Dealing with the Uncertain and the Unexpected: A Report on the First Kidney Transplantations in Aden, Republic of Yemen Robert D. Fitzgerald MD * Felix Stockenhuber MD ** Annelies Fitzgerald PhD *** * Associate Professor, Department of Anaesthesia and Intensive Care, Lainz Hospital, Vienna, Austria & Ludwig Boltzmann Institut for Economics of Medicine in Anaesthesia and Intensive Care, Vienna, Austria ** Professor of Internal Medicine, Chairman of the Department of Internal Medicine, General Hospital, Oberpullendorf, Austria *** Director of Health Care Communication, Institute for Management and Communication, Vienna, Austria ANNALS OF TRANPLANTATION, Vol. 10, No. 1, 2005, pp. 44-47 Abstract: First kidney transplantations were perfomed in Aden, Jemen in 2003. A difficult medical environment and unrehearsed decision- making process in a country of scant resources were the background of this undertaking. A brief report is given on the medical situation, training and preparedness of the Yemeni medical community for transplant procedures. Initial impressions of psychological aspects of the first ever organ transplantation in this Islamic country are presented. Key words : Kidney Transplantation; living – Related; Yemen; Psycholgical Aspects The event took place in March 2003 during The Project the the war in Iraq. This led to warnings by In the fall of 2002 the authors were asked the Austrian government concerning visits to participate in an international team for to Yemen, but as the preparations for the the conduction of the kidney transplants in congress and surgery were well advanced Aden, Republic of Yemen to be performed neither we, nor any of the other members together with the 1st International Congress of the international team took this into of Uro-Nephrology. We accepted with consideration. pleasure to supply anesthesiological, Already at the airport the extensive nephrologicall and psychological support. security measures were apparent, including Other team members were Abdulla Al- a transport in a convoy with a police car Khader and Faissal A.M. Shaheen from the with blue lights leading the convoy. Saudi Center of Organ Transplantation However, these measures seemed to be (SCOT) as organizers and nephrologists, unnecessary as all the people we met, Hussein Al-Kaff and Abdulla Karama showed an impressive friendliness and Musa from the Yemeni Society for Uro- hospitality. Already few hours after our Nephrology as urologist, Nadey Hakim arrival we were at the hospital making and Anas Zarka from the United Kingdom rounds to see the patients. Donors and as surgeons (Figure 1). Wojchiech recipients were all related, young and the Rowinski, President of the ESOT, joined recipients all on hemodialysis. It was the Congress and the team in Aden and apparent, that while they have been helped with valuable advise. prepared that the transplantation would take place, they did not trust the news, that others were so disapointed, that they doctors from Europe would come to decided to leave and not even to stay for perform the transplantations and the their lectures at the congress. perioperative care without any pay, while But on the first day of the congress, a war was escalating in Iraq. Our appearance personal phone call of the President of the was faced by astonishement and a breakout Yemeni Republic H.E. Ali Abdullah Saleh, of sentiments, leaving some of them crying put an end to all discussions, when he while we made our rounds. Visit of the ordered that the transplantations should be operating theaters and the post-operative performed without any further delay. care unit led us to believe that extensive While some team members were stopped preparation was still necessary, especially in the last moment from leaving to the concerning cleanliness. However, all of our airport, the authors were fetched from the suggestions were taken with enthusiasm congress hall and was transported under and fullfilled perfectly. The whole hospital military escort to the hospital. We seemed to be working with us to reach goal proceeded with the surgeries immediately and there were not many people in the city and within 24 hours we performed five of Aden, who did not know about the living related kidney transplantations. surgeries to be performed and did not share When a press conference was held on the the enthusiasm which we met at every third day the donors were all in the place in the hospital. In an attempt to conference room, which they reached and optimize the preparations the hospital was left on their feet. More important, the closed to the public. recipients were all well and instantly While everything seemed to be prepared, a showed production of urine and decreasing discussion evolved between the Yemeni serum creatinine levels. Once again the Ministry of Health in Sana’a and the enthusiasm within the hospital staff, the Authorities in Aden, concerning the unversity and the whole city was question whether it was possible to overwhelming and was commented in the perform these transplantations in the press and television. setting available at the Aden Hospital. For three days these discussion continued The Psychological Aspects involving various levels of the government Stress was not the only psychological and on each day the transplantations were aspect the participants of the international permitted, but only to be cancelled a few team was confronted with. While routine hours later. The stress on the transplant reduced the extent and number of team was enormous. While we had to face emotionally difficult situations in the our patients, who trusted in us and tell European transplant Centers reactions them, that we just did not know, if and how unexpected to the European Doctor and the project is going to continue, our Psychologist confronted us during our surroundings became more and more whole stay. fierce, as colleagues armed themselves. While waiting on the list for The third night we spent discussing with a transplantation is already a heavy burden representative of the Yemeni Ministriy of for patients with terminal organ failure in Health. The outcome of this discussion was developed countries, it constituted a case so disappointing, that when the congress of life or death for the five recipients we was started on the next day, we were all treated in Aden. They were well aware that convinced that the transplantations were no second chance or alternative to their cancelled. The members of the treatment was available. Thus, their international team reacted in different emotional situation was extremly tense ways: while the authors decided, that they ranging from outburst of relief, when the will stay on and try to do the possible, team arrived in Aden, to dissapointed 2 aggression when a delay occurred. As only As trained nurses were not available, related donors were accepted the bondage medical students were trained for preparing between the donor and recipient displayed the patients and on call postoperatively sometimes critical levels (Figure 2). One (Figure 3 and 4). While the medical recipient with a hypertensive knowledge of these students was far cardiomyopathy received a kidney from his behind that of European Students, they brother, which like the others showed displayed a enthusiasm and a willingness sufficient function and urinary output. to learn that was extremely impressive. However, in the postoperative period this These students supplied a 24 hours recipient developed left ventricular failure coverage for all needs of the patients. They and pulmonary edema. While he was followed the steps of the members of the responding well to the pharmacologic international team constantly asking for the therapy, he accused himself of having expertise of the doctors. Yemeni students harmed his brother, who gave a kidney to are suffering from a desperate lack on him, which he is not making use off. While books or modern medical treaments. the brother tried to calm the recipient, the A constant problem for the European self-accusations progressed into a doctor who is used to be able to deliver the psychotic state accompanied by a necessary treatment, when a disease is deterioration of the cardiological state of recognized, is the overwhelming lack of the patient as he refused to accept any medical supplies and possibilities. One of drugs, finally leading to the death of the the authors (F.S.) who visited and worked patient. in a nephrology clinic, was confronted with Another problem constituted the role of the almost unbelievable medical situations, woman in the Arabic society. Already sometimes only requiring simple treatment, when the international team entered the that just cannot be delivered in the setting room with the female patients the first time of the Yemeni medical system. Patients during the initial rounds in the hospital the were not only encountered in Clinics but reaction was one of panic and shame. This waited in the Lobbies of the Hotels was immediately realized by one of the desperatly asking for help for themselves authors (A.F.), who urged the large group or for their relatives. While we collected of visiting doctors to leave the room. all the medical supplies we brought with us However, even without being able to and distributed them freely to the patients, communicate with the women in Arabic or took addresses with us to organize some language, it was possible to establish a relief from our home countries, even in the close relationship of trust and short period we were confronted with this understanding to the female patients, constant presentation of such cases, left us which endured all the forthcoming troubles with more severe signs of burn-out than of the delayed transplantations. much longer periods of our regular work at The Yemeni members of the medical team home would induce. displayed the same enthusiasm, that we With all the success of the project the met throughout our stay and which question remains, if it is reasonable to compensated for their lack of knowlegde perform kidney transplantations in a of modern treaments resulting from the developing country, where more simple isolation of the country.