Refugee Relief International After Action Reports

Tanzania - July 4, 2006

Mission: To provide surgical services to displaced refugees of the Rwanda civil war and under-served citizens of Tanzania on the border with the People's Democratic Republic of the Congo.

A three-person Refugee Relief International medical team left San Francisco international airport on July 4, 2006. The team arrived at Kilimanjaro Airport (JRO), the evening of July 5,2006. We were met by our ground contact, Tom Lithgow, for assistance with clearing customs. After clearing customs, we were taken to the Arusha hotel. The hotel had kindly donated rooms to the relief team on both arrival and departure.($130 value times 4 rooms total).

Tom Lithgow had not been able to find a medical supply house. We went to a small clinic in Arusha that had been built by Tom's father and was now run by Dr. Arras. Dr. Arras is a Fellow of the Royal College of Surgeons and completed a surgical fellowship in cardio-thoracic surgery in Edinburgh, Scotland. Dr. Arras provided us with a case of IV fluid and Cydex chemicals. These were critical to performance of the surgical mission.

The following morning we loaded 400 pounds of medical supplies and surgical equipment into our charter aircraft at Arusha airport. The charter company provided the flight to us at cost, $6000 dollars round-trip for a Cessna Caravan.

The aircraft landed at a dirt strip at Katavi National Park. We were met by two Land Rovers and off-loaded the team and all our equipment into these vehicles. We then drove five hours to the shore of Lake Tanganyika, to the town of Kipili.

The town of Kipili has approximately 500 inhabitants living in individual mud brick houses. It is right on the shore of Lake Tanganyika. There is a Moravian mission and a Benedictine monastery just behind the town.

The medical clinic is a three room mud brick building without electricity or running water. There are active termite mounds inside the building. The center room had been prepared for us with temporary fluorescent lighting and a 5000 kilowatt generator.

We met the local medical assistant who worked out of one section of the building. He maintains medical records on the villagers, and provides referral services to the regional hospital as well as immunization services and basic medical care. He was assisted by a nurse who lived in the village. The village has two small market stalls with an extremely limited number of items for sale. The water from the lake was tested and found to be completely safe for drinking from both a chemical and bacteriologic standpoint. Village sanitation is by open burning, and use of covered latrines. They are numerous venomous snakes, including puff adders, black mambas, spitting cobras, and king cobras.

Five hundred meters beyond the village is a secure warehouse where the construction materials for the Lupita Island resort are stored. The medical supplies were secured at that location, and we then took an open boat to the island, two miles offshore. The resort is under construction and will not be finished until approximately December 2006. We moved into staff quarters with electricity, running water and flush toilets.

The following morning, we went into the town of Kipili by boat. We secured out medical gear and went to the clinic. The center room had been designated for our surgery efforts. We cleaned out the dirt from the termites' overnight activity, and set up our medical and surgical equipment on long tables for easy access.

The local village chiefs had been informed several months ago about our impending visit. They selected approximately 250 people with medical problems for review. Each of the chiefs had submitted names and chief complaints. Approximately 100 of these people came the first day to be evaluated. The prior evening, the local medical assistant had received a letter from the district medical officer indicating that our activities were not permitted. The district had been contacted several weeks prior by our ground representative, informing them out of our capabilities and intentions. Because of the contents of the letter, it was clear we could not proceed until we had obtained permission from the regional Medical Officer. We secured our medical gear and returned to the island of Lupita, where the team worked on infrastructure construction, including preparing telephone lines and installation of the security system. Tom made multiple phone calls to regional Medical personnel, and ultimately secured permission for us to proceed with our surgical activities the following morning. The main concern of the regional authorities was that we would not perform general anesthesia with intubation and complex operations for which there was inadequate medical support at the village clinic level. They were reassured about our capabilities with Ketamine anesthesia as well as our extensive experience in these circumstances where operations can be performed with safety and minimal complications.

With assistance from our local translator Micha, as well as anesthesia tech/EMT team member, Katharine, and the assistance of the clinic nurse, we began the evaluation of the patients. The vast majority of patients consisted of primary care issues and chronic diseases. Respectful attention was given to these patients while we attempted to identify surgical cases among those waiting.

After two hours of evaluations, we had identified one person with a large subcutaneous tumor in the buttock, as well as a 5 year old boy with a partially paralyzed leg from a sciatic nerve injection. There also were multiple patients presenting way hydroceles, which were diagnosed and then explained that there is no need to operate on these self-limiting cases. We did find an inguinal hernia on a seven-year-old girl. There also several individuals presenting with club feet and post-traumatic deformities.

At 1 p.m. we began preparations for surgery. The gentleman with the tumor in the buttock was initially selected. His resection was performed with valium intravenous sedation, and local anesthetic. The 7 centimeter tumor was removed, and this was consistent with a complex lipoma, with fibrous features. Blood and fluid precautions were strictly observed.

We then broke down the instruments and surgical field and had all instruments cleaned and sterilized in CIDEX. Medical trash was burned in a pit behind the clinic specific for that purpose.

The following morning we intended to screen additional patients, and then proceed with surgery on the five-year-old boy with foot drop. However, the previous night, the two neighboring villages were attacked by bandits armed with AK-47 rifles. When we went to the clinic the following morning, one of the villagers who had fought back had been bayoneted in the abdomen. He was at the clinic seeking assistance. The patient had an acute abdomen and an entrance wound near the solar plexus. I immediately prepared him for surgery. A regional medical doctor, Dr. Kasimba, had come to observe this day. Dr. Kasimba is one year out from his fellowship training. He works at the Karenga hospital, which is only 30 minutes away by boat. The hospital has very limited resources, but it is able to do to C-sections and simple emergency surgery, and has inpatient capabilities. Dr. Kasimba and I evaluated the patient and prepared him for exploratory laparotomy. The patient was found to have a penetrating wound into the abdomen, with a small laceration on the superior dome of the liver. There was no penetration of the hollow organs. The patient was washed out, the liver laceration oversewn, and drains placed (foley catheters for improvised drains). He was begun on an antibiotic and was then transferred to the hospital for further intravenous antibiotic therapy and drain management. We supplied him of with two days of intravenous antibiotics. Dr. Kasimba managed the patient over the next several days, and he made a complete recovery. We then proceeded to operate on the boy with the foot deformity and paralysis with a modified Bridal procedure and tendon lengthenings. We were successful in achieving a plantigrade foot he could walk on.

We performed additional screening and evaluation the following day. A seven-year-old girl with a direct inguinal hernia was identified. This was surgically corrected that afternoon. A five year old boy, Juma Kulwa of Kipili, with a severe club foot was also identified , but this was our final day for surgery. He was evaluated for surgery on a follow –up mission. Pictures were taken for surgical planning and identification. Carlos Kagia, A 37-year-old man with a painful partial amputation was also identified for a surgical correction the following year.

Each day we saw our previous day's patients or received reports on their status. All patients did well with no wound complications. The villagers were very grateful and presented us with a goat.

At the end of the mission, we separated our supplies into those we left pre-positioned on Lupita island in anticipation of a return visit, and to provide fundamental medical resources for the local population. I also left tropical medicine handbooks, out-patient medical treatment guides, and manuals of outpatient orthopedic and plastic surgery.