In January, Dr. Freed and a team of doctors from Mount Sinai returned to Bongo County, Liberia for the first time since the Ebola outbreak...
We arrived at Phebe hospital in the evening of January 10th after an arduous journey. Apparently, patients had lined up to be screened earlier in the week. Early the next day, we began rounds with the obstetrician/gynecologist team of residents, as well as a Peace Corp volunteer obstetrician/gynecologist. New admissions and overnight deaths were reviewed briefly. The team then split up: one group to prepare the operating rooms and distribute our supplies, another to do rounds with a medical resident and the student nurse anesthetists (SNA) on the admitted patients that were waiting for surgery
The main purpose of the mission was to provide classroom training for the Liberian obstetrically/gynecology residents in general surgery topics that were required for completion of their residency training program. A secondary goal was to continue the intern, resident, and anesthesia training necessary to improve general care of patients.
Upon arriving to the OR, the SNAs and the supervising nurse anesthetist reported that the ventilator didn't work; they could use it by hand only. Further inquiry showed that they didn't know how to test it. Therefore, they assumed it was broken. The only way to test the ventilator was to remove the self-inflating ambu bag and attach it to the circuit.
The first case of the mission involved an intubation by a local SNA who didn't realize that the endotracheal tube was too small for the patient’s airway. After several attempts, he placed it in the esophagus. It was immediately recognized and we reparalyzed the child and ventilated, while an appropriate tube was prepared and successfully placed.
On the second day, there was a discussion about an unobserved death overnight in the hospital. We found it unusual for someone to die unobserved in a hospital. Apparently, nurses only call the medical officer after the patient expires so that they can verify that there are “no signs of life”. When we raised questions about what else could have been done the response was “nothing”. We realized that in this resource poor environment, little critical care medicine is practiced beyond the operating room.
Each day we gave didactic sessions to the student nurse anesthetists. We also gave a few lectures to Ob/Gyn residents. Over 8 operating days, we did 34 procedures and anesthesia on 33 patients.
Through intensive didactic teaching help, as well as impromptu sessions in the classroom, at the bedside and in the operating room, we accomplished our main goal. By teaching at rounds and the bedside, we also accomplished our secondary goal. After the 10 day interaction, there is no doubt that they became acutely aware of many shortcomings, the need to improve simple technological capabilities, and have tighter controls over their teaching activities. We hope that the one takeaway lesson was, "It's alright to ask questions, and necessary to obtain the answers!"
*Submitted by Dr. Jeffrey Freed*