Hope Through Healing Hands

Traveling with Cinterandes Foundation

Fri, 11 May 2012 12:00:01 EST

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.

5 reasons deficit hawks should lay off global health initiatives

Tue, 24 Apr 2012 12:00:01 EST

by Bill Frist

The Week

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

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

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

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

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

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

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

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

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

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

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

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

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

Health Facilities in Brazzaville, Congo

Mon, 16 Apr 2012 12:00:01 EST

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.

Tobacco Control Implementation Reports and Reviews: Brazzaville, Congo

Thu, 29 Mar 2012 12:00:01 EST

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.

Hospital Rounds and Clinic Visits: Riobamba, Ecuador

Sun, 25 Mar 2012 12:00:01 EST

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.

How the Supreme Court's 'ObamaCare' ruling will affect you

Tue, 13 Mar 2012 12:00:01 EST

The nation's highest court is about to judge the president's signature legislative achievement — and it's not just politicians who are invested in the outcome

The Week
MARCH 13, 2012, AT 6:45 AM
by Bill Frist, MD

Is the new health care law constitutional? You might think it doesn't matter — or at least, that it doesn't matter to you. But the fact is, the Supreme Court's decision on President Obama's Affordable Care Act (ACA) will almost certainly affect you directly.

How, exactly? For one thing, the court's decision could play a key role in determining our next president and possibly your next congressman. If you are poor, the ruling may decide whether or not you have coverage. If you are not poor, it will impact how much you pay for health care. If you own a small business, it might determine if you must purchase health insurance for your employees. And if you work for a large business, it may determine whether you still receive your insurance from your employer. If you're a doctor, it will likely affect your reimbursement. If you're a patient, it will determine your benefits.

On March 26, 27, and 28, the Supreme Court will hear extensive oral arguments on the constitutionality of the ACA. This is the culmination of 26 states filing suits in federal district courts and opinions from seven federal appellate courts. A final written opinion likely will be delivered in June, 18 months before the individual mandate kicks in and just five months before the presidential election.

If the individual mandate is ultimately deemed constitutional, then for the first time in our history, you will have to purchase a product to live in America.

The ACA is a highly charged law that, according to the latest RealClearPolitics average, is viewed unfavorably by half of Americans. The law essentially does two massive, controversial things: (1) Mandates that individuals purchase health insurance coverage, and (2) expands Medicaid by 16 million enrollees. This expansion means almost one in four Americans will be on Medicaid, the government program originally intended for our poorest citizens. If you don't purchase insurance, you will pay a fine of $695 per adult and $347 per child.

Together, these provisions will reduce the uninsured by 32 million, but will still leave an estimated 23 million individuals uninsured in 2020.

The focus of the Supreme Court opinion will be on the constitutionality of these two issues, though two additional items will also be considered. One is whether the entire law falls if a part of it, such as the mandate, is ruled unconstitutional, and the other is whether the court has jurisdiction to rule at all now, since the law has yet to go fully into effect.

There is already plenty of discussion on the legal merits of the case, particularly as it regards the taxing power and the Commerce Clause. But what are the very real implications of the upcoming ruling? Here is what to look for:

1. If the court upholds the individual mandate, it will take effect 18 months later — unless Congress acts to repeal or postpone it (which won't happen as long as Obama is in the White House). If the individual mandate is ultimately deemed constitutional, then for the first time in our history, you will have to purchase a product to live in America.

2. If the individual mandate is ruled unconstitutional, the court will then decide whether to let the rest of the law stand, including the expansion of Medicaid and the largely popular individual insurance reforms. If the rest is left intact, the Congressional Budget Office projects that 16 million of the 32 million Americans expected to gain insurance under the law would be ineligible for the new coverage and that non-group, individual premiums might increase 15 to 20 percent. It would then be up to each state to decide whether or not to adopt the individual mandate.

3. If the court decides that the Medicaid expansion is constitutional, it will take effect in 2014 — unless Congress acts to postpone, repeal, or not fund it. But if the expansion is left intact, with almost a quarter of all Americans covered by Medicaid, the program would grow to include a portion of the middle class.

4. If Medicaid expansion is overruled, coverage will remain at current, varying state levels, and an estimated 16 million low-income individuals will not be able to take advantage of the new Medicaid coverage that would have begun in 2014.

5. Politically, if the new law is judged constitutional, Democrats will celebrate the judicial affirmation of the spirit and substance of the historic reform, illustrating President Obama's leadership. Republicans would fan the existing flames of unpopularity among the majority of Americans, citing federal government overreach, rallying around an election call for repeal as they did in 2010. If any part is unconstitutional, the bases of both parties will be emboldened to make health reform the defining issue, after the economy, in the elections in November.

This one is worth following. It will be a game-changer. And not just for the politicians and pundits in Washington. It's a game-changer for you, too.

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

Unfortunate Delays: Military Arms Depot Fire in the Congo

Wed, 07 Mar 2012 12:00:00 EST

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 5^th 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.

Tobacco Control Unit in Brazzaville, Republic of the Congo

Wed, 22 Feb 2012 12:00:00 EST

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

Morbidity and Mortality in Kijabe, Kenya

Wed, 15 Feb 2012 12:00:01 EST

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.

Inside and Outside the Hospital: Operating Theatre and Orphanage in Sri Lanka

Tue, 07 Feb 2012 12:00:01 EST

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.

Mahamodara Maternity Hospital: A Place of Hope

Tue, 07 Feb 2012 12:00:00 EST

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!

On the Pediatrics Ward: Learning in Sri Lanka

Thu, 26 Jan 2012 12:00:01 EST

Holly Stump
Duke University
Physician Assistant Student
Galle, Sri Lanka

We arrived on the pediatrics ward this Monday, a little less naive and much less shell-shocked. I had grown accustomed to hearing only the whirring of ceiling fans, barking dogs, and the quiet chatter of Sinhalese in place of the traditional mind-numbing beeps and alarms of our medical equipment. I was pleased to see protective screening over the open air hallways, to keep the children from tumbling two stories, and to keep out the birds. It was surprising to see the number of children waiting to be evaluated for possible admission. Nearly all the beds were full, and it seemed as though they were in the habit of converting previous storage closets, consultant lounges, and any available space into treatment areas. The need for even more space remains evident.

We were greeted by Dr. Jayantha, the department head, and were quickly incorporated into rounds. My incredible learning experience began the moment we arrived at the first patient. Rapid fire questions regarding minute details about pneumonia. "Inspect this X-ray, what do you see? What organisms cause the X-ray to appear this way? How do you know? Are you certain? Why is this child's pneumonia not caused by Klebsiella?" As the only visiting students on the ward, we were not spared! He is a fantastic educator and we were soaking in every piece of information. The ward was full of interesting cases. Kawasaki disease, meningitis, dengue fever, juvenile rheumatoid arthritis, osteogenesis imperfecta, just to name a few. About 25% of our patients that day were hospitalized due to new occurrences or relapses of nephrotic syndrome. Dr. Jayantha explained the incidence is very high here, mostly caused by minimal change in his younger patients. He calls them his "nephrotics" and he holds a special renal clinic for these patients every Wednesday morning, which we attended. Collectively, we saw nearly 50 patients that Wednesday morning with some variation of this syndrome. He has spearheaded a study on his nephrotics over the past 15 years. It will certainly be an interesting read once his results are published.

Regretfully, Friday was our last day on the Peds ward. We were benefited from phenomenal teaching by a handful of consultants who were intent on actively involving their students during rounds. "Palpate this child's skull, Holly. What do you find?" "An open fontanelle sir," I responded. "Quickly, in your notebook, write down 3 reasons you may find an open fontanelle in children over the age of 18 months" he demanded. Apparently noting the oppressive heat in the ward, and the obvious sweat forming on my face, he continued, "Quickly, and then we will go snowboarding!" Snowboarding? "I'll take it," I said. "Too slow," was his response. Then he erupted in laughter, gave me a pat on the back and moved on to the next patient. This kind of rousing I was familiar with!

The opportunity to go into the community and provide antenatal care, well child checks, and give immunizations was extended to us by Dr. de Silva in the Department of Community Health. We had been waiting for this! We boarded the bus with 20 medical students from the University of Ruhuna Faculty of Medicine and set out towards a primarily Muslim clinic in Gintota, about 10km from Galle. 10km came and went, then 20km, maybe 30km. There was much discussion between the bus driver, the spotter, and the instructor in charge of this outing. I didn't need to speak Sinhalese to understand that we were lost! When we finally made it to the road leading to the clinic, the bus was unable to fit, so we walked the final 2km. We walked through tiny villages, past small shops, and many people who hadn't seen many (or any) fair skinned, light haired women walk past their homes. They were curious, and came off of their porches to watch where our journey would end. It ended at a clinic at the top of a hill, which was closed! A cyclone had badly damaged the structure three weeks prior. We now had to make the trek back down the hill, into the Muslim town, where we were shuttled by a community doctor to the temporary location at a school. 35 moms-to-be and 35 children were seen that day. Although cramped in their temporary clinic, their system worked well.

We visited a Sinhalese clinic a different day this week, which strictly provided antenatal care. We found this to be just as efficiently run, with roughly 60 mothers receiving exams. I was amazed at how integral a role the midwife plays in prenatal care in the villages. She performs all exams, including albumin and blood sugar checks, fundal height measurements, and even listens for fetal heart sounds through a pinard stethoscope! A "pinard" is a cone shaped instrument made of wood, plastic or aluminum, with a second cone at the top through which you are to listen. The fundus and the baby's head are palpated, pressure is placed at the top of the fundus, and the pinard is placed approximately over the baby's left shoulder. The provider then places their ear on the top side of the pinard and listens closely (very closely) for fetal heart sounds. Warning: The aforementioned technique may read as an easy procedure; however, after being spoiled by dopplers and fetal ultrasound, this takes much practice and a well trained ear!

I read somewhere that Sri Lanka has been called the "gem" of the Indian Ocean. It is most definitely unique. The people, the food, the language, the landscape, the culture, all novelties to me. Every day is an adventure here, and I am cherishing every one.

Casualty Day: Karapitiya Hospital in Sri Lanka

Thu, 26 Jan 2012 12:00:01 EST

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!

In the Operating Theatre: Kijabe Hospital

Sun, 22 Jan 2012 12:00:01 EST

Joseph Schlesinger
Resident
Kijabe, Kenya
Vanderbilt International Anesthesia

We arrived safely in Nairobi and stayed at the Mennonite Guest House. The next morning we ate breakfast with missionaries from all over the world in different stages of their calling around Africa. Kijabe’s reputation is well known and they wished as well as we were picked up and driven to Kijabe via a road that had terrible slums juxtaposed with sweeping views of the Rift Valley.

We toured the hospital and got settled in our lodging for the month and got sign-out from the ICU as one of us was on-call the first night. It took adjusting to drugs and equipment that were foreign to us. All of the patients did well overnight leading into our first day in the operating rooms, or “theatres,” as they are called.

The staff comprises one MD anesthesiologist and in our case, two anesthesia residents, missionary and local surgeons, surgery residents, KRNA (the Kenyan version of a CRNA), and anesthesia students. Patients present with late-stage disease, terrible trauma, and for obstetric emergencies without previous prenatal care. One could take care of a neonate with a tracheoesophageal fistula followed by a patient after a road traffic accident followed by a C-section. The steep learning curve of anesthesia is addressed with intense didactics combined with a sick and varied patient population. The KRNAs and students do a great job. However, there is not insignificant morbidity.

I had the pleasure to oversee a few operating rooms, help the KRNAs and students perfect there neuraxial anesthesia techniques, discuss pharmacology and physiology, and teach them approaches to regional anesthesia that they have not seen before. The way they gather around and pay attention exhibiting their willingness to learn is refreshing.

After the first day, we brought two heavy suitcases of medical supplies to the anesthesia workroom as most of the equipment is donated. It caused me to step back and realize the amount of equipment we use in America and how we take many things for granted at our institution.

Everyone at Kijabe has been extremely welcoming and the missionary spirit of providing excellent medical care in the midst of educating the local medical staff is encouraging for the future. All of this paired with the beautiful land, delicious food and chai, and local wildlife seen on our weekend hikes prepare us for a busy week next week in the operating theatre.

Patient Care is Universal

Wed, 18 Jan 2012 12:00:01 EST

By Sage P. Whitmore, M.D.
Vanderbilt University Medical Center: Emergency Medicine
Georgetown, Guyana

I had plenty of time to contemplate all that I had seen during 12 hours of travel back home from a medical mission trip to Georgetown, Guyana. I had just spent three weeks working in the Accident & Emergency (A&E) department at Georgetown Public Hospital and using my training as an Emergency Medicine resident in the United States to help teach new ER doctors core material such as EKG reading, airway management, and the approach to shortness of breath and chest pain. I had not realized when I arrived how much of my time would be dedicated to sitting in the metaphorical trenches and caring directly for patients coming to the A&E. I was prepared for a foreign experience in a distant land, but instead I found myself right in my element.

The minute-to-minute practice of medicine was in Georgetown was very similar to what I was used to; see as many patients as possible, gather all the information you can, make a decision—often instinctual—to admit a patient or treat them at home. One important difference, however, is that in the United States it is easy to get caught up in which hospital has a trauma center, who has immediate cardiac catheterization capabilities, and how long it might take to get a specialized MRI or exotic blood test; these distinctions do not exist in Georgetown, and as a physician I got back to basics. In medical school what we really learn is how to interact with and assess a patient; how to sit, what to ask and how to listen, where to push and prod, how to translate the patient’s presentation into terms of anatomy and disease process, and how to offer comfort. These remain the most useful tools in a physician’s arsenal and are the foundation of all medical care no matter how many elaborate adjunctive capabilities you have at your disposal.

When a concerned mother presented her coughing infant for evaluation, rather than immediately ordering an expensive antibody test for respiratory viruses, I got to be a doctor. Does the patient look ill, or does she look like a normal baby who happens to be coughing? How long had she been sick, did she have a fever, did she have any prior medical problems? What do her lungs sound like? While I was thinking about the possibilities, I used the moment to reassure the mother how well her baby looked, and her look of relief reminded me why my job can be so gratifying. Ultimately the baby checked out fine, required no testing, and the decision to discharge her was as practical as it was scientific—her mother was reliable, lived nearby, and would return if the situation worsened. In this case, practicing medicine meant relieving anxiety and educating a family member, at the cost of merely a few minutes of focused attention and interaction.

One early morning, a young man was brought in by his family members for confusion and shortness of breath. Sitting in a wheelchair, he was having difficulty concentrating on my questions and panting as if he had just finished a marathon. Virtually any cause of confusion and shortness of breath can be diagnosed for the price of a couple CT scans, a blood gas analysis, full panel of labs, possibly a cardiology consult and stress test, maybe an ultrasound or MRI. If resources were unlimited, one could simply check all the boxes on an order sheet at home if so inclined. Instead, we started with the basics—looking and listening. This shortness of breath had not started suddenly. He had no pain. He was not blue from lack of oxygen. He looked very dehydrated. Despite his rapid rate of breathing, his lungs sounded clear and he was not sucking in at the ribs or working hard to breath through fluid or inflammation in the airways. In medical school we learned about “Kussmaul” respirations, a pattern of deep breathing meant to get rid of acids in the blood, usually from undiagnosed diabetes. We did have a glucose meter on hand, and it turned out his blood sugar was critically elevated, proving the diagnosis. The treatment is simple, and he improved over several hours with IV fluids and insulin. In this case, practicing medicine meant a thorough history and physical examination, and the cost of one glucose check and widely available basic medications.

In a blur of activity, orderlies whipped into the A&E with a woman found unconscious at home. She was limp, unresponsive, snoring and gurgling through her oral secretions. In this situation, protecting the patient’s airway with a breathing tube is essential to prevent secretions from draining into the lungs and getting infected. There is no fancy test required, but getting the tube in place can be difficult and can require specialized equipment. At my home institution, a cutting edge machine with a fiberoptic camera at the tip and a high definition screen can be used to look around the patient’s tongue and place the breathing tube through the vocal cords. In this A&E we had one basic device, and with it the resident was having difficulty passing the tube as the patient’s oxygen dropped lower and lower. Even in this extreme case, going back to the basics proved life saving. As we learn in our airway courses, what saves lives initially is not placing a breathing tube, but rather simply ventilating the patient with a bag and a facemask, by holding the jaw just so. Employing this technique brought the patient’s oxygen back up and gave us time to change the patient’s position, the size of the breathing tube, the height and angle of the bed, and optimize the conditions for the procedure. When the situation had calmed down, we took a slow, deliberate look for the vocal cords and passed the tube successfully.

I came away from these clinical scenarios with a new appreciation for basic medicine. In the era of whole body CT scans, unlimited lab analysis, and myriad medical gadgets, the fall back is always our own eyes, ears, and hands. Forming a therapeutic bond with a patient, asking the right questions, searching for the right clues, combining instinct and basic life support skills, and caring for patients with compassion are principals that know no borders.

The Positive Impact of International Health Efforts

Wed, 04 Jan 2012 12:00:01 EST

By Sage P. Whitmore, M.D.
Vanderbilt University Medical Center: Emergency Medicine
Georgetown, Guyana

As I was packing for my first international medical trip to Guyana, South America, my wandering mind conjured image after image of third-world medicine based on popular notions and dramatic stories I have heard over the years. I imagined a row of soiled cots where emaciated children without IV access spent their final hours. I pictured a sweltering tent full of tuberculosis patients collectively coughing up blood; or a bathroom-sized emergency department packed with fever-stricken, jaundiced, indigenous peoples dying of AIDS, malaria, and other ailments while overwhelmed healthcare workers looked the other way out of emotional self-preservation because they had nothing to offer. As described to me by some physicians who had been there in recent years, some of these were features specific to the hospital I was heading to in the capital city of Georgetown.

I am delighted to tell you how antiquated and cynical my preconceived notions had been.

On my very first day in the Accident and Emergency Department (A&E), my first patient did not have AIDS or malaria or tuberculosis; he had hypertension and diabetes, and came in for chest pain. I have seen this exact patient many times in my own tertiary hospital in the States! I caught myself thinking perhaps my view of international medicine was a bit narrow. But, I thought, we probably wouldn’t have the equipment to diagnose him, and even then certainly we would have no treatment to offer. Wrong again. A junior resident from the brand new graduate training program in Emergency Medicine appeared beside me and handed me an EKG. “Inferior wall MI (heart attack). He’s gotten fluids, aspirin, oxygen, and morphine. Holding the nitro. We’re waiting for his portable chest x-ray so we can start heparin, and the admitting team is on their way down to evaluate him for streptokinase (clot busting medication).” Incredible! His care was nearly equivalent to that in thousands of small hospitals across the United States.

My very next patient was brought in on a gurney in full cardiac arrest for unknown reasons. Far from looking the other way, a team of three physicians including myself and four nurses started CPR, provided oxygen and ventilation, established two IVs, started fluids, checked his blood sugar, attached a cardiac monitor, gave epinephrine and sodium bicarbonate, and attempted defibrillation before finally pronouncing him dead. This was fully consistent with my own training.

Time and time again, I was surprised and humbled by the world-class care being delivered in this developing nation, from the availability of a neurosurgery consultation for head trauma, to blood cultures and antibiotics for septic shock, to the text book intubation of a comatose stroke patient (there was an available ventilator in the ICU), to the use of an “asthma room” for wheezing asthmatics receiving inhaled medications, oral steroids, and intravenous magnesium just like we would do back home. To be sure, this is not always the case, and there are countless places in the developing world with no medical resources at all, but the quality of care delivered in this public hospital in one of the poorest western nations is remarkable. I believe this is a great example of the success and power of international health efforts.

In Georgetown, an American team of Emergency Medicine residents and faculty, of which I am a member, are staying in a compound called Project Dawn, an international collaboration which houses teams of physicians and healthcare workers from the United States, Canada, Scotland, India, and many other countries around the world year-round. Like ours, these teams spend intensive time in the city helping provide direct patient care, teaching at the bedside, and setting up infrastructure and training programs. This, combined with the ambition of the local physicians who have trained in Guyana as well as places like Canada, the US, Cuba, India, and Europe, is a recipe for excellent patient care.

I am particularly proud of my home institution, Vanderbilt University and its Department of Emergency Medicine, and our involvement here. Within the last few years, we have had the privilege of assisting the Georgetown Public Hospital Corporation create a self-sufficient Emergency Medicine residency program to train new classes of emergency physicians who are specially trained in resuscitation and acute care of a wide variety of problems, from cardiac arrest to broken bones to childbirth to infections and trauma. As we’ve seen in the US, this training benefits patients by relieving the surgeons and family practitioners who typically cover emergency rooms but may not be well versed in the care of medical problems outside their usual scope of practice.

As my American colleagues and I led a didactic conference last week with the new residents, I witnessed with awe the geographical boundaries and disparities of health care dissolve. Together we interpreted the mysterious subtleties of EKGs, discussed strategies for resuscitation of shock, airway management, differentiating types of bleeds around the brain on CT scan. The local residents brought their own real-life cases for a conference, calling on each other to think though work-up and treatment of various life-threatening conditions. These residents would be as at home in our conference room in Tennessee as we are in theirs.

The far-reaching positive impact of international health efforts are all around me, and it is truly remarkable. Of course, none of this is possible without the enthusiasm and dedication of a well-educated and well-trained Guyanese health care force. I feel very honored to be part of something so inspirational, and I urge readers to continue to support international health efforts, as the gains from these investments are tangible and quite amazing to behold.

Appendectomies in a New Light: Poverty and Surgery in Kenya

Tue, 03 Jan 2012 12:00:01 EST

Matt Landman
Resident
Kijabe, Kenya
Vanderbilt International Anesthesia

(Photo: Matt Hansen and Kenyan Colleague)

I've probably done more than 30 appendectomies so far during my general surgical residency. For all the times I've taken care of someone with appendicitis, rarely, if ever, has the thought that they might die from the illness crossed my mind. Indeed, some of these patients were quite sick; but once they presented to medical attention, we could get them through their illness. Many of these patients were young which help in their recovery.

My first week in Kenya changed my history with this nearly ubiquitous American surgical disease. We took care of a 20 year old male who presented to an outside facility with appendicitis of about two weeks duration. While he didn't have a CT scan to review, I'm sure his appendix was perforated. He, appropriately, underwent an open appendectomy by these physicians. Unfortunately, he required another operation shortly thereafter necessitating resection of the right side of his colon (the part of the colon to which the appendix is attached). He was discharged from that hospital and presented to Kijabe Hospital with stool leaking from his wound. The connection of his intestine had completely broken down, likely result of weeks of malnutrition and intra-abdominal infection. We performed additional operations to resect the damaged colon but the insult was too great. He died during my second weekend in Kijabe.

There I was, presented with a 20 year old, previously healthy man who died of an illness I’d not ever known in my short professional career to be fatal (although I think it's important to note that there is still a generation of American surgeons who certainly understand death secondary to appendicitis). Admittedly, appendicitis is much less common in Kenya, but nevertheless, his death was a tangible reminder to me of how the lack of medical resources and access to healthcare can truly affect patient outcomes. I’m not sure what kept this young man from presenting to medical attention sooner, it was probably a combination of lack of financial resources, poor access to care and cultural limitations, but had he presented earlier, he would have likely survived.

This, and other, experiences in Kijabe changed my view of global health. It’s so much more than just doing operations or treating patients in a hospital or clinic. Where the real efforts are being made and continue to be made is in creating a system in which patients get open access and timely care for both acute and chronic disease. Surely, as long as there is poverty, this will be difficult. However, if healthcare professionals of the caliber I interacted with in Kijabe continue to commit time and resources to a needy people, the outlook continues to look bright.

Investing in Health and Security

Thu, 15 Dec 2011 12:00:01 EST

By: Bill Frist

Politico
December 15, 2011 12:03 AM EST

While Congress remains deadlocked in fiscal debates, American families are holding their own budget negotiations. How much can we spend this year on gifts for the children, home projects or even food for the holidays? Congress and families alike are tightening their belts, cutting costs and planning ahead.

This week, Congress is to vote on a drastic reduction of foreign assistance. While most Americans shy away from the language of foreign aid, polls show that despite continuing economic problems, more than half all Americans support funding for health, including education and emergency relief, in developing nations.

On World AIDS Day, President Barack Obama, joined by former Presidents George W. Bush and Bill Clinton, spoke about the global commitment to end HIV/AIDS by 2015 and recommitted the U.S. effort to do so. He announced new targets to combat the pandemic — including providing anti-retroviral drugs to more than 1.5 million pregnant women with HIV over the next two years.

Obama received a sustained standing ovation when he announced his administration has set a goal to get six million people with HIV on anti-retroviral treatment by the end of 2013.

These are worthy targets to celebrate. But to achieve it, we must have the support of Congress. Continued investment in the fight to end global AIDS is more than an investment in the lives of families and communities in developing nations — it is an investment in security, diplomacy and our moral image worldwide. It uses health as a currency for peace.

Millions of lives are at stake — literally. Under the current budget cuts, more than.4 million people will likely lack mosquito nets, a cheap way to prevent malaria. More than 900,000 children will lack access to vaccinations for measles, tetanus and pertussis. These numbers are staggering, but real.

Yet, as with any good investment, there is need for accountability, transparency and results. The Millennium Challenge Corporation is a good example of promoting aid effectiveness from “input to impact.” There is mutual responsibility for both donor and recipient to achieve the goals agreed on — an expectation that the recipient take ownership, as a partner, of both the aid and its implementation. Washington should and does require seeing results in practice.

For example, one of the best investments is providing access to clean, safe water. Every $1 invested in safe drinking water and sanitation, according to the U.N. Development Program, produces an $8 return in costs averted and productivity gained. Children are healthier, girls can go back to school and women can begin to work again.

A Millennium Challenge Account compact funding package for El Salvador now invests nearly $24 million to provide access to potable water systems and sanitation services to benefit 90,000 people in the country’s poorest region. This money creates healthier and more economically sound communities with something as basic as clean water.

More than 68 percent of Americans in a recent holiday poll said that because of the economy, we should be committed to charity this year more than ever before. With Americans reaching deep into their pockets to fill the coffers of red-hatted Santas on street corners or offering plates at houses of worship, Congress should follow their constituents’ leadership as they consider foreign assistance this week.

This holiday season, let’s recommit to investing in global health and development in the parts of the world that need our assistance the most. Foreign aid is less than 1 percent of our national budget, so cutting it would have a miniscule effect on our deficit reduction.

But it means the world to a mother whose child’s life we will save.

For the hope of greater peace on earth, investments in health and security could be the best bargain in town.

Former Sen. Bill Frist, a doctor, served as Senate majority leader. He is the chairman of Hope Through Healing Hands, a nonprofit charity that promotes using health as a currency for peace.

A Decade of Progress on AIDS

Thu, 01 Dec 2011 12:00:01 EST

By BONO
New York Times

I’LL tell you the worst part about it, for me.

It was the look in their eyes when the nurses gave them the diagnosis — H.I.V.-positive — then said there was no treatment. I saw no anger in their expression. No protest. If anything, just a sort of acquiescence.

The anger came from the nurses, who knew there really was a treatment — just not for poor people in poor countries. They saw the absurdity in the fact that an accident of geography would deny their patients the two little pills a day that could save their lives.

This was less than a decade ago. And all of us who witnessed these dedicated African workers issuing death sentence after death sentence still feel fury and shame. AIDS set off an almost existential crisis in the West. It forced us to ask ourselves the big, uncomfortable questions, like whether capitalism, which invented the global village and kept it well stocked with stuff, could also create global solutions. Whether we were interested in charity... or justice.

The wanton loss of so many lives in Africa offended the very idea of America: the idea that everyone is created equal and that your destiny is your own to make. By the late 1990s, AIDS campaigners in the United States and around the world teamed up with scientists and doctors to insist that someone — anyone — put the fire out. The odds against this were as extreme as the numbers: in 2002, two million people were dying of AIDS and more than three million were newly infected with H.I.V. Around 50,000 people in the sub-Saharan region had access to treatment.

Yet today, here we are, talking seriously about the “end” of this global epidemic. There are now 6.6 million people on life-saving AIDS medicine. But still too many are being infected. New research proves that early antiretroviral treatment, especially for pregnant women, in combination with male circumcision, will slash the rate of new H.I.V. cases by up to 60 percent. This is the tipping point we have been campaigning for. We’re nearly there.

How did we get here? America led. I mean really led.

The United States performed the greatest act of heroism since it jumped into World War II. When the history books are written, they will show that millions of people owe their lives to the Yankee tax dollar, to just a fraction of an aid budget that is itself less than 1 percent of the federal budget.

For me, a fan and a pest of America, it’s a tale of strange bedfellows: the gay community, evangelicals and scruffy student activists in a weird sort of harmony; military men calling AIDS in Africa a national security issue; the likes of Nancy Pelosi, Barbara Lee and John Kerry in lock step with Bill Frist and Rick Santorum; Jesse Helms, teary-eyed, arriving by walker to pledge support from the right; the big man, Patrick Leahy, offering to punch out a cranky Congressional appropriator; Jeffrey Sachs, George Soros and Bill Gates, backing the Global Fund to Fight AIDS, Tuberculosis and Malaria; Rupert Murdoch (yes, him) offering the covers of the News Corporation.

Also: a conservative president, George W. Bush, leading the largest ever response to the pandemic; the same Mr. Bush banging his desk when I complained that the drugs weren’t getting there fast enough, me apologizing to Mr. Bush when they did; Bill Clinton, arm-twisting drug companies to drop their prices; Hillary Rodham Clinton, making it policy to eradicate the transmission of H.I.V. from mother to child; President Obama, who is expected to make a game changing announcement this World AIDS Day to finish what his predecessors started — the beginning of the end of AIDS.

And then there were the everyday, every-stripe Americans. Like a tattooed trucker I met off I-80 in Iowa who, when he heard how many African truck drivers were infected with H.I.V., told me he’d go and drive the pills there himself.

Thanks to them, America led. Really led.

This was smart power. Genius, really. In 2007, 8 out of the 10 countries in the world that viewed the United States most fondly were African. And it can’t be a bad thing for America to have friends on a continent that is close to half Muslim and that, by 2025, will surpass China in population.

Activists are a funny lot. When the world suddenly starts marching in step with us, we just point out with (self-)righteous indignation all that remains to be done. But on this World AIDS Day I would like you to stop and consider what America has achieved in this war to defend lives lived far away and sacred principles held closer to home.

The moonshot, I know, is a tired metaphor; I’ve exhausted it myself. But America’s boldest leap of faith is worth recalling. And the thing is, as I see it, the Eagle hasn’t landed yet. Budget cuts ... partisan divisions ... these put the outcome in jeopardy just as the science falls into place. To get this far and not plant your flag would be one of the greatest accidental evils of this recession.

Bono is the lead singer of the band U2 and a founder of the advocacy group ONE and the (Product)RED campaign.

An Impatient Optimist

Thu, 01 Dec 2011 12:00:01 EST

An Impatient Optimist's View of HIV
by SENATOR WILLIAM H FRIST MD

Impatient Optimists: The Bill and Melinda Gates Foundation

In 1981, I was a surgeon in training at Massachusetts General Hospital in Boston. I still remember the day we learned about a strange, new, deadly infection that presented on the West Coast. A little over a year later, we learned it was caused by a virus transmitted in the blood, a vital fact for a doctor performing surgery every day.

As I watched the epidemic grow from a handful of cases to a few hundred to several million, I also witnessed the cases grow in biblical proportions in less developed nations, namely across Africa. While I served in the Senate, I volunteered on annual mission trips to do surgery in villages ravaged by civil war. In these forgotten corners of the world, I witnessed how HIV was hollowing out societies.

Drawing on these firsthand experiences, as the Senate Majority Leader I encouraged and supported both the PEPFAR program and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

The Global Fund, a multilateral institution with the U.S. as the leading contributor, leverages $2 for every single dollar given, all to combat this trilogy of diseases that disproportionately attack children and young adults in the poorest nations on the planet.

The remarkable news is that millions of lives have been saved by these investments. Thanks to the Global Fund, over 3.2 million people living with HIV are on lifesaving treatment.

I am proud to have been part of a government whose leadership, acting on behalf of the American people, has led the world and literally saved the lives of millions of people globally.

In 2008, I co-chaired the ONE Campaign’s ONE Vote ’08 Campaign. We brought a delegation of Republicans and Democrats to Rwanda to see firsthand the good work being done by the funding of the Global Fund, PEPFAR, and the President’s Malaria Initiative.

In Eastern Rwanda we visited the inspiring Rwinkwavu Clinic, run by Dr. Paul Farmer’s Partners in Health. With 110 beds and eight health centers, this clinic provides essential medicines, supplies, and equipment and recruits, trains, and retains staff to ensure a sustainable infrastructure for the future.

But without Global Fund funding, the Rwinkwavu Clinic could not provide health care services to the people of Rwanda. This is true for so many organizations and clinics worldwide.

And it’s unfortunate that even though we see investments pay off, lives saved, and economies grow, the Global Fund was forced to cancel its round 11 funding. This means clinics like Rwinkawvu will only be able to support those currently on HIV treatment and not add any new patients. This is alarming because in low-income countries half of people living with HIV are not receiving treatment.

At a time when our own economy is faltering, and our national debt is growing unacceptably, we have to tighten our belts. To do so, we need to decide where we make smart investments and where we do not.

The fact is that the American people spend less than one-quarter of 1% of our federal budget on global health and fighting global epidemics like HIV, tuberculosis, and malaria. With this little sliver of the pie, the Global Fund’s return on investment means more sustainable economies, less global instability, and healthier families. For less than a penny to the dollar spent on all foreign aid, we are investing in the lives of children, mothers, and our own national security.

On the horizon is excellent news for HIV. New evidence suggests male circumcision, microbicides, and quicker AIDS treatment will markedly decrease the disease. Combined with known prevention methods like condoms and nevirapine, we are on the right track to substantially halt the growth of HIV/AIDS.

I’m an optimist, an impatient optimist. We will win the war on HIV, tuberculosis, and malaria. Our investments have worked. The end is in sight. We just have to be smart enough to continue to invest wisely, using health as a currency for peace around the world.