Anesthesia in Developing Countries: The Road to Entebbe

After a leisurely morning packing and a quick trip to Target (bless the Daytons, they stock insect repellant in December for people like me), I showed up at the Delta counter two hours before departure. The airport was nearly empty. Once the counter agent and I came to an agreement: Kevin Healy's bag to Uganda, Daniel Healy's bag to India, the rest of the check-in and security screen was a breeze. I'm going to spend a week in Kampala at a course entitled Anesthesia in Developing Countries. Grant Maxted, one of my anesthesiologist friends from Toronto, recommended the course very highly so I am keen to get started.

TERRAMOTO!!!

Wednesday is a market day in Nuevo Progreso, so clinic was busier than usual. There was a crowd waiting to register and Sor Veronica was at the head of the line, calling names and giving direction.We had three operating room cases today: removal of a scalp lesion, tonsillectomy and cholecystectomy. The list was completed by 10:05. 

Line up for registration on Wednesday morning

Sor Veronica calling names for clinic patients

On the way back to the dorm I worked up the courage to try a bit of ice cream from the street vendor. Small serving but tasty, and for Q2 you can't beat the price. 

 I like the pictures on his cart at least as much as the ice cream.

 The earthquake struck about ten minutes later. It was a pretty vigorous shake, lasting about fifteen seconds. I kept expecting the quaking to diminish but it got stronger until the walls were perceptibly moving and a couple of the big terra cotta flower pots on the sun deck tipped over. 

As I type, this plant is being watered by our afternoon down pour.

 No structural damage, no injuries for patients or staff. Tara Starr, one of our ophthalmologists, had to complete a blepharoplasty by flashlight. No one was undergoing cataract surgery at the time.

Tara looks pretty relaxed (and just plain pretty!) after performing surgery under trying conditions.

A couple of bottles broke in PACU and a package of Beaver blades fell on the floor in the operating room. At the behest of the local authorities we spent two hours at the soccer field, a precaution against after shocks. We felt pretty silly when we came back to find that the Guatemalan doctors had been seeing patients all along. It's been quiet all afternoon so I hope the excitement is over. 

A member of the Hospital de la Familia board of directors accompanies each team. Bill Stewart is our board member. He's a great guy, neither as old or as rich as Montgomery Burns. Their political views do align pretty closely,

http://www.youtube.com/watch?v=ltCIEbLMaQg

so it was a bit of a sad morning for Bill. Better luck next time, Bill! (Not really).

First Report from Nuevo Progreso

I had major misgivings in the days prior to our departure on November 1. Recruiting for the 2012 team was difficult. Mark Taylor, general surgeon from Ames and a stalwart member of the team since 2002, could not attend. Three of the four ophthalmologists from 2010 were not returning. None of the optometrists from 2010 returned. A plastic surgeon who was referred by a friend played cat-and-mouse with me through the summer and fall. In October he declared his commitment to the team and intention to join us, and cancelled 24 hours later saying he had an open house in his new office on November 7. I wasn’t mad; who hasn’t had an open house pop up at the last minute? To top it all off, our medical repair engineer cancelled the day before we were scheduled to leave USA.

The morning of departure didn’t look any better. I couldn’t find my shoes and had to sneak away in a pair of trainers I found in the bowels of the hall closet. My apologies to Kyle, Matt or Luke (they were last seen in a trash can in Coatapeque).  In Chicago I found out that one of the volunteers overslept and missed her flight from SFO.

  

After that last bit of pain the trip has gone very well. We got our twenty-one pieces of luggage checked in at Des Moines airport and they arrived intact in Guatemala. The customs people were a little confused. They had a waiver for another team and couldn’t find any of our drugs on it. Sr. Veronica saved the day and we were in the hotel by 11:30.

Enough about travel. Here’s a photo of Debbie Wise RN, Lloyd Smith MD and Amanda Poppe: all from Ontario. Amanda is studying kinesiology at Thunder Bay; Debbie and Lloyd are from Toronto. I hope no one in Iowa will tell Mark Taylor how good a surgeon, and fast, Lloyd is. Amanda is applying to medical school.

This is the view from the dining area, looking over Nuevo Progreso. On a very clear day you can see the ocean

This is a partial view of the open-air kitchen, newly remodeled since my last visit in 2010.

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Amanda is the head of the kitchen ladies. She oversees food preparation. She and Rosanne  hit it off while Rosanne was working on the Cooks' Dinner in 2008.

And these are the roasted peppers that we had for Monday lunch.

Mansoura Egypt Cleft Lip & Palate Surgical Volunteers International October 2012

This year my path to Egypt took me through Zurich. 

I flew Swiss International from Zurich to Cairo (here’s a picture of the flight over the Alps). They hand out chocolate bars in economy, a big improvement over the pretzel bits you get on US carriers. 

After arrival in Cairo we waited for a second wave of team members and then loaded up and headed for Mansoura. We had a good turn out for clinic the next morning. Here’s a video of the waiting room, fairly early in the morning. The man in the hat was a character; I saw him later that week when his relative had surgery. The waiting room in Mansoura

 The evening after clinic we went to dinner at a club along the Nile. On the way back we passed a circus, but were too tired to go in.

 I can’t say enough good things about the medical students in Mansoura. They were helpful in clinic, well prepared in basic science and eager to get some clinical experience. Dr. Laura Monson is an excellent plastic surgeon with cranio-facial experience and there was always a crowd around her table. I didn’t have much of a view but I could watch the bag move up and down.

I talked about the technique of direct laryngoscopy and tracheal intubation all week and on our last day I let one of the students go after it without me beside him. This is how we did it: an inhalational induction with oxygen and volatile anesthetic, followed by an IV under deep inhalation anesthesia. I do my own laryngoscopy, to make sure there are no surprises, and spray lidocaine on the vocal cords. 

Then I gently control ventilation until the patient is apneic. At that point I hand the laryngoscope to the student and walk to the end of the table. Holding tightly onto the table, I breathe slowly and don’t let go until the pulse oximeter reading falls below 94%.

Here are some photos of the students at work. I gained a new understanding of co-operative learning. And, yes, they got the child intubated. 

Gaza Peds Urology PCRF September 2012

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We stayed at Al-Mathaf Hotel on the north end of the Gaza strip.

http://www.almathaf.ps/hotel/.

Al-Mathaf is a first-class hotel with a good restaurant and a museum that displays artifacts found in Gaza. Some date back more than two thousand years. Across the road a mosque is under construction. The site overlooks the Mediterranean and the mosque will be beautiful when it is completed.

 

Our morning commute was always interesting. We travelled to and from the hospital in an ambulance. Horse-drawn carts are common.  Passing depends on the relative abilities of your vehicle and the one being overtaken, as well as a snap assessment of the character and motivation of motorists in the opposite lane. I think Gaza would offer a good surfing venue if it wasn’t so difficult to get in and out. Here's a YouTube clip of the commute: http://youtu.be/7wi_FMvqQ8w

The fish market was interesting. We usually got there after the peak of activity, but some days there was still some commerce underway. 

http://www.youtube.com/watch?v=oEBskDFDg_4&feature=g-upl

You could also see guys on sailboards fishing closer to shore.  Fishermen who go too far out will be chased by the Israeli coast guard.   -->

We worked at the Al Aqsa Martyr’s Hospital in central Gaza. http://topics.nytimes.com/topics/reference/timestopics/organizations/a/al_aksa_martyrs_brigades/index.html

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The staff at the hospital is uniformly friendly and helpful. Our host, Dr. Fayez Zeidan, is a kind and generous physician who worked very long hours while we were in town. Here you see Dr. Fayez and Dr. John Gazak operating to correct a kidney deformity in a three year-old girl. She had beautiful red hair. She was not personally pleased to be there but her parents were very grateful that we could help her.

 

 

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Getting home from Tel Aviv was a bad news, good news story. Part of the problem was my fault: I got to the airport at 9:30 pm, only two hours before departure. Also, I don’t think that Ben-Gurion airport puts their A-list security team on duty during the Shabbat that abuts Rosh Hashanah. They X-rayed my gear a couple of times and then had to consult with higher authorities (probably about why they had to X-ray it so much). The guy who seemed to be in charge had undergone a major craniotomy within the last six months and I wonder if the plate in his head is seated properly.

I was told that a man travelling alone is suspect. Thus, the family: My husband, my daughter from a previous marriage, and "our" son.

The good news? I met some swell people who also missed their United flight.  We were routed through Moscow on Aeroflot (try the lamb). The Aeroflot flight attendants’ outfits are to die for. I loved the hammer-and sickle-on the cuffs.

Two of the attendants in economy wore name tags saying "Ekaterina".  One more and I would have been concerned.

 

Wrap up on Beit CURE Blantyre Malawi

The anesthesia equipment and staff at the hospital were terrific. I had a monitor with end-tidal CO2 and agent analysis and some wonderful people to work with and help me.

I mentioned Polena in my last post. I also worked with Steve, a CRNA who is six months out of training (vs. thirteen years for Polena) and Ruth, a registrar from England who has been working in South Africa and Malawi for the last couple of years. They were all happy about learning to do an infra-orbital nerve block for the lips.

Steve and me in the staff room.

I told Steve that I didn't think he was as good as Polena, but not to feel bad because I don't think I'm as good as Polena, either. Ruth will return to England this fall to begin training to become a consultant anesthetist. After her work in Africa she is more experienced than some of the junior consultants she'll be working under. She's a good soul, seems very spiritual and I think she will tolerate the experience well.

My one disappointment was a 2 3/12 year-old girl for a cleft palate repair. It was an isolated defect (her lip was intact). She was very small for her age, only 7 kg, but seemed vigorous and had trouble with milk coming out of her nose. So, despite some misgivings we put her on the list. She was our first case on Tuesday morning. The induction was uneventful but try as we might, none of us could get an IV in her.  During the IV flail Roy came to me and said that the palate instruments had not been sterilized and that it would be fifty minutes before they were ready. We decided to reschedule her for Wednesday, rather than keep her anesthetized for an extra hour. Wednesday, after making certain that the gear was sterile, we went ahead with the induction. The IV was a problem again but I managed to put one in a vein (name unknown to me) in the right side of her neck. I thought we'd be in good shape, but between her small mouth and the Dingman retractor we had it wasn't possible to get exposure of her palate without kinking the endotracheal tube.

I don't have a scale marker here, but the distance between the blade and her upper incisors was less than two inches.

As we tried different maneuvers the endotracheal tube popped out of her windpipe (this is not a good thing) and I hurriedly--fat man moving at the speed of light--replaced it with a larger tube. Still the kinking! I didn't want to try putting in a yet larger tube, so we reluctantly cancelled the case. Roy had the task of explaining to the mother why we had anesthetized her child a second time to no purpose.

I'll finish up with my success story. A seventeen year-old woman came into screening, hoping to have her cleft repaired. She brought her three month-old daughter, who also had a cleft, with her. She had been told that her daughter was too young for the surgery. I explained to her the “rule of tens” that I like to follow: ten weeks, ten pounds and a hemoglobin of 10 g/dl. She was skeptical and wanted me to show how I had calculated the baby’s age. Fortunately the doctor whose exam room I was using had a calendar on his desk, so we counted out the weeks for her and she agreed to surgery. He was our youngest patient of the mission. We operated on mother Tuesday afternoon and child Wednesday morning. The photos were taken on Friday afternoon.  There’s nothing better than getting a twofer and having such good results.

Blantyre: Screening and the first day of surgery

This is Roy, our plastic surgeon, checking his email.

I ran into Roy Kim in the line for check-in at the airport. The lady who checked me in was very friendly. She asked if I could eat a seafood dinner and when I replied, "I'm on a seafood diet. When I see food, I eat it." she gave me a high five. You don't see that at the Minneapolis airport. The airport in Blantyre is smaller than I expected but eventually we got all our gear and headed for the CURE Beit hospital to unload and organize. I looked at the anesthesia machines and hope they will let us use the one that has both halothane and isoflurane vaporizers. The two make a good combination: halothane for induction, isoflurane for maintenance. There seems to be plenty of anesthesia supplies so I should be in good shape.

Blantyre airport, Malawi. Nice big 737 from J'burg.

I talked to Kristie Bishop, a lady I've worked with in Egypt, about my plan for analgesia for the kids. She thought it sounded do-able so I'm anxious to get started. We got back to the hotel about 2:30 and talked, had some lunch, talked some more. The internet works best in the courtyard and there is a tent with table and chairs that is very pleasant. I managed to stay awake all through dinner and turned in at 8:00.

Later Sunday night


We just got back from the screening clinic. Twenty children and adults came through; we put 17 on the schedule for the coming week. One lady, 17 years old, came in for a cleft lip repair and we put her 3 month old daughter with a cleft lip on as well. She was hesitant to approve her daughter's surgery (someone told her the child was too young) so I went over the rule of tens with her: ten weeks, ten pounds and a hemoglobin of 10 g/dl. Fortunately there was a calendar on the desk I was using because she wanted to know how I'd calculated her age. Oh, and I got to practice my singing skills. The ditty about the fishies and the hootchie-cootchie dance was a big hit.

Courtney Bradley, RN from Cedars-Sinai LA, checking pulse
oximetry on one of our prospective patients.

Our first day of surgery went well. We ended up in an operating room with no windows and an anesthesia machine that was under the weather. The CURE staff switched it out for another and we were under way. Our four cases, all lip repairs, went well. I worked with Polena, an excellent CRNA, who was interested to learn about LTA for mask induction and infraorbital nerve blocks. Also got to treat some halothane dysrhythmias (nothing serious).

Immaculately clean and well-staffed hospital.

Kuche Kuche, the pride of Malawi. The Pride
of San Francisco in the background.

Polena, the CRNA who worked with me on Monday.
She's terrific.

Precious, our first patient, the resting after surgery

Berthe, our second patient Monday, enjoys a little porridge.

Overnight in Johannesburg.

The flight from Minneapolis to Johannesburg was long but uncomplicated. I changed planes at Dulles airport in Washington. The Dulles to Johnnesburg leg was broken up by a stop at Dakar Senegal at 5:30 in the morning. We were on the ground for about 1.5 hours while we refueled and accepted new passengers, but they wouldn't let us get off to stretch our legs. I was very fortunate in that I got an upgrade to first class from MSP to Dulles and had an empty seat beside me on both legs of the flight from Dulles to Johannesburg.
A man from the guesthouse gave me a ride from the airport. He started the car while I returned the luggage cart, and when I went to enter the car I nearly crawled into his lap. Left-hand drive!


Tonight I'll sleep at a quiet bed & breakfast, the Sunflowers Guesthouse, 15 minutes from the airport. I hope to leave at 7:45 Saturday morning for a 10:00 flight to Blantyre Malawi.

Preparing for the trip to Malawi Africa with Operation of Hope.

I spent most of Wednesday packing for a trip to Malawi. We will be doing cleft lip and palate surgery at the CURE hospital in Blantyre. It will be a long trip, with an over-night in Johannesburg South Africa on Friday. 

Mary Greeley Medical Center, Ames IA,  donated most everything you see in the picture. I bought the children's Advil and acetaminophen suppositories on-line.

My plan is to use pre-op acetaminophen, an infra-orbital nerve block during surgery and Advil in PACU. I hope to minimize the use of narcotics, avoiding nausea, vomiting and respiratory depression. 

Sunday was a Crazy Day

The team: Amahl, Teresa, Samer and I met breakfast at the hotel before heading off to the hospital. My previous experience with screening on the West Bank involved pediatric urology and a surgeon who spoke no Arabic. Today was much different, with patients coming in suffering from medical illnesses that would not benefit from surgery. We did two cases in the operating room. One was especially memorable: a fourteen year-old girl for a revision of her ventriculo-peritoneal shunt. I did not have her endotracheal tube sufficiently secured and it came out while the surgeons were tunneling the distal portion of the shunt. I tried deflating the cuff and blindly pushing it back into her larynx without success. At this point standard procedure would have been to tell the surgeon to cover the wound, pull down the drapes and re-intubate her. Since she was well oxygenated I removed the tube and put a mask over her face, giving her gentle positive pressure ventilation. Happily I did not use a muscle relaxant for this case so she started breathing spontaneously within a few minutes. I had a stable, satisfactory situation so I kept this up for the forty minutes it took to complete the surgery. Given the risk of shunt infection with a break in sterile technique I think I managed the case appropriately. I want to stress to anyone in an anesthesia training program that this is not the management I would describe to a board examiner. Keep in mind the sentiments found on this box of exam gloves.

Photos from Nablus

We got to spend some time away from the hospital and the operating room. We finished early one day and got to visit Jacob's Well, where an Orthodox church is built over the well where Jesus asked a Samaritan woman for a drink. I had some of the water. It was pretty good, and an hour later I was thirsty again, just like He said.

Here you see a bucket leaping out of the well.

I think this picture tells of the life of St. Bartholomew,
who converted a king of Armenia (l.) before being flayed (r.).

Amahl Jubran, Teresa Bubb and Samer Elbabaa. I loved
working with you guys and hope to do so again. 

Dr. Achman (seated on left), the neurosurgeon from Nablus, was a great host in the hospital
and invited us to a cookout at his home Friday afternoon. 

Eating luz (green almonds) from Dr. Achman's orchard.