by Kelly Tschida

Vanderbilt, School of Nursing

November 1, 2009

  

1) Patient Beds

2) Hospital Compound where families clean clothes and make food for patients

3) Ingredients for Hand Sanitizer

It has been one month since I arrived in Rwanda and I am continually amazed at the obstacles my patients and coworkers face. The work can be very frustrating. Everyday I see ways to keep people alive and reduce the severity of illnesses, but implementing change is never easy, especially when resources are extremely limited.

One particular frustration is the lack of hand washing by the medical staff. An estimated 60,000 in Rwanda are infected with illnesses in hospital, which are called nosocomial infections. Nosocomial infections are often caused by health providers not having properly washed their hands. They significantly increase patient death rates as well as costs to the patient and hospital. I have seen diseases being spread in our hospital and the staff seems to accept it as normal.

All the nurses and physicians know they are supposed to wash their hands between patients, but it just is not practical. There are no sinks in the patient rooms and the nurses have to move quickly from one patient to the next to provide care for everyone. There is only one sink per floor, and it is located very far from the patients. A great majority of the patients have infectious diseases such as HIV, tuberculosis, intestinal parasites, and infectious hepatitis, so hand washing is especially important.

After two weeks of frustration I found a solution. Hand sanitizer is an effective way of killing most germs and does not require running water; unfortunately it is too expensive for the hospital to purchase. With some research I found some recipes for homemade hand sanitizers that costs a fraction of the price of commercial products yet are effective disinfectants. I tested recipes until I found one the staff members like the most. I am now working with the chief of nursing to ensure that the hospital can afford to make it in sufficient quantities indefinitely. This is only a small change but I believe it will result in a significant reduction of infections passed from patient to patient and to the workers themselves. My hope it that they not only continue to use the hand sanitizer but that this will begin to instill confidence that there are ways we can start to limit unnecessary hospital born infections.

 

 

Time For Renewed Global Action Against This Forgotten Killer Of Children

The Lancet

October 31, 2009

by Former U.S. Majority Leader William H. Frist, M.D. and Minister of Health of the Republic of Rwanda, Richard Sezibera

Whether a political leader or a physician, one of the cruel ironies we face is that we are losing children we know how to save. The heart-breaking truth is that financial barriers—not medical or scientific ones—are preventing 9 million children every year from reaching the age of 5 years.

Take, for example, pneumonia, labeled as the forgotten killer of children by WHO and UNICEF. It surprises most people to learn that pneumonia kills more children than any other disease, taking more than 2 million young lives annually. Nearly half of these deaths could be prevented with existing vaccines and most cases could be treated with inexpensive antibiotics. Yet, lives continue to be lost from this preventable and treatable disease, and, until recently, there was little outcry. There are growing signs that the global community is ready to take action to fight childhood pneumonia. The recently formed Global Coalition against Pneumonia, nearly 100 members strong and counting, is an international network of organisations dedicated to fighting childhood pneumonia. On Nov 2, 2009, advocates from around the world will commemorate the first-ever World Pneumonia Day to raise awareness and mobilise efforts to fight this disease. The enthusiasm of this diverse group from dozens of countries gives hope that this deadly disease is finally going to get the attention it deserves. On Nov 2, WHO and UNICEF will release a road map, the Global Action Plan for Prevention and Control of Pneumonia (GAPP), which represents a turning point in our global approach to fighting childhood pneumonia. GAPP outlines a 6-year plan for the worldwide scale- up of a comprehensive set of interventions to control pneumonia. These interventions fall under a three- pronged framework: protect children by providing an environment where they are at low risk of pneumonia; prevent children from developing the disease; and treat children who become ill. Key interventions include exclusive breastfeeding during the first 6 months of life, use of pneumococcal and Haemophilus influenzae type b vaccines, and management of illness in clinics and importantly at the community level. 

These recommended interventions are based on rigorous scientific evidence, accumulated over the past 20 years, which shows efficacy in controlling pneumonia. This evidence was reviewed in 2008, and specific estimates of the projected benefits of implementing these interventions are available. These advances have helped the global community reach a unique point where we now know which interventions will have the most benefit in controlling pneumonia. Each of these interventions is safe and available now. GAPP’s projections are that, by 2015, the scale-up of existing interventions can substantially decrease mortality from pneumonia in children. This dramatic decline is not only a substantial contribution, but a critical step towards meeting Millennium Development Goal 4. Although meeting the costs of fully implementing GAPP will be a challenge, the good news is that many countries are already beginning to implement recommended interventions. For example, in April of this year, Rwanda was the first developing country to launch a national immunisation programme against the pneumococcus,12 a major cause of severe pneumonia. The GAVI Alliance, a global health partnership that helped Rwanda introduce these vaccines, plans to do the same in a total of 42 low-income countries by 2015. This addition to the national immunisation programs is crucial; whilst infant mortality is dropping in Rwanda, further decreases depend on addressing pneumonia, which is responsible for one in four deaths of children under 5 years of age.

We live in a world with infinite possibilities. Hearts are transplanted, DNA is decoded, and new medical discoveries are made every day. Yet we continue to be stymied by how best to reach those in resource-poor settings with the most basic care and medicines that we take for granted. What could break through this conundrum? The answer is a committed community in both donor and developing countries to make the health of children a priority, combined with a simple package of interventions that address the greatest challenges to survival. Resources and political will are standing between children and their futures. With the right tools, we should not fail the next generation of leaders and doctors. 

World Pneumonia Day

Nov 02 2009

November 2, 2009

World Pneumonia Day News Conference Audio: Bill Frist, Mary Beth Powers, and Orin Levine

MEDIA CONTACTS: 

Eileen Burke, Save the Children

+1 203-221-4233

EBurke@savechildren.org

 

Lois Privor-Dumm

Johns Hopkins Bloomberg School of Public Health

+1 484-354-8054, lprivord@jhsph.edu

 

Mala Persaud +1 202-841-9336

mala.persaud@gmmb.com

 

Leading Organizations Join Forces to Launch First Annual World Pneumonia Day,  Fight World's Leading Child Killer

WHO and UNICEF Release Global Action Plan to Combat Pneumonia as Part of Historic Effort

"Resources and political will are standing between children and their futures,"

Write Senator Bill Frist and Rwandan Minister of Health Dr. Richard Sezibera

 

WASHINGTON, D.C. (November 2, 2009) - Nearly 100 leading global health organizations from around the world joined forces today to recognize the first-annual World Pneumonia Day and urge governments to take steps to fight pneumonia, the world's leading killer of young children.  The first steps in this fight are outlined in the Global Action Plan for the Prevention and Control of Pneumonia, released today by the World Health Organization (WHO) and UNICEF.

"It surprises most people to learn that pneumonia kills more children than any other disease - taking more than 2 million young lives annually," write former U.S. Senate Majority Leader and Save the Children Board member, Bill Frist, MD and co-author Dr. Richard Sezibera, Rwanda's Minister of Health in this week's edition of The Lancet.   "Nearly half of these deaths could be prevented with existing vaccines and the vast majority of cases could be treated with inexpensive antibiotics.  Yet, lives continue to be lost from this preventable and treatable disease, and, until recently, there was very little outcry."

Pneumonia takes the lives of more children under 5 than measles, malaria, and AIDS combined.  The disease takes the life of one child every 15 seconds, and accounts for 20% of all deaths of children under 5 worldwide. While pneumonia affects children and families everywhere, it has the most deadly impact in South Asia and sub-Saharan Africa, where 98% of pneumonia deaths occur. It can be prevented with simple interventions, and treated with low-cost, low-tech medication and care.

"Today the world is coming together like never before to address the number one threat to the world's children," said Orin Levine, executive director of PneumoADIP at the Johns Hopkins Bloomberg School of Public Health. "Together we call on country governments to implement life-saving pneumonia interventions for those that need them most."

Global Action Plan for Prevention and Control of Pneumonia

The Global Action Plan for the Prevention and Control of Pneumonia (GAPP), released today by  WHO and UNICEF, outlines a six-year plan for the worldwide scale-up of a comprehensive set of interventions to control the disease.  Countries are urged to implement a three-pronged pneumonia control strategy that:

  • protects children by promoting exclusive breastfeeding and ensuring adequate nutrition and good hygiene; 
  • prevents the disease by vaccinating them against common causes of pneumonia such as Streptococcus pneumoniae (pneumococcal disease) and Haemophilus influenzae type b (Hib); and
  • treats children at the community level and in clinics and hospitals through effective case management and with an appropriate course of antibiotics.

The GAPP estimates the cost of scaling up exclusive breastfeeding, vaccinations and case management in the world's 68 high child mortality countries. Together, these countries account for 98% pneumonia deaths worldwide. With this investment, the GAPP projects that by 2015, the scale-up of existing interventions can decrease child pneumonia mortality substantially. 

Ensuring Treatment, Achieving Prevention

Studies show that implementing pneumonia prevention and treatment interventions worldwide could save more than one million lives each year and significantly reduce the burden of families and communities that must cope with pneumonia-related illnesses and deaths.  Pneumonia can be treated effectively with antibiotics that cost less than a dollar, but less than 20% of children with pneumonia receive the antibiotics they need, according to WHO.

Safe and effective vaccines exist to provide protection against the primary causes of pneumonia, Streptococcus pneumoniae (pneumococcal disease) and Haemophilus influenzae type b (Hib).  However, use of Hib vaccine has only recently expanded to low-income countries and pneumococcal vaccine is not yet included in national immunization programs in the developing world, where children bear the highest risk for pneumonia and where most pneumonia-related child deaths occur.   

As the result of collaborative efforts by WHO, UNICEF, the GAVI Alliance, academia, foundations, vaccine manufacturers, and donor and developing country governments, low-income countries can now access existing and future pneumococcal vaccines with a small self-financed contribution of as little as US $0.15 per dose.  To date, 11 countries have received GAVI Alliance approval for support to introduce pneumococcal conjugate vaccine (PCV) and 12 additional countries have submitted applications. 

"For the first time in history, we have the commitment from countries and the tools and systems in place to deliver new life-saving vaccines to protect millions of children against the world's biggest childhood killer pneumonia," said Dr. Julian Lob-Levyt, CEO of the GAVI Alliance. "With increased donor support, we can save many more lives and make an incredible leap in progress towards further reducing child mortality in the world. This is an historic opportunity we must not ignore."

World Pneumonia Day: A Global Effort

The Global Coalition against Childhood Pneumonia, made up of nearly 100 influential global health organizations has led the World Pneumonia Day effort.  Events are taking place in more than 25 countries around the world.

"Pneumonia takes a devastating toll on families and communities in resource-poor countries, so it is vitally important that this message be amplified throughout the developing world," said Mary Beth Powers, chief of Save the Children's Survive to 5 campaign. "The involvement of these countries in this effort is an important step toward reducing pneumonia deaths."

World Pneumonia Day events and activities will raise awareness, outline solutions and call upon governments to act to combat pneumonia. In New York City, more than 100 leaders in science, politics and global health will gather for the first World Pneumonia Day Summit.  Other activities will include week-long activities in Nigeria including educational events, policy briefings and rallies; a policymaker roundtable and symposium in Bangladesh; a Run for Survival in Kenya; pediatrician workshops in Nepal; a health symposium in the Philippines; and a briefing in London at the House of Commons.  Additional events are planned in China, the DRC, Ethiopia, India, Malawi, Mali, Pakistan, the Philippines, South Africa, Thailand, and Uganda.  An event list can be found at http://worldpneumoniaday.org/events/upcoming-events/.  These events all underscore the need for urgent action to protect the lives of children everywhere.

"We live in a world with infinite possibilities," write Frist and Sezibera. "Hearts are transplanted, DNA is decoded, and new medical advances are made every day. Yet we continue to be stymied by how best to reach those in resource-poor settings with the most basic care and medicines that we take for granted."  They continue, "Resources and political will are standing between children and their futures. With the right tools, we should not fail the next generation of leaders and doctors."

To learn more about World Pneumonia Day and the Global Coalition against Child Pneumonia, visit http://worldpneumoniaday.org.  To download the Global Action Plan for Prevention and Control of Pneumonia, visit http://whqlibdoc.who.int/hq/2009/WHO_FCH_CAH_NCH_09.04_eng.pdf.

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About The Global Coalition against Child Pneumonia

The Global Coalition against Child Pneumonia and the World Pneumonia Day Coalition, was established in April 2009. It seeks to bring focus on pneumonia as a public health issue and to prevent the millions of avoidable deaths from pneumonia that occur each year. The coalition is grounded in a network of international government, non-governmental and community-based organizations, research and academic institutions, foundations, and individuals that have united to bring much-needed attention to pneumonia among donors, policy makers, health care professionals, and the general public. Learn more at www.worldpneumoniaday.org

 

 

 

 

 

 

 

 

 

Global Health Essay Contest

October 23, 2009

The Center for Strategic & International Studies Commission on Smart Global Health is calling for essay submissions. The essay seeks to answer the vital question, “What is the most important thing the U.S. can do to improve global health over the next 15 years?”

Essay submissions must be between 500 and 800 words are due at midnight EST on November 20, 2009. CSIS is so dedicated to answering this question that they are offering a $1,000 scholarship for the winning essay.

We encourage you to submit your philosophy and your thoughts on how the U.S. can improve Global Health, ultimate to aid in achieving the Millennium Development Goals.

Spread the word. Tell your friends.

Check out the Smart Global Health website for more details.

October 22, 2009

This article was submitted by Global Health Leader Danielle Dittrich who is serving as a nurse at the Primeros Pasos Clinic in Quetzaltenango, Guatemala. The article is in Spanish, but for those of you not fluent -- we suggest simply cutting and pasting the language: http://translate.google.com from Spanish to English.

El Quetzalteco Newspaper

http://www.elquetzalteco.com.gt/22.10.2009/?q=breves/solidaridad

Global Health Leader Starts Women's Clinic

October 20, 2009

By Danielle Dittrich

    

News travels fast in small rural communities, and the word about the women's clinic is quickly getting around. Women from the community women's groups have been bringing their sisters, daughters and neighbors. Each patient exam has been taking about an hour, as it includes a full history and physical. The appointment also includes an explanation of female anatomy, how a Pap smear is preformed, and how it is used to check for the changes caused by human-papilloma virus (HPV) which can cause cervical cancer. Many of the patients have never had a pelvic exam or Pap smear so teaching has become a large part of every appointment.

Primeros Pasos's mission includes increasing education about methods of disease prevention. Though it is common practice that Guatemalans only come to the clinic once already very ill, Primeros Pasos women's education program is doing a great job promoting wellness and annual check-ups. Some patients have come in for symptoms of anemia related to heavy and irregular menstrual bleeding, however many healthy feeling women have come in specifically for their Pap smear and annual physical. Currently, the Primeros Pasos clinic has the ability to process a handful of laboratory tests in house. Unfortunately, the Pap smear is not one of them. Where as many of Primeros Pasos volunteers are being trained to identify intestinal parasites from stool samples, or run different blood tests, a Pap smear slide must be read by a trained cytopathologist. Therefore, the Pap smears are being processed at a lab in the city of Xela. Once a week I take my bundle of Pap smears to the lab in the city. Each Pap smear costs 25 Quetzales, which is about the equivalent of three American dollars.  It's amazing how three dollars can make such a difference in the lives of these women.

Cervical Cancer has been the hot topic the last two weeks. Rightfully so, as it deserves a lot more attention than it ever gets. In the United States, we almost never hear of deaths from cervical cancer because we have so many methods of early detection already in place. However, according to the American Cancer Society global cancer statistics report (2002), cervical cancer is the second most common cancer among women worldwide. In select countries, such as Guatemala, cervical cancer ranks even higher as the number one cancer among women with a reported rate of less than 10% of women receiving regular screening (Ministry of Public Health and Social Aid of Guatemala, 2003). Many myths and misconceptions about cervical cancer exist in the rural communities. The last two weeks I have helped teach phase two of the women's education curriculum, which focuses on women's health issues such as uterine, ovarian and cervical cancer. In the past many, most women have lumped all the aforementioned together as the same "women's cancer" that is rarely spoken about due to fear and stigma. Through the women's education program, the myths around cervical cancer are slowly being unraveled and addressed.

The patients are not the only ones inquiring about cervical cancer. The buzz among the Guatemalan medical students prompted a lunch lecture dedicated specifically to the topic. Upon request, I will now be running a weekly lunch lecture on the essentials of obstetrics and gynecology. The new group of medical students is inquisitive and hard-working. They have already made huge leaps and bounds in their time at the clinic. I am working closely with the two female medical students to teach them to perform women's health exams. It is very culturally taboo for females to be treated by male healthcare providers for any issues related to women's health or pregnancy. So although I am foreign, my presence is accepted because I am female. Each day I hope to slowly build my patients' trust, which is the biggest thing that you can ask for as a foreigner in the Valley of Palajunoj, in a country like Guatemala that is still feeling the aftermath and distrust of a 36 year civil war.

For More Photos, Go to:  http://primerospasoswomensclinic.shutterfly.com/

First Impressions: Nyamata Hospital, Rwanda

 

by Kelly Tschida

 

October 15, 2009

 

  

 

1) Nyamata Internal Nursing Hospital Staff

2) Nyamata Hospital

 

It is hard to believe it has only been two weeks since I arrived in Rwanda. I landed late Thursday evening and was taken directly to the Nyamata hospital guest house where I will stay the next three months. I started work in the hospital the next day at 7:30 am and I have been busy ever since.

 

The Nyamata hospital is a public hospital serving the people of the Buresera district in Rwanda. The patients are generally from the surrounding villages and do not have much money. The services are not expensive, but the patients have to pay for everything before they are treated. For example, if they need to have an intravenous line (IV) put in so they can receive IV fluids and it is not an emergency, they have to send someone to the pharmacy to buy the IV and all the equipment before it is done. Yesterday, when I asked the staff why a patient had not had an IV started yet, they told me the patient’s family had gone home to sell a goat to get the needed money.  

 

The hospital offers much more than I had expected. Inpatient units of the hospital include surgery, post surgery care, maternity, obstetrics and gynecology, pediatrics, emergency care, internal medicine, and mental health. They also have several rooms designated for isolating patients with severe cases of TB. On site services include a pharmacy, out-patient consulting, physical services, imaging, laboratories, a dentist and an optometrist. There are also consultation offices for HIV and tuberculosis (TB) and a voluntary HIV testing center.

 

I am spending my first month working as a Registered Nurse in the internal medicine unit. After this first month I will start working as a family nurse practitioner in the outpatient area and in the community. Working as a nurse is a great way to learn the common illnesses, the skills of the staff, and the challenges they face here. Every morning I see patients with the physicians and am able to discuss the problems and treatments of the people I care for. I spend the rest of the day working with the nurses. The nurses are well trained and we spend the day exchanging techniques and caring for the patients. There are usually 40-45 patients in our area with only two nurses taking care of them on each shift.

 

Although there are a full range of services resources are limited. For example, there are a total of 170 beds in the hospital and they seem to run at near capacity. Patients stay in rooms together, with as many as 11 per room with the beds spaced only two feet apart. They sometimes lack some basic equipment. Last week we were unable to find a working nasal cannula in order to deliver oxygen to a patient who desperately needed it. Fortunately, as in the case of the cannula, the staff are accustom to working under these conditions and are often able to fix broken equipment or find another way.

 

Patient illnesses vary, but there seems to be some common trends. Acute cases of malaria, TB, HIV, and hepatitis are all common. Gastrointestinal problems, caused by parasites and bacteria, are present in the majority of the patients. Pneumonia and severe anemia are also common problems. Parasites that cause internal bleeding and malnutrition seem to be the reason for 90% of the anemia. It’s tragic that people are dying from things so easy to fix.

 

I have been there long enough to have seen many patents sent home healthy after having arrived in critical condition. For example, one elderly woman with severe malaria was brought in from one of the nearby villages. She had a severe fever and anemia and was unconscious, and going into shock. I was not sure if she could survive. However, she after receiving anti-malaria medications and a few blood transfusions she started improving. A couple of days ago she walked into the nurses’ station, smiling and full of energy. She had come to thank the nurses and say goodbye. I cannot express how good this made me feel.

 

Of course not everyone gets better. Although there is a full range of services the limited resources has an impact. We seem to lose a few patients a week. It is heart-breaking to see someone die when you know how to help them but the medications, manpower, and equipment needed are not available.

 

It is not always easy to work in the hospital but I am grateful for this opportunity. I am helping people who are in desperate need while gaining invaluable experience. I don’t know what else someone could ask for.  

 

 

3) Looking at Blood Smears

 

 

 

 

Saving a Life: Meet Olken Foncime, a Haitian Orphan

 

By Jenny Dyer

 

  

           

     

Christian Gilbert, M.D., Associate Medical Director of International Children's Heart Foundation (www.babyheart.org) in Memphis, TN connected with Senator Frist about a year ago to let us know the great work he was doing: providing pediatric cardiac surgical services and education to the children and health care providers in developing countries around the world.

 

We invited the International Children’s Heart Foundation to join the HTHH Tennessee Global Health Coalition, and he and his wife attended our first Gathering at the First home September 29, 2009. I had been apprised by Senator Frist of a situation in Haiti, where a young orphan, Olken, was suffering from congenital heart disease, Tetralogy of Fallot, and would likely die without immediate surgery. In meeting Dr. Gilbert for the first time, I asked him what the likelihood of his reaching this child in rural Haiti would be.

 

I’ll let Christian relay the rest of the story through his letter:

 

Jenny,
This story begins with a letter to Senator Frist which you answered and as a result invited me and ICHF to participate in the HTHH foundation. That led to an invitation to the gathering at the Senator's house. There I found out about this Haitian orphan in need of heart surgery from you.

 

I checked it out with my director and the director of the program in Dominican Republic, where I was headed for a two week mission and got the OK to help him on our mission to the DR later in the week. That set the wheels in motion and before too long I had pictures of him and his caretakers and knew his name, Olken Foncime.

 

He arrived in the Dominican Republic on Wednesday the 7th of October with his guardians, Marc, Leslie, and Pauline. When I first met him I was stunned at the profound degree of cyanosis, and equally impressed by his gentle sweet demeanor. He quickly became everyone's favorite. He was a high risk surgery with an estimated mortality risk of 15-20%. I reminded myself that it was 100% without it. He needed some things done before we could operate on him such as antibiotics and exchange transfusions because his hematocrit was 80, with normal being around 40. His blood coagulation was so abnormal the anesthesiologists was reluctant to put him to sleep for the IV line to do the exchange transfusion. Because he was so sick it was decided that rather than try a complete repair which carried a very high mortality risk I would do a shunt procedure and defer the total repair for a time when he was not so sick and had a better chance of survival.

 

On Monday October 12th he was taken for a Blalock Taussig shunt. He did very well with the operation and for the first time in his life he had pink nail beds and lips. In the picture, he is bravely holding onto his teddy bear and heart just a few hours after his surgery.

 

 

      

 

He is now 3 days post op and is starting to open up and smile and eat some food. All of his IV lines and drainage tubes are out and he has been transferred to the regular ward. It is my expectation he will be ready to return to the orphanage on Saturday or Sunday. I hope that some time in 2010 we will be able to bring him back for a total repair. We all have been blessed by this child and his caregivers who demonstrate amazing love and selflessness. God put us together and I give him all the glory as we are simply his servants here on earth. He clearly has a plan for this beautiful little boy. Thank you for bringing his story to my attention. God Bless.

 

Christian

 

…Sometimes little miracles happen through the most simple of circumstances. Building partnerships is crucial for saving lives, like Olken's, around the world. This is just the beginning of what is possible with a robust, well-connected coalition...

       

Taking Care of Newborns: From Kijabe Hospital, Kenya

October 15, 2009

by Amelia Wood

   

        Pretty sure I have fleas.  Jim found these two little guys buried deep in my hair and wriggling up itches everywhere.  Now I learn that the previous neonatologist had also acquired some type of stow-away and so would not sit on the mom's beds or wear his white coat thru maternity.  But what am I to do?   The mom's wait longingly as I speak to the woman in front of them.  The want attention for their babies and for their concerns.  They delight when the blond mazungu doctor hugs them and stops to visit. Maybe if I were here long term it would be different, but for just six weeks, though its not very lady like - I guess I'll have fleas.

         Don't be mislead...I am not that cool about having fleas.  The first night we discovered them I must have combed 1 pound of Ultrathon repellent thru my hair.   I then got three "999" pages to maternity for worrisome deliveries.  Yup, there I was resuscitating babies with my deet drenched head.  I can't wait to hear what the Samali women have named me, something like "sour smelling doctor."

          Most of the on call pediatric emergencies are in the delivery room which has verified my decision to specialize in neonatology.  For the most part, a sick newborn in the delivery room does not stress me out in the same way that it bothers non-neonatal physicians.   I am working hard to teach the general interns here how to be calm and act even when the babies are tiny or need to be intubated.   My soap box has ben intubating babies who need to have meconium (first baby stool) removed from their tracheas prior to resuscitation.  The interns know tracheal suctioning needs to be done, but they are terrified.  So if a baby is floppy, not breathing, and covered in meconium the interns have been stat paging the pediatrician and then just waiting: intern shaking, child dying.  Now we review the steps at every delivery that I go to with them and we prepare.  If the child needs suctioning it is up to the intern to be the baby's doctor and I am there for support.   Jim says I am like a duck - above water smoothly floating along, underneath my webbed toes are spinning out prayer.

            During the night of three stat delivery pages, I had my first death in the delivery room.  The hospital is downhill from our apartment so I was pretty swift to respond to the call, but the baby was a still birth.  The intern briefly tried to resuscitate him, but then made the decision that the child was truly gone.  When I walked in there was a blue baby on the bed warmer with the end of scrub bottoms covering his face.  His mom was silent, stretched out toward him, blinking in disbelief. It was awful.  I went to consol her, but quickly realized this was not the time for a rich white woman whose fat, healthy baby sleeps at home to become involved.  I left quietly.

            I remember passing the guard on the walk home.  My mind was busy trying to figure out what I am doing here.  I am suppose to be a teacher.  I didn't teach anything.  Of course, that would have been inappropriate but why was I suppose to be there at all?  At home where my family slept, I wondered and waited for the next page.  I did finally realize, my intern had made the decision to let the baby "go" on his own - How advanced?  How intimidating?  So I called him and told him he did the right thing.  I told him that in my country we frequently get babies who didn't have a heart rate for 30 minutes but no physician was brave enough to stop.  I reminded him that saving the body once the person has gone is not triumphant.  Learning when to stop is not easy and is almost never clear, but is essential.  I told Jeremy I was proud of him and he was grateful (quiet and Kenyan, but grateful).

by Danielle Dittrich

Vanderbilt School of Nursing

Quetzaltenango, Guatemala

The past two weeks have been an absolute whirlwind. After overnighting in Antigua I took a small bus for five hours up the winding mountains into the western highlands, finally arriving in Quetzaltenango. Quetzaltenango was and still is a principle center of Maya Ki'che and is often referred to by its Ki'che name Xelaju and abbreviated to Xela. Xela is a large city seemingly disconnected from the surrounding cities but by small winding dirt roads which the revamped and repainted yellow school buses ride along. Most women in the city still dress in traditional Mayan clothing, which becomes even more prevalent as you head out into the country side. Every morning we take the unmarked school bus from the bus stop at the Calvario Church into the mountains of Tierra Colorada Baja. Outside the church, venders sell flowers freshly cut from the mountains and beans and eggs out of street charts.

Now is the perfect time for me to be at the Primeros Pasos clinic, as many exciting changes are going on around me. Originally a pediatric clinic, the Healthy Schools Program is one of Primeros Pasos largest components. Health educators go out into the local community schools and teach about prevention of infection and communicable disease. By participating in this program, the children receive free healthcare at the clinic. For the schools that are too far from the clinic, Primeros Pasos has a mobile clinic which runs at the end of the school year. The end of the Guatemalan school year is now approaching so we have been hiking into the mountains with backpacks full of medications and medical equipment. As we are about to hit a lull in pediatric consults, all focus is on the new women's clinic.

The women's clinic will run in conjunction with the women's groups that have recently started up in the community. Similarly to the Healthy Schools program, women that participate in the women's group will receive free care. The objective is for patient to invest in their healthcare through commitment to health education. In the afternoons we have been hiking into the mountains to teach the women's groups and to talk about the new women's clinic. The women's education group has three phases: The first phase focuses on nutrition, hygiene and traditional medicine. The second phase focuses specifically on women's healthcare topics such as cervical, endometrial, and breast cancer, pap smears and self breast exams, pregnancy and prenatal care, menstruation and menopause. The last phase focuses on self esteem and leadership. In this phase, the women have a choice to start a community wellness project or to become a health educator. We are hoping to find the next group of women's health educators from this group. Each day of the week is a different women's group meeting in a different community, all in different phases of the program. The women at the women's group range in age from teens to grandmothers. Most women bring along their children, tied onto their back and over their shoulder with a traditional woven clothe. The first groups are entering the third phase; it will be very exciting to see these women become leaders. You can easily tell the difference between the timid participants of groups in phase one as compared to the outspoken individuals starting phase three, who eagerly ask me inquisitive health questions and willingly discuss women's issues.

On the first day of my clinic orientation I already had a patient. I had been told that many mothers had been asking for help when they brought in their children, but I had not anticipated for things to happen so quickly. Unfortunately, all the clinic supplies were still in the apartment, so I did the best I could with what I had.  I guess you can say the women's clinic unofficially opened the first day and officially opened two days later and I have had at least one patient every day since.  A new group of medical students have just started their rotation at the clinic. Two of the six medical students are females and I will be training them in the basics of obstetrics and gynecology in the primary care setting. It will be exciting to see them grow into the role of provider over the course of their eight week rotation. I can already tell that everyday will be a new adventure.

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