Magdi & Professor Narmandakh

3rd Annual Mission June 2012

Magdi & Professor Narmandakh

Magdi & Professor Narmandakh

As a Specialist Registrar in General Surgery, I was extremely fortunate to join the 2012 Operation Hernia mission to Mongolia through the great generosity of the Pitts-Tucker Fellowship. This Fellowship was kindly donated by the JPT charitable trust, which provides opportunities for young adults to travel in the exchange of cultures and to bring delivery of medical facilities in difficult to reach foreign areas, and awarded through Association of Surgeons in Training.

The Mongolian mission was led by Professor Juri Teras (Estonia), together with Magdi Hanafi (British), Fennie Wit (Dutch) and Kristjan Kalling (Estonian Anaesthetist). The Mission was also joined by Vahur Laiapea, a film-maker making a documentary on the Mission for Estonian television. Fortunately the filming predominantly focused on the Estonian speaking members of the trip!

We all met in Ulaan Baatur by Mrs Enkhtuvishin of the Swanson Charitable Foundation, who was again the tireless local co-ordinator for this third Mongolian mission, together with the Chief of the department of Surgery Professor Tsagaan Narmandakh. There was momentary anxiety as Magdy, together with all the meshes, sutures and local anaesthetic for the mission had missed the flight- he did finally make it a day later (minus the local anaesthetic, confiscated by customs). We immediately headed out to the Khustain National Park, a short distance but very long and bumpy drive from the Soviet-style sprawl of Ulaan Baatur into the vaste grassland steppes. Here, the Przewalski’s horse, once extinct in the wild and limited to 12 animals in captivity, was reintroduced via Dutch conservationists. They now number more than 300 in the wild, mostly in Khustain, and we were fortunate to be given a tour of the park by Piet Wit (Fennie’s father) who managed the reintroduction program for many years in Mongolia.

Przewalski's horses in Khustain

Przewalski’s horses in Khustain

The hosts and Operation Hernia Team in Hospital #2

The hosts and Operation Hernia Team in Hospital #2

We returned, inspired and enthused, to the capital for the first part of the mission, in the capital’s Teaching Hospital #2. This hospital has been host to two previous missions, and we were pleased to hear that they have regularly been performing tension-free inguinal hernia repairs in the intervening period, and had almost finished the stock of mesh left over from the last visit. They had arranged a pre-assessment clinic on Sunday afternoon, and we recruited a large number of patients for surgeries over the coming days. Most of these were very large incisional hernias, with many of the inguinal hernias having being performed by the surgeons prior to our arrival. We had access to two theatres with monitoring for general and regional anaesthesia, and a third more basic theatre for local anaesthetic repairs. Parallel cases allowed training to be provided to a wide range of staff, from medical students and residents to staff surgeons. The theatre equipment was very adequate, but all team members commented on the scrub nursing staff who were exceptional. Interestingly, there were some new laparoscopic stacks, and largely re-sterilised disposable laparoscopic instruments which are being used for laparoscopic cholecystectomies.

For the second half of the mission, we headed north, to the town of Erdenet, just a short distance from the border with Russia. This industrial town is centred on the fourth-largest copper mine in the world, and is the second largest city in Mongolia, with around 90,000 population. One specific local problem was that most local community healthcare workers would refer patients presenting with a hernia directly to Ulaan Baatur, an 8-hour journey each way, rather than to the local hospital. As in Ulaan Baatur, we were interviewed on local television which advertised our presence (increasing recruitment) and we hope ultimately serving to validate the surgical department in Erdenet. Unlike Teaching Hospital #2, the preoperative clinic was unscreened, and so we saw a number of interesting and varied non-hernia pathologies, such as penile hypospadias and undescended testes in adults. The hospital in Erdenet was well equipped, with a state-of-the-art high-definition laparoscopic stack in one theatre, whilst one of our patients became the first patient to undergo an abdominal scan in the newly installed CT scanner. The bulk of the surgical workload was inguinal hernia repair, predominantly paediatric. Again, we performed a large number of cases training both staff surgeons and residents. Perhaps the timing of the mission immediately prior to the Naadam festival, a three-day national holiday which sees almost every Mongolian taking to their horse and riding to their local village, limited adult recruitment, explaining the high percentage of children treated!

Wresters warming up at the Naadam Festival

Wresters warming up at the Naadam Festival

Alongside the surgery, we were very well entertained by our always generous hosts and included a concert featuring traditional Mongolian throat-singing. Dr Sanchin, a staff surgeon from Hospital #2, took us to visit his uncle’s ger camp where we sampled fermented mare’s milk beer and cheese, while elsewhere we gorged on an entire stewed goat. The highlight was a visit to the Naadam festival, where we watched Mongolian wrestling (the rules of which I am no clearer about now) and long-distance horse racing over a course of 40km with jockeys aged between 5-8yrs old.Overall it was an excellent mission to a rapidly developing country. The work that Operation Hernia has performed on previous trips was evident, and it is clear than in Teaching Hospital #2 use of tension-free meshes is becoming routine part of practice. Meanwhile I hope that we have provided some teaching and training to surgeons in Erdenet which can be built on during future missions. The success of the mission was due to the extensive planning and organization, both by Mrs Enkhtuvishin and the hosting surgeons, especially Professor Narmandakh- many thanks once again!

Adam Stearns

After several months of planning, fund and equipment raising landed Team Estonia in Banjul, the capital of The Gambia. There were three of us – anesthesia would be covered by Dr Kristjan Kalling, a resident surgeon Dr Martin Adamson from Estonia, a resident surgeon Slawomir Koziel from Poland and myself as consultant surgeon.

Instantly were we greeted by dry hot air of Africa, the Smell of Africa as we used to call it. It’s just not the high temperature but the different scents in the air: smoke, rotten food, dirt and ocean – it all makes together an unique flavor one can only get in Africa. Jim Jallow, our man in The Gambia, greeted us in the airport. We had been talking over phone some times and exchanged a lot of emails and now indeed he was there to take us to Leybato Motel on the beach. Nothing fancy, no 5 star resort, but neat and tidy place a bit further away from the touristic attractions and noise. A place for travelers and expats as Lonely Planet puts it. And a place with a wonderful kitchen! So after some days of waiting and a meeting with Permanent Secretary of Ministry of Health where we had the opportunity to give a short presentation on Operation Hernia, we were free to go to Farafenni, our final and only destination in The Gambia.

Travel there was an adventure in itself. Although Jim Jallow had promised to provide free transportation to the site, nothing of the kind happened. So finally we simply crossed the Banjul river with a ferry and rented a local taxi to take us the 150km along the north bank to Farafenni. Taxi-drivers shouting, fighting, grabbing our luggage, begging for some money – it all only put some colors onto our journey. Police checkpoints everywhere along the road, in some we had to produce also some id-s, well hidden so far in the underwear.

But Farafenni hospital greeted us with warmth and sincerity that really took breathless, especially after adventures in Banjul. CEO Alhagi Saine, hospital manager Baboucarr Saine and our constant companion Sainey Dibba, the communication officer of Farafenni Hospital were the nicest people we have met in Africa so far and to be honest it seemed these guys really do need help in Farafenni. Although the hospital is state run and financed, the possibilities for patients in The Gambia are by far not the same we are used to in Europe. We were able to collect some medical equipment, surgical instruments, meshes and sutures which we donated to Farafenni hospital. We could also take along a cardiac monitor, that we left later in the OR, we hope it will find good usage. Medical personnel. Nurses are mostly local, Farafenni people, and to be honest very capable. Doctors on the other hand are mostly Cubans spending year or two in the hospital and afterwards being replaced by others. No surgeon had been around for a year. And patients were simply waiting. When the word spread that we were around, patients started to come from close and far, some came even from Senegal. Talking to them wasn’t easy, Mandinka and Wolof was beyond us, but local nurses were very helpful. Specially capable of solving all possible problems was Mr Bondi, anesthesia nurse who was running the OR and usually also giving anesthesia.

The hospital. A beautiful two storey building, built some 10 years ago with different pavilions for specialties all connected by hallways. Second floor of the hospital is used mostly as a huge storeroom, lack or inadequate electrical supply prevents them to use elevators. A Man with golden hands could get work there easily… Next team going to Farafenni could take an OR technician along, so many things needed to put in order and working state. But patients kept coming and we operated as many as possible. Electrical supply was from 9-16, afterwards some hours of generator supply, so head-torches were of good usage. Small children, older children, young people, old people, people with small hernias, people with huge hernias, people we could operate and people we had to put on hold for next teams to come.

Living conditions. Motel AMCR: again a place for travelers, the best in town. Clean and mostly quiet. We were lucky to get every morning transportation by Mr. Dibba. And every evening after work a nice guided tour to some interesting spot: either a local village, border-town in Senegal or something else fascinating and beautiful.

So in conclusion. Farafenni is definitely a place in need. In need for surgeons, anesthesiologists, technicians. To take supplies along would be nice, but there was a lot also around waiting for someone to put it into order and work. And most important: Farafenni needs us to show we care. It is definitely an Operation Hernia destination.

J’ri Teras