by Emma Apatu
ETSU College of Public Health
American Samoa

Photo: Dr. Aga, (preceptor; Emma Apatu, Kasie Richards (East Tennessee State DrPH candidate); Aufa'i Areta, Associate Director/Acting Extension Program Coordinator)

Talofa (greetings)!  I arrived in American Samoa almost a week ago, and have fallen in love with the Samoan culture.  I have found the people to be very friendly, the fresh foods are delicious, and the oceanic and mountainous views to be postcard worthy.

 I have also been fascinated by the beauty of the traditional Samoan garb.   It is very common to find men wearing Lava Lavas which is a cloth like wrap skirt, and the women to be clad in beautifully printed dresses complimented by a flower in their hair.

 As I witness the beauty of this island, I have also taken note of the obesity problem.   It baffles me to see people of an island that has a plethora of nutritious food to have one of the world’s highest obesity rates.

The World Health Organization attributes American Samoan’s obesity problem on the fact that a great number of the people have stopped eating traditional foods and have adapted diets rich in processed foods.  A few days ago, I talked to some of the local people, and they also agree that a great part of the obesity problem is due to poor diet choices. 

Today I met with my field experience preceptors Dr. Aga and Aufa'I  Areta, at the American Samoan community college.  The meeting today was very productive and Kasie and I will meet with Dr. Aga and Aufa’I Areta who is the Associate Director/Acting Extension Program Coordinator later this week to finalize the scope of our community based Food and Nutrition project. 

by Shannon Langston
Department of Emergency Medicine
Vanderbilt Medical Center
Georgetown, Guyana

It usually comes to me in a super market, sometimes Wal-Mart.  This time, it was in a Chili’s restaurant in Miami International Airport.  I was returning from 6 weeks in Guyana and the bustling airport led me to seek refuge in a restaurant.  The burger I ordered, with a thick slab of bacon, nearly overcame me with emotion.  It wasn’t that it was such an incredible burger. It was my reflection, the contrast, of the place I often take for granted and the place I was returning from.   The excess we have become accustomed to.  Something so simple as a good burger is not obtainable everywhere.  Many things aren’t. 

The Emergency Department at GPHC, Georgetown Public Hospital Corporation, the country’s tertiary care facility, is busy.  It sees about 70,000 patients per year.  The House Officers and Residents work tirelessly to sort the truly ill from the baseline chronic disease present in the population.  I spent the majority of my time consulting on patients, standing at the bedside, and teaching the Emergency Medicine Residents and House Staff alike on the care of acute and chronic illness.  Often, as I went through the differential diagnosis of the patient, I would realize, we might never discover the exact cause of the patient’s illness.  Many of the diagnostic tests so easy to obtain here, are simply not available.  Blood cultures, to determine the infectious bacteria of a septic patient, aren’t easy to obtain.  A CT scan of the head, often ordered to excess in the US, is expensive for the population of Guyana, sometimes costing a months salary for a test that may be negative or have little impact on a patients’ subsequent care. Cardiac enzymes, used to diagnose heart attacks, aren’t readily available.  And, even if they were, neither is a catheterization lab.  I had to ask myself often where to draw the line between teaching good care and teaching appropriate care. 

The patients presenting to the emergency department in Guyana are often complex.  In addition to the ills that face patients in the US, tropical disease such as Malaria, Dengue, and Typhoid are present, complicating the clinical picture.  One child in particular nearly died from something so simple as touching a caterpillar, the most toxic known.  TB was a common complaint and is seen daily at GPHC, often in advanced stages.  At times it seemed as if the taxi drivers are actually aiming for the children as they make their way to school, so common is their appearance in the trauma bay with broken bones and head injuries.  Those injured in the interior, the jungle, often have to endure many hours over rough inland roads, or a choppy river, to reach the hospital.  I was often surprised by their survival and endurance of what must be agony, only to be gracious for the care provided.  Those intubated in the emergency department are ventilated by hand until a ventilator can be found in the ICU, sometimes hours later.  The nurses often take turns ventilating with few complaints. 

As I choked down my burger, I thought back to the infant with meningitis, gasping for air.  There was no spinal needle for children that would allow a lumbar puncture.   Despite aggressive treatment and antibiotics, the baby succumbed, as did another a few days later.  I recalled the young lady that presented with mild confusion and fevers.  In a matter of a few hours she was unresponsive with a dangerously low blood pressure.  I spent hours at her beside with the residents, struggling to keep her alive, without the rapid tests that would give me the cause.  One resident intubated and another started a central line.  Fluids, antibiotics, and multiple drips were started.   A lumbar puncture and an ultrasound were performed.  We wracked our brains to discover the missing piece of information that would keep her alive, a diagnosis that fit.  Her husband, whom I kept updated, was brought into the room.  I told him she was gravely ill, and would not likely survive.  I encouraged him to talk to her and say anything he wanted.  He whispered into her ear and kissed her on her cheek before walking away, sobbing.  Our efforts were not enough.  She died a short time later. 

Despite the challenges and material limitations, the physicians are eager to learn.  Suggestions to improve care are readily embraced by residents and management and solutions are sought to overcome an often challenging work environment.  In my short time there, through the work of many people, I was able to secure a readily available supply of much needed blood for trauma patients.  A resident is now teaching the calculated administration of vasopressors to other interns and sharing new knowledge to improve patient care for the local population.  By saving patients that would have died just a few years ago, they are learning to be hopeful as they provide compassionate care.   These things, it seems, are available everywhere

by Shannon Langston
Department of Emergency Medicine
Vanderbilt Medical Center
Georgetown, Guyana

She was only six years old.  She had somehow fallen from a height, landing on her head…unfortunately on concrete.  It’s always concrete here.  Her father told me she had been knocked unconscious immediately and she had not spoken since she fell.  She had not vomited, but she also had not moved since the fall. 

My residents and I performed a physical exam on the girl based on the “ABCDE” pneumonic I had been reinforcing:  Airway, Breathing, Circulation, Disability, and Exposure.  It is designed to simplify the assessment of trauma victims and to ensure that examinations are performed that same, every time, by every person.  The theory is that if you do something the same way every time, there is less of a chance that you will miss something important. 

Her airway was intact and she was breathing, and her blood pressure was just slightly elevated.  Unfortunately, she was still unconscious and I could not get her to respond with movement, even to painful stimulation.  A careful head to toe examination revealed only a large lump on the back of her head.  Her pupils were slowly reactive and equal, but she stared blankly, not bothering to blink or look away as I shined the light in her eyes.  The residents started IV’s and prepared airway equipment should it become necessary, riding with her across the street to the CT scanner, a relatively new diagnostic modality in Guyana. 

The images showed an epidural hematoma.  Essentially, it is a big blood clot pressing against her brain.  It was dangerously close to damaging structures essential for life.  Luckily, her spine was not injured in the fall.  Although there is no formally trained neurosurgeon at Georgetown Public Hospital, a general surgeon has taken on the task.  Mentored by a Canadian Neurosurgeon that works in Guyana for a few weeks a year, he has learned the basics of brain surgery.  When he has questions, he will send photos of the patient, and CT scan, over his cellular phone to the neurosurgeon for guidance.   He has had great success, although he often wishes for others to bounce his ideas off of or someone to help him refine his technique in shunt placement. 

This small girl had a serious injury, and none of us were sure she would have a good outcome.  The surgeon took her immediately to the operating room and relieved the pressure growing inside her head.  He placed a small drain for the blood to evacuate and transferred her to the pediatrics ward, a large open room with multiple beds and cribs.  Within several hours she opened her eyes and started to moan. 

I checked on her for the next three days hoping to see her up and smiling, perhaps talking.  Her family stayed at her bedside, hoping along with me.  Unfortunately she would only lie there, sometimes moaning in discomfort, other times appearing to sleep.  The fourth day I went in and noticed she was missing.  I feared the worst.  The nurses informed me that she had been discharged.  She had been talking and playful since the day before and the drain had been removed from her head.   I was fortunate enough that my student had taken the time to get a photograph of her prior to her discharge.  It shows her standing in her bed (with rails up), smiling at the camera. 

That a general surgeon would take it upon himself to be the neurosurgeon for those in need, without a formal residency, is a demonstration of the kindness and ingenuity of the Guyanese.  

by Shannon Langston, MD
Department of Emergency Medicine
Vanderbilt Medical Center
Georgetown, Guyana

Physiologically, people are essentially the same no matter where you go.  Yet, when I first arrived in Guyana, I was surprised at how quickly death came for many.  Infections, head injuries, road accidents, malaria…they all take their toll.  There is no fanfare, drama, or ceremony.  The body is covered and taken away and another patient placed in the bed.  Relatives grieve, but they don't seem surprised.  It is as if the boundaries between life and death are much narrower.  Life seems much more fragile. 

So used to medical technology and medications, the gulf between the living and dead seems large from an American viewpoint.  We take for granted the public safety campaigns that protect the majority of our children from threats ranging from lead poisoning to traffic hazards.  Things we assume are intrinsic knowledge are often due to the foresight and hard work of others.  Critical care units, advanced chemotherapy drugs, nearly unlimited blood supplies, dialysis, we could not imagine not having them at our disposal if ever needed.  Yet, much of the world has no access to these modalities.  Often, in remote villages, people have access only to the most basic of medicines while their contact with nature puts them at increased risk for injury and disease. 

In my short time in Guyana I have seen several people die from snakebites, something I had never before witnessed.  Most of them come from the remote interior region.  They call the deadly snake Labaria, we know it as the Fer-de-lance.  It is well known in Guyana and feared by most people, including myself.  Although effective antivenin for the snakebite is made, it is not always effective or available at the public hospital.  Recently, a young boy came into the hospital complaining of bleeding.  Any place on his body that had a small scrape started to ooze blood.  Nurses had to refrain from drawing blood as it took hours to stop the bleeding from the puncture.  Even his gums were bleeding. He told me that he was stung by a worm, a black hairy worm, that he touched by accident. 

He showed me little red spots on his hand that had mostly faded from view, spots he claimed were caused by touching the worm.   The physicians, myself included, all assumed it was a baby Labaria bite, since he came from the interior where the bites are common. The boy insisted, ”It was a worm.”  Once admitted, they treated the boy with plasma and vitamin K in an effort to stem the bleeding.  A pathologist, interested in the case, did some research.  Sure enough, there is a caterpillar, mostly found in Brazil, that is known to have one of the most potent toxins known to man.  Simply brushing against the caterpillar is enough to cause bleeding and death.  When I questioned the boy’s mother, she recalled a neighbor that died of something similar the previous year after touching an insect.  Being rare in Guyana, and being present for only three months per year in caterpillar form before it turns into a moth, most people are not aware to be cautious of the deadly caterpillar.  It lurks, unassuming, on a tree branch. 

The boy was given fifteen units of fresh frozen plasma (at my last count) and some vitamin K, which eventually stopped the bleeding.  Thanks to an interested pathologist, aggressive care, and a good dose of luck, the boy was saved.  Living in a place where the odds can be stacked against you, something so beautiful as a caterpillar can be deadly.