by Orville Bignall, MD

Meharry Medical College

Georgetown, Guyana

I am sorry it has taken me this long to post again; the work here in Guyana is so great, and keeps me busy and exhausted. I’ll try to do better this week.

Today, I’ll share a bit about my hospital. Georgetown Public Hospital Corporation (GPHC) is the primary referral center for the country of Guyana. The “Accident and Emergency” Department treats roughly 75,000 patients a year. In a country with a total of only about 750,000 people, that’s roughly 10% of the nation’s population. To get an idea of what that’s like, imagine if one emergency room in the United States saw 30 million patients a year!

georgetown hospital

Unfortunately, the hospital lacks many resources US hospitals take for granted. Patient beds lack basic heart monitors, and IV lines do not have automated pumps to tell the staff how much medicine is being given to their patients. Lab results that would take minutes to obtain in the US take hours or days here. Even the blood bank can be critically low, sometimes having fewer than a dozen units of blood for the entire hospital!

georgetown male medical ward

As is often the case in resource limited settings – including in America – the lack of high-tech equipment, fancy tests, and expensive medicines means that the doctors here are skilled at diagnosing disease by relying on their brain and not a computer. The physicians at GPHC are some of the smartest I’ve ever met! Here I learn to think outside of the box to deliver the best care possible. I’ve learned to not only appreciate the luxuries I have as a doctor in America, but I’m acquiring the creativity and brilliance necessary to take care of all my patients, no matter the situation.

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.  

Mother-and-child health challenges persist globally

The Tennessean

This Mother's Day, moms in Tennessee and around the world have more to celebrate than ever before. Infant mortality rates are declining in many communities and many countries. Yet even today, where a woman gives birth determines dramatically different odds of survival for her child. We can, and must, change that.

A baby in Shelby County has a 1 in 77 chance of dying before her first birthday. In some of our rural counties, 1 in 45 babies die. Those frightening rates are on par with Sri Lanka and Mongolia, respectively.

Overall, the U.S. child mortality rate is worse than in 40 other countries. It's one of the main reasons Save the Children ranks our nation 31 out of 43 developed countries on the Mothers' Index of its new State of the World's Mothers report.

Within the United States, Tennessee has long had one of the worst infant mortality rates. But our state's effort to change that is paying off. We've moved up from 46th to 41st in the latest national comparison on child health. That's good news, but I'm sure you'll agree, it isn't nearly good enough.

Even in tough times, state programs making a difference — including Healthy Start, which makes home visits possible for new moms in rural areas — must be protected if we are to improve the health of moms and kids across the state. Healthy kids lead more fulfilling and productive lives. They create jobs and grow economies.

Children's programs face possible federal cuts

Together,we must speak up for mothers everywhere. Federal programs that have helped reduce global child mortality by a third in the last 20 years are in danger of major cuts.

Worldwide, 8 million children still die each year, mostly from preventable causes. Imagine if diarrhea or pneumonia became a death sentence for your child. This is a daily risk for millions of mothers with no access to trained health workers or the most basic, inexpensive medicines. In Afghanistan, one in seven infants dies.

Why should Tennesseans worry about this when we have our own challenges right here at home? First, it's not an either-or proposition. We should save every child's life when we know how to do it inexpensively and so well. It doesn't take much more than political will to give a child a real shot as a long, fulfilling life,

And it's more than that. When we save children's lives abroad, we help countries develop and give them hope. And when we do that, we help create the conditions for growth and prosperity.

That relates directly to Tennessee, where 44 of our 46 export industries are growing and our state benefits from nearly $26 billion in exports every year. U.S. economic growth increasingly depends on growing markets in developing countries. We are living in a world that is increasingly interconnected. Simply put, by helping mothers and their children everywhere, we help ourselves.

So, as we celebrate this day for mothers, let's make a bold commitment to improve the lives of mothers and children in communities across the globe.

Bill Frist, a heart surgeon, served Tennessee in the U.S. Senate from 1995 to 2007. He is co-chairman of Save the Children's newborn and child survival campaign.

Bipartisan agreement on mothers

By Bill Frist and Jon Corzine - 05/04/11 02:22 PM ET

Political gridlock aside, this is a time of year when Democrats and Republicans can remember one important thing we all have in common: none of us would be here without our mothers. But the truth is, many of us might not be here today if our moms hadn’t had access to basic care during pregnancy, delivery and afterward.

As we honor our moms on Sunday, let’s honor motherhood itself by giving all moms the gift they want most — the chance to deliver and raise healthy children. Worldwide we lose about 1,000 mothers and more than 22,000 children under the age of 5 every day, a daily death toll on par with the recent Japanese disaster repeated day after day. But we can act now to save tomorrow’s mothers and children.

The United States has a long, proud and bipartisan history of leadership in the fight to save children’s lives. We must stay the course.

American researchers pioneered simple solutions that led to a remarkable decline in child mortality worldwide: life-saving vaccines, oral rehydration solutions to treat diarrhea, vitamin A supplements and zinc to fight malnutrition and disease. Much of this was accomplished with generous funding from the U.S. government.

Between 1990 and 2009, the United States worked with developed and developing country partners to reduce the global number of under-5 deaths by more than one-third, from 12.4 million per year to 8.1 million. For years it was unthinkable that our country would abdicate its leadership in this realm.

Polls have consistently shown that more than 90 percent of Americans believe saving children should be a national priority. Congress and administrations since the early 1980s have responded, funding the U.S. Agency for International Development and others to advance the reach of medical breakthroughs and reduce child mortality rates in the world’s poorest countries.

Today, some of our former colleagues in Congress suggest that development assistance is irrelevant to national security, and as a result, foreign aid is ripe for cuts. But they should listen to those who know firsthand the threats we face.

Drawing on his recent experience leading the U.S. Counterinsurgency Training Center in Afghanistan, retired Army Col. John Agoglia says: “It’s difficult to build a stable democracy when health, education and opportunity indicators for women and children are at such low levels. Our policymakers must remember: an investment in people that improves their chances to survive and progress is an investment in our national security.”

Former Xerox CEO Anne Mulcahy is also speaking out. “Let’s make no mistake,” she says, “investing in women and children abroad is an investment in our own economic future.” She notes that U.S. corporations increasingly rely on developing countries for new-income growth, and points out that many of the world’s largest importers of U.S. goods and services were once recipients of U.S. assistance.

Mulcahy and Agoglia are among the prominent individuals and everyday citizens pressing for continued U.S. investment in women and children in Save the Children’s latest “State of the World’s Mothers” report. The report also discusses particularly effective solutions that may surprise you. For instance, a cadre of community-based health workers, given just six weeks of training and a few basic tools, can reduce child mortality by 24 percent or more.

As countries like Malawi and Nepal have shown, U.S. assistance can help empower some of the world’s poorest nations to deliver a child survival success story through strategic choices that deliver the greatest returns with limited resources.

It’s difficult to find much that politicians can agree on these days, but saving the life of a child is surely a goal we can all support. Mother’s Day is no time to deny moms the most meaningful gift of all: the survival of their children.

Bill Frist, M.D., is a former Senate majority leader. Jon Corzine is a former senator and governor of New Jersey. They are co-chairmen of the Save the Children’s Newborn and Child Survival Campaign.

 

Source:
http://thehill.com/blogs/congress-blog/healthcare/159265-bipartisan-agreement-on-mothers

by Raynard Jackson

Whenever the U.S. government enters into a state of fiscal austerity, politicians always look for budget cuts from programs they deem to be less important or have little or no constituency. Foreign policy budgets, especially those directed towards Africa seem to always show up near the top of that list.

The left will blame it on the "mean" Republicans who don't care about Africa. The truth is that Africa seems to benefit more from Republican control of Congress/White House than from Democratic control. Isn't it amazing that former President George W. Bush did more for Africa than any president in the history of the U.S.? But, yet, he gets little or no credit for his policies towards Africa.

It was the Bush administration that first labeled what was going on in the Sudan as genocide (made by then Secretary of State, Colin Powell before the Senate Foreign Relations Committee). Bush played a critical role in helping to end the civil war in the Sudan.

Under the Bush administration, development aid to Africa quadrupled from $ 1.3 billion in 2001 to more than $ 5 billion in 2008. The Millennium Challenge Corporation (MCC) was created by Bush. Africa has received in excess of $ 3.5 billion from the fund so far. The MCC was established to reward poor countries that encouraged economic growth, good governance, and social services for its citizens.

The Africa Growth and Opportunity Act (AGOA) was created in 2000 and expanded under Bush in 2004. The bill provides trade benefits with the U.S. for 40 African countries that have implemented reforms in their countries to encourage economic growth.

The President's Emergency Plan for AIDS Relief (PEPFAR) was created by Bush and had $ 15 billion appropriated over five years (2003-2008). I find it amazing that the program has been cut by the Obama administration (though Obama pledged to increase it by $ 1 billion annually during his presidential campaign).

Along with PEPFAR, Bush established the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (or the Global AIDS Act) established the State Department Office of the Global AIDS Coordinator to oversee all international AIDS funding and programming

Bush's policies are credited with saving the lives of millions of Africans.

The political right would argue that America just can't afford to continue some of these programs. They don't question the merits of the programs, just the financial ability of the U.S. to continue to fund them.

I put the blame for this type of myopic thinking on two groups. The first is U.S. supporters of these programs (this includes, politicians, faith based groups, American citizens, etc.). America must do a better job in explaining why and how these programs impact the U.S. If we don't spend the money on the front end (for prevention), we will spend the money on the back end (for treatment, humanitarian intervention, nation building, etc.).

I would put most of the responsibility on the second group

How many African diplomats can pick up the phone right now and get Congressman Chris Smith (at home, on his cell, or in his office)? Smith represents New Jersey's 4th congressional district and is one of the biggest supporters of Africa that most people have never heard of. He also happens to be a member of the House's Committee on Foreign Affairs and chairs the Subcommittee on Africa, Global Health, and Human Rights.

African diplomats constantly complain about what the U.S. is not doing for them or their country's interests. They hire high powered lobbyist who have little ability to translate their needs into a language that is understood in the political arena. They rarely engage the American people as to why their country is important to the U.S and why they should care. They have no media strategy, no advocate within the halls of the U.S. Congress, and they lack the "friends in high places."

Africans must understand that it is important to engage the American people whether there is a crisis going on in their country or not; whether there is an adverse policy percolating through Congress or not.

The new Congress convened in January and there are many new members in both the House and the Senate who are new to their respective African committees. African diplomats have made little, if any, effort to establish relations with these new members beyond any perfunctory meet and greet.

There will most definitely be across the board budget cuts for the foreseeable future. How deep they are relative to Africa will depend on how well the African diplomatic community communicates their country's importance to the American people and relevant members of both the House and the Senate.

Based on my private conversations with members of Congress, the White House, members of civil society, and NGOs, Africa doesn't make the cut in terms of understanding how to make things happen in the U.S.

Raynard Jackson is president & CEO of Raynard Jackson & Associates, LLC., a D.C.-public relations/government affairs firm. He is also a contributing editor for ExcellStyle Magazine (www.excellstyle.com <http://www.excellstyle.com> ) & U.S. Africa Magazine (www.usafricaonline.com). —African heads of state and their designated U.S. ambassadors! African leaders and their ambassadors show very little understanding of how to get things done through our political process here in Washington, DC. Most African ambassadors have no relations with relevant members of Congress on the African committees of the U.S. Senate and House of Representatives.

Touchdown in Guyana

Apr 20 2011

by Orville Bignall, MD
Meharry Medical College
Georgetown, Guyana

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...

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

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.

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

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.

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

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.

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