Malawi Mission

Boston -> Paris -> Nairobi -> Lilongwe (22 hours)

This marks the beginning of another surgical mission, this time to Lilongwe, Malawi. Malawi is a small country in southern Africa, with an estimated population of 16.5 million. The two national languages are Chichewa and English. Approximately 80% of the population lives in rural areas, 53% live below the poverty line and 11% of the adult population is living with HIV/AIDS. The current life expectancy is 52 years. As of 2013 there are only 37 registered surgeons working in the country. Lilongwe is the centrally located capital city with a population of 800,000.

During this trip, Operation Medical will be partnering with local organization, World Camp Inc, to provide surgical and emergency medical care.  World Camp Inc is a nonprofit organization committed to educating children and adults about locally challenging issues. Operation Medical is an organization of volunteers made up of trained medical professionals and other individuals committed to promoting and providing high quality medical care and education to communities that do not have adequate access to medical care.  

This mission will occur at Kamuzu Central Hospital (KCH). KCH is a government run hospital and is the tertiary referral center for the central region of Malawi, serving approximately 5 million people. The hospital's size ranges from 600-1000 beds, with actually occupancy far surpassing bed occupancy. The hospital has 5 floors, 4 operating theaters, 1 ICU with 4 beds, and a radiology department with plain films and ultrasound. The only pathologist is located 200 miles away in Blantyre requiring 3 months to obtain pathology reports! Currently there are 3 general surgeons at KCH

During this mission we will be providing general, plastic, and ENT surgery, alongside of emergency medical care. The group will consist of 16 people with varying backgrounds. So far 20+ surgeries are booked with another 50+ awaiting the screening process, so it is shaping up to be a busy week. 

As always thanks for reading this blog, and for your thoughts and prayers along the way. 

 

Admedabad to Khambhat

My flight last night was delayed by 1.5 hours because they couldn't identify the correct number of people, not sure what that really means? The boarding system in Dubai turned out to be crazy. There was no order. Everyone just lined up, the tickets got scanned, and we were basically placed in a holding pin. after being there for an hour they opened the plane. It was a mad dash. no lines, no organization, Just a crowd of pushing people headed in a general direction. due to this chaos, boarding lasted close to another hour. Finally we were ready to fly. After a grueling 3 hour flight, full of screaming babies, we made it to Admedabad. Customs was not difficult to go though, collecting the luggage was a different story. It took another hour just to collect the bag. I went out and met the team. There was a truck for all of our luggage and a bus for us. Finally, at 6 am we started the 2 hour bus ride to Khambhat. It was amazing the gross property that was everywhere. Every 50 feet were a group of people huddled around a fire just to stay warm. There was trash everywhere. Cows, camels, goats and story dogs roamed the streets looking like skim and bones. The driving here is absurd. There is no real speed limit and you are supposed to drive on the left hand side of the road, however that seems like a suggestion more so than actual law. After passing through many villages, farms, and towns we made if to Cambay general hospital. The hospital is spread out over a decent size campus. We took a tour, and amazingly they have some decent technologies. They have a ct scanner, mammography machine, cardiac center, new dialysis unit and 10 bed ICU. The operating room was surprisingly nice in the fact that had lights. The surgeons operated in their regular clothes with a pair of flipflops, and the scrub nurses were outfits of some sort and flipflops. Their masks and hats were two towels stapled together to form some sort of contraption. Although it was not up to American standards, it gets the job done. fter the tour we went and ate breakfast. I am not sure what it was but it was tasted, minus the yogurt which tasted sour and was more liquid than solid. The tea here is wicked strong and the coffee super bitter. After breakfast we dropped off our medical supplies and went to the guest house where we will be staying. We have the entire third and forth floor. The room has two beds, a fan, and a bathroom. The bathroom consists of a toilet you flush by dumping down a bucket of water (thank you Tanzania for teaching me that skill) no toilet paper, and another set of buckets where you use one to mix the cold and hot water and the other one to dump the water mixture on you in essence creating a shower." I thought I would give the shower a shot so I went to get my toiletry bag out from the top of my checked luggage bag and what do you know...it's not there. Someone at some point over the last 3 days of travel stole my soap, shampoo, conditioner, sunglasses, razor, flashlight, mosquito lotion and vitamins. Who take that kind of stuff? So now I have to figure out where to get it, not something I was planning on having to do. So after a water shower it was nap time for everyone for three hours. After naps we went back to the hospital for lunch, which again was something that I don't know, but rather tasty. After lunch we went to setup all the operating rooms, while the surgeons screened for patients. We unloaded 15 bags of medically supplies onto 2 sets of shelves and two stretcher. With all of the supplies laid out we went to the operating rooms to look at the anesthesia machines. I was a disaster. There is only 1 machine that works and it has a halothane vaporizer but no halothane. The other machine has no vaporizer and has some old school way of delivering anesthesia that I have never learned about nor have any of the other anesthesiologist who have been practicing for 40 years. The other anesthesia machine does not work at all. This was a huge let down because we were told there would be working anesthesia machines or else the group would have brought their own portable ones. So tomorrow should make for am interesting day. I am not sure how many cases are scheduled but it appears that everything will be down under local or spinal. Here's to hoping it goes smoothly.

Tonight, over dinner, we meet with members from the local India society of medicine. They thanked us for being here and presented us all with roses. For dinner we had a thick and thin pancake made from rice floor, which gives the pancake a saltier flavor. For 1/2 of the thin and thick, plus a cup of soup was around 8 rupees. 48 rupees is $1, so it's basically pretty cheap to eat over here per person. However, since they are covering all of our food and lodging, I imagine everything adds up.

Oh, I also took a rickshaw ride, well two actually. it was an experience to say the least. i took a video and will try to upload. It's now 9:45 pm, time for bed. The 6am wake up call will come early tomorrow. Especially since there is loud prayer going on over megaphones right outside the window. I will try to add some pictures when I can, the Internet is extremely slow. I may have to do a separate photo page when I get back since some pictures are on the iPad, some on the iPhone, and some on a real camera

OR continued

It's crazy how easy you begin to get acclimated to a place. Everything is starting to become routine. It is almost like I have lived here forever, minus the fact that I don't speak the language. The food is less foreign tasting, the the smell is gone, and a warm bucket bath does not seem so bad anymore. We have been introduced to a place 5-10 miles outside of the city, full of palm trees, lakes, and birds. Those of us who choose start our day with a nature walk to stretch our legs and breath the fresh air. They say the reason the palms trees Re so far inland is that it is the location of the old coast line. I am not sure if that is true or not, but it makes for a great story. One one of the walks we were able to enter a village, meet the people, and see how they live. It was crazy to see 7 people living in a "home" the size of my kitchen, with all of their possessions in this one room. It was an eye opening experience, one that I am glad I was able to be a part of.

The operating room has started to run better. I have actually only run out of oxygen 5 times since the first 2 days, which is a vast improvement from 20 times the first day. The tanks a still not full but the Indian assistants are catching on and are looking to recognize the lack of oxygen before it happens. I had a difficult intubation on someone with a short jaw, and small mouth opening, which I successfully intubated over a bougie by myself. I have not only surprised myself, but those that I am working with, with my anesthesia skill set. I am by no means comfortable in this primitive setting with no equipment, but I am less scared. I have performed all of my cases from start to finish without the assistance of anyone else. It will be weird going back to the USA and having someone look over my shoulder with everything I do, however it will be nice to have proper equipment and drugs. I have learned a couple of Gujarati words, the language spoken here, so I am able to communicate with the patients a tiny bit. At least it is better than nothing. By the end of the week things were starting to run like a well oiled machine,which of course would happen when it was time t pack up an leave. I think the final count for surgeries is somewhere between 160-180. At the end the community got together to provide us with a celebration. We went to a hindu temple where we were presented with beautiful sarees by the head of the temple and then brought to a farm where we were provided with entertainment around a fire and a delicious meal. When we arrived back in town there was a stage set up in the middle of town, surrounded by 3000 local people in every spot they could occupy around the stage. Signers were brought in to perform, and we were called up and recognized on stage to a standing ovation. I was a spectacular moment, one that is hard to put into words.

OR day 2

New day, new cases, new challenges, new successes. With every passing day things get a little bit better. The morning started out at 6 am with delicious chai tea and breakfast. We were hoping for a 7:30 start to the cases but realistically probably started at 8. Much improved from the 10 am start from the day before. Everyone started getting in routines. The hospital nurses that are assisting started understanding our techniques and processes. Efficiency is still much to be desired, but we have come leaps and bounds from the day before. The final count for the previous day was 36 surgeries and I think today we did more than 40 cases. My room today consisted of more ENT and plastics cases...1 ear reconstruction, 1 wart removal, 2 tonsillectomy's, 1 parotid rumor biopsy and drainage and a dermoid cyst removal. My room was the second to last out for the day and we finished around 6 pm. Most of the cases here are being done under spinal anesthesia with the exception of my room and the plastics room. It is more challenging to do general anesthesia because there are no ventilators, and I still don't know how much anesthesia gases the patient is receiving. It is amazing to see how much you can do without all of the abundant resources we have in the US. It is making me think more, and communicate better. You have to be an improviser and fixer to be able to survive here. One of the challenges is there is no circulation in the operating room. We have two tables in 1 room so two different cases are occurring side by side. The chemicals used to disinfect the instruments sits in the room as the fumes evaporate around us. Typically with the gases machine the excess gas the patient breathes out gets sucked away in a vacuum, however this does not exist. The type of circuit that fits on this gas machine is called a Bain circuit. So essentially all the excess gas the patient breathes out comes out of the circuit and into my face. A little gas for the patient, a little gas for me. I am pretty sure everyone in the room is partially anesthetized. There is an air conditioner in the room but then the patients are freezing so it boils down to picking your poison.

After the hospital we went wandering the streets and looking around at all the shops and people. We were supposed to have dinner on the roof of the hotel again last night but we got in trouble for bring meat up there the night before so we had to find someone to hosts us, which is not hard. Everyone here is going above and beyond to make our stay exceptional. Dinner started at 9 pm and finally finished up around 10. This dinner was a little more disappointing than the others because they served fish but there were so many little bones it was practically inedible. On the bright side there was a delicious chocolate cake. After dinner it was back to the hotel for a colder, rather than warmer, bucket washing. At least this time the water did not feel like ice. After the "shower" it's all you can do to dry off, get dressed, and get under the covers and fall asleep before you freeze. Anyway that's all for now. Will attempt pictures but it probably won't happen because of the connection.

OR day 1

Wow...that's really all I can say about today. I woke up at 5 am after barely any sleep due to a wedding that lasted until 3 am. This week is wedding season due to some luck of the way everything aligns. There is a wedding that just started outside the window. The weddings are full of music, karaoke, and of course fireworks from 2-3 am. We left the hotel at 6:30 and arrived at the hospital with a warm meal. It may be 80 during the day but it is in the 40s at night with no heat. After breakfast we went to get started. I was originally supposed to be paired with a CRNA but am anesthesiologist dropped out at the last minute for medical rooms so I did my own cases without any assistance. It was overwhelming beyond believe. At first there was no oxygen, then no nitrous, and who knows how much anesthesia gas they were getting because we have to put sevo in a halothane vaporizer. I did actually see a bottle of it laying around. While everyone else was doing spinals I was doing general anesthesia with a gas machine I knew nothing about. It was beyond my comfort zone and a giant learning experience. I did ENT cases today. Removed 2 nasal polyps, fixed a hole in the side of someone's face and removed a giant blood vessel conglomeration called a hemangioma. After these cases I did an inguinal hernia repair with a spinal anesthetic and no sedation. The only monitors I had was a blood pressure cuff, a pulse oximeter, and my precordial earpiece, which allows you to listen to every breath. Everything was a challenger. I knew nothing about my patients, I didn't get to meet them before. I would take a patient to PACU and would come back and another patient would just be lying on the table waiting. While there were some hiccups along the way, everyone was alive at the end.

Airport life

So it is now January 18 at 6:50 am London time, 1:50 am EST. I have been in airports/planes for 10 hours and I still have 19 hours left until I reach my final destination. So far the journey has been an interesting one. I am not afraid of flying, nor have I even been, however this flight did push a couple buttons. We left from Raleigh in the middle of the storm that is hitting the east coast. It was an adventure to say the least. As we taxied down the runways you could see the wind blowing the rain in all directions. We sped down the runway and lifted off. The first two minutes were problem free, and then the turbulence happened. I looked out of my window and the wings appeared as though they would actually snap in half. The drama of the accent was not helped by the others in the plane. People were screaming, babies were crying, and people were praying out loud. At that point what ever was going to happen, was going to happen. I decided to take joy in the situation and just thought of it was a really expensive roller coaster ride. I mean how can you not be happy thinking about roller coasters? From there, the flight did not get much better. I have flown on many planes, all around the world, and this was by far the worst aircraft. The plane did not have individual tv's in each seat, instead they had three little overhead tv's down the middle isle, coach bus style. I know beggars can't be choosers, however, not only could I not see any of the tv's from my seat, but the audio did not work either. It was not like i was just flying to another state, it was a 7 hour flight to London. I have been on better planes flying from Chicago to San Fran that had tv's. I know, it's pretty pathetic my dependence on technology and things to occupy my mind. I did however have my iPad equipped with multiple episodes of Royal Pains, which filled my entertainment needs. Outside of those debacles the rest of the flight was pretty smooth. The food was pretty decent, chicken with rice for dinner, and a croissant with yogurt for breakfast. Also on the plus side, I had my row to myself, which is always nice.

London airport is actually a pretty decent airport. I get 45 minutes of free wifi so please excuse any typos and grammatical errors...this goes for future blogging too as Internet time will probably be limited. Looks like I am about to beat the storm here. It just started snowing as I boarded the plane, and there is 2 inches on the ground already as we took off.

Talk about a change of scenery. As soon as you walk to the Emirates international gate it is an entirely different world. Free newspapers and magazines await you in the pre-boarding area. Once you enter the plane (I am on an A-380) it is pure magic and luxury. You are greeted with a warm lemon scented towel to wash your hands, and given a menu (breakfast again, and lunch). There is Internet on board, over 200 movies to choose from, individual plugs to change electronic made to accommodate every country, cup holders, and USB connectors so you can plug your device into your personal tv. Maybe it's the plane, maybe it's flying to Dubai, but it just feels like money! This might be the best flight ever. Oh and there are stickers on your seat to let the, know if you want to be woken up for food or beverages (how simple is that, yet i have not seen it on any other aircrafts) I am sure not going to mind the next 8 hours on this plane!

Now for a little information about my trip. My eventual destination is Khambhat, India (formerly known as Cambay). It is a city of 80,000 people in the Gujarat state. The economy is pretty stagnant and the only business they have is local goods. There are 23 volunteers participating on the mission: 8 surgeons, 3 residents, 6 anesthesia providers, 3 nurses, and 3 support staff. We are being provided room and board at the local hospital. As of now,we are expecting to do 200 surgeries in 6 days in 5 operating rooms. To give you a comparison, at Wake Forest we do 200-250 cases in 1 day in 40 operating rooms, so this is ambitious, but will be done.

Welcome to Dubai. Everyone says that Paris is the city of lights but I beg to disagree. Flying into Dubai was remarkable, more lights than Vegas, and more lights than Paris. It was a beautiful sight, especially at night...It is now January 18, 8:35 pm Dubai (11:36 EST). A major plus...free internet, yay!! Another 3 hour layover, 3 hour flight, 1 hour wait for all the volunteers to arrive and 2 hour bus ride and I will finally be at my destination. To kill time, and stretch, I have been walking around the terminal and where are the longest lines...yep, you guessed it...McDonalds followed by Burger King. On another note, they do have very nice gardens at both ends of the terminals.

The Road Less Traveled

So it's January 17, 2103 and I am sitting in the Raleigh airport awaiting my flight. I am starting to get a little nervous. I mean who travels to India? At least that is what a lot of people have said to me. Ever since reading the book Shantaram by Gregory David Roberts (introduced to me by Ali in Tanzania) I have had this deep desire to travel halfway around the world. There is just something about that book that sets the stage for desire to see this amazing country. If you have not read it, which I assume is most of you, I highly recommend it. It is in my top 5 books I have ever read. So reading that book in 2009 took me to where I am in 2013. 

Many of you know that I am in nurse anesthesia school at Wake Forest University. I graduate in 7 months and 1 day...exciting I know! My school is very big into mission trips and we are allowed to go during our senior year. Typically students go to Rwanda, Ghana, Kenya, or the Dominican Republic. Me being me, I wanted to be different. I thought I have been to the Caribbean and Africa multiple times, what else could I do? I did a little research and made contacts with different surgical mission groups. Many of them wanted experienced Anesthesia providers and I don't blame them. I mean I have no idea what I am getting myself into anesthesia wise, but only one way to find out. Finally, I was able to make contact with a group named www.worldsurgicalfoindaton.org and they said sure, the more the merrier. I got approval from the school and the next thing I know I'm sitting in the airport about to embark on a 3 week adventure. 

I leave today from Raleigh an arrive in Admedabad at 3 am on Saturday morning. After a 2 hour bus ride we will get to Khambat, the city of our mission. There are 200 surgeries scheduled for the 7 days in the 5 operating rooms we have access to. After the mission part we are doing a R & R trip with the group. I will be going to Delhi, Agra, and Jaipur. After the organized trip I will be going solo to Goa and Mumbai for 4.5 days. Needless to say this is another adventure of a lifetime. I will try to blog as much as I can time and Internet depending, of course. I hope you enjoy reading and coming along on my adventure with me! 

pyramids and sphinx