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.

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

It is good to be back in Guyana.  It has been a week since my arrival and there is a feeling of returning home.  Although I left this country when I was very young, the culture, the food, the sayings, even the hot humid climate and cooling ocean breeze are all so familiar and welcomed. 

I have been working in A&E at Georgetown Public Hospital, the country’s tertiary care center, for the last 5 days.  I am amazed at the broad spectrum of pathology that we see in any given day - some of these have included cerebral malaria, snake bites, herbicide poisoning, tetanus, advanced HIV, acute myocardial infarction, infected diabetic foot ulcers, and strokes.  What is most impressive to me is how many complications I have seen from poorly controlled chronic medical conditions, many of the same disease processes that we deal with in the US.  As an internal medicine resident, I think about my own panel of patients back home and how aggressively we are taught to manage diseases such as hypertension, diabetes, and coronary disease.  Unfortunately, this is not possible in Guyana in large part due to lack of a trained physicians to take care of these people and poor medical records (surprisingly, many of the first line drugs that we use to manage chronic illness are available here).  Guyana, like so many developing countries, continues to struggle with “brain drain” as more and more trained professionals migrate in search of a more economically secure way of life.  In the medical profession, those who are left behind do the best they can, but are often overworked and undertrained. 

Working in a developing country with so limited resources certainly requires that I adjust the way I think about and approach a disease process; this is easier said than done.  The emergency medicine residents do the best that they can to be aggressive in the resuscitation of very sick patients - unfortunately, often with so few ICU beds, ventilators, equipment for monitoring, it is difficult to sustain a high level of care for the critically ill and many do not survive.

There is just so much that we take for granted in the U.S.  I met a 17 year old girl who was brought in to A&E by her parents with 6 months of a progressive motor weakness and spasms that left her wheelchair bound and in significant pain.  She had been in and out of the hospital, with essentially negative work up including lumbar puncture, plain films and CT head.  She had seen a private neurologist and needed a MRI.  Due to the cost she has not yet gotten the test and even with her consultant advocating her case to the ministry of health, the outcome is still pending.  Getting such a simple test that is so easily accessible to us in the U.S. seems an almost insurmountable hurdle to overcome in the work up of her disease.

It is humbling experience to be here and is a great reminder of what a privilege it is to be able to practice medicine and to serve those who need the most help.  I am constantly being reminded to how much I don’t know and how much I can learn from my patients. 

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

Over the past two weeks, I have continued to work on the research paper on the status of the Framework Convention on Tobacco Control (FCTC) supply strategies in the African Region as reported by the Parties to the Convention. My plans to have the first event of the employee community service program in March have been stalled. We also had an unfortunate incident in Brazzaville on the 5th of March. A fire started at a military arms depot and set off a series of explosions killing more than 150 people and leaving thousands displaced. This sad event was felt at the office as many workers lost their homes. As a result, things were a bit slow at the office this week.   The event has been postponed to April to allow time for things to settle back down.

However, I have been able to make contact with two Units- Human Resource for Health; and Planning, budgeting, monitoring and evaluation.  The Human Resource for Health Unit is engaged in ensuring an available, competent, responsive and productive health workforce in the African region to ensure improved health outcomes. The latter unit enables the effective and the efficient implementation of the WHO managerial framework through the development of regional policies, systems and tools.

The mission of these two units was explained to me and I was given materials to read in order to have an understanding of their work. I am hoping to do a rotation in those units soon.  

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

Brazzaville!!!!I can’t believe I am finally here! After weeks and months of applications and planning and finally a twenty-two hour journey from Johnson City in Tennessee, I have arrived and I am ready to do some public health. Driving into town from the airport, the driver with the World Health Organization, the Organization with whom I would be working with during my three month stay, showed some of the remarkable places in town.  He pointed out the President’s residence, the ministry of defense and biggest market in the area known as Marche Makelekele. “Marche” means market in French which is the widely used language in Congo Brazzaville. I completed a three month intensive course in French about four years ago and as a result I am able to understand the language. However, I have difficulty speaking because I have been out of practice for those four years. Right across from Brazzaville was Kinshasa. The two capital cities are separated by a huge river known as Djoue. Congo Brazzaville is a small country located in Central Africa. It houses the African Regional Office of the World Health Organization (WHO).  This is my internship affiliate organization.

My duties as an intern involves, primarily, monitoring and evaluation of country compliance to the Framework Convention on Tobacco Control (FCTC) as well as production of tobacco control country report cards. The WHO FCTC is the first negotiated treaty under the auspices of the WHO and a regulatory strategy to address additive substances. It focuses on cutting off the demand and supply of tobacco products within countries. However, apart from the above mentioned duties, I also get to do rotations in other departments in order to get a well-rounded field experience

 Having arrived on a weekend, I had the opportunity to rest and recharge my batteries in order to be ready for my first week as an intern. On Monday morning, I was at the office bright and early. I got introduced to my supervisor, Dr. Nivo Ramanandraiben and my preceptor, Dr. Ahmed E. Ogwell Ouma. My preceptor is the Regional Advisor on Tobacco Control. I also met other members of the Tobacco Control Team. I was briefed on my duties and by Tuesday, I set to work by trying to understand and extract the information in the FCTC Parties Reports. Countries that have acceded to, ratified and agreed to implement the articles of the FCTC are known as Parties. The agreement to implement these articles is known as entry into force.  These Parties are expected to produce implementation reports two years and five years after entry into force. In the African region, 41 out of the 46 countries in the region have entered into force. Each Party report is 47 pages long and that would be keeping me busy for the next two weeks.

I am very fortunate to be given an opportunity to intern with the Tobacco Control Unit of the WHO for the next twelve weeks and want to thank Hope Through Healing Hands and the Niswonger Foundation for their scholarship support.   I will keep everyone “posted” so be on the lookout for my next blog report.  In the meantime, here is where you can find me :  http://maps.google.com/maps?hl=en&cp=12&gs_id=0&xhr=t&q=brazzaville+congo&qscrl=1&nord=1&rlz=1T4SUNA_enUS310&gs_upl=&bav=on.2,or.r_gc.r_pw.,cf.osb&biw=1672&bih=762&ion=1&wrapid=tljp132818884994700&um=1&ie=UTF-8&hq=&hnear=0x1a6a32ac441bb83b:0xab3deababe7de443,Brazzaville,+Congo&gl=us&ei=sY0qT7mxO4fAtgfAq6zmDw&sa=X&oi=geocode_result&ct=title&resnum=3&sqi=2&ved=0CE4Q8gEwAg

by Joseph Schlesinger
Vanderbilt International Anesthesia
Kijabe, Kenya

joe schlesinger blog 2

Death and dying are never easy to deal with as a physician.  However, that process is different in Africa.  Morbidity and mortality are more commonplace and seem to be accepted.  Religion is pervasive in all aspects of healthcare: the Wednesday morning chapel service, the preoperative prayers, and the prayers after meetings. 

I was taking care of a very sick patient that was not expected to do well.  Previous deaths in the ICU were simply accompanied by filling out the Kenyan Death Certificate and the family finding out the news when they arrived in the morning.  However, this patient’s family drove about two hours from Nairobi to discuss the hospital course and prognosis.  All six of them spoke perfect English and were aware of lab values and surgical findings.  They were more informed than typical American families I have had discussions with.  Despite the expected grief and frustration, they were grateful for the dedication of the hospital and physicians.  We prayed together at the end of the meeting.  The patient died later the next day.

Despite several deaths in the ICU during the previous week, the evaluations of the anesthesia students were completed.  The improvement was remarkable.  They were pushed harder than they have been pushed before, and they rose to the challenge.  This was evident in the final didactic portion on our final clinical day where we asked the students to present a given topic to their classmates.  Not only did they exceed our expectations, they started quizzing their fellow classmates.  The lecture was completed by presenting us with high quality coffee table photography books of the Mara.  The students signed the inside cover, we took group photos, and we were asked why we can’t stay longer and when we will return.

As we took care of final business with the hospital such as paying for our lodging and Kenyan medical license, the operating room manager asked to meet with us because she wanted feedback on how we can improve things.  Kijabe is a place that can follow through on initiatives for change.  The cohesive atmosphere is amazing and will provide the impetus for being one of the leaders in Africa for healthcare and mission work.  It has been a sincere pleasure to be part of the global health initiative here, and for me, it won’t end here.

by Tracy Curtis
Duke University, Physician Assistant Student
Galle, Sri Lanka

duke office

In my third week at Karapitiya Hospital I was introduced to Dr. Kumara, senior lecturer in Surgery. Participating in various surgical cases was what I was most looking forward to on my rotation in Sri Lanka. Walking into the OT I noticed it was quite a different set up from the operating rooms back in the states.  Patients were lined up on a bench right outside of the open theater doors with their medical chart in hand. Some patients were even curious enough to stand and watch the ongoing procedures from the doorway. On the other side of the patient bench was a make-shift PACU where the post-operative patients were still coming out of their anesthesia. Inside the operating theater, there were multiple procedures going on at the same time. In one corner of the room, a woman was having a lumpectomy under local anesthesia. In the center of the room, a man was under general anesthesia having an open cholecystectomy. Finally, off to the side of the room a woman was getting a carpal tunnel release.

As I was taking in the similarities and differences of the OT, one of the general surgeons asked me to scrub for a thyroidectomy. The case got underway and I was impressed by the speed and precision of the surgeon. Thyroidectomies are a very common procedure here in Sri Lanka and these surgeons perform so many each day, I’m sure they could do this procedure in their sleep. Following the procedure, I noted that the turnover time between cases is quite rapid. Turning over an OR at home takes a bit of time, but here, there is no time to waste. They have so many patients in need of surgery and not enough resources to do so.

One thing I found truly amazing about the Sri Lankans is their strength to overcome adversity. But more impressive is the way they do so without complaint. The patients waiting in the hallway of the theater could be there all day long, sometimes not having their surgery until 1 in the morning, but there was no complaining. I commented to one of the orthopaedic about how refreshing it was to have people be thankful for the help they are receiving instead of complaining about the wait time, or cosmetics of the scar, or the post-op pain, or even the food at the hospital! The surgeon told me that Sri Lankans are very accepting of their own problems and illnesses. Then he smiled, leaned in and said, “Sri Lankans don’t sue their physicians and that’s something you all have to worry about over there.” Sri Lankans understand that this is the life they were given and they will deal with it as best as they can. They do not blame physicians (or others) for their problems, but instead are grateful for the care they receive.

After a few orthopaedic surgeries, I stepped into the general surgery suite to watch an open cholecystectomy. Since we do these procedures laparoscopically in the states, it was a new operation to me. There is only one scope for the entire hospital so most all procedures that we would do laparoscopically at home are performed as an open procedure here. Similarly, the hospital does not have mesh implants for hernia repairs. Instead, I learned an old suturing technique to weave a meshwork of suture over the opening. Quite impressive and cost effective. As a global practitioner, I’ll need to be prepared to assist in surgeries with fewer resources and embrace both old and new techniques to achieve good end results. I am very grateful to have watched so many procedures and techniques that I won’t get to see (or rarely see) in my training in the US.

I also spend time with Dr. Kumara during his thyroid, vascular, and endoscopic clinics. In the thyroid and vascular clinics, I was surprised to see patients bring their own injections to Dr. Kumara. In the endoscopy clinic, I was stunned to see that patients were not sedated for upper endoscopies or colonoscopies. But once again, there are no resources available to take care of these patients post-procedure if they were to have an anesthetic so using a local anesthetic is the only feasible option.  

With that, we headed to meet up with two German medical students, also doing an elective clinical rotation. They were already in the casualty theater where we spent the rest of our day assisting in I&D’s, suturing small lacerations and bandaging head wounds. Overall, surgery in Sri Lanka very much surprised me. For the limited resources available, the shortage of qualified surgeons and the ever increasing number of patients in need of surgery, the surgeons here are very efficient with their time, skilled in technique and quite resourceful. We may have different ways of carrying out a procedure, but we all get the job done.

When I wasn’t in the OT, I was out in the community, learning more about the public health system, specifically the care of orphans and elderly. My colleagues and I have already been to a government run orphanage, and this week we wanted to see how the private orphanages compared. We visited an SOS Village, an Austrian run organization which hosts 12 children per home in 12 total homes on the property. Each “family” home consists of children aged 0-16 years brought in by the courts in cases of abuse or abandonment. The children are cared for by a “mother” in each home who cooks, cleans, and teaches the children valuable life lessons. These “mother’s” undergo years of training and a very intensive screening and selection process. The children still attend public schools like their peers, and return to the village to live a life as close to their peers as possible. It was wonderful to see an organization like this one, working so hard to give these children a rich and meaningful childhood.

We also made our way to a catholic-run elderly home where I had the pleasure of meeting an amazing woman who was blinded by the tsunami. She told us her story and how the sisters had found her on the streets, nearly dead, and brought her to the facility because she had no money, no family and no way to survive. The sisters were able to find a surgeon, who just this past year, performed an incredible surgery to restore her vision! She was able to see for the first time since 2004.

There were so many great stories from the folks at the elderly home, but what I liked most about the facility was that every resident helped out in any way they could. Some set the dining room tables for meals, others cleared dishes, or peeled vegetables, and some knitted bedding or doilies for the sisters to sell at the markets to bring in money for the home. Not everyone could pay, but no one was turned away.

With another fantastic week in the books, it’s hard to believe my time in Sri Lanka is coming to a close. I have learned so much in my short stay; it will be hard to leave. I am very grateful to have had this learning opportunity here in Sri Lanka and I hope that I may return here as a provider one day. 

 

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