The prototypical international surgery experience is the short-term surgical mission (STSM). The transient nature of STSM attracts volunteers who can afford to spend limited time away from careers, families, and other responsibilities. However, the temporary care and support provided avails the organizations running these missions to criticism. Continually, several questions go unanswered: what happens when the mission team goes home and who is taking care of the patients after surgery and to what ends?
As the Benjamin Rush Endowed Global Surgery Fellow at Rutgers NJMS, I aimed to address these questions on a recent mission with the International Surgical Health Initiative (ISHI). For four consecutive years, ISHI has been providing surgical care by STSM at Tetteh Quarshie Memorial Hospital (TQMH), located in Akuapem, a rural region of Ghana. A strong relationship with the medical superintendent, Dr. Mawuli Gyakobo, has been forged over this time. A team of twenty or so surgeons, surgical residents, nurses, and OR techs performed 58 surgeries for the local population free of charge over the course of one week. The operations primarily consisted of inguinal and ventral hernia repairs, hysterectomies, and mass excisions. Although all of the surgical patients were discharged prior to the ISHI team’s departure, one of the members remained behind for extended follow-up beyond the usual few days.
Prior to this mission, follow-up has typically been performed by the local Family Medicine residents at TQMH, with a senior physician available for guidance and support. Through this method, only basic reports on short-term patient outcomes could be delivered to the ISHI team. Asking for more would be an unreasonable burden for already busy residents. However, after the most recent mission, a different approach was implemented; a Surgical Resident remained on-site after the team left in order to assess outcomes and provide continuity in follow-up. With the help of the invaluable local nursing staff, and fueled mainly by Pebbles[1] and instant coffee, I saw roughly forty patients consecutively the following Monday. I took down dressings, removed sutures, reinforced post-operative instructions, and provided a lot of education and reassurance regarding not routinely prescribing antibiotics post-operatively. To my relief, I encountered no major issues and only clean incisions. By the afternoon, my hand was clawed from writing notes in both the local hospital records and the ISHI charts. I saw the remainder of the patients and repeat visits over the next several, thankfully slower, days as well as many of the patients from previous missions to assess some of our long term outcomes.
The operating theatre and surgical wards slowed back to a relative calm from the hurried pace set by the ISHI team the previous week. Once again the theatre was relegated to mainly seeing emergency cases (of which only one occurred during my week-long stay). The patient census on the ward dropped back to single digits. Aside from me bothering them for help translating with a patient or asking for a chart, the nurses and OR staff were free to enjoy the serenity of a ward without ISHI. A stark difference than the fury with which they worked to accommodate our team and help with patient care the previous week.
Outside of the hospital, I figured out how to eat fufu, met a number of “Charlies”, explored a bit of the countryside, and had an interesting run in with a one-eyed security guard. As always when visiting a new culture, I learned several things; among those are that dancing, smiling, and enjoyment of libations are integral to Ghanaian culture. This shows through everyday, as most of the people you meet are vibrant and optimistic.
My personal experience in Ghana was immensely enriching, but our mission was not without its flaws. Several patients at follow up suffered from spinal headaches and one gentlemen required catheter placement for urinary retention after a hernia repair. I also learned that not everyone had been given proper discharge instructions after the mission in the previous year. One gentlemen had been refraining from sexual activity simply because nobody told him he could resume these activities after surgery. He was understandably ecstatic to see me and obtain medical clearance.
By the end of my time in Ghana, the patients recovered from their minor complications, and I left with a sense of closure; I could sleep soundly knowing not only that our patients were well, but we did not burden the local staff with the extra work or complications. I came home with a deeper understanding of Ghana, and humanity as a whole. As a community of humanitarian surgeons, we have a responsibility to audit ourselves, to see and attempt to measure the actual impact we have on the communities we visit before we pat ourselves on the back for a job well done. By performing research, educating the local healthcare teams, and focusing on long-term partnerships we may reach our overall goal of becoming obsolete as surgical missionaries.
[1] A Ghanaian candy very similar to peanut M&Ms, though differs in that they will easily send you to the dentist urgently if not softened properly in one’s cheek prior to biting.