Africa mission #2, June 2014

July 5, 2014



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June 2014 – CHP Kpalime’ Togo, Africa

Romain Onteniente, DPM
Timothy Graham, DPM
Mario Cala, DPM

May 29th 2014:

The Podiatry Overseas team met at Miami International Airport, carrying over 200lbs of donated supplies that had been specifically requested by the hospital officials in Kpalime’. After a quick check-in and an itinerary meeting, PODOA was on its way back to Africa.

May 30th 2014:

Prior to our much anticipated arrival to Togo, a 2 hour layover in Paris allowed us to relax at the airport and dine on a typical French breakfast with cappuccino. We departed from the ‘City of Lights’, having only experiencing the humming lights of the airport.

May 30th 2014:

“Bienvenue a Lomé” came over the airplane speakers just as the plane’s tires finished their screech down the Togo runway. Again we were greeted by an airport lobby with no lights, no air conditioning, and a winding line that guided us to customs. Passports with visas and vaccinations booklet in hand we waited as security officers screened travelers. Once we arrived in the baggage claim area, a surgeon from the university hospital was waiting eagerly with a grin from ear to ear and a 8.5″ x 11″ paper sign that read “Podiatry Overseas”. A couple of handshakes later and the Togolese TSA stamped our donation boxes and escorted us to the exit. Another university employee was waiting at the gate with an SUV to carry our luggage and donations, while the university’s surgeon took us to our hotel in the heart of the capital city.

June 1st 2014:

We awoke after only a few short hours of rest, and began the 2 hour car ride to our final destination, Kpalime’. We quickly recognized the streets and the buildings, it was as though time had stood still since our last trip. As we approached the hospital entrance, we were swarmed by the Togolese friends that we had left in December. It was the same feeling one gets from visiting relatives over the holidays. The director of the hospital Mr. Francis Awala snapped a few pictures on his cellphone of his visitors and their donations, eager to send the photos to his colleagues and friends. We were then greeted by the Chief of surgery, Dr. Gamal Ayouba, who clapped his hands together and said, “Okay.. lets get busy!”.

That morning we had prearranged a workshop and lecture with Dr. Ayouba for surgeons and residents from Lomé. 22 doctors carpooled from the University of Lomé to make the 2 hour drive. The lecture/inservice was led by Dr. Mario Cala, he educated these physicians on the multiple uses of external fixation in the lower extremity.

For some, it was their first exposure to the concept and theory of external fixation. For most, it was the very first time they actually had a hands on experience with the devices. Of the 10 Ilizarov external ring fixators donated to the hospital, 4 were later demonstrated. We chose 4 highly variable cases to demonstrate the application of external fixation, from patient presentation to operative application all the way to post-operative care regiments.

A luncheon had been organized at a nearby restaurant named ‘Gourmet’. We dined with the doctors from the university and discussed medicine, politics, and life in general. Surprisingly, the majority of these physicians spoke English, which made the extent of our stay all the better.

3:30pm: Patient number 1 was a 30 year old male with no remarkable medical or surgical history. He presented 2 weeks ago to the hospital of Lomé after a motorcycle accident. The patient did not receive surgical or medical care, other than regular dressing changes. Patient presented with a comminuted mid-shaft open tib-fib fracture on the left leg.

6:30pm: Surgery was complete. We performed an open reduction with external fixation (Ilizarov frame) to left lower extremity. Post-operative management instructions were given to the hospital staff. Dr. Ayouba agrees to follow the patient at Kpalime Hospital.

7:30pm: Shortly after stepping out of surgery the director of the hospital approaches us and invites us to quickly change clothes, as we were expected to meet the President of Togo’s brother-in-law for dinner.

10:30pm: Fresh barbequed lamb was the main dish at this very informal, yet very political gathering.

June 2nd:

7:00am: A mile long walk from our hotel to the hospital. Passing through an African market on our morning journey, greeted by the welcoming community with a friendly “Bonjour!” around what seemed like every corner.

At the hospital, we are introduced to Patient # 2: 36 years old male with history of trauma to the left leg that resulted in a transverse tib-fib fracture with anterior and lateral displacement.

9:00am: The doctors from the university gathered back at K’palime Hospital, busy deciding who was going to scrub into Patient #2’s surgery. We then performed a closed reduction with application of Ilizarov frame External Fixator to the left lower extremity.

12:00pm: As a token of their appreciation for our work and successful surgical reductions, we were granted a trip to a remote water source deep in the African jungle near the border of Ghana.

3:00pm: Back from an amazing sightseeing in the type of environment you can never get tired of experiencing, we arrive at a local hotel where the surgical team from the capital was staying, and where a traditional Togolese meal called “Fufu” was awaiting us.

5:00pm: Rest and relaxation, before another business meeting.

8:00pm: We decide to walk to one of our favorite locations from our previous trip, ‘Gourmet Restaurant’, to have a meal. Continued handshakes and warm welcoming from people who recognize us from our December trip to Togo. We continue to take pictures and greet various hospital administrators, who choose to dine at Gourmet regularly.

10:00pm: After dinner, our group conducts a mini-meeting to go over our first 2 days.

June 3rd

7:00am: The morning walk to the hospital is coupled with continuous greetings, “Bonjour!.. bonjour.. Bonjour! “. The Togolese populous could easily hold the world record in hospitality.

9:00am: After rounding on the ER patients as well as our post ops from the weekend, Dr. Ayouba starts his consultations for the day. We quickly realize how overwhelmed he is on a daily basis, dozens of patients stand outside his office waiting hours to be seen. In K’palime there is a hospital rule, as a patient if you don’t show up by 10am you will not be seen on that day.

12:00pm: 3 hours of non-stop consultations during which patients enter the office as the previous one walks out, 2 patients with lipomas triggered our interest.

Patient #3 was an 8 years old boy with a lipoma on the dorsum of the right foot. This young boy was embarrassed of his deformity which prevented him from playing outside with other children. The patient’s father was also worried about his son injuring himself if he chose to play with the other children, because of the physical limitations that the lipoma placed on him, as this patient was unable to wear normal shoe gear.

Patient #4 was a 42 year old female with a history of a lipoma 6cm proximal to left patella, which had been growing for a couple of years and had gotten to the point of hindering her day to day life.

A couple of protein bars for lunch followed by two successfully surgically excised lipomas made up our 3rd day in Africa.

8:00pm: We walked to Gourmet for a quick dinner before bedtime.

June 4th

7:00am: The walk to the hospital has by now become our daily meeting, 20 minutes during which we discuss events and cases that we experienced the day before and what could be done in the future. All that while practicing our French phonetics.

9:00am: By this time we had finished rounding on patients as well as educating and assisting the nursing staff with wound dressing protocols for patients with podiatry specific pathologies.

10:00am: After Dr. Ayouba had completed multiple walk-in consultations, including a female patient with a 500gram lipoma on the posterior aspect of her scapula that the doctor decided to excise later on that day. Dr. Ayouba’s surgical assistant was out sick and asked for our assistance in the OR.

10:30am: Our scheduled surgery is on patient #5: a 38 year old female with a history of erysipelas superficial infection that led to a circumferential loss of dermis to her left lower extremity from the tibial tuberosity all the way down to the dorsum of her foot. Split thickness Skin graft was harvested from bilateral thighs using a manual dermatome, fenestrated, and sutured onto the affected leg. Upon completion of suturing, Dr. Cala recommended the benefit of applying an external fixator for offloading purposes. Again an Ilizarov type external fixator was applied using a foot plate, a high tib ring and a floating ring with no wire to allow for dressings changes and access to grafts location.

3:00pm: Time for a protein bar and a turnover before we entered the OR again for patient #6: 38 year old female patient presenting with soft tissue mass on the posterior aspect of the right scapula extending to deep muscular fascia. The lipoma was by far the largest any of us had ever seen.

7:00pm: The team is yet again invited for dinner, this time at TsiTsia’s hotel, an entrepreneur and influential Togo personality whom we had met during our previous trip.

10:00pm: Another successful day comes to an end as we arrive back to our hotel.

June 5th

7:30am: After discussing post op protocols for the patients with external fixators, Dr. Ayouba mentioned that he has read that the wound type on patient #1 would benefit from negative pressure wound vac therapy. Our team agreed and asked Dr. Ayouba if the hospital had access to wound vacs. We were shocked when handed was a dilapidated medical vacuum from the 50’s with variable pressure settings. When in Africa, you use what you have available. Using gauze, sponges, and tegaderm our team constructed a makeshift negative pressure wound vacuum. The picture shall speak for itself, as we performed procedure #8, a Bedside application of wound vac to left open tib fib comminuted fracture S/P 4 days.

9:30am: 30 minutes into consultations, and along comes patient #8: 13 year old female patient with residual club foot who failed to respond to ponsetti casting early in life. We deliberate over the pros and cons of surgical treatment. After deciding that surgical intervention is the best choice for this patient, her parents inform us that they won’t be able to afford to care. Our team decides to covers all costs.

10:30am: Patient #9: 47 year old female presented to the ER 6 months after surgery with surgical incision dehiscence on dorsolateral aspect of right foot. Split thickness skin graft harvested from patient’s right thigh, fenestrated and applied to wound after thorough curettage and wound bed preparation.

1:00pm: Lunch at Gourmet Restaurant with the Rotary Club of Kpalimé. We were honored when informed that we had the support from the Rotary Club for continuation of future missions.

2:30pm: Back to the hospital. Open reduction of residual club foot with gastrocnemius lengthening, flexor tenotomies and plantar fasciotomy of left lower extremity with use of Ilizarov type external fixator to left lower extremity.

7:30pm: Final procedures review with Dr. Ayouba and chart completions for the day. Post op protocols reviewed and staff explained the importance of proper dressing changes and hygiene.

9:00pm: Final dinner at Gourmet restaurant for end of mission meeting with Dr. Ayouba and Francis. Accomplishments and future projects discussed, partnership and agreement contracts signed.

June 6

8:00am: For our last day there was no walk to the hospital, a chauffeur was waiting for us at our hotel entrance. Upon arrival to the hospital, the feeling of satisfaction was palpable.

9:00am: Final rounding on all our post op patients as well as the floor patients, final post-procedural orders given to nursing staff.

10:00am: We treated all of the hospital employees with pastries. When we asked Dr. Ayouba why everyone was so excited for something as simple as a pastry, he replied, “That little luxury costs half a week’s wages to most of these people.”

10:30am: A line of hospital staff members and administration waited to say thank you and wish us farewell.

1:00pm: Arrival at University Hospital of Lomé to meet the Chief of Surgery, Dr. Abalou. His words: “We all enjoyed your stay and appreciate your generosity. This is not a goodbye, it’s a see you later”. This final farewell meant a great deal to our group.

2:30pm: Final stop at Alt Munchen restaurant for lunch before our flight.

8:00pm: Departure from Lomé airport, Miami bound.