While working in the Accident & Emergency Department in Georgetown, Guyana, I noticed one thing that was very different from what I’m used to back in Nashville: few to no ambulance arrivals. That is because there is essentially no EMS system in Guyana.

There are a few ambulances that are a part of the hospital system. These are used mainly for transport between outlying hospitals and GPHC, where I was working. They are also used to transport patients in our hospital to the CT scanner, located in another building, or to transport laboring mothers from the L&D ward to the main hospital, where the operating rooms are located. When used for transport from an outlying facility, they are staffed with a driver, sometimes a nurse, and an “attendant”, who might be able to assist the nurse. In addition, multiple family members will usually ride with the patient.

I happened to glance in the back of one of these ambulances to see what sort of equipment they carry. Not much, I found out. There is room for a stretcher along one wall, and along the other wall is a long bench for other passengers. There was an oxygen tank under the stretcher, although I could not tell how much, if any, oxygen was present. Having worked in EMS, I am used to seeing a bag full of airway equipment, some suction equipment, and some basic medications and IV start supplies; none of this was present on this ambulance.

While working in the A&E I received a few patients who had been transferred via this ambulance service. Occasionally, they came with a nurse who could give a patient report, as well as some papers with labwork and a history, but often we had little to no information about these patients. Notably, I never treated a patient brought in by an EMS crew from any sort of scene (i.e. an automobile accident or a medical emergency from home). Guyana does have a 911 equivalent for calling for an ambulance, but this number is not staffed at all times. Even when you can get through to someone, there is no telling how long it will be before an ambulance is available to pick you up, or what sort of personnel and equipment will come with it.  Most people who are the victims of some sort of trauma will either take a taxi or have a family member drive them to the hospital.

The problems with this are many. First, for trauma patients, there is no spinal immobilization. There are occasional attempts to stop bleeding by family members or bystanders, but often these were unsuccessful. At home, our fully trained paramedics will often pick up a patient with heart failure and severe respiratory distress and by providing treatment in the field and in the ambulance will have them almost asymptomatic by the time they arrive in the Emergency Department.

As an Emergency Physician and former EMT, I have read about the start of EMS in my country, when there was little to no actual medical care provided and was more just transportation. I was continually reminded of that while in Guyana.

The week I left, the Rotary Club had returned for the second part of a series of paramedic classes for the nurses in the hospital. While I think it is wonderful to provide this additional training, there is still much do be done in terms of infrastructure to create a functional, though needed, EMS system. More ambulances will need to be obtained, and a minimal level of equipment will need to be stocked and maintained on the ambulances. There must be a more cohesive system for dispatching the ambulances, as well as some sort of base at which the ambulance and crew is quartered. There will also need to be qualified personnel to work on the ambulances.

There is tremendous potential in creating a transport system that can respond to emergencies, provide some minimal, life saving care, transport patients to the hospital rapidly, and communicate with the receiving hospital to give basic patient information and acuity, particularly for the trauma population.

It took a while for me to realize how spoiled I am back at my home hospital, as compared to GPHC. Of course I immediately realized that that had different medications, fewer medications, and access to fewer labs and imaging tests, but I had expected and was prepared for most of that. But then one day it hit me: individually wrapped alcohol prep pads. There are at least a hundred of them in every patient room back home. In my haste to grab one, I probably drop about 3 on the floor and never pick them up.  They don’t exist at GPHC. Here, there is a large container of cotton (like a giant cotton ball), over which someone pours alcohol and then you pull off a piece of cotton.

Ashley Brown baby

After that, I began to notice more and more how spoiled I had been. One patient had accidentally ingested a bit of formalin. What would have been a 5 minute call to the poison center became over an hour of research and calculations to figure out if she had ingested a lethal amount. A 6-year-old child with an unrepaired congenital heart lesion arrived cyanotic (blue), with dangerously low oxygen levels. Though I had just given the residents a lecture on the topic a week prior, this was the first patient I had actually seen with the condition, as most patients in the US with this lesion have had it repaired very early in life. We gave the appropriate treatment within the bounds of available medications, but what I really wanted was a conversation with a pediatric cardiologist.

I will come home appreciating all of these experiences when I had to figure it out on my own, and I think I am a better physician because of it. Now, though, I have a new appreciation for the vast resources that are just a phone call away.

There are currently 222 million women worldwide who want access to modern contraception but don't have any way to get it. We know that the healthy timing and spacing of pregnancy can improve the health of both mother and child, but did you realize there was a significant economic benefit to making contraception accessible to women living in extreme poverty? This short video by Population Action International summarizes the economic benefits beautifully.

My first week back in Guyana began with the third annual Crash Course in Emergency Medicine. A couple of years ago, Vanderbilt began an Emergency Medicine Residency Training program at Georgetown Public Hospital Corporation (GPHC). With every new class of residents, we put on a “Crash Course,” an intensive four-day lecture series, so that all the new residents can get some intensive training on common emergencies, and all the older residents get an intensive review.

This time, we welcomed our third class of residents. First things first, though—tests for the senior residents! The very first day, we got up early to put all of our upper level residents through an entire day of in-service exams. They had a written test all morning, oral exams, and then an individual simulation case. For the simulation scenario, I was the “nurse” assisting the examinee. It’s a fun position to be in because I get to provide helpful hints if they’re going down the wrong path, or make the case more challenging for the more advanced residents who were knocking it out of the park.

FGHL Ashley Brown Chalkboard

The next day we got up bright and early to begin the crash course. For this four-day session, the new class of residents joined us as well. I participated in the crash course last year, and it was great to see how much the upper level residents had grown, both in knowledge and confidence. I got to lecture on some favorite topics of mine and listen to some great lectures by Vanderbilt faculty as well. One of the most encouraging parts of crash course was the return of faculty from the University of the West Indies in Trinidad. Dr. Joanne Paul, a Pediatric Emergency Physician, returned again to crash course to lecture, along with Dr. Georgia Baird, an Emergency Physician. They both also lectured for a CME course over the weekend that was open to the community. During their visit, they were also able to network with our residents to discuss the role of Emergency Medicine throughout the Caribbean. Our residents are in uncharted territory in Guyana; in fact, Emergency Medicine is a relatively new field throughout the Caribbean. Dr. Paul and Dr. Baird helped to give the residents some insights about how to make the field more recognized and accepted, and how they might begin and organize specialty groups.

FGHL Ashley Brown students

After four days of around 8 hours of lectures daily, we went as a group to tour a local sugar factory (although I think most of the residents were so tired at that point they probably would rather have taken a nap!). It was great to have that time to get to know the new residents I would be working with in the coming weeks, and to see them immediately welcomed as part of the group. Now that we had given them a foundation, it was time to get back to work in the A&E!

Anyone you talk to will tell you that they care about mothers and babies. But many people here in the United States don't realize that a mother dies somewhere in the world every two minutes. Every two minutes. The data is staggering.

Our hope is to make sure Christians don't let that overwhelming statistic leave them feeling overhwelmed to the point that they fail to act. Because the connection between maternal health and faith is so important.

We recently discovered this Q&A article with Courtney Fowler, a conference lay leader in the United Methodist Church, who connects the dots between maternal health, faith, and reproductive justice. It's a great resource for those who are starting to dip their toes in this issue of women's health and who passionately care about the lives of women all over the world, because you believe God cares about them too.

1,000 Days March 4 Nutrition

Last week, 1,000 Days was honored to join with Hope Through Healing Hands and Senator Bill Frist to engage community leaders in Nashville in the effort to improve maternal and child nutrition. With leaders from the faith, business, and academic communities around the table, we examined the issue of poor nutrition around the world and in Tennessee, where one in four children are food-insecure. The gathering of diverse voices—united by their passion to help mothers and children throughout the world—was a unique opportunity to bring greater attention to the issue of poor nutrition early in life and discuss ways that churches, businesses, and individuals can make an impact. 

What became clear is that the importance of good nutrition, right from the start, is universal. Whether a baby is born in Nashville, Tennessee, or Nairobi, Kenya, every child needs basic nutritional building blocks to achieve healthy growth and brain development.   

Poor nutrition—whether measured as hunger, undernourishment, or obesity—is pervasive throughout the world.  Unfortunately, it is also all too pervasive in the US as well. 

As a result, poor nutrition is arguably this generation’s largest public health issue. Globally, nearly half of all childhood deaths worldwide are caused by malnutrition and 165 million children are permanently stunted as a result of chronic undernourishment, leaving them unable to reach their full potential to grow, learn and thrive. In the US, food insecurity and the epidemic of obesity are together fueling a burgeoning health crisis. In the US, about a quarter of preschool children ages 2-5 year are overweight or obese.

Ensuring that children get the right nutrition early in life is one of the most basic yet powerful things we can do to ensure healthier and more prosperous societies. 

There is strong scientific evidence that points to one moment when the quality of a person’s nutrition can shape the foundation of lifelong health and well-being.  It all starts in the first 1,000 days. The 1,000 days between a woman’s pregnancy and her child’s second year of life is a critical window of opportunity when nutrition serves as the foundational building block for a person’s intellectual development, growth and long-term health.  Research shows that a child that is well-nourished early in life is more likely to do better in school, earn more money as an adult and have a lower risk of illnesses such as diabetes and heart disease.  The effects of good nutrition early in life have been estimated to boost economic prosperity as much as 8 percent in terms of GDP gains. 

In this way, improving nutrition for mothers and children during the critical 1,000 day window is one of the most powerful tools we have to unlock greater human and economic potential and help break the cycle of poverty.  It is the reason why the 1,000 Days Partnership was formed and includes over 80 partners working to promote greater action and investment in maternal and young child nutrition.  While the 1,000 Days partnership has helped galvanize much-needed momentum to improve maternal and child nutrition globally, much remains to be done. 

There’s a simple way to get engaged in this conversation. Throughout the month of March, 1,000 Days is hosting an online “March for Nutrition” to raise awareness about the critical role of good nutrition for women and children everywhere. I invite you to join us by sharing your stories and insights on Facebook and Twitter and by following #March4Nutrition.

 

 

Whenever I’ve heard people reflect about their international medical experiences (especially among my colleagues who have worked here in Guyana), there tends to be a few common themes that emerge. There are statements about the gratitude of the local population, and their resilience in the face of adversity in nearly every aspect of their lives. They discuss the lack of resources available; how the hospitals/clinics can lack the most basic of amenities (gloves, bandages, water), or how few and far between medical practitioners are located. Universally, people say the experiences have changed them at their core; they now have a greater appreciation for the resources/opportunities available back in the US, and will continue to work to improve the plight of those less fortunate.

Looking back upon my experiences here in Guyana, my colleagues could not have been more right. Despite significant influence from first world nations, life in Guyana is hard and often unforgiving. Conditions that seem routine back home can often prove fatal down here, and both the medical providers and patients are well aware of this fact. This doesn’t stop either of them, however, from fighting as hard as they can, and utilizing their resources as fully as possible. I feel blessed to have had many opportunities to help care for patients here, and the experience has without question pushed me to higher places as both a physician and a person.

Above all else, my time here in Guyana has left me motivated to come back and do more. The potential that exists amongst the medical community, especially in Emergency Medicine, is quite palpable, and there seems to be a feeling that the tipping point can soon be reached. Once that happens, it could ripple through the rest of Guyanese society and hopefully produce successes and advancements that might have once seemed impossible. Of course, it’s not a guarantee, and many obstacles need to be dealt with. However, there is genuine hope, and that’s often the most important first step. 

Our mission at the Faith-Based Coalition for Healthy Mothers and Children Worldwide is to create advocates for maternal health, infant and children’s health, and for the healthy timing and spacing of pregnancies for women in developing world. This includes mothers in Africa, India, Mongolia, Guatemala, and everywhere where moms and children are living in extreme poverty. Where 222 million women (mostly married) want access to contraception, but it’s simply not available where they live.

It’s hard for us in the United States to get outside of our own experience when we look at these issues. The debate about domestic healthcare rages on, and it’s difficult for us to separate this from international maternal health. But once we’re able to imagine a daily experience outside our own, the need for advocacy becomes crystal clear.

Unicef photo childPhoto (c) Unicef

In the country of Niger, for example, 75 percent of girls become child brides. Of course, this is the country that has the highest prevalence of child marriage, but the truth is that young girls—often around eleven years old—are regularly given in marriage across Africa and southeast Asia. When these girls marry, they’re often forced to leave school, stunting their intellectual development and their social growth. They've also frequently not been educated about reproduction, and their young bodies simply are not ready to become mothers, evidenced by the fact that a girl is 10-14 times more likely to die in childbirth if she has her children before the age of 18.

Or consider Beatrice Namulondo. She was 13 when first became a mother, and she had dreams of raising a small family of children. But at age 36 she’s now mother to 17, because she had no access to any kind of contraception. This is compounded by the fact that the women in her village told her timing and spacing her pregnancies to suit the life she dreamed of and to match what she was economically and emotionally prepared to care for would make her weak and unable to work her garden, when the exact opposite is the truth.

But good work is being done to turn the tide, and in countries like Ethiopia the maternal mortality rate is dropping, the country’s GDP is rising, and political leaders believe these things are intimately connected. With Ethiopia’s Health Extension Worker (HEW) program, women and children receive visits from the 38,000 HEWs like Miheret, who travel to hard-to-reach places (like Ethiopia’s border with South Sudan) to administer vaccines, test for diseases like diarrhea or pneumonia, and monitor the hygiene in the home. Women are given access to contraception and maternal care when they do choose to have children. The results are staggering—child mortality has been slashed in half, poverty rates are down, and twice as many children are in school.

If you want to learn what you can do to help more women get access to this kind of life-saving assistance, visit our Faith-Based Coalition for Health Mothers and Children Worldwide page and see what advocacy activities we’re involved in at the moment. Follow us on Twitter @HTHHglobal and on Facebook. We need you!

Prior to my arrival in Guyana, I had the opportunity to spend a considerable amount of time with one of the Guyanese EM residents when they visited Vanderbilt. In one of our discussions, he brought up a fact that surprised me: the majority of Guyanese in the world do not reside in Guyana. Instead, they are scattered throughout North America, namely New York and Toronto. Only 10-20 percent of his family, for instance, remained in the nation, with the rest living in one of New York’s five boroughs. When I asked him if he would eventual join them in the US, he said no. His colleagues, however, had a much different approach.

After being here, I can understand why that sentiment exists. Guyana is a nation in flux. On one hand, it is quite modern; many people have cell phones, the Internet is widely available (I had WiFi in the middle of a rainforest), and the dissemination of information can occur rapidly and quickly (via Facebook, or other methods). Many of the excesses of our time are at the fingertips of a large portion of the population, especially in Georgetown. Unfortunately, it seems luxury has outpaced necessity, with the end-result being a palpable level of frustration.

This is quite evident in the sphere of healthcare. The physicians here harbor much of the same knowledge and skills that we possess and they know what interventions are needed to treat the most complicated of medical or trauma patients. However, they have very limited resources in terms of pharmaceuticals, imaging, and surgical support to adequately treat the conditions they see. I’ve only been here a few days and I have often felt handcuffed. I can’t imagine how hard it is on the local staff to feel constrained to that degree all the time. When faced with the options of either staying home and going through the growing pains (which may take decades and is by no means guaranteed), or moving to a place (the US or Canada) that has already arrived and that boasts a seemingly thriving ‘local’ Guyanese community, the decision to stay can seem illogical. This is probably why many young, educated folks, especially doctors, leave, which in turn only serves to delay progression further. It’s a detrimental dynamic.

The doctor who visited me at Vanderbilt says he’ll stay in Guyana. Being a part of the construction of not just the specialty of Emergency Medicine but of his nation is something he cannot leave. It’s a brave stance to take, and I genuinely think the new residency program in Emergency Medicine will help him avoid succumbing to the temptation to leave. For me, I am honored to be able to help support this institution, even though it’s in a very minor way.

In the end, while it’s a baby step, it’s still a step, and they will eventually add up. 

Andrew Pfeffer headshot

The next two weeks I found myself much better able to engage in the hospital system. Now I had learned the names of Benson, Mugo, Humphries all clinical officer or medical officer interns. It became my pleasure on night and weekend call to lead them through surgical triage or procedures. On subsequent calls I was able to help one of the medical officer interns through two chest tube placements. These patients had spontaneous pneumothoraces, but were not in extremis, thus I could take my time and coach the intern through the procedure. By the second placement, Mugo was able to anesthetize the patient appropriately, make the incision, and perform this life saving procedure. He remained a bit tentative, but I had seen vast improvement by this second time. These guys and gals are the front line of the Kenyan medical system, and are seeing patients in isolated places with no surgeons, or even residency trained physicians available. Teaching Mugo to place a chest tube well could benefit multiple Kenyan patients in the future.

We also had opportunity to entertain these learners in our home. We got to learn of some of the struggles they had to overcome. One resident commutes nearly an hour each morning and evening for the benefit of her family. Other interns come from extremely poor or difficult circumstances. The Kenyan health care system relies on these young men and women.

Jason Axt with staff

Another sad and challenging case that I encountered was that of D. He is 45 year old man who had been diagnosed with appendicitis over a month prior to my meeting him. He had been taken to theater for an appendectomy at an outlying hospital. When I met him he was post op day 2 and 3 from a second laparotomy for peritonitis and periappendiceal abscess. He had succus pouring from the lateral portion of a “hocky stick” incision. It seems he had been diagnosed with a post appendectomy abscess, and the medical officer (almost certainly not a surgeon) had encountered dense adhesions as he or she had attempted to drain this abscess. The operation had resulted in multiple enterotomies and now enterocutaneous (EC) fistulas. He likely had generalized peritonitis after his first operation or maybe at the time of his first operation. EC fistulas are difficult problems in the United States; here an EC fistula is devastating and likely fatal. We took him to theatre and did a diverting ostomy while closing or resecting the 5 enterotomies or anastomoses that had been left. We placed him on TPN – a rare and expensive resource here. We were unable to close his abdominal fascia, and settled for closing the skin.

He remains alive now 1 ½ weeks later. He remains on TPN after an episode of central line related sepsis and partial opening of his abdominal wound for infection. D. is an example of advanced surgical care done amidst quite austere and resource limited setting. He also is an example of a patient who would have fared much better with initial treatment by a well-trained surgeon. Simple ultrasound guided abscess drainage could have avoided this morbid procedure in this patient, but is available here in a limited fashion. D. remains very grateful for his care and is asking the hospital clergy and medical staff to pray with him and for him. Surgery in Kenya is far different from that at home. Learning to work and teach amidst the resource constraints here has been a stretching and eye opening experience. 

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