Fistula Surgery on the Africa Mercy

AFRICA MERCY
If you are unfamiliar with MercyShips, they are an organization that uses a completely volunteer workforce to do life-changing surgeries off the coast of Africa using a hospital ship. The advantage of this approach is that even in a war-torn country with minimal infrastructure, they bring all of their equipment and personnel right to the shore, dock for 10 months, and then move on to another country. I had the privilege of working alongside an experienced fistula surgeon (former Vanderbilt faculty) named Andy Norman. As he mentored me, I was able to mentor a Cameroonian GYN who is part of the medical capacity building program that MercyShips provides. Being fluent in French, I was able to translate for her as Dr. Norman explained various aspects of the surgery in English. We did 30 operations in the three weeks. Over half were fistula cases, and the rest were hysterectomies and prolapse cases that really affected the quality of life for these women.

THE PROCESS
MercyShips provides all surgeries for free, and they focus on surgeries that are not usually done in the country due to requirements for multidisciplinary teams or special imaging like CTs or due to lack of resources. If the surgeries are done in-country, MercyShips provides training so that local surgeons can improve their skills or perhaps learn a different way of doing things. In this way, there is a concerted effort to avoid competing with local doctors and their source of income. Because the surgeries are free, there is quite a demand for the services, and lines are long at screening sites. Some of our ladies came from 3 days journey, sent by the government of Cameroon in buses. I believe they went from village to village and asked anyone with problem of leaking urine or stool to join them on the journey. As a doctor coming to work, the process is very streamlined. The patients have already been interviewed by the screening team. The surgeons then have one or two days of their scheduled time on board to screen the patients. We would see as many as possible, diagnose the problem, decide if surgery was needed, and then put a priority on them. The rest of our days were entirely surgical.

Part of our surgical team. Dr. Andy Norman is center.

A DAY
We made our postoperative rounds to see patients just after breakfast and headed to the OR. The hospital is all on one deck of the ship with wards and beds on one side, and the 5 operating rooms, lab, CT and Xray, and pharmacy on the other side. As you can imagine, there are no windows in this part of the ship and patients and nurses alike enjoy their afternoon time to go up on one of the upper decks for fresh air. There are places for children to swing and ride trikes, but most of the time the women would walk around and sing. We surgeons typically finished surgeries just before an early dinnertime. After dinner, we would go back down to the ward to check on the patients and to consent the patients who were scheduled for surgery the following day.

Beautiful! Patient waiting for her turn to be introduced at the dress ceremony

A PATIENT

One particular patient had been having problems of leaking urine for 10 years. This was not uncommon, as the range was from a few months to 27 years. The sad part of her story was that she had been going from hospital to hospital looking for a solution without result, for 10 years! Indeed, when we filled her bladder with the blue dye, there was none that came out into the vagina that would have indicated a fistula connecting the bladder to the vagina. Although these are the most common type of obstetric fistula--even our name tags said VVF surgeon for vesico(bladder)-vaginal(vagina) fistula surgeon-- they are not the only fistulas we see. There are also connections between the ureter (the tube coming from the kidney before it goes into the bladder) directly to the vagina or the rectum to the vagina. For our patient in screening that day, after further questioning she mentioned that she has blood in her urine once a month, just like her period, but she doesn't have any vaginal bleeding. Bingo! We diagnosed Yousseff's syndrome by injecting contrast into the bladder and looking on CT to see that there was a connection between the uterus and the bladder. So every month, she would have a period but all of the blood would flow into the bladder because it was easier than going through the thick muscle of the cervix. And conversely, only if her bladder were extremely full, the urine would flow into the uterus and then have enough pressure to come out of the thick muscle of the cervix. So she would leak urine intermittently from the cervix and into the vagina, but she would always have her period through her bladder. During a long abdominal surgery, we were able to separate the uterus from the bladder, remove the uterus, and close the bladder.

Putting on makeup prior to the dress ceremony

THE DRESS CEREMONY
The patient is one of many who are so grateful to finally have resolution to a problem that has significantly affected their life. Each woman who has found a cure (or at least a significant improvement in their condition), has an opportunity to be involved in a dress ceremony. They get dressed up in a new dress, their makeup done, and they then dance together down the hall of the hospital deck in their bright new clothes and enter a room of cheering MercyShips crew. It is a highlight. They sing and dance and then (usually tearfully) share their stories, praising God that they were healed. Comically, they usually have to get up one by one to use the bathroom during the ceremony. And I always smile. Imagine needing to go to the bathroom after all those years!

Dancing through the hallway during the dress ceremony