PEDIATRIC SURGERY CAMPAIGN GAMBIA APRIL-MAY 2023

SURGEONS IN ACTION-ASEDA-CHOSAN

DATE May 23, 2023

1. TECHNICAL REPORT:

1. DATES AND LOGISTICS DEVELOPED: The campaign was held at Bundung Hospital in Serkunda from April 30 to May 8, 2023.
   • The group of volunteers consisted of 5 pediatric surgeons, 3 pediatric anesthesiologists and 3 operating room nurses, all SAS personnel.
   • The project was supported by the work of local volunteers from the Chosan Charitable Foundation, many of them Bundung Hospital staff and volunteers from Aseda Gambia.
2. PEDIATRIC PATIENTS:
   • Umbilical hernias
   • Inguinal hernias
   • Testicular maldescent
   • Soft tissue tumor removal
   • Circumcision (in patients included for any of the other pathologies)

Total procedures: 168

• Inguinal hernia 78
• Umbilical hernia 61
• Orchidopexy 7
• Circumcision 18
• Tumor excision 2
• Urethral meatotomy 1
• Hydrocelectomy 1

Total patients: 132

3. COMPLICATIONS: in the days following the campaign have been documented:
   • Surgical wound infection in 4 patients, one of them required drainage, the rest were treated with oral antibiotics.

2. CAMPAIGN REPORT

1. THE PLACE:
   • Bundung Maternal-Children’s Hospital in Serekunda. Monographic maternity and children’s hospital with obstetrics, gynecology and pediatrics hospitalization area. It has a consultation area, several laboratory facilities, emergency area and surgical block. It also has a private obstetrics wing that is currently unused.
     1. The SURGICAL AREA has a wake-up room/area, two operating rooms, office (for local staff), rest room (for local staff) and dressing room with toilets. It has a reception area, instrument washing and preparation room, sterilization room (with non-functioning equipment) and a lobby. The area has two operating rooms, separated by a door.
        1. Endowment of the awakening/area:
           1. 5 beds
           2. A single working oxygen inlet
        2. Operating room facilities: The two operating rooms are in very condition, have sufficient electrical outlets, are spacious and neat. They have tables for instrumentation as well as some work/intrumentation tables. In the area there is a medication cart, which is not up to date, and there is no crash cart or defibrillator.
           1. Air conditioning
           2. Operating Room 1:
              1. Respirator with sevofluorane vaporizer, without adapter (the sevo is “poured” directly into the vaporizer), halothane.
              2. Monitoring: EKG, blood pressure and pulse oximetry
              3. Oxygen from bottles
              4. Operating room table
              5. Light
              6. Vacuum cleaner
           3. Operating Room 2:
              1. Respirator for halothane and isoflurane gases.
              2. Monitoring: electro, tension and pulse oximetry.
              3. Oxygen in wall outlet
              4. Operating room table
              5. Light
              6. Vacuum cleaner
        3. There is a sterilization service, where we were able to sterilize the instruments.
     2. OUTPATIENT CONSULTATIONS: We had two consultation rooms in a pediatric outpatient area. Only one of the rooms has a couch for examination.
     3. Preoperative preparation:
        1. Patients waited for surgery in the outpatient waiting room or in the corridor leading to the operating room. There is no specific area, since Bundung only performs surgery on a regular basis on women.
     4. Postoperative care: patients were transferred to the “High Dependency Unit” ward until they were ready to be discharged. It is a shared hospitalization room with 8 beds, annexed to the postpartum admission room.
2. RECRUITMENT: It was carried out by Dr. Sanyang, Chosan and Aseda-Gambia. A campaign was conducted through radio and Lamin’s school (Aseda). More than 200 child candidates were recruited, many of them are still pending for future campaigns.
3. SURGICAL CIRCUIT: The work dynamics were established following the CMA circuit:
   • Assessment of patients in consultation
     1. The initial plan was to review the patients recruited on the first day, which was lost when our arrival in Banjul was delayed.
     2. Patients pre-selected by the local team (Dr. Sanyang (surgeon) and Ebrima Fatty (pediatric nurse) were assessed for surgery and anesthesia and scheduled each day at the beginning of the day.
     3. Patient registration, medical record documentation provided by Bundung/Kanifing hospital, identification.
     4. Preanesthetic assessment, patient marking, informed consent.
     5. Patients with suspected hernias or other pathologies were reviewed and scheduled for subsequent dates or registered for future campaigns.
   • Preanesthetic evaluation: Together with the surgeons, and with the help of nursing students who acted as interpreters to facilitate communication with the families, a preoperative evaluation of all patients recruited for the campaign was performed. Patients with intercurrent respiratory processes, probable difficult airway, or unfiliated heart murmurs were qualified as ineligible.
   • Preparation of the surgical report: Given the resources available in the operating room, and the unavailability of sevoflurane in one of them, an attempt was made to schedule patients of lesser age or greater complexity in the operating room with sevoflurane vaporizer.

• CMA Circuit
  1. Waiting room
     1. Attempts were made to maintain patients on oral hydration until two hours before surgery.
  2. Anesthesia room
  3. Operating Room
  4. Wake-up room
  5. (HDU), some patients stayed overnight because of difficulties in returning home or because they were operated on very late.
• Review of surgical patients:
  1. Some patients who consulted for postoperative pain or suspected complications were reviewed. No patient presented complications during our stay in Bundung.
  2. Appointments at Kanifing Hospital in 7-10 days after surgery.
  3. 1. (brief description of the hospital and the area in which it is located, surgical equipment, post-surgical and hospitalization rooms, how we have found it, operation of the practice, recruitment,….)
1. THE TEAM (group members):
   • Team leader: Rosa M Romero Ruiz
   • Pediatric surgeons: Rosa M Cabello Laureano, Rocío Vizcaíno Pérezo, Eloísa Díaz Morenoo, Constanza Valenzuela López.
   • Pediatric anesthesiologists: Felisa Marin Hernándezzo, Rosario Picón Mesa, Álvaro José Sepúlveda Iturzaeta.
   • Nursing: Rosa María Soldevila Rodríguezo, María del Rosario Gil Muñoz, Rocío Sanjusto Bravo.

3. LOCAL STAFF
   • Chosan Charitable Foundation: (Haruna Jallow) The Chosan Charitable Foundation, formed by health professionals with the aim of improving the health system in The Gambia, was responsible for the organizational tasks in The Gambia. Its president Haruna Jallow was in charge of the legalization of the volunteers of this project at the Ministry of Health, College of Doctors and Nurses of The Gambia. Her organization was responsible for the transportation of volunteers from accommodation to the hospital, food on working days and relations with local professionals and patients. They were instrumental in the recruitment of patients, organization of the working days and support work.
   • CEO of Bundung Hospital (Dr Mamady Cham) made available to us the consultation rooms, surgical block and HDU for the development of the campaign.
   • Health personnel Bundung Hospital:
     1. Outpatient clinics: Ebrima Fatty (Bundung nurse and Chosan volunteer) was instrumental in recruiting, organizing the clinics, administrative work and patient assessment.
        1. The percentage of patients who do not read or write and only speak local languages is very high. The nursing students and other volunteer nurses and laboratory scientists (Chosan) were instrumental in enabling us to communicate with patients and families.
     2. Operating room: Betts Rikiatou (nurse anesthetist, responsible for the surgical block). She supported us at all times in the organization of the operating room and cooperated clinically with our team.
        1. All the operating room staff (nurse anesthetists, orderlies/cleaners, nurses) were involved and collaborated with our team.
   • Kanifing Hospital. Kanifing Hospital was the place where this campaign was to take place. However, our dates coincided with the dates of a group of Canadian volunteers (Doctors in Action).
     1. Visit to Kanifing Hospital: it is a general hospital, which has two operating rooms, one for emergencies and one for emergency. The most frequent urgent procedure is cesarean section.
        1. Respirators: only one of the respirators can be used with sevoflurane.
        2. Electric scalpel: available in both operating rooms.
        3. Smaller operating rooms and generally not in such good condition.
        4. During our stay, the Canadian volunteers informed us that they had to interrupt their activity due to ventilator malfunctions.
        5. This hospital has an ophthalmology operating room that looks pretty good, albeit with a very old ventilator. Monitoring?

6. EQUIPMENT:

• Operating rooms:

1. Operating Room 1:
   1. Boaray 600D Respirator with halothane and sevoflurane vaporizers
   2. Standard monitoring (ECG, SpO2, PANI)
   3. Wall-mounted oxygen intakes. Portable aspirators. Portable oxygen concentrator.
   4. General anesthesia was performed with induction and maintenance with inhalation anesthetics.
2. Operating Room 2.
   1. Dräger RIMAS 2000 respirator with halothane and isoflurane vaporizers. This ventilator has a connection for external circuit that, in order to use it, it is necessary to disconnect a piece that cancels the possibility of alternating with mechanical ventilation. It does not have a pediatric mode.
   2. Standard monitoring (ECG, SpO2, PANI)
   3. Wall-mounted oxygen intakes. Portable aspirators. Portable oxygen concentrator.
   4. Both general anesthesia (TIVA) and neuroaxial anesthesia were performed.
3. Shortcomings in the surgical area:
   1. Anesthesia machines should undergo daily calibration to ensure adequate ventilation of the patient.
   2. Capnography not available in any of the operating rooms.
   3. Defibrillator
   4. Power outages
   5. Interruptions in oxygen supply
• Postoperative care
  1. Recovery room: Located in front of the operating rooms. It has 5 beds. A single oxygen outlet on the wall, which was solved by three-way connectors that allowed having up to three external circuits to be used simultaneously. It only has two portable pulse oximeters.
     Postoperative analgesia is prescribed orally with ibuprofen (oral suspension or tablets).
  2. High Dependency Unit” hospitalization ward: Once the patient was conscious, with adequate muscle tone and controlled pain, he was transferred to the ward (HDU) to continue nursing care and start tolerance. The average stay was 4-5h, including time in the awakening room and on the ward. The anesthesiologist in charge of the postoperative period assessed the patients prior to discharge, and the doctor on duty at the Bundung Hospital signed the discharge home.

7. ASEPSIS AND SURGICAL MATERIAL:
   • Surgical hand washing: Hibiscrub / alcohol gel
   • Field preparation:
     1. Chlorhexidine wash and dye chlorhexidine
     2. Expendable ophthalmology sterile drapes/adhesive drapes.
     3. Expendable gowns.

• Instrument preparation: scrubbing and washing with instrunet, local steam sterilization.

8. OUR LIFE IN SEREKENDE:

We stayed at the Senegambia Hotel, where we had breakfast almost every day together. The days started at approximately 8:00 a.m., when we were picked up by the volunteers from Chosan and taken to the hospital in their vehicles. Upon arrival at the hospital, one team would go up to the surgical area to prepare the operating rooms and another team would go through the consultation. Once the operating room was prepared and checked, the surgical activity started and the consultation continued at the same time until all the patients planned for that day were checked. The two operating rooms were used simultaneously, sharing the electric scalpel, giving preference to smaller patients in the operating room with sevo.

We took advantage of the break to sterilize the instruments to eat. The volunteers from Chosan (Martida, Binta, Timah, Rohey) brought us local food, fruit, drinks….

At the end of the day, the patients who were to remain on the ward were checked and the operating rooms were tidied and the material was prepared for the following day.

“Normality” was interrupted by urgent cesarean sections, which used operating room 2, limiting us to a single operating room during those hours.

Once the work day was over, the volunteers from Chosan would take us back to the hotel and we would have dinner at one of the nearby restaurants.

We had two visiting days, one that we organized ourselves and the day we were traveling back organized by Haruna Jallow and the Chosan volunteers. On that day we were received by the president of the Gambian government and visited Lamin Lodge and Senegambia beach.

3. CONCLUSION

Strengths of this place:

• Involvement of the management team
• Involvement of cooperating NGOs in the project:
  • Aseda: Involvement of NGO management, financing of expenses and relationship with Bundung’s management.
  • Chosan: involvement of the president of the association, interest in establishing a long-term project and involvement of volunteers. It is worth mentioning the collaboration of Dr. Sanyang who, as a surgeon, is very involved in the diagnosis, recruitment and follow-up of patients for this and future campaigns.
• Involvement and willingness to cooperate by the Hospital Bundung Leaders.
• Involvement and willingness to cooperate on the part of hospital personnel
• Good general condition of the facilities
• Ability of facilities to accommodate similar campaigns
• Translators: the involvement of volunteers from Chosan, Bundung and nursing students is essential. Most families do not speak English.
• Good health status of the patients: in general the children were in a good state of nutrition and health, they were well cared for and family support could be seen. The families were initially quite reluctant, but later they were very grateful and confident.

Improvement objectives:

• Better adjust the material for the campaign and reduce the material that can be acquired locally and that is cheap:
  • Syringes/needles
  • Gowns
• Equipment:
  • Electric scalpel generator
  • Sevofluorane vaporizer: it would improve work dynamics if sevo could be used in both operating rooms.
  • Capnograph: would allow for safe surgery on smaller patients than those operated on in this campaign
  • Postoperative analgesic medication
  • Maintain the planning of the campaign, with assessment of patients on the first day and organization of the reports in a more efficient way.

4. BUDGET: (small breakdown of expenses)

COST PER PARTICIPANT: 1152,93 €.

TOTAL COST OF THE CAMPAIGN: 12682.26 €.

Fdo: Rosa M Romero

Responsible for the campaign

Surgeons in Action

You can see a selection of photos from the campaign in our Gallery.