Maria & Stephen

Giants of Gambia return December 2012

Maria & Stephen

Maria & Stephen

Maria Boutabba (Registered ODP and Sister Maria to the team and hospital community) reports

Operation Hernia Mission, AFRPC hospital, Farafenni, Gambia – 8th December -14th December 2012.

This trip proved to be extremely profound for both professional and personal reasons. I had a fantastic time, was incredibly busy dividing myself between different roles, including surgical assistant… but was so in my element. It was and remains a great privilege to have worked with like minded professionals who value safe patient care and doing the right thing for the right patient at the right time in a clinical environment so different to what we are used to in our own familiar healthcare systems. We all bonded so well and enjoyed each others company, particularly in the relaxing evenings, listening to Brian’s very funny anecdotal stories and saucy jokes.

In surgical assistant role

The multinational (English, Welsh, Irish working in Scotland, Polish and Swiss) team comprised of Andrew Kingsnorth, Lead Surgeon, Brian Stephenson, 2nd in command surgeon, Alan Woodward, Surgeon, Stephen Brennan, Surgeon, Slawek Koziel, Registrar surgeon, Katharina Wentowski, Anaesthetist, Michael Wentowski, Medical engineer and myself. Andrew has fondly named us the ‘Giants of Gambia’ for achieving what we did under the conditions we worked in.

Michael's den (self-made EME department)

Michael’s den (self-made EME department)

Katharina taking her patient to recovery

Katharina taking her patient to recovery

We had an eventful arrival into Banjul, where one of Andrew’s small bags got whisked off in error to a resort hotel. After a delay and interesting police reporting process, it was returned intact, not something we would expect in the UK! We later made our way to Banjul port, where we waited in anticipation for the ferry that would take us across the impressive Gambia River to Farafenni.

Following what felt like hours and after polishing off some chicken and rice, our ferry eventually arrived. Amongst much local excitement, and eruption of frustrated tempers by queuing lorry drivers, we were herded on mass onto the ferry. We travelled the smooth, oil like river under the guidance of beautiful star constellations. We landed safely in Farafenni and made our way to what would be our very basic accommodation for the stay, Eddies Hotel, checking in somewhere around midnight on the 7th December 2012.

Throughout that initial experience we were looked after by the hospital communications officer, Saini. Saini would prove to be our valued friend easing our right of passage throughout our entire stay. Saini very efficiently organised our off duty entertainment time; we would sample an African music and dance evening, eat barbecued goat, visit the Senegal border, fishing village, women’s garden and eventually the Atlantic ocean waves on our last day.

The next day we met with the hospital administration. The hospital architecture is impressive but does not reflect what we were to come to accept as an under funded, under resourced, disorganised healthcare system. Following group prayer we discussed what we hoped to achieve during our stay. The administration was welcoming but hinted at the lack of resources at the hospital.

A lot of work was undertaken by the team to turn a ‘shell’ into an efficient, fully functioning mini day surgery unit. The ‘theatre’ developed into 3 operating spaces, with all surgical equipment, instruments and make shift operating tables scrubbed clean and organised to be fit for purpose. We set up a sterile storage area, scrub and gowning area and mini sterile services unit. We had one working diathermy machine that had travelled with Andrew. A startling Gambia fact is that in the whole of the country there are only 4 surgical diathermy machines!!

The transformation of the ‘shell’ would prove to become the pride and joy of the team and the few local staff who joined us to help. Of benefit to our clinical work, was our magical medical engineer, Michael, who fixed life saving equipment, we so often take for granted in the UK. Without this repaired equipment, which included suction and a couple of abandoned pulse oximeters, we would have found it difficult to achieve safe anaesthesia for the 16 children we later treated.

Katharina and I quickly realised we would not have a functional anaesthetic machine, despite several modern machines being available. Sadly these were all in need of spare parts to put them back in working order. However with Michaels help, we had proper basic monitoring, an ambu bag, suction and access to cylinder oxygen. We trawled abandoned equipment from previous missions to retrieve IV access and airway management devices. Katharina is a brilliant and committed anaesthetist, who showed so much maternal compassion for the children. Together, we carefully planned how we would safely pre medicate, anaesthetise the children and recover them post operatively – We went right back to clinical basics which we both found professionally satisfying.

We operated on 29 adults, the majority having local anaesthetic, with or without the support of Ketamine and Midazolam. A small number of adults had spinal anaesthesia. We operated over 4 days, with an efficient turnaround, with a ratio of approximately 1 child to 2 adults. All 3 operating spaces were kept fully utilised. An average operating day would typically reflect up to 9 patients operated on before lunch around 2pm and then 3 more complex cases in the afternoon and tidying up time ready for next day operating.

Brian, Michael, Andrew, Alan, Maria, Stephen & Katharina (picture by Slawek)

Brian, Michael, Andrew, Alan, Maria, Stephen & Katharina (picture by Slawek)

Child ready for postop care

We saw and operated on large paediatric inguinal and umbilical hernias. The adults had primarily very large inguino- scrotal hernias. We had a couple of complex umbilical hernia repairs which became mini laparotomies to repair them! We also operated on femoral hernias including, rather unusually, a mother and her two daughters. All the patients, where screened using the Kingsnorth classification, with Andrew, booking the patients to the operating list which was reviewed with me on a daily basis.

We had little chance to teach and train the local hospital community – there were no surgeons apart from one Obstetrician from Cuba. I did some basic theatre training with the few local nurses who were assigned to help us in theatre, and I hope to bring one particular nurse to the UK for an exchange visit. We had a Scottish medical student, on overseas placement join us for 2 days, and she found the exposure within our team rewarding. On a couple of days, 2 volunteers joined us from the schools for Gambia project – this assisted us tremendously as they helped bring patients to theatre, reassure them and they also helped wash and pack instruments.

We all acknowledged that Farafenni is very reliant on mission teams to assist with elective surgery. It is a sobering fact that once mission teams leave, there is no sustainable system in place to allow the local health community to carry on. We were humbled by how far patients will walk to access surgical care. The patient’s appreciation was immeasurable but the smile said it all.

On the last day we met the hospital administration again and exchanged niceties. Each member of the team was rewarded with a hand made shirt and letter of appreciation. We were reminded that we had been absorbed into the hearts and minds of both the hospital staff and local community.

I hope that the ‘Giants of Gambia’ team will make another visit to Farafenni in 2013 as per the wishes of the hospital administration.

Giants of Gambia OH team

Welcome to Operation Hernia

Welcome to Operation Hernia

Welcome to Operation Hernia

Following a really successful trip to Farafenni in January 2011 an enlarged team comprised of the original group from Estonia led once again by Surgeon Juri Teras and a new team from the UK lead by Surgical Registrar Michelle Tipping ventured once again into the depths of Africa to build on the valiant efforts of the Estonians earlier in the year.

Having linked up with the Estonian team via e-mail before departure our UK contingent was large: 1 consultant anaesthetist – Scott Farmery, 2 consultant surgeons – Mr Andrew Wan (UGI) & Mr Andy Ramwell (Colorectal), 1 senior scrub nurse Adrian Kasparian, 2 surgical trainees Hannah Wright (FY2) and myself (ST4), and two general volunteers Christopher Mason and Helen Durance.

We arrived a day after the Estonians which was lucky as they were able to organise transport for us to the hospital, even then, the amount of supplies we had managed to secure seemed to take our hosts by surprise! 100kg of drapes, a surgical operating table, 1 portable ultrasound machine, 8 volunteers, 10 bulging bags and a huge box of donated vacuum packed teddy bears. One small hospital ambulance and half the length of the country along a pot-holed African road later, we all knew each other much better than when we set off! The adventure had officially started.

We found the hospital and the breath-taking hospitality exactly as described by the Estonian team. Baboucarr Saine, Mr Bondi and Sainey Dibba once again went out of their way to make us feel at home and we stayed in the same accommodation they had used previously.

As the Estonian team had made a head-start we were already almost up & running on arrival. The plan was to get three theatre teams working so we could maximise the work we could do. We managed to get enough resources together to get two theatres running simultaneously and got started with the first patients. The UK team had discussed our long-term mission prior to arrival as well as our immediate objectives. We left the UK with aspirations to help train local people to start doing their own hernia repairs. Once we started we realised that the needs of the hospital were a lot more basic. It became apparent very quickly that basic theatre practice & education was desperately needed. Basic knowledge regarding concepts of sterility and instrument handling were just unknown. So, we started at the beginning. Luckily due to the size of our team we could educate and develop practice as we went along and by the end of our time things were much improved although it will take time and effort to train surgical nurse practitioners to the standards required to complete their own repairs.

Another basic concept which needed addressing was the organisation of supplies in the hospital. As we explored we found lots of locked rooms containing boxes & boxes of donated supplies but no-one seemed to know what was in them! This was where our extra non-clinical volunteers made a huge impact. Using a lot of elbow grease and any of the surgical team not currently operating they re-organised the whole of the hospital surgical supplies into 2 labelled rooms so that everyone knew what was there and how to find everything. This also came in extremely handy when we were asked to see other surgical problems that didn’t involve hernias but needed treatment! Safe to say the hospital does not need any more urinary catheters or neonatal ITU equipment!!!

This was a great hospital to visit and the enthusiasm they have as hosts clearly shows they appreciate the efforts of the volunteers who give up their time to go. It is a place where people are keen to improve and develop to offer the best possible for their patients. We see a long-term future for Operation Hernia in this hospital although the two things I would recommend as vital for future teams (apart from all your surgical kit) . CO2 monitors for the anaesthetist to assist with childrens hernias and head torches; some-things never change!

Inguinal hernia repair under local anaesthesia

Inguinal hernia repair under local anaesthesia

The local market

The local market

Rural Gambia

Rural Gambia

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