Operation Hernia - Rwanda February 2014: Report by Eleanor Zimmerman

I had the tremendous privilege of accompanying the UK and German teams to Rwanda in February this year for what would be my first trip with Operation Hernia.

Rwanda, or the 'Land of a Thousand Hills', is a landlocked country with 23 lakes, five volcanoes and a luscious green countryside filled with plantain fields and dense wild forests in the west and tropical savannah in the east. The population of around 11 million is largely rural, and although the country has recently invested in outstanding developments, for example, the perfect tarmac road traversing the country between all major cities, healthcare facilities are too often difficult to come by for those who live in the villages; there is an average of 0.1 doctor per 1,000 people which compares to 2.7 in the UK and 3.8 in Germany. The medical system however is one of the best in Africa. At a cost of approximately €2 per year, every individual is expected to buy health insurance, the rest of the cost is provided by the government and charitable donations. Unfortunately, we found that many patients would still not have medical insurance, as even this is a large cost to a big family and buying school uniforms and books takes priority.

There are eight medical schools in the country, but up until 3 years ago, there was only one medical school, providing 42 graduates a year. The number of doctors per person is therefore expected to rise rapidly in the coming 10 years, and will contribute to the improvements in health that the government has instigated since 2000. Surgery and anaesthetics remain the least competitive specialties in Rwanda, due to the long working hours and understaffing. This is in part why Rwanda still depends upon a large proportion of its medical workforce coming from neighbouring Democratic Republic of Congo, Uganda and Burundi – especially since the Genocide in 1994 where a large proportion of doctors fled the country or were killed.

Our first weekend was filled with good food and stories shared by team members who were attending a mission in Rwanda for their third time, as well as trips to the buzzing city centre of Kigali. By the end of the Saturday, the team was complete, and we began planning for the busy week ahead of us.

Our group was divided into three teams located at different hospitals around the country: Nyamata Hospital, Gahini Health Centre, and Harare Hospital.

The UK team consisted of myself (an excitable FY1 – by far the most junior group member), Mr Chris Oppong (Consultant Colorectal Surgeon and Charity founder), and Helena, our scrub nurse from Plymouth. Our base was Gahini Health Centre, a small hospital built in 1920 by the Church Missionary Service, at the top of a hill overlooking the stunning Lake Muhazi. This hospital was to receive Operation Hernia for the first time.

 

We received a huge welcome from the department, and were introduced to the staff at their morning meeting. We were put up in the clinical director s house which he had so kindly organised. We were cooked hoards of amazing local dishes, and were soon to learn that this would be a daily occurrence! Dissemination of the news that we would be arriving and working in Gahini was in two parts: through hospitals throughout the country, who would refer patients directly to us (these patients would arrive with an accompanying short slip that often read 'hernia' the extent of transfer of information!). The other means was by local radio: approximately a month prior to arrival, regular announcements were made of the medical mission that would be operating on hernias free of charge. They appear to have neglected to explain the term 'hernia' very thoroughly, as we later learned that hernia in local lingo can be translated as loosely as 'ailment', which explained the gentleman who turned up at one of our clinics who, when asked to point to the site of his hernia, pointed to his back As it was the first trip that Operation Hernia had made to this site, we were not only performing numerous hernia repairs, but Chris was training local surgical trainees and we were also gathering information such as the type of equipment needed and the specialty specific expertise that this population base may benefit from.

As we expected, the equipment was limited and out-dated, and facilities were poor. We had brought a large number of basic equipment with us, including sterile drapes, gloves and sutures, so as to minimise the burden on the hospital hosting us. The electricity was temperamental, and we were soon regretting not bringing head torches.

Our working day was usually 12 hours, starting at 7:30. Chris devised a strict educational programme to coincide with back-to-back operating, enabling the training of five local surgical trainees to perform mesh hernia repairs. Approximately 15 trainees had attended at different stages throughout the five-day week, to observe and learn the methods demonstrated by Chris. It was humbling to see the enthusiasm with which they threw themselves into the work, desperate to be taught, shown and practice. I was thrilled to witness the patience with which Chris took his time to teach every single one of us, demonstrating each step meticulously with each operation, testing us and reminding us of the anatomy as we took it in turns to assist him. I have never been taught with such devotion and care, and the local trainees echoed this.

Gahini hospital's surgical department is staffed by the surgical director (Clovis), an FY2 equivalent – then Year 1 surgical trainee (our fantastic host Emmanuel) and William, a South African surgeon who has lived the last 12 years in Rwanda with his family, and devoted his career and life to performing life saving operations in the remote town of Gahini.

The anaesthetists in Gahini Hospital aren't doctors but are trained practitioners, and one was fairly junior, which sadly became evident through a sequence of events on Day 2 of our trip.  A 5 year old was due to have a simple herniotomy but he went into bronchospasm while being extubated.  After resuscitation he thankfully recovered fully, and we kept a close eye on him for the rest of the week. This was a valuable lesson, and after discussion and reflection with the whole team we set a minimum age limit of 8 years for all future patients. This was a tough decision, as it meant that many parents were turned away, but given the lack of close monitoring facilities it was an essential one.  In fact, we instigated many systems that might seem second nature to us, including consenting, marking, intraoperative antibiotic prophylaxis and implementing ‘time-out’.

By day 4 we were running two parallel operating lists, with the now confident surgical trainees running their own lists in the room neighbouring ours. This hugely increased the number of patients we were able to operate on, and was a rewarding experience for all involved.  We operated on inguinal hernias, femoral hernias, epigastric hernias, hydroceles – and each and every patient left with a huge smile on their face, keen to be able to get back to work and not be debilitated by pain any longer.

By the end of the five days we had operated on 42 patients, fixed 34 inguinal, two epigastric, four umbilical and one femoral hernia and performed 8 herniotomies and one Lord’s procedure (all despite numerous power cuts), but above all we had built strong friendships and a firm foundation to build upon on for the next humanitarian mission to Gahini Hospital.

We were waved off after a generous leaving lunch party on the side of Lake Muhazi with the whole department, where we were thanked for all our efforts, and we each received a parting gift to remind us of Rwanda. It was with a heavy heart we all said our goodbyes.

At the end of this fantastic medical experience, I rewarded myself with a short safari in Akagera National Park, surviving a perilous journey where the tour guide managed to topside our car into a ditch and Helena, Sandra and I watched 20 locals lift the car up in the air and place it back on the road for us! I also braved the hilltop minibus ride north and trekked the beautiful Mount Bisoke, topped by the crater-lake at 3,711m, despite altitude sickness and the freezing temperatures at the top! Sadly my path didn't cross that of a mountain gorrilla – but I did have to leave one adventure to another year in Rwanda's gorgeous countryside….........

Eleanor Zimmerman