by Rebecca Cook

Vanderbilt School of Medicine

Lwala, Kenya

rebecca cook

One of the unique aspects of the model of Lwala Community Alliance, is that while there is a clinic, the program is multi-dimensional, there is also a strong water, sanitation, and hygiene program (WASH), a education initiative that partners with schools and helps to provide secondary school scholarships based on academic merit and need, Umama Salama, an initiative to train community members on basic lifesaving skills to reduce maternal and infant mortality, and a sewing cooperative. The clinic staff goes on school outreaches at local primary schools which includes health education and free preventive care.

I've had the chance to participate in the training-of trainers in the WASH program, wrote the malaria curriculum and have attended the roll-out trainings for the Umama Salama initiative, and have attended two school outreaches with the clinic staff. I've loved the opportunity to interact with individuals outside of the context of the formal clinic setting. Community members often have more candid discussions about community issues and health-related questions they have than they may when they visit as a patient. This week, I was at an Umama Salama (safe motherhood) training attended by men and women ranging from late high school to grandmothers, some were pregnant or with young kids, some were leaders in their community. One of the attendees came with some powerful persuasion from neighbors essentially because they wanted her to get medical care. They asked me to talk with her. She was cachectic with a rattling cough and became short-of-breath with talking. I learned that she'd been sick for months but had resisted going to the hospital for multiple reasons, including fear, stigma, as well as financial and family burdens. While we don't provide medical services at trainings, we were able to build enough trust to get her to come to clinic and overcome the practical barriers with the help of her friends mobilize a motorcycle ride to the health center since she was too weak to walk the 30 minutes. While this was happening, the training continued; participants first learn the lessons through verbal teaching and drawings, and then the messages are reinforced with role-play, which they really get into.

The community work at Lwala, both in terms of educating and empowering people to prevent disease as well as enabling them to be informed advocates who can capably identify illness and assist in bringing patients to appropriate care will ultimately have the greatest impact on the health of this community.

by Jeff Wagner, Coordinator - LWW Appalachian Field Operations

springfields water

Alberta and Clarence Stringfield; with Mike Skytta of LWW

You've probably heard of the plight of people living in developing countries and the struggles they go through to get water. Often they may have to walk six to ten miles to the closest water source and then back again carrying the full containers of water – some weighing 40 – 60 lbs.

Consider, if you will then, that there are communities in the US where water may only be a couple hundred yards away from your home – clean, safe water coursing through a water main and yet, you have no access to it.

That is the dilemma for many families in Appalachia – municipal water may be located 1000 feet away from their home but they simply cannot afford to access it. "How can they afford not to," you may wonder? Utility companies charge connection (tap-on) fees for residents to connect to the municipal water supply and often before the company will even consider running a pipe alongside the road, they must have a minimum number of families who will commit to connecting to the main.

Tap-on fees may exceed $700 if the resident can even have a water line run to the main. Depending on what is between the water main and the house – a road, culvert/ravine, solid bedrock, etc. the cost of accessing safe water can easily run into the thousands of dollars beyond the reach of many families.

Take for example, Alberta and Clarence, both in their 70's, on the same property near Wartburg since being married 55 years ago. They live just outside the water district that serves their area In Morgan County, TN and between their home and the road where a water line would be run if the water district had funds to lay one is a river. The cost of connecting to the water line would exceed their financial resources so for the past few years Alberta and Clarence have carried drinking water in to their house, done laundry in the small creek near their house and have otherwise had to make do as the water in their well had become unusable long ago.

Through a generous grant from Hope through Healing Hands and the efforts of Living waters for the World mission teams from West Emory Presbyterian Church and First Presbyterian Church of Cookeville, that changed recently. The two churches, installed a clean water system at Clarence and Alberta's home to treat the bacteriological contamination found in their well – now they have water that is safe for drinking, cooking bathing and washing – what a blessing it is to know there are people actively working to bring safe, clean water to people who lack access to it – no matter where they live.


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

Georgetown Public Hospital Corporation (GPHC), is the central hospital for the country’s public health system. The A&E (Accident and Emergency) functions as the essentially Level 1 Trauma Center and the Emergency Department for the country. Referrals come in from all over the country from outlying health clinics and hospitals if more specialized care is needed. Georgetown is also the population center of the country and so most patients arrive to be seen first here with acute complaints. There are multiple clinics ranging from diabetic foot clinic to eye clinic to pediatric and surgery clinic that see and refer patient to the A&E for admission or further treatment as well.
The A&E has about 15 beds in addition to multiple treatment chairs and an asthma room.  It is divided into a trauma and medical section just like many US EDs. It’s air-conditioned and there aren’t any mosquitoes so it makes for a comfortable work environment. Crowds fill the waiting room and along the outside wall waiting patiently for their names to be called. Attendants carrying stretchers haul unconscious patients with hypoglycemia, seizures or bad trauma right in to a bed past the less acute crowd waiting to be seen. Multiple doctors sit at desks seeing the “non urgent” triaged complaints as other doctors tend to the sicker patients who are “urgent” and in a bed. When ready for the next patient, the doctor rings a bell and calls for staff to bring back the next patient. It all seems to flow nicely.
The pathology is diverse - everything from malaria to acute myocardial infarctions. In just a few hours I had seen array of trauma like femur fracture, 60% burns, mandible fracture. Medical issues like rigid abdomen with free air under the diaphragm, typhoid, multiple asthma patients and pediatric patient complaints.
The sea of patients in the waiting room seems endless, but sometime during the evening it beings to thin out. The medical officers keep moving patients through. Sick ones get reviewed by medicine or surgery and are admitted. Most are discharged to home with clinic follow up and maybe a prescription for a medication. A visit to A&E is free and so are the prescriptions written by the MDs, the variety of medications is limited, but there is a drug for most everything. Only pregnancy tests and CT scans cost money, the rest of the work up is covered.
The staff are very friendly and welcoming. Many MDs have trained in Cuba. A few of the hospital surgeons have been to Canada for extra training in their specific trade.
Off to a good start. Am enjoying doing bedside teaching and reviewing cases with the general medical officers and the residents in the Emergency Medicine program here. More to come on some specific cases.

by Rebecca Cook
Vanderbilt School of Medicine
Lwala, Kenya

lwala cook

One of the most heart-rending patients I saw was young man with HIV/AIDS. He had initially presented to the clinic on 12/10 with advanced disease (for the medical folks his CD4 count was 3) and was started on antiretroviral therapy (HAART). He came back to clinic in January dehydrated with diarrhea, some fairly advanced skin ulcers, cough and fever. I remember the morning he arrived he was laying outside the clinic on a mat an hour before opening, I could tell from a distance that he was incredibly emaciated, I went over to make sure he was okay, and this man, despite his illness gave me the sweetest smile. He continued to have such a warm smile throughout the few days he spent on observation with us while receiving IV fluids and antibiotics, and gradually improved though he was still very weak. He was discharged on home-based care and I walked with the community health workers to his house a few days later to see how he was. He continued to be incredibly cachectic and weak, but was interactive and eating some. We were able to clarify some of the medication regimens for the family and asked them to come back to clinic the following day. It was incredibly humbling being in his home. His wife was so happy we had come; her generosity was overwhelming, she gave us a generous basket of produce from her garden. I found out 3 days later that he had passed away at home. I felt overwhelmingly sad, and I must confess, still have lingering questions about the best plan of care. Would his course been different had he been at a major medical center? This is a question I will always have to wrestle with. In the course of the month I have seen a lot of HIV/AIDS patients, most of them have been amazingly well, living productive lives on HAART. Several at one stage or another have had immune systems as weak as this man and have recovered remarkably. There is so much hope here, but for those that do pass, like this one, are still devastating for the families and health care workers. I consider it a huge privilege to have known him and his family.

This case is just one on the spectrum of patients I have seen this month. Daily we've seen patients for a range of medical needs including wound debridement, motorbike accidents, sickle cell anemia, along with a range of infections I rarely see in the US: tuberculosis, brucellosis and of course malaria. I've helped deliver a few babies and am in awe of these women who endure childbirth with no pain medicine and very few creature comforts. I have mostly worked in the outpatient department with the clinical officers, but also spend some time in the maternal and child health room on busy days helping with prenatal care and well-child visits. One of the greatest joys has been working with and investing in the clinic staff. I have learned a lot from them about taking care of patients here, and also try to share knowledge about up-to-date treatment guidelines, management of chronic illnesses and broadening their differential diagnoses. Many have family elsewhere and living here is not without sacrifices, so we also just enjoy spending time together outside of work. Leaving Lwala is definitely bittersweet, the month has not been without frustrations or times of loneliness, but I am really sad to leave people here. I take with me lifelong lessons, not only on how to be a better individual clinician, but also in thinking about how to design systems, as well as invest in people to help effectively improve health in resource-poor settings.


by Liz Lightner
Vanderbilt University, Department of Emergency Medicine
Santiago Atitlan, Guatemala

I received a 24 year old pregnant woman in the ED via ambulance. Her prenatal care consisted of one ultrasound at the city clinic months earlier. She was about 36 weeks pregnant by the date of her last period, and this was her first pregnancy. She had been pushing for 3 hours at home, and someone had administered an unknown IV medication to her at her home hours earlier. She was having contractions every 2-3 minutes, her cervix was fully dilated, and late decelerations were evident on the monitor. I called Dr. Laura, the on call OB physician on call, and asked her to come as soon as she could. On her arrival, she discovered that the baby was transverse and was unable to be rotated. Delivery by forceps and vacuum was not possible. The fetal heart rate by this time was dropping into the 60s with every contraction, thus we rushed to the OR for a C-section. There are no OR teams or standby OR's here, so Drs. Laura and Carrie set up for the surgery and I prepared for procedural sedation, this process seemed to take a very long time. Another on call physician arrived and set up to resuscitate the baby. Two other volunteers heard about the situation and arrived by the start of the procedure to assist in any way possible. Nobody on our team had much more experience than a training course on neonatal resuscitation, so we were very relieved when the baby started breathing and crying seconds after delivery. The mother tolerated the surgery well. I was amazed how well our team of volunteers with experience in various areas of medicine were able to come together to ensure a good outcome for these two patients, despite practicing outside our usual scopes of practice.

Coalition links Tennesseans to help for Haiti

The Tennessean

By Jenny Eaton Dyer, Ph.D.

One year ago today, a 7.0-magnitude earth­quake hit the poorest nation in our hemi­sphere:
Haiti. More than 300,000 people died, and more than 1 million Haitians were left without shelter or work. With the subsequent onslaught of Hurricane Tomas and cholera, thousands more have lost their lives.

Former U.S. Sen. Bill Frist, M.D., arrived in Port­au- Prince immediately fol­lowing the disaster with a medical mission team for the victims of the earth­quake. Hundreds waited for emergency surgery at Bap­tist Mission Hospital where the team worked day and night for the trauma patients. Within hours of his arrival, the doc­tor- senator sent back blog postings and pho­tos to his Nashville-based global health organization, Hope Through Healing Hands, sharing the stories or both horror and hope of so many who had survived.

One of his patients, 16-year-old schoolgirl Rouite Tisma, had been found alive under the rubble of her schoolhouse. Knowing she had been at the school, her frightened father
searched the site, calling her name for any sign of life. He finally heard a small sound from beneath the collapsed stone building indicating she was still alive. Three days later, they dug her out of the rubble. Her right leg was crushed, and her left forearm and hand swollen. But she and the family rejoiced that she was simply alive.

‘Network of mutuality’

How does the extreme poverty of Haiti affect Tennesseans? The Rev. Martin Luther King Jr. once said, “We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly affects all indirectly.’’ Even in this landlocked state, there is a robust global health community addressing emergency relief, prevention of disease, education, extreme poverty and sustainable health care in developing nations.

Hope Through Healing Hands’ Tennessee Global Health Coalition boasts more than 60 in-state members, including nonprofit organ­izations, churches, universities and corpora­tions who touch lives in almost every coun­try in the world.

At the time the earthquake hit in Haiti, the coalition had been in existence for six
months. Yet, even in that short period, the partners were able to quickly and efficiently communicate with one another the needs, intentions and goals to begin the work of relief.

Mobile Medical Disaster Relief inoculated thousands of Haitian children against tetanus and diphtheria. Soles 4 Souls committed to providing more than 1 million pairs of shoes to Haitians. And Sweet Sleep shipped beds, mattresses and linens for children newly orphaned, for a clean, safe place to sleep.

On this anniversary of one of the most devastating earthquakes in history, we are reminded of King’s “inescapable network of mutuality.’’ Wonderful local groups and indi­viduals are changing lives in forgotten cor­ners of the world, albeit quietly, from right here in our own backyards. Tennessee’s vol­unteer spirit is alive and well.

We applaud the global efforts of these groups on behalf of Tennessee and the United States, using health as a currency for peace. In this increasingly globalized world, these countries are our neighbors in the world village, and addressing poverty — whether in Pulaski or Port-au-Prince — means a better, safer world for us all.

Jenny Eaton Dyer, Ph.D., is the executive director of Hope Through Healing Hands.

by Liz Lightner
Vanderbilt University, Department of Emergency Medicine
Santiago Atitlan, Guatemala

During my last Turno, I saw two patients who had clear diagnoses and needed transfer for care that I could not provide in Santiago Atitlan, but whose families refused to allow the patient to go.

The first was an 80 year old female with acute left eye pain, headache, and photophobia. She had acute narrow angle glaucoma on exam, although I was not able to check intraocular pressure. After searching the pharmacy, I was only able to find one medication out of 3-4 recommended medications for this condition, which helped some but didn't fix the problem. She was going to require treatment by an ophthalmologist if she was going to keep her vision. I discussed this with the patient and her family. The family decided that they did not want to have the patient transferred, nor did they want to take her themselves, despite understanding that she would likely be blind in her affected eye without treatment. I believe it may have been related to financial concerns, however, they would not tell me this. Care in the national hospitals is free; the family only has to pay for transfer to the hospital (which is 200Q or about $30). The patient left the hospital with her family, with a bottle of the only medication that we had to treat her condition and the invitation to return should they change their minds.

The second patient was a 3 year old female with abdominal pain, fever, and anorexia for one day. Her examination was very consistent with appendicitis. I discussed the diagnosis and need for treatment with antibiotics and surgery with the patient's mother and grandmother. They declined any treatment of the child until they were able to discuss the problem with the child's father, who was out of town for a few days and not able to be reached. Despite repetitive explanations about what could happen to the child without treatment and pleas to at least allow antibiotics to be given until they were able to reach the child's father, they left without any treatment.

by Rebecca Cook
Vanderbilt School of Medicine
Lwala, Kenya

After a wonderful few days to spend time with my family and friends and recover from jet lag, I have arrived in Lwala, a small village in Western Kenya. My month in Lwala will be a combination of serving along side the clinical officers (similar to a nurse practicioner or physician assistant in the US) and nurses in clinic as well as a project focusing both public health and clinical services for malaria prevention and treatment.  I thought I would provide a little context for my work this month.


Propelled by their father’s dream and the loss of their parents, Milton and Fred Ochieng’, friends and recent Vandy alumni, founded the Lwala Community Alliance in order to bring health care to their community. The health center opened in April of 2007 and offers primary outpatient care, maternal health services, and HIV treatment, serving more than 1,000 patients each month, 55% of whom are children under 5 years. Patients are most frequently treated for malaria, respiratory infections, parasites, diarrhea, HIV, and TB. In my first few days in Lwala, in addition to the routine outpatient complaints I see in the US, I have seen many patients with malaria, typhoid and several with HIV, both those with new diagnosis of HIV and those who are followed on antiretroviral treatment here. It’s amazing the amount of health care that is provided from this little clinic.

Malaria in Kenya

Malaria is the number one cause of death in Kenya and one of the main barriers to economic and social development. It accounts for ~34,000 deaths among children under five years and 8 million outpatient treatment visits each year. Lwala is in an area of Kenya where malaria is endemic, meaning that there is malaria transmission occurs every year. Immunity is often acquired before adulthood, so the greatest burden of disease and death is amongst children and pregnant woman.

During pregnancy, malaria causes anemia, miscarriages and can result in preterm or low birth weight infants. Children under five years have not yet developed immunity to the parasite and are thus most likely to suffer from severe malaria, which can be life-threatening. The parasite prevalence in children often exceeds 50%.  Because of the significant burden of the disease in Lwala, I will spend some of my time here focusing on malaria from 2 aspects:

  1. Community Health Education: Lwala has had a successful community health education program on basic lifesaving skills for mothers and infants called “umama salama”, and the clinic staff go out into the local schools to provide community health outreach; I hope to utilize those existing networks to implement malaria education focusing on malaria prevention and target health-seeking behaviors to ensure prompt and effective treatment for pregnant women and children.
  2. Clinical care:  One of the challenges of treating malaria in Kenya is the emergence of drug resistance; the first-line treatment in Kenya is now arteminisin-based regimens which while effective, bring new challenges in that this treatment is more expensive and fear of developing drug resistance to one of the last remaining effective treatment regimens in the region. By observing and collecting data on current diagnostic and treatment practices in the clinic, I hope to help identify any areas for improvement.  The head clinical officer has also invited me to help with the weekly continuing medical education sessions for the clinic staff which will be a great opportunity to help make sure they are all practicing updated malaria treatment guidelines, along with targeting some other common clinical problems.



The Ambulance Ride

Jan 05 2011

by Liz Lightner
Vanderbilt University, Department of Emergency Medicine
Santiago Atitlan, Guatemala

lightner hospital

A previously healthy 29 year old female arrived in the ED via motor taxi, accompanied by her family, early in the afternoon on a day I was working in the outpatient clinic. I stopped by the ED on my way home, and saw that Turno doctor had her hands full with the patient, so I stopped to help. The patient was hypoxic (74%), tachypneic (58 breaths per minute), and somewhat hypotensive (90/50). She complained of chest pain and shortness of breath for 3 days, and also thought she may have had a fever although she was afebrile on arrival to the ED. Her EKG showed sinus tachycardia, but was otherwise normal (we were only able to obtain limb leads). She appeared chronically ill. We were unable to get labs because of the time of day, and the patient was too unstable to transport for a chest x-ray. Pulmonary embolism was a major concern even though she had no risk factors, thus we gave Heparin for anticoagulation and started to arrange transfer to Guatemala City for diagnostic testing and treatment. After two hours of preparing for transport, collecting supplies (as there are none on the ambulance), and deciding which family member was going to accompany the patient, we were finally ready to go. Just prior to departure, the lab was able to run a rapid HIV test, which came back positive. This added more to the list of possible diagnoses. By this time the patient was on 10L O2 and a Dopamine drip. We added on several antibiotics for possible infection, and started the journey.

The ambulance is a van without the back seats. There is a bench next to the stretcher for family and medical staff. Our crew consisted of the driver, his co-worker, a nurse from the hospital, and me. The patient's husband accompanied us in the back of the ambulance. The terrain in this area of Guatemala is incredibly rugged, and the roads suffer much damage during every rainy season, thus the ride was anything but smooth. During the first 30 minutes of the 3 hour trip, the batteries to the portable pulse oximeter died. I was able to replace these with batteries from my flashlight. A few minutes later, the patient's oxygen saturation dropped from 80% to 60%, signaling that the first oxygen tank of three partially full tanks was empty. The driver pulled over, the other bombero jumped out and changed the tank, the patient recovered, and we got back on the road. We realized that we should have been able to go about twice as long on that tank of O2, meaning we had a leak or a problem with the regulator. If the next two tanks had the same problem, we were not going to have enough O2 to make it to the city. During the next few minutes, the infusion pump stopped working due to dead batteries meaning I had to push medications through a needle into the established IV. After another hour, the second oxygen tank ran out, leaving only 1000L of O2 in left on the ambulance enough for about 30min and we still had more than an hour to go to the hospital in Guatemala City. We had to find a closer hospital that would either care for the patient overnight or give us an oxygen tank so we could make it to the city. The bomberos took us to a nearby hospital, we wheeled the patient inside, and explained our situation. They were happy to give us the oxygen tank; their beds appeared full and their staff already too busy for a very sick patient. The last hour went as smoothly as could be expected under the circumstances. We arrived at the hospital in Guatemala City, took the patient inside, and told the doctors there what we knew. The bed we took the patient to was in the middle of a room full of ill appearing patients. There were no monitors, no private rooms, and very little space to move around. They started her on oxygen and got to work with labs and medications. The nurse and I walked out of the hospital, relieved that our patient had survived the trip.

I don't know what the diagnosis of the patient was or if she survived. At home, this patient would have undergone imaging of her chest, lab testing, been transferred to an ICU, and would have received the appropriate care for the diagnosis found on labs and imaging within hours of arrival in the ED. In Guatemala, she received 3 hours of supportive care in the back of an ambulance, nearly died twice when we ran out of O2, and hopefully was able to receive a diagnosis and care at a hospital hours from her family and home. The nurses and local physicians back in Santiago Atitlan were doubtful that the patient would receive much, if any, treatment given her HIV diagnosis.

Liz Lightner
Vanderbilt University, Department of Emergency Medicine
Santiago Atitlan, Guatemala

liz lightner

I have spent the last three weeks working in the Hospitalito in Santiago Atitlan, Guatemala. Santiago Atitlan is a city of 50,000 people, located on beautiful Lake Atitlan, surrounded by three towering volcanoes. The hospital consists of a four bed ED, two labor and delivery rooms with two beds in each, three inpatient rooms, and an operating room. The two upper levels are currently under construction, but will greatly increase the capacity of the hospital. The staff consists of mainly volunteer physicians and local nurses and technicians. The main language spoken by the patients is Tz'utujil, which is then translated by the nurses to Spanish for the physicians. Patients came to the hospital from towns all around the lake and surrounding area. They often arrived via Tuc-Tuc (motorcycle-taxi), but sometimes walked, were carried by family members, or arrived by Bomberos (volunteer firefighters without medical training or resources).

Resources in the hospital were limited, thus the methods diagnosis and treatment of patients varied greatly from what I have become used to at Vanderbilt. Most of the medication and supplies for the hospital are donated by volunteers when they come to work, thus there were times when items that were needed were not available. There are no ventilators or cardiac monitors, mainly because there is no one there to maintain this type of equipment. Laboratory studies are only available Monday through Friday 8-12am and 2-4pm. Imaging is limited to occasional x-rays and a later model ultrasound. There were several OB physicians available at all times to manage obstetrical issues, and a general surgeon every two weeks. Patients requiring a higher level of care or a specialist have to be transferred to one of the national hospitals in Solala or Guatemala City, 2 or 3 hours away by ambulance. The staff did everything possible to conserve available resources, such as cleaning and reusing endotracheal tube stylets (there was only 1 in the hospital), making their own cotton balls, and using suction cup EKG leads rather than disposable stickers for the leads. Adjusting to the differences in practice was challenging for me. In our medical culture, labs and imaging guide treatment. Suddenly, I was unable to use these tools in my medical decision making process. I was also not able to tell patients to go see their doctor or a specialist for follow up; most of them did not have the money to see another doctor or undergo further testing.

I mainly worked in the Emergency Department (ED), but also spent a few days working in the outpatient clinic. Each day one person would be "Turno", which meant they were in charge of the ED as well as all of the patients admitted to the hospital (post-op patients, post partum patients, neonates, and medical patients). Turno is a 24 hour shift. The majority of the patients would arrive between 7am and 9pm, the hours that the Tuc-Tucs run. Those that came outside these hours were generally very ill, as they would have to find private (and expensive) means of transportation. On each of my 24-hour shifts, I saw about 15 patients in the ED. Many of these patients had problems such as vomiting and diarrhea, sprained ankles, cough, and lacerations. A few patient encounters were remarkable, I will discuss them below. 

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