The 4-month-old boy was blue, with a decreasing heart rate, and my cleft-lip technique did not involve an endotracheal tube, which propelled me back to the luxury of the “theatres” (a British term, as many areas of Africa were colonized many years ago) in Vanderbilt Children’s Hospital. But as the seconds passed, and I was in the Horn of Africa where the medical infrastructure must certainly be in the bottom few in the world, that image quickly faded, and this Somali boy needed someone trained in these situations and not a dreamer!
I have just returned from an eight-day trip to an area of the Horn of Africa which has been without a functioning government for many years. The 5.5 hour journey in a plane (8 seats) designed for the African bush allowed us to fly over one UN Refugee Camp with around 200,000 men, women and children who have fled the area we were about to enter. (Sue gives me permission before each trip!) To help educate the readers of this report, a plane “designed for Africa” refers to the bucket in the back of the plane where the “Lavatory Occupied” sign is not needed and the pilot can adjust the wings so that the cows, goats and sheep will scatter as the plane is brought in to land on the dusty, bumpy road that is called a runway. I have visited this area many times over the last few years as we are assisting Amound University, and we are very busy surgically.
When we were greeted by the regional security force and transported to the hospital (which was built when the British were in the area and not much has been built since that time), we were surprised by what appeared to be a Cleft Lip and Palate Convention. The 115 patients who had lost all hope were now waiting in the penetrating sun for an opportunity to have their lips repaired. In their culture, their deformities cause them to be considered “cursed.” We were able to complete 54 cases over the 6 days of operating, and by the week’s end we had a list of more than 180 patients waiting for a miracle. As patients would be transported outdoors from the operating room area to return to the pediatric ward, the crowds would gather and the mothers would thrust their child into our arms seeking help. To describe the medical needs would be similar to describing the needs on the moon if one had no measure of a visit to this comparatively “other world.”
We only intubated two children, used our little oxygen-flow concentrator, used total intravenous anesthesia (no anesthesia machine was available in the entire region and possibly the country), infraorbital blocks for all patients, and a keen eye on the clinical signs as the wide-eyed Somali medical students absorbed the information from the observation and discussions. After a day of 10-12 cases in one room, we lectured for two hours until 9:30 when we were then escorted back to our “Hilton” and had a plate of goat or fish, from the Gulf of Aden. My anatomy, physiology and basic anesthesia lectures were welcomed, and a significant contribution to the first few classes of medical students who have not had a school since 1991.
I was able to develop initial contacts to have an anesthesia survey, have meetings with Amoud University’s Chancellor regarding partnerships and research, and see the ongoing development of the National VVF Hospital, which was funded with minimal support internationally. During one two-day stretch, the medical problems of African pregnant women overshadowed our enthusiasm to perform “one more cleft lip surgery.” I was called to resuscitate an eclamptic mother who arrested (later the mother and newborn died); discovered that three women just had C-sections at a smaller, private hospital under ketamine with no fetal survival; and then I helped with an emergency C-section for a mother with preeclampsia and pulmonary edema, also with no fetal heart tones. In these two days, one mother died and five pregnant mothers lost their children. The issues are complex, the medical terrain packed with obstacles, and the slow international response blindingly stark.
As I was returning and feeling very close to the clouds that hung over the African plains that we were passing, while leaving the masses of patients and untrained medical students behind, I was reminded that so often we would rather be discussing issues “from the clouds.” This perspective allows us to not get too close to people who are suffering, since that stirs emotions that are hard to delete. As a member of the Department of Anesthesiology at Vanderbilt, I am encouraged that our actions have taken us below the cloud cover and into a place where we “will get our hands dirty.” Our efforts to train nurses to perform anesthesia appropriately for the rural areas of Africa will, over time, positively affect an entire region of a part of the world that needs serious medical help. But, as we look closer, we will see the immediate impact on “cursed” children who can walk away from surgery with new smiles and mothers who can carry their pregnancy to completion in a rural African setting. Then as I look even closer, I remember the 4-month-old little boy who survived a rough night due to a pneumonia undetected by an initial exam. His mother was afraid to tell us of the illness thinking that this may be this boy’s sole chance for the repair of his face, and she may have been correct.
I appreciate the support for VIA, which includes the opportunity for VMC anesthesia residents to come help teach and see the world from a new and hopefully, life-altering perspective. In the next Report from Kenya, I will give an update on the Kenya Registered Nurse Anesthetist Program (KRNA) and other activities within the VIA scope, which will include a report from our recent team trip to Guatemala.
Dr. Mark Newton