Hospital Dr Gustavo Dominguez

Report of Spanish Team November 2012

Hospital Dr Gustavo Dominguez

Hospital Dr Gustavo Dominguez

MISSION IN SANTO DOMINGO DE LOS TSACHILAS-ECUADOR

24 Nov – 1 Dec 2012

Team: Dr. Enrique Navarrete, Dra Pilar Concejo, Dr Juan Moreno, Dr, Antonio Dominguez, Dra Cristina Gonçalves, Dra M. Luisa Reyes, Dra Marina Infantes, Dr Francesc Marsal, surgeons , and Dr Antonio Dominguez anaesthesist. General surgeons from Sevilla, Ponferrada, Tortosa, Tarragona, and anaesthetist from Sevilla.

Last 24th November 2012, the Spanish Team left from Barajas airport (Madrid, Spain) to our destination in Ecuador, Quito. The doctors came from different towns and hospitals from Spain, and some are members of the group who participated in the mission in Aliade (Nigeria) in Nov 2011.

After a long trip with one stop in Panamá airport to change aeroplane, we arrived on Saturday night at the Mariscal Sucre airport, located in the center of the City.

In the airport Sandra Ocampo, our local contact and Dr Kathia Tinizaray, Provincial Director of Health in Sto Domingo de los Tsachilas, was waiting for us and helped us through customs.

The group rested at night in Sandra Ocampo´s house in Quito. On Sunday morning we visited a Quito historical centre, guided by Francisco Sandoval, a surgeon trained in Sevilla (Spain) years ago and his grandfather, who was born in Quito. After a lunch we started off to La Concordia, with a mini-bus. After a 4-hour trip (150 km) we arrived at night at our destination and we went to our lodgings in the Atos Hotel.

The Team

The Team

2 tables at work

2 tables at work

On Monday after breakfast, we started to Santo Domingo de los Tsachilas (de los Colorados) 45 km from La Concordia, where the Provincial Hospital Dr Gustavo Dominguez is, and where Dr. Kathia Tinizaray prepared one operation theatre with two surgical tables for the Spanish group this week.

We arranged the surgical material and prepared to start the operations on Monday morning.

Two surgeons visited the patients before the surgical assistance with the collaboration of Dr Angel Solorzano, rural physician from La Concordia and the rest of the group carried out the surgery and the control in the recovering area.

After four days and a half the team performed 63 interventions on 56 patients including children.

Recovering a child

Recovering a child

One afternoon we visited an “hacienda” together with Dr Sarmiento, the head anaesthetist at the hospital. He explained us about the local fruit and flora of the area such as cacao.

Afterwards the team, accompanied by Sandra Ocampos and bodyguards visited the local Indian Reserve “Los Colorados”. The visit was very interesting and the place very beautiful. The Indians danced native dances and showed us their customs and culture.

On Friday we returned to Quito and we took advantage to visit Otavalo and surroundings. After a lunch on Saturday morning at the Quito Golf Club in El Condado, invited by the local surgeon Francisco Sandoval and his family, we went to the airport to catch our flight back home.

We all felt very satisfied with our mission, and we made a lot of good friends.

Dr Francesc Marsal

Student Reflections

The team: Dan, Angeline, Constancio, Renata & David

The team: Dan, Angeline, Constancio, Renata & David

This summer, I traveled to South America for the first time to attend Operation Hernia’s mission Ecuador. In your position about 9 months ago, looking through this website, my mind was a hodgepodge of questions. Will I actually be able to help? Can what I learn be useful to me at my level of training? Is it worth flying to a whole new continent for this?

The answer to all the above questions is simple. Yes.

I heard about Operation Hernia (OH) at a conference in Cardiff University, where one of the surgeons who had recently attended a mission in Africa gave his account of what they had done. The concept of OH attracted me for several reasons.

1) I have a keen interest in surgery, particularly gastrointestinal surgery, and I enjoy volunteer work and traveling. The mission sounded like a great way to combine my three great passions.

2) OH is a very transparent organisation, the aim was clear and there appeared to be much more of a personal touch in their work than other organizations that I was also considering. (My gut instincts were accurate – not once was I made to feel like another cog in a huge machine. My contribution was always valued by all the team, and the doctors treated me like an equal during pre-operative discussions and planning.)

3) I had never been to South America!

Lunchtime

Lunchtime

Knot tying practice

Knot tying practice

A whirlwind few months of preparation later, I found myself in a four wheel drive with some amazing surgeons, with our luggage in the back, driving down the steep but beautiful mountains of central Ecuador on our way to La Concordia, a small town in northern Ecuador, to start our project.

Almost 80 patients were waiting for us to arrive the Sunday afternoon before the operations began. We were working in a public health centre as well as a mobile unit graciously loaned to us by the local ministry of public health. We delegated quickly, and the surgeons each began to see patients with the help of the local bilingual junior doctors. I helped unpack all the items we had brought with us and made a list of everything we had. An hour and a half later, we discovered that we had brought 23 different types and sizes of sutures, and had about 60 patients listed for the rest of the week.

7am the next morning, I was running from one unit to the other, making sure each of the tables had adequate equipment, photocopying operating lists to be put up in front of each table, searching for more gauze and several other miscellaneous tasks. The surgeons were also working on rearranging the tables to suit our needs. By 8.30am we had made ourselves a makeshift theatre that felt familiar despite the fact that none of us had ever worked with such limited equipment or in Ecuador before.

Our first patients were anaesthetized, and the operations began.

We operated on 78 patients throughout the week, with our youngest a little 8 month old boy and our oldest an 83 year old great-grandfather. It was one patient after another, with more coming to see us between cases. There were some very complicated cases, with large defects, or rare hernias, including several femoral hernias in men and a lumbar hernia.

We realised very quickly that while hernias are hernias wherever you are, we would have to do things very differently from what we were used to. We had a large volume of patients to operate on in a short period of time, and a language barrier with the locals, who spoke only Spanish. It was imperative that we adapt our methods quickly in order to perform safe surgeries as best we could with what we had.

Dan operating

Dan operating

Despite the challenges we faced in terms of logistics, the unspoken language of the world is universal. With each patient we led into our operating room, we understood the message conveyed by the look they gave us as we helped them lie down on the table.

“I trust you.”

Many of them had waited years to be able to have their surgeries. Many experienced pain or discomfort from their hernias. Most suffered in silence. Without any knowledge of who we were or what our qualifications were, they allowed us to operate on them, and were more than grateful for our help. Even though hernia repairs are relatively simple procedures, I felt like we really made a difference in the quality of life for some of our patients, especially those who were breadwinners in their families and whose work had been impeded somewhat by their large defects.

I found new mentors in the surgeons and anaesthetist on the mission with me, all of whom gave me excellent advice and teaching about everything from the history of surgery to how to behave in a new environment amongst new colleagues. I learned surgical anatomy, knot-tying, assisted in 24 cases! I also got to learn how to handle different items of equipment, types of sutures and meshes (including mosquito net mesh!) as well as their uses. They were patient with my ignorance and very keen to teach me, and I don’t have to tell you that this opportunity was invaluable for a young medical student with an interest in surgery.

The local staff were more than helpful to us throughout the project, demonstrating dedication and patience in working with us and our language problems. Many stayed back after we finished for the day to make sure our operating room was cleaned and our patients reassured, despite the fact that they wouldn’t be paid for their time. Where we were unable to calm some of our younger patients down, they stepped in and soothed them for us. They opened hundreds of sterile packs for us, tied up our gowns, ran up and down with equipment, rounded up our patients, and greeted us with big smiles every morning. They really took teamwork to the next level.

Ecuador itself is one of the most diverse places in the world, with scenery and landscapes that I have never seen before, splashed with colour from the strong cultural heritage that they still keep. If you haven’t already gathered as much from what I’ve already told you, the local Ecuadorians were some of the nicest people I have ever met, and I had a great time getting to learn about their culture and heritage, as well as the fantastic geography and biodiversity of their country.

As I left Quito airport to return home, the immigration officer asked if I had enjoyed my stay in Ecuador. ‘It was the trip of a lifetime,’ I told her. It really was.

Angeline Hwee Yin Lee

Third-year medical student,

University of Bristol,

United Kingdom

al9436@my.bristol.ac.uk

Members of the German Team: Dr. Karl Moser (surgeon), Prof. Dr. Markus Heiss (surgeon), Dr. Andreas Kremer (anesthetist), Marion Koell (photographer)
Organizing Team in La Concordia: Kathia Tinixaray, Sandra Ocampo and Theresa Butron (Madrid)
Scientific Support: Samuel Shillcut.

Andreas Kremer the Anesthesist

Andreas Kremer the Anesthesist

When we arrived after our 16-hours journey from Düsseldorf to Quito, we were heartily welcomed by Sandra and her brother. They brought us in very comfortable cars within 4 hours to La Concordia, where we stayed in the nice Hotel Atos. On the same day we saw around 50 patients in the nearby area de salud 23 which was run by Kathia. This preoperative consultation was very well organized by Kathia and Samuel, who did also an excellent paperwork.

Situation at the Quninde District Hospital
The next day Sandra and Kathia took us to Quininde to the local district hospital, which was 40 minutes drive away. We were welcomed by the leading surgeon and led to the operating area. There we were left alone and really nobody took any notice of us. The whole crew including the surgeon in charge was lying on the patient´s stretchers and was not really willing to help us. A little bit puzzled about this situation we tried to start with the first operation. As we did not bring along drapes and gowns (we were informed by Theresa, that this would be provided) we asked a nurse. She said that we are not allowed to change the gowns between the operations – only the gloves. When we told her that we won´t accept this, she suddenly managed to get enough gowns for us. When we asked for a scrub nurse this was refused and between the operations the floor was not cleaned or the waste taken out. After 6 operations totally working on our own, while the local staff enjoyed a lazy day, we stopped working and complained to Kathia. She took care of this by bringing a nurse from the area de salud 23 to the hospital on the next day. During the week the support from the hospital staff got better and on the last 2 days it can be named good. They crew helped us with the patient transport, cleaned the operating theater and brought us the instruments. This was probably due to the pressure of Kathia and some thankful patients, who complained very forcefully to the manager of the hospital, about how we were treated.

Security
Unfortunately on 2 days parts of our equipment were stolen, although we left it in a locked room in the operating area. I was missing 3 of my 10 hernia sets, 2 presents for Kathia and Sandra and Andreas Kremer 5 bottles of local anesthesia and 3 precious clamps. Even the locks were cut. This was reported by Sandra to the local police, which is still investigating. According to Sandra the hospital is now willing to pay for the stolen hernia sets.

Patient details
64% of patients were male, with patient ages ranging from 10-72 and a median age of 41. Average family size was 4 people – 28% of patients were fathers.
The average years lived with hernia was 8.4 (6 median, 0-36 range). 67% of patients were in pain before surgery and 6% had vomiting. 88% of patients with inguinal hernias received mesh.

Operation details
In total we operated 43 Hernias: 24 inguinal hernias, 2 femoral hernias, 6 incisional hernia, 10 umbilical hernias and 1 epigastric hernia. Three patients (8%) had bilateral hernias, and 5 patients (14%) had two hernias that were not bilateral.
Inguinal hernias were reducible in all but one patient, who had a large inguinoscrotal hernia. 80% of all hernias repaired were primary.
Of 25 inguinal hernias, 24% were H1, 48% were H2, 24% were H3, and 4% were H4. Of the 6 H3 and H4 hernias, the inguino-scrotal component was Of 54 inguinal hernias evaluated, 28% were direct, consistent with an expected 25%-30%.
One lady with a huge incisional hernia was operated with a modified Ramirez procedure

Anesthesia
72% of patients received spinal anesthetic, 22% received local anesthetic, and 6% received general anesthetic. Due to a leak in the anesthetic machine it was one time very dangerous for one of our patients receiving general anesthesia. But Dr. Kremer was able to lead the patient through this difficult time.

Postop Course
Three patients were hospitalized, one for six nights (the lady with the huge incisional hernia). Antibiotic prophylaxis was not used in keeping with European Hernia Society (EHS) recommendations.
In the so-called ICU no nurse took really care of our difficult case. Therefore Dr. Kremer had to keep an eye on this case the whole day. As he was very busy, we had to cancel some of our patients on this day. As we did not want to risk the live of our patients we did not operate 3 additional patients with huge incisional hernias as planned.
Up to now all patients do fine and according to our knowledge no infections occurred.

Summary
Despite the trouble we experienced we had a marvelous time, because our patient were so grateful and Sandra was such a wonderful host. However in accordance with Kathia we advice not to send more teams to this hospital. We think that it is a very good idea to perform the next mission in the Centro de Salud La Concordia, where Kathia is in charge. We will definitely do another mission to La Concordia after this is arranged. We also want to thank Samuel for his excellent record keeping and wish him the best for his wedding next month with the his ecuadorian fiance.

Markus Heiss, me and a local surgeon

Markus Heiss, me and a local surgeon

Dr José Antonio Pascual Montero, 12 Octubre Universitary Hospital, Madrid, Surgeon. Dr Jesús Salvador Torres Jiménez, Infanta Sofía Hospital, Madrid, Surgeon. Dr Jesús Ángel Garijo Ílvarez, Infanta Sofía Hospital, Madrid, Surgeon. Dr Miguel López Vizcayno, Sanitas La Moraleja Hospital, Madrid, Anaesthetist.

We left Madrid on April 23rd at the appointed time without any difficulty in booking the medical material. The flight was normal for some of us and rather exceptional for others who witnessed the landing from the cockpit, courtesy of the pilot. On arrival at the Mariscal Sucre Airport, Carlos Criado (airport commercial director) and Sandra Ocampo were waiting for us and speeded us through customs. The Health Centre staff took directly to La Concordia the parcels with surgical material.

We put up at Sandra Ocampo’s house to be taken later to know Quito’s historical centre, particularly La Ronda, where we saw one of the typical processions of the city, after which we went for dinner to Casa Dami?n, a restaurant owned by one of Dr Pascual’s friends from Segovia. After a night rest at Sandra Ocampo’s house in Quito, we started for La Concordia, where we were received by Dr Kathia Tinizaray and Haydee Caicedo, the three of them essential persons in the organization of the mission. We collected the surgical material to take it to the Alberto Buffoni Hospital in Quinindé where the mission was going to take place and where we were received by the staff very cordially and warmly. We arranged all the material we had with us and left everything ready to begin surgery the next day. Then we came back to the Health Centre where we checked 70 patients in order to programme surgery for the following days. We programmed 50 out of those 70 patients, and we finished work at 18:30 hours.

After some rest we had our supper, a typical barbecued grill from the place, prepared for us by our hosts at La Concordia, Sandra Ocampo and Dr Kathia Tinizaray. After supper we went to our lodgings in the Atos Hotel to gather strength for our mission the following day.

On Monday 25th we got up at 6 a.m. and after taking breakfast we started for Quinindé, at about 40 kms from La Concordia, and we arrived at 7:30 at the Alberto Buffoni Hospital where the staff and the 14 patients in readiness were expecting us. We started operating in the operation theatre they had arranged, but as we were three surgeons and one anaesthetist, we asked for the collaboration of surgeons and nurses of the hospital in order to be able to use the other operation theatre, with the understanding that if an urgency would occur, we would vacate it and would offer our collaboration if necessary.

On that first day we performed 15 interventions on 14 patients (2 eventrations, 6 inguinal hernias, 1 hydrocele, 1 scalp tumoration, 4 umbilical hernias, and 1 epigastrial hernia). One of the eventrations was very large and it required draining and hospitalisation for 48 hours. We want to stress that, besides the help from the hospital staff, two sisters, Carmen Alcibar and Rosa Alcibar, both helping nurses in the infirmary whom we had known in our previous Operation Hernia mission in CSDP in La Independencia, offered their selfless help which, in some moments, was of crucial importance. The work ended at 18:00 hours, and we made our way back to La Concordia in about 40 minutes thanks to the kindness of Sandra Ocampo who lent us her car for coming and going. After a short rest at the Atos Hotel we all had dinner together and got ready for the mission next day.

Tuesday 26: We again arrived at Quinindé Hospital at about 7:30 and started interventions at 8:00 with the collaboration of Dr Zhunala and Dr Preciado, so that we could use both the operation theatres, and we showed them our technique in hernioplastia with mesh, as the use of meshes is not common with them due to the scanty resources at their disposal. On that day we performed 11 interventions (2 eventrations, 2 inguinal hernias, 2 epigastric hernias, 1 criptoquidia, 3 umbilical hernias and 1 abdominal sebaceous cist). One of the eventrations was a huge one and it required drainage and 24 hours hospitalisation. We then left for La Concordia as the previous day in the car Dr Tinazaray had lent us in the morning.

Wednesday 27: Same time of leaving the hotel and arriving at the hospital, beginning our day at 8:00 with the help of the auxiliary staff of the operation theatres, with 12 interventions (2 eventrations, 5 inguinal hernias, 2 epigastric hernias, and 3 umbilical hernias). After finishing work at 16:00 hours we were invited for a meal by the two auxiliary sisters (Rosa and Carmen Alcibar) in their humble house in the outskirts of Quinind?, where we were introduced to their family and we duly appreciated her readiness, selflessness, and the great effort that going to work for the mission entailed. Back at La Concordia we, together with Dr Tinazaray and Haydee Caicedo, were invited for dinner by Sandra Ocampo. With them we planned future missions, and they indicated the possibility of extending such missions to villages in Esmeraldas and Santo Domingo de los Colorados.

Thursday 29: We begin operating at the usual time with 12 interventions (5 inguinal hernias, 4 umbilical hernias, 2 epigastric hernias, and 1 abdominal lipoma). We end at about 15:00 hours and, as a sign of gratitude, we share an aperitif with the operation theatre staff that had collaborated with us. We had a meeting with the director of the Alberto Buffoni Hospital, Dr Saavedra, in which we signed an agreement between Operation Hernia (Dr Pascual signing in the name of professor Kingsnorth), the Hospital and the La Concordia Health Region (Dr Tinazaray) for a three year period. Dr Javier Saavedra thanked us for the work done and urged us to carry out new missions in the Alberto Buffoni Hospital. We collected all the left-over material and we gifted part of it to the same Alberto Buffoni Hospital, and part to the La Concordia Health Centre.

We came back to La Concordia where we were received by the municipality mayor. In a simple act the statement of gratitude for our work was read out, and a copy of it was given to each one of us personally, and one to Operation Hernia. We then started for Santo Domingo de los Colorados, a city of about 200.000 inhabitants, where we were urged to open conversations for the possibility of future missions there. We want to emphasise that out of the 50 interventions carried out, 10 were on children between 2 and 10 years, and 2 on elders over 80. After a night in La Concordia, on Friday 30th we went back to Quito to come back to Madrid on May 1st.

Chris Oppong
Aby Valliatu