Penny Howell reports from Chachapoyas, Peru
OPERATION HERNIA, CHACHAPOYAS, PERU
23 March - 5 April 2013
Operation Hernia ran 2 missions to Peru in 2012, both to the capital city, Lima. This was the first visit to a rural area of the country, run again in conjunction with Dr Jaime Herrera, President of the Society of General Surgeons of Peru. The local co-ordinator was Dr Rolando Ramos, Consultant Surgeon in Chachapoyas in the Amazonia region of Northern Peru.
The mission was based in Chachapoyas, a small town 650km north of Lima. For logistical reasons of patient transport, the first 3 days were spent in Bagua, a smaller town 160km away, but co-ordinated through the hospital in Chachapoyas. Bagua is at an altitude of 400m, was hot, with temperatures of 30 degrees and humid. Chachapoyas, at an altitude of 2,300m was colder, about 16 degrees, and still suffering from the rains of the wet season. It was also high enough to cause some altitude sickness in susceptible individuals.
The incoming team comprised surgeons Alan Cameron (leader), James Barnes and Ria Rosser from UK, Dan Scopetta from USA, Cea Cea Moller from Australia and anaesthetist Penny Howell from the UK. Dan Scopetta's son, Andy, was the only non-medical member of the team, who had been co-opted for his Spanish language skills.
The Peruvian surgeons were Dr Jaime Herrera from Lima and Dr Rolando Ramos from Chachapoyas, with surgical assistants Drs. Enrico, Lucio and Jesus. An enormous amount of work had been done locally before the arrival of the team. 440 potential patients had been identified and about half the number had been selected for surgery. Many came from distant villages, some as far as 12hr travel away, and transport had been organised. The incoming team met in its entirety for the first time at Tarapoto airport, there to be greeted by Drs Herrera and Ramos, 3 vehicles and their drivers. We set off on the 260km drive to Bagua, arriving there at about 10pm after a very long day of travel.
At 7am the next morning we were taken to the hospital where the first stop was the ward, to examine the 27 patients for the day and mark them with operation site and type of anaesthetic.There were 3 theatres, only one with airconditioning, which was unfortunate with temperatures of 30 degrees. There were 2 operating tables in each theatre, except when one theatre was used for emergencies. Each table had its own scrub nurse, but often only one runner for both tables. The nursing staff worked extremely hard: several had come from Chachapoyas to help, along with the 3 surgical assistants. If spinal anaesthesia was used, the scrub nurse often assisted the anaesthetist, before prepping the patient, preparing the instruments and then assisting the surgeon.
Communication could have been a problem: two surgeons spoke a little Spanish, Dr Herrera was with us for 3 days and spoke fluent English. After he returned to Lima we relied heavily on Andy Scopetta, who was fairly fluent in Spanish. He also rapidly learnt the ways of the operating theatre, and was able to find sutures and mesh for the nurses and acted as an extra runner in theatre. The whole team learnt some rudimentary medical Spanish (dolor=pain, toser=cough, poncho=drape) and the enthusiasm of the nurses ensured that we eventually understood what they were trying to communicate.
We worked 2 long days in Bagua, finishing at about 9pm, followed by a beer, a meal and an early night. The last day was a half day, as we were due to move on to Chachapoyas: we finished the last patient at 4pm, celebrated with a pisco sour (a Peruvian speciality of brandy, lime juice and egg white, delicious!) with the theatre team, and then helped pack up all the equipment. After a late lunch we set off for Chachapoyas as darkness fell, arriving there at about 9pm. We were met by hospital and local medical staff, including the head of Health services for the Amazonas Region. After a brief tour of the surgical ward, where the 25 patients for the following day were in the process of being admitted, we went for dinner with all the staff. 2 of the team, already suffering the effects of altitude, went straight to the hotel: in all we lost 2.5 surgeon operating days to altitude sickness.
The next morning started with press conference with team members and representatives of the hospital and local health authorities. The mission was featured on local TV and radio programmes. Chachapoyas is a larger hospital with more staff than Bagua. Of the 4 theatres, one was only used when free from emergency operating, and two others had two operating tables apiece. Additional anaesthetic assistance was provided by Dr Laura, wife of Dr Rolando Ramos, who also helped ensure the paperwork was completed and kept in order.
It was good to work alongside members of the team who had joined us in Bagua, now on their home territory of Chachapoyas and it made our new environment seem less strange. Although the daily number of patients was greater in Chachapoyas, being a larger department the turn around time between cases was quicker so we finished slightly earlier in the evenings, by about 7pm. The system in both hospitals was that the patients were admitted the evening prior to surgery, and were clerked on the ward by the intern. The 3 interns were excellent and very hard working: they were expected to clerk the patients and then join us at meals and later, on sightseeing expeditions to act as interpreters (their English was good).
The pathology was inguinal, femoral, epigastric, umbilical and incisional hernias. There was one post-traumatic hernia from a stab wound. During the 8 days of the mission a total of 211 patients underwent 243 operations. Of the multiple operations, most were bilateral inguinal hernias, although one patient had 4 hernias repaired, bilateral inguinal, epigastric and umbilical. Local anaesthesia was mainly administered by the surgeons, sometimes with sedation. Spinal anaesthesia was performed for 44 cases, mainly for multiple or irreducible hernias. General anaesthesia, for 16 children aged 3 - 12, was with mask and airway, the one adult GA was intubated.
One patient returned to theatre for exploration of scrotal haematoma on the day of surgery, and no other complications have been notified to the team. The chief of the local health authority was interested in the work of the mission, and very helpful. She was also keen to audit the results, which will guarantee robust follow-up. A daily tally of patients treated by Operation Hernia was displayed outside the hospital in Chacapoyas for all to see.
The work done by the mission seemed generally appreciated. At the end we had a formal send-off from the mayor and various health authority officials, with speeches and presentations.
The middle weekend was Easter, and although we worked through the weekend, we witnessed and joined a procession carrying a statue of the Virgin through the streets on Good Friday, accompanied by crowds and a brass band. There was time for sightseeing in this interesting and less frequently visited area of Peru at the end of the trip.
The pre-Inca remains at Kuelap, 500 years older than Machu Picchu were fascinating, although the approach road was disconcertingly primitive and precarious (and since our visit has been washed away in the rains). The visit to the Gocta waterfall, reputedly the 3rd highest in the world was a very damp affair, with pouring rain and landslides causing road blockage on the way home, the waterfall only dimly glimpsed through the cloud and mist.
The museum at Lleylebamba, with the mummified remains of Chachapoyas dead was well worth the 2.5 hour trip into the remote mountainous region. The mission took place in the wet season, which is not a good time to travel in this region. Closure of the only road out of Chachapoyas due to landslides was a daily occurence, causing transport delays. The team left one or two days earlier than planned, to avoid missing flights, but then all managed a last meal together in Lima, with Dr Herrera, who had returned earlier for official duties.
Lasting impressions? From the patients and their relatives, the appreciation of and gratefulness for our efforts. From the staff, the warmth and friendliness, despite a lack of common language. The acceptance and the sense of humour, as always, carrying off the sticky moments in theatre. The team, working together across nationalities and cultures, for the benefit of those tremendously disadvantaged patients.
It was an unforgetable experience, hard work but enjoyable and the team, as well as the patients, all benefitted in different ways. We were all privileged to have been part of it.
Dr Penelope Howell