Mukinge Hospital visit 2014 Report for the AAGBI International Relations Committee Following my fifth visit to Mukinge Hospital I am pleased to report on another enjoyable and productive period. As in previous years the aim was to reduce the workload on the local anaesthesia provider, Sr. Proctor and contribute to safe anaesthesia care in more complex cases as well as offering teaching and training as requested. This shorter visit was none the less busy; there are now two full-time surgeons at the hospital. Not only this but there were three other doctors and a medical licentiate covering medical wards and outpatients which enabled the surgeons to focus on their own ward and operative case-load. Thus I undertook 63 cases in just over two weeks, in addition to the 51 cases anaesthetised by the resident anaesthesia provider (appendix attached). This increase in workload certainly challenges the current infrastructure with two operating theatres (one of which is a minors room with only basic monitoring and no facility for inhaled anaesthesia). Clearly also there is a need for more dedicated anaesthetists whether local or expatriate. There is a plan to re-build Child with a 4 month history of facial abscess for incision and drainage (taken with parental permission) the theatre facility with increased capacity (five theatres) and a formal recovery area (music to my ears!), pending funding. The head of the nearby nurses training school this year requested me to deliver teaching on anaesthesia, giving an overview of the subject and specifics about drugs and equipment to the second year nursing students. While a challenging brief, it was interesting to prepare and deliver and I found them to be engaged and encouraging to teach. I had not anticipated covering the physiology of the neuromuscular junction as became necessary following questions about neostigmine and pancuronium! I also enjoyed teaching an Australian medical student on his elective who had asked to spend a week attached to anaesthesia during his visit. In-theatre training included an introduction to TAP blocks and optimal airway positioning among other topics. Themes which struck me this year included the interaction between a wellregarded but remote hospital like this and the many wider organisations which impact its functioning. The nearest referral hospital at Solwezi has closed its operating theatres for renovation and as a consequence we received a number of referrals from them; on one occasion four in one ambulance, all of whom required emergent surgery. Government inspections and NGO projects alike offer great opportunities but demand manpower, frequently at short notice which can challenge the hospital s day to day functioning.
Planning for disaster was also uppermost in many minds. In fact I was impressed to see the response to a bus crash with about 40 casualties. When I was asked to attend the outpatient/emergency department to assist, the team already had a clear and functional structure in place for triage and management. This was clearly borne of experience as multi-casualty accidents are sadly common on the roads. Additionally much thought is being given to the hospital response in the event of the Ebola outbreak reaching Zambia (which is more probable from the Congo than from West Africa). Already local communities are concerned about the issue with some starting to implement their own vetos on handshaking outside church, for example almost unheard of in a culture where greeting and hand-shaking are fundamental courtesies. Traction for femoral fracture (with patient permission) A note on oximeters: both theatres have non-portable pulse oximeters as part of their monitors. However there is still a need for portable oximeters not only in the event of power failure but also for monitoring patients post-op (they currently recover in the theatre corridor) and pre-op (for the children given oral ketamine sedation). The value of measuring and acting on pulse oximeter readings is becoming apparent in the wider hospital and consequently the two portable machines are now shared with wards and the maternity units. Provision of Lifebox oximeters would still therefore be of great value to the theatre unit. I am very grateful to the International Relations Committee of the AAGBI for their continuing support of this project, also to Craig Oranmore-Brown of Mercy Flyers, Flying Mission Zambia, Oxford University Hospitals NHS Trust and most of all the team at Mukinge Hospital and its Director, Mr Fumpa who continue to welcome me and, more importantly, provide compassionate care to those who come to them for help.
Appendix: case summary Date Age Sex Operation Anaesthetic 2-Sep-2014 29 M Laparotomy ischaemic gut 3-Sep-2014 22 M ORIF patella 3-Sep-2014 15 F C/S placenta praevia ETT 3-Sep-2014 74 F R BKA and L leg debridement 3-Sep-2014 Paed F MUA tib/fib fractures and POP 4-Sep-2014 5 F Burn debridement 10% 4-Sep-2014 2 F Burn DSD 4-Sep-2014 66 M Prostatectomy and TAP 4-Sep-2014 4 F Evisceration eye 4-Sep-2014 23 M I&D penile abscess 4-Sep-2014 39 F I&D finger abscess LA 4-Sep-2014 51 F I&D abscess head 5-Sep-2014 43 M Laparotomy appendix abscess and TAP 5-Sep-2014 29 F E/O trochanteric mass Laparotomy typhoid 5-Sep-2014 44 M phlegmon 5-Sep-2014 41 F Laparotomy ectopic MUA and POP ankle 5-Sep-2014 31 M fracture MUA and POP ankle 6-Sep-2014 69 F fracture 8-Sep-2014 70 M Hydrocoele repair 8-Sep-2014 74 F DSD MUA and collar and cuff 8-Sep-2014 Paed F fractured radius and TAP PO + IM ket 8-Sep-2014 4 F Skin graft for burns 8-Sep-2014 Adult F Amputation arm and ISB 8-Sep-2014 18 F D&C 9-Sep-2014 29 F D&C 9-Sep-2014 21 F C/S breech and fetal distress 9-Sep-2014 9 M DSD PO ket 2014 31 F C/S CPD 2014 74 F Skin graft leg 2014 68 M Bladder stone removal 2014 26 F C/S fetal distress
2014 23 M Arrest bleeding post circumcision 2014 29 F D&C 2014 21 F C/S CPD and fetal distress 2014 9 M R/O sutures from eye PO ket 2014 9 M DSD and Ex-fix ankle PO ket 2014 29 F D&C 2014 22 M MUA and POP fracture tib and fib 2014 4 M I&D facial abscess 2014 75 M Prostatectomy 2014 44 F D&C 2014 6 F I&D brow abscess 2014 9 F R/O FB vagina IV 2014 31 F D&C 2014 25 F C/S multiple previous SB 2014 40 M Wound cleaning and femoral traction pin and FB 2014 9 M DSD and pin resite PO ket 2014 24 M Traction pin for fractured femur and FB 2014 25 M Leg wound debridement 2014 28 F C/S FTP 2014 38 F C/S FTP and IUD 2014 28 F Laparotomy post-cs bleeding 2014 9 M DSD PO ket 2014 8 M Completion amputation index finger PO ket 16-Sep- 2014 28 F Laparotomy removal of packs and BTL ETT 16-Sep- 38 F Laparotomy removal of
2014 packs and BTL 2014 Adult F C/S bleeding and fetal distress 2014 10mon ths F I&D abscess behind ear 2014 85 M Attempted urethral dilation 2014 39 F BTL 2014 7 M Debridement wound PO ket 2014 9 M DSD leg 2014 21 F Laparotomy E/O pelvic cyst PO ket + IM ket