Giants of Gambia return
Maria Boutabba (Registered ODP and Sister Maria to the team and hospital community) reports
Operation Hernia Mission, AFRPC hospital, Farafenni, Gambia – 8th December -14th December 2012.
This trip proved to be extremely profound for both professional and personal reasons. I had a fantastic time, was incredibly busy dividing myself between different roles, including surgical assistant… but was so in my element. It was and remains a great privilege to have worked with like minded professionals who value safe patient care and doing the right thing for the right patient at the right time in a clinical environment so different to what we are used to in our own familiar healthcare systems. We all bonded so well and enjoyed each others company, particularly in the relaxing evenings, listening to Brian’s very funny anecdotal stories and saucy jokes.
In surgical assistant role
The multinational (English, Welsh, Irish working in Scotland, Polish and Swiss) team comprised of Andrew Kingsnorth, Lead Surgeon, Brian Stephenson, 2nd in command surgeon, Alan Woodward, Surgeon, Stephen Brennan, Surgeon, Slawek Koziel, Registrar surgeon, Katharina Wentowski, Anaesthetist, Michael Wentowski, Medical engineer and myself. Andrew has fondly named us the ‘Giants of Gambia’ for achieving what we did under the conditions we worked in.
We had an eventful arrival into Banjul, where one of Andrew’s small bags got whisked off in error to a resort hotel. After a delay and interesting police reporting process, it was returned intact, not something we would expect in the UK! We later made our way to Banjul port, where we waited in anticipation for the ferry that would take us across the impressive Gambia River to Farafenni.
Following what felt like hours and after polishing off some chicken and rice, our ferry eventually arrived. Amongst much local excitement, and eruption of frustrated tempers by queuing lorry drivers, we were herded on mass onto the ferry. We travelled the smooth, oil like river under the guidance of beautiful star constellations. We landed safely in Farafenni and made our way to what would be our very basic accommodation for the stay, Eddies Hotel, checking in somewhere around midnight on the 7th December 2012.
Throughout that initial experience we were looked after by the hospital communications officer, Saini. Saini would prove to be our valued friend easing our right of passage throughout our entire stay. Saini very efficiently organised our off duty entertainment time; we would sample an African music and dance evening, eat barbecued goat, visit the Senegal border, fishing village, women’s garden and eventually the Atlantic ocean waves on our last day.
The next day we met with the hospital administration. The hospital architecture is impressive but does not reflect what we were to come to accept as an under funded, under resourced, disorganised healthcare system. Following group prayer we discussed what we hoped to achieve during our stay. The administration was welcoming but hinted at the lack of resources at the hospital.
A lot of work was undertaken by the team to turn a ‘shell’ into an efficient, fully functioning mini day surgery unit. The ‘theatre’ developed into 3 operating spaces, with all surgical equipment, instruments and make shift operating tables scrubbed clean and organised to be fit for purpose. We set up a sterile storage area, scrub and gowning area and mini sterile services unit. We had one working diathermy machine that had travelled with Andrew. A startling Gambia fact is that in the whole of the country there are only 4 surgical diathermy machines!!
The transformation of the ‘shell’ would prove to become the pride and joy of the team and the few local staff who joined us to help. Of benefit to our clinical work, was our magical medical engineer, Michael, who fixed life saving equipment, we so often take for granted in the UK. Without this repaired equipment, which included suction and a couple of abandoned pulse oximeters, we would have found it difficult to achieve safe anaesthesia for the 16 children we later treated.
Katharina and I quickly realised we would not have a functional anaesthetic machine, despite several modern machines being available. Sadly these were all in need of spare parts to put them back in working order. However with Michaels help, we had proper basic monitoring, an ambu bag, suction and access to cylinder oxygen. We trawled abandoned equipment from previous missions to retrieve IV access and airway management devices. Katharina is a brilliant and committed anaesthetist, who showed so much maternal compassion for the children. Together, we carefully planned how we would safely pre medicate, anaesthetise the children and recover them post operatively – We went right back to clinical basics which we both found professionally satisfying.
We operated on 29 adults, the majority having local anaesthetic, with or without the support of Ketamine and Midazolam. A small number of adults had spinal anaesthesia. We operated over 4 days, with an efficient turnaround, with a ratio of approximately 1 child to 2 adults. All 3 operating spaces were kept fully utilised. An average operating day would typically reflect up to 9 patients operated on before lunch around 2pm and then 3 more complex cases in the afternoon and tidying up time ready for next day operating.
Child ready for postop care
We saw and operated on large paediatric inguinal and umbilical hernias. The adults had primarily very large inguino- scrotal hernias. We had a couple of complex umbilical hernia repairs which became mini laparotomies to repair them! We also operated on femoral hernias including, rather unusually, a mother and her two daughters. All the patients, where screened using the Kingsnorth classification, with Andrew, booking the patients to the operating list which was reviewed with me on a daily basis.
We had little chance to teach and train the local hospital community – there were no surgeons apart from one Obstetrician from Cuba. I did some basic theatre training with the few local nurses who were assigned to help us in theatre, and I hope to bring one particular nurse to the UK for an exchange visit. We had a Scottish medical student, on overseas placement join us for 2 days, and she found the exposure within our team rewarding. On a couple of days, 2 volunteers joined us from the schools for Gambia project – this assisted us tremendously as they helped bring patients to theatre, reassure them and they also helped wash and pack instruments.
We all acknowledged that Farafenni is very reliant on mission teams to assist with elective surgery. It is a sobering fact that once mission teams leave, there is no sustainable system in place to allow the local health community to carry on. We were humbled by how far patients will walk to access surgical care. The patient’s appreciation was immeasurable but the smile said it all.
On the last day we met the hospital administration again and exchanged niceties. Each member of the team was rewarded with a hand made shirt and letter of appreciation. We were reminded that we had been absorbed into the hearts and minds of both the hospital staff and local community.
I hope that the ‘Giants of Gambia’ team will make another visit to Farafenni in 2013 as per the wishes of the hospital administration.
Giants of Gambia OH team