REPORT on the 'Missionary Expedition' of OHA! e.V.-Ortho Hilfe Afrika,November 8 - November 23, 2013 to the CMA Paul VI, Ouagadougou, Burkina Faso
Friday, Nov. 8, 2013:
6:00: participants assemble at Frankfurt/Main airport
"We" consist of:
> David, Barrigah, male nurse qualified in anaesthesia
> Tanja Wendling, qualified in op procedures (COA)
> Andrea Laufer, qualified in op procedures (OTA, medical student)
> Dr. med. Klaus Völmle, specialist anaesthesia
> Dr. med. Christoph Meister, specialist surgery, first-aid surgery and orthopaedist
> Dr. (B) Etienne Heijens, orthopedic specialist and specialised orthopedic surgeon
First off, extensive re-packing of some luggage items exceeding the weight limit.
Yesterday afternoon we had received an additional 14 cement-less protheses which we had been able to order, following a flow of donations... Everything has to go along, nearly 200 kg worth. 650 kg should already await us.
8:30: take-off for Ouagadougou, via Brussels. In Brussels we meet up with David. After the mission he is due to continue to his home Togo, and to return from there in mid-December. That's why he booked his own flight. He had to get up at 2:00 and looks tired.
16:00: on-time arrival. We had pasted documents identifying our mission onto the luggage pieces, hence there are no problems with customs, except for David.After taking his finger prints, a clever official demands an Euro from him...
There it is again, the smell of wood fires which hangs over the city. And another thing reminds us of the first visit, in December 2012... Nobody here to pick us up. A misunderstanding. We were thought to be on the Air France flight which had landed an hour earlier, so our drivers left for a while. Our cell phones don't work here, but fortunately there are street peddlers galore who sell us telephone cards-at ten times the price as we find out too late. Thus we have done our good deed for the day, and reach someone, very late in the afternoon, in the clinic director's office.She is sending help!
After a two-hour wait we're taken to the mission hostel "les Lauriers", then a late dinner in town, "Chez Simon": Colourful hustle and bustle, and the much longed-for beer is wonderfully cool.
Saturday, Nov. 9:
7:00: pick-up and transfer to CMA Paul VI where consultations take place till 14:30.
On Nov. 9 and 10 we examine approximately 100 patients. They have been pre-selected by local surgeons ins the course of the year. Their medical records had been mailed to us, unfortunately a mere two weeks before our departure.
As a preliminary, the social indications are determined by the African colleagues who communicate the results to us. The patients' occupations are documented (cf. below).
We cannot operate on multi-morbidity patients or those with accompanying illnesses, there being no intensive-care unit at the hospital, and the patients we treat could not pay for a transfer to a hospital with one, if any. Furthermore, for each patient we have the data from the hemoglobin-electroforesis (blood data) which tell us if an increased danger of haemorrhaging--due to the endemic sickle-cell anaemia--exists. Such patients we cannot treat either.
As long as social anamnesis and general condition (expert opinion by Dr. Völmle, anaesthesist and mission member) do not stand in the way, we proceed to orthopaedic expertise by Drs. Meister and Heijens. To this purpose, the patient has to answer an established questionnaire (for Africa modified hip-score acc. to Lequene). Based on the gravity of pain and impairment, the evaluation of the answers assigns "grades" from 1 to 5 . Grade 4 (11-13 points) means "very pronounced impairment", grade 5: "extreme unbearable impairment/complaints". But for a minimal number of exceptions, only patients of grade level 5 are taken into consideration. "Scores" are documented.
Vwry soon Christoph and I look into one another's eyes having the same thought...
"What is it we are doing here?" It resembles wartime triage. We have to reject people who at home would throw stones at us, and rightly so. Or, at the least, rake us over the coals in the tabloids. But we didn't come here to practise geriatric orthopaedics. We cannot save Africa and have to be guided by our aims. Our concern are patients of employable age, whose hip problems prevent them from making a living for themselves and their families.And there are very many of those. So we go on.
Then naturally follows the clinical exam as well as the evaluation of the x-rays. This entails another selection, since the anatomical gravity of complaints might require special implants for some patients in order to give them the best-possible care.
We inform the patients accordingly. We'll try to have these implants available the next mission.
Finally, colleagues with longtime experience in medical missions reassure us that patients "customarily" pay an appreciation contribution. Our African colleagues inform us whether the patient agrees. If not, the colleagues (we're not involved) try to urge such patients to reexamine "what might be feasible". We take down the names anyway, and, a few days later check what the patient has decided. Whatever, we schedule destitute patients for surgery anyway.
Here we wish to point out that the appreciation contribution in no way covers costs.
But it helps in making treatments possible. And it contributes to the acquisition of those special and costly implants we will need during future missions, in order to assure quality care for patients with grave problems.
15:00: light lunch and refreshing beverages at the clinic's kiosk annex,
followed by visit to the "Village artisanale".
Dinner at the "Stade municipale". A lot of stalls, each one specialising (chicken, lamb, side dishes, beverages, telephone card, kleenexes (very advisable, as we were to find out, there being neither cutlery nor napkins...)); 10 sellers surround our table, and in the end each wishes to be paid separately. A bit confusing. And was the chicken really what it claimed to be? Perhaps this evening was the trigger for one or the other indigestion we experienced in the following days.
Sunday, Nov. 10:
7:00: pick up and drive to the CMA, same routine as yesterday, except that consultations go until 15:30.
Plans for a total of 20 op's/patients.
During the past two days, Tanja and Andrea have been unpacking our entire material, storing it in the surgical area. We are ready to roll.
David assists Klaus during the anaesthesia consultation, and not just as a valuable interpreter.These consultations generally proceed in an atmosphere of such spontaneity and colleagueship that we might at times wish for at home. The triage grid has to reject many truly needy patients, but, following the "Primum nihil nocere" leitmotif, hesitation has to give way to decision. We must not risk complications. Being certain in all situations, sans safety net... That, however, does not change the fact that we encounter no "simple hips".
17:30: arrival at "les Lauriers".
19:30: dinner at the "Verdoyant", a cozy garden spot. Mouisse is our guest. He is a very educated man, did several stints of practical training in Europe; at the clinic he is in charge of all that goes wrong, around the clock, seven days a week. And now, the weekend when the drivers are off, he's the one to drive us all over the place.
Through him we slowly learn how deeply enrooted poverty is in this society. Qualifications, having a good job, working hard, none of these amount to being well off in our terms. Mouisse's house, built from the savings skimped from allowances for his educational stays abroad, consists of the walls, sans inner doors, sans windows, sans roof. His son is studying medicine at a tuition we think low. For Mouisse, however, it amounts to a third of his annual income. And he has three children. The bill for our evening meal for seven persons we think most reasonable, for him it's the equivalent of a month's salary...
Monday, Nov. 11:
6:45: pick up, first day of surgery, 3 op's (artificial hip-joint implants).
Under normal circumstances, the first op would start at 8:00. At the point in time determined by the anaesthesist, patient #2 would be prepped in theatre 2, and op 2 begun--semi-parallel--by orthopedist #2. For didactic reasons the African colleagues assist, with Tanja or Andrea responsible for the instruments. David oberves the patient, as long as the op's (all under local anaesthesia) proceed in parallel. In addition, he assists Klaus at the start of the anaesthesia. We have 2 adequate sets of instruments. The third op is to take place once more in theatre 1. In the normal course, the time lapse between op 1 and 3 would be 1,5-2 hours. (as compared to 1 hour in well-organised German clinics.)
Our chronology, alas, is seriously impaired. The larger of the two sterilizers isn't working. In practice this means a five-hour sterilization process (the time between op 1 and 3) for one instrument set. Additionally it means that after the last surgery the local sterilization experts have to work till midnight so that we can begin on time next morning. The problem is a defective seal, a new one has to be hand-made, replacements no longer being available. Thus, chances for a solution before our departure are slim. (As it turned out, we were right.)
As this weren't enough: when readying the second op theatre, water wells up from the sewer. The area cannot be used. In the light of the first problem this break-down becomes secondary, even though soon fixed, for the time span between op 1 and 3 is long enough so that we do not need a second room...
Hygienic safety is not affected by these "snags"
Now as later the op's proceed without complications. As a rule, they are, however, quite strenuous, due to the anatomical gravity of the cases.
17:30: surgery over, followed, as every day, by rounds to the newly-operated patients. While the op theatres are up to hygienic standards, the sickrooms are very primitive.
The legend to this photo might read: pole-position, Nr.1, privacy with screen, ample menu selections. We see a patient with compression stockings, on day 3 after surgery,
The "mattresses" are covered in artificial leather. Patients provide their own linen. There is no hospital kitchen. The patients are provided for by relatives who prepare meals on outside wood fires. These relatives also "live" in the sickrooms, between the beds among cooking pots and eating utensils. Our fears that the affluent might cadge our services are greatly alleviated.
Of course, dressings are changed acc. to hygienic norms.
Pick-up for return to "les Lauriers" late, at 20:30, due to a misunderstanding.
"the bus is here!!" "now it's gone.............."
Then, at 21:30, dinner. The previous evening, at the "Verdoyant", we had listened to live music from next door where we are now, at the "Jardin de l'Amitié": great atmosphere, very African, as is the food. Apparently David had cued the proprietors what we are doing here in Ouagadougou... whereupon the singer launches into a (many) minutes-long paean of gratitude.
Tanja is ill, can hardly leave her room. As we're about to relocate to "les Palmiers"
(our reservation at the "Lauriers" having run out), we arrange with Sr. Lucie that Tanja can stay on until tonight. Under the circumstances the term "basic" hardly covers the reality. Seeing her in this dark room which soon turns very hot, toilet in the hall, for a moment evokes images of "Papillon" or "Alcatraz":
Consequently, the departure for the "healthy ones" takes place a little later today, at 7:30. Tanja's absence leads to some delay, but is compensated for by additional effort of the others.
3 op's in sequence, in one theatre. Op 1 and 3 sans resulting problems.
Due to technical-anaesthesiological problems op 2 cannot proceed. Spinal anaesthesia is unsuccessful while general anaesthesia is not indicated, i.e. in justifiable quality over 1-2 hours.
On Nov.16, however, the op can proceed, with local anaesthesia and a suitable canula.
Now the second sterilizer has broken down. Another hospital takes over sterilization of our instruments overnight. Our appliance is to be repaired overnight.
18:00: end of program. We fetch Tanja and move to "les Palmiers". She is still not well, but here it is "more comfy" if you are ill, even though we have to double up, if only for economic reasons.
Wednesday, Nov. 13:
Tanja's decidedly better, but we keep her "out of things". Recharging is indicated.
7:15: departure: sterilizer No.2 is functional again, and our "steri-outsourcing" was successful, so our instruments are sterile. 3 op's without any unusual occurrences, even though the pauses have to be bridged...
For the rounds we examine the post-op x-rays of the patients operated the day before yesterday. Then, on post-op day 2, our patients, accompanied by their relatives, "march" across the hospital grounds to the x-ray department.The reason being that the stride of our patients appears surer than the all-terrain capability of the wheelchairs...
19:00: departure for the hotel. Dinner there from 20:00. We enjoy being able, simply, to stay in an evening, without having to go out again, while having the day draw to a pleasant close with one of the "Brakina" beers we've come to frelish.
Plus, there is WLAN!
Christoph daily posts our "Live-Stream" with photos and video clips , where Manu, our treasure minder, puts it all on the net. Reactions from the home front are prompt and numerous. Lovely!
Thursday, Nov. 14:
7:30: departure. Tanja is back on board.
Op1: essential instrument is not sterile, has to be borrowed from sieve 2, ergo longer pause between op and 2. Tanja holds the fort:
Op 2: aggravated conditions for Christoph. Because of his hip problems the young patient suffers from a considerable shortening of the leg which is to be adjusted. Setting proves difficult, but succeeds after Klaus puts the patient briefly under general anaesthesia, in order to achieve absolute muscle relaxation.
Followed by extended surveillance, as no wake-up area is available. In the sequel the patient does very well.
Op 3 proceeds without problems.
19:00: return after rounds.
Then dinner at the "Gondwana", in Ouagadougou's "green lung". Very nice!
Friday, Nov. 15:
Three op's, all go well.
Patient 3, YP, is destitute. At age 21 her hip problems forced her to break off her training as a hairdresser. The op is funded by donations from pupils in Germany (cf. www.oha-ev.de"Schüler"). Their action will soon enable her to continue her training. In return she will establish a pen-pal correspondence with the form!
18:00: departure from CMA following rounds.
Before dinner at the "Verdoyant" we have the honour of being invited to the name day celebration of suffragan Léopold. No trace of pomp here. The bishop receives us with soft drinks, incl. beers. We have a very nice conversation, e.g. about his memories of a visit to Germany. He was particularly impressed by the Munich steins... a fitting present for our next mission!
After Léopold has donned his cross and sash we're ready for a farewell photo.
Saturday, Nov. 16:
Three op's, proceeding normally.
Time and again during our entire stay Drs. Meister and Heijens are included in the parallel consultations of the colleagues. We discuss treatments and view the patients scheduled to be operated on during our next stint.
19:00: return, after rounds.
No op's planned for today. The collaborators of the CMA Paul VI are likewise glad.
Like us, they have been working continually since Nov.9, at times until deep into the night so that everything would go smoothly. When we leave they'll have to take care of what's been left unfinished. And on Dec.6 the Belgian mission will be back, and they too want to achieve a lot...
Together with our new friends we first visit the opera village 40 km away. Complete info under www.operndorf-afrika.de and www.schlingensief.com.
What has been and still is being achieved here deeply impresses us. Here a few impressions...
Then, after the noon break, visit to a zoo in the president's domain...
there must be happier animals in Africa...
Monday, Nov. 18:
Contrary to the arrangement (we're always ready to go at 7:30) we're picked up an hour late... Driver's error. That's what you get when you don't show up every day.
Three op's were planned for today. One, however, we canceled after Saturday's last op, the probability being high that we did not have a sufficiently small prothesis left.
The first op (not a hip TEP) can only proceed after a delay. Scheduled considerable expense of time, due to the need for an intraoperative x-ray outside the op area. It means that the patient, after temporary closure and with sterile dressing, must be wheeled across the hospital grounds. Then he is mistakenly taken back to the ward instead of the op area. In the end everything proceeds as previously discussed with the patient.
The last op, our oldest patient, she is 63 (there it is again, the "other" world) is normal. A great burden drops away from us... we've managed all the op's sans complications!!
During rounds, Pélagie (cf. Nov. 15) demonstrates her progress, applauded by her relatives. Her gratitude, as that of other patients, is so immense, spontaneous, and deep that we feel embarrassed...
19:00: departure folowing rounds
No more op's planned. It is one of the principles of the mission to terminate surgery before the last day. Thus we could react, if necessary, should any early complications occur among the latest cases.
Nevertheless, a work day:
> packing tthe things we take back for the return flight
> remaining materials (instruments, unused protheses, drugs, coverings, disin-
fectant solutions, etc.) are stored in lock-ups, some air-conditioned (drugs, bone
cement) ready for the next mission.
> inventary of used materials
> inventary of materials staying behind
> completion of the clinical documentation, including taking photos of the post-
operative x-rays of all patients. Finalisation on Nov.22.
It's a "big day" today. Burkina Faso is playing in the final African game to qualify for the world championship in Brazil. A draw against Algeria would suffice.The city has been honking since dawn, everything is covered in green-red.yellow, what could go wrong. We're all for it.
At the official provider's we stock up on Burkina shirts and bet 0:3 for "us". Our loyalty is appreciated. At the "Palmiers" in fan garb we watch the game. Alas, it's not enough... We lose 1:0 and are out........ :-(
But we'll be back until we succeed, there's time.
In the evening we dine with colleagues in an all-African restaurant. The mood in the city has cooled down a bit following the missed chance...
We can't see the food (why didn't we bring the head lamps from the surgery?), but in exchange it tastes great.
Wednesday, Nov.20 and Thursday Nov. 21:
For these two days we have planned an excursion to David's home Togo. Our destination is the valley of the Tamberma in the North. In the 17th century, animists here constructed fortified villages as defenses against the Benin kings. It is one of the main attractions in Togo which David has never seen himself! At our own cost we rent a small bus plus driver, not comfortable but spacious (anything else would have been self-destructive as we soon realize).
Parts of the highway are good, in other places there are potholes big enough for our bus, the road belongs to everyone... and everyone uses it as if alone.
Although we can only see what lies along the highway, we note how the countryside and the "living standard" differ from busy Ouagadougou.
Does one have to drive that far? Not necessarily, but the border-crossing Burkina Faso - Togo is an experience. No congestion,but it takes two hours because there are control posts everywhere where you have to wait and pay, for what?... At one point we pay so that we don't have to pay at the next post. Where nobody knows anything about that...The reward: two pages of colourful entries in our passports, giving the impression that this is a world trip! And the observation of a colourful, busy people...
The last 100 kms in the dark and we feel that it's enough. Mopeds guide us to the "Auberge de la Cloche". We're late and the only guests. The proprietess is willing to cook us a meal, but we must settle for something that won't take so long, so that after two hours of much rattling of pots and a few beers we can dine. Followed by a schnapps on the house. In the early morning rattling noises again, and a breakfast prepared with great love.
Then 25 kms unpaved road to the Takienta of the Tamberma Valley. The fortified houses and villages are considered tourist attractions , but are lived in. Pictures say more than words here.
We say farewell to David at "Western Union Station"... incredible what he accomplished, for he is actually older than he looks. A few times we had to wait for him, when he missed an appointment...
Now we will miss him. We're no longer "complete".
We are setting out, back to Ouagadougou. Again we are driving into the night.
It's hard to believe that more does not happen here. Bicycles without lights suddenly loom up in the modest beams of our headlights. A lorry is having its left rear-wheel changed, taking up a third of our lane, no lights...
If you drive here at night, you must realize that at any moment you may run over someone. This awareness is the only protection...
9:00: arrival at the clinic, rounds, finalisation of the clinical documentation. Final discussion with colleagues and the director of the clinic, Abbé Joanny Kouama.
OHA! e.V. thanks all supporters with a farewell dinner for all, in the op anteroom.
We have a couple of hours to visit the city...
This is one of the last photos of our journey... a little bit like "Stranger than Paradise", J. Jarmush.
We are exhausted, as are they we have just left... emptiness??
This report was written 6 weeks after our return. These two weeks in Burkina Faso have not left us untouched... After the mission is before the next mission. The way it looks, the mission team will be full. All will see to it that they'll stay in good health!
What follows corresponds without any changes to the final lines of the activity report for the inland revenue.
20:00: departing the clinic for the airport, take-off punctual at 22:50
Saturday, Nov. 23:
7:30: arrival Frankfurt, sans luggage, alas
Sunday, Nov. 24:
Luggage arrives... from 14:00 to 17:00, TW and AL put away the instruments borrowed from the GPR-Klinikum Rüsselsheim which will be needed for Monday's surgery.
Each patient, each op has been carefully documented. A statistical break-down is on file.
A few data:
> median age of patients with hip prothesis: n = 18 : 40,22 yrs. (21-64 yrs).
> only 4 of 18 patients were over 60, all were under 65
> The 14 remaining patients were all under 56
> one op (op 19) did not involve artificial hip replacement. No appreciation contribution.
> 2 of the hip replacement patients proved destitute and did not contribute either.
> Occupations of patients:
unemployed/house wife/cleaning lady: n = 6
clerk: n = 2
apprentice (hairdresser, nurse) n = 2 (in both cases training interrupted due to hip complaints)
carpenter: n = 2
gardener: n = 1
soldier: n = 1
electrician: n = 1
driver: n = 1
printer: n = 1
policeman: n = 1
teacher: n = 2
Hip Score (degree of gravity), cf. above):
grade 4 (very pronounced impairment): n = 4
grade 5 (extreme unbearable impairment/complaints): n = 14
Median hospital stay: 3,5 days, then return home, no rehab available.