First Slovenian Team
2nd Slovenian and Hernia International Foundation and Expedition
Ghanta City, November 11 – 19, 2017
This year’s planned charity mission led the Slovenian national team to Liberia, to Ghana City and to Ghanta’s “Esther and Jereline Koung Medical Centre” (E&J MC).Our team consisted of 10 members: 3 surgeons, 3 assistants, 2 anaesthesiologists, 1 radiologist and 1 nurse.
We traveled to Monrovia with the Dutch airline KLM via Munich and Amsterdam, with a short stop in Freetown. In the capital, Dr. George’s team picked us up in the middle of the night with a couple of powerful 4-wheel-drive vehicles. There were two reasons for a one hour delay at the airport in Monrovia: 1 piece of lost baggage and a missing customs’ approval for importing the goods into the country. When the person authorized to “approve” the import of medical equipment to Liberia was finally reached over the telephone, we hit the road. The good thing about the 4 hour drive to Ghana at night was the reasonable traffic conditions. On the way back we needed more than 5 hours. The road, built recently by Chinese, was a very good one and made traveling much easier.
The weather during the week was quite good: partly cloudy with frequent afternoon/night showers that we only heard because of the thin metal rooftops. The temperature of 30°C felt like 35°C and more because of the humidity. Accommodation at Jackies Guest House was a good decision (privacy, air conditioning, WiFi with some interruptions, a restaurant with reliable food and a mini-shop with all the essentials that one needs, even in the case of lost luggage). Some members decided to share a room to minimize the costs, which exceeded the costs of some airport hotels in Europe (USD 50, dinner about USD 20, breakfast about USD 10). Jackies Guest house was built and first owned by a local politician Mr. Koung and has now a new owner.
After some hours rest upon arrival, the welcoming ceremony in the hospital started with a prayer and speeches by Dr. Peter Mathew George and the hospital director. The hospital was constructed in July 2016 and was built by Mr. Koung.
All the patients for the week gathered in a big hall. The decision for the mission to start the next day was well accepted among all team members, although it was Sunday.
All OT’s (0perating theaters) in the hospital were airconditioned. We had to use head lamps in just one of them, the other OT lamps functioned well. The tables were adjustable for height, which was not expected. 2 OT’s were close to each other, which made any interventions easier, especially for anesthesia. Two diathermies were working properly, there had been some trouble with the one that we brought with us. Before it is finally donated to the E&J hospital, it will be rechecked in Europe. Many thanks to Sister McDermot from South West Acute Hospital in Enniskillen, for this donation.
For the first three days, the work in all three operation theaters (OTs) ran smoothly. A special thanks goes to Dr. George, who selected the patients personally. On day four, a huge number of patients who had been waiting for surgery (almost 200) forced Dr. George to start operating himself in OT Nr. 4. This was not a very good idea from the organizational point of view as his hospital colleagues were (not yet) fully capable of recruiting and diagnosing patients for 3 or 4 OTs. Our radiologist with the ultrasound was a great help, excluding some patients (with enlarged lymph nodes, other swellings, etc.), who initially expected to be operated on.
On day four we stopped operating on children, as one of them had aspirated just recently breastfed milk during an anesthesia induction (it took some time for the mother to understand that milk is considered as a food and not just a simple liquid). Our anesthesiologists and the nurse managed to solve the situation skilfully with emergency drugs, an improvised aspirator and an oxygen concentrator. Under self-built intensive care, supplying antibiotics and oxygen over the following days, the aspiration pneumonia was managed and the child was saved. After this event, Dr. George took over the patient recruitment again and the mission continued smoothly. Dr. George, MD, PhD is basically an obstetrician and gynecologist with the good skills of a general physician and is capable of performing hernia surgery, including Lichtenstein mesh repair. And of course, with organizational talent. One of his reliable co-workers, Dr. Charles might also be an important link for future missions. Emanuel, an anesthesiology assistant, showed a lot of readiness to upgrade his anesthesiology skills. In the absence of HI teams, the whole anesthesia issues in the hospital depend on him.
We worked daily from 9am to 7pm, sometimes even longer. The local staff were always ready to work, even late into the evening. Lunch break (chicken gyros sandwiches like doner kebabs, sometimes French fries with fish) was also an opportunity for briefing the morning patients and planning the rest of the day.
The good thing of having a self-sufficient team (surgeons, assistants, anesthesia) was to work with people that one knew from hospitals at home and that were used to working as a team. Anyway, we educated the local staff as well, among them were many very motivated volunteers who applied to work for free during the week and helped so that the mission could succeed.
As we did not have enough gloves to fully support all the teams in 4 operation theaters in the sense of double gloving (as a Spanish team had done some months earlier), we used single gloves because of the expectation that all patients were HIV and Hepatitis B tested. As this was only possible for 2 days from the side of the hospital and further on against additional payment, we paid for the tests for the rest of the patients ourselves. It was not realistic to expect that the patients should cover these costs as they expected that the management would be free of charge. Covering some minimal costs from the side of the patients (or the hospital) is an issue that can be discussed in the future.
Anyway, the best surgical infection prophylaxis is a considerate and careful operating technique.
A good decision was to bring along over 300 disposable sterile gowns and sterile hole-drapes to ensure the sterility of the operative field. With additional education of the scrub-teams, we were more and more satisfied with the preparation of the operative field. One of the suggestions to the new hospital director Mr. Victor W. Kpaiseh (the general directors of the hospital had changed during our mission) was providing cloth gowns at least for the scrub personnel. This would demand improving the sterilization capacities (buying the second charcoal-run autoclave pot), which are one of the bottle-necks of the process. This idea is probably not immediately applicable, but might be solved in the future.
In 6 working days (4 full days, 2 half days) we performed 103 procedures on 86 patients (14 female, 72 male). The average age of the patients was 36.5 years. The oldest patient was 89 years, the youngest 1 year. The majority of patients had inguinal and large inguinoscrotal hernias (71).
Predominantly we repaired inguinals using the Lichtenstein (>95%) and sometimes the Shouldice technique with young patients (<5%). In 14 pediatric patients with inguinal hernia, the Mitchell Banks and Ferguson techniques were used. We performed 2 incisional repairs (retromuscular), 17 umbilical repairs, 2 undescended testicle repairs, 1 femoral hernia repair and 1 hemorrhoids operation (acute). We performed 2 revisions, 1 due to a postoperative hematoma, 1 for a suspicious hematoma (negative revision). As we had a reliable anesthesia team, the anesthesia was predominantly spinal (72), general (13) and local in only 2 cases.
The presence of a radiologist on such a mission was a very good idea: 70 performed ultrasound diagnostic checks preoperatively, 3 postoperative ultrasound checks, 12 pregnant women with ultrasound (education of midwives), 16 emergency ultrasounds.
At the end of the team work, we agreed with Dr. George, that it was a good mission. The farewell ceremony was much more a cultural event than just saying thanks and we were thankful to be able to be in Ghanta City, Liberia, together with the local hospital staff for their patients.
All this would not be possible without a skilled, experienced and enthusiastic team:
- Tomaž Benedik (consultant, surgeon, 2nd mission)
- Maria Greiner (consultant, surgeon, 1st mission)
- Marija Jekovec (consultant, radiologist, 1st mission)
- Irena Urbancic (consultant, anaesthesiologist, 1stmission)
- Katarina Primožic (registrar, anaesthesiology, 1stmission)
- Katja Carli (registrar, surgery, 1st mission)
- Luka Kovac (registrar, gynaecology and obstetrics, 2nd mission)
- Selena Benedik (medical student, 2nd mission)
- Mateja Selic (scrub nurse, acted as an anaesthesiological nurse, Hernia International mesh sterilizing support)
- Jurij Gorjanc (consultant, surgeon, team leader, 7thmission)
Spanish Successes at E&J Hospital
Memory Of The Mission Carried Out From 19 To 28 April 2018 By “Cirujanos En Acción” in the “Esther & Jereline Medical Center” Of Ganta City (Liberia)
The Ganta City (Liberia) mission was proposed several months in advance, and from the start it was a wonderful challenge: for the majority of the members of the team (except the lady anaesthetists) that was our first visit to Africa. The team was finally made up by 9 members:
César Ramírez (surgeon and team coordinator), Javier Moreno (surgeon), Elena González (surgeon in residence, 5th year), José Pradillos (paedriatric surgeon), Inma Giménez (anaesthetist), Ana López (anaesthetist) plus Paco Gomez, Sara Corredera and Verónica Fernandez. On April 19 we started each from his or her city (Málaga, León, Valencia and Murcia) and we met in the Casablanca airport to take our Air Maroc flight and its 23 hours to Monrovia. Then after a 4 hours flight in a commercial plane with unbearable heat, we reached Monrovia at 2.25 a.m.
We found waiting for us the Medical Director of the Esther and Jereline (E&J) Medical Center and alma mater of the local mission, Dr. George, and the highest authorities of that center. The Monrovia airport is small, all up-and-down, and lacking even the minimal conveniences of safety and luggage control, with a single customs with works with utter laziness. In this mission we’ve had no problem with our luggage (10 bags 30 Kg each, including a generator for electrical scalpel) thanks to the help we got at the Málaga airport from an Air Europa pilot, Nacho Ballesteros, personal friend of Dr. Javier Moreno, who worked hard to get everything properly done. For Verónica, Sara and Elena this was their first mission with “Cirujanos en acción”; the rest of us had already taken part in previous campaigns.
The way from Monrovia to Ganta City takes almost 4’30 hours along a rudimentary commercial road, and we occupied 3 local lorries that Dr. George books for us for all our stay in Liberia. Our lodgings in Ganta City are in a small guesthouse called Jackie’s Guest House where we have been able to choose either individual or shared room; that is the best available in the city and we have hot water, air-condition and a “tex-mex” meal, more than acceptable, which does for breakfast and supper “in situ”, and is taken along to the E&J Medical Center at lunch time.
There is absolutely nothing worth seen in Ganta City and no possibility for any excursion to touristic places, so that our days had been intense and very repetitive. Every morning we met at 7.30 a.m for breakfast, and half an hour later they took us to the Medical Center. On arrival we found a group of patients (children and adults) who had been called by the local doctors so that we would evaluate them.
Daily one of the surgeons of our team and the pediatric surgeon had a small room in which we saw the patients, examined them selected them for surgery. No pre-operation information has been asked by us, and the patients (children and adults) have been operated after the surgical evaluation.
The E&J-MC is something similar to what in Spain could be a small ambulatory with two operation theaters whose sterility conditions are just basic, and then a small room for patients had been arranged for a third operation theater. We have practically no material as it is a medical center in which only caesarians are performed, and now they are just beginning to carry out some cesarian sections as acute appendicitis.
Though there are respirators in the operation rooms they cannot be used because there is no oxygen; thus when general anesthetic with breading help is required for some patient, this has to be ventilated by hand by the anesthetist.
We had brought 3 whole sets of surgical material to operate hernias and one for pediatric surgery which we donated to the E&J-MC when the mission was over. We have fully utilized the more than the 300 Kg of surgical material we had brought with us, as they hardly have any gloves, gauze, antiseptics, sterilized gowns, sterilized fields, dressings (in fact since our coming, they have made use of our material for their surgical needs). Similarly we have taken their and the donated to them more than 200 boxes of omeprazole, paracetamol and analgesics for their use in Ganta City.
During the mission a total of 175 patients have been operated upon (83 children and 112 adults) with 249 surgical interventions. In 74 patients (almost a 40%) several 2 or 3 processes have been carried out. We have been struck by the amount of patients with inguinal hernia who associated umbilical hernias of at least 1.5-2 cm, and all the more as the majority were young, thin and with apparently good mussels. We have utilized 80 mosquito net gauzes donated by Hernia International and about 100 large opening and low molecular wait which had been donated by BBraun; we had enough and to spare. The patients remained for a night (the hospital has some common rooms for 3-4 patients and then one large common hall for men and another for women, were at least 20 patients could be accommodated. They were revised by us early each day to be able to release them and realize that there was no problem. A patient operated upon for an epigastric hernia had to be operated again for an important hematoma on the first day after the operations, and 4 patients have presented minor post-operation scrota hematomas which have needed no intervention. For a personal petition of Dr George we operated upon two young women with evident symptoms, who otherwise they wound have never been healed.
The medical and administrative authorities of the E&J Medical Centre have been most help from the start. We have received all kind of help, and all have tried to make us happy. On our arrival and farewell we were received with local songs and prayers by the local people, and as a special thanksgiving they have gifted us clothes with local motives which we’ll keep with all love. They have repeatedly asked us to come again as soon as possible because they are very much in need, and we surely will do it as it has been an unforgettable mission.