Medical Mission to Rwanda
Our Dr. Jeffrey Segil is currently on a medical mission in Rwanda. We'll be posting his reports as they arrive. Here is the first one:
We arrived yesterday in the early evening in KIGALI, the capital of Rwanda.
Our group from America is called Operation Medical. In short, a mission to provide free surgical services of all types to people in need around the world. This is our first visit to Rwanda. We are working at ‘Rwanda Military Hospital’. It is a large campus, with what we have seen so far, excellent staff, equipment and support. Our goal is to help provide free services as well as to educate local staff on best practices, and new techniques.
This is far from ruffing it here. Our first 24 hours has been great. A wonderful hotel in downtown, three hot meals a day, Air-conditioned rooms. This is the life :).
The city is amazing, clean, minimal traffic, no litter anywhere, all locals have been polite and helpful.
Our introduction today was to the hospital facility. Several of the department heads came in to tour us around and we started to unload gear. I was fortunate that I was able to work with the OB/GYN department chair. Although not schedule to operate till tomorrow there where two cases that need immediate attention and we were able to jump right in and scrub with him.
Their medical training is excellent, very competent and skilled with surgery, and equipment much better than we have experienced on prior mission trips.
After the hospital orientation we were able to visit the Genocide Remembrance Museum. Very emotional and extremely well done. There are approx 250 thousand buried in mass graves as part of the memorial. Over 800K Tutsi and moderate Hutu’s where massacred in a few month window in 1994. Through a combination of almost brain washing techniques the Hutu controlled government was able to convince the civilians to take up arms against the Tutsi and literally slaughter their neighbors, their spouses from intermarriage, the atrocities are amazing. Somehow healing has occurred and all live in peace now as one nation of Rwandan’s, with no ethnic labels allowed. It will still take generations for complete healing to occur.
I am excited to start tomorrow as the department chair has several pelvic prolapse cases scheduled each day for us. Prolapse surgery is a procedure he has only seen done in the past, and really wants to learn to be able to combine with his Vaginal Hysterectomies. It is so rare that I have been on missions where the local surgeon actively wants to learn. Usually we are just performing the procedures. Since he has 8 of these cases already booked for this week, it is very realistic that he will be performing these cases alone by the time the week is over. Cross your fingers for me.
In addition we hope to be able to help with C-Sections and anything else needed. The Midwives deliver almost all the vaginal births, but the doctors assist with complicated deliveries as well as performing the C/sections. This location acts as the referral center for the region, so they also get all the transfers of OB complications which are mostly ‘Obstructed labor’ and PostPartum Hemorrhage.
Our team is large, almost 30 of us. 4 general surgeons, one plastics, and me (GYN), in addition to 2 anesthesiologists ,and 3 CRNA’s. Lots of RNs and associated support staff. And do not forget Midge, our photographer. As usual the group coalesces quickly with everyone looking out fo one another, and very supportive.
Tomorrow night the minister of health and his entourage is joining us for dinner at the hotel. Should be interesting.
Will write more when I can.
Day 3 In Rwanda:
Hello from Kigali,
Well we started officially Opperating yesterday. Over all a great experience.
We are on a large Military Medical campus. It has and is all being rebuilt.
The Women’s health services are housed in its own building away from the main OR’s, but they are entirely self sufficient, less than two years old. We have a Triage bay of four rooms, two large ORs, recovery room, GYN ward for pre op and post op care with at least 12 beds.
A labor area with another 12 beds as well as separate delivery rooms, and PostPartum wards. Everyone in the country has basic coverage, (how a advanced) and if you have additional private insurance then you might qualify for a semi private room.
This hospital serves as the Tertiary Referral center for the region and all the outlying provinces. From an OB perspective that means they do not do huge volumes, but a significant amount of the high risk come here. C/section rates of 30%, similar to US are common, but the parity (number of births per women) can be significantly higher. Birth control, although available, is not as accessible, and abortion is illegal. Today a young women with eclampsia, (seizures) was admitted from an outside region, actively seizing and elevated BPs. Yesterday an emergency C/S resulted in an emergency hysterectomy do to a placenta acreta, where the placenta invades the uterus itself and can cause massive and potentially fatal bleeding.
The point is, they are good here, they no what they are doing, and they see a lot of high risk OB. Midwives, male and female deliver almost all the vaginal deliveries, doctors only there for complications.
Gynecology is a little more basic. While very competent with basic GYN surgeries, they is no one here doing any Urogynecology. So I feel fortunate that I am able to educate. And even more fortunate that they want to learn.
I have spent the last two days Opperating with the department chair. A very knowledgeable and skilled surgeon. He expressed an interest in improving his skills at being able to treat pelvic prolapse (when things fall out). Insightful, he knows that a simple hysterectomy does not correct the underlying problem of lack of support. Something that is still ignored by numerous GYNs in the US. He has scheduled at least 2 procedure per day for us to work on together, the goal is that he can treat these patients alone, once I leave. A realistic goal.
So yesterday 2 of our Prolapse patients did not show up :(, we had a warm up day with an abdominal hyst with adhesions, and then the repair of a recto vaginal fistula. ( a hole between the back wall of the vagina and the rectum. Almost always due to Obstetrical Trauma. This results in uncontrollable loss of stool from the vagina. A devastating condition as women can be ostracized from there families and homes. This 25 year old had delivered 6 months ago in a rural area, and her repair from birth broke down and resulted in this defect. Fortunately is was easily reached and was a simple repair. This will hopefully restore her to a normal quality of life. Although a C/section will be recommended for her in the future.
Today we did two prolapse surgeries. THIS was a HUGE!!!
We had two patients with procedentia, that means total uterine prolapse, the uterus literally falls out of the body. This is obviously a significant quality of life issue for these patients. Pain, pressure, frequently continence. We did two different procedures on these patients, both of these procedures are performed vaginally with or without combined hysterectomy. Neither of which he has done himself. These went very well, and we assisted each other through them. He was very pleased with the results.
The goal is to repeat each day for the next few days so he is comfortable preforming alone. This should be realistic. And very exciting for me. As always the patients are so appreciative of the care. The OR staff and RNs have been wonderful. Very cooperative and willing to learn new techniques. As I have mentioned they are very good. But we are trying to instill ‘best practices’, that we use in America.
As we got out a little early yesterday we were able to be tourists for a few hours on the way to the hotel. We visited the Rwandan National Art museum, As well as the former presidential palace which is now a museum with extensive folk art collection. There is tremendous history here. We last stopped at a Women’s coffee shop. The coffee production, which is a huge agriculture crop, is totally run by women. From the farming of the beans, production, roasting and exporting. We felt obligated to have an espresso, Yum.
Will try and send out an update at the end of the week time permitting.
: Rwanda day 6
Today was our last day at the military hospital of Rwanda.
What a week. I have so much I would like to share, I will try and be methodical so I do not forget, and forgive me if it feels scattered.
I am at the Kigali airport this afternoon waiting to board for Nairobi. Not sure when this will actually mail out.
GYN: Today we competed our last Prolapse repairs with the local GYNs.
Again, this is a condition where the uterus falls out through the vagina. Essentially it is a type of hernia, from stretching of the pelvic ligaments, with the most common cause being numerous vaginal deliveries. Our patients have on average 6-10 deliveries.
Our host and department chair has really warmed up to us over the week, and we have seen his confidence grow as we continue to perform these procedures together. Yesterday when we operated I was able to just assist and advise, but he was able to complete with minimal assistance. We are both so pleased. He will be able to continue theses procedures after I leave, we are both confident, and he has promised to keep practicing immediately.
For these local women this is huge step forward as no one else at the hospital performs prolapse repair, our patients have been so grateful.
My patient this morning was a 76 year old, how has been suffering from prolapse for over 20 years. She has no money, can not afford the very inexpensive government insurance and had been putting this off till now. What a quality of life difference.
We gifted the GYN department today with a special retractor called a Brietsky retractor, specifically designed for vaginal prolapse surgery. While it is itself a simple instrument, it makes the procedure much easier to actually visualize what you are doing.
I brought a small kit of “must have instruments” and my home hospital, Wentworth-Douglas, graciously offered to donate this retractor to the hospital here in Kigali. THANK YOU.
Last post I think I mentioned about three patients I met on consult for Fistula’s. Again, that means a whole between two spaces where there should not be one.
Pt # 1, had a corrective procedure yesterday. She had 2 years of chronic and worsening complications from a C/section in the rural region. Initially complicated with injury to her Ureters, the tubes that bring urine down from the kidneys to the bladder. Ureters are the enemy of the OB/GYN as they travel adjacent to the uterine arteries, and therefore very prone to injury. This unfortunate women had to have an emergency hysterectomy at time of her C/S due to heavy bleeding, that is when her ureters where cut. They had to go back in and repair them shortly after as a second procedure. After that procedure she suffered a peritonitis, An infection in the abdomen.
This can often result in pus in the abdominal cavity, needing another surgery to clean out infection as well as antibiotics.
Wait, it gets much worse.
As a result of the peritonitis, her bowel stuck to her abdominal wall, the incision broke down, and ultimately a piece of her colon fistulized to the abdominal wall. Yes, that means her stool exited through the broken down abdominal wall incision. What a horrific mess. AND, her bladder stuck to the top of the vagina, and the tissue there also broke down and fistulized, so she has a Vesico Vaginal fistula, A hole about 1 cm between her bladder and the vagina. All her urine just leaks out of the vagina. Totally incontinent of both stool and Urine. As well as in incision that never healed over 2 years out. Coupled with no money, she has not been able to receive any care for this.
Yesterday our colorectal surgeon was able to take down the colonic fistula, and reconnect her colon to her rectum. Amazing, no stool except where it should be. The bladder fistula will have to wait till this surgery heals, but what a relief to at least get the colon repaired. They bladder fistula will actually be an even harder repair, but it could not be combined for safety purposes with yesterdays repair. Hopefully the vesicoVaginal fistula can be repaired as well In the future.
Pt #2, A similar story, not quite as horrific, but also with a Fistula in this case of the small intestine to the abdominal wall. She also had a C/S In the rural region, developed a peritonitis, (infection) and ultimately had her small intestine fistulized to an area below her belly button, and an incision that was gapping. Literally a Triangle from belly button to her pubic bone, 8 inches wide.
She leaked all liquid stool from the fistula, but was able to pass solid stool.. Luckily her bladder was intact. Today she was able to have her small intestine reconnected and her incision closed this morning before we left.
Both of these patients will have a long road of recovery ahead of them, and the first patient will need a follow up procedure for her bladder fistula. But we all feel very blessed that we where able to assist these women on the road to recovery. To be incontinent results in being ostracized from family, their husbands leave them, and they are out casts. This is a huge problem in various countries through out this whole continent. In fact some surgical missions doing nothing but specializing in these repairs. Whole hospitals set up to care for these patients. Unfortunately none are here in Rwanda. This week we were able to help, educate improve quality of life for many.
A little about our group:
There where 29 of us in total, 6 surgeons 5 anesthesia providers, and accompanying RNs, techs, assistants, project manager, and photographer. I am not mentioning names here only because everyone of them had an invaluable contribution to our team.
Opperation Medical provides free surgical services on a global level. One trip at a time. We currently support trips to India, Haiti and Africa. With other countries in the future. A 100% volunteer organization, with all overhead covered by the participating individuals and Donations. There have been numerous persons who have given generously to help support trips, and equipment, and offering scholarships when appropriate. To our Rwandan hosts with are grateful for the opportunity to work together. Our group has already been invited to return. We will see what the future holds.
Off to Kenya, hope to see some wild animals on our return to America.