Land of the Blue Sky

Fourth Year for Operation Hernia in Mongolia September 2013

Land of the Blue Sky

Land of the Blue Sky

Mongolia 8-20 September, International Team

Country

Mongolia is a country on the central part of Asian plateau situated between China and Russia. In Europe Mongolia is known as a low-income country, where the healthcare system has poor infrastructure and old equipment – in my opinion it is not truth in 100%. Mongolian people are also known as a very proud and brave nation – and this is absolutely true. The best chance to see all wonders of The Land of Blue Sky is to travel by car (better to take 4×4). What a traveller can see, meet and taste are beautiful and breathtaking landscapes, hospitable herdsmen who own totally 40 million horses, goats and sheep (the goats and sheep were very important for the team). The taste of a mutton stew, horse meat, tea with goat’s milk and especially khoomis is something what cannot be forgotten. Let’s say something about Operation Hernia in Mongolia – because it was the main goal of this trip for all of us.

Team

It was a pleasure to work with this truly International Team comprising Andrew Kingsnorth (UK); Maciej Śmietański Poland), Kamil Bury (Poland), Teresa Butron (Spain), Giorgio Giorgobiani (Georgia) and Martin Kriz (Sweden). We received huge support from every surgeon that we met on our route but especially we are grateful to Dr. Naraa and Dr. Sanchın and Enkhee

A herdsboy

A herdsboy

Performance at the National Theatre

Performance at the National Theatre

Journey

We landed at the airport of Chinggis Khan – Ulan Baatar (UB) on Sunday morning – as it turned out we all flew from Moscow on the same flight so there was no problem with the gathering. After breakfast we set off on a journey through the wilderness of Mongolia.

During the two-day trip we drove nearly 400km, we spent one night in the middle of nowhere and during the same night we took part in a Mongolian wedding. A lot of drinks and strange meals – but it was a marvellous experience. On the way back to UB at the special invitation of one of the surgeons we were able to take part in a horse race – a lasting impression and experience that we will never forget. After returning to UB we were divided into two teams. The team I was operating at the University Hospital and the other at the prison hospital. Operations performed at prison hospital resulted in three interviews for Mongolian TV and an invitation to dinner by the Head of the prison hospital. During our stay in UB, thanks to the hospitality Dr Naraa, we admired a fabulous performance in the National Theatre. The performance presented the culture and history of Mongolia in a magnificent way.

Teaching

Teaching

Operation Hernia

We operated on 78 cases, which included 20 children, 16 prisoners and 4 reconstructions including Ramirez and one cholecystectomy. We had a mixture of incisional and inguinal cases. The operating lists were tightly-organized but thanks to very good organization of work in the operating theatres we had no problems with performing all procedures. So we were able to do cases ourselves or assist and teach the Mongolians surgeons as appropriate. Andrew, Teresa and Martin gave lectures to the local surgeons. In the opinion of Mongolian surgeons the topics were well chosen and the knowledge gained will be very helpful in normal everyday work.

In a nutshell– the work was the same as on every Operation Hernia mission – early start in the morning for a post-operative ward round, followed by assessing into the new cases, then operating all day long and in the evening… night life in UB.

The great success of that mission was mainly possible because of the distinguished capacity for teamwork of every participant. All team-members expressed their wish to participate on the next humanitarian mission under the auspices of Operation Hernia.

We will be back…

For Operation Hernia from Ulaan Baatar

Kamil Bury

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!

Sunday

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.

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

This was the second visit of the charity to one of the most remote countries in the world. The team was Andrew Kingsnorth, John Schumacher Shaw (so-called by our hosts as he was the fastest scalpel in history), Alan Cameron, and Frank MacDermott. We had the unique privilege of having Tsetsegdemberel Bat-Ulzii Davidson (Tsetske) as our translator unique because although Mongolian, she is undergoing surgical training in the UK. As on the previous mission, we had the smooth, efficient and capable organizational skill of Mrs Enkhtuvishin of the Swanson Charitable Foundation.

Andrew Kingsnorth wrote about the first Mongolian visit in last year s report so I am doing this account as a novice to both Operation Hernia and to Mongolia. Before going further I must say that this mission was one of the most enthralling, worthwhile and fun things I have ever done. I was hugely impressed by the dedication of the Mongolian doctors and nurses; here in the UK we seem to have interminable delays in theatres, but in Mongolia the organization was superb (which did also mean we were kept busy in theatres all day!). And the anaesthetists skill with spinals was amazing. The Mongolian people were friendly and charming, and the scenery was stunning.

We arrived at Chinggis Khan airport -everything in Mongolia is named after their marauding hero and were loaded into 4x4s to travel down to Mandalgobi, our base for the first week. First surprise was the absence of any road for nine-tenths of the 260km journey; just tracks through the steppe. Seemingly relying on celestial navigation we arrived long after dark!

Mandalgobi is a one-horse settlement of 11,000 people on the edge of the Gobi. The hospital had been through some bad times after the fall of communism, but seemed to be improving rapidly under the able direction of Dr Dolzodmaa, who was herself a surgeon. We spent a very happy week operating on a mixture of adults and children. The equipment was fine and the theatre environment very satisfactory (although I was amazed to find that one of the couches had been manufactured in my home town of Ipswich). We had the usual somewhat stilted dinner with the deputy provincial governor, but Andrew s explanation of the purpose of the visit was well-received.

At the end of the week the whole team decamped (literally; the nurses came with us and brought the food and drink) for a bit of sightseeing so we were taken hundreds of miles into the Gobi to look at spectacular rock formations. We had two nights in ger camps out in the vast stillness of the desert before getting to the chaos of urban Ulaanbator.

The capital is a sprawling mass of pollution and congestion with some of the worst traffic in the world, but fortunately the 2nd hospital was within walking distance of the hotel. (John Shaw went to the paediatric hospital during this week). So we were on duty early for a post-operative ward round, followed by seeing the new cases, and then operating all day. There were attentive medical students, and lectures after the lists. We had again a mixture of incisional and inguinal cases. The operating lists were tightly-organized, with Andrew in one theatre and me in the other. So we were able to do cases ourselves or assist the Mongolians surgeons as appropriate (Andrew had met and taught many of them in 2010 and they were keen to show off newfound skills). We had a couple of evening social events, but there was actually no time for sightseeing in UB I don t think we missed much because the steppes had been wonderful and were a hard act to follow.

The success of this mission was due to the enthusiasm of our two professors, AK in the UK, and Tsagaan Narmandakh in Mongolia. There was a great feeling of teamwork at all levels and in the two weeks I felt we had achieved a great deal. In simple terms the team did 124 cases (58 children) cases, but more importantly we supervised the local surgeons who can hopefully build on this teaching. Mongolia is the ideal place for this kind of mission because the infrastructure exists to carry on the work after the visiting surgeons have left. Before I signed up Andrew told me this would be the most worthwhile holiday ever; he was wrong about the holiday bit, but it was certainly worthwhile in every other sense.

UK, Israeli, USA and Slovenian Team, Mongolia 1-15 MAY 2010

Mongolia is a country situated on the central Asian plateau wedged between China and Russia. It is classified as a low-income country, providing a healthcare system with poor infrastructure, old equipment and little money for basic supplies.

mongolia_11

The country has an average elevation of 1600 meters, a land mass the size of Western Europe and is situated at the headwaters of river systems that flow to Siberia, the Arctic, China and the Pacific. It has a dry climate yet affords 250 sunny days a year and is known as Land of the Blue Sky . Only 3 million people live in Mongolia and half of these reside in the capital Ulaanbaatar. Travel is best undertaken in a four wheel drive or by horse since there are only 1500 kilometres of paved road and most travel is via an improved earth surface or earth tracks. This gives wonderful opportunities to meet the hospitable herdsmen who tend the 40 million horses, goats, sheep and cattle that roam over the fenceless and treeless steppes. It is an exotic experience to visit a ger (a traditional round felt tent) and enjoy the hospitality of a nomadic family, which may include mutton stew, horse meat, goat s milk tea and khoomis (fermented mare s milk).

Our two week mission from 30th April to 15th May 2010, was undertaken with the very able assistance of the Swanson Family Foundation (SFF) represented in Ulaanbaatar (UB) by Mrs M Enkhtuvshin (Enkhee). Planning had begun more than six months earlier. Surgery and teaching took place during the first week in the central Teaching Hospital #2 in UB (under the leadership of the Chief of Surgery, professor Tsagaan Narmandakh) and during the second week at the central hospital in Moron, a distance of 800km to the north in Khuvsgol province. Surgeons from district hospitals attended for teaching and lectures in Lichtenstein inguinal hernia repair, incisional hernia repair with mesh and components separation, and some paediatric surgery. To reach Moron involved an unforgettable drive across the steppes and taiga to the still-frozen Khuvsgol lake adjacent to Siberia.

Our team consisted of myself, Professor Motti Gutman from Israel, Dr Todd Heniford and Dr David Earle from the USA (the first representatives of the American Hernia Society) and Dr Juriy Gorjanc from Slovenia. We arrived at the Chinggis Khan airport early on the morning of Saturday 1st May and were met by Enkhee, the Chief of Surgery and the Director, of Hospital #2. The remainder of the day was spent orientating in the city of UB and adjusting to the cheerful faces of Mongolians dressed in their exotic and colourful deels (three-quarter length gown that buttons at the right shoulder to a high round-necked collar), hats, scarves and sashes. Our clinical work began the following evening (Sunday) with pre-assessment of 20 or so patients who had a variety of hernias. On the Monday morning we attended a dignified official opening ceremony with appropriate speeches and then set to work. In 2 operating theatres we completed 10 cases, surrounded by up to 20 curious surgeons seeing modern techniques of hernia surgery for the first time. During the following week we were able to take several of these surgeons through hernia operations and then proceed to teach them under direct supervision. In the meantime we had a guided tour of the hospital, made occasional visits to the emergency room and on one occasion witnessed the expert treatment of a bleeding liver tumour. In the evenings Mongolian entertainment was laid on, including a visit to the Naran Tuul black market and a glimpse of ancient Mongolian culture at a presentation of the National song and dance Ensemble. We gave TV interviews to the national network which were broadcast during the evening and vastly increased the recruitment of patients. By the end of the first week over 50 patients had been treated and we celebrated with a farewell well dinner in a restaurant that had a copy of the famous painting of One Mongolia by Sharav, as a backdrop.

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In Moron each morning began with an 800 meter walk to the hospital from our small hotel, rubbing shoulders with colourfully-dressed school children on their way to lessons and ordinary citizens going about their business. During four working days we completed another 50 cases and taught the surgical staff techniques of mesh repair. We operated on fifteen children, some as young as 4 months. By doing this, we would have saved each family two days travel each way to UB, plus a 2 or 3 day stay in the capital during the hospital admission. The cost of a journey such as this would often be beyond the means of a herdsman living a hand-to-mouth existence. Finally, the hospital staff entertained us to an evening meal in a ger camp when the whole delicious carcass of a goat cooked by traditional methods was consumed with vast quantities of Chinggis Khan vodka, which greatly assisted the content of subsequent spontaneous speeches.

On return to UB and prior to our departure we visited the Zanabazar fine art museum to view the long history of Mongolian art outlining the history of this interesting and fast-developing country. The hospitality had been enormous, and the surgeon s thirst for surgical knowledge enviable. An invitation to return has been accepted. We departed with a rudimentary knowledge of the Mongolian language, including the phrase of greeting when approaching a nomadic ger – nokhoi khor (hold off the dogs!)

The Operation Hernia team members wish to express their deep admiration of the Mongolian doctors with their high level of professionalism, their committment to the traditional values of the art of surgery, their recognition that medicine in low-income countries is still a vocation,.and their appreciation that the craft of surgery is a continuous learning process. We also wish to thank them for: preparing the mission with Enkhee, recruiting the patients, being attentive and willing learners, looking after our patients postoperatively and providing a sustained and entertaining social and culinary programme. The Mongolian doctors who were involved in the success of the mission were: (i) At Hospital #2: G. Bayasgalan (Director), Ts. Narmandakh (Head of Surgical Department); the following surgeons B. Onon, U Sanchin, Ya. Altanchineg, S. Ulambayar, G. Bilguun, P. Tseden-Ish, Ya. Batsumber; A. Khandaa (OR nurse); and the following anaesthesiologists: Z. Tumenjargal, A. Saranbaatar, J. Munkhzul. (ii) At Khuvsgol Central Hospital: D. Erdenebaatar (surgeon), D. Chuluunbaatar (Head of Surgical Department); D. Chuluunbat (surgeon) and Tumenjargal (anesthesiologist). We salute them all!

Andrew Kingsnorth