Learning from a Master Surgeon: The Northern Nigerian Realm of Dr. Waaldijk

Documenting all

I was in Northern Nigeria at the end of January for a couple of weeks to visit with one of the world’s most experienced fistula surgeons and see the centers he has established over the last few decades. Dr. Kees Waaldijk is a surgical mentor of mine for over the last 10 years. He single-handedly has done the most fistula repairs of anyone in the world, over 25,000. Dr. Waaldijk is one of the best vaginal and fistula surgeons I have ever worked with. The execution of expertly placed suture, the precision of an incision and the economy of motion (as I teach it to my residents and trainees) is a beautiful thing to witness. That, coupled with meticulous documentation of each operation and outcome, is a good as it gets.

Notes on instruments and inventory

As IMR is preparing to help launch a new fistula ward in southern Malawi in April, it was important to visit with him and see how these centers were planned and how they are run. Over 2 weeks and 1500 km we went to 4 centers in Sokoto, Zaria, Kano and Katsina. All have served as training centers for 100’s of nurses and surgeons, all have high volumes of patients with obstetric trauma and fistulas. It was important to see how these centers have set up the operating rooms, the rehabilitation centers and importantly, training of surgeons and nurses.

Sokoto’s only fistula center

Thoughtful post op ward design

What is the best way to train surgeons in a highly complex surgery like fistula surgery, where the best shot a success is on the 1st attempt? How do you prepare trainees in the anatomy and surgical techniques needed for a vaginal approach.  Much of the same questions are asked when trainees are learning other surgical operations. Focusing on providing the best care and best training possible is our goal. Looking forward to April when we launch the project. Stay tuned.

-Ambereen Sleemi, MD

Urogynecology Seminar in Montego Bay

By: Ambereen Sleemi, MD, Surgical Director

At the end of October, IMR was invited to be on a panel of physicians who presented “Current Trends in Urogynecology”. This conference we sponsored by the Western Gynecology Association of Jamaica and Medicine in Action. I presented on genitourinary fistulas in developed and under-resourced healthcare systems, expanding on IMR’s work in Malawi, Liberia and Haiti. IMR has projects in these regions focusing in on surgical training in pelvic reconstruction and fistula repairs. Our work over the last few years in Liberia has been to work with the Liberian National Fistula Project, the Ministry of Health and the College of Physicians and Surgeons to train the Ob/Gyn residents in pelvic reconstruction and basic obstetric fistula repairs. I also spoke about urogynecology issues that arise during pregnancy, ranging from the commonly seen complaint of urinary incontinence and the less frequent condition of prolapse in pregnancy. 

Update: IMR in Puerto Rico

Municipal water trucks delivering water to mountain towns in Lajas

Water is life everywhere

Homes destroyed, bits and pieces of a family’s home strewn down the mountainside in Morovis

Home visits, like this one to a 90- year old in Lajas, to the most elderly and infirm. Her severe arthritis in arms and legs makes walking impossible

Commonly seen sights along roads all over the island

The profound intimacy of home visits. Home bound seniors like Rosa, 97 years old, still have no running water

We have just returned from a week in Puerto Rice working with the Department of Health and the Puerto Rican College of Physicians and Surgeons. Each day, the DOH identified municipalities in need. This was done in cooperation with local mayors and community workers. Liz Santaniello, a family nurse practitioner joined me for the week long trip.

Our first day was spent in Canovanas and Loiza, one of the hardest hit areas on the island and the one with hundreds of people in refugee centers. We set up a clinic in town and saw dozen’s of people who needed care. None had electricity or running potable water. Over the week, we traveled to the south to Lajas, the mountains of Morovis, refugee's shelters in Salinas, and the hardest hit areas of San Juan, including Hill Brothers. Home visits to the elderly and frail, as support and reassurance that they will not be forgotten, were much needed.

Everywhere, we saw old and young alike in need of medicines, water and electricity. And everywhere we saw Puerto Ricans from all walks of life rise to this need and do the work that needed to be done to care for people. We were able to deliver 8 large bags of medicines, syringes, pain relievers, water purification tablets, bug spray and more to 100’s of people. 

Working with the local doctors and authorities ensured our efforts were directed to the most needy areas of the island.  IMR has committed to return to work with local Puerto Rican doctors to provide care, supply medical goods as well as technical support as long as the need exists.

- Ambereen Sleemi, MD, MPH

Surgical Director 

IMR begins assisting physicians in Puerto Rico

Approximately a month after Hurricane Maria devastated Puerto Rico, a team from IMR will travel to work with physicians and nurses at the Medical Center in San Juan. The Medical Center and Department of Health have been key local responders to the medical crisis in nearby towns.

Blue tarps over homes damaged by Hurricane Maria

Puerto Rican physicians we’ve spoken to report widespread illnesses such as infectious diseases like scabies and conjunctivitis, as well as untreated chronic disease like diabetes, asthma, and high blood pressure. All these left diseases left untreated can lead to severe complications. The fear of water-borne diseases exists and cases of Leptospirosis have been reported. Due to the continued lack of clean, potable water, there’s real concern of widespread infections.

We’ll spend a week working with the Medical Center teams. Thanks to the many who donated supplies and funding to help make this happen. Thanks to JetBlue and MAP International for in-kind donations.

This will be the first of many trips to help healthcare workers and the patients they care for. We’ll continue to return as long as we are able to help fulfill a need. 

Summer Update: Building more partnerships in Haiti

Christie Louis, WHNP, talks to healthcare workers and medical students about hypertensive emergencies in obstetrics

In June, IMR was invited again to present at "World Health: Special Focus on Haiti", a medical conference in Limonade, Haiti in collaboration with NOAH-NY, Healthfirst, and Howard University Hospital. We gave lectures on Pelvic Floor Disorders and held a workshop on Ob/Gyn emergencies including postpartum hemorrhage, hypertensive disorders of pregnancy and ectopic pregnancy to a room full of Haitian medical and nursing students. We were joined by Christie Louis, WHNP, first-time volunteer with IMR. 

After the conference, Dr. Sleemi traveled to southern Haiti to begin a partnership with St. Boniface Hospital in Fond-des- Blancs. St Boniface is located in a remote mountain region about a 3 hours drive from Port- au-Prince. It’s remote area lends to a very large patient cachement area, treating over 100,000 patients per year with over 200 surgeries per month. The Department of Ob/Gyn invited IMR to come and work with the 2 staff physicians, Chairman Dr. Guerrier and Dr. Germinal. Enhancing the vaginal surgical approach in pelvic reconstructive techniques for prolapse and incontinence will be the focus.

Dr. Meyer working with Dr. Guerrier, Chief of Ob/Gyn, to repair an obstetric fistula at St Boniface

Clinically, Dr. Sleemi and IMR volunteer Dr. Bill Meyer saw many patients with complete prolapse that had been untreated for years, leading to extreme discomfort and bleeding. We treated pelvic organ prolapse, genital fistula and a few congenital vaginal abnormalities.

We look forward to continuing our growing relationship with St. Boniface Hospital and improving care for women with devastating childbirth injuries and other debilitating gynecologic conditions.

“My experience at the conference in Haiti was beyond my expectation... Interacting with individuals that are passionate about teaching and helping those who are not as fortunate as us is a rewarding feeling. Living in a country where medical technology is so far in advance you easily forget about the basics. This trip has changed my perspective in life and how I will practice as a Clinician. I’m more determine then ever to master my craft and learning alternative ways to practice preventive care and treatment. ”

— Christie Louis, WHNP

Staff and faculty of "World Health: Special Focus on Haiti"

Unite for Sight's Global Health and Innovation Conference

By: Nicole Turturro, Development Intern

This past month, I had the pleasure of going to Unite For Sight’s Global Health and Innovation Conference.  Every year students and professionals convene at Yale University to discuss the current situation in global health and to exchange ideas on how to move forward in everyone’s respective field.  Much of this year’s conference focused on cultural humility and how we, as a Western country, can humbly serve the communities we work with.  Vanessa Kerry, the first keynote speaker, talked much about how listening to the communities we work with and learning to conduct our work in the context of their cultures greatly improves patient and program outcomes.  One of the first panels I attended was the “Thinking Outside of the Box:  Careers in Global Health Panel.”  Although I will be pursuing an MD degree, this panel showed me the various paths to a career in global health and the various niches within the global health sector.  Those on the panel included a global health consultant, a professor, and a photographer!  

The next keynote speaker was perhaps the most interesting talk of the day.  Jeffrey Sachs, a professor at Columbia University, gave a talk on universal health coverage in the US and what the current situation is in this country.  Although the US spends the most on healthcare, it has a shorter life expectancy than most high-income countries.  The United States is also the only country that treats healthcare as a business.  The US has the second highest relative poverty rate and the most income inequality among high-income countries.  As a young person, this talk was extremely enlightening and demonstrated the amount of work that my generation and future generations need to do.  

Throughout the day, I also learned about the role of surgical care in global health and experts’ opinions on different healthcare systems, such as customer-centered and value-based healthcare.  One of the most interesting talks was about MEDSINC, an app developed by two pediatricians that enables the user to triage patients and make treatment recommendations.  This allows clinics that are mainly run by nurses and secondary healthcare workers to more efficiently treat their patients.  

Attending the Global Health and Innovation Conference was a wonderfully cerebral and inspiring experience.  Thank you so much to IMR for asking me to attend.

Royal College of Obstetrician and Gynecologist Annual Congress

by: Dr. Ambereen Sleemi, IMR Surgical Director

I was invited to talk to members of the Royal College of Obstetricians and Gynecologists (RCOG) at their annual Congress in Cape Town this past month.. A full-day workshop focused on current topics in Obstetric Fistula repair was offered as a pre-Congress event. I was honored to speak about IMR’s work and to join expert surgeons from Zambia and Tanzania and representatives from FIGO’s ( International Federation of Gynecologist and Obstetricians) Fistula Training Initiative. Travel was made possible through generous funding from the RCOG and a grant from the Polan-Bennack Foundation.

Topics ranged from current practices, urologic abdominal approaches to VVF, vaginal stenosis, and how to approach RVF’s. I spoke on training the next generation of VVF surgeons, using IMR’s work in Liberia and now Malawi as examples of how post-graduate training programs are now incorporating fistula training into the teaching curriculum. I’ve relied on my experience as a surgeon with the Eritrean Women’s Project over the last 9 years to help shape our teaching.

The surgical burden of fistula cases is enormous. The actual numbers are elusive given the nature of the condition, but an estimated 2 million women are currently suffering with fistula. We have been able to markedly increase the number of cases we do, but it is not nearly enough to decrease the incredible backlog that exists. Add to it a new 50-100,000 cases per year and it will take over a century to even catch up.

Table Mountain, Cape Town

There are many thoughts on how best to train the next generation of fistula surgeons, including vetting candidates to find the best fit for this type of work. Our patients are the poorest, most marginalized people on earth. The pay is low and the surgeries are extremely complex and challenging. Even in the most expert hands, no one has 100% success with repairs. We’re hoping with early introduction to obstetric fistula training, some will make it their life’s work and others will incorporate it into their practice.

Well into our 2nd year of training residents in Liberia and a few months from launching fistula and training services in Malawi, IMR continues to strive to bring best practices in surgical work to areas with great need. We are fortunate to partner with WAHA (Women’s and Health Alliance) , the Liberian College of Surgeon’s and Physicians and UNFPA Liberia and UNFPA Malawi to treat women who suffer with obstetric fistula.

Supporting Surgical Access to Restore Women's Lives in Malawi

by: Ambereen Sleemi, IMR Surgical Director

In early December this year, I travelled to Malawi in partnership with the United Nations Population Fund (UNFPA- Malawi) to assess a surgical need for obstetric fistula surgery in the southern part of the country. Mulanje is a town nestled in the foothills of Mulanje Mountain. It's an area known for large tea plantations and borders Mozambique. It is also an area that is near five hotspots for development of maternal mortality, obstetric fistula and birth trauma in the region.

IMR was invited to help assess the feasibility of refurbishing a hospital ward in the Mulanje District Hospital. This ward would be renovated and reopened as an obstetric fistula word complete with a dedicated operating room. We would also help train and support hospital staff in surgical and nursing care.

My trip started in the capital Lilongwe with a visit to the only fistula ward in the country, the Bwaila Fistula Care Center, established in July 2012. It’s a wonderful model to inspire the proposed center in the south. A large operating room and open, well-lit ward offer services of repair and hope. A room for rehabilitation services with instructions on literacy and trade was just adjacent to the ward.

The Bwaila Fistula Ward opened in 2012

I was invited to the National Fistula Task Force meeting, a group that included staff from the hospitals where surgeries are performed, a Ministry of Health representative and other important participants in the fight to end obstetric fistula. I was impressed with the dedication of all members to moving forward in the efforts to prevent fistula with safe access to maternal health, and the need for surgical repair, including re-integration and rehabilitation services.

I next went to the Mulanje District Hospital, about 4.5 hours south via road. I traveled with Grace Hiwa, the the UNFPA point person on obstetric fistula. Grace is a former midwife and very impassioned advocate for the women and girls suffering from obstetric fistula. We met with administrators of the hospital and a had a detailed tour, focusing on the ward that is being considered for transformation into an obstetric fistula ward.

Proposed future fistula ward in Mulanje. It needs work, but has amazing potential to heal women and restore dignity.

I returned to Lilongwe and met with the UNPFA Country Representative, Dr. Dan Odallo. Dan is a committed advocate for reproductive health rights for women and girls. He knows the issue of obstetric fistula well, including the associated stigma. We had worked together in Eritrea a few years ago on this very issue.

IMR's work ahead is great. We are committed to expanding surgical capacity, finding partners and funding for the rehabilitation and transformation of this ward into a safe and effective place to care for women with fistulas. We also look forward to working with UNFPA, the Ministry of Health and partners to train healthcare providers in caring for women with fistula.

Building Anesthesia Capacity and Knowledge in Acute Care

By: Vipul Shah, MD

I am a critical care physician and anesthesiologist who recently had the opportunity to travel to Liberia with the support of IMR. I had met IMR’s Dr. Sleemi during a prior trip when we overlapped during our time at Phebe Hospital in Bong County. Since that time, I have been involved in helping to develop the nurse anesthetist program at Phebe, as well as creating an acute care curriculum in collaboration with IMR's Dr. Josh Schiller. The purpose of my most recent trip was to scout auxiliary sites where the nurse anesthetists could attain a wider breadth of clinical experience, as well as find interested Liberian partners for the acute care curriculum.

Travelling to Liberia during the rainy season was a much different experience than what I had previously experienced. The rain comes down in sheets, not at all like the constant mist of my current hometown of Seattle. Much of the country is inaccessible during this time given the condition of the roads, which made my goal of seeing multiple clinical sites, some of which were far off the main road, unrealistic. Instead I focused on the hospitals near Phebe along the main highway, CB Dunbar and Ganta. CB Dunbar is a Ministry of Health hospital run by Dr. Obed Dolo; the facility specializes in obstetrics and women’s health. Dr. Dolo was very receptive to our ideas and it seems as though the nurse anesthetists will be able to rotate through CB Dunbar soon. This will allow them more exposure to OB anesthesia, a specialty that is sorely lacking in Liberia, as well as give them more gynecologic cases to add to their overall case mix. I also was able to visit Ganta Hospital, which is located near the Guinea border. There I had a very productive meeting with the director of the hospital and made plans to work on the collaboration, the biggest logistical hurdle being housing.

Through out this time, I continued to work with the nurse anesthetist students as a clinical mentor. The nurse anesthetist program is based in Phebe, and they have struggled with inconsistent NGO support and a lack of resources. Mr. Wilmot Fassah, an amazing gentleman who has basically kept the anesthetist program afloat during the difficult periods of the civil war and Ebola, is my primary contact there. He has been working diligently with Mary O’Sullivan, a nurse anesthetist stationed at Phebe, through a program with the Peace Corps designed to adapting the curriculum to fit the needs of the Liberian students and population. It was amazing to work with such dedicated people, and the students are the reason I stay so involved as they have sacrificed a great deal to continue their training in spite of a lack of recognition by the Ministry of Health as nurse anesthetists. . Progress is slow but steady; I am hopeful that in time there will be a robust anesthesia program that can safely serve the people of Liberia.

Overall, I had an excellent trip and look forward to returning to Liberia in continuing this work. I really appreciate the support of IMR and hope that we can continue this fruitful collaboration.

2016 Update

2016 has been a fulfilling year for IMR as we continue to commit to improving the lives of those in underserved areas of the world by educating and collaborating with local healthcare professionals.

This summer, Ambereen traveled with a Haitian medical group, NOAH-NY, and Howard University School of Medicine to participate in a 2 day health educational seminar for medical students, doctors and nurses in Cap Haitian, Haiti. She spoke about pelvic floor disorders in Haitian women, a wide-spread problem that many had not heard of. In August, she and other experts in the fieldpresented a workshop on complex surgical repair of Obstetric Fistula at the International Urogynecological Association's annual conference (iuga.org) in Cape Town, South Africa. Through her lecture series, Dr. Sleemi continues to strengthen the dialogue about obstetric fistulas and pelvic floor disorders and help equip those who care for patients who suffer from these conditions. 

We also continued our work in in Liberia on the Liberian Fistula Project with trips both in April and September. Almost 50 women were treated for obstetric fistula with surgery. Local doctors in training were trained in a static this for repairs as part of an ongoing commitment with the Ministry of Health and United Nations Population Fund (UNFPA) to train Liberian doctors in this surgery. Additionally, IMR supported the staff with donations to cover food and essentials during the campaigns as all days require overtime and extra hospital staff.

We hope 2017 will be another productive year for IMR and that you will help us continue our work!