Providing medical care in unfamiliar settings; experience of an Egyptian campaign
Ahmed Hasanin1,&, Nadine Sherif1, Mohamed Elbarbary1,
1Faculty of medicine, Cairo University, Egypt
Ahmed Hasanin, Faculty of medicine, Cairo University, 28 alarkam ibn abi-alarkam
street, Almeeraj, almaadi, Cairo, Egypt
Medical service in many African countries is affected by the limited infrastructure and the lack of economic and human potentials. Uganda is one the countries that suffers from lack of physicians as well as shortage of many medical facilities with many endemic health problems such as Goiter.
A surgical camp was done by an Egyptian team of 8 physicians; three general surgeons, one pediatric surgeon, two gynecologists and one anesthetist. Over two hundred cases were screened in the outpatient clinic.
Eighty nine operations were done in four days. General surgery procedures were 45 operations (50%), Pediatric procedures were 23 operations (26%) and Gynecological operations were 21 operations (24%)
In conclusion Humanitarian relief for poor population in the developing world countries needs vigilant international collaboration. Special attention should be given to goiter in African countries. Training doctors from sub-Saharan African nations should be on the top of the agenda of the international medical community in order to reach a definitive solution for their health problems.
Medical service in many African countries is affected by the limited infrastructure and the lack of economic and human potentials. Few numbers of physicians are present with marked shortage of some specialties that give limited chances for proper treatment of patients even in minor health problems.
Uganda is one the countries that suffers from lack of physicians as well as shortage of many medical facilities. Approximately there is one doctor per 20000 sick people, thus many people go untreated. Uganda is a landlocked country in East Africa it is also known as the "Pearl of Africa". It is bordered Kenya, South Sudan, Rwanda, Tanzania, and Democratic Republic of the Congo.
Surgical camps have been one of these initiatives performed by many countries and committee to many African countries aiming to; provide a good service to the largest possible number of patients, train the present physicians at the country, explore and clarify the extent of the current health problems to the international community.
We previously described our experience in working under unfamiliar circumstances during the Egyptian revolution [1
]. Here we discuss our experience in a four day camp to Kampala (Ugandan Capital).
Endemic health problems in Uganda:
Goiter is a major health problem in
many African countries including Uganda due to environmental and nutritional
of goiter (Figure 1
reached 30% in some areas due to dietary iodine and selenium deficiency [2
Also uterine fibroid (Figure
) is another common health problem among the Africans [4
Thus most cases managed during our short camp were focused on these two disorders
(Goiter and uterine fibroid) in addition to pediatric cases
Location (Kibuli hospital):
The surgical camp was at Kibuli hospital;
charity hospital located on Kibuli hill in the southeastern part of Kampala.
founded as an outpatient facility at 1975, added 59 beds in 1995, and finally
reached 200 beds. It has a blood bank, 3 operating rooms with 5 operating tables,
and a laboratory. However it had a few number of physicians and no ICU beds.
The surgical team:
The team consisted of 8 physicians; three general
surgeons, 1 pediatric surgeon, 2 gynecologists and one anesthetist. Over two
hundred cases were screened in the outpatient clinic; Eighty nine operations
of different specialties were done in 4 successive days. All physicians were
volunteers, all medical and surgical services provided were free.
Procedures: General surgery procedures
were the most frequent operations with total number 45 operations
included; Hemithyroidectomies (27 cases), Total Thyroidectomies (4 cases),
Hernias (13 cases), and open cholecystectomy (one case). Pediatric procedures
reached 23 operations (26%) and included hernias (19 cases), Hypospadius repair
(3 cases) and undescended testis (one case). Gynecological operations reached
21 operations (24%) most of them were Hysterectomies (10 cases), Myomectomies
(6 cases), Classical repair (two cases), Ovarian Cystectomy (one case), Vulval
mass excision (one case), and drainage of pyosalpinx (one case) (Table
Few adverse events were experienced during the
camp with no effect on the final outcome. Repeated break in the electric power
was an evident problem. Oxygen cylinders had nonfunctioning pressure gauges,
this resulted in repeated emptying of the cylinders during the operations without
alarm, and this needed close monitoring to the gas flowmeters to detect any
decrease in oxygen flow. A case of massive post-operative bleeding after myomectomy
operation needed urgent exploration that revealed massive oozing from the surgical
bed. The patient done total abdominal hysterectomy and was packed for 24 hours.
The patient received 8 units of whole blood and 10 units of fresh frozen plasma.
Packs were removed after 24 hours with no additional sequelae.
Surgical challenges: Many challenges have faced
the surgeons because of the lack of equipment, difficulties in
communication, lack of assistants
and shortage of medical supplies. Very poor light sources were
present, only one diathermy and a vessel sealing device (LigaSureTM)
delivered with the team from Egypt. Another challenge was the need
for screening and operating a large number of cases in a very short
time by a few number of physicians, this needed extra ordinary
effort from all the team members working long hours with few breaks.
For pelvic surgeries, the high rate of PID (Pelvic Inflammatory diseases) [5
] made the pelvic surgeries challenging due to the extensive adhesions present, which reached in some cases to frozen pelvis.
Another challenge for the surgeons was the prevalence of HIV AIDS which reached more than 10% of the adult population in Uganda. This made screening for HIV AIDS a routine investigation for all patients. Five patients (5.5%) of those needed surgical intervention were HIV positive.
There were five operating table in three operating
rooms with variable levels of equipment. Four anesthesia machines were present
with only two ventilators (Figure 3
The term "Bagging" is a known term there which means manually ventilating the
patient under general anesthesia by an anesthesia nurse when the anesthesia machine
has no ventilator. Bagging was frequently used during our convoy. Gas cylinders
were the only source of medical gases as there was no pipeline, only one table
had a monitor with non-invasive
blood pressure monitoring, pulse oximetry and ECG but there were no ECG electrodes
available. Monitoring for other operating tables was done using a portable
pulse oximeters and manual blood pressure monitors. These limited monitoring
facilities added another burden to the management of anesthesia. Another obstacle
was the availability of one anesthetist which was compensated by the aid of anesthesia
nurses who are well trained
for monitoring. The presence of these nurses helped to operate 5 operating
rooms at the same time. Most cases received spinal anesthesia except for
thyroidectomy operations this helped to overcome the relative deficiency of
anesthetists and the shortage in ventilators.
Drugs and intravenous fluids
: Most basic anesthetic agents were present
however muscle relaxants were relatively deficient. We used propofol, thiopental
induction of anesthesia. Both Halothane, and Isoflurane were used in maintenance
of anesthesia. Most cases received atracurium or cisatracurium except cases
of suspected difficult intubation (e.g. huge goiters) who received suxamethonium
in induction of anesthesia. The only vasopressor present was epinephrine .
There were no airway devices except endotracheal
tubes, oral airways, and face-masks. Laryngeal mask airways were delivered
with the team from Egypt. Huge goiters (Figure
) were challenging in their
airway management however there were only two choices either to manage the
cases with the available resources or to leave the patients untreated .
Due to the lack of post-operative monitoring facilities
and the large number of operations done in a limited period, there was no proper
post-operative pain management except non-steroidal anti-inflammatory agents.
An interesting finding was that most patients in this country showed high pain
tolerance with minimal complaints regarding post-operative pain.
As "Swahili" is the main popular language in
Uganda followed by English language, communication between the members of the
team with the Ugandan medical personnel faced many barriers especially because
even those who speak English among the Ugandans had their special accent. Of
course the communication with the patients during screening was much more difficult
as most of them don´t
speak English at all. Another communication problem was that most of
the personnel were not trained well for surgical assistance and they even don't
know well the name of instruments. Another problem was the brand names of drugs
which are different from what the physicians were accustomed to in Egypt.
Comparing our experience in working in unfamiliar
environment during the Egyptian revolution on January 2011 [6
with our experience in this surgical camp; we assume that the main difficulties
during the Egyptian revolution was that large number of injured in a very short
time and the shortage of medical personnel due to security issues, but we had
the advantage of working in a well-equipped tertiary hospital with all facilities.
In our camp there were no trauma patients and the rate of cases was more organized
but the main disadvantage was working with limited equipment and in unfamiliar
settings with many language barriers.
Another article describing the anesthetic practice in Haiti after the 2010 earthquake
assumed many similar challenges as we faced in our camp such as communication
and language barriers, shortage of medications, and large number of patients
but our camp differed in the type of procedures [7
Poor available resources made the team work with a known logic of "do the best
for the most" and not "everything for everyone". We aimed to bring the best possible
care not the best care as described in the academic literature. This is well
known in mass causalities and war surgery [8
Key messages and lessons:
In future camps we recommend focusing on simple
procedures that can be done in small hospitals with limited facilities. We
also recommend paying more attention
to endemic problems such as Goiter and Vesico-vaginal fistulae. Good preparation
needs communication with the health committee in the country to prepare the patients
and the equipment and Communication with colleagues who previously visited these
areas to obtain information about the facilities. We also recommend accompanying
nursing personnel in future camps to facilitate proper assistance and communication.
instruments and drugs with the camp is also essential. Training doctors from
sub-Saharan African nations should be on the agenda of the international medical
community in order to
reach a definitive solution for their health problems.
Humanitarian relief for poor population in the developing world countries needs
vigilant international collaboration. More attention to African countries,
especially countries of river Nile, should be paid by Egyptian society.
The authors declare that they have no conflicts of interest.
Ahmed Hasanin: participated in the camp and shared in writing the manuscript
Nadine Sherif: participated in the camp and shared in writing the manuscript
Mohamed Elbarbary: participated in the camp
Doaa Mansor: participated in the camp.
1: Surgical interventions (number, %)
Figure 1: Huge goiter
Figure 2: A case of multiple uterine myomas
Figure 3: Operating room
with two operating tables
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