Trio in the African country of Chad awake to a familiar cry: ‘We need anesthesia’

Ian Hewer, assistant professor and director of Western Carolina University’s nurse anesthesia doctoral program, traveled to the Republic of Chad in Africa with WCU nurse anesthesia students Ben Woody and Jenny Della Posta late in fall semester 2018. The three, accompanied by Della Posta’s husband, A.J. Della Posta, were participating in a medical mission trip to assist a surgeon providing free services for residents of the village of Bere. This is Hewer’s first-person account of that trip.

Ian Hewer prepares to place a breathing tube to administer general anesthesia for a patient in Chad.

I think it’s fair to say that when we left Charlotte at 6 a.m. on Nov. 5 we had little idea exactly what would await us. The adventure began in July when Mason McDowell, my friend and colleague in the nurse anesthesia program, mentioned that he had been asked to travel to Chad in November to give anesthesia for a visiting plastic surgeon. Mason had lived and worked in Chad for 18 months in 2014-15 and had many good memories, but was unable to travel this time. The thought immediately occurred to me that this could be a great experience for our students, who consistently comment on the importance of international experiences, but could I do it? Could I take two to three weeks in the middle of a busy semester? Could I persuade my wife I was not in danger of getting typhoid/abducted by terrorists/eaten by a lion? (No lions in Chad, so safe there!) Could I convince students a location without wi-fi was even possible to survive in for more than 24 hours? A less than resolute “yes,” and four months later here we were on the first leg of a 52-hour journey to Bere Adventist Hospital, located about 260 miles from the capital, Ndjamena. That’s 260 bone-shaking, stomach-turning, strange bathroom-avoiding miles that will take 10 to 12 hours, by the way.

Having arrived in Bere at 4 a.m. local time, we were woken at 10 a.m. by a familiar cry: “We need anesthesia!” So much for a day to acclimatize. Once we donned our scrubs, walked through the surprisingly well-tended gardens of the hospital, which was filled with patients and families camped out, and found the operating room, there was our first patient waiting for us on the operating room table. Now you might think, “Ian, what’s the big deal? You’ve been an anesthetist for over 20 years. Just put the guy to sleep already!” True, but there are a few important details…no oxygen, an anesthetic agent that hasn’t been used in the U.S. for more than 10 years, no electrocardiogram monitor, no monitor to check for breathing and only about 10 percent of the drugs available that we use on a regular basis at home. To an anesthetist, that’s a scary prospect. Our whole ethos is about safety and avoiding complications, so we needed to recalibrate and find other options to technology to monitor a patient safely.

Solution: a precordial stethoscope, an old-fashioned device that basically functions like one arm of a regular stethoscope, but allows us to monitor breathing continuously, as well as many other factors related to depth of anesthesia from the quality of breath sounds heard. How ironic that the U.S. is reeling from the effects of the opioid crisis, but here we had no opioids to give patients undergoing major surgery. Solution: use alternative medications, many of which anesthetists in the U.S. are beginning to substitute for narcotics in an attempt to curb opiate consumption early on.

Jenny Della Posta

That was the beginning of a hectic two weeks during which we gave anesthesia for surgeries six days per week, typically from 6:30 a.m. to 5:30 p.m., but sometimes later. We took care of all ages, from babies to seniors, and all kinds of surgeries from cleft lips to thyroids and from fractures to outlandish tumors that none of us had ever seen the likes of in the U.S., to arrows in the abdomen. Through it all, we were constantly challenged with the need to find new solutions to issues arising from lack of resources. Travelers to Africa frequently cite the culture shock of yawning poverty, or inadequate infrastructure, as the lasting impressions made, which without a doubt was profoundly impactful. However, from an educator’s perspective, what is also critically important is the need to improvise, to critically think, to find new and often less straightforward solutions to problems.

Instead of going to the storeroom to get foam padding to protect our patients’ eyes when we laid them on their stomach, we had to create our own from sheets. Instead of picking up the phone and calling the pharmacy for any one of thousands of medications, we had to consider what other techniques can keep the patient safe and pain-free using the very limited options available. In addition to the challenge provided by the problem, it’s important to realize how empowering it is for students to find solutions alone, without being told the answer by their instructor. In Chad, solutions were not just related to health care or anesthesia problems, but also the more mundane tests, such as what are we going to eat today? What is the word for rice in French? Should I drink soda from a street seller in the market? (Answer: not if the top is loose.)

Ben Woody

After we returned, everyone asked us if we had a good time. No, it wasn’t “good” to see such profound poverty and work with minimal resources and to be exhausted at the end of each day, but if education is about creating lifelong experiences that change the way you view the world forever, that box was definitely checked for all of us. Ben and Jenny said they would not return to Bere; they were glad to have been part of the experience and would like to go on a humanitarian trip again, but perhaps somewhere less austere. I hope to go back next November with another group of students.

But this time I’ll be more careful about the soda in the market.