First Week in Honduras

Alyssa Small talks about her struggles with Spanish, the similarities between Meharry and her new hospital, and getting out into the countryside

Aug 04 2012

Corozal
By Alyssa Small
Meharry Medical College
Ciriboya, Honduras

This first week has been a lot of preparation. For the orgnization - preparing for the upcoming medical student brigade and the confrence, for me - learning Spanish and helping out where I can. I try to spend an hour in the morning in language school, which is me in front of the fan looking at my Spanish materials. I´m already more comfortable saying Spanish phrases and I can understand what people are saying to me every once in a while. So I guess I´m on the road to success.

I finished translating the document. It was a long 25 page paper that outlined the history of the Hospital and the student health brigade. It was actually really good for me to go through because I learned more about the activites of the Hospital. In short, The Primer Hospital Popular Garifuna de Honduras was founded by Dr. Luther Castillo Harry.  He was a graduate of the first class of medical students from the Latin American School of Medicine (ELAM) in Cuba.  He wanted to build a clinic to serve the Garifuna population who are medically and socially underserved. This population didn´t have any medical services and suffered from high morbidity, especially infant and maternal mortality. The mission of the Hospital and the workers reminds me a lot of Meharry Medical College, my medical school.  They both exist to provide needed health services to a disadvantaged group of people. He chose Ciriboya as the location for the main hospital because it sits on a site where people must pass through to go and come from the area.  This makes it very convient for the local population.

The Hospital also supports a network of clinic outpost in about 7 other communities.  The network is staffed by Garifuna doctors, nurses, and staff along with a Cuban medical team.  The Garifuna and Honduran medical students who are studying medicine in Cuba travel to Ciriboya and the surrounding villages during their holiday from school.  This year they are going to be building a health record system as well as educating people on diabetes, high blood pressure, and sickle cell anemia. Tomorrow morning we will leave La Ceiba bright and early at 6am and travel to Ciriboya. This afternoon we had a little conference of the members of the student health brigade Dr. Luther talked about the histoy of the program and Hospital as well as the plan for the brigade and another doctor spoke about the pathology and management of hypertension and diabetes.

Yesterday I got out and was able to see more of the city. It reminds me a lot of the cities and towns of the Caribbean islands. The buildings and the architecture are similar.

If it wasn´t for the mosquitoes feasting on me, this would have been a really good experience. This little waterfall was hidden away. I wish I had brought my real camera, but I was glad to be able to capture its beauty on my cell phone.

After we visited the community of Corozal, which is part of La Ceiba. It is mainly Garifuna, but I saw a mix of ethnicities. It´s a poorer community that sits right on the beach. The water was extremely warm and the beach was nice.  It seems they had a circus in town, but there was no action while I was there.

Random item of the week... I watched some blue crabs go from happy and snappy into dinner.

Off to go learn some Garifuna!

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Alyssa Small is a 4th year medical student studying at Meharry Medical College. She was born and raised in Canada to a Caribbean family¨from Barbados and is a self proclaimed ¨Canadian born Bajan.  She credits her parents for instilling in her the importance of volunteerism and serving the community. She also recognizes the impact of seeing the disparities between the Caribbean and Canada for her interest in working with disadvataged groups. Her area of focus is the Caribbean and Central America. During her undergraduate career, Alyssa minored in Caribbean Studies (majored in neuroscience) and spent half a year doing study abroad at the University of the West Indies at the Cave Hill campus in Barbados. During medical school she spent a summer in Barbados studying the caregiver burder associated with HIV.

Alyssa is very excited to get some Latin American experience under her belt.  She is traveling to Ciriboya, Honduras a small coastal village, where she will work at the Primer Hospital Popular Garifuna de Honduras under the leadership of Dr. Luther Castillo Harry. This is a small general, mainly non surgical hospital. Alyssa will work with team seeing patients in the clinics and hospital.  She will also conduct a follow up self breast exam survey in the community of Ciriboya. Alyssa´s interest lie in women´s health and she will pursue a residency in ob-gyn after graduation in May 2012.

Goodbye to Kijabe

FGHL Rondi Kauffman reflects on his time in Kenya

Jul 13 2012

Kijabe Hospital

By Rondi Kauffman, MD
Vanderbilt University: Department of General Surgery
Kijabe, Kenya

It is hard to believe that my four weeks in Kijabe will be over tomorrow. It has been a wonderful trip- from the joys of getting to know a new culture and working alongside talented colleagues, to having the privilege to take care of the patients here in Kenya. I will carry many lessons home with me- how to accomplish much with limited resources, how to arrive at a diagnosis by means of a good physical exam and without the luxury of advanced imaging, and a new appreciation for the necessity of balancing cost of health care with benefit. For the many ways the delivery of medical care is different in Kenya- what treatments are available, how disease present, and  the populations affected, so much is the same. Healthcare providers striving daily to improve their practice and provide the best care possible, the look of gratitude on a mother’s face when I tell her we can help her child, the concern on a family member’s face when a relative is ill in the ICU.  My time in Kenya has been a privilege and an honor, and I am changed for the better.

Mass Casualty

Jun 05 2012

By Rondi Kauffman, MD
Vanderbilt University: Department of General Surgery
Kijabe, Kenya

I took my first weekend of call this past weekend.  As I was checking on a patient Sunday evening, I was informed by my junior resident that there was a “mass casualty” bus accident in a nearby town, and the police had called to say they were bringing a number of victims to Kijabe Hospital. No one knew any additional details, and as I arrived in the Casualty unit (Emergency Department), a tour-bus size vehicle pulled through the front gate. Within minutes, injured patients began being rapidly unloaded. As the most senior resident present, I was in charge of triaging, organizing resuscitations and directing patient care until an attending arrived. We very quickly identified several patients needing immediate attention, and moved quickly to stabilize them.

I was amazed at the efficiency of the staff in identifying what needed to be done, getting supplies, and working as a cohesive team to get patients taken care of. Medical interns had turned out by the dozens to assist, nurses not on duty quickly arrived to work on starting IVs, and every attending who was in town showed up to lend a hand. What an amazing team of professionals! Someone brought a portable Sono-Site ultrasound that allowed us to perform FAST exams to look for intra-abdominal fluid in the Emergency Department. Xray techs worked overtime to image cervical spines and fractures, and several operating theaters were rapidly made ready for the injured who required operations. 

By last count, we had received 35 patients, some critically ill and all requiring some intervention (an operation, laceration closure, xrays etc).  All were stabilized, treated and admitted or discharged as appropriate within 6 hours. That many injured patients arriving at once would overwhelm almost every trauma center, but the team at Kijabe did an excellent job coming together to provide excellent trauma care in a setting with limited resources. 

By Rondi Kauffman, MD
Vanderbilt University: Department of General Surgery
Kijabe, Kenya 

One of the great benefits of spending time in a place like Kijabe is the opportunity to “cross train”.   I am a general surgery resident. But this week, I have learned a bit about being a urologist, an otolaryngologist, and an obstetrician.

Specialists are in very short supply in the developing world, and therefore, one needs to remain flexible and willing to learn new trades in order to take care of the patient in front of you.  It strikes me that, as American surgery continues to be further compartmentalized into narrower and narrower sub-specialties, international surgery provides the opportunity to remain not only a true “general surgeon”, but a medical doctor- treating the wide range of non-surgical complaints that find their way into the surgical clinic.  

By Rondi Kauffman, MD
Vanderbilt University: Department of General Surgery
Kijabe, Kenya 

Being diagnosed with a malignancy in Kenya is a very different thing than being diagnosed with a malignancy in the United States. CT scans and PET scans as means to evaluate for metastases are not locally available. A patient must travel to Nairobi, and frequently, these imaging studies are too expensive for most patients to afford. Furthermore, many malignancies are very advanced when they first come to the attention of a physician. Patients may delay being evaluated because of the cost, because of the distance required to get to a clinic, or because they must choose between obtaining health care and their family eating.  Finally, chemotherapy and radiation therapy have limited availability.  At the private hospitals, the costs are prohibitive for many patients which means that the queue to access the limited government sponsored facilities is exceedingly long making access to treatment all the more difficult.  As a result, all of the procedures I have done in my first week in Kenya on patients with malignancies have been palliative in nature. This is emotionally challenging for clinicians who are accustomed to being able to offer surgery for cure.  Still, it is a way by which to provide improved quality of life for whatever time a patient may have left, and that is certainly valuable to both the individual and their family.

It has struck me though, the number of malignancies I have seen here. I have been surprised- having expected rather to see more infectious diseases. I wonder if public health campaigns to provide mosquito nets, community education projects to teach about modes of transmission of HIV, and global health programs to provide free immunizations haven’t started to lead to some progress in the battle against communicable diseases in the developing world. Not that there isn’t still work to be done, but perhaps we are getting somewhere.   Maybe it is time to bring the fight against cancer to the forefront of the global health platform. There is clearly a need.

By Rondi Kauffman, MD
Vanderbilt University: Department of General Surgery
Kijabe, Kenya

I delivered a baby today. Via Cesarean section. And an intern taught me how. Three remarkable statements to be made by a General Surgery resident about to begin her Chief year.

I am finishing my fourth clinical year in General Surgery, and feel as though I have had remarkable training thus far- both in its depth, breadth and quality. Vanderbilt is a wonderful place to train as a surgeon. I am about to begin my Chief year, where I should be honing my skills and functioning as a junior attending. And yet here I was, three days into my stay in Kijabe, learning a brand-new operation that I’ve never seen, much less been a part of, from someone who is 6 weeks into his intern year. How humbling, how awesome.  What a reminder that every day is another opportunity to learn, to grow, to be stretched a bit more. I have already been amazed at the interns with whom I have had the opportunity to work here in Kenya. They are eager, they are confident, and they are desperately wanting to learn everything that they can from me, so that they can be better clinicians.  I have already enjoyed our interactions- as we both have so much to teach one another- mine from more years of clinical experience, and them from their familiarity with disease processes and presentations not commonly seen back home. I am eager to experience the many more opportunities that I will have to work side by side these amazing Kenyan trainees in the coming weeks.  

By Rebecca Pfaff
Meharry Medical College 
Riobamba, Ecuador

Truck

My first day with the Cinterandes Foundation we left for a trip to Palmer.  The large truck with an operating room in the back had left the day before and we traveled in a small vehicle.  This trip was my first time out of the Andes since my arrival a month earlier.  We drove the Cajas National park where llamas run down the middle of the highway and alpine lakes dot the landscape before we began the decent; the humidity and heat increasing and the vegetation changing from alpine to tropical with every turn of the road.  The houses also changed from concrete Spanish houses to wood houses on stilts with hammocks on the porches.  

 Palmer is a small pueblo of less than 2000 people on the Pacific Ocean and most of the people there are considered very poor by Ecuadorian standards.  There is a public health clinic run by a German born nurse who finds cases appropriate for these trips and pre-screens the patients so that when we arrived all that was to be done was review lab results, EKGs, and perform quick physical exams.  

 Two patients were turned away because of fever and one because of irregular heart rate.  The patients need to be carefully selected so that there are minimal complications with recovery because the PACU consists of cots in the clinic and the team leaves at the end of the week.  Dr. Rodas calls all patients to insure that they are recovering well, but this system works best when there are minimal complications.  Sometimes the surgeons travel with a family physician who sees patients while they operate.  However on this trip the team included Dr. Rodas and Dr. Sacoto, two well experienced surgeons.  

 Dr. Rodas founded Cinterandes because he felt that Ecuadorian doctors could help their population just as traveling Americans could.  He was inspired by the ship Hope and trained in the US but was born and raised in Ecuador.  Dr. Sacoto, the other surgeon is the dean of a medical school in Cuenca.  During the ride to Palmer he and I had a long conversation about evidence based medicine and the pedagogy of medicine.  There was also Dr. Anita the anesthesiologist and executive director of the organization.  Her role on the trip made me think about anesthesia in a whole new way.  She not only anesthetized patients from 5-76 years old and with everything from local nerve blocks to general anesthesia but also serves as an extra set of unsterilized hands in surgery helping with everything from preparing the patient (cleaning) to helping set up the laparoscopic equipment.  

 In Ecuador anesthesiologists are at a premium.  Dr. Cruz, the pediatrician I worked with in Riobamba is trained as a surgeon but works as a generalist because there is no anesthesiologist at the children’s hospital.  While working with the ob/gyn and head of the department in the public hospital in Riobamba, we had to wait two hours for an anesthesiologist to arrive so that he could operate. In addition, Dr. Anita is involved in primary care, coordinating rural rotations for medical students.  

 The final physician was Dr. Valasco who, like many physicians in Ecuador, is working as a physician before residency and after his year of rural service. He serves as the scrub tech but also does much of the pre- and post-operative care.  

 Like the physicians, the two other staff members had multiple jobs.  Freddy knows where absolutely everything is on the tightly packed truck and throughout all the surgeries the doctors often shouted, “Freeeeeedy” and he would appear from nowhere and supply the necessary item.

 The final members of the team were us 6 American medical students (there are usually also Ecuadorian students but they had final exams). We assisted in all surgeries and helped with pre- and post-operative care.  

 There seems to be 2 purposes to these trips.  First and foremost, the foundation truly believes that it is far more humane to provide surgeries, for carefully selected patients, close to their homes so that they are spared the expense of travel and the trauma of time away from their families.  Many of our patients needed these surgeries and would not have received them without this foundation.

 But students, both foreign and Ecuadorian, also play a role.  Not only do we bring labor, supplies, and funds to the organization, but the team of doctors all clearly enjoy teaching and explicitly encourage students to learn how to provide humanitarian medicine (for example instructing us on how to tie knots so as to spare suture).  It is a symbiotic relationship in which the students gain important skills and the team gains extra hands to help with the work.

 The surgeries performed were hernia repairs, lipoma removals (lipomas are benign tumors that can be disfiguring and painful), and lots of cholystestectomies.  Cholystestectomies are common here, not only because of the frequent occurrence of gallbladder disease, but also because gastric cancer is common here (more common than colon cancer in the Andean region).  In fact, endoscopy of stomachs rather then colons are the preventative tests of choice here and choystestectomies for symptomatic patients are considered part of prevention.  

 We worked for 3 days operating from 8 in the morning until long after dark and then rounding on patients recuperating in the clinic.  Many of surgeries were laproscopic and, save for the fact that the drapes and gowns are cotton rather then disposable paper and the conversations being in Spanish, you would never know you were outside the U.S., let alone in the back of a truck.

 It was a privilege to work with physicians helping their own people in this unique and creative way.  The Cinterandes team is traveling to the Sudan this year to help establish a similar truck there.  Hopefully the idea will catch on because it is a great way to utilize urban specialists to help poor rural populations without the need for expensive infrastructure development.

Truck 2RPfaff op room 3

Difficult Cases

May 09 2012

By Catherine Burger, MD
Vanderbilt University: Department of Emergency Medicine
Georgetown, Guyana 

Sometimes the most difficult parts of a job produce the situations you learn the most from. Often doctors will remember their most challenging patients for the rest of their lives and rarely forget what they’ve learned through those interactions. Working at Georgetown public hospital has afforded me a wealth of opportunities such as these in my short time here. 

Near the end of a shift one day I saw a patient with chest pain, a thin, uncomfortable-appearing woman in her 50’s. When asked where her pain was she did the classic motion of waving her hand over her entire chest and abdomen, attempting to help me pinpoint where she was hurting. I started with x rays, an ecg and blood tests but unfortunately these would take quite a long time during this busy day. Hoping for faster results, I looked for the ultrasound machine to assist in my work up. After a long search and a battle to keep the battery on, we had it at the bedside. Looking at her heart, lungs, kidneys, liver, and great vessels with the ultrasound machine gave me a wealth of information. I could see she had fluid around her heart and one of her lungs. That provided me a clear start that ended up guiding much of my treatment for her. Although getting the ultrasound, using the machine, interpreting the US (no Radiology to help interpret the scans) were all much more difficult than doing the same would have been in the United States, I can honestly say I learned even more from the process than I would have in my home institution. The difficulty in getting the machine caused me to use it as a precious resource, getting every possible use out of it that I could for that patient. Not having Radiology back up or easily obtainable diagnostic tests caused me to fully scrutinize every image, think outside the box, focus on physical exam clues, and tested my confidence in my own ability to obtain and interpret ultrasound findings. On top of all that, I got to teach a group of residents and nurses aspects and uses of ultrasound that they had never seen before. The experience highlighted learning opportunities I take for granted working in the United States and helped me develop my own diagnostic abilities.     

Andrew Pfeffer Pic 2

by Andrew Neil Pfeffer, MD
Vanderbilt University: Department of Emergency Medicine
Georgetown, Guyana

Whenever I’ve heard people reflect about their international medical experiences (especially amongst 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 1st 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. 

By Catherine Burger, MD
Vanderbilt University: Department of Emergency Medicine
Georgetown, Guyana

We are taught during medical training to be very cautious and to only proceed with decisions and procedures when we are well prepared. Putting in a breathing tube, for example, when a patient is having difficulty breathing or has lost consciousness, is a procedure that can be done with just a few simple pieces of equipment. But in an attempt to ensure success, we bring in advanced tools for back up, cameras to get a better look down the throat, smaller tubes in case the size we have chosen doesn’t fit. Once we are prepared for anything we are ready. But in many places around the world, including Georgetown Public Hospital in Guyana, those backups are simply not available.

In so many ways the Guyanese healthcare providers have used their limited resources not as an excuse to give up but as an education in how to efficiently and effectively work with what you have. Although the Accident and Emergency Department has less than 20 beds and staffs only a handful of nurses and doctors they are able to see over 70,000 patients a year, what would be a sizable number for any large tertiary care hospital in the United States. Hallways are lined with chairs for patients who are healthy enough to sit up and often patients walk themselves to the lab to have blood work done or x ray for their imaging. While working in the A&E one day I saw a 21 day old baby with a large infected abscess on his arm. The mother brought the child to my chair where I was doing initial evaluations, after seeing the infection we set the baby on a nearby stretcher, cleaned the area and sprayed it with an anesthetic, used a scalpel blade to drain the infection and wrapped the arm back up. We gave the infant some antibiotics and had them go back out into the waiting room until there was a bed available in the Nursery. Neither the staff working with me, nor the mother, was bothered by our inability to get blood cultures, the lack of a crib or incision and drainage kit, or the fact that they had to wait outside the A&E for a bed. Everyone was just glad this was a child we could clearly help, as opposed to the unfortunately numerous cases where the patients are too sick to turn around.

At times I would find myself frustrated by the lack of certain simple but effective drugs, easily available CT scanners or even ventilators. But then a coworker would teach me about how they have found older, cheaper drugs that works, they use x rays instead of CTs, and they ventilate the patients by hand. It’s not ideal but for the most part it works. It’s refreshing to watch the innovative ways resources are used and how nothing is wasted. Even in the sometimes harsh environment of Guyana the people have remained quickly adaptable to their changing world, generous, and extremely thankful, it is a fantastic privilege to work with them.  

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