The campaign of Hernia International and Cirujanos en Acción took place in the public hospital of the Ventanilla neighbourhood in Lima, Peru, from 11th 21th 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 9th and 10th 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 5th 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 21st.
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.
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 2nd to the 5th 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.
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, 5th 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.
1st Austrian “Hernia International Foundation” Mission
Korogwe, February 24th – March 3rd 2018
Our group was the 10th 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 10th 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 1st 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, 1st mission)
– Hannes Lienhart (consultant, anaesthesiologist, 1st mission)
– Sarah Bertsch (anaesthesia nurse, 1st mission)
– Marija Jekovec (consultant, radiologist, 2nd mission)
– Maria Greiner (consultant, surgeon, 2nd mission)
– Jurij Gorjanc (consultant, surgeon, team coordinator, 8th mission)
To view a short film about the mission, click on the following link:
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 2nd 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
We began our journey to Tanzania at the Barajas airport on 9th 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 11th 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
DURATION: Departure from Madrid 9th March 2018, arrival in Madrid 19th 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.
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.
(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.
