Brazil team

Maranhao, Brazil March 2013

Brazil team

Brazil team

Brazil Report, 16-25 March 2013

Operation Hernia Team: Andrew Kingsnorth, Todd Heniford, Shambhu Yadav, James Brewer, Heidi Miller & Lorenzo Dimpel (anaesthetist). Brazilian coordinators: Flavio Malcher, Luis Soares.

Brazil is the engine of South America. A vast country with 200 million population, bordering all the other South American countries except Ecuador and Chile, and with extensive natural resources and protected habitats. Its topographical diversity includes not only the Amazon, the largest river in the world by volume, but also hills, mountains, plains, highlands and scrubland. Brazil has a highly advanced technological industry concentrated in Sao Paolo, manufactures & exports cars and aeroplanes, and is due to take delivery of a French nuclear submarine in 2015. A two million kilometre road system includes 184,000 of paved roads. Statistics for the various ethnic groups indicate that 48% are classified as white, 43% brown (multi-ethnic, or pardo), 8% black and 0.4% Ameri-Indian. These limited facts give a mere glimpse into the amazing cultural, scenic and human elements that make a trip to Brazil a thrilling experience.

Our destination was Maranhao State in the north east. It is the second poorest state in Brazil (after Amazonia) with 24% illiteracy and the highest levels of inequality. It features the spectacular sand-dunes of Lencois (Lencois Maranhenses National Park) and the Parnaiba river delta with stunning lagoons, deserted islands and beaches. The northeastern part of the state is heavily forested and is the eastern extension of the tropical moist forests of Amazonia.

Two tables

Two tables

Dunes of Lencois

Dunes of Lencois

From Rio de Janeiro we flew into the San Luis, the State capital of Maranhao, just 3 degrees south of the equator with a tropical monsoon climate, and a population of one million. The city is situated on an estuary of three rivers and has a vast deep water seaport, and the best preserved historical city centre of colonial Portuguese architecture of all Latin America. On account of its striking architecture it is known as “The Tiles City”.

In the last decade significant progress has been made to provide public services to deprived regions in Brazil. In Maranhao two recently built modern highways (BR-010, BR320) criss-cross the State, new schools have been constructed and over 30 new hospitals with approximately 50 beds are being built. Presently, the government is having difficulty in recruiting trained doctors to staff the hospitals in these remote areas. Our first destination was to one of these hospitals in the town of Coroata (population about 50,000), where we travelled overnight by road on a four and a half journey from San Luis to arrive in darkness, but ready for the first days work.

The home team was extremely well-organised. Cases had been prepared and worked up to include not only straightforward inguinal hernias, which we used to teach the local surgeons and residents, but also children and several incisional hernias. Our programme had been supported by the Minister of Health for the State and extra staff had been drafted in, including a locum anaesthetist from Rio who was able to handle several simultaneous spinal anaesthetics, and intravenous general anaesthetics, so that 21 cases were achieved on the first day.

The town’s hotel was situated just behind and over a petrol station. Early morning breakfast on the verandah of the hotel afforded exciting views of the town as it awoke amidst the noise of goats, motor cycles and mule-drawn carts going about their daily business. On the second day we worked until 9PM to complete another 19 cases and then set off for another night drive back to San Luis arriving at 3AM after a splendid midnight feast at a truck stop in Mirando do Norte

Luiz, James & Flavio

Luiz, James & Flavio

After this rather exhausting start to the mission, the next day consisted of a tour of the Old City, a traditional business lunch at a Senac restaurant, and in the evening a tour of the flood-lit city, the presidential palace and a visit to the Sarney museum of fine art, followed by a buffet dinner hosted by the State Minister of Health.

During the next two days Flavio had organised a Hernia Congress followed by a hands-on workshop in Hospital Tarquinio Lopes Filho to teach complex hernia surgery to consultant surgeons. Both days were very interactive. More than 100 surgeons attended. Each Operation Hernia member gave at least one lecture, and we demonstrated several complex techniques in the operating theatres. The dinner on the night after the congress took place in the beach restaurant of Cabana Del Sol where Lorenzo’s birthday was celebrated by a barber shop quartet (actually the waiters)!

The next day we headed for the second hospital in the town of Barrierinhas, a four hour drive to the east of San Luis. Here we had the luxury of staying in a beach hotel and took a trip up the Parnaiba river to see the dunes of Lencois. The operating consisted of two long days with four operating theatres active to complete another 50 cases. The support from the Brazilian team was amazing, with constant refreshments, and even time to celebrate another birthday- red pixie hats were donned in the operating theatre, balloons strewn around the coffee room before the a cake was cut and more songs sung!

This was a very well-structured and advanced mission which will be repeated in another region of Brazil in 2014

Andrew Kingsnorth

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.

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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