by Holly Stump
Duke University, Physician Assistant Student
Galle, Sri Lanka

duke group photo

I wasn’t sure what to expect when I arrived at Mahamodara Maternity Hospital. The tuk tuk dropped us off outside of what appeared to be fortress walls. We were met by our Duke coordinator and led through the gate, past a building that was in disrepair and dilapidated. We traversed through a labyrinth of crumbling plaster and boarded up windows. There was a smell of mildew lingering in the air. I thought to myself, “Women come here to give birth”? Once we rounded a corner, I noticed an area to my right which looked as if it should have been full of expectant women, but was eerily vacant. It was then I realized what I was seeing was the shell of the Mahamodara which stood during the 2004 tsunami. I stared into the ward, and could imagine this area full of pregnant women and newborns on that day, and could almost feel their terror. I was told the hospital was hit by 3 waves. The first wave destroyed the “fortress” walls that I had seen earlier, but these barriers had lessened the impact to the building. It flooded the first level and knocked out the electricity. The doctors and staff evacuated the mothers and infants, some to higher ground, and others to Karapitiya Hospital. The second wave was estimated between 20-30 feet high. There are many stories of heroic men and women from that day, including one physician who calmly completed a Cesarean section by flashlight after the first wave hit. He then safely evacuated the mother and child. Due to lack of funds to demolish the building, it now stands as a temporary memorial.

We moved on, and at the end of the hallway we entered a courtyard. In front of us was a beautiful new building which now housed high risk expectant mothers. The ward contained 64 mothers who had a variety of problems, such as gestational diabetes, hypertension, and preterm premature rupture of membranes. There were strict visiting hours here, so there were no hovering families or concerned husbands. The hospital has very few fetal heart rate monitors, so the midwives and nurses monitor the fetus through the use of a pinard.  I spent a lot of time in this ward, and in the antenatal clinic, examining patients. I practiced with the pinard, straining to hear the fetal heartbeat as clearly as these experienced midwives, who could easily estimate fetal heart rates. I did many abdominal examinations, measuring the fundus, palpating the fetal position, and attempting to guess the baby’s weight in kilograms. I was certainly attaining one goal I had for this rotation, to get back to basics!

I witnessed the miracle of birth for the first time this week. I made my way through the maze of exterior hallways at Mahamodara to the labor and delivery room. Once I entered, I saw 10 wrought iron beds sitting side by side, each containing a woman in varying stages of labor. Two had just given birth and were coddling their newborns, encouraging them to breast feed for the first time. Several were in the final stages of labor. I chose a mother and joined the midwife and medical student who were at her side. I again noted the palpable absence of the typical “cheering squad” you see in America. These women were left to hold their own legs, and labor alone. There are no epidurals or pain medication, just pure will and true grit. After another hour of exhausting effort, she gave birth to a healthy baby girl. A new mother’s joy transcends all language barriers!

This was my final week in Sri Lanka. I cannot express enough gratitude to the doctors and staff at Karapitiya Hospital, and the University of Ruhuna Faculty of Medicine, for all of their time and willingness to share their vast knowledge.  The long journey home gave me time to reflect on my experiences here, and all that I have learned. Of course I am extremely grateful to have had the opportunities to assist in surgeries and delivering babies, to learn about rare illnesses not seen in the United States, and to practice primitive examination skills; but some of the most invaluable lessons I have learned were from the Sri Lankan people themselves. They are a hopeful people. Having recently suffered through a natural disaster, as well as a three-decade long civil war, they see brighter days ahead and are working hard to be sure the whole world can see them too. They are patient people, accepting of the fact they may have to return to the hospital daily in hopes of being admitted, or that their surgery may be delayed by many weeks. They are people who are full of grace, willing to undergo painful procedures without pain medication or anesthesia, with no complaints. Finally, they are a grateful people. They understand they are fortunate to have free healthcare and very skilled physicians. The phrase “medical malpractice” is foreign to them, and litigation against their physicians is unheard of. They are grateful for visitors from faraway lands and are eager to share their history and culture with all those who are willing to make the trip!

Holly Stump
Duke University
Physician Assistant Student
Galle, Sri Lanka

We arrived on the pediatrics ward this Monday, a little less naive and much less shell-shocked. I had grown accustomed to hearing only the whirring of ceiling fans, barking dogs, and the quiet chatter of Sinhalese in place of the traditional mind-numbing beeps and alarms of our medical equipment. I was pleased to see protective screening over the open air hallways, to keep the children from tumbling two stories, and to keep out the birds. It was surprising to see the number of children waiting to be evaluated for possible admission. Nearly all the beds were full, and it seemed as though they were in the habit of converting previous storage closets, consultant lounges, and any available space into treatment areas. The need for even more space remains evident.

We were greeted by Dr. Jayantha, the department head, and were quickly incorporated into rounds. My incredible learning experience began the moment we arrived at the first patient. Rapid fire questions regarding minute details about pneumonia. "Inspect this X-ray, what do you see? What organisms cause the X-ray to appear this way? How do you know? Are you certain? Why is this child's pneumonia not caused by Klebsiella?" As the only visiting students on the ward, we were not spared! He is a fantastic educator and we were soaking in every piece of information. The ward was full of interesting cases. Kawasaki disease, meningitis, dengue fever, juvenile rheumatoid arthritis, osteogenesis imperfecta, just to name a few. About 25% of our patients that day were hospitalized due to new occurrences or relapses of nephrotic syndrome. Dr. Jayantha explained the incidence is very high here, mostly caused by minimal change in his younger patients. He calls them his "nephrotics" and he holds a special renal clinic for these patients every Wednesday morning, which we attended. Collectively, we saw nearly 50 patients that Wednesday morning with some variation of this syndrome. He has spearheaded a study on his nephrotics over the past 15 years. It will certainly be an interesting read once his results are published.

Regretfully, Friday was our last day on the Peds ward. We were benefited from phenomenal teaching by a handful of consultants who were intent on actively involving their students during rounds. "Palpate this child's skull, Holly. What do you find?" "An open fontanelle sir," I responded. "Quickly, in your notebook, write down 3 reasons you may find an open fontanelle in children over the age of 18 months" he demanded. Apparently noting the oppressive heat in the ward, and the obvious sweat forming on my face, he continued, "Quickly, and then we will go snowboarding!" Snowboarding? "I'll take it," I said. "Too slow," was his response. Then he erupted in laughter, gave me a pat on the back and moved on to the next patient. This kind of rousing I was familiar with!                                     

The opportunity to go into the community and provide antenatal care, well child checks, and give immunizations was extended to us by Dr. de Silva in the Department of Community Health. We had been waiting for this! We boarded the bus with 20 medical students from the University of Ruhuna Faculty of Medicine and set out towards a primarily Muslim clinic in Gintota, about 10km from Galle. 10km came and went, then 20km, maybe 30km. There was much discussion between the bus driver, the spotter, and the instructor in charge of this outing. I didn't need to speak Sinhalese to understand that we were lost! When we finally made it to the road leading to the clinic, the bus was unable to fit, so we walked the final 2km. We walked through tiny villages, past small shops, and many people who hadn't seen many (or any) fair skinned, light haired women walk past their homes. They were curious, and came off of their porches to watch where our journey would end. It ended at a clinic at the top of a hill, which was closed! A cyclone had badly damaged the structure three weeks prior. We now had to make the trek back down the hill, into the Muslim town, where we were shuttled by a community doctor to the temporary location at a school. 35 moms-to-be and 35 children were seen that day. Although cramped in their temporary clinic, their system worked well.

We visited a Sinhalese clinic a different day this week, which strictly provided antenatal care. We found this to be just as efficiently run, with roughly 60 mothers receiving exams. I was amazed at how integral a role the midwife plays in prenatal care in the villages. She performs all exams, including albumin and blood sugar checks, fundal height measurements, and even listens for fetal heart sounds through a pinard stethoscope! A "pinard" is a cone shaped instrument made of wood, plastic or aluminum, with a second cone at the top through which you are to listen. The fundus and the baby's head are palpated, pressure is placed at the top of the fundus, and the pinard is placed approximately over the baby's left shoulder. The provider then places their ear on the top side of the pinard and listens closely (very closely) for fetal heart sounds. Warning: The aforementioned technique may read as an easy procedure; however, after being spoiled by dopplers and fetal ultrasound, this takes much practice and a well trained ear!

I read somewhere that Sri Lanka has been called the "gem" of the Indian Ocean. It is most definitely unique. The people, the food, the language, the landscape, the culture, all novelties to me. Every day is an adventure here, and I am cherishing every one.

Tracy Curtis
Duke University
Physician Assistant Student
Galle, Sri Lanka

After a long journey to the other side of the globe, I was finally in Sri Lanka. It was 1:00 am when I landed then I arrived at my lodging at 4:00am. I had 4 hours to sleep and be ready to work! When I woke up to monkeys howling and playing in the trees 20 feet away, I knew I would like this place.

I was excited and nervous to start my global health rotation at Karapitiya Teaching Hospital. Despite the fact that the University of Ruhuna Faculty of Medicine is conducted in English, there is still quite the language barrier with the Sri Lankan version of English and the amount of slang that we unknowingly use. Even the everyday medical language and abbreviations varies between the U.S. and Sri Lanka. I wasn't sure how this would pan out when I arrived on the medicine ward.

Three of us are here in Sri Lanka from the Duke Physician Assistant Program. Since Duke University and the University of Ruhuna Faculty of Medicine have an established relationship in medicine and research, many of the professors and researchers were very welcoming to us. We met with Professor Ariyananda, the Senior Professor of Medicine, and he was quite excited to bring us to Grand Rounds and introduce us to his faculty and fellow consultants before we got started the next day.

The next day, we began clinical activities on the women's internal medicine ward, where we spent the week. We met with the Senior Registrar (similar to our Chief Resident) and she hurried us to the first patient to begin morning rounds. It was definitely intimidating on the first day while rounding with their equivalent of residents and attending.

After a few days, I was able to understand how the ward works to admit patients, complete investigations and diagnostic assessments and carry out a treatment plan. There are many similarities, but a greater number of differences between the U.S. and the Sri Lankan inpatient wards. The overall appearance of the ward and staff, the admitting process itself, and the types of illness and their treatment protocols are notably unique.

When I first walked onto ward 11, I noticed there were more patients than beds, with some patients lining up with their belongings on the floor or with a make-shift mattress on the ground in the hallway. Some privacy is maintained with green curtain that can be drawn to a close, though this greatly reduces the air circulation and increases the already hot temperatures found on the ward.

Another distinct difference between the U.S. and Sri Lankan hospitals is the admitting process. Patients can only be admitted to a ward on Casualty Day. While casualty typically means trauma or catastrophic event, here in Karapitiya Hospital, it simply means acute care. Each ward has its own Casualty Day, rotating every 5 days, so on any given day there is at least one medicine ward holding a Casualty Day. It's quite obvious which ward is having their day because the hallway outside the ward is lined with sick people waiting their turn to speak to a House Officer (intern). Because Sri Lanka has a public health system, and Karapitiya is a public teaching hospital, patients are first seen at their local community health clinic or rural hospital and if their illness is deemed to be beyond the capabilities of the small hospital or clinic, they are referred to the teaching hospital. The patient brings their diagnosis card to the House Officer- a laminated square paper with their personal identification information, their chief complaint, lab work if done, and treatment to date. The House Officer is the first to speak to the patient; they do a complete history and determine if they need to be examined or treated outpatient. If they are in need of an exam, they proceed to the line for the single admitting bed where the Junior House Office and/or Senior Registrar (residents) examine the patient. They will determine whether the patient gets assigned a bed or follows up with outpatient treatment. Unless the patients’ illnesses warrants a longer stay, most patients are typically released to outpatient care after 4 days- just in time for the next Casualty Day.

When admitted to the hospital, patients must bring their own medical record, clothing, toiletries, pillow and blankets. The hospital only provides one pillow case and one blanket which are typically used to cover the bed. Visitors are only allowed between 1-5pm, though one person is allowed to stay at all times.


Needless to say, patients who get admitted here are very ill. We have seen many patients with Dengue and Typhoid fever, severe heart murmurs, and strokes. Many of these illnesses are quite advanced at the time of initial evaluation. There was one patient who had such a loud heart murmur that it took me a minute to realize that it was her mitral valve making all that noise and not her breath sounds! I've never heard such a loud, distinct murmur in my training. When I felt for her apical pulse, it was as though her heart was punching my hand through her ribs. Thankfully, the patients here are accustomed to medical learners examining and questioning them every day, so it was nothing new for me to listen and palpate myself. In fact, these patients have a crew of consultants, house officers, registrars, medical students and nurses rounding on them daily.

Another interesting difference that struck me was the absence of beeping monitors and other technology on the wards. Vitals are obtained manually at regular intervals and charted on a paper above the patient's bed. There were no oxygen tanks hooked up for the COPD patients, no controls to adjust the hospital bed for comfort and certainly no television sets. The physicians and students are heavily reliant upon their physical exam skills. It was impressive how well these physicians could hear breath and heart sounds with all the background noise and conversations amongst providers. I hope I will be able to acquire this same level of competency in my physical exam!

I can already tell that I will learn a great deal here in Sri Lanka, both culturally and medically. I'm grateful to have already seen so many tropical diseases that are rare or non-existent in my hometown. This will certainly prove beneficial for future international aid work. Also, learning about the public health system and adapting to the difference in technology will allow me to be a better global practitioner. In the next few weeks, my colleagues and I will also participate in pediatrics, OB/Gyn, community medicine and surgery. There will be many interesting patients and experiences to come!

Joseph Schlesinger
Resident
Kijabe, Kenya
Vanderbilt International Anesthesia

joe schlesinger blog 1

We arrived safely in Nairobi and stayed at the Mennonite Guest House.  The next morning we ate breakfast with missionaries from all over the world in different stages of their calling around Africa.  Kijabe’s reputation is well known and they wished as well as we were picked up and driven to Kijabe via a road that had terrible slums juxtaposed with sweeping views of the Rift Valley. 

We toured the hospital and got settled in our lodging for the month and got sign-out from the ICU as one of us was on-call the first night.  It took adjusting to drugs and equipment that were foreign to us.  All of the patients did well overnight leading into our first day in the operating rooms, or “theatres,” as they are called.

The staff comprises one MD anesthesiologist and in our case, two anesthesia residents, missionary and local surgeons, surgery residents, KRNA (the Kenyan version of a CRNA), and anesthesia students.  Patients present with late-stage disease, terrible trauma, and for obstetric emergencies without previous prenatal care.  One could take care of a neonate with a tracheoesophageal fistula followed by a patient after a road traffic accident followed by a C-section.  The steep learning curve of anesthesia is addressed with intense didactics combined with a sick and varied patient population.  The KRNAs and students do a great job.  However, there is not insignificant morbidity.

I had the pleasure to oversee a few operating rooms, help the KRNAs and students perfect there neuraxial anesthesia techniques, discuss pharmacology and physiology, and teach them approaches to regional anesthesia that they have not seen before.  The way they gather around and pay attention exhibiting their willingness to learn is refreshing.

After the first day, we brought two heavy suitcases of medical supplies to the anesthesia workroom as most of the equipment is donated.  It caused me to step back and realize the amount of equipment we use in America and how we take many things for granted at our institution.

Everyone at Kijabe has been extremely welcoming and the missionary spirit of providing excellent medical care in the midst of educating the local medical staff is encouraging for the future.  All of this paired with the beautiful land, delicious food and chai, and local wildlife seen on our weekend hikes prepare us for a busy week next week in the operating theatre.

By Sage P. Whitmore, M.D.
Vanderbilt University Medical Center: Emergency Medicine
Georgetown, Guyana

I had plenty of time to contemplate all that I had seen during 12 hours of travel back home from a medical mission trip to Georgetown, Guyana. I had just spent three weeks working in the Accident & Emergency (A&E) department at Georgetown Public Hospital and using my training as an Emergency Medicine resident in the United States to help teach new ER doctors core material such as EKG reading, airway management, and the approach to shortness of breath and chest pain. I had not realized when I arrived how much of my time would be dedicated to sitting in the metaphorical trenches and caring directly for patients coming to the A&E. I was prepared for a foreign experience in a distant land, but instead I found myself right in my element.

The minute-to-minute practice of medicine was in Georgetown was very similar to what I was used to; see as many patients as possible, gather all the information you can, make a decision—often instinctual—to admit a patient or treat them at home. One important difference, however, is that in the United States it is easy to get caught up in which hospital has a trauma center, who has immediate cardiac catheterization capabilities, and how long it might take to get a specialized MRI or exotic blood test; these distinctions do not exist in Georgetown, and as a physician I got back to basics. In medical school what we really learn is how to interact with and assess a patient; how to sit, what to ask and how to listen, where to push and prod, how to translate the patient’s presentation into terms of anatomy and disease process, and how to offer comfort. These remain the most useful tools in a physician’s arsenal and are the foundation of all medical care no matter how many elaborate adjunctive capabilities you have at your disposal. 

When a concerned mother presented her coughing infant for evaluation, rather than immediately ordering an expensive antibody test for respiratory viruses, I got to be a doctor. Does the patient look ill, or does she look like a normal baby who happens to be coughing? How long had she been sick, did she have a fever, did she have any prior medical problems? What do her lungs sound like? While I was thinking about the possibilities, I used the moment to reassure the mother how well her baby looked, and her look of relief reminded me why my job can be so gratifying. Ultimately the baby checked out fine, required no testing, and the decision to discharge her was as practical as it was scientific—her mother was reliable, lived nearby, and would return if the situation worsened. In this case, practicing medicine meant relieving anxiety and educating a family member, at the cost of merely a few minutes of focused attention and interaction. 

One early morning, a young man was brought in by his family members for confusion and shortness of breath. Sitting in a wheelchair, he was having difficulty concentrating on my questions and panting as if he had just finished a marathon. Virtually any cause of confusion and shortness of breath can be diagnosed for the price of a couple CT scans, a blood gas analysis, full panel of labs, possibly a cardiology consult and stress test, maybe an ultrasound or MRI. If resources were unlimited, one could simply check all the boxes on an order sheet at home if so inclined. Instead, we started with the basics—looking and listening. This shortness of breath had not started suddenly. He had no pain. He was not blue from lack of oxygen. He looked very dehydrated. Despite his rapid rate of breathing, his lungs sounded clear and he was not sucking in at the ribs or working hard to breath through fluid or inflammation in the airways. In medical school we learned about “Kussmaul” respirations, a pattern of deep breathing meant to get rid of acids in the blood, usually from undiagnosed diabetes. We did have a glucose meter on hand, and it turned out his blood sugar was critically elevated, proving the diagnosis. The treatment is simple, and he improved over several hours with IV fluids and insulin. In this case, practicing medicine meant a thorough history and physical examination, and the cost of one glucose check and widely available basic medications.

In a blur of activity, orderlies whipped into the A&E with a woman found unconscious at home. She was limp, unresponsive, snoring and gurgling through her oral secretions. In this situation, protecting the patient’s airway with a breathing tube is essential to prevent secretions from draining into the lungs and getting infected. There is no fancy test required, but getting the tube in place can be difficult and can require specialized equipment. At my home institution, a cutting edge machine with a fiberoptic camera at the tip and a high definition screen can be used to look around the patient’s tongue and place the breathing tube through the vocal cords. In this A&E we had one basic device, and with it the resident was having difficulty passing the tube as the patient’s oxygen dropped lower and lower. Even in this extreme case, going back to the basics proved life saving. As we learn in our airway courses, what saves lives initially is not placing a breathing tube, but rather simply ventilating the patient with a bag and a facemask, by holding the jaw just so. Employing this technique brought the patient’s oxygen back up and gave us time to change the patient’s position, the size of the breathing tube, the height and angle of the bed, and optimize the conditions for the procedure. When the situation had calmed down, we took a slow, deliberate look for the vocal cords and passed the tube successfully.

I came away from these clinical scenarios with a new appreciation for basic medicine. In the era of whole body CT scans, unlimited lab analysis, and myriad medical gadgets, the fall back is always our own eyes, ears, and hands. Forming a therapeutic bond with a patient, asking the right questions, searching for the right clues, combining instinct and basic life support skills, and caring for patients with compassion are principals that know no borders. 

By Sage P. Whitmore, M.D.
Vanderbilt University Medical Center: Emergency Medicine
Georgetown, Guyana

As I was packing for my first international medical trip to Guyana, South America, my wandering mind conjured image after image of third-world medicine based on popular notions and dramatic stories I have heard over the years. I imagined a row of soiled cots where emaciated children without IV access spent their final hours. I pictured a sweltering tent full of tuberculosis patients collectively coughing up blood; or a bathroom-sized emergency department packed with fever-stricken, jaundiced, indigenous peoples dying of AIDS, malaria, and other ailments while overwhelmed healthcare workers looked the other way out of emotional self-preservation because they had nothing to offer. As described to me by some physicians who had been there in recent years, some of these were features specific to the hospital I was heading to in the capital city of Georgetown.

I am delighted to tell you how antiquated and cynical my preconceived notions had been.

On my very first day in the Accident and Emergency Department (A&E), my first patient did not have AIDS or malaria or tuberculosis; he had hypertension and diabetes, and came in for chest pain. I have seen this exact patient many times in my own tertiary hospital in the States! I caught myself thinking perhaps my view of international medicine was a bit narrow. But, I thought, we probably wouldn’t have the equipment to diagnose him, and even then certainly we would have no treatment to offer. Wrong again. A junior resident from the brand new graduate training program in Emergency Medicine appeared beside me and handed me an EKG. “Inferior wall MI (heart attack). He’s gotten fluids, aspirin, oxygen, and morphine. Holding the nitro. We’re waiting for his portable chest x-ray so we can start heparin, and the admitting team is on their way down to evaluate him for streptokinase (clot busting medication).” Incredible! His care was nearly equivalent to that in thousands of small hospitals across the United States.

My very next patient was brought in on a gurney in full cardiac arrest for unknown reasons. Far from looking the other way, a team of three physicians including myself and four nurses started CPR, provided oxygen and ventilation, established two IVs, started fluids, checked his blood sugar, attached a cardiac monitor, gave epinephrine and sodium bicarbonate, and attempted defibrillation before finally pronouncing him dead. This was fully consistent with my own training.

Time and time again, I was surprised and humbled by the world-class care being delivered in this developing nation, from the availability of a neurosurgery consultation for head trauma, to blood cultures and antibiotics for septic shock, to the text book intubation of a comatose stroke patient (there was an available ventilator in the ICU), to the use of an “asthma room” for wheezing asthmatics receiving inhaled medications, oral steroids, and intravenous magnesium just like we would do back home. To be sure, this is not always the case, and there are countless places in the developing world with no medical resources at all, but the quality of care delivered in this public hospital in one of the poorest western nations is remarkable. I believe this is a great example of the success and power of international health efforts.

In Georgetown, an American team of Emergency Medicine residents and faculty, of which I am a member, are staying in a compound called Project Dawn, an international collaboration which houses teams of physicians and healthcare workers from the United States, Canada, Scotland, India, and many other countries around the world year-round. Like ours, these teams spend intensive time in the city helping provide direct patient care, teaching at the bedside, and setting up infrastructure and training programs. This, combined with the ambition of the local physicians who have trained in Guyana as well as places like Canada, the US, Cuba, India, and Europe, is a recipe for excellent patient care.

I am particularly proud of my home institution, Vanderbilt University and its Department of Emergency Medicine, and our involvement here. Within the last few years, we have had the privilege of assisting the Georgetown Public Hospital Corporation create a self-sufficient Emergency Medicine residency program to train new classes of emergency physicians who are specially trained in resuscitation and acute care of a wide variety of problems, from cardiac arrest to broken bones to childbirth to infections and trauma. As we’ve seen in the US, this training benefits patients by relieving the surgeons and family practitioners who typically cover emergency rooms but may not be well versed in the care of medical problems outside their usual scope of practice.

As my American colleagues and I led a didactic conference last week with the new residents, I witnessed with awe the geographical boundaries and disparities of health care dissolve. Together we interpreted the mysterious subtleties of EKGs, discussed strategies for resuscitation of shock, airway management, differentiating types of bleeds around the brain on CT scan. The local residents brought their own real-life cases for a conference, calling on each other to think though work-up and treatment of various life-threatening conditions. These residents would be as at home in our conference room in Tennessee as we are in theirs.

The far-reaching positive impact of international health efforts are all around me, and it is truly remarkable. Of course, none of this is possible without the enthusiasm and dedication of a well-educated and well-trained Guyanese health care force. I feel very honored to be part of something so inspirational, and I urge readers to continue to support international health efforts, as the gains from these investments are tangible and quite amazing to behold.

Matt Landman
Resident
Kijabe, Kenya
Vanderbilt International Anesthesia

matt landman and erik

(Photo: Matt Hansen and Kenyan Colleague)

I've probably done more than 30 appendectomies so far during my general surgical residency. For all the times I've taken care of someone with appendicitis, rarely, if ever, has the thought that they might die from the illness crossed my mind.  Indeed, some of these patients were quite sick; but once they presented to medical attention, we could get them through their illness.  Many of these patients were young which help in their recovery. 

My first week in Kenya changed my history with this nearly ubiquitous American surgical disease.  We took care of a 20 year old male who presented to an outside facility with appendicitis of about two weeks duration.  While he didn't have a CT scan to review, I'm sure his appendix was perforated.  He, appropriately, underwent an open appendectomy by these physicians. Unfortunately, he required another operation shortly thereafter necessitating resection of the right side of his colon (the part of the colon to which the appendix is attached).   He was discharged from that hospital and presented to Kijabe Hospital with stool leaking from his wound.  The connection of his intestine had completely broken down, likely result of weeks of malnutrition and intra-abdominal infection.  We performed additional operations to resect the damaged colon but the insult was too great.  He died during my second weekend in Kijabe. 

There I was, presented with a 20 year old, previously healthy man who died of an illness I’d not ever known in my short professional career to be fatal (although I think it's important to note that there is still a generation of American surgeons who certainly understand death secondary to appendicitis).  Admittedly, appendicitis is much less common in Kenya, but nevertheless, his death was a tangible reminder to me of how the lack of medical resources and access to healthcare can truly affect patient outcomes.   I’m not sure what kept this young man from presenting to medical attention sooner, it was probably a combination of lack of financial resources, poor access to care and cultural limitations, but had he presented earlier, he would have likely survived.

This, and other, experiences in Kijabe changed my view of global health.  It’s so much more than just doing operations or treating patients in a hospital or clinic.  Where the real efforts are being made and continue to be made is in creating a system in which patients get open access and timely care for both acute and chronic disease.  Surely, as long as there is poverty, this will be difficult.   However, if healthcare professionals of the caliber I interacted with in Kijabe continue to commit time and resources to a needy people, the outlook continues to look bright.   

 

An Impatient Optimist

Dec 01 2011

An Impatient Optimist's View of HIV
by SENATOR WILLIAM H FRIST MD

Impatient Optimists: The Bill and Melinda Gates Foundation
 
In 1981, I was a surgeon in training at Massachusetts General Hospital in Boston. I still remember the day we learned about a strange, new, deadly infection that presented on the West Coast. A little over a year later, we learned it was caused by a virus transmitted in the blood, a vital fact for a doctor performing surgery every day.

As I watched the epidemic grow from a handful of cases to a few hundred to several million, I also witnessed the cases grow in biblical proportions in less developed nations, namely across Africa. While I served in the Senate, I volunteered on annual mission trips to do surgery in villages ravaged by civil war. In these forgotten corners of the world, I witnessed how HIV was hollowing out societies.

Drawing on these firsthand experiences, as the Senate Majority Leader I encouraged and supported both the PEPFAR program and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

The Global Fund, a multilateral institution with the U.S. as the leading contributor, leverages $2 for every single dollar given, all to combat this trilogy of diseases that disproportionately attack children and young adults in the poorest nations on the planet.

The remarkable news is that millions of lives have been saved by these investments. Thanks to the Global Fund, over 3.2 million people living with HIV are on lifesaving treatment.

I am proud to have been part of a government whose leadership, acting on behalf of the American people, has led the world and literally saved the lives of millions of people globally.  

In 2008, I co-chaired the ONE Campaign’s ONE Vote ’08 Campaign. We brought a delegation of Republicans and Democrats to Rwanda to see firsthand the good work being done by the funding of the Global Fund, PEPFAR, and the President’s Malaria Initiative.

In Eastern Rwanda we visited the inspiring Rwinkwavu Clinic, run by Dr. Paul Farmer’s Partners in Health. With 110 beds and eight health centers, this clinic provides essential medicines, supplies, and equipment and recruits, trains, and retains staff to ensure a sustainable infrastructure for the future.

But without Global Fund funding, the Rwinkwavu Clinic could not provide health care services to the people of Rwanda. This is true for so many organizations and clinics worldwide.

And it’s unfortunate that even though we see investments pay off, lives saved, and economies grow, the Global Fund was forced to cancel its round 11 funding. This means clinics like Rwinkawvu will only be able to support those currently on HIV treatment and not add any new patients. This is alarming because in low-income countries half of people living with HIV are not receiving treatment.

At a time when our own economy is faltering, and our national debt is growing unacceptably, we have to tighten our belts. To do so, we need to decide where we make smart investments and where we do not.

The fact is that the American people spend less than one-quarter of 1% of our federal budget on global health and fighting global epidemics like HIV, tuberculosis, and malaria. With this little sliver of the pie, the Global Fund’s return on investment means more sustainable economies, less global instability, and healthier families. For less than a penny to the dollar spent on all foreign aid, we are investing in the lives of children, mothers, and our own national security.

On the horizon is excellent news for HIV. New evidence suggests male circumcision, microbicides, and quicker AIDS treatment will markedly decrease the disease. Combined with known prevention methods like condoms and nevirapine, we are on the right track to substantially halt the growth of HIV/AIDS.

I’m an optimist, an impatient optimist. We will win the war on HIV, tuberculosis, and malaria.  Our investments have worked. The end is in sight. We just have to be smart enough to continue to invest wisely, using health as a currency for peace around the world.

Matt Landman
Resident
Kijabe, Kenya
Vanderbilt International Surgery

matt landman kijabe 1

(Photo: Matt Landman at left)

It’s now been one full week since my arrival in Kijabe, Kenya.  Simply speaking, to understand everything I’ve seen and experienced in the past week will take months of careful thought and reflection.   I’ve seen the shackling consequences of poverty, the natural history of surgical disease more advanced than I’d ever seen before, a lack of medical resources, and the list goes on; but, overshadowing all of this, I’ve seen the good several committed people can do at one place in time to positively affect patients and their families for a lifetime. 

My first full day in the hospital was spent in the general surgery clinic.  I use the description “general surgery” but in reality, if forced to label it back at my home institution in the U.S. it would be better described as the general surgery - urologic surgery- otolaryngology -surgical oncology -endocrine surgery -thoracic surgery –vascular surgery-wound care-palliative care clinic. 

I never imagined a more unique conglomeration of surgical diseases coming through the door in a single day.  While the pathology was interesting (and inspiring to hit the books to expand my surgical knowledge) I was most struck by what each procedure meant for the patient—particularly the financial toll.  Instead of flashing an insurance card and putting down a small copayment, each patient (and many times their family) was required to produce a down payment for the recommended procedure.  If they required a cholecystectomy it would be x-amount of Kenyan shillings.  If they required a colonoscopy it would be y-shillings.  Quite foreign to me (and most in the US) was the readily available price tag, if you will, for each procedure (I should note that the payment system was different for emergency cases).  That price tag allowed me to clearly see the financial sacrifice, relatively extreme in some cases, made by patients and their families to improve (or simply maintain) their health. 

I often wonder what would happen to Americans if we were put in a similar situation.  Would we still spend most of our healthcare dollars at the end of life?  Would we be doing radical resections with small chances of cure?  Would emergency rooms still be overcrowded?  What would I give up in order to pay for me or my family’s medical care?  While I’m not sure of the answers, I know that many Americans, as I’ve seen these Kenyans do countless times this week, would step back and evaluate their priorities and healthcare need. 

The knowledge of these costs has another effect.  Physicians are forced to understand their healthcare consumption.   I certainly have been more cognizant here of what each laboratory test, imaging procedure or recommended operation would mean for my patients and have tapered my practice and recommendations to be cost-conscious while maintaining medical effectiveness.   Seeing the results of our operations and care here, I’m confronted with excellent results that don’t necessarily correspond to the amount spent on each case. 

It’s been a week and I’ve learned quite a bit, both medically and professionally.  I look forward to the coming weeks for more experiences in which I can look back and evaluate my role in this place and in surgery as a whole globally and in the U.S.

 

by Allison Greening

Vanderbilt International Anesthesia

Kibaje, Kenya

anesthesia

I arrived in Kijabe, Kenya with two other senior anesthesia residents from Vanderbilt midday Sat Oct 29th, after departing Nashville Thursday Oct 27th, flying overnight to London, and then all day to Nairobi. We spent the night in the Mennonite Guest House in Nairobi, where we met several missionaries coming and going to and from various parts of east Africa, and then were driven up to Kijabe the next morning.

We had been scheduled to travel Monday Oct 24th, but were delayed with security concerns due to the Kenyan army invading Somalia in response to recent kidnappings in northern Kenya, and threats of Al-Shabaab retaliation in Nairobi for a few days. Effectively this means we’ve missed a week, but three weeks are better than none! One of the first things we noticed about the place is its utopian feel. Justin, one of the other residents, referred to it as a “summer camp” feel.  It seems funny to think of any sort of terror attack happening here, in an idyllic small town mostly made up of missionaries who either work at the hospital or international school, but evidently someone has thought of it, as it’s surprisingly secure.

We spent the weekend getting settled in, and then started in the operating rooms on Monday. I have an interest in pediatric anesthesia, so have been running the pediatric room, though my compadres have been doing lots of regional anesthesia with the new ultrasound donated to the hospital recently from Vanderbilt and Dr. Randy Malchow. (1st photo) We’ve also been involved in a couple of airway cases, using the brand new glidescope, all of which has drawn quite an audience! (2nd photo below) I’ve done some amazing pediatric cases; the two that stand out the most were an open thoracotomy to repair a patent ductus arteriosus (PDA) in a 15 kg, 7 year old boy who was an achondroplastic dwarf, and a debridement of a severe, 48 hour old burn to the face of a 3year old boy. 

jace perkerson

The first case was a pretty big deal, basically minor heart surgery in a third world country, and I was the experienced one in the room, with both a Kenyan nurse anesthetist and a Kenyan nurse anesthetist student helping. A few aspects of the case amazed me, especially how well we did with so much less than we do in the states, and even more so, how well the boy did after having such a major, and painful, surgery. Kenyans are tough!

The burn case was very memorable as well, and also good teaching for the nurse anesthetist and student. The boy also happened to have muscular dystrophy, which presented its own anesthetic challenges, on top of those unique to burns, such as not being able to use certain drugs, and potentially having trouble breathing for the patient after putting him to sleep. The burn patient, like the PDA patient, looked great the next day. There’s even quite a lot to be learned from a fairly basic case like we did today, when just a few minor speed bumps along the way became important teaching points! I should be clear though, that I am not the only one doing the teaching!! I have learned quite a bit, and already in the first week had experiences that will rival any that I’ll get during my pediatric anesthesia fellowship next year!

 

Subscribe to our newsletter to recieve the latest updates.