Truck

My first day with the Cinterandes Foundation we left for a trip to Palmer.  The large truck with an operating room in the back had left the day before and we traveled in a small vehicle.  This trip was my first time out of the Andes since my arrival a month earlier.  We drove the Cajas National park where llamas run down the middle of the highway and alpine lakes dot the landscape before we began the decent; the humidity and heat increasing and the vegetation changing from alpine to tropical with every turn of the road.  The houses also changed from concrete Spanish houses to wood houses on stilts with hammocks on the porches.  

 Palmer is a small pueblo of less than 2000 people on the Pacific Ocean and most of the people there are considered very poor by Ecuadorian standards.  There is a public health clinic run by a German born nurse who finds cases appropriate for these trips and pre-screens the patients so that when we arrived all that was to be done was review lab results, EKGs, and perform quick physical exams.  

 Two patients were turned away because of fever and one because of irregular heart rate.  The patients need to be carefully selected so that there are minimal complications with recovery because the PACU consists of cots in the clinic and the team leaves at the end of the week.  Dr. Rodas calls all patients to insure that they are recovering well, but this system works best when there are minimal complications.  Sometimes the surgeons travel with a family physician who sees patients while they operate.  However on this trip the team included Dr. Rodas and Dr. Sacoto, two well experienced surgeons.  

 Dr. Rodas founded Cinterandes because he felt that Ecuadorian doctors could help their population just as traveling Americans could.  He was inspired by the ship Hope and trained in the US but was born and raised in Ecuador.  Dr. Sacoto, the other surgeon is the dean of a medical school in Cuenca.  During the ride to Palmer he and I had a long conversation about evidence based medicine and the pedagogy of medicine.  There was also Dr. Anita the anesthesiologist and executive director of the organization.  Her role on the trip made me think about anesthesia in a whole new way.  She not only anesthetized patients from 5-76 years old and with everything from local nerve blocks to general anesthesia but also serves as an extra set of unsterilized hands in surgery helping with everything from preparing the patient (cleaning) to helping set up the laparoscopic equipment.  

 In Ecuador anesthesiologists are at a premium.  Dr. Cruz, the pediatrician I worked with in Riobamba is trained as a surgeon but works as a generalist because there is no anesthesiologist at the children’s hospital.  While working with the ob/gyn and head of the department in the public hospital in Riobamba, we had to wait two hours for an anesthesiologist to arrive so that he could operate. In addition, Dr. Anita is involved in primary care, coordinating rural rotations for medical students.  

 The final physician was Dr. Valasco who, like many physicians in Ecuador, is working as a physician before residency and after his year of rural service. He serves as the scrub tech but also does much of the pre- and post-operative care.  

 Like the physicians, the two other staff members had multiple jobs.  Freddy knows where absolutely everything is on the tightly packed truck and throughout all the surgeries the doctors often shouted, “Freeeeeedy” and he would appear from nowhere and supply the necessary item.

 The final members of the team were us 6 American medical students (there are usually also Ecuadorian students but they had final exams). We assisted in all surgeries and helped with pre- and post-operative care.  

 There seems to be 2 purposes to these trips.  First and foremost, the foundation truly believes that it is far more humane to provide surgeries, for carefully selected patients, close to their homes so that they are spared the expense of travel and the trauma of time away from their families.  Many of our patients needed these surgeries and would not have received them without this foundation.

 But students, both foreign and Ecuadorian, also play a role.  Not only do we bring labor, supplies, and funds to the organization, but the team of doctors all clearly enjoy teaching and explicitly encourage students to learn how to provide humanitarian medicine (for example instructing us on how to tie knots so as to spare suture).  It is a symbiotic relationship in which the students gain important skills and the team gains extra hands to help with the work.

 The surgeries performed were hernia repairs, lipoma removals (lipomas are benign tumors that can be disfiguring and painful), and lots of cholystestectomies.  Cholystestectomies are common here, not only because of the frequent occurrence of gallbladder disease, but also because gastric cancer is common here (more common than colon cancer in the Andean region).  In fact, endoscopy of stomachs rather then colons are the preventative tests of choice here and choystestectomies for symptomatic patients are considered part of prevention.  

 We worked for 3 days operating from 8 in the morning until long after dark and then rounding on patients recuperating in the clinic.  Many of surgeries were laproscopic and, save for the fact that the drapes and gowns are cotton rather then disposable paper and the conversations being in Spanish, you would never know you were outside the U.S., let alone in the back of a truck.

 It was a privilege to work with physicians helping their own people in this unique and creative way.  The Cinterandes team is traveling to the Sudan this year to help establish a similar truck there.  Hopefully the idea will catch on because it is a great way to utilize urban specialists to help poor rural populations without the need for expensive infrastructure development.

Truck 2RPfaff op room 3

Whenever I’ve heard people reflect about their international medical experiences (especially among my colleagues who have worked here in Guyana), there tends to be a few common themes that emerge. There are statements about the gratitude of the local population, and their resilience in the face of adversity in nearly every aspect of their lives. They discuss the lack of resources available; how the hospitals/clinics can lack the most basic of amenities (gloves, bandages, water), or how few and far between medical practitioners are located. Universally, people say the experiences have changed them at their core; they now have a greater appreciation for the resources/opportunities available back in the US, and will continue to work to improve the plight of those less fortunate.

Looking back upon my experiences here in Guyana, my colleagues could not have been more right. Despite significant influence from first world nations, life in Guyana is hard and often unforgiving. Conditions that seem routine back home can often prove fatal down here, and both the medical providers and patients are well aware of this fact. This doesn’t stop either of them, however, from fighting as hard as they can, and utilizing their resources as fully as possible. I feel blessed to have had many opportunities to help care for patients here, and the experience has without question pushed me to higher places as both a physician and a person.

Above all else, my time here in Guyana has left me motivated to come back and do more. The potential that exists amongst the medical community, especially in Emergency Medicine, is quite palpable, and there seems to be a feeling that the tipping point can soon be reached. Once that happens, it could ripple through the rest of Guyanese society and hopefully produce successes and advancements that might have once seemed impossible. Of course, it’s not a guarantee, and many obstacles need to be dealt with. However, there is genuine hope, and that’s often the most important first step. 

Sometimes the most difficult parts of a job produce the situations you learn the most from. Often doctors will remember their most challenging patients for the rest of their lives and rarely forget what they’ve learned through those interactions. Working at Georgetown public hospital has afforded me a wealth of opportunities such as these in my short time here. 

Near the end of a shift one day I saw a patient with chest pain, a thin, uncomfortable-appearing woman in her 50’s. When asked where her pain was she did the classic motion of waving her hand over her entire chest and abdomen, attempting to help me pinpoint where she was hurting. I started with x rays, an ecg and blood tests but unfortunately these would take quite a long time during this busy day. Hoping for faster results, I looked for the ultrasound machine to assist in my work up. After a long search and a battle to keep the battery on, we had it at the bedside. Looking at her heart, lungs, kidneys, liver, and great vessels with the ultrasound machine gave me a wealth of information. I could see she had fluid around her heart and one of her lungs. That provided me a clear start that ended up guiding much of my treatment for her. Although getting the ultrasound, using the machine, interpreting the US (no Radiology to help interpret the scans) were all much more difficult than doing the same would have been in the United States, I can honestly say I learned even more from the process than I would have in my home institution. The difficulty in getting the machine caused me to use it as a precious resource, getting every possible use out of it that I could for that patient. Not having Radiology back up or easily obtainable diagnostic tests caused me to fully scrutinize every image, think outside the box, focus on physical exam clues, and tested my confidence in my own ability to obtain and interpret ultrasound findings. On top of all that, I got to teach a group of residents and nurses aspects and uses of ultrasound that they had never seen before. The experience highlighted learning opportunities I take for granted working in the United States and helped me develop my own diagnostic abilities.     

Andrew Pfeffer Pic 2

Whenever I’ve heard people reflect about their international medical experiences (especially amongst my colleagues who have worked here in Guyana), there tends to be a few common themes that emerge. There are statements about the gratitude of the local population, and their resilience in the face of adversity in nearly every aspect of their lives. They discuss the lack of resources available; how the hospitals/clinics can lack the most basic of amenities (gloves, bandages, water…), or how few and far between medical practitioners are located. Universally, people say the experiences have changed them at their core; they now have a greater appreciation for the resources/opportunities available back in the US, and will continue to work to improve the plight of those less fortunate. 

Looking back upon my experiences here in Guyana, my colleagues could not have been more right. Despite significant influence from 1st world nations, life in Guyana is hard and often unforgiving. Conditions that seem routine back home can often prove fatal down here, and both the medical providers and patients are well aware of this fact. This doesn’t stop either of them, however, from fighting as hard as they can, and utilizing their resources as fully as possible. I feel blessed to have had many opportunities to help care for patients here, and the experience has without question pushed me to higher places as both a physician and a person.

Above all else, my time here in Guyana has left me motivated to come back and do more. The potential that exists amongst the medical community, especially in Emergency Medicine, is quite palpable, and there seems to be a feeling that the tipping point can soon be reached. Once that happens, it could ripple through the rest of Guyanese society and hopefully produce successes and advancements that might have once seemed impossible. Of course, it’s not a guarantee, and many obstacles need to be dealt with. However, there is genuine hope, and that’s often the most important first step. 

One of the best things about healthcare delivery in Guyana is that it is nationalized.  Care is free and available to every citizen.  It is financed and managed through the Ministry of Health working together with regional and local government. There is an independent private sector.   However, despite a national health system, there are several gaps in the delivery of health care in Guyana.

Chronic diseases, such are hypertension, diabetes and heart disease, are becoming more prevalent in Guyana and currently there is not an infrastructure in place to help manage this growing problem.  Patients are presenting to the emergency department at advanced stages at which time there may not be great treatment options available.    Unfortunately the regional health center, which would ideally be the place for primary care, is not very equipped. There is usually just one physician available to staff a large local population and he/she may not be well trained to manage chronic disease.  The availability of equipment such as blood pressure cuffs, glucometers, monofilaments, debridement tools for diabetic ulcers are often in limited supply. Lab testing and monitoring are usually not available.  The idea of routine screening and preventative medicine is nonexistent.  Ancillary staff, if available, is also not well trained. 

While most patients living along the coast have access to some sort of health care, whether through regional health centers or the local emergency department, those who live in the interior have little to no access.  This is largely because of the sparse population and difficult terrain. The population comprises mostly of indigenous people and miners - in emergency situations, they travel for days to the capital to receive care.

In Guyana, there is very little support for persons with mental health disorders or substance abuse.  During my short time in Guyana, there were more than a handful of persons presenting with suicide attempt, often with paraquat, a freely available but deadly herbicide.  At a public health level, there needs to be better regulation of who has access to these poisons as this is an easily preventable cause of morbidity and mortality.   There is poor education about mental illness among the population as well as among providers.  If a patient survives a suicide attempt, he/she is discharged from the hospital without any resources or treatment to address with underlying mental illness.  Substance abuse, specifically alcohol, is never addressed.  Training providers as well as the development of a psychiatric unit or treatment center will be a small step to help address this growing problem. 

One of the largest challenges to health care delivery in Guyana is the lack of an integrated health information system.  Medical records are completely on paper and patients’ charts do not go with them throughout their contact with the medical field.  The medical record is not used to support decision making.  For example, if a patient presents to the ED with hypertensive emergency, a new chart is made up for the admission.  Even though the same patient presented a week prior with the same issue, the record is not automatically included and there is no way to use information about their previous treatment to guide treatment decisions now.  In addition, the contents that make up the medical record are sometimes sporadic and often incomplete.

There are many areas that need to be built up for the health care system in Guyana to become what it needs to be.  There needs to be programs in place for advance training of physicians and compensation and work plans that keep these well trained physicians interested in staying in Guyana. Local health centers need to become the first line for screening and management of chronic diseases.  Also, within the public health sector education programs need to be developed that teaches local population about disease, mental illness and a healthy lifestyle.

In Guyana, there appears to be a commitment by the government to improve the overall healthcare delivery system.  With the monetary support and partnership with many foreign agencies, Guyana is slowly on its way to delivering the care its people need.

 

by Bill Frist

The Week

America's national debt is ballooning at a worryingly rapid pace. But some programs ought to be spared the chopping block

POSTED ON APRIL 24, 2012, AT 7:10 AM

Government spending is about to get chopped — no matter who wins the next presidential election. President Obama and his GOP challenger Mitt Romney have both prioritized deficit reduction, which, of course, is a worthy goal. However, not all cuts are created equal. And many surveys put global health at the top of the list of things to slash. That's a mistake, and here's why.

1. Global health initiatives save lives abroad?Investments in global health pay off a lot more quickly and dramatically that you might think. PEPFAR, initiated by President George W. Bush and strongly embraced and expanded by Obama, was the largest direct investment any country has made in defeating a single virus (HIV) or disease. Our taxpayers' leadership has provided 7.2 million people with access to lifesaving, anti-retroviral therapy for HIV/AIDS, 8.6 million with treatment for tuberculosis, and more than 260 million — mostly kids — with anti-malarial resources. This U.S.-led historic initiative to prevent and fight disease has directly saved millions of lives, put kids back in school, and helped rescue entire societies from collapse over the past eight years. 

Saving lives and societies leads to better and stronger relationships for trade, enterprise, and foreign investments. It enables economic growth, democracy, accountability, and transparency in these countries. 

2. Global health initiatives protect U.S. families?Deadly microbes know no borders. They are just one plane ride away. HIV did not exist in the U.S. when I was a surgical trainee in 1981. But since then, it has killed more than 600,000 individuals here (and 25 million globally) and infects another 54,000 U.S. citizens each year. It arrived here from Haiti, migrating there from Africa.  

Imagine the devastation avoided if we had identified HIV and our National Institutes of Health had figured out how to treat the virus a decade before it arrived on our shores. Our current global surveillance and engagement system might have done just that.

3. Global health initiatives enhance national security?A hopeful people are a people who shun terrorism. And nothing destroys hope more than a society without a future, hollowed out by diseases that decimate middle-aged civil servants, police, doctors, and teachers. A bleak and nonproductive future for an individual sets the stage for societal discontent and chaos.

Our investments in public health reverse these tragedies, and fuel the smart power of health diplomacy. Kaiser Family Foundation surveys have repeatedly revealed that more than half the public thinks U.S. spending on health in developing countries is helpful for U.S. diplomacy (59 percent) and for improving America's image in the countries receiving aid (56 percent).

4. Global health initiatives are a bargain?Treating HIV costs a tenth of what it did a decade ago, and the costs continue to plummet. Globally, of the 8 million children under 5 years old who will die this year, half could be treated and cured with a low-cost intervention. Pneumonia, the number one killer of young children in the world, is easily treated for less than a dollar! And the No. 2 killer, diarrhea, can be prevented by increasing access to clean water. The price? For $20, we can provide clean water to a family for 20 years. For $14, we can fully vaccinate a child. 

5. Global health initiatives are simply the right thing to do?I was born in Nashville by the luck of the draw. It could just as well have been South Africa, where life expectancy is only 49 years. We are all the same. Lifting others up no matter where they live is part of what makes us American. It's what we do. Americans overwhelmingly say the U.S. should spend money on improving health for people in developing countries "because it's the right thing to do." Nearly half (46 percent) say this is the most important reason for the U.S. to invest in global health.

Yes, out of control entitlement spending and a deep recession have put everything on the chopping block. But let's be smart about where we cut and where we don't.

Dr. William H. Frist is a nationally acclaimed heart transplant surgeon, former U.S. Senate Majority Leader, the chairman of Hope Through Healing Hands and Tennessee SCORE, professor of surgery, and author of six books. Learn more about his work at BillFrist.com.

We are taught during medical training to be very cautious and to only proceed with decisions and procedures when we are well prepared. Putting in a breathing tube, for example, when a patient is having difficulty breathing or has lost consciousness, is a procedure that can be done with just a few simple pieces of equipment. But in an attempt to ensure success, we bring in advanced tools for back up, cameras to get a better look down the throat, smaller tubes in case the size we have chosen doesn’t fit. Once we are prepared for anything we are ready. But in many places around the world, including Georgetown Public Hospital in Guyana, those backups are simply not available.

In so many ways the Guyanese healthcare providers have used their limited resources not as an excuse to give up but as an education in how to efficiently and effectively work with what you have. Although the Accident and Emergency Department has less than 20 beds and staffs only a handful of nurses and doctors they are able to see over 70,000 patients a year, what would be a sizable number for any large tertiary care hospital in the United States. Hallways are lined with chairs for patients who are healthy enough to sit up and often patients walk themselves to the lab to have blood work done or x ray for their imaging. While working in the A&E one day I saw a 21 day old baby with a large infected abscess on his arm. The mother brought the child to my chair where I was doing initial evaluations, after seeing the infection we set the baby on a nearby stretcher, cleaned the area and sprayed it with an anesthetic, used a scalpel blade to drain the infection and wrapped the arm back up. We gave the infant some antibiotics and had them go back out into the waiting room until there was a bed available in the Nursery. Neither the staff working with me, nor the mother, was bothered by our inability to get blood cultures, the lack of a crib or incision and drainage kit, or the fact that they had to wait outside the A&E for a bed. Everyone was just glad this was a child we could clearly help, as opposed to the unfortunately numerous cases where the patients are too sick to turn around.

At times I would find myself frustrated by the lack of certain simple but effective drugs, easily available CT scanners or even ventilators. But then a coworker would teach me about how they have found older, cheaper drugs that works, they use x rays instead of CTs, and they ventilate the patients by hand. It’s not ideal but for the most part it works. It’s refreshing to watch the innovative ways resources are used and how nothing is wasted. Even in the sometimes harsh environment of Guyana the people have remained quickly adaptable to their changing world, generous, and extremely thankful, it is a fantastic privilege to work with them.  

Andrew Pfeffer Pic 1

Prior to my arrival, I had the opportunity to spend a considerable amount of time with one of the Guyanese EM residents as they visited Vanderbilt. In one of our various discussions, he brought up a fact that surprised me; the majority of Guyanese in the world do not reside in Guyana. Instead, they are scattered throughout North America, namely New York and Toronto. In his family for instance, only 10-20% remained in the nation, with the rest living in one of New York’s five boroughs. When I asked him if he would eventual join them in the US, he said no. His colleagues, however, had a much different approach.

After being here, I can understand why that sentiment exists. Guyana is a nation in flux. On one hand, it is quite modern; many people has cell phones, internet is widely available (I was in the middle of the rainforest and had WIFI), and the dissemination of information can occur rapidly and quickly (via Facebook, or other methods). Many of the excesses of our time are at the fingertips of a large portion of the population, especially in Georgetown. Unfortunately, it seems luxury has outpaced necessity, with the end-result being a palpable level of frustration. This is quite evident in the sphere of healthcare. The physicians here harbor much of the same knowledge and skills that we possess and they know what interventions are needed to treat the most complicated of medical or trauma patients. However, they have very limited resources in terms of pharmaceuticals, imaging, and surgical support to adequately treat the conditions they see. I’ve only been here a few days and I have often felt handcuffed, I couldn’t imagine how hard it is on the local staff to feel constrained to that degree all the time. When faced with the options of either staying home and going through the growing pains (which may take decades and is by no means guaranteed), or moving to a place (the US or Canada) that has already arrived and that boasts a seemingly thriving ‘local’ Guyanese community, the decision to stay can seem illogical. This is probably why many young, educated folks, especially doctors, leave, which in turn, only serves to delay progression further. It’s a detrimental dynamic. 

He says he’ll stay. Being a part of the construction of not just the specialty of Emergency Medicine, but of his nation, is something he cannot leave. It’s a brave stance to take, and I genuinely think the new residency program in Emergency Medicine will help him avoid succumbing to the temptation to leave. For me, I am honored to be able to help support this institution, even though it’s in a very minor way.

In the end, while it’s a baby step, it’s still a step, and they will eventually add up. 

Ifeoma - Hospital Visit

I paid a visit to the local hospital called Makelekele, the second largest hospital in Brazzaville where  I visited the different sections in the hospital and spoke with the staff. The hospital was a little crowded due to the explosion that occurred a few weeks ago. A number of people are still receiving treatment from the hospital.

My purpose for visiting the hospital was to gain a better understanding of the health status of the Congolese people especially as it regards tobacco-related diseases and view the state of their health facilities.  Following a tour of the hospital I chatted with the exceptionally nice staff and enjoyed an informative discussion the Medical Director of the Hospital, Dr. Loussambou. The Director explained to me that from their observation, the leading cause of morbidity was bronchitis and pneumonia while the leading cause of mortality was malaria and heart attack. He also explained the national strategy to combat malaria. When I inquired about the prevalence of cancer of the lung, he said that it was quite low.

My visit to the hospital opened my eyes to the sacrifices made by the medical personnel in the Brazzaville; they are able to do much with so little. The personnel seemed interested in their patient’s conditions and the well-being of other staff. They also did their work with so much joy such that it was infectious.

Finally, during the week, I completed my research paper on health workforce norms. I am also done with reviewing the monitoring and evaluation committee report. In the next final 2 weeks, I am looking forward to having the employee service event and putting finishing touches to my work.  Expect to see all the pictures from the event.

Georgetown, Guyana

All I can say is, I don’t know how they do it.   I have finished my time in A&E and have been on female medical ward for the last week and a half. The female medical ward is housed in a new facility that opened several months ago.  There are approximately 8 patients per room.  Patients have to bring their own sheets, clothes, toilet paper, water, and any other supplies that they might need.   There are many nurses and even more nursing students around, but I have yet to figure out exactly what they do.  Care by the nursing staff is haphazard at best.

It is so busy here!  There are two interns who take care of 60-80 patients at any given time and every 3rd day they do a 36 hour shift.  Rounds every morning are quite exhausting and interminable.  We either help the interns pre-round (this may involve checking vitals, starting IVs, updating orders) or we round with the sole internal medicine consultant (in the country!) during bedside teaching rounds.   There are about 20 medical students who attend these rounds and it is the only semi-structured teaching they receive during their internal medicine rotation. I spent some time going over a few cases with them and though they are eager and enthusiastic to learn medicine I worry about how they will develop the skill sets needed to identify and manage disease processes.

Unfortunately, because the wards are so busy and it is often only the interns around to manage patients, many things are missed or overlooked.  Labs take a long time to return and once they do show up may be forgotten until the next day on rounds.  A patient’s clinical status may deteriorate without anyone recognizing or alerting a physician of the change for hours.   There is a lot of death and, unfortunately, sometimes it seems all but inevitable.  

Despite all the obstacles present, the best part about being here is the patients I get to work with.  There is such a sense of gratitude and appreciation for the care that they receive and readily acceptance and trust even when things do not go quite right.  There is such strength and resilience in the human spirit.

Yesterday was the last day of the rotation and I spent part of the day in medical records going over a couple charts of patients that I had heard about or taken care of.   As I sat on the hard wooden bench, in the cloying sticky heat waiting for them to pull the records, I looked around and saw the tall shelves of recorded births and deaths at GPHC for the last 50 years.  It was particularly striking to me at that moment that somewhere amidst all of that paper, the record of my birth could be found.  Looking at GPHC currently, it is hard to imagine what it must have been like so many years ago.  Nonetheless, I feel like I have come full circle and I never could have predicted it.  I am grateful for the opportunity to be here and I look forward to creating opportunities to come back to teach, work and help build up the healthcare of Guyana.

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