Madagascar Report, March 2008
The project in Tulear is advancing at a rapid rate. A large team visited for two weeks in November 2007 consisting of two orthopaedic surgeons, Dr Graham Forward and Dr Will Brycson, gastroenterologist Dr Digby Cullen, anaesthetist Dr Conrad Makrokanis, general practitioner Dr Sarah Rylance and two nurses namely Kelly Pride who is a trained theatre nurse and Scott McKay, an orthopaedic plaster nurse from Princess Margaret Hospital. Invaluable assistance to the team was given by Muriella and Tiana from the Toliara Sands Project and by Jules Le Clezio. Their linguistic ability and logistic skills enabled us to make a major breakthrough in our communication with the Madagascan doctors and hospital staff. As a result a large amount of operating and teaching was carried out at the General Hospital and at the Clinique St Luc. Digby and Sarah saw and treated several hundred patients with gastrointestinal and general medical problems.
The orthopaedic team saw approximately 100 patients with complaints such as talipes equinovarus, active joint infections, acute and neglected trauma, tumours and arthritis. We performed a number of operative cases including eight children with talipes treated surgically. The cases included knee arthrodesis for chronic sepsis, fibula excision and corrective osteotomy as well as application of external fixation and internal fixation of trauma cases. Scott McKay developed an excellent rapport with the physiotherapy staff and has made major steps in teaching the Tulear doctors about treatment of talipes with serial plastering. We are working hard on a plan to get her back to Tulear in October 2008.
A DVD of this visit has been made and is available through the Australian Doctors for Africa office.
The most recent visit to Madagascar was in February 2008 by Dr Mick Tiller and Dr Rob Genat orthopaedic surgeons and theatre and general nurses Cherie Genat and Jan Tiller. It was again supported by the interpretive and logistic services of Jules Le Clezio, Muriella and Mulalla.
Report of Humanitarian Visit, 18 November to 1 December 2006
Dr Michael Tiller - Orthopaedic Surgeon
Dr Mark Salib - Emergency Specialist and Anaesthetist
Janice Tiller - Nurse
Emily Forward - Nurse
Graham Forward attended during the second
week.
We left Perth airport Western Australia on Saturday morning at 1.15 a.m. for an 8 and a half hour flight to Mauritius. Due to some difficulties with time tables we didn't then move on to Madagascar until approximately 6.00 p.m. on Saturday 18th November 2006 arriving in Anatananarevo at approximately 8.30 p.m. their time. We stayed overnight in the Hotel de France and left the following morning for Tulea on the South West Coast of Madagascar Island which is quite large. From Monday 20th November we commenced clinics at a combination of St Lukes clinic in Tulea together with clinics also at the government run hospital.
The work time was a little different to what we have in Australia in that we would appear in the theatres or clinics approximately 0800 and it would take a little time to get things started and then all would stop at 12 midday for a 3 hour siesta/break. Again we would resume at 1500 and then carry on into the early evening.
It was interesting that the wards were somewhat of a worry in that they were not particularly clean and as an example I saw one child there with 50% burns of the body and she was lying on a bed with flies all over her and no intravenous therapy being utilised from the point of view of fluids.
In regard to the types of procedures, I carried out an open reduction and internal fixation of a fractured clavicle where on fragment was coming through the supra clavicular fossa area, this being plated. I also was involved in treating a very nasty compound fracture of the right forearm of a young man who had come off his motor cycle and we took some two and a half to three hours to complete this as the only drill they had was a Black and Decker type which packed up in the middle of the procedure, and they did not have any hand drills that they knew of. We eventually sorted out the drilling of holes with an extra drill that we had brought but I am somewhat worried about the sterility of what took place. Nevertheless we eventually plated both the radius and ulna and the patient post operatively looked a lot better and his temperature had fallen and he was comfortable. Other procedures were of club feet on which we operated on four plus a number of babies with trigger thumbs and also one man who had avulsed part of the distal phalanx of his finger.
Orthopaedic Surgery and Gastroenterology visit to Tulear - November 2005
A gastroenterology and orthopaedic visit was made to Tulear in November 2005. Dr Digby Cullen and anaesthetist Dr Mark Thackray carried out an assessment of the needs in a small private clinic and the large general hospital. Orthopaedic and gastroenterology operations were carried out at the St-Luc Clinic. This was largely an appraisal visit and will be followed in November 2006 by a further operating visit. The needs at the moment are for the provision of a video endoscopy unit to the general hospital along with a suitable image intensification x-ray system for the fracture clinic.
It is planned to establish a free visiting service for the surgical correction of talipes along with the selection and training programme for suitable nursing and medical staff to allow the early detection and treatment of talipes with corrective plaster.
Each visit requires cash funding of approximately $25,000.00 accompanied by donated goods, services and pharmaceuticals of approximately $150,000.00. In addition there are specific capital items requiring more significant expenditure when funds become available. At the same time we have been working on improving the insurance availability, emergency evacuation plans, procedure manuals and organisation charter.
Madagascar Report - November 2006
Personnel
Dr Graham Forward Orthopaedic Surgeon, Chef de mission
Dr Digby Cullen Gastroenterologist
Dr Mark Thackray Anaesthetist
Emily Forward Notre Dame Nursing Student
Objective
- Assess the medical facilities at the Hospital Publique de Tulear and the Clinique St. Luque, Tulear
- Conduct outpatients clinics for orthopaedic and gastroenterology patients.
- Conduct operating/theatre training sessions for orthopaedic and gastroenterology patients.
- Deliver and install/integrate donated medical and surgical equipment and supplies
The follow report details the successful meeting of these objectives. Due to the theft of a briefcase containing passports, money, airline tickets and documents, some of the names and details are not recorded precisely
Travel and Logistics
The team travelled with the support of Kumba Resources and the invaluable help of M. Jules LeClezio from Madagascar Resources NL. Australian Doctors for Africa thanks these two companies who are developing the Toliara Sands Project.
Travel from Perth required overnight stops in Mauritius and Antanarivo before the transfer to Tulear in the arid south west of the country. Visa for entry to Madagascar was available for purchase on arrival. We were transporting 300kg of donated medical and surgical equipment including video-endoscopes, the carriage of which was provided generously by Air Mauritius and finally by Air Madagascar. The return journey was more manageable with an excess of 50kg, but the bulk of the goods made transfers difficult.
In Tulear we were met by a delegation including The Clinique St. Luque, Madagascar Resources and the regional representative, Marsellain and taken to the Hotel Eden.
Consultations and Operating - Clinique St Luque
Consultations with orthopaedic and gastro-enterology patients were conducted at the Clinique St Luque between 8.00 – 12.00 and 3.00 – 6.00pm. The Clinique is clean and well maintained on 2 hectares of land on the main highway RN 7. The chef de service, Dr Noell welcomed us and explained that during our visit, patients would not be charged the usual fees for attendance.
102 orthopaedic patients were seen over the course of 8 days. Many were treated with exercise programmes, medication, and injection or splinting. At this stage the operating theatre is not suitable for significant orthopaedic surgery because of its cramped nature and the difficulty in maintaining a sterile field. 12 patients have been listed for surgery next visit including correction of burns contractures, osteotomy for fracture mal union and arthritis, fixation and grafting for non union and talipes correction. 3 orthopaedic operations were carried out including mobilization of knee ankylosis requiring extensive release and quadriceps lengthening.
- Anaesthetic services were somewhat disorganised on our arrival. Mark Thackray was able to help with the layout of equipment, availability of essential items and the giving of anaesthesia, sedation and analgesia. Digby Cullen consulted with over 50 patients, finding a need for an accurate interpreter in the area of gastro-enterology history taking. The most common diagnosis were oesophageal varies secondary to hepatitis, ulcers and reflux. Hepato-splenomegaly secondary to malaria, tuberculosis, schistosomiasis, filariasis, venereal diseases and renal tones were common diagnoses. Endoscopy, teaching and treatment such as variceal banding, was carried out on 12 patients.
- Emily Forward took on the responsibility of the endoscopes, cleaning and drying and teaching the nursing staff (especially the Chief Nurse, Janine) how to do this using glutaraldehyde and appropriate protection including ventilated face masks.
A. General Hospitals
A subsequent visit to the General Hospital (Hopital Be)
Gastro-enterology revealed a very well equipped endoscopy suite where Dr Gregoire carries out 10 endoscopies every Thursday. Even at this public hospital, patients pay for services.
It was agreed that this was a facility at which future endoscopy services could be based, and that future needs are:
- video endoscopy system to replace the existing Olympus scopes
- injection system for varices
- test kit for helicobacter pylori
A large amount of equipment including surgical gowns, biopsy forceps, gluteraldehyde and ventilated masks, and suitable medication was given to the unit.
B. Anaesthetics
Dr Mark Thackray made extensive observations and enquiries regarding the anaesthesiology and reanimation services run by Dr Caroline. A large amount of anaesthetic drugs, needles and syringes, spinal needles etc were given to the unit, having been donated generously by St John of God Subiaco. Overall he has some suggestions for the improvement of anaesthetic monitoring and other aspects in a separate report.
C. Orthopaedics
The orthopaedic service is based around trauma with no significant elective surgery carried out. Dr Georges is the chef de service, but all 6 surgeons on staff are generalists. After the Monday morning grand round, during which 40 and 50 inpatients were reviewed, the theatre allocation and booking for the week was carried out by a group consensus. There are 2 operating rooms, 2 session per day, 6 days per week. Approximately 24 cases were scheduled for the week. Post-operative infection rates are in the range 5 and 10%.
- There is a radiology department with good X-ray capability. There is a dedicated fracture theatre, not utilized because the image intensifier is unserviceable and can never be repaired because it is too old. There is a significant community hepatitis incidence. HIV infection rate in the community is low: in the range 0.35% to 1.5%. Ward accommodation is on open wards with no fly wire, running water or electricity at night. Patients were seen with untreated osteogenic sarcomas, traumatic and tuberculosis paraplegia, fracture non-unions, extensive burns after house fire, abscess (staph and non-pyogenic) as well as a range of urologic, obstetric and general surgical conditions. A large amount of orthopaedic and general surgery supplies and equipment were left with the chef de service.
Infrastructure Summary
1. The Hospital Publique is the major referral hospital for 5 – 8 million people and is well maintained but under-resourced. There has been assistance provided in the past, on a sporadic basis, by projects from Japan, Germany and France. The Australian Ambassador is currently assisting with renovation of the kitchen block.
Australian Doctors for Africa could best assist the Hospital Publique by
- providing the equipment needed to upgrade the endoscopy unit
- providing shipping, installing and maintaining an image intensifier system for the fracture clinic.
2. The Clinique St Luque is a private clinic with one operating theatre and a new larger operating theatre under construction. There is an X-ray machine (US military pre World War). There are hopes for a new X-ray machine from Germany in 2006. The staff are well trained and very receptive to the support of visiting medical and nursing staff.
Australian Doctors for Africa could best assist the clinic by
- providing theatre nursing training with emphases on hygiene, cleanliness, sterile techniques, sharps awareness, preparation and draping.
- provision of surgical training visits
- establishment of a free visiting service for the surgical correction of talipes equino varus = club foot = pied bot. This is a common condition in the Toliara region, is simply treated surgically and has good results.
- Select and train suitable nursing and medical staff in the early detection of talipes in neonates and the treatment with serial, corrective plastering.
Time Frame
The implementation of the above may take 3 and 5 years and require 2 visits per year by teams from Australian Doctors for Africa.
Wider Perspective
The Toliari Region is highly populated and impoverished with a high rate of tropical and venereal infections. Prioritizing medical effort is important: balanced with the reasonable expectation of being able to provide a needed service on a sustainable basis.
Areas of possible early assistance are
- Venereology - diagnosis, treatment, prevention, education
- Urology - renal calculi are very common
- Pre-natal screening and maternal education