London, Nyall

Medicine

Cameroon

Mbingo Baptist Hospital in Mbingo, Cameroon

I am currently obtaining surgical training in Otolaryngology - Head and Neck Surgery as a resident at Johns Hopkins. During my time in Cameroon, I will be involved in the diagnosis, operative, and post-operative care of complex Otolaryngology cases. In diagnosis, I will be exposed to advanced pathology including head and neck manifestations of tuberculosis and HIV. In operative care, it is anticipated that I will be involved in 30-40 cancer surgeries, many of which are pathologically advanced. In post-operative care, I anticipate overseeing and teaching staff at Mbingo Baptist Hospital appropriate post-operative care as well as management of any post-operative complications that may arise. These experiences will not only train me how to be involved in global health care delivery in the future, but will also enhance my education in Otolaryngology through exposure to advanced pathology one may not otherwise see in the United States. The program at Mbingo Baptist Hospital was established and continues to be run by a Johns Hopkins Otolaryngology faculty member, Dr. Wayne Koch. He has mentored multiple Hopkins Otolaryngology residents and fellows, and will serve as an excellent experienced supervisor for me. I have worked with him personally here while a resident and look forward with high anticipation for the opportunity to go with him to Cameroon.

Traveling to a resource limited country and helping provide medical care is something I have wanted to do for many years.  The timing and funding had not aligned until the travel fellowship.  I anxiously awaited my trip to Mbingo Baptist Hospital and prior to my travel I had spoken to several residents who had traveled to Cameroon and met and discussed the trip with my mentor.  While this prepared me to get ready for the trip, some things are best learned with ones’ own eyes and by personal experience. 

Practicing a surgical specialty such as Otolaryngology - Head and Neck Surgery has increased challenges in a limited resource environment.  Many patients present to the hospital after severe disease progression which can be particularly devastating in head and neck cancer.  Cameroon only has one machine capable of delivering radiation therapy in the entire country, thus we have to work under the presumption that the patient will likely not be able to obtain radiation therapy for their cancer.  For advanced laryngeal cancer in the United States we often treat with radiation therapy first.  Where surgery is the only option in a limited resource setting this led to us perform total laryngectomies more frequently as a primary treatment modality for transglottic laryngeal cancer.  Furthermore, in head and neck cancer surgery we often rely on intraoperative frozen section pathological analysis to guide us as to whether we have resected all of the cancer and achieved negative surgical margins.  Frozen section analysis was not available for us in a resource limited setting.

A significant aspect of head and neck cancer surgery is reconstruction after the resection.  This can be important both for cosmesis but also functionally for swallowing.  In the United States, it is very common to reconstruct a defect with a free flap (moving tissue and/or bone with its associated artery and vein).  Oftentimes there are two teams of surgeons, one for removing the cancer and one for reconstruction along with two teams of scrub technicians.  This utilizes an enormous amount of resources and strain which in a limited resource setting may not be tenable.  This therefore changes reconstruction options.  On our trip there was a young man who presented with an ameloblastoma the size of a softball growing from his mandible.  In this country we would resect the affected mandible and reconstruct with a fibula free flap.  For this patient however he chose reconstruction with an arch bar nearly the size of half his mandible and will have to return for a second surgery in six months for a bone graft.  These are several instances in which I observed the effects of practicing Otolaryngology – Head and Neck Surgery in a limited resource environment.

An additional challenge facing the region is both access to surgeons as well as trained local surgeons a challenge which is currently being addressed by PAACS (Pan-African Academy of Christian Surgeons).  PAACS has set up surgical residency programs at several locations in Africa including at Mbingo Baptist Hospital in Cameroon to help train residents from Africa.  Furthermore, Dr. Wayne Koch, the Otolaryngology - Head and Neck cancer attending and mentor that I did my trip with has recently set up a Head and Neck cancer surgery fellowship for specific further surgical training in Head and Neck cancer for surgical residents from Africa.  These experiences helped to teach me the importance of training local surgeons to impact global health. 

The need is so great in resource limited areas for both providing care and teaching Otolaryngology – Head and Neck surgery.  One may feel overwhelmed with the volume of cases, the disease progression or difficult cases, and feel that it may be difficult to make a difference.  However, you make a difference to that person and that local community.  Providing surgical care in a limited resource setting possesses its own challenges, but I also learned that no matter what the specialty training, a person in any specialty can contribute and find an appropriate location/situation to fit their expertise.

 My mentor Dr Koch and I in the operating room;

In front of Mbingo Baptist Hospital;

View of Mbingo Baptist Hospital from further away;

 The Otolaryngology clinic;

A hike up Mbingo mountain with the hospital below in the distance;

People

Caitlin Kennedy, PhD MPH,BA

Co-Director, MPH concentration in Social and Behavioral Sciences in Public Health; Associate Director, Center for Qualitative...

Robert Bollinger Jr., MD MPH

Director, Johns Hopkins Center for Clinical Global Health Education (CCGHE); Associate Director, Johns Hopkins Center for Global...

Joanne Katz, ScD MS,BSc

Associate Chair, Director of Academic Programs

Stefan Baral, MD MPH,MBA,MSc

Director, Key Populations Program

Yukari C. Manabe, MD

Associate Director of Global Health Research and Innovation

Noreen Hynes, MD MPH

Director, Geographic Medicine Center of the Division of Infectious Diseases
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July 2020

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