Vesicio-Vaginal Fistula Visit 2009

St Mary’s Hospital, Isle of Wight (UK)-Juba Teaching Hospital (Southern Sudan) Link

REPORT OF TRAINERS’ VISIT TO JUBA TEACHING HOSPITAL, SOUTHERN              SUDAN
                              24th November to 12th December 2009

Introduction:
This was the third training visit to Juba Teaching Hospital (JTH) by healthcare professionals on behalf of the St Mary’s Hospital,Isle of Wight-Juba Teaching Hospital Link. The main objective was to undertake surgery for and offer training in the management of vesico-vaginal fistula (VVF). This condition is extremely common in Southern Sudan and a recent survey suggests that it may affect >19% of the population between the ages of 15 and 49. The visit was also used as an opportunity to undertake other training and related activities
The visiting team consisted of :-
Mr Tim Walsh – Surgeon
Mr John Makunde – Urologist
Mr Mike Bishop- Urologist
Mrs Sharon Evemy- Staff Nurse
Dr Fiona Henderson- Anaesthetist
Mrs Zorina Walsh- Educational Manager
The main activities during the visit :
Vesico-vaginal fistula programme:-
A total number of 15 operations were performed on 13 patients by Mike Bishop and John Makunde. Of these patients only 2 had primary vesico-vaginal and recto-vaginal fistulae and were repaired transvaginally. Three patients had recurrent fistulae and were all extremely complex. Of these 2 required repair by the transabdominal and transvaginal/transanal routes. The remaining 8 patients underwent assessment under spinal anaesthesia. Six were found to have stress incontinence following previous fistula repair and underwent surgery for this. One underwent cystoscopy for suspected uterovesical fistula and one required urethral dilatation only.
The team felt this was a disappointing number and certainly would have been able to have undertaken more cases. The major problem was that the venue for the fistula programme had originally been Juba Teaching Hospital but was relocated to Wau approximately one month prior to the visit only to be relocated back to Juba 2 days before the visit (because of inadequate facilities in Wau). As a result potential arrangements to get patients to JTH only happened at the last moment. There were less patients than expected and all but 2 were redo cases and hence more complex.
Other factors which mitigated against the smooth running of the visit included :-
i) The staff at JTH only appeared to know of the switch back to JTH at the very last minute and in the case of the Matron only after our arrival. Hence most of the preparatory work of theatres, wards, essential drugs, food for patients and equipment only happened after the start of the visit.
ii) The Maternity Theatre, where the surgery took place, was not ideal. It was cramped, required completely clearing out before we started and the operating table was only partially functioning. Turnover was slow as the instruments had to be sent to Main Theatre between cases for sterilisation. The use of the Main Operating Theatre would have been better.
iii) During the visit we were informed that there was another team from Nigeria who would be undertaking fistula surgery at JTH at the same time. This created problems of capacity and also caused organisational confusion.
iv) We were given to understand that for previous fistula visits the nurses had been offered incentive payments but that this was not available for the current visits. This did create a degree of resentment. Nevertheless, a number of nurses did understand that we were trying to help and were extremely supportive.
Inspite of these concerns the fistula visit successfully treated a number of patients, several with very difficult problems. It highlighted the importance of this condition in Southern Sudan. We featured on South Sudan TV and were able to promote support for the patients with VVF and the need for good quality and more widely available obstetric services.
The team also had a very useful discussion on Friday 11th December 2009 with Dr Makur, Dr Buwa, Dr Mergani, Dr Dario and Matron Susan at which some of the problems were discussed. This was very constructive for the future and the Link would certainly be delighted to be invited to be involved in further VVF programmes. There is certainly a need for this surgery.
Other Clinical Activities :-
The visiting team was able to work with the local doctors and nurses and there were a number of memorable events.
 Fiona Henderson was able to use her experience as an anaesthetist to resuscitate 2 critical newborn babies.
 The team was involved in the surgery of a patient who had been shot through the right shoulder, damaging the lung and the main artery and nerves to the arm. The anaesthetic skills were particularly important in this patient’s survival.
 We were involved in the postoperative care following a number of major surgical operations. There were serious concerns. No observations appeared to be done, no fluid balance charts were kept and if the IV fluids or drugs for the patient ran out then they were simply discontinued by the nurse without any reference to a doctor.
 Zorina Walsh attended a workshop on a mental health programme for prisoners hosted by UNODC.
 Additonally Tim Walsh undertook 2 training sessions in surgery on the wards and Zorina Walsh was involved with the development of the Resource/Education Centre. A major problem is that internet access for this centre has previously been funded by USAID but that contract ran out during our visit. The Link was able to persuade the Real Medicine Foundation to fund a further 3 months but there is an urgent need to secure this ongoing funding (which is only a few thousand dollars per year).
Strategic Plan:-
 The St Mary’s Hospital,IW-JTH Link has been invited to be involved in developing the strategy for secondary and tertiary care in Southern Sudan. This visit provided an opportunity to discuss wide-ranging issues with the staff at JTH, UNFPA, officials at the Ministry of Health and Dr Sarah Petrie, Sector Co-Lead Health (NGO).
 Tim Walsh, Zorina Walsh and Sharon Evemy were kindly invited to visit a state hospital in Torit. This gave us a broader perspective on the issues and problems faced in providing a hospital service in Southern Sudan.
Link Accommodation:-
Accommodation for the visitors during the recent visit was kindly provided by the UNFPA and we would like to express our sincere thanks for this.
The St Mary’s Hospital,IW-JTH Link is in the process of developing a small bungalow in the grounds of JTH to accommodate future trainers. This is a shared venture with a Norwegian group from Haukeland University who are undertaking similar training to ourselves but more specifically in orthopaedics.
We have so far collected about two thirds of the estimated cost through fundraising, have been given the site by MoH (GOSS) and hope to start construction within the next few months.
The present visit allowed a more detailed inspection of the site and discussions with the proposed architect.
Recommendations :
 The present fistula programme achieved limited success in that several difficult and complex cases were treated. There were some organisational problems, as described above, most of which stemmed from inadequate time for preparation as a result of late changes in venue.
 It is important that all necessary hospital staff are informed of visiting teams as early as possible.
 There is a desperate need for surgical capacity to treat VVF in Southern Sudan. This would be best served by concentrating treatment in a dedicated centre. With proper organisation this could avoid the difficulties described above, could markedly increase the number of patients treated and could well be used to develop training of local healthcare professionals.
 Fistula centres in most African countries are developed and run mainly through external donations. This avenue should be explored.
 Notwithstanding the above, the long-term solution to VVF is development of countrywide obstetric services.
 Wau Teaching Hospital clearly needs urgent attention both in terms of structural maintenance and adequate equipment.
 Ensuring that there is ongoing internet access in the Resource Centre at JTH (and other teaching hospitals) is essential both for education and communication.
 Postoperative care was found to be poorly structured and this was especially evident for major cases and if there were no relatives who could buy drugs, food, fluids etc. Basic clinical processes do need to be improved if 21st century medicine is to be achieved.
Acknowledgements :
We are very grateful to the many people who welcomed us, those who worked on the fistula programme and helped to make this an enjoyable and productive visit. It is difficult to do justice to everyone but would especially like to thank :
Dr Makur Kariom and Dr Gabriel Loi from MoH (GOSS), Dr Dragudi Buwa, Dr Alex Dimiti, Bilha Achien and Mary Marle from the UNFPA and the staff at Juba Teaching Hospital. Dr Mergani and Dr Dario in particular gave tireless support and this was very much appreciated by all the team.

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