Outside the OR

Alyssia McEwan reports
November 2012

Outside the OR

Outside the OR

Medical Student Experience (Alyssia McEwan) – Operation Hernia – Ghana, Nov 2012

Africa. I really had no idea what I was getting myself into when I bought my plane ticket to Accra, Ghana. It had taken a year to solidify the plans to join the Operation Hernia team – a year filled with board exams, medical school rotations, and sleep deprivation. It was hard to believe that the day had finally come to board the flight.

My first impression of Accra – the heat was sweltering! After traveling 10 hours from New York City in the aftermath of Hurricane Sandy, the hot African sun beating down was particularly impressive. I had already begun to feel the camaraderie and team mentality that was brewing amongst the United States members of our Operation Hernia Team. Our portion of the team was composed of: Dr. Pedro Cordero, the surgeon from the US team who I had the privilege of working with during my third year surgery rotation and who was instrumental in my being involved in this mission; Aida St. John, a theatre nurse who I had worked with also during my surgery rotation; Carol Turner, a traveling theatre nurse who I met for the first time on this mission; Peter Dixon, a surgical resident from New Jersey; and myself, a fourth year medical student from NYC. From the very beginning of our journey – dealing with missing documents, our bus breaking down on the way to the airport and a variety of other minor meltdowns – it was clear that we were bonding, whether we liked it or not!

The first time that we were all together with the entire team was outside the house where we were staying in Accra. Meeting the Chair of the Board of Trustees of Operation Hernia and lead consultant of the UK team, Dr. Chris Oppong was wonderful – he greeted me with a huge hug and said “call me Chris!” which broke any barriers of formality that could have theoretically been in place. We met the two registrar surgeons from the UK that morning (after a brief hello the night before)– Dr. Surajit Sinha and Dr. Frank McDermott. Immediately it was clear that we would all get along and that this was going to be an extraordinary trip.

The trip from the capitol city of Accra to the much smaller town of Ho was eye opening. Little tiny villages speckled amongst lush green countryside. Small children running around in near-nothing, women dressed exquisitely in form fitting clothing of the most captivating colors, people carrying a variety of items in baskets on their heads, goats, and a lot of selling, trading and working. Structurally-sound thatch roofed houses and above all a sense of community which was obvious in each of these villages, even while driving past at 55 km/hr. The smiles on the faces of the people were unlike smiles that I have ever seen in the United States – these were smiles portraying honest happiness. I kept asking myself “what do these people look forward to?” “what do these people worry about?” – the answer, I imagine comes down to the basic needs of human beings – food, shelter, water, family – the things that actually matter in this world. How different than what so much of the world thinks of.

I found our welcome to Ho Hospital unexpected. An impressive number of regional officials and hospital administrators joined in to welcome our team. There was a lot of this during our stay, lots of introductions to important people and making connections. Though, in my mind, none of these people were as important as the people who we met later that day, our patients.

We entered the doors of the ward that evening to see the patients who we would be operating on the following day. I had seen a handful of hernias over the past year but I had never imagined hernias like this. Basketball-sized masses extending into the scrotums of these men – one after the next. Its difficult to imagine how they managed for the many years that most of these men were carrying these burdens. How they could work and provide for their families is a mystery to me. These men were unlike any pre-op patients that I had ever come across. There was no air of nervousness or being frightened or any requests or questions. They were stoic and ready – ready for surgery and ready for their new lives.

The following day was day 1 in the operating theatres. We met the theatre staff who we would grow to love by the end of the week. Pedro had the brilliant idea of labeling everyone with makeshift tape nametags so that we could get to know the people who we would spend the week working with. In my mind, this was probably one of the most influential decisions of the entire mission. Being able to call each other by name is something that I believe contributed to the bond that we all formed. Nothing is sweeter to our ears than the sound of our own name, and being in an environment of strangers where we can begin to know each other by calling each other by name was very powerful. We learned that the person in charge of the theatres (and quite possibly in charge of the world) was Sister. Though she seemed very “all-business” in the beginning, by the end of the week the soft humanistic side of her was clearly shining through.

The kindness, generosity and politeness of Ghanaians is really beautiful. I felt so welcomed into the community and the hospital. The saying that is repeated over and over by Ghanaians is “you are welcome” – when you walk into a room, when you meet someone. The thing about this, is that it is honest – they were really welcoming us. It wasn’t just something to say to be polite, they really meant it. As much as the members of our team gained from going on this mission, I can say that the people who we worked with gained also. On the last day, one of the scrub techs who we worked with, Senyo, said to me in the most heartfelt and honest way “It has been so wonderful having you all here. It has really brought a lot to us and we will really miss you. I don’t even know how to say how I feel about the way that you have interacted with us and made us all feel. We really wish that you will come back.” It sent goose bumps up my arms when he said this because it became clear at that moment that every single person involved in this mission benefited – the international team, the local nurses and staff, the local surgeons, the hospital administrators and officials, and of course the patients and their families.



As a medical student, I was able to first assist during the cases. I spent time assisting Pedro, Chris and Sinha. Assisting with approximately 30 inguinal hernia repairs over the course of 5 days offered a unique opportunity for me. For the first time, it gave me the chance to really truly understand what was happening in the operating theatre. During the third year of medical school, we are briefly exposed to a variety of specialties. The rotations in each of these specialties last 1-2 months and by the end of the year we are expected to have made a decision about which specialty we would like do commit to for the rest of our lives. During my surgery rotation, I realized that I loved surgery but the problem that I had was that I could not understand how I could ever be a great surgeon. During my medicine, pediatrics, emergency medicine, and psychiatry rotations it was simple to understand that after 3-4 years of specialized training one could obtain the skills necessary to do those jobs. As a student, I was doing more or less the same things that I would do as a physician – interviewing patients, suturing, making decisions about antibiotics, counseling patients about smoking cessation, etc. But in surgery, I was never really holding the scalpel, understanding why decisions were being made, seeing the big picture, knowing what to do next or even truly understanding what I was looking at. I was retracting tissue and trying to ensure that the surgeon had good visualization, I wasn’t acting as a surgeon by any means. By assisting with the SAME procedure 30 times in a row in 5 days on this mission, I began to understand what was happening and what to do next. For the first time, I believed that I could become a surgeon – I could recognize the difference between a nerve, an artery and the vas deferens. I understood the anatomy of the inguinal canal and what went into the actual repair of a hernia, and why. I could actually for the first time visualize myself being on the other side of the table and knowing what to do next. This was a HUGE realization for me.

In order to feel this way, it wouldn’t have been enough to have simply observed and assisted in the operations. I was fortunate to be in the company of surgeons who love to teach, Pedro and Chris. During one case, I asked Chris a question about the anatomy (a question which he had probably already answered 5 times) and he realized that I was still confused. He removed all of the retractors from the deep tissue and skin and held the skin closed. Then he started at the beginning and slowly retracted each layer explaining and quizzing me on what we were looking at and what had been done. It was important to him that I understood, and somehow this man has been gifted with a seemingly endless amount of patience. At the end of that day, I expressed to Pedro that I felt much more comfortable with the anatomy but wished that I had packed my anatomy books so that I could review before tomorrows cases and understand even more. Pedro has been a surgeon for probably close to 30 years and thus naturally has an extensive and impressive knowledge of anatomy. He instinctively grabbed a piece of paper and drew out in exquisite detail the anatomy of the entire inguinal region – explaining every structure to me and confirming that I understood. By the next day, I was even more comfortable and was able to soak in even more from the cases.

Whatever the rationale that these two gifted and seasoned surgeons had for taking the time and putting the effort into teaching me I cannot say for certain. But what I know is that their efforts resulted in me leaving Africa with the confidence and belief that I could become a surgeon. I have always been interested in international medicine and global health and knew that no matter what specialty I chose, I would incorporate international work into my career. I see, however, through the Operation Hernia that simple surgeries such as hernia repairs can have an enormous impact on communities worldwide. Surgeries to correct hernias, cataracts, and cleft palates are simple yet absolutely life (and community) changing. Without this experience, I would not have believed that I could become a surgeon or have been able to see the results of correcting surgical disease in the developing world. I hope to be involved with future Operation Hernia missions in the future. I am very impressed with the mission of this organization – they are interested in sustainable and innovative improvements. Using mosquito net in place of brand mesh is just one example of the forward-thinking ideas that are born through leaders of this organization. This trip has changed the course of my life and I am forever grateful for the opportunity to have been a member of the 2012 Operation Hernia team.

Alyssia McEwan, BA, MS

4th year medical student

Touro College of Osteopathic Medicine – New York, NY, USA

Frank McDermott’s Second Mission November 2012

Team Ghana

Team Ghana

OH Mission to Volta Regional Hospital, Ho. (3rd – 10th November, 2012)

This was my second mission with Operation Hernia having returned from an amazing experience in Mongolia in 2011. I flew with a registrar colleague and friend, Mr Surajit Sinha, and we arrived into Accra to be greeted by Godwin, a hospital administrator from Volta Regional Hospital. Godwin was very welcoming and demonstrated throughout the week what a useful asset he is to the Hospital. Unfortunately one of my bags had not made the journey with me on the airplane which made for a challenging 48 hours in a hot and humid country!


We spent the first night in the Baptist Guest House in Accra before travelling to the Volta Regional Hospital. On Sunday morning I met the rest of the team. Mr Chris Oppong I already knew as I had just completed a surgical rotation with him as a Colorectal Registrar in Derriford Hospital, Plymouth. He co-founded the charity with Professor Kingsnorth and as a Ghanaian was the perfect guide for my first adventure in this fascinating country. Joining us on the mission was an American team headed up by Dr Pedro Cordero, an Attending Surgeon based in New York. Pedro runs his own charity that has provided surgical care to Haiti and Philippines and we shared many interesting stories about providing surgical care in the developing world. The rest of his team comprised Aida St John and Carol Turner (American Theatre nurses), Peter Dixon (surgical trainee) and Alyssia McEwan (medical student). We all jumped on the hospital bus and began the 3 hour drive to the Volta Regional Hospital in Ho. You learn so much from driving through a new place. It gave the team the opportunity to gel and also see the captivating scenery fly by. We passed many small towns and witnessed the hustle and bustle of Ghanaian life with many street vendors selling some staple produce such as cassava, plantain and Tilapia freshwater fish interspersed with electronic stores selling sim cards for your mobile phone! Crossing the toll bridge over the Volta River gave stunning views of the region. I was not sure what to expect having never been to Ghana before but the hills were lush albeit the victims of deforestation over many years.

Eun balancing

Eun balancing

We arrived in Ho in the afternoon; it is the fifth most populous town in Ghana with a population of around 100,000. We drove to the hospital for a formal introductory ceremony with management from the hospital, the lead surgeon Geoff and a representative from the Ghanaian Royal Family, Mamma Tratto. This was all filmed by Ghanaian TV! The introductions all done we went to the ward to meet our patients and assess them prior to starting the real work the next day. Professor Kingsnorth has developed a scoring system for hernias grading them between H1 and H4. H1 being a small hernia that reduced on lying supine and H4 a recurrent or irreducible inguinoscrotal hernia. This scoring system is very useful for planning the list from a point of view of resources, type of anaesthesia proposed and for on-going data collection and audit. We assessed all the patients, checked blood pressure, Haemoglobin and sickle cell status and then planned the lists for the next day.

Monday – Friday

We were allocated three theatres in the surgical block for the 5 day mission. The theatre staff were very welcoming and we quickly developed a good rapport. We all stuck our first names on a label which broke down any barriers and emphasised that we wanted to work as a team to maximise the work we could do in this short time. We set a goal of operating on 100 hernias. We donated a diathermy machine to the hospital as well as 6 suitcases full of equipment that Pedro had brought. I operated with Sinha in Theatre 3 alternating cases. Our theatre team included ‘Old Sam’ an anaesthetic practitioner who was an expert at spinal anaesthesia, Eunice and Felica our theatre nurses and Gloria a circulator. The conditions were sweltering and even the Ghanaian staff said it was hot. On that first day I had to change my scrub top 7 times! As well as the heat we had some serious hernias to contend with. A lot of the hernias had been neglected for many years and were very large and stuck to cord structures. This made a big difference to the small hernias I’m used to operating on in the UK. We worked from 7:30 am when we were picked up from our hotel until the last case was done which was usually anywhere from 8-10pm. All patients had an operation note completed by the operating team and were sent home with a 5 day course of oral antibiotics and analgesia. We kept a prospective database of all the patients that we operated on. One of the main aims of OH is frugal innovation. Surgery is expensive but potentially lifesaving as Mr Oppong found out when two of the patients that were due to come in electively turned up with strangulated hernias. OH uses sterilised mosquito net as alternative to the expensive alternatives although we still rely on industry support for their kind donations. As mosquito net is very cheap it allows the local surgeons to perform an economical tension free mesh repair with consequent low recurrence rates.

Patient safety is the most important factor when we operate and something that has been in the spotlight over the last few years. We used a simple ‘timeout’ on the theatre whiteboard with patient details, operation proposed and who the team was for each day. This is something that the local staff found useful and was beneficial to us as Surgeons in a different environment. Aida and Carol also spent the week acting as scrub nurses but also sharing the benefit of their experience from working in the USA with the local theatre team. Some small changes could lead to a great improvement in patient safety. This was brought into focus when we met the local Governor whose brother had died following hernia surgery when a surgical glove had been left inside the abdomen.

Adapted ‘time out’

Over the 5 days we made many friends in theatre. We worked 13 hour days from Monday – Friday but were well looked after with beautiful local dishes. Sister Josephine, the theatre matron, deserves special mention. There was a stern side to her and she ran a tight ship but as the days went on we all developed a fondness and respect for her management and people skills. We managed to perform 99 procedures including 80 inguinal hernias, 50% of which were inguinoscrotal. 21 cases were performed under local anaesthetic, 2 under general anaesthetic and the rest were spinal. On the last day we shared a bottle of champagne with all of the theatre staff. There was an amazing feeling of accomplishment but also an immersive sensation of friendship and team work. I looked around at the American team, my friends from the UK and the Ghanian staff and found it utterly bizarre that I had only met a lot of them 6 days before. This is what OH does, it brings likeminded hard working and resourceful individuals together who want to make a difference and I hope this is what we’ve done.