May 11 2012
Traveling with Cinterandes Foundation
By Rebecca Pfaff
Meharry Medical College
Riobamba, Ecuador
My first day with the Cinterandes Foundation we left for a trip to Palmer. The large truck with an operating room in the back had left the day before and we traveled in a small vehicle. This trip was my first time out of the Andes since my arrival a month earlier. We drove the Cajas National park where llamas run down the middle of the highway and alpine lakes dot the landscape before we began the decent; the humidity and heat increasing and the vegetation changing from alpine to tropical with every turn of the road. The houses also changed from concrete Spanish houses to wood houses on stilts with hammocks on the porches.
Palmer is a small pueblo of less than 2000 people on the Pacific Ocean and most of the people there are considered very poor by Ecuadorian standards. There is a public health clinic run by a German born nurse who finds cases appropriate for these trips and pre-screens the patients so that when we arrived all that was to be done was review lab results, EKGs, and perform quick physical exams.
Two patients were turned away because of fever and one because of irregular heart rate. The patients need to be carefully selected so that there are minimal complications with recovery because the PACU consists of cots in the clinic and the team leaves at the end of the week. Dr. Rodas calls all patients to insure that they are recovering well, but this system works best when there are minimal complications. Sometimes the surgeons travel with a family physician who sees patients while they operate. However on this trip the team included Dr. Rodas and Dr. Sacoto, two well experienced surgeons.
Dr. Rodas founded Cinterandes because he felt that Ecuadorian doctors could help their population just as traveling Americans could. He was inspired by the ship Hope and trained in the US but was born and raised in Ecuador. Dr. Sacoto, the other surgeon is the dean of a medical school in Cuenca. During the ride to Palmer he and I had a long conversation about evidence based medicine and the pedagogy of medicine. There was also Dr. Anita the anesthesiologist and executive director of the organization. Her role on the trip made me think about anesthesia in a whole new way. She not only anesthetized patients from 5-76 years old and with everything from local nerve blocks to general anesthesia but also serves as an extra set of unsterilized hands in surgery helping with everything from preparing the patient (cleaning) to helping set up the laparoscopic equipment.
In Ecuador anesthesiologists are at a premium. Dr. Cruz, the pediatrician I worked with in Riobamba is trained as a surgeon but works as a generalist because there is no anesthesiologist at the children’s hospital. While working with the ob/gyn and head of the department in the public hospital in Riobamba, we had to wait two hours for an anesthesiologist to arrive so that he could operate. In addition, Dr. Anita is involved in primary care, coordinating rural rotations for medical students.
The final physician was Dr. Valasco who, like many physicians in Ecuador, is working as a physician before residency and after his year of rural service. He serves as the scrub tech but also does much of the pre- and post-operative care.
Like the physicians, the two other staff members had multiple jobs. Freddy knows where absolutely everything is on the tightly packed truck and throughout all the surgeries the doctors often shouted, “Freeeeeedy” and he would appear from nowhere and supply the necessary item.
The final members of the team were us 6 American medical students (there are usually also Ecuadorian students but they had final exams). We assisted in all surgeries and helped with pre- and post-operative care.
There seems to be 2 purposes to these trips. First and foremost, the foundation truly believes that it is far more humane to provide surgeries, for carefully selected patients, close to their homes so that they are spared the expense of travel and the trauma of time away from their families. Many of our patients needed these surgeries and would not have received them without this foundation.
But students, both foreign and Ecuadorian, also play a role. Not only do we bring labor, supplies, and funds to the organization, but the team of doctors all clearly enjoy teaching and explicitly encourage students to learn how to provide humanitarian medicine (for example instructing us on how to tie knots so as to spare suture). It is a symbiotic relationship in which the students gain important skills and the team gains extra hands to help with the work.
The surgeries performed were hernia repairs, lipoma removals (lipomas are benign tumors that can be disfiguring and painful), and lots of cholystestectomies. Cholystestectomies are common here, not only because of the frequent occurrence of gallbladder disease, but also because gastric cancer is common here (more common than colon cancer in the Andean region). In fact, endoscopy of stomachs rather then colons are the preventative tests of choice here and choystestectomies for symptomatic patients are considered part of prevention.
We worked for 3 days operating from 8 in the morning until long after dark and then rounding on patients recuperating in the clinic. Many of surgeries were laproscopic and, save for the fact that the drapes and gowns are cotton rather then disposable paper and the conversations being in Spanish, you would never know you were outside the U.S., let alone in the back of a truck.
It was a privilege to work with physicians helping their own people in this unique and creative way. The Cinterandes team is traveling to the Sudan this year to help establish a similar truck there. Hopefully the idea will catch on because it is a great way to utilize urban specialists to help poor rural populations without the need for expensive infrastructure development.
Apr 16 2012
Health Facilities in Brazzaville, Congo
by Ifeoma Ozodiegwu
East Tennessee State University: College of Public Health
Brazzaville, Republic of the Congo
I paid a visit to the local hospital called Makelekele, the second largest hospital in Brazzaville where I visited the different sections in the hospital and spoke with the staff. The hospital was a little crowded due to the explosion that occurred a few weeks ago. A number of people are still receiving treatment from the hospital.
My purpose for visiting the hospital was to gain a better understanding of the health status of the Congolese people especially as it regards tobacco-related diseases and view the state of their health facilities. Following a tour of the hospital I chatted with the exceptionally nice staff and enjoyed an informative discussion the Medical Director of the Hospital, Dr. Loussambou. The Director explained to me that from their observation, the leading cause of morbidity was bronchitis and pneumonia while the leading cause of mortality was malaria and heart attack. He also explained the national strategy to combat malaria. When I inquired about the prevalence of cancer of the lung, he said that it was quite low.
My visit to the hospital opened my eyes to the sacrifices made by the medical personnel in the Brazzaville; they are able to do much with so little. The personnel seemed interested in their patient’s conditions and the well-being of other staff. They also did their work with so much joy such that it was infectious.
Finally, during the week, I completed my research paper on health workforce norms. I am also done with reviewing the monitoring and evaluation committee report. In the next final 2 weeks, I am looking forward to having the employee service event and putting finishing touches to my work. Expect to see all the pictures from the event.
by Ifeoma Ozodiegwu
East Tennessee State University: College of Public Health
Brazzaville, Republic of the Congo
It has been two months now! Yes, Two months! Over the past two weeks, I have focused on writing and designing the layout for country-level reports on the Status of Implementation of the Framework Convention on Tobacco Control (FCTC) for two countries-Madagascar and Lesotho. While writing the report for Madagascar, I observed that the tax on the most widely sold brand of tobacco is 76%. “Impressive”, I thought, given the difficulties and politics involved in the implementation of such tax policy. Upon inquiry, I learnt that Madagascar has the best practice in Africa. Madagascar also has health warnings on tobacco labeling and packaging covering more than 50% of the package and labels. The issue of health warnings reminded me of the events in the US where the implementation of graphic health warnings on tobacco packaging and labels were ruled as unconstitutional by the courts. I hope tobacco advocacy groups continue to fight for the adoption of such policies. Policies recommended by the FCTC has been shown to reduce tobacco consumption and in turn, premature mortality from tobacco use.
The Human Resources for Health Unit has also assigned me to write a literature review on health workforce estimation, with the aim of determining if it can be done on the regional or country-level, for use by the Regional Director. Whereas, the Planning, Budgeting, Monitoring and Evaluation Unit asked me to review their annual report and budget as well as create a summary of performance indicators for Budget Centers (Regional and Country offices) to be used in their annual report. All these have kept me on my toes.
By Rebecca Pfaff
Meharry Medical College
Riobamba, Ecuador
My first week here in Riobamba, Ecuador has been fantastic. In the mornings I attend rounds in the pediatric hospital with residents and attendings. Rounds are a lot like in Nashville except that x-rays are read by holding films up to the light and, of course, everything is in Spanish. Also, an epidemiologist joins us, and sometimes a dentist, though they rarely contribute to the discussion. It is amazing what an international language medicine is. Even with my limited Spanish skills I can follow, and occasionally contribute to, rounds with relative ease. After rounds I go with Dr. Cruz to his clinic on the first floor of the hospital. I enjoy working with Dr. Cruz both for his obvious skill as a practitioner and enjoyment of teaching, but also because he speaks very clearly, making it easier to follow him. In clinic we see 8-10 patients to fill out the morning before he and the other pediatricians head to their private clinics in the afternoon. There are no well child visits in the clinic, only hospitalization follow-ups and sick visits. Riobamba is the capital of Chimborazo Province and surrounded by mountains populated by small villages and farms. Families bring their children in from long distances to see the doctors. Pulmonary complaints are by far the most common with gastrointestinal a close second. In fact, the hospital has two large main rooms for inpatients, one for pulmonary complaints and one for gastrointestinal, with smaller rooms for infectious disease, neonatology, and other complaints. There is no importance given to privacy either on the wards or in the clinic. Curious mothers will follow the physicians as they round in the one large room containing 6-8 patients and in clinic other patients, nurses, pharmacy representatives, and administrators all walk into the examination room while the doctor is seeing patients.
After clinic I return to my host family’s house for the most important meal of the day, lunch. Everyone comes home from work and school to eat together. After this I head off to my medical Spanish language course. We are all in the fourth year of medical school in the U.S. and excited about starting residency soon but enjoying Ecuador a great deal in the mean time. I can't believe I have already been here a week, these 11 weeks are going to fly.
by Ifeoma Ozodiegwu
East Tennessee State University: College of Public Health
Brazzaville, Republic of the Congo
Over the past two weeks, I have continued to work on the research paper on the status of the Framework Convention on Tobacco Control (FCTC) supply strategies in the African Region as reported by the Parties to the Convention. My plans to have the first event of the employee community service program in March have been stalled. We also had an unfortunate incident in Brazzaville on the 5th of March. A fire started at a military arms depot and set off a series of explosions killing more than 150 people and leaving thousands displaced. This sad event was felt at the office as many workers lost their homes. As a result, things were a bit slow at the office this week. The event has been postponed to April to allow time for things to settle back down.
However, I have been able to make contact with two Units- Human Resource for Health; and Planning, budgeting, monitoring and evaluation. The Human Resource for Health Unit is engaged in ensuring an available, competent, responsive and productive health workforce in the African region to ensure improved health outcomes. The latter unit enables the effective and the efficient implementation of the WHO managerial framework through the development of regional policies, systems and tools.
The mission of these two units was explained to me and I was given materials to read in order to have an understanding of their work. I am hoping to do a rotation in those units soon.
by Ifeoma Ozodiegwu
East Tennessee State University: College of Public Health
Brazzaville, Republic of the Congo
Brazzaville!!!!I can’t believe I am finally here! After weeks and months of applications and planning and finally a twenty-two hour journey from Johnson City in Tennessee, I have arrived and I am ready to do some public health. Driving into town from the airport, the driver with the World Health Organization, the Organization with whom I would be working with during my three month stay, showed some of the remarkable places in town. He pointed out the President’s residence, the ministry of defense and biggest market in the area known as Marche Makelekele. “Marche” means market in French which is the widely used language in Congo Brazzaville. I completed a three month intensive course in French about four years ago and as a result I am able to understand the language. However, I have difficulty speaking because I have been out of practice for those four years. Right across from Brazzaville was Kinshasa. The two capital cities are separated by a huge river known as Djoue. Congo Brazzaville is a small country located in Central Africa. It houses the African Regional Office of the World Health Organization (WHO). This is my internship affiliate organization.
My duties as an intern involves, primarily, monitoring and evaluation of country compliance to the Framework Convention on Tobacco Control (FCTC) as well as production of tobacco control country report cards. The WHO FCTC is the first negotiated treaty under the auspices of the WHO and a regulatory strategy to address additive substances. It focuses on cutting off the demand and supply of tobacco products within countries. However, apart from the above mentioned duties, I also get to do rotations in other departments in order to get a well-rounded field experience
Having arrived on a weekend, I had the opportunity to rest and recharge my batteries in order to be ready for my first week as an intern. On Monday morning, I was at the office bright and early. I got introduced to my supervisor, Dr. Nivo Ramanandraiben and my preceptor, Dr. Ahmed E. Ogwell Ouma. My preceptor is the Regional Advisor on Tobacco Control. I also met other members of the Tobacco Control Team. I was briefed on my duties and by Tuesday, I set to work by trying to understand and extract the information in the FCTC Parties Reports. Countries that have acceded to, ratified and agreed to implement the articles of the FCTC are known as Parties. The agreement to implement these articles is known as entry into force. These Parties are expected to produce implementation reports two years and five years after entry into force. In the African region, 41 out of the 46 countries in the region have entered into force. Each Party report is 47 pages long and that would be keeping me busy for the next two weeks.
I am very fortunate to be given an opportunity to intern with the Tobacco Control Unit of the WHO for the next twelve weeks and want to thank Hope Through Healing Hands and the Niswonger Foundation for their scholarship support. I will keep everyone “posted” so be on the lookout for my next blog report. In the meantime, here is where you can find me : http://maps.google.com/maps?hl=en&cp=12&gs_id=0&xhr=t&q=brazzaville+congo&qscrl=1&nord=1&rlz=1T4SUNA_enUS310&gs_upl=&bav=on.2,or.r_gc.r_pw.,cf.osb&biw=1672&bih=762&ion=1&wrapid=tljp132818884994700&um=1&ie=UTF-8&hq=&hnear=0x1a6a32ac441bb83b:0xab3deababe7de443,Brazzaville,+Congo&gl=us&ei=sY0qT7mxO4fAtgfAq6zmDw&sa=X&oi=geocode_result&ct=title&resnum=3&sqi=2&ved=0CE4Q8gEwAg
Feb 15 2012
Morbidity and Mortality in Kijabe, Kenya
by Joseph Schlesinger
Vanderbilt International Anesthesia
Kijabe, Kenya
Death and dying are never easy to deal with as a physician. However, that process is different in Africa. Morbidity and mortality are more commonplace and seem to be accepted. Religion is pervasive in all aspects of healthcare: the Wednesday morning chapel service, the preoperative prayers, and the prayers after meetings.
I was taking care of a very sick patient that was not expected to do well. Previous deaths in the ICU were simply accompanied by filling out the Kenyan Death Certificate and the family finding out the news when they arrived in the morning. However, this patient’s family drove about two hours from Nairobi to discuss the hospital course and prognosis. All six of them spoke perfect English and were aware of lab values and surgical findings. They were more informed than typical American families I have had discussions with. Despite the expected grief and frustration, they were grateful for the dedication of the hospital and physicians. We prayed together at the end of the meeting. The patient died later the next day.
Despite several deaths in the ICU during the previous week, the evaluations of the anesthesia students were completed. The improvement was remarkable. They were pushed harder than they have been pushed before, and they rose to the challenge. This was evident in the final didactic portion on our final clinical day where we asked the students to present a given topic to their classmates. Not only did they exceed our expectations, they started quizzing their fellow classmates. The lecture was completed by presenting us with high quality coffee table photography books of the Mara. The students signed the inside cover, we took group photos, and we were asked why we can’t stay longer and when we will return.
As we took care of final business with the hospital such as paying for our lodging and Kenyan medical license, the operating room manager asked to meet with us because she wanted feedback on how we can improve things. Kijabe is a place that can follow through on initiatives for change. The cohesive atmosphere is amazing and will provide the impetus for being one of the leaders in Africa for healthcare and mission work. It has been a sincere pleasure to be part of the global health initiative here, and for me, it won’t end here.
by Tracy Curtis
Duke University, Physician Assistant Student
Galle, Sri Lanka
In my third week at Karapitiya Hospital I was introduced to Dr. Kumara, senior lecturer in Surgery. Participating in various surgical cases was what I was most looking forward to on my rotation in Sri Lanka. Walking into the OT I noticed it was quite a different set up from the operating rooms back in the states. Patients were lined up on a bench right outside of the open theater doors with their medical chart in hand. Some patients were even curious enough to stand and watch the ongoing procedures from the doorway. On the other side of the patient bench was a make-shift PACU where the post-operative patients were still coming out of their anesthesia. Inside the operating theater, there were multiple procedures going on at the same time. In one corner of the room, a woman was having a lumpectomy under local anesthesia. In the center of the room, a man was under general anesthesia having an open cholecystectomy. Finally, off to the side of the room a woman was getting a carpal tunnel release.
As I was taking in the similarities and differences of the OT, one of the general surgeons asked me to scrub for a thyroidectomy. The case got underway and I was impressed by the speed and precision of the surgeon. Thyroidectomies are a very common procedure here in Sri Lanka and these surgeons perform so many each day, I’m sure they could do this procedure in their sleep. Following the procedure, I noted that the turnover time between cases is quite rapid. Turning over an OR at home takes a bit of time, but here, there is no time to waste. They have so many patients in need of surgery and not enough resources to do so.
One thing I found truly amazing about the Sri Lankans is their strength to overcome adversity. But more impressive is the way they do so without complaint. The patients waiting in the hallway of the theater could be there all day long, sometimes not having their surgery until 1 in the morning, but there was no complaining. I commented to one of the orthopaedic about how refreshing it was to have people be thankful for the help they are receiving instead of complaining about the wait time, or cosmetics of the scar, or the post-op pain, or even the food at the hospital! The surgeon told me that Sri Lankans are very accepting of their own problems and illnesses. Then he smiled, leaned in and said, “Sri Lankans don’t sue their physicians and that’s something you all have to worry about over there.” Sri Lankans understand that this is the life they were given and they will deal with it as best as they can. They do not blame physicians (or others) for their problems, but instead are grateful for the care they receive.
After a few orthopaedic surgeries, I stepped into the general surgery suite to watch an open cholecystectomy. Since we do these procedures laparoscopically in the states, it was a new operation to me. There is only one scope for the entire hospital so most all procedures that we would do laparoscopically at home are performed as an open procedure here. Similarly, the hospital does not have mesh implants for hernia repairs. Instead, I learned an old suturing technique to weave a meshwork of suture over the opening. Quite impressive and cost effective. As a global practitioner, I’ll need to be prepared to assist in surgeries with fewer resources and embrace both old and new techniques to achieve good end results. I am very grateful to have watched so many procedures and techniques that I won’t get to see (or rarely see) in my training in the US.
I also spend time with Dr. Kumara during his thyroid, vascular, and endoscopic clinics. In the thyroid and vascular clinics, I was surprised to see patients bring their own injections to Dr. Kumara. In the endoscopy clinic, I was stunned to see that patients were not sedated for upper endoscopies or colonoscopies. But once again, there are no resources available to take care of these patients post-procedure if they were to have an anesthetic so using a local anesthetic is the only feasible option.
With that, we headed to meet up with two German medical students, also doing an elective clinical rotation. They were already in the casualty theater where we spent the rest of our day assisting in I&D’s, suturing small lacerations and bandaging head wounds. Overall, surgery in Sri Lanka very much surprised me. For the limited resources available, the shortage of qualified surgeons and the ever increasing number of patients in need of surgery, the surgeons here are very efficient with their time, skilled in technique and quite resourceful. We may have different ways of carrying out a procedure, but we all get the job done.
When I wasn’t in the OT, I was out in the community, learning more about the public health system, specifically the care of orphans and elderly. My colleagues and I have already been to a government run orphanage, and this week we wanted to see how the private orphanages compared. We visited an SOS Village, an Austrian run organization which hosts 12 children per home in 12 total homes on the property. Each “family” home consists of children aged 0-16 years brought in by the courts in cases of abuse or abandonment. The children are cared for by a “mother” in each home who cooks, cleans, and teaches the children valuable life lessons. These “mother’s” undergo years of training and a very intensive screening and selection process. The children still attend public schools like their peers, and return to the village to live a life as close to their peers as possible. It was wonderful to see an organization like this one, working so hard to give these children a rich and meaningful childhood.
We also made our way to a catholic-run elderly home where I had the pleasure of meeting an amazing woman who was blinded by the tsunami. She told us her story and how the sisters had found her on the streets, nearly dead, and brought her to the facility because she had no money, no family and no way to survive. The sisters were able to find a surgeon, who just this past year, performed an incredible surgery to restore her vision! She was able to see for the first time since 2004.
There were so many great stories from the folks at the elderly home, but what I liked most about the facility was that every resident helped out in any way they could. Some set the dining room tables for meals, others cleared dishes, or peeled vegetables, and some knitted bedding or doilies for the sisters to sell at the markets to bring in money for the home. Not everyone could pay, but no one was turned away.
With another fantastic week in the books, it’s hard to believe my time in Sri Lanka is coming to a close. I have learned so much in my short stay; it will be hard to leave. I am very grateful to have had this learning opportunity here in Sri Lanka and I hope that I may return here as a provider one day.
Feb 07 2012
Mahamodara Maternity Hospital: A Place of Hope
by Holly Stump
Duke University, Physician Assistant Student
Galle, Sri Lanka
I wasn’t sure what to expect when I arrived at Mahamodara Maternity Hospital. The tuk tuk dropped us off outside of what appeared to be fortress walls. We were met by our Duke coordinator and led through the gate, past a building that was in disrepair and dilapidated. We traversed through a labyrinth of crumbling plaster and boarded up windows. There was a smell of mildew lingering in the air. I thought to myself, “Women come here to give birth”? Once we rounded a corner, I noticed an area to my right which looked as if it should have been full of expectant women, but was eerily vacant. It was then I realized what I was seeing was the shell of the Mahamodara which stood during the 2004 tsunami. I stared into the ward, and could imagine this area full of pregnant women and newborns on that day, and could almost feel their terror. I was told the hospital was hit by 3 waves. The first wave destroyed the “fortress” walls that I had seen earlier, but these barriers had lessened the impact to the building. It flooded the first level and knocked out the electricity. The doctors and staff evacuated the mothers and infants, some to higher ground, and others to Karapitiya Hospital. The second wave was estimated between 20-30 feet high. There are many stories of heroic men and women from that day, including one physician who calmly completed a Cesarean section by flashlight after the first wave hit. He then safely evacuated the mother and child. Due to lack of funds to demolish the building, it now stands as a temporary memorial.
We moved on, and at the end of the hallway we entered a courtyard. In front of us was a beautiful new building which now housed high risk expectant mothers. The ward contained 64 mothers who had a variety of problems, such as gestational diabetes, hypertension, and preterm premature rupture of membranes. There were strict visiting hours here, so there were no hovering families or concerned husbands. The hospital has very few fetal heart rate monitors, so the midwives and nurses monitor the fetus through the use of a pinard. I spent a lot of time in this ward, and in the antenatal clinic, examining patients. I practiced with the pinard, straining to hear the fetal heartbeat as clearly as these experienced midwives, who could easily estimate fetal heart rates. I did many abdominal examinations, measuring the fundus, palpating the fetal position, and attempting to guess the baby’s weight in kilograms. I was certainly attaining one goal I had for this rotation, to get back to basics!
I witnessed the miracle of birth for the first time this week. I made my way through the maze of exterior hallways at Mahamodara to the labor and delivery room. Once I entered, I saw 10 wrought iron beds sitting side by side, each containing a woman in varying stages of labor. Two had just given birth and were coddling their newborns, encouraging them to breast feed for the first time. Several were in the final stages of labor. I chose a mother and joined the midwife and medical student who were at her side. I again noted the palpable absence of the typical “cheering squad” you see in America. These women were left to hold their own legs, and labor alone. There are no epidurals or pain medication, just pure will and true grit. After another hour of exhausting effort, she gave birth to a healthy baby girl. A new mother’s joy transcends all language barriers!
This was my final week in Sri Lanka. I cannot express enough gratitude to the doctors and staff at Karapitiya Hospital, and the University of Ruhuna Faculty of Medicine, for all of their time and willingness to share their vast knowledge. The long journey home gave me time to reflect on my experiences here, and all that I have learned. Of course I am extremely grateful to have had the opportunities to assist in surgeries and delivering babies, to learn about rare illnesses not seen in the United States, and to practice primitive examination skills; but some of the most invaluable lessons I have learned were from the Sri Lankan people themselves. They are a hopeful people. Having recently suffered through a natural disaster, as well as a three-decade long civil war, they see brighter days ahead and are working hard to be sure the whole world can see them too. They are patient people, accepting of the fact they may have to return to the hospital daily in hopes of being admitted, or that their surgery may be delayed by many weeks. They are people who are full of grace, willing to undergo painful procedures without pain medication or anesthesia, with no complaints. Finally, they are a grateful people. They understand they are fortunate to have free healthcare and very skilled physicians. The phrase “medical malpractice” is foreign to them, and litigation against their physicians is unheard of. They are grateful for visitors from faraway lands and are eager to share their history and culture with all those who are willing to make the trip!
Jan 26 2012
Casualty Day: Karapitiya Hospital in Sri Lanka
Tracy Curtis
Duke University
Physician Assistant Student
Galle, Sri Lanka
After a long journey to the other side of the globe, I was finally in Sri Lanka. It was 1:00 am when I landed then I arrived at my lodging at 4:00am. I had 4 hours to sleep and be ready to work! When I woke up to monkeys howling and playing in the trees 20 feet away, I knew I would like this place.
I was excited and nervous to start my global health rotation at Karapitiya Teaching Hospital. Despite the fact that the University of Ruhuna Faculty of Medicine is conducted in English, there is still quite the language barrier with the Sri Lankan version of English and the amount of slang that we unknowingly use. Even the everyday medical language and abbreviations varies between the U.S. and Sri Lanka. I wasn't sure how this would pan out when I arrived on the medicine ward.
Three of us are here in Sri Lanka from the Duke Physician Assistant Program. Since Duke University and the University of Ruhuna Faculty of Medicine have an established relationship in medicine and research, many of the professors and researchers were very welcoming to us. We met with Professor Ariyananda, the Senior Professor of Medicine, and he was quite excited to bring us to Grand Rounds and introduce us to his faculty and fellow consultants before we got started the next day.
The next day, we began clinical activities on the women's internal medicine ward, where we spent the week. We met with the Senior Registrar (similar to our Chief Resident) and she hurried us to the first patient to begin morning rounds. It was definitely intimidating on the first day while rounding with their equivalent of residents and attending.
After a few days, I was able to understand how the ward works to admit patients, complete investigations and diagnostic assessments and carry out a treatment plan. There are many similarities, but a greater number of differences between the U.S. and the Sri Lankan inpatient wards. The overall appearance of the ward and staff, the admitting process itself, and the types of illness and their treatment protocols are notably unique.
When I first walked onto ward 11, I noticed there were more patients than beds, with some patients lining up with their belongings on the floor or with a make-shift mattress on the ground in the hallway. Some privacy is maintained with green curtain that can be drawn to a close, though this greatly reduces the air circulation and increases the already hot temperatures found on the ward.
Another distinct difference between the U.S. and Sri Lankan hospitals is the admitting process. Patients can only be admitted to a ward on Casualty Day. While casualty typically means trauma or catastrophic event, here in Karapitiya Hospital, it simply means acute care. Each ward has its own Casualty Day, rotating every 5 days, so on any given day there is at least one medicine ward holding a Casualty Day. It's quite obvious which ward is having their day because the hallway outside the ward is lined with sick people waiting their turn to speak to a House Officer (intern). Because Sri Lanka has a public health system, and Karapitiya is a public teaching hospital, patients are first seen at their local community health clinic or rural hospital and if their illness is deemed to be beyond the capabilities of the small hospital or clinic, they are referred to the teaching hospital. The patient brings their diagnosis card to the House Officer- a laminated square paper with their personal identification information, their chief complaint, lab work if done, and treatment to date. The House Officer is the first to speak to the patient; they do a complete history and determine if they need to be examined or treated outpatient. If they are in need of an exam, they proceed to the line for the single admitting bed where the Junior House Office and/or Senior Registrar (residents) examine the patient. They will determine whether the patient gets assigned a bed or follows up with outpatient treatment. Unless the patients’ illnesses warrants a longer stay, most patients are typically released to outpatient care after 4 days- just in time for the next Casualty Day.
When admitted to the hospital, patients must bring their own medical record, clothing, toiletries, pillow and blankets. The hospital only provides one pillow case and one blanket which are typically used to cover the bed. Visitors are only allowed between 1-5pm, though one person is allowed to stay at all times.
Needless to say, patients who get admitted here are very ill. We have seen many patients with Dengue and Typhoid fever, severe heart murmurs, and strokes. Many of these illnesses are quite advanced at the time of initial evaluation. There was one patient who had such a loud heart murmur that it took me a minute to realize that it was her mitral valve making all that noise and not her breath sounds! I've never heard such a loud, distinct murmur in my training. When I felt for her apical pulse, it was as though her heart was punching my hand through her ribs. Thankfully, the patients here are accustomed to medical learners examining and questioning them every day, so it was nothing new for me to listen and palpate myself. In fact, these patients have a crew of consultants, house officers, registrars, medical students and nurses rounding on them daily.
Another interesting difference that struck me was the absence of beeping monitors and other technology on the wards. Vitals are obtained manually at regular intervals and charted on a paper above the patient's bed. There were no oxygen tanks hooked up for the COPD patients, no controls to adjust the hospital bed for comfort and certainly no television sets. The physicians and students are heavily reliant upon their physical exam skills. It was impressive how well these physicians could hear breath and heart sounds with all the background noise and conversations amongst providers. I hope I will be able to acquire this same level of competency in my physical exam!
I can already tell that I will learn a great deal here in Sri Lanka, both culturally and medically. I'm grateful to have already seen so many tropical diseases that are rare or non-existent in my hometown. This will certainly prove beneficial for future international aid work. Also, learning about the public health system and adapting to the difference in technology will allow me to be a better global practitioner. In the next few weeks, my colleagues and I will also participate in pediatrics, OB/Gyn, community medicine and surgery. There will be many interesting patients and experiences to come!