During our first mission to rural Nigeria, we set up a medical and surgical clinic in a small town called Ibi. Our host organization, Pro-Health International, had hand-picked this location—an old, derelict government hospital about eight hours east of Abuja. Our team was composed of volunteer Nigerian and American physicians, surgeons, technicians, nurses, and other support staff. On the first day at the site, we resurrected the run-down shell into a busy, working hospital. There was no running water, but our hosts did bring a diesel generator that provided sporadic electricity.
Even though news of our presence spread primarily by word of mouth, hundreds of patients flocked to this makeshift hospital each of the five days we were there. Patients came from far and wide, usually on foot, to receive medical or surgical care for the first and only time in their lives. Most patients had infections or chronic illnesses for which we could give them only a small allotment of medication.
The tools available to the medical clinicians included anything they could bring by hand and that could run on batteries if power was required—limiting their instrumentation to stethoscopes, otoscopes, and opthalmoscopes. The team had no radiology capability, but we did have the means to do basic laboratory work, including hematocrit, HIV testing, and urinalysis.
Operating in a challenging environment
A smaller cohort of the patients (both adult and pediatric) presented with surgical problems to which we could tend. The team primarily performed hernia repairs (inguinal, umbilical, and ventral), orchiopexies, hydrocelectomies, and excision of soft tissue masses. Additional procedures included a mastectomy for a presumed phyllodes tumor in a young woman. The pathology we encountered was usually an extreme version of what is typically seen in the U.S.
Our operating room (OR) consisted of one small room with six operating tables cozily aligned in a mobile army surgical hospital, or MASH, style. Between the three attending general surgeons and a cadre of surgical residents, our team performed about 25 cases a day. We operated primarily using local anesthesia. We worked with three anesthetists who administered intravenous sedation in the form of ketamine, diazepam, and pentazocine for the bigger cases. Unfortunately, we did not have the capability to intubate, nor did we have supplemental oxygen or standard monitoring devices, which limited the scope of procedures we could undertake in Ibi.
We did have basic surgical instruments and functioning electrocautery, and suction that worked when the generator was working; we sterilized instruments by soaking them in Cidex. Our lighting was provided by battery-powered headlights. Patients would spend a few hours in a team-built recovery room before walking home. The patients’ families were the primary caretakers in the recovery room, but a few Nigerian nurses were available to supervise the postoperative care.
Though it was a humble and simple setup, the OR ran with amazing efficiency and miraculous energy. We were inspired to make the best of the spartan conditions and assist the endless line of patients camped outside the door.
Pro-Health has years of experience organizing medical missions and they were an outstanding host. The Ibi trip was an example of a well-developed and time-tested model successfully applied for more than 20 years.
Although operating was certainly challenging in this environment, rarely did it feel as though the lack of resources was significantly compromising the outcome. We were doing the standard operations that we would do in the U.S., albeit under severely substandard conditions. The level of teamwork, grace, and camaraderie was unparalleled. Our patients were universally grateful, whether or not they received surgical care or not. They seemed to recognize the sacrifice we were making to try to help them. I will always remember one case in particular from this experience.
Team effort saves a life
A family brought a 22-year-old woman into the clinic. She presented with a syncopal episode and an altered mental status. The patient was also complaining of diarrhea and vaginal discharge. Upon further questioning from the medical staff, she indicated that she had been having abdominal pain for three to four weeks. She was too weak and altered to give any additional history.
On exam, the patient had a weakened radial pulse and heart rate of 120 and she was lethargic and diaphoretic. Her conjunctiva appeared markedly pale, and her abdomen was diffusely tender and distended.
An intravenous line was placed, and a finger stick was checked, revealing a glucose level of 36. An ampule of D50 was given with an improvement in her mental status. Her abdomen was still diffusely tender with worsening distention. At this point, a peritoneal tap was performed, which demonstrated gross, unclotting blood. A serum hematocrit returned at 14 percent. Blood donations were sought from her family as well as from other patients waiting in line to be seen.
The patient was quickly carried to our OR. As the team prepped and draped for emergent laparotomy, our anesthetists administered ketamine, diazepam, pentazocine, atropine, and promethazine. A urinary catheter was placed. An anesthetist monitored the patient’s ventilation by placing a hand over the mouth and through the use of a battery-powered pulse oximeter. Another anesthetist placed an additional intravenous line and started a saline bolus.
Upon exploration, the patient was found to have an approximately 2 liter hemoperitoneum. The clot was evacuated, and the abdomen was packed. The bleeding was emanating from the pelvis, where it became clear that the patient was hemorrhaging from a ruptured ectopic pregnancy. A left salpingo-oophorectomy was performed. The abdomen was irrigated and closed after we confirmed that there was no further bleeding.
She was then carried to our recovery room and given two bags of uncross-matched, fresh whole blood that we were able to procure from other patients waiting in line. The team gave one of the nurses in the recovery room careful instructions for intensive care unit (ICU)-like care: BP q 30 minutes, strict I/O, and bolus with isotonic crystalloid if UO less than 20 cc/hr. We were required to return to our quarters that night, but we did go back later for a postoperative check. The nurses in our make-shift ICU were following our directions faithfully, and the patient appeared to be stable.
Short-term missions make a difference
The following morning, she looked remarkably better. The patient’s mental status was markedly improved, and her blood pressure and heart rate started to normalize. Her pain was well-controlled. Her conjunctiva were still pale, however, so we administered an additional bag of whole blood.
The following postoperative day the patient looked even better. Her blood pressure was now 120, and her heart rate 80. She was started on clears and began to ambulate freely.
On postoperative day three, she gave me a hug. It was our last day at this site, and time for us to go home. We will always remember her grateful eyes as our own filled with tears.
I do not think that she realizes how close to death she was, or just how extraordinary the effort of the Pro-Health team was that helped to save her life. We are grateful that she is now well. We happened to be in Ibi when she became sick, she had a pathology that was within the reaches of what we could treat with our setup that day, and she lived. She may not understand all these details, but her story certainly energized each member of our team and helped us understand in small part why we had come to Ibi. And the experience changed us all.
Short-term surgical missions clearly are not the long-term solution for sustainable health care in the developing world; however, this type of work is too often disparaged because of its limitations. Some members of the surgical community will point to these shortcomings as a reason for surgeons to abstain from missions. For this team, it became clear after that first trip to Nigeria that although our efforts might be just a small contribution in the grand scheme of things, our efforts can make a profound difference one life at a time.
The authors would like to acknowledge the four general surgical residents from St. Luke’s-Roosevelt who each contributed to this patient’s care and provided many of these pictures: Deva Boone, MD; Gary Schwartz, MD; Daniel Kirchoff, MD; and Elizabeth Myers, MD.