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.  

Andrew Pfeffer Pic 1

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

Prior to my arrival, I had the opportunity to spend a considerable amount of time with one of the Guyanese EM residents as they visited Vanderbilt. In one of our various 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. In his family for instance, only 10-20% 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 has cell phones, internet is widely available (I was in the middle of the rainforest and had WIFI), 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 couldn’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. 

He says he’ll stay. 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. 

Ifeoma - Hospital Visit

by Ifeoma Ozodiegwu
East Tennessee State University: College of Public Health
Brazzaville, Republic of the Congo

I paid a visit to the local hospital called Makelekele, the second largest hospital in Brazzaville where  I visited the different sections in the hospital and spoke with the staff. The hospital was a little crowded due to the explosion that occurred a few weeks ago. A number of people are still receiving treatment from the hospital.

My purpose for visiting the hospital was to gain a better understanding of the health status of the Congolese people especially as it regards tobacco-related diseases and view the state of their health facilities.  Following a tour of the hospital I chatted with the exceptionally nice staff and enjoyed an informative discussion the Medical Director of the Hospital, Dr. Loussambou. The Director explained to me that from their observation, the leading cause of morbidity was bronchitis and pneumonia while the leading cause of mortality was malaria and heart attack. He also explained the national strategy to combat malaria. When I inquired about the prevalence of cancer of the lung, he said that it was quite low.

My visit to the hospital opened my eyes to the sacrifices made by the medical personnel in the Brazzaville; they are able to do much with so little. The personnel seemed interested in their patient’s conditions and the well-being of other staff. They also did their work with so much joy such that it was infectious.

Finally, during the week, I completed my research paper on health workforce norms. I am also done with reviewing the monitoring and evaluation committee report. In the next final 2 weeks, I am looking forward to having the employee service event and putting finishing touches to my work.  Expect to see all the pictures from the event.

By Nadine Harris, MD
Vanderbilt University: Department of Emergency Medicine
Georgetown, Guyana

All I can say is, I don’t know how they do it.   I have finished my time in A&E and have been on female medical ward for the last week and a half. The female medical ward is housed in a new facility that opened several months ago.  There are approximately 8 patients per room.  Patients have to bring their own sheets, clothes, toilet paper, water, and any other supplies that they might need.   There are many nurses and even more nursing students around, but I have yet to figure out exactly what they do.  Care by the nursing staff is haphazard at best.

It is so busy here!  There are two interns who take care of 60-80 patients at any given time and every 3rd day they do a 36 hour shift.  Rounds every morning are quite exhausting and interminable.  We either help the interns pre-round (this may involve checking vitals, starting IVs, updating orders) or we round with the sole internal medicine consultant (in the country!) during bedside teaching rounds.   There are about 20 medical students who attend these rounds and it is the only semi-structured teaching they receive during their internal medicine rotation. I spent some time going over a few cases with them and though they are eager and enthusiastic to learn medicine I worry about how they will develop the skill sets needed to identify and manage disease processes.

Unfortunately, because the wards are so busy and it is often only the interns around to manage patients, many things are missed or overlooked.  Labs take a long time to return and once they do show up may be forgotten until the next day on rounds.  A patient’s clinical status may deteriorate without anyone recognizing or alerting a physician of the change for hours.   There is a lot of death and, unfortunately, sometimes it seems all but inevitable.  

Despite all the obstacles present, the best part about being here is the patients I get to work with.  There is such a sense of gratitude and appreciation for the care that they receive and readily acceptance and trust even when things do not go quite right.  There is such strength and resilience in the human spirit.

Yesterday was the last day of the rotation and I spent part of the day in medical records going over a couple charts of patients that I had heard about or taken care of.   As I sat on the hard wooden bench, in the cloying sticky heat waiting for them to pull the records, I looked around and saw the tall shelves of recorded births and deaths at GPHC for the last 50 years.  It was particularly striking to me at that moment that somewhere amidst all of that paper, the record of my birth could be found.  Looking at GPHC currently, it is hard to imagine what it must have been like so many years ago.  Nonetheless, I feel like I have come full circle and I never could have predicted it.  I am grateful for the opportunity to be here and I look forward to creating opportunities to come back to teach, work and help build up the healthcare of Guyana.

by Ifeoma Ozodiegwu
East Tennessee State University: College of Public Health
Brazzaville, Republic of the Congo 

Ifeoma - BrazzavilleIfeoma - WHO Team Meeting

It has been two months now! Yes, Two months! Over the past two weeks, I have focused on writing and designing the layout for country-level reports on the Status of Implementation of the Framework Convention on Tobacco Control (FCTC) for two countries-Madagascar and Lesotho. While writing the report for Madagascar, I observed that the tax on the most widely sold brand of tobacco is 76%. “Impressive”, I thought, given the difficulties and politics involved in the implementation of such tax policy. Upon inquiry, I learnt that Madagascar has the best practice in Africa. Madagascar also has health warnings on tobacco labeling and packaging covering more than 50% of the package and labels. The issue of health warnings reminded me of the events in the US where the implementation of graphic health warnings on tobacco packaging and labels were ruled as unconstitutional by the courts. I hope tobacco advocacy groups continue to fight for the adoption of such policies. Policies recommended by the FCTC has been shown to reduce tobacco consumption and in turn, premature mortality from tobacco use.

The Human Resources for Health Unit has also assigned me to write a literature review on health workforce estimation, with the aim of determining if it can be done on the regional or country-level, for use by the Regional Director. Whereas, the Planning, Budgeting, Monitoring and Evaluation Unit asked me to review their annual report and budget as well as create a summary of performance indicators for Budget Centers (Regional and Country offices) to be used in their annual report. All these have kept me on my toes. 

By Rebecca Pfaff
Meharry Medical College
Riobamba, Ecuador

My first week here in Riobamba, Ecuador has been fantastic.  In the mornings I attend rounds in the pediatric hospital with residents and attendings.  Rounds are a lot like in Nashville except that x-rays are read by holding films up to the light and, of course, everything is in Spanish.  Also, an epidemiologist joins us, and sometimes a dentist, though they rarely contribute to the discussion.  It is amazing what an international language medicine is.  Even with my limited Spanish skills I can follow, and occasionally contribute to, rounds with relative ease.  After rounds I go with Dr. Cruz to his clinic on the first floor of the hospital.  I enjoy working with Dr. Cruz both for his obvious skill as a practitioner and enjoyment of teaching, but also because he speaks very clearly, making it easier to follow him. In clinic we see 8-10 patients to fill out the morning before he and the other pediatricians head to their private clinics in the afternoon.  There are no well child visits in the clinic, only hospitalization follow-ups and sick visits.  Riobamba is the capital of Chimborazo Province and surrounded by mountains populated by small villages and farms.  Families bring their children in from long distances to see the doctors.  Pulmonary complaints are by far the most common with gastrointestinal a close second.  In fact, the hospital has two large main rooms for inpatients, one for pulmonary complaints and one for gastrointestinal, with smaller rooms for infectious disease, neonatology, and other complaints.  There is no importance given to privacy either on the wards or in the clinic. Curious mothers will follow the physicians as they round in the one large room containing 6-8 patients and in clinic other patients, nurses, pharmacy representatives, and administrators all walk into the examination room while the doctor is seeing patients.

 After clinic I return to my host family’s house for the most important meal of the day, lunch.  Everyone comes home from work and school to eat together.  After this I head off to my medical Spanish language course.  We are all in the fourth year of medical school in the U.S. and excited about starting residency soon but enjoying Ecuador a great deal in the mean time.  I can't believe I have already been here a week, these 11 weeks are going to fly.

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