MAY 1992, VOL 55, NO 5 AORN JOURNAL

Mission Liberia-1989 A MEMORABLE EXPERIENCE

Gail W. Holzworth, RN

n the industrialized nations of the world, medical and surgical advancements are I taken for granted. Skilled physicians pro-

vide consultation to urban areas, and nurse practitioners help to meet this need in rural areas. In third world countries, only a few trained physicians and nurses are available in the urban areas, and they practice with a short- age of equipment and supplies. In the outlying areas, the local medicine men use their skills with herbs and incantations. People lack the transportation and money to travel to cities for care.

The more advantaged nations of the world need to provide services, equipment, and train- ing for people in poorer countries to have access to a better quality of health care. Governments, corporations, individuals, and churches are sponsoring the education of talent- ed young people from third world countries to enable them to return to their homeland and provide care. One such organization is Operation Smile International.

Operation Smile is a nonprofit organization in Norfolk, Va. The founder, William Magee, MD, is a plastic surgeon who was vacationing with his wife in the Philippines in 1982 and saw many people with unrepaired cleft lips and palates. He approached the local government and requested permission to return with a surgi- cal team to repair these defects. When he returned to the Philippines, the word had spread. He found many more people waiting for surgery than he and his team had anticipat- ed. Dr Magee made arrangements to return

again to treat the remaining patients. Nine years later, surgical teams are still traveling to three different sites in the Philippines to treat patients.

Over the years, the services offered by Operation Smile have been requested by other areas of the world such as Haiti, Columbia, Africa, and Vietnam. The surgical team has grown from a few plastic surgeons, anesthesiol- ogists, and nurses to include hand, orthopedic, urologic, gynecologic, and oral surgeons and dentists.

Operation Smile developed a new focus in 1989. They recognized that they cannot contin- ually provide aid; the indigenous population must be educated to allow Operation Smile to move on to another area of the world. The m i s - sion to Liberia, as well as to other sites in Africa, was to teach our counterparts to become self sufficient.

In August 1989, I was officially accepted to go to Liberia and participate on a perioperative team that included an intraoperative team, a child life specialist, a social worker, a physical therapist, a dental prosthetic technician, and an emergency medical technician. In preparation for this trip, I was inoculated for yellow fever and cholera; I was given a polio booster, a

Gail W. Holzworth, RN, BSN, CNOR, is a staff nurse at the Cooper Institute for In Vitro Fertilization, P C, Mariton, NJ. She received her bachelor of science degree in nursing from Stockton State College, Pomona, NJ.

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Fig I . The Republic of Liberia ( a r r o ~ ' ) is located on the west coast of Africa.

gamma globulin injection, and had blood drawn for a hepatitis B titer. My colleagues also advised me to take prophylactic doses of antibacterial products (eg, Bactrim) or broad spectrum antibiotics (eg, Vibramycin) and chloroquine as an antimalaria agent. In my lug- gage I also carried cans of various types of bug sprays.

I was scheduled to depart September 24 and return on October 9. An advance team was sent to set up the equipment and supplies and was scheduled to leave a few days before my team. I was scheduled to remain with the postopera- tive team to do dressing changes and teach wound and cast care.

Operation Smile had to anticipate all equip- ment and supplies that we would need to per- form our surgical procedures. If any of our sup- plies ran out, we could not buy more from a Ftore or borrow from another hospital.

The Setting

he Republic of Liberia is located in west Africa. on the Atlantic coast (Fig 1). The T name Liberia comes from the word lib-

erty because it was settled by freed American

slaves in the late 1800s. Monrovia is the largest city and the capital. It was named after the American president James Monroe. We were assigned to John F. Kennedy (JFK) Hospital, one of the two hospitals in Monrovia. We had limited contact with the other hospital.

At JFK Hospital, there were 100 to 150 inpa- tient beds and a designated intensive care unit, although no ventilators were used in that unit. We had three ORs available to us, and the nor- mal OR schedule was suspended for the week and a half that we were there. Two of the rooms contained three OR beds, and the other con- tained two OR beds because of the large num- ber of patients who needed surgery while we were there. In one three-bed OR, we performed cleft lip and cleft palate repairs and other plas- tic surgery procedures. In the other three-bed OR, we performed plastic surgery, bum repairs, and urology procedures. The two-bed OR was dedicated to orthopedic cases.

The OR walls were covered with ceramic tile, and the floor coverings were similar to vinyl tiles. Each of the ORs had windows look- ing out at the Atlantic Ocean, which was amaz- ing to us; but the fact that the windows were opened when it got too hot, amazed us even more. The sea breezes came in, but along with them came dust and insects.

Each room had a built-in stainless steel cabi- net for storage. but equipment and instruments were limited. I saw perhaps seven metal basins, a few metal pitchers, and three or four small instruments sets in their storage area, although I may not have seen all the available storage areas.

The sterile instrument sets came to the OR from a central area where there were two large autoclaves. We had one flash sterilizer between the three ORs. The scrub nurses each had a Mayo stand, but there were only three back tables. Each OR had one common back table that stayed sterile all day. The instruments that were used from the Mayo stand were flash-ster- ilized between cases. The scrub nurses added new instruments from the common back table, as needed, for new case setups.

There were a total of eight very old OR beds

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and two OR lights in each room. Two portable lights were added to the three-bed ORs so that each bed had one light. There was one old electrocautery machine with a metal plate for grounding the patients. We had shipped an electrocautery machine but could not use it because the electrical circuits were incapable.

One small self-contained suc- tion unit was available in each OR for both the surgeon and the anesthesiologist. It was unusual for two beds to request the SUC- Fig 2. A medicine store located in one of the nearby villages. tion unit at the same time.

anesthesia machine. Anesthesia gases were stored in tanks attached to each machine. Ventilators or electrocardiogram monitors were not available for every OR bed and were used rarely. The only monitors that I saw used were those we had brought with us. It was not a problem to have only one anesthesia machine in the multiple-bed ORs because our anesthesi- ologists were busy teaching their counterparts the technique of caudal, spinal, and regional blocks rather than general anesthesia tech- niques.

Each OR had one very basic

The People, Culture

ut the native 0 It was

OR windows we could see the village below us and the beach. difficult to imagine that on the

other side of that expanse of water was the western hemisphere. In the village, the houses were only big enough to sleep in, so much of the people’s daily life was in view. Sanitation was very poor. People used the beach as a com- mon toilet. Liberians as a group do not like the water, so they did not perceive polluted salt water as a problem. Fish comprises a large part of their diet, but the fishing is done either away from the shore or by Ghanaians living in Liberia.

The Liberians are generally very friendly and

proud of their formal English. A patois is spo- ken among themselves, using a mixture of English, Dutch, and tribal words. They are a quiet, patient people who often use head and hand gestures to indicate their needs. Courtesy is very important to them, and their social life is more formal than that of middle class Americans. When introducing someone, they always use titles; if there is no title, they prefix the last name with Mr, Mrs, or Miss. When they send invitations they include the mode of dress that is expected.

The population is very poor. Street vendors sell anything that someone might be willing to buy. They sold cigarettes one or two at a time, rarely by the pack. Fruit vendors carried large trays of lemons, limes, and other fruits that I did not recognize. Bags of water also were sold on trays by the street vendors.

The populated areas of Monrovia have medicine stores (Fig 2) designated by a red or blue cross painted in the front. First aid, over- the-counter medicine, and herbal remedies are dispensed by each proprietor.

The currency consisted of a large coin that represented a Liberian dollar, and smaller coins for 50, 25, and 10 cents. The largest bill in print is a $5 bill.

There was a defined class structure. If any of the local village people needed surgery, the

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patient had to pay for everything in advance. This included the cost of the hospital stay and all supplies used. The patient’s family provided sheets and food for the patient. During our time there, family members visited the patients daily with pots of food and drinks for all three meals. Operation Smile, however, is funded from pub- lic donations and fund-raising activities. The people who had surgery while we were there did not have to pay for any of the medical sup- plies or services.

Patient Population

ur advance team screened potential patients. In Africa, patients needed 0 plastic and orthopedic surgeries more

than the cleft lip and cleft palate repairs that Dr Magee had seen in the Philippines. Most Liberian children who are born with cleft lips or palates are left to die in the bush. Contractures from burns are common, however, because people use open fires for cooking. This predisposes their children to burns, and con- tractures result from either poor or nonexistent medical care.

Another devastating problem was cancrum oris, a fulminating gingivitis that eats into the soft tissue of the cheek and nose and leaves gaping holes in the face. All members of our teams participated in the care of these patients.

I was most involved with patients who had complications from childbearing. Vesico-vagi- nal fistulas were common. Our surgeons used both an abdominal and vaginal approach to repair these fistulas. One young woman had no pelvic floor, apparently from the injudicious use of a vacuum extractor during birth.

One interesting case was a 19 year-old girl who was born with extrophy of the bladder and ureters. It was difficult for me to imagine the extent of this problem. She had no way to con- trol urination, her mode of dress was limited to trying to stay dry, and her body image was very poor. I worked with the surgeons as they removed her bladder and performed a uretero- sigmoid implant. They used an abdominal skin flap to cover the deficit that was left by the

Fig 3. A young boy with a burn contracture that has formed a web between his arm and chest.

excised bladder. Because of the extensiveness of the surgery, the patient remained in the recovery area overnight.

The next morning, the plastic surgeon and I visited her before we went to the OR. She would not let us look at her incisions. and refused to look at herself. A few days later, however, I saw her during postoperative rounds and asked her how she felt. Without hesitation she pulled down the sheet and gave me a big smile.

We frequently saw severe burn contractures. A three-year old boy was unable to close an eye because of scarring. A young man of twelve was unable to lift his arm because the scar had formed a web between his chest wall and upper arm (Fig 3). Another boy’s hand was pulled out of alignment by a scar on the dorsal surface. He

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Fig 4. A boy whose hand was deformed because of a bum contracture.

was able to touch his thumb and fifth finger on the dorsal aspect of his hand, rather than from the palmar surface (Fig 4).

Orthopedic problems included patients with club feet and growth disorders. While we were there, a baby was born with what they first thought were backward legs; but the x-rays showed that the legs were only bent in the opposite position. With a few months of cast- ing, the physicians projected that the legs would be in a normal position.

OR Duties

here were five people on my team who usually participated in circulating nurse T duties: two RNs, one licensed practical

nurse (LPN), and two surgical technicians. We each teamed up with a counterpart from the staff of the hospital. The Liberians who worked with us were either nurse aides or nurses who had trained in a program that is similar to the diploma programs i n the United States. Liberian scrub nurses were assigned to each occupied OR bed, but there was only one or two circulators available in the three-bed ORs. Most of our procedures did not involve entering a major body cavity so sponge and needle

counts were not a concern. For our cases, there was no documentation or paperwork done by the circulating nurses.

The majority of time I worked with a urolo- gist who had brought a set of instruments, donated by his local hospital, to be used for this mission. This was a privilege because we had our own back table and did not have to share the common back table and the limited assort- ment of instruments.

For sterile attire, we brought our own dispos- able gowns, but the Liberians had cloth gowns that they used from their own supply. We also brought our own supply of sterile gloves. As we took off our gloves and disposed of them in the trash, the Liberian nurses very discreetly retrieved them and washed and resterilized them for their own future use.

In a period of six very long, full days in the OR, we completed 145 surgeries on 142 patients. More than 300 individuals had been screened, and about 155 were prepared for surgery. Our medical records personnel did a magnificent job of putting patient charts togeth- er, especially with the handicap of an unfamil- iar language.

Supply coordination was a difficult job, and we did run out of gloves and 4 x 4 radiopaque

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sponges. Many of the sur- geons brought extra gloves with them, and using those and working with ou r Liberian counterparts to gain access to Liberian supplies, we managed to get through the days. Without the assis- tance of individual contribu- tions and corporate sponsor- ships, the task of caring for these individuals would be insurmountable.

Teaching Fin 5. The author (leji) posing with one of the patients and his father. -

ducation was part of my responsibility as a E postoperative team member in Liberia. It

was very difficult for me to plan an educational session ahead of time without knowing the kind of equipment the Liberians used and the level of expertise of the people I would be teaching. Before we arrived, I was told that my lecture would be addressed to a general audience, con- sisting of RNs, student nurses, and LPNs possi- bly from all over Liberia, not just JFK Hospital.

I decided to do a review of OR positioning. I received permission from the AORN Journal to use the patient positioning article and post test in the May, 1987 issue. I chose a review of basic OR positioning, using the assumption that all ORs have beds that are capable of moving into the postures needed for procedures. I wrote my script and prepared my slides at my hospi- tal, Thomas Jefferson University, Philadelphia, before leaving for Africa. When I arrived at JFK Hospital in Liberia and saw the equipment, I revised my lecture to more basic terminology, but I kept my basic assumption that all ORs had mechanical beds and accessories.

My lecture was attended by both students and nurses and included some people from areas outside of Monrovia. The windows did not have shades so it was difficult to darken the room sufficiently to show the slides clearly. Space and weight was a problem when packing so I did not bring enough handouts for all who

attended the lecture. I did the best I could with what was available to me, however, and the basic positioning review was well received. The questions at the end of the lecture were indicators to me that the participants had under- stood. One question stands out in mind: “What would you suggest using for a jackknife posi- tion if the table does not break?” So much for my basic assumption that every OR has a mechanical bed with accessories.

Summary

s I write this article, Liberia is being torn apart by a bloody civil war. A Information about individuals is nonex-

istent. One of our biggest supporters was a church that was bombed, and the civilians tak- ing refuge within the church courtyard were all killed by rival soldiers. The main headquarters of Opera t ion Smi le in Liber ia a l so was destroyed. Reports indicate that the insurrec- tionists seem to be concentrating on the educat- ed population.

The time I spent with Operation Smile in Liberia was one of my most rewarding and memorable experiences (Fig 5). Perhaps this experience can never be repeated, but it will never be forgotten. ci

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