By Brett Bechtel, MD
Department of Emergency Medicine
Vanderbilt University Medical Center 
Georgetown, Guyana

I have learned a lot from my time in Guyana. It is amazing to see how long patients will wait patiently to be seen. Crowded onto benches for hours just waiting their turn.

The "asthma room" as it is termed is one of my favorite areas of A&E. Patients magically appear there from the waiting room and are started on breathing treatments. All doctors have heard the term "all that wheezes is not asthma." So daily I would make my way through the group placed in the asthma room searching for the one who didn't have asthma but some other process. I found one elderly lady in heart failure and another baby who had a murmur and heart issue as well. Largely though the asthma room works as it gets those who need breathing treatments quickly the medicine they need. Teaching the residents at GPHC to be cautious about those other kind of wheezers was enjoyable and they will be on the lookout in the future as well.

Sadly I saw a few deaths this month including a few being pediatric. Death is much more accepted, as resources aren't as abundant here like they are in the US. I also saw some patients persevere and do well with diseases and ailments I would never have expected people to survive let alone be functional with. There is a saying here that "God is Guyanese." Essentially these people are looked after by a higher power. One man who was stabbed in the belly made it to the our A&E a full day after his wounds from deep inside the interior of Guyana after a trek through the jungle to a landing strip and then by plane to Georgetown. He remarkably ended up doing ok after surgery to his intestines.

The team working here is amazing. They all are very friendly and dedicated. We had young man come in shot in the abdomen one evening. We quickly had the whole staff helping to resuscitate and care for him. He was taken to the OR in record time but succumbed to his injuries as the bullet had hit the great vessels as well as the liver. He had the best chance to survive due to their quick action and the surgeons being ready as well. Unfortunately where he was shot he wouldn't have lived even at the best US trauma center either.

I did a grand rounds type talk to the Emergency Medicine residents, staff nurses and other doctors on one day. They don't have any Neurologists in the country and I saw many, many seizures of all sorts of etiologies. So after a week of seeing what they had to treat seizures and the kinds that were coming in. I lectured on strategies to manage the seizures using their pharmacological armamentarium. The power of course went out in the room I was lecturing in so it became more of a discussion and me using my computer and its battery as the projector wouldn't work. Overall though it was a great experience and the nurses and doctors were very interactive.

I also did lots of bedside teaching. Many of the doctors in the ED itself are relatively new and have just completed medical school training mostly in either Guyana or Cuba. They are eager to learn and fun to work with. They routinely stop me and ask questions about what I would do with different patient presentations. I would definitely like to return here some day.

by Rebecca Cook
Vanderbilt School of Medicine
Kijabe, Kenya

I've spent my first 2 weeks at Kijabe Hospital working on the internal medicine team of the men's ward. Inpatient medicine at a tertiary care hospital is a quite a change of pace from rural primary care at Lwala. We have more diagnostic and treatment abilities, but also "sicker" patients. The variety in what I've seen has been tremendous – everything from the "bread and butter" medicine cases I see in the US like COPD, CHF, and diabetes but also lots of infectious diseases (HIV/AIDS, TB infections in every manifestation (brain, lung, abdomen), meningitis). I've taken care of men as old as late 80s and as young as 15 (the cut-off for pediatrics here is 12). I work on a team with a medical officer intern (equivalent of an intern in the US), a clinical officer (equivalent of a nurse practicioner/physician's assistant), along with two family practitioners that come on attending rounds with us once a day and are there for "back-up" if we need it. Besides my amazing patients, my favorite thing about Kijabe is the people I work with. The medical intern and clinical officer on my team are really bright, hardworking, and compassionate Kenyan women; they have tons of experience, especially with physical diagnosis skills and they're a pleasure to work with. The hospital always seems to be at or above capacity, basically our 80-bed men's ward almost always has beds in the hallway. The wards are fairly public with 10 beds in a room. The advantage is that many times when I get stuck with language I have a built in interpreter in the bed next door, or if I'm trying to gauge the progress of one of my patients a brain infection and altered mental status, his neighbors will chime in and tell me how he's doing. They often times really look out for each other. Yet this "built-in" community does also bring the challenge of maintaining confidentiality and privacy for patients; for example when a patient is newly diagnosed with HIV, they often have not yet decided to disclose their infection to their family, much less the stranger in the bed next door.

A few firsts for me this month:

-Being the one to share with a previously healthy 51-year old police officer that he has advanced cancer, follow him and his wife through 10-days in the hospital while stabilizing him from acute kidney failure only to have him pass away while traveling to the national hospital for chemotherapy

-Performing my first lumbar puncture (and second, and third)

-Seeing my first case of rheumatoid lung, TB pericarditis, HIV cardiomyopathy, cryptococcal meningitis, thyrotoxicosis, among others....

Sometimes the limitations in terms of nursing staff, diagnostics, or therapies are frustrating. At the same time, I'm amazed by how much can be done, and how often patients and their families fill the gap in care. Once a week all of the hospital staff gather for a chapel service and I've found this time to be important. It's a time when titles don't matter, when the lab tech and a nursing student may be leading the singing, and we're all just there to renew strength and hope when we reach our own limits.

by Steve Badger, M.D.
Vanderbilt International Anesthesiology
Kijabe, Kenya

Late one evening about 4 months ago, Josephine, a 31 year old Kenyan female, was riding home from a long day of work on the back of a motorcycle. An oncoming vehicle swerved directly in front of her to pass another vehicle. As the motorcycle swerved to avoid a collision she was thrown to the ground, severely fracturing her right ankle. She was taken to the hospital, where she underwent surgical repair of the ankle. Following the operation, she continued to have pain and weakness, to the point that she could not bear weight and had to walk with a crutch. After a repeat evaluation, she was referred to Kijabe Hospital, in Kijabe, Kenya, for ankle fusion.

Kijabe hospital, a mission hospital located an hour northwest of the capital city Nairobi, has a vast number of medical missionaries from all over the world serving the residents of the area and training locals in the practice of medicine and surgery. One of these missionaries, Dr. Mark Newton, is the only full time anesthesiologist in the region, and runs a training program for Kenyan Registered Nurse Anesthetists. The hospital, which is one of the most respected mission hospitals in the country, relies on donations of time, financial support, and supplies in order to maintain an exceptionally high quality of care. One such donation came approximately one year ago, in the form of a state-of-the-art ultrasound machine used specifically for the practice of regional anesthesia (peripheral nerve blockade). Ultrasound guided regional anesthesia is an advancement that is relatively new in the United States, and unheard of in East Africa. Though the overall resources and supplies in Kijabe are slim, hundreds of patients have benefited from improved post-operative pain control with the practice of peripheral nerve blockade, which involves injecting local anesthetics around large nerves of the arms and legs causing a portion of the limb to become numb. A single injection can last 15-20 hours, during which time it can provide complete pain relief following a surgical procedure. When the local anesthetic effect subsides, patients begin taking intravenous or oral pain relievers to control their pain.

Josephine, as mentioned above, had a severely injured ankle and was to undergo a very painful surgical procedure. We were readily equipped to provide excellent pain relief for her for 15-20 hours with an ultrasound guided peripheral nerve block, but we knew that when the block wore off she would still be in severe pain. Luckily, some supplies had just been donated to the hospital by Dr. Randy Malchow from Vanderbilt University Medical Center, including some peripheral nerve catheters, which allow the anesthesiologist to leave a catheter near a nerve and either attach it to a pump for a continuous local anesthetic infusion or give repeat daily injections through it while the patient remains in the hospital. Peripheral nerve catheter placement is an advanced form of regional anesthesia - many medical centers and university hospitals in the U.S. have yet to develop such programs - but through generous donations even a remote hospital in Kijabe, Kenya has the ability to provide this service in special situations, such as Josephine's. The decision was made to place a popliteal sciatic nerve catheter, which was done just prior to her going to the operating room. She then underwent operative fusion of her ankle. Following surgery, her ankle was completely numb and she had no pain. She was smiling from ear to ear because she remembered having terrible pain after her previous surgery. The following morning, her ankle remained numb, and she continued to have no pain. She was surprised at how well the nerve block continued to work. Later that day, she began to feel the numbness subsiding, and started to feel some gradually increasing pain in her ankle. A second dose of local anesthetic was injected through the nerve catheter that was taped to her leg and her ankle again became numb, with her pain disappearing completely. The nerve catheter remained in for 3 days following surgery, during which time she recieved one daily dose of local anesthetic and remained very comfortable, always smiling and thanking us for helping her. When the catheter was removed on post-operative day 3 and the numbness resolved, her pain was only mild and was able to be controlled well with oral pain pills. She was extremely satisfied with her experience.

It is amazing to realize that medical advances have progressed to the point that patients are able to undergo normally very painful surgical procedures with only minimal pain. What is even more amazing is that through incredible generosity by so many individuals these advances are able to be shared with patients like Josephine, living in a remote location such as Kijabe, Kenya.