners next to our well-deserved beers after the long days of work.

 The next day we finally arrived at the Shinyanga hospital, 3 days after our departure. There, Dr George, surgeon in charge of coordinating the mission, and Dr Onesmo, who has been in charge of recruiting patients, await us. With them we began to coordinate to start operating patients as soon as possible.

We are informed that each patient (except children under 5 years of age) must pay 80,000 TZS (approximately 29 euros) for hospital and personal expenses. In addition, there are waiting for us 2 inspectors of the TDFA (Tanzanian Food and Drugs Authorithy), who review all the material for hours, confiscating everything they do not consider adequate (sutures recently expired) and withdrawing medication with an expiration date nearby.

Meanwhile, we started reviewing patients and scheduled the first surgeries. Once all the material was placed and the operating room was prepared, we began to operate that same day in the afternoon. We settled in one of the 3 operating rooms available in the hospital, to operate in two tables separated by a screen.

One for children and one for adults. And so we began a very hard campaign, working about 14 hours every day. The selection made by Dr Onesmo was excellent, it was only necessary to review some patients with diagnostic doubts and some pediatric patients. Approximately 18 patients were operated daily, with a lot of effort and dedication from our team, who every day gave everything to carry out all the daily work, including Sergio, our photographer, who did an accelerated nursing assistant course. The collaboration on the part of the native staff was quite deficient, although I must emphasize the enormous collaboration of Dr Onesmo, Dr Nelson, Simon (anesthesia technician) and of course, Ezequiel, who did everything on their part to help us. The work days were so intense, that we didn´t have any time to know the city, only the surroundings of the hospital and the hotel. Every day they served us the lunch in a hospital room. The food was good and plentiful.

After 5 and a half days of intense work, we are ready for our return. Again driving to Mwanza, with a tyre puncture included in the middle of nowhere. At the airport they open all the packages before entering and check all the material, despite having all our permits in order.

Finally we arrived in Madrid after 10 days of travel, with a strange feeling. Maybe we could have done better, maybe we could have operated more, but the conditions were what there were, and things don´t change in one day. I hope that in future campaigns, all the problems that were presented to us in this first mission in Shinyanga, can be solved and thus be able to carry out more useful campaigns in a hospital with a lot of potential.

After a month of our return, after which I had contradictory feelings regarding this mission, I only have in mind the good things, the smile of the children when giving them a toy or a simple caress, with their parents grateful for our help, and all the patients that we have improved their quality of life after our passage through Shinyanga. In the end this is the essence of this work. And of course, in my mind there is always the team spirit, the union that occurs between the group, especially in the difficult situations that have been presented to us. Without a doubt, this has been essential for the development of this mission and the reason why there is always a desire to repeat a mission . ASANTE SANA.

TECHNICAL MEMORY:

 PARTICIPANTS:

Ana María Gay Fernández, general surgeon Álvaro Cunqueiro Hospital, Vigo

Pablo Lozano Lominchar, general surgeon Gregorio Marañón Hospital, Madrid

Lucía Garrido López, 4th year resident of general surgery Álvaro Cunqueiro Hospital, Vigo

José Miguel Morán Penco, pediatric surgeon, Quirón Salud Hospital, Cáceres and Badajoz

Beatriz Revuelta Alonso, anesthesiologist, University Healthcare Complex of León

Almudena Ceballos Ruano, nurse, Poniente Hospital, Almería

Sergio Sánchez Agullo, photographer

DURATION: Departure from Madrid 9^th March 2018, arrival in Madrid 19^th March 2018.

RESULTS OF THE CAMPAIGN:

Adult surgeries: 44 patients. 50 procedures.

Inguinal hernias: 34

Eventrations: 3

Hydroceles: 5

Epigastric hernias: 5

Sigma volvulus: 1

2 reinterventions for hematoma.

Pediatric surgeries: 34 patients, 41 procedures

Inguinal hernias: 15

Umbilical hernias: 5

Cryptorchid: 4

Phimosis: 5

Hydroceles: 1

Burn Cures: 3

Other procedures: 8

THE HOSPITAL:

It´s a large hospital, with 3 operating rooms and several rooms for hospitalized patients, for men, women and children separately. They have a sterilization room with an autoclave. The cleaning of the hospital and specifically the operating room area is very poor. In addition, the operating room area has many windows, which are permanently open, with the consequent entry of insects and dirt from the street.

SURGICAL MATERIAL:

-They don´t have any electric scalpel generator that works correctly, neither terminals and plates.

– They have a lot of surgical equipment, although quite old and rusty. Some boxes for laparotomy are in good condition, but the material for hernia surgery is very poor. They don´t have specific material for pediatric surgery, because children are not routinely operated in this hospital.

-they have gowns and surgical covers, but not enough for daily surgeries that are performed in this type of campaigns, so it´s convenient to include gowns and surgical fields, as well as gauzes and antiseptics.

-they have a lamp on each operating table, but light cuts due to overload are frequent, so it is advisable to wear a frontal light.

– Pediatric patients with severe burns are taken care of daily, so it´s important to take material to make cures of this type

ANESTHESIA MATERIAL:

-The hospital is equipped with a modern anesthesia machine and an older one, one in each operating room. We used the most modern one, to be able to do pediatric anesthesia. It consists of two vaporizers: one of halothane and the other of sevorane. They only have halothane, but for future missions it is good to know, for the possibility of getting sevorane and use it. The oxygen was in bottles, and they have enough for surgeries that were performed

-With regard to the medication for general anesthesia, there are muscle relaxants such as succinylcholine, ketamine and little else, so it is important to carry everything we consider necessary.

– Endotracheal tubes, aspiration probes, after being asked repeatedly, appear. There aren´t laryngeal masks.

-Fluids, systems for intravenous lines are available,

-We work in two tables in the same operating room, as already mentioned. At one table we made adults and in the other one children with the respirator. There are also several oxygen concentrators, so it is possible to use them if necessary.

-Staff local, there are no anesthetists trained as such. They are anesthetic technicians, who perform mainly spinal anesthesia, but also general anesthesia when surgery requires it. They have a great capacity to adapt to the situations that are presented to them, taking into account the means at their disposal and the little accessibility to the best in our speciality. They listen everything we told them and try to use devices like masks, which they have heard but have never seen. Their collaboration was essential to carry out the mission given the large volume of patients we had.

In summary, and although there are some material and medication, it´s preferable to take anything that we can think we need. In addition to this, the expense that we can cause over the days is diminished.

ASPECTS TO IMPROVE:

-cleaning  conditions of the operating rooms. It is necessary to place mosquito nets in all the windows.

– train local staff in asepsis and antisepsis, as there are many aspects that are unknown or poorly practiced. 

– help from local staff to expedite the entry and exit of patients to the operating room and then to the room. 

-correct identification of patients and their clinical history.

-include patients who don´t have the financial resources that have been required in this campaign.

 Ana Gay

Team Leader

CAMPAIGN IN FARAFENNI (GAMBIA), MARCH 2018.

After months of preparation and bureaucracy, on Saturday March 10, We, the Spanish team of “Cirujanos en Acción” in collaboration with Hernia International, started our mission in Farafenni (The Gambia). Two groups of people travelled to Banjul from Barcelona and Madrid: Pepa Fornier (nurse at the Hospital Materno-Infantil, Badajoz) and Inmaculada Vílchez (nurse at Hospital Universitario La Fe de Valencia), Ana Arnalich (anesthesist at Hospital Universitario Gregorio Marañón, Madrid), Asuncion Azpeitia and Nagore Solaetxe (paediatric surgeons at Hospital Universitario de Cruces de Barakaldo) and Antonio Satorras (general surgeon, Hospital da Costa, Lugo).  We arrived in Banjul at night. Once there, we could enjoy the smell of Africa and see an incomparable starry sky. We were received by Mr Sainey Dibba (the public relations officer of the Farafenni General Hospital) and by Amadou (our driver). We spent our first night at Grand Villa Guest House, a nice colonial style place near the airport.

After a short night, only altered by the imam calling to prayer, we met Mr Wandifa Samateh, Chief Executive Officer of the FGH, and we set off to our destination. We travelled along the Gambia river in a crowded old ferry. The trip lasted over two hours due to the blowout of a wheel. Eventually, we arrived at the AFPRC Farafenni General Hospital, where we were introduced to part of the local team. There are no local doctors there. That is why nurses and technicians as well as a few doctors from Cuba are responsible for the things done there. It was in that place where we had our first hot meal. As regards the facilities in the hospital, I would like to highlight the fact that there are 160 beds available, as well as two poorly equipped operating rooms. We had at our disposal the biggest one, in which there was enough room for three tables. However, there was only a real surgical table and there were just two stretchers. There was only a surgical light and an old anesthesia machine, which worked with Halothane. There was only one oxygen tank and power cuts were very frequent, so we needed to make use of our front lights.

Near two hundred kilos of materials and drugs were brought by us, including a diathermy. I would like to mention that on the one hand, we could use another local Valleylab. On the other hand, intravenous fluids were provided by the hospital. Anyway, the equipment and materials were not in good condition either (gowns, sheets and gauzes were sterilized in an autoclave there, and were often wet).

After a tiring day, we went to our hotel, the Mone Berre Lodge, near the hospital. Its spartan rooms did not comply with the minimum hygienic conditions. However, there was air-conditioning, Wi-fi connection, there were also mosquito nets and cold beers. Anyway, Rastaman (the owner) made an effort to make our stay enjoyable speaking to us and playing Reggae music.The next day, we had breakfast at the hospital at 7.30 a.m. and at 8.00 a.m. we began to work. The Spanish campaign had been announced by the media, then a lot of patients, without previous selection, started arriving at the hospital. Some of them had to be refused. Nobody had gone through a preoperative study, and there was no time nor a possibility to do so. Almost nobody spoke English, but we had Mandinga and Wolof (the main local languages) translators at our disposal. Finally, after doing a first selection and solving some new technical problems, we could start with the surgery. Yudelines Denis (a Cuban General Surgeon) and Luís Anglada (a Cuban Anesthetist Technician) who work at the Medical Centre, were of great help for us as they started working partially as part of our team. They explained to us about the local idiosyncrasy and the African way of doing things. Thanks to their help, we could operate eleven patients (both adults and children) who were suffering from a total of 13 pathologies. This way, we put an end to the first but exhausting working day. It was a bit later that we were told those patients had to stay at a recovery room without any monitoring system and without any qualified medical staff. That is why while we stayed there we tried to teach the local staff as much as we could though the results were not as good as expected.

At cockcrow and the call to prayer we began a new working day. We were picked up and driven to the hospital at the fixed time. The meals were made by a local cook. Breakfast and lunch at the hospital and dinner at the hotel were served for six euros per person a day. We could eat rice with vegetables and a different side dish every day. The food was very tasteful. But the hygienic food storage and preparation was not the best.

We decided to establish some rules so that the patients who were going to be operated had to arrive shaved and washed to the surgery. The working pace, there, is different from the one we are used to and for that reason only a maximum of twelve patients could be operated a day (3 per turn and team). Those were from Gambia and Senegal. They were mostly men. It seemed to us that women did not require our services… Nevertheless, women came to bring their children (who usually suffered from malnutrition). Medical treatments were cheaper than usual there but not free; and almost everybody had to remain hospitalized for a night. In case any of them required a check-up to remove the drain, they had to stay at one of their relatives’ house and could come back to see us two days later.

We had to be really careful in order not to be infected with AIDS or hepatitis. Then, wearing double gloving was recommended by local doctors.Despite having informed the Head of the hospital about the members of our team thoroughly, the number of pediatric patients was very low. It was a pity they missed the opportunity of being helped by the two experienced and available pediatric surgeons. On Thursday, we were astounded as only a few people attended the medical practice. There were only six people to be operated, so we had a free afternoon and we could visit the Farafenni’s market.

Although they had organized surgical activity for us to do until Friday morning, we decided to work later the last afternoon to help as many patients as possible before we left. On Friday night, they celebrated a farewell dinner (both surgery staff and management staff attended it). They were very grateful to us and so they gave some speeches to let us know.

On Saturday just before coming back, we visited the Wassu Stone Circles, a megalithic and world heritage monument of the UNESCO, and the old slavery place of Jamjamboreh. On the road, our van broke down and we had to wait four hours for another one to arrive. Then, the trip lasted 3 hours at night. The cars had no lights. We travelled in a crowded ambulance along dark roads. On the way, we met risky pedestrians, free animals (a run-over sheep), and dozens of police controls. Luckily, in the end we arrived at Leybato Beach Hotel where we were able to rest in appropriate conditions. On Sunday we could visit a crocodile pool at Kachikaly, we could also see monkeys at the Banji National Park, we could go on a boat ride through the mangroves and to the fish market in Tanji. At night we took our flight. A stopover at the airport in Casablanca allowed us to visit the city for a while. Finally, we arrived in Madrid save and sound.

The final result of the campaign has been very positive. We assisted fifty-three patients in total with sixty-one processes due to double pathologies. I would like to highlight not only the number of patients we had assisted (41 adults and 12 children, aged between 1 and 5. Most of them (48) were male) but also the human and technical quality we could offer with the limited resources we had. Regional anesthesia was used in 35, general in 14 and 4 were done under local anesthesia. Inguinal hernia, some of them giant, was operated in 38 patients; mesh hernioplasty was done in all adults. 12 hydroceles, 4 umbilical hernia, a non-descended testicle and 6 lipoma were also treated. Only one hydrocele patient needed a review after early hematoma. All the others went right.

Expenses other than plane tickets were 16€ for accommodation and 8€ for meals per person and day. Lots of water bottles were included. We had no other expenses apart from tips, excursions and last-minute gifts.Once the mission has finished, we think that it would have been better a duration of two weeks, because when things started to work well, we had to go. Perhaps, with more time we could have taught better to the local staff, some of whom were very willing and eager to learn. But this will be on future visits.

 Antonio Satorras