Our mission in Mauritius 1/2

First day

Arrival of Dr Bosson in Mauritius on 20.10.2019. Been welcomed by officials of the Ministry of Health. Met Dr Gopal, orthopedist in charge at Victoria Hospital, who came to Hotel Voila in Bagattelle. They established the main axis of this mission which is an assessment of skills and available equipment. Arrival of Dr Suren Naiken on 21.10.2019. Unsuccessful attempt to visit Jawaharlal Nehru Hospital due to the arrival schedule. Welcomed by the hospital superintendent, Dr Bondon, who showed us around the emergency room.

Our observations in this hospital:

– 2 categories of emergencies: acute and non-acute emergencies
– sorting at the entrance 
– 1500-2000 patients / day 
– most are non-urgent cases, only 20% of cases are hospitalized 
– 12 doctors in the emergency room but are very often understaffed 
– after assessment, patients are referred to the specialists concerned. Our assessment concerns specialist boxes where the equipment is rudimentary and several doctors in a single box, leaving confidentiality to be desired 
– visited the plaster room and noted that they are equipped only with plasters of paris, no resin, no vacoped or other means of immobilization 
– also visited the small outpatient surgery room and observed poor hygiene. The material is very rudimentary. The floor is in critical condition 
– we were pleasantly surprised by the level of the caregivers with very competent nurses for dressings, sutures and plasters .

They have come to us on their own asking us to make suggestions to improve their care and are very open to receiving training. We then visited the relatively modern operating room with Dr Aboubakar, the hospital surgeon. The detailed assessment will follow tomorrow once we are in the operating room. We also met Dr Ramcharita, head of the orthopedics department who told us the total number of hip and knee prostheses, which is 200 / year. According to him, they have a low rate of post-operative infection. The hospital stay for prostheses is 1-2 weeks, which is relatively long due to the health system in Mauritius having no home care and no real family doctor system. One of the problems noted is the problem of post-amputation orthoses; they are looking for assistance or collaboration in this expertise. We also had a brief chat with an anesthesiologist who was trained in Bordeaux and a surgeon trained in Montpellier on the concept of the outpatient clinic. A certain enthusiasm exists but will remain to be developed during the next missions.

Part 2

Meeting with Mr. Dassin, permanent secretary of the Ministry of Health. Very cordial interview. We have again clarified the purpose of our mission and the philosophy of the HFE. Mr. Dassin is quite clear with this and he explained to us that given the holding of elections in the near future, it is very difficult to move forward with agreements that must go through validation procedures within the Stettlor office and Ministerial Cabinet with notice from the Ministry of Foreign Affairs and the Ministry of Finance. We have also agreed that we will meet again at 48 hours with the Chief Medical Officer, Dr Ramen. The interview took place at the Ministry of Health. He asked us to obtain a report following our visits to the various establishments. We also visited the SSNH Hospital in the north of the island where we met the General Manager who was unfortunately occupied with other functions but who made it a point to welcome us. We were then greeted by Dr. Dinawa, Superintendent of the Hospital. She explained to Dr. Bosson the different practices within the facility. Then we had a long interview with the head of the department, Dr. Kinu, general surgeon, a surgeon who was trained in France. He is quite favorable about the introduction of intraoperative cholangiography for cholecystectomies. However, he explained to us that the problem is with the brilliance amplifier? which is located in the orthopedic room located at a distance from the laparoscopic room. 

We have again explained all the benefits of minimally invasive surgery with our long-term vision allowing: – to have outpatient surgeries – to have trained surgeons within 5 to 10 years. We felt a slight reluctance on the part of the head of service, which he explained by the fact that there were many complications by laparasocopic route and that the surgeons who were trained for a few months outside could not be autonomous in these types of surgery. We agree on this point, however, we made it clear that the aim was to do teaching and not to operate for them, but also to set up a structure for teaching with probable exchanges so that the surgeons quickly become independent. We then met with Dr Ramtual, head of the orthopedics department. It was an excellent discussion with many proposals for the introduction of the concept of subspecialties with referring surgeons according to the subspecialties. We have promised that this will be followed in our meeting with officials from the Ministry of Health. We also have that this will appear, along with some recommendations from Dr Bosson regarding this specific point.

Second day in Mauritius hospital

Suren Naiken went to Didou Hospital in the capital and Dominique Bosson went to Victoria Hospital. 

Narrated by Dr S. Naiken:

“So I donated all the equipment brought thanks to the sponsors, nurses and operating room managers who were delighted”. 
We then operated and performed 3 cholecystectomies. 

To note : 
– the patients are not seen by the operating surgeon preoperatively on the day of the operation. 
– patients are not identified 
– no time out at the start of the operation before the incision 
– the positioning during cholecystectomy is different; they do not operate on patients with their legs apart, nor do they do intraoperative cholangiography. Positive: The operating room staff are very inclined to initiate changes. People want to be trained, they have an extraordinary will and an extraordinary capacity for adaptation, they are also very resourceful with the material at their disposal. Three cholecystectomies were performed and there was teaching. The first intervention was made by Dr Aboubakar, during the 2nd intervention I showed the Swiss technique and the 3rd intervention was carried out by Dr Aboubakar with the Swiss technique in collaboration with a young surgeon graduated but who does not do of laparascopy. We then discussed with the anesthetists how it works. It should be noted that they are not against the introduction of day surgery in the public hospital system. They report that this is already done in the private sector, but for unknown reasons, this practice cannot be done in a public hospital. We tried to investigate but did not get a concrete answer. “

Reported by Dr Dominique Bosson: 

“Visit to Victoria Hospital. The Hospital consists of a set of dilapidated buildings and a relatively new building, which is about 3-4 years old. On arrival I was immediately struck by the state of poor maintenance, as already mentioned by Naiken, with an obvious lack of handling. The first person we meet is the operating room manager, who seems to know his room relatively little, unable to provide figures on the number of operations performed each year, etc. However, it raises a problem which I think is essential from the outset, namely the lack of training for instrumentalists. The people are in fact nurses who learn on the job, explaining the low level of asepsis on the part of these collaborators. In the operating room, it is important to emphasize that there is a total absence of flow between the clean sterile side and the non-sterile side. People move freely in civilian clothes mixed with people dressed to go to the operating room. I then met Dr Gopal, the orthopedist in charge at Victoria Hospital. His reception is correct. He does not show great enthusiasm for this visit which seems to him to be a little imposed. He explains to me a little how the block works, which is unremarkable. On the program, he has planned a total knee replacement and a change of total hip replacement. The 2 interventions are carried out in a completely correct way. From an orthopedic point of view, Dr Gopal has a good command of all surgical procedures and places good quality implants, namely Depuy prostheses. On a purely technical level there is not much to say. Regarding the asepsis of the instrumentation and the instrumentalist, there is a relatively large number of asepsis faults. In terms of rehabilitation, patients are up the day after surgery and receive standard thromboembolic prophylaxis. At this level again nothing in particular to raise. The return home is between 1-2 weeks post-op. At this level, the whole home care system could be discussed again.

After the surgery, Dr. Gopal asks me if I am okay with seeing a patient with a knee problem. Of course, it is with pleasure that I see this patient who is brought in by our colleague, with a rather brief presentation of the case, a poor quality MRI and I am immediately asked what I propose for this patient. I allow myself a few additional questions to have a precise anamnesis and I also propose a clinical examination which does not seem to me to have been carried out systematically. I am therefore surprised by the care of this patient with a boss who, after a few brief questions, decides to operate on him without explanations to the patient, simply asking him if he wants to have the operation or not. Here too, with the younger generation, there might be an important education to be done in the management and the history. Again, at the level of patient privacy, as already mentioned in other Jeetoo emergency room visits, this is a fairly random notion. Dr. Gopal asks me if I’m okay with doing arthroscopies. I tell him that I am not there to operate but to help them and we agree to do 2 cruciate plasties the next day but in another hospital since this one seems under-equipped arthroscopically. An appointment is therefore made for the next day at the Jeetoo Hospital to perform these 2 crisps plasties. I am impressed that it is so easy to transfer two patients from one hospital to another and change operating schedules, but this does not seem to be too much of an organizational problem. ” 

(Continuation of the article: Mission to Mauritius – 2/2)