UK, Israeli, USA and Slovenian Team, Mongolia 1-15 MAY 2010

Mongolia is a country situated on the central Asian plateau wedged between China and Russia. It is classified as a low-income country, providing a healthcare system with poor infrastructure, old equipment and little money for basic supplies.

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The country has an average elevation of 1600 meters, a land mass the size of Western Europe and is situated at the headwaters of river systems that flow to Siberia, the Arctic, China and the Pacific. It has a dry climate yet affords 250 sunny days a year and is known as Land of the Blue Sky . Only 3 million people live in Mongolia and half of these reside in the capital Ulaanbaatar. Travel is best undertaken in a four wheel drive or by horse since there are only 1500 kilometres of paved road and most travel is via an improved earth surface or earth tracks. This gives wonderful opportunities to meet the hospitable herdsmen who tend the 40 million horses, goats, sheep and cattle that roam over the fenceless and treeless steppes. It is an exotic experience to visit a ger (a traditional round felt tent) and enjoy the hospitality of a nomadic family, which may include mutton stew, horse meat, goat s milk tea and khoomis (fermented mare s milk).

Our two week mission from 30th April to 15th May 2010, was undertaken with the very able assistance of the Swanson Family Foundation (SFF) represented in Ulaanbaatar (UB) by Mrs M Enkhtuvshin (Enkhee). Planning had begun more than six months earlier. Surgery and teaching took place during the first week in the central Teaching Hospital #2 in UB (under the leadership of the Chief of Surgery, professor Tsagaan Narmandakh) and during the second week at the central hospital in Moron, a distance of 800km to the north in Khuvsgol province. Surgeons from district hospitals attended for teaching and lectures in Lichtenstein inguinal hernia repair, incisional hernia repair with mesh and components separation, and some paediatric surgery. To reach Moron involved an unforgettable drive across the steppes and taiga to the still-frozen Khuvsgol lake adjacent to Siberia.

Our team consisted of myself, Professor Motti Gutman from Israel, Dr Todd Heniford and Dr David Earle from the USA (the first representatives of the American Hernia Society) and Dr Juriy Gorjanc from Slovenia. We arrived at the Chinggis Khan airport early on the morning of Saturday 1st May and were met by Enkhee, the Chief of Surgery and the Director, of Hospital #2. The remainder of the day was spent orientating in the city of UB and adjusting to the cheerful faces of Mongolians dressed in their exotic and colourful deels (three-quarter length gown that buttons at the right shoulder to a high round-necked collar), hats, scarves and sashes. Our clinical work began the following evening (Sunday) with pre-assessment of 20 or so patients who had a variety of hernias. On the Monday morning we attended a dignified official opening ceremony with appropriate speeches and then set to work. In 2 operating theatres we completed 10 cases, surrounded by up to 20 curious surgeons seeing modern techniques of hernia surgery for the first time. During the following week we were able to take several of these surgeons through hernia operations and then proceed to teach them under direct supervision. In the meantime we had a guided tour of the hospital, made occasional visits to the emergency room and on one occasion witnessed the expert treatment of a bleeding liver tumour. In the evenings Mongolian entertainment was laid on, including a visit to the Naran Tuul black market and a glimpse of ancient Mongolian culture at a presentation of the National song and dance Ensemble. We gave TV interviews to the national network which were broadcast during the evening and vastly increased the recruitment of patients. By the end of the first week over 50 patients had been treated and we celebrated with a farewell well dinner in a restaurant that had a copy of the famous painting of One Mongolia by Sharav, as a backdrop.

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In Moron each morning began with an 800 meter walk to the hospital from our small hotel, rubbing shoulders with colourfully-dressed school children on their way to lessons and ordinary citizens going about their business. During four working days we completed another 50 cases and taught the surgical staff techniques of mesh repair. We operated on fifteen children, some as young as 4 months. By doing this, we would have saved each family two days travel each way to UB, plus a 2 or 3 day stay in the capital during the hospital admission. The cost of a journey such as this would often be beyond the means of a herdsman living a hand-to-mouth existence. Finally, the hospital staff entertained us to an evening meal in a ger camp when the whole delicious carcass of a goat cooked by traditional methods was consumed with vast quantities of Chinggis Khan vodka, which greatly assisted the content of subsequent spontaneous speeches.

On return to UB and prior to our departure we visited the Zanabazar fine art museum to view the long history of Mongolian art outlining the history of this interesting and fast-developing country. The hospitality had been enormous, and the surgeon s thirst for surgical knowledge enviable. An invitation to return has been accepted. We departed with a rudimentary knowledge of the Mongolian language, including the phrase of greeting when approaching a nomadic ger – nokhoi khor (hold off the dogs!)

The Operation Hernia team members wish to express their deep admiration of the Mongolian doctors with their high level of professionalism, their committment to the traditional values of the art of surgery, their recognition that medicine in low-income countries is still a vocation,.and their appreciation that the craft of surgery is a continuous learning process. We also wish to thank them for: preparing the mission with Enkhee, recruiting the patients, being attentive and willing learners, looking after our patients postoperatively and providing a sustained and entertaining social and culinary programme. The Mongolian doctors who were involved in the success of the mission were: (i) At Hospital #2: G. Bayasgalan (Director), Ts. Narmandakh (Head of Surgical Department); the following surgeons B. Onon, U Sanchin, Ya. Altanchineg, S. Ulambayar, G. Bilguun, P. Tseden-Ish, Ya. Batsumber; A. Khandaa (OR nurse); and the following anaesthesiologists: Z. Tumenjargal, A. Saranbaatar, J. Munkhzul. (ii) At Khuvsgol Central Hospital: D. Erdenebaatar (surgeon), D. Chuluunbaatar (Head of Surgical Department); D. Chuluunbat (surgeon) and Tumenjargal (anesthesiologist). We salute them all!

Andrew Kingsnorth

In the operating theatre

Spanish, Puerto Rican and Andorran Team, Eruwa 18-27 MARCH 2010

It was incredible! is all we can say. We began our project when I first came to Eruwa, in June 2009, when we decided to undertake part of our work after talking with Dr. Awojobi. The Foundation Dr. Ramon Vilallonga has been involved in many projects, but since we met Dr. Awojobi, we cleary decided to continue this colaboration. On this ocasion, we met, a group of five people, from three different countries, Puerto Rico (Dr. Vangie Teixidor), Andorra (Mr. Josep Maria Puy) and Spain (Dr. Candy Semeraro, Miss Cristina Andreu and myself, Dr. Ramon Vilallonga), at the airpot of Lagos.

Spanish, Puerto Rican and Andorran team

Spanish, Puerto Rican and Andorran team

We arrived late in the evening and we were met at the airport by the team from the Clinic who took us in the clinic’s bus to Eruwa the next morning after spending the night in Lagos. The same day of our arrival, we began surgeries. Hernias of course. Baba, the person in charge of the theater and assistant for us, has been working a lot, and in a very efficient way. Accommodation was very changed since the last time. We did not stay at the town s hotel anymore, but at the clinic. Two houses were fixed for us. Perfect! We have repaired many hernias. Cristina, our scrub nurse, has taught Shakira, a local nurse who helps with the surgeries. Candy and I have taught some trainee residents and specially Daso, who is now perfectly able to perform a hernia repair with mesh. We were very pleased about that. The Awojobi familiy, as usual, has been very helpful and kind. No need to say that again. We have been treated like kings. Vangie even wanted to taste the local food we did.

Laying the foundation stone

Laying the foundation stone

 

“Sweets, pencils and a ball were offered to the kids. We can still hear the shouts of happiness.”

“Sweets, pencils and a ball were offered to the kids. We can still hear the shouts of happiness.”

As usual, we did a nice visit to the neighbourhood school. All the kids were so happy and excited. It was a great experience and we enjoyed it a lot. Sweets, pencils and a ball were offered to the kids. We can still hear the shouts of happiness.

We have continued treating Kundus, the little boy who got burnt almost one year ago. With material from our hospital, we changed the dressing every two days and he is improving but it is going to be very slow, as the burns are so extensive. Candy made a fantastic doll for him and Joe, an ambulance.

We also had the opportunity to assist Dr. Awojobi in his elective and emergency surgeries: testicular torsions, recurrent laparotomy hernia repairs, humerus realignment, thyroidectomies an experience.

Finally, we also laid the first stone of the future Ramon Vilallonga Puy Ibarapa Hernia Center. An incredible experience. We wish to continue in this way, trying to improve heath care in Nigeria. We hope to come back soon.

Dr. Ramon Vilallonga

In the operating theatre

In the operating theatre

Anglo-Irish and Swiss Team

Anglo-Irish and Swiss Team, Aliade, Nigeria 17-27 FEBRUARY 2010

Annyar You’re welcome. With a touch to the forehead and chest followed by a slight bow, each colourfully dressed greeter would then take our hand and shake it. Regardless of social or financial station, the heartfelt greeting was the same annyar.

Anglo-Irish and Swiss Team

Anglo-Irish and Swiss Team

Four European surgeons (Richard Stephens, Shorland Hosking, Peter Nussbaumer, Andrew Kingsnorth) and one anaesthetist (Richard Salam) bumped for six hours in a very full minibus from the airport to our hospital base for the next week. Presentation of flowers, singing and dancing greeted us as we stepped into the 41°C heat. Posters around the town (photo) had heralded our arrival Operation Hernia by Professor Kingsnorth and team . Boxes of instruments, diathermy machines, gloves and sutures were hoisted onto porter s heads and taken to the operating theatre for unpacking and sorting. No electricity for 24 hours a day is normal, necessitating a new generator being installed to provide continuous (African style) power for theatres.

And so we started. By dawn patients with hernias started arriving; young, old, fit, HIV negative, HIV positive, pregnant, curious. Following confirmation of a hernia(s) they made their way to the theatres where they waited their turn. Nobody seemed to mind waiting for as long as it took word on the street came back that this was a small price to pay for a well performed procedure as a day case. Like the children of Israel they kept coming and we kept operating two tables on the go from 8 til 5. Eighty patients and one hundred hernias later we reached full time and still they kept coming. Names were taken with the promise that the next hernia team arriving three months later would see to their hernia.

The Team - Operating

The Team – Operating

Training the local medical team

Training the local medical team

By day two an important discovery was to change our approach in a significant way. Initially, the hospital s medical officers came to theatre for training but it quickly became apparent that their surgical skills were considerably less than those of the theatre scrub nurses. Furthermore, these nurses interest and enthusiasm to learn the mesh repair (they were familiar with the Bassini technique) was impressive. And so they began to assist, progressing naturally into performing under supervision. As they were taught (see photo), their enthusiasm visibly increased, work rate and efficiency improved further and the whole team worked so well. What a difference empowerment makes. It needed to, for it was the Europeans who began to wilt by mid-afternoon. Despite three air conditioners, theatre temperatures reached 30°C during the afternoon session.

Armed with mesh generously donated by several companies the pile of mesh nonetheless shrank rapidly at the rate of 20 hernias per day. The solution was simple but brilliant. Mosquito net was cut to size and sterilised. Initial attempts at high temperatures were rapidly modified when the net melted in the autoclave. The right temperature was found and the problem of sterile mesh was solved easily and cheaply.

Boys swimming, Aliade, Nigeria

Boys swimming, Aliade, Nigeria

Stepping outside the theatres onto the wards revealed a much bigger problem. HIV. Sub-Saharan Africa has been devastated by this virus. In our area of Nigeria forty per cent of the population are affected. In our hospital eighty per cent of the work load is HIV related. Thanks to huge inputs by overseas charities, antiviral drugs are now available free of charge. The effort in education and community is impressive.

As we said our goodbyes at the Hospital, “annyar came at us from all directions. How strange, until we learnt that annyar not only means welcome; it means thank you.

Shorland Hosking