The Leighton & Derriford team

Leighton & Derriford Hospital Team, Carpenter 1-14 NOVEMBER 2009

Magdi Hanafy, reporting.

The Leighton & Derriford team

The Leighton & Derriford team

On the last day of October 2009 the Leighton Hospital team arrived at 7:00 am to my house in two mini-buses. I opened my garage and we shifted all 22 boxes and bags filled with our and medical equipments to one of the buses, and headed off to Manchester Airport. We took turn, transporting our luggage, upstairs to departures, where BA opened a check-in counter especially for us. 22 luggage counted and checked- in without problems. We flew to Heathrow, terminal 5. Janet and I noticed people walking around wearing a T shirt with GHANA written on it. She went and talked to some of the ladies and we discovered they were the Canadian team who have just arrived from Toronto on their way to Accra and then Carpenter. We introduced ourselves and met with Dr. Jennifer Wilson their team Leader. She explained to us the way they were introduced to Carpenter through Mrs Mensah, who is originally from Canada. The Canadian group have met Prof Kingsnorth two years ago when they were travelling to Ghana, and a new destination for Operation Hernia was born. We had a potential problem with Ginny s ticket as it was a free ticket donated by British Airways. We were told that if the plane was full she would have to wait for the next available place which could be the next day. That could cause a problem as we had to travel by land to Carpenter the next day. I could not have left her to travel alone the day after. Luckily there were enough spaces on the plane and we boarded together to Accra.

In Accra airport we made a long queue (at least two hundred meters) extending from customs and excise to the trucks and buses waiting for us outside the terminal. People with their trolleys loaded with boxes, hockey bags full of medicines etc… (Total of 102 pieces of luggage). We went to the hotel in Accra where we spent the night after meeting with the Plymouth team and Prof Kingsnorth who arrived on Ghana Airlines two hours beforehand.

The next morning we were waken up at six a.m. had a breakfast and off we started our journey to Carpenter. That took 12 hours, including three stops. We arrived in a big compound next to the village. Mr and Mrs Mensah have prepared our accommodation AND OUR DINNER. We were accommodated in a large compound with security and all facilities in constant supply, electricity, water, transport.etc. We were told about the project they are running and the efforts they are doing in sustaining this community. We went to our rooms. Each room had from one to three beds, each with mosquito net and a washing bag. Rooms and toilets are clean. The area is calm. It rained twice on that day.

The next day we woke up early in the morning, warm weather. We went early to operating theatres (which were empty rooms) and started opening the boxes and distributing the equipment on both theatres, knowing what is available and what is not. Craig, Ali, Helen, Dee, Janet, Ginny worked hard mobilising heavy equipment into both theatres with the help of the local boys. We gave Brenda, three bags of children school equipment we brought as a gift to the community. By the middle of the day it became very hot, and we became tired. We started screening patients for HIV and listing them for an appropriate operation, i.e. local or general. We did not have enough nurses, but a surplus of surgeons. We had to sit down in the night and arrange a rotating list between us to see who is doing what, when. We all had lunch together. The Canadians started work already, screening people from the compound. We started operating at three o clock, finished two operations in each theatre, and had to stop when night fell down, due to inability to work with only headlight, and insect s invasion. We had dinner and Prof started to organise our list for the next day. With that number of surgeons and staff the work had to be organised so that nobody would be left out, and others would not feel tired. We listed ten patients per theatre for the whole day, a big task. We had to go early to bed as we decided to start at first light, to reduce the likelihood of working in the dark, at the end of the day.

One of many operations performed each day

One of many operations performed each day

 

Patient care

Patient care

Tuesday 03 November 2009

Woke up early at six a.m. Perry Board before me. A quick shower before everybody else and off we went to theatre. Patients were there waiting for us. A quick ward round, yesterday’s patients were seen and discharged, new patients were allocated to their rooms, Ali started to excel, in organising the local helpers and the flow of patients. Theatres were prepared by Craig, Ginny, Dee and Janet, and we started one after the other. We performed 20 patients with 26 procedures. We finished late after sunset. When all the insects concentrate where light is shining (i.e. the wound). The air-conditioners started to fail. We started screening for the next day and allocated lists for both theatres. I was asked to go to the community with the Canadian team. I had dinner and went to bed early.

Wednesday 04 November 2009

Off with the Canadian team to the nearest village one hour away. A big organised place was set up for us. Chiefs waiting to great us, and each medical, nursing and pharmacy group was allocated a room. The Canadian team was prepared for the invasion by all the local population with and without any illnesses. But many of them have already been triaged by David Mensah, so those with genuine complaints were allowed to be examined. The day started very busy, and we had lots of surgical referrals until things started to calm down by 2:00 pm and I managed to see medical conditions as well, bringing me back to the old days in medical school. I have diagnosed malaria, yaws, and chest problems. I was very happy with the experience. At the end of the day, we gathered to be greeted by the chiefs who offered us gifts of vegetables and a ram as a token of gratitude. We went on to our vehicles for the long trip home which we had to reach before sunset.

Thursday 05 November 2009

Raj’s day out in the villages today. I have had a whole list on my own and managed to finish five cases in the morning. Prof did many cases as well, in the afternoon Richard managed a list on his own while we were seeing new cases and making the lists for tomorrow. Ginny did not feel well and had to retire. Many of us have been falling for slight diarrhoea, and exhaustion from heat. Especially when the air conditioners in Brenda operating room packed up and the room turned into a sauna. We had dinner together that was followed by a speech of thank you for Prof Kingsnorth, Jane and Ginny before their leaving home on the next day. They were thanked and praised.

Friday 06 November 2009

I started a GA list after Breakfast. Prof Kingsnorth and Ginny said their Good byes and left for Accra. Richard was out in the villages today. Raj went on to do the local anaesthetics list in Brenda s theatre when the A/C packed up again. But he continued operating. The last patient on my list was Kunako Koene a 120 years old man. We do not know whether this is true or not but he was very old. He had bilateral inguinal hernias. He was booked for general anaesthetic. He weighed 32 kgs. Walked with a light stick. We helped him up to the table, Perry started his anaesthesia and I performed the two operations. We decided to wake him up and recover him in theatre where the A/C is still working. When he woke up he asked the interpreter to tell us. I pray to God for all those people who came from far away, leaving their families, and jobs and countries to treat us for free, may God may bless you all. May God reward you and give you all the money that you need and more, not only you, but your children as well during and after a long life. Most of us started crying as we were very touched. He continued praising us while we all stood surrounding the operating table looking at him. The interpreter was quick and flawless. We were amazed at his way of thinking and talking, the way he realises all what is happening to him, the confidence that he had, the strength to go through such an operation at such an age, the wisdom and presence of mind. We helped him down from the table, gave him water to drink, and walked him to his room. The same evening at dinner David asked me to say what happened. In the middle of the talk I was so emotional I had to stop.

Saturday 07 November 2009

Raj was exhausted yesterday and took the morning off. I started the GA list and Richard the LA list. We went to see all the Patients and the old man Kunako Koene was doing very well. We kept both lists light, but still finished at 8:00 o clock. We managed to see all the patients for Monday s lists. At the evening we had dinner together and went to Brenda and David s house for tea and had a lovely evening with Craig s magic and a nice game. We went to sleep late.

Sunday 08 November 2009. Our Day off.

After a late breakfast we went to the buses heading for the church. While driving we found Richard s (one of our theatre helper staff) motor bike on the road with him standing with a piece of cloth against his head, full of blood. He had a fall while driving to Church. He sustained a small laceration to the scalp and a deep wound to the left knee that was bleeding profusely. I decided to take him back to the theatre in the compound and Janet offered to come with me. We cleaned his wounds, infiltrated them with Local anaesthetics and prepared our instruments. All the wounds were debrided, edges freshened, foreign bodies removed. The scalp wound was easily closed with sutures. The knee injury was deep reaching the patella. The quadriceps tendon was torn in two. I had to suture the tendon with interrupted number 1 ethilon. Then subcutaneous tissue than skin, with silk. We bandaged the wound for the day and provided antibiotics, pain killers etc.

In the afternoon David took us in a tour around the compound. Not known to us, there were fish farm and an ostrich farm as well. Nice big trees surrounding the farm from its fruits the ladies extract oil that is sent to Body Shops around the UK.

Bernard came to visit us on his way to Takoradi from the North. During the evening meal Chris Oppong arrived as well. We had dinner together. And sat down to chat over a cup of tea, discussed the next morning list before retiring.

Part of the Leighton & Derriford team

Part of the Leighton & Derriford team

Tuesday 10 November 2009

We woke up early and did a ward round, changed the dressings, and prepared the rooms to accommodate today s patients. I went for breakfast and followed the Canadian team to the school in Carpenter. On that day there was a queue of patients with only hernias. I examined and listed 61 hernia patients and examined 16 non hernia patients.

I operated on a patient under local anaesthetic and evacuated two abscesses from her neck and her pubis. A man came back two days after a hydrocoele operation, with melena and fainting attacks, I examined him and found no problem with the scrotal wound. I decided to resuscitate him on the floor in the clinic, with fluids first. Followed by transfer to the compound. He felt much better after the fluid load and proton pump inhibitors he was given. There was some confusion about whether to send him to a nearby hospital or to continue treating him in the compound. I heard that Raj is not feeling well and decided to come back around 3:30 to the compound and theatres. I managed to help with two cases on Brenda s list. Finished at 9:00 o clock pm and went for dinner. Than a shower and sleep.

Wednesday 11th November 2009

I had a whole day list. Started by a large irreducible indirect inguinal hernia under GA that did not have any contents in the thickened hernia sac. But there were a large prolapsed diverticulum of the bladder sliding with the sac that I could not identify. I injured the bladder and corrected the whole with two layers of viryl. I finished the repair and inserted a urinary catheter. The patient did very well. I operated on two children afterwards followed by adults. We finished the day at 8:00 pm, having hit more than 140 patients.

We had a nice dinner together, had a nice chat and were congratulated by the team on the achievement. By that time 146 patients and 186 procedures.

Thursday 12th November 2009

I woke early as usual went and packed two boxes full of sutures and gloves and the remaining medicines. After Breakfast we had a meeting down in the garden, when the old man Kunako Koene came with David to give us a speech, thanking all of us on the care that he had received and giving us praise and praying for us. Brought few more tears down. Jennifer controlled her tears while giving a speech. The Canadian team gave the man a small gift, and we thanked him for his kind words.

I felt tired and left theatre to have a quick siesta. Janet, Craig, Perry, Helen, Sarah and Ali all were in theatre logging numbers of meshes left (95), packing the instruments, theatre furniture and equipment in one room and closing the doors for next year.

We still had to operated on some facial lumps, clean wounds, change dressings and evacuate abscesses. The final count was 191 procedures on 151 patients. The next day we said Good bye and travelled home on a long trip of 11 hours inland drive, six hours overnight flight and one hour internal flight to arrive home 28 hours afterwards on Saturday 14th November 2009. Still much quicker than our Canadians colleagues.

Conclusions: This mission was exceptional, our achievements were as follows
– 191 surgical procedures in 151 patients in 8 ½ days.
– Collection, packing and transportation of 16 bags of medical equipment.
– Listing patients with hernias for next year. (60 pts/day)
– Helping support the Canadian Medical Team. Canadian team supporting us with medications, bandages, dressings etc.
– All in all, a Life Changing Experience!

Leighton Team: Mr Magdi Hanafy (Surgeon), Dr Perry Board ( Anaesthetist), Dr John Kerslake (General Practitioner), Dr Helen Simpson (Trainee surgeon), Sister Virginia Long (Theatre Manager) Sister Janet Burrows (Theatre Sister).

Plymouth Team: Professor Andrew Kingsnorth (Surgeon), Dr Jane Kingsnorth (General Practitioner), Mr Raj Dhumale (Surgeon), Mr Richard Dalton (Surgeon), Mr Craig Brown (Theatre Manager) Sister Dee Richards (Theatre Sister), Miss Sarah Hasted (Volunteer), Sister Alison Stout (Ward Sister), Dr Stephen Lewis ( Consultant Gastro-enterologist).

In surgery, Eruwa, Nigeria

Leighton Hospital Team with others, Eruwa, Nigeria 8-14 AUGUST 2009

 Arriving in Nigeria with all our luggage

Arriving in Nigeria with all our luggage

MY DIARY: Saturday 8 August

I (Nicola Eardley) arrived at Magdi Hanafi’s house at 6:00 am to find him still asleep! After he hurriedly got dressed, we packed the car and set off for Manchester Airport with our luggage and three boxes full of medical equipment. We met Ginny Long (theatre sister) at the airport, and checked in without any problems, although some swapping of contents between bags was needed to ensure that we didn’t exceed our weight allowance! We flew to Heathrow airport where we met up with Professor Kingsnorth and Eyston Vaughan-Huxley, a surgical trainee who had just finished his F2 year. We boarded the plane and unfortunately were delayed for an hour on a hot day without air conditioning (hotter than we were in Nigeria!), but eventually we took off and had a smooth flight to Lagos.

When we arrived at Lagos Airport, we were relieved to see that our luggage had also arrived, having survived the transfer at Heathrow’s Terminal 5. Customs questioned their contents, but allowed us to pass without any problems. We were warmly met by Dr Oluyombo Awojobi and his son at the airport. From there they took us to a hotel near the airport where we were able to wash (in the dark due to a power cut!) and have dinner. Over dinner we briefly discussed the following day’s itinerary before heading to bed (again in the dark due to another power cut!). Many of us were then woken with a start during the night when the electricity came back on and so did the lights and television!

Sunday 9 August

We had an early start with breakfast at 7:00 am. We checked out and packed the cars and off we went. Dr Awojobi had a busy day planned for us. We drove through the traffic of Lagos and once we were at the periphery of the city we stopped to visit the town where Dr Awojobi grew up. He told us all about his family and visited the grave of his elder brother, a respected engineer. We then went to a church, which had been built by his grandfather, and visited his grave. We then travelled for another hour to visit Dr Awojobi’s mentor and teacher, Professor Ajayi. He made us feel very welcome, discussing with us the difference between the old and new schools of medical education, over a cup of tea whilst sat on the front lawn of his house. After an hour or so we set off again and then stopped at his brother s house where we had a fantastic lunch. We thanked him and his wife and then set off to go and pay a visit to Dr Awojobi’s mother-in-law before the last leg of our journey to Eruwa. It was a long journey and we could see why it was best to travel during daylight hours as some of the roads were in very poor condition. Ten hours after we set off from our hotel in Lagos we arrived at Dr Awojobi’s home. We were warmly greeted by Tinu, his wife, and the rest of the family, and sat down to a nice dinner before heading back to our hotel to rest before our work was to begin the next day.

The Leighton Hospital team

The Leighton Hospital Team

In surgery, Eruwa, Nigeria

In surgery, Eruwa, Nigeria

Monday 10 August

Another early start, meeting at 7am (apart from Magdi who overslept again and met us at 7.15!). We had met Richard Salam, an anaesthetist, at the hotel on the previous night and that morning he told us how he had crashed his car on the journey from Lagos to Eruwa. We were amazed when we saw the photograph of his wrecked car that he had managed to escape with only minor cuts and bruises! We were driven to Dr Awojobi’s house and had breakfast before walking across the fields to the clinic. We were introduced to Kareem, the operating theatre supervisor, whom we were to find invaluable over the forthcoming days, and also some junior theatre helpers. In the operating theatre we found two operating tables for twin operating. We unpacked our boxes of supplies, which included gowns, gloves, local anaesthetic, antibiotics, analgesia, sutures, dressings, finger-switch diathermy, diathermy plates, sharps boxes and surgical scrub fluid and skin prep, in fact pretty much everything we needed to repair the hernias!

We met up with some Nigerian doctors, surgeons and GPs, who had come along to get some experience of performing hernia repairs with mesh. Professor Kingsnorth gave a lecture to the local doctors about the Lichtenstein repair and then we set to work. We examined the patients in the consulting room (2 patients at a time stood in the room, naked except for a sheet which they wrapped themselves in) and then they walked into theatre and climbed onto the table. Here they were given oral antibiotics and analgesics before lying down.

The vast majority of our operations were adult inguinal hernia repairs and all but the biggest (and I mean big!) were performed under local anaesthetic. Even the bilateral hernias could easily be repaired under local anaesthetic as our patients were, on the whole, nice and slim. We starting operating, assisted by the Nigerian doctors who were keen to learn. They had varying skills and all had differing aims and objectives of what they wanted to learn from us. For some it was how to perform a Lichtenstein hernia repair well, for some it was simply a matter of learning all about aseptic technique, tissue and instrument handling and effective suturing and knot tying. We kept working like a conveyor belt, interrupted only by lunch which was brought to us in lunch boxes. After only a 30 minute break we were operating again! All in all in the first day we performed thirteen procedures on ten patients. During the course of the day and also at the end of the day we visited the patients in the ward area, where they were usually surrounded by many family members before we discharged them home. Many travelled home on a motorbike just a few hours after their surgery! After a long day we walked back to the house and sat drinking tea and talking about our day until dinner was served. We then headed back to the hotel to rest before another busy day.

Tuesday 11 August

Another early start. Professor Kingsnorth and Dr Awojobi headed off on a trip to look at potential locations in Nigeria for further Operation Hernia missions. Today was to turn out to be slightly more adrenaline filled! Magdi Hanafi had to deal with a patient who had a right neck swelling and bilateral inguinal hernias. He started with the neck swelling and immediately encountered a difficult dissection and lots of pus. The internal jugular vein was injured and he found himself in a situation where he had to control venous bleeding with no suction, bad light, pus filling the wound, no provision for extra swabs and as an assistant, a GP who had very little operative experience. Fortunately he managed to get control, suture the tear in the vein, dissect out and excise the cyst, all under local anaesthetic and sedation! The second case was no easier, a 40 year old lady with the build of Magdi and an incisional hernia from a lower midline caesarean section. After a failed spinal she had to have a general anaesthetic with ketamine. It proved to be another difficult procedure as bowel was immediately underneath the skin with no peritoneal covering. There were several Nigerian doctors around who wanted to learn and scrubbed with each case. It was a relief to all that the remaining cases for the day were relatively straight forward.

Wednesday 12 August

An early wake up call this morning as they decided to turn the generator on at the hotel at 5am. Another busy day in theatre. We saw a 65 years old man with a scrotal swelling reaching down to his knees. This didn’t appear to be a hernia as it was very hard in some areas and cystic in others and he had only had an inguino-scrotal hernia repair a month before. It turned out to be a giant haematoma which was evacuated and included an orchidecomy.

Thursday 13 August

Slight stress this morning as the patient who had had the giant haematoma evacuation was nowhere to be seen, He has already gone home, even though he had a drain in situ (the finger of a glove acting as a drain!). Other patients relatives chased him up in a car and brought him back from the road. We were able to remove the drain and redress his wound. Professor Kingsnorth and Dr Alowojobi arrived back this morning and operated with us. They operated together on another giant inguinal hernia. After another long day we had a tour of Eruwa and got to see the original clinic before it moved to its current site. We were also fortunate enough to meet the chief (Oba) of Eruwa in his palace.

Friday 14 August

All packed and ready to go but a few more operations to perform before we left. Our tally for the week was 49 operations, the vast majority being performed under local anaesthetic, and no major complications. We set off for the airport, thanking everyone for their hospitality and a few hours later we arrived at Lagos airport. A long journey back home and plenty of time to think about the next mission

Leighton Hospital Team: Magdi Hanafy, Nicola Eardley and Virginia Long.
Others: Andrew Kingsnorth, Eyston Vaughan-Huxley (surgical trainee), Richard Salam (anaesthetist)

Theatre Superviser Kareem

Theatre Superviser Kareem