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.  

orville bignall operating

This is my first post. I want this journal to be exciting, insightful, and encouraging. Most of all, I want to share the resilient spirit of these families, and encourage you to help better the lives of children around the block and around the world. 

Located on the north coast of South America, Guyana is the only anglophone ("primarily English-speaking") nation on the continent. 83,000 square miles large, only 750,000 people call it home, making Guyana one of the most sparsely populated countries in the western hemisphere. It also has some of the largest, undisturbed tropical rain forests anywhere on earth! The infrastructure is very underdeveloped: power outages are not uncommon, many roads are in disrepair, telecommunications are unreliable, and tapwater is not always safe to drink. The people, however, are some of the most welcoming and kindhearted folks I've ever met; I've been treated well and respected everywhere I go.

I'm stationed at the Georgetown Public Hospital Corporation, the largest health center in the country. If you want to know what it's like, imagine a hospital in the United States... 40 years ago! Large open wards with patients, limited medical supplies and medications, and unreliable air conditioning. I have seen several dramatic traumas, and I've been put to good use so far!

Make no mistake about it: I miss my parents, my sister, Ebony, my friends and my Riverside family intensely! It helps that my mom has been checking in with me faithfully each morning to pray with and for me before I leave for the hospital (Skype = WINNING)! I have so appreciated the prayers and steadfast support of my family; the encouraging Facebook, Skype, and email messages of my friends; and even the unexpected monetary gifts of my church family! I am already "more than a conqueror" (Romans 8:37).

I'm experiencing answers to your prayers daily, so please, keep the prayers, notes, and encouraging words coming! I'll write again soon...

langston surgery pic

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.

badger kijabe 2

As my brief time at Kijabe hospital has come to an end, I'm amazed at all that I have been able to experience over the past 4 weeks. I wasn't sure what to expect when I arrived, but I found a resourceful medical center in a beautiful rural town, full of hardworking, enthusiastic and selfless individuals, with the primary goal of providing the best possible health care to the people of East Africa. The hospital is short on funding, resources and supplies when compared to American standards, but the incredible work they are able to accomplish with the little that they have is truly remarkable.

Kijabe hospital runs 8 very busy operating rooms, where tireless surgeons, nurses, and anesthetists work endlessly to care for a vast array of patients with very complicated surgical problems. The OR's are staffed by a mix of foreign missionaries and locally trained African surgeons, with a number of surgical residents who are being trained by these individuals to provide high quality surgical care for remote corners of the country. The hospital has an innovative anesthetist-training program where nurses come from all over the country to train in the provision of anesthesia. When they are finished, they are expected to return to their home community and deliver a safe anesthetic – often being the only anesthesia provider in the area.

Much of my work at Kijabe Hospital was in educating and training the group of anesthetists – from giving morning lectures to instructing and supervising in the OR. Every Tuesday and Thursday we held continuing medical education conferences where we would discuss how to manage important medical conditions in patients undergoing anesthesia. Topics included common conditions such as diabetes, renal failure, liver failure, pre-eclampsia, and many others. These lectures were very rewarding in that the anesthetists would quickly and enthusiastically put into practice what they were learning. I was impressed by the deep fund of knowledge that they had obtained through the quality education provided at Kijabe hospital – not only do they work hard, but they also study very hard and are well prepared to care for sick patients.

I also spent time working in the intensive care unit, a five-bed unit reserved for the five sickest patients in the hospital. Most of them had very complicated medical issues and were on circulatory and ventilatory support, and were a challenge to care for. It was a rewarding experience to work with and teach the interns, student anesthetists and nurses in the unit – hopefully they are better prepared to care for critically ill patients.

Kijabe hospital is truly an amazing place. What it lacks in resources it more than makes up for with dedicated, hardworking, charismatic individuals who, despite their own challenges in life, are tirelessly caring for the ill and less fortunate among them. I am incredibly lucky to have been able to spend time with these wonderful people and will never forget my experience. I am a better physician and a better human being for having spent time at Kijabe Hospital.

by Senator Bill Frist, M.D.

If you are a health professional, what can you do to influence global health? How can you get involved in health care around the world? What does health diplomacy mean?

This short video serves as an introduction to a lecture on health diplomacy and global health for those who currently serve in medicine in the United States. We invite you to watch and let us know what you think.

bechtel and patient

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.

cook baby E

These last two weeks at Kijabe I've been working on the pediatric service. I've worked on a fabulous team in pediatrics. My main "partner in crime" is a Kenyan clinical officer who loves kids and has a tremendous fund of knowledge and experience. Between the two of us, we see all the patients every morning in preparation for team rounds, write their daily notes and orders, and see outpatient pediatric consultations and admit patients in the afternoon. Everyday we go on rounds with a short-term family practice volunteer doctor from the US with years of experience, and a brilliant Kenyan pediatrician who trained at the top national hospital in Kenya.

Although I didn't spend much time in the nursery, I also interact with the nursery team: an amazing American pediatrician who has spent the last 15 years working in rural Uganda and a pediatric resident from India with an incredible bedside manner. We round with a nutritionist or a nutrition intern who not only provide great plans in how to get our babies gaining weight, but also spend a lot of time with families, often informally serving as ad hoc social workers/counselors. One of the best aspects about working at Kijabe has been the diversity and richness of the people I get to work with and learn from everyday.

I've had an amazing range of patients from the "bread-and-butter" babies with bronchiolitis and viral gastroenteritis that are fairly easy to admit and care for, to some really sick little babies with multiple serious medical problems and some surgical conditions I may not see twice in my lifetime. These are the ones that you really get to know and worry about. One in particular is Baby E. He's a 7 month old baby who came to the hospital about a week before I started on pediatrics in a coma, severely dehydrated and really sick. My first day, he had just transferred back to our pediatric ward from the ICU and his condition was still tenuous. Baby E is Massai, one of the most traditional people groups in Kenya; his family lives in fairly remote part of Kenya and eeks out a living through raising cows. I cannot even begin to imagine what it is like for his mother to be in the hospital, a day's travel away from her 8 other children for 3 weeks, she definitely had her moments of discouragement, but at the same time she displayed incredible graciousness and generosity to me as her "baby's doctor."

One morning when I came to examine Baby E she said, "I want to give you a Massai blessing," reached out her hand and gently slid a vibrant beaded Massai bracelet onto mine. Baby E was still in the hospital when I left and to be honest, I don't know his long-term prognosis, he has devastating neurologic sequelae. We were very honest with his family about the extent of the damage and that we did not know how much he would recover in the long-term. I internally struggled in caring for baby E with the tension between providing the standard of care for this individual patient and taking into account the tremendous financial and social burden on this family, especially when the ultimate outcome was so uncertain. By advocating that baby E stays in the hospital to get the oxygen and nutrition support to give him the best possible chance of recovery, what am I doing to the 8 other children this family has at home? Their mother is not with them to care for them or feed them and they are accumulating a hospital bill that is possibly even more than a year of this family's average income. These are impossible dilemmas and it was easy to become discouraged. At the same time, I had to keep reminding myself that despite the hardship for the family he is my patient and my greatest obligation is to do what is best for him.

My final afternoon at the hospital I had a glimmer of hope for baby E. I saw a three year old girl in the outpatient pediatric clinic who had been severely ill at 5 months of age with tremendous neurologic damage but who was now not only still living, but was thriving; she had some muscle weakness on one side of her body but she was a happy, playful three-year old . I hope and pray that this will be true for baby E.

Despite the numerous challenges in the US health care system and the fact that I have taken care of many patients in America without insurance and with tremendous needs, my time in Kenya has been the time of greatest personal awareness (and anguish) of the limited resources of my individual patients and the impact on their care. I have learned good lessons about being creative and ways to reduce waste; I have also had more personal heartache over my patient's dilemmas that I hope will shape the contributions to individual and population level care I have in the future.

Senator Bill Frist, M.D. is board member of the Kaiser Family Foundation.

The Kaiser Family Foundation has released a collection of new resources examining global health and HIV/AIDS funding in the Obama Administration’s budget plan for fiscal year 2012.

On global health, a new fact sheet breaks down the $9.8 billion in the budget request for the Administration’s Global Health Initiative (GHI), a proposed six-year, $63 billion effort to develop a comprehensive U.S. government strategy for global health. The fact sheet reviews proposed funding for the initiative, including breakouts by program area (HIV/AIDS, malaria, etc.) and by agency, including trend data where available.  It also examines support for the President’s Emergency Plan for AIDS Relief (PEPFAR).  The Foundation also has updated its Global Health Budget Tracker to reflect the President’s proposed fiscal year 2012 budget; the tracker will be updated to reflect changes as Congress considers and acts on global health appropriations.

A second fact sheet examines the $28.3 billion in proposed funding for HIV/AIDS programs both within the U.S. and overseas.   On the domestic side, the fact sheet breaks out support for programs that provide health care, drugs and other services to people with HIV or AIDS, as well as prevention and research funding.  The global budget examines spending for HIV/AIDS through bi-lateral and multi-lateral efforts.

In addition, the Foundation has updated the relevant Kaiser Slides charts to reflect the President’s budget proposal.  The charts can be downloaded for use in presentations or slide decks.

The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible information and analysis on health issues.

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.

badger kenyaLate 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.

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