A Privilege
12/10/11
Posted by Ahmed Salem, DO (a third year Internal Medicine resident from Kaiser Permanente, San Francisco serving a global health elective in Cairo, Egypt at Kasr Al-Ainy Hospital, Cairo University through the Resala organization.
It was truly a privilege to have the opportunity to work alongside physicians and medical professionals in Egypt. It was an enriching experience which allowed me to reconnect with the reasons for why I went into medicine in the first place. Every moment that I spent with patients I felt my intentions were pure and that I was there to serve and provide any assistance to the best of my ability. I was able to practice medicine in the largest academic/county facility in Egypt and witness health disparities in a large urban center up-close and personal. I was also able to see how major public health issues, such as the Hepatitis C epidemic, are being dealt with in the developing world. I was fortunate to be able to part take in providing free medical care to underserved rural populations. I worked with an organization based in Egypt and run by locals that has done amazing work throughout Egypt and the entire Middle East. It was truly inspirational to see how people, who despite having their own financial struggles, were giving so much to help others who were in even more dire situations.
On other fronts it was a pleasure and an honor to witness and be a part of history. The current Egyptian revolution effectively removed a 30-year old dictatorial regime which had stifled the both the advancement of medical knowledge and access to advanced healthcare. The change in the Egyptian culture, mindset, and political framework was truly palpable. I felt extreme optimism and hope throughout the streets of Cairo. I am fortunate to have witnessed the first legitimate elections in Egypt’s modern history, which may very well lead to an economic and scientific revolution in Egypt.
I feel grateful to the KP Global Health Program for facilitating this amazing opportunity. I have been fortunate to participate in international medical trips as a medical student and as a resident at previous programs. The Kaiser Global Health Programs excels above the others because of two key components: they allow you the necessary time and the necessary financial assistance for an enriching experience. I feel connected to international medicine and I hope to continue this needed work throughout my career.
Optimism, Hope, and Satisfaction
6/27/11
Posted by Tara Hulbert, DO (a second year Ob/Gyn resident from Kaiser Permanente, Oakland serving a global health elective in Jalapa, Nicaragua with Prevention International: No Cervical Cancer (PINCC)).
The first day is always chaotic. That is what Carol, the Prevention International No Cervical Cancer (PINCC) director told us. I felt myself relax and remembered why I love working abroad. We come with goals and ideas of how we want to help and make a difference, but the local environment will ultimately dictate the work done. And the environment is difficult to predict. PINCC has a successful track record of working in many different countries in a variety of settings, so this “chaos” is something written into their agenda. I had come on the trip with Dr. Gupta, one of my own OB/GYN attendings who is fluent in Spanish and well-versed to international work. So I knew whatever the day and trip would bring, there would be plenty of support.
Briefly, PINCC is a unique, truly sustainable educational NGO that focuses on bringing the World Health Organization’s “see and treat” method for preventing cervical cancer to different communities worldwide. In developing countries, cervical cancer is the leading cause of cancer mortality in women – which is in stark contrast to the rare incidence of this disease in developed countries which illustrates how preventable it really is. This method is important where pap screening programs are not possible due to cost, resources, and access. PINCC strives to bring these methods to local doctors and nurses with rigorous training and close follow-up over several years. The volunteers on my leg of the trip had just returned from San Salvador where they watched a PINCC trained and certified local doctor training several other medical personal from around the community in a busy clinic. Some of the volunteers had been to the first trip several years prior where that doctor was first being trained. It was an emotional moment for them as they were truly seeing the sustainable nature of PINCC’s work.
The first day’s agenda included reviewing VIA (visual inspection with acetic acid), with the attendings and residents from the local OB/GYN residency program and then we would see about 40 of the pre-screened women with difficult cases from the community. Some of these doctors had already been trained and certified from PINCC. This is what makes PINCC so unique and special – the follow through which ensures that the education and training is being practiced. Once we started seeing patients, I was assigned a few local doctors to work with. As a resident, my job was to observe how they went through the steps of VIA and chose the appropriate treatment and follow up. I surprisingly felt comfortable with my limited Spanish giving my opinion on diagnosis and plan. I worked closely with my own attending and medical director for any questionable cases. We worked with this same group of doctors the rest of the week, did cryotherapy and LEEPs (both treatments for cervical dysplasia), and put on educational sessions with the residents including simulation labs with the LEEP machine. The week ended with a wonderful evening out on the town with the PINCC volunteers and dancing with all the Nicaraguan doctors we had made friends with.
VIA training
The second week proved to be much more challenging. We trained primary care doctors from outlying towns for the first time. The VIA method takes a lot of time and practice to become proficient, which became very clear with this new group of doctors. I also learned how much misinformation the patients were getting about cervical cancer and HPV, the unnecessary worry and stress over vague lab results, the difficult situations and distances these women had faced coming to the clinic, and how challenging filling prescriptions and getting lab results was.
The rest of the week was spent doing lectures and seeing patients with this lively group of doctors. Dr. Gupta and I were exhausted every night but we were rewarded by the motivation and progress of the group. The PINCC volunteer group was amazing and absolutely devoted to the project which helped to make our work as providers seamless.
In conclusion, my global health experience with PINCC was everything I hoped it would be. Most work trips I have done in the past have left me wondering if I really made any difference at all. This trip was different. I understood I was part of a process, a meaningful process that would help to transfer a specific life-saving skill to the hands of the local doctors that could and would help to save many women’s lives from a preventable cancer. And I left with optimism, hope, and satisfaction that PINCC was truly doing something positive in every community they touched and I was honored to be a part of it. My self growth was also very apparent throughout this trip and was very fortunate to accompany and learn from Dr. Gupta, who is an inspiring obstetrician/gynecologist devoted to global health, on this trip. I look forward to being a future PINCC supporter and volunteer in the future.
Me, Dr. Gupta, and fellow PINCC volunteers
My Matibabu/Kenya Summary
6/27/11
Posted by Erika Kwok, MD (a third year Ob/Gyn resident from Kaiser Permanente, Santa Clara serving a global health elective at Siaya District Hospital and The Matibabu Clinic in Kenya).
Arriving at the Nairobi airport on April 3 after 24 hours of flying, I was both excited and nervous about what my experience in Kenya would be. This was my first visit to sub-Saharan Africa. My experiences in Peace Corps Morocco certainly prepared me for traveling in a developing country, but I had no idea what to expect in Siaya and Ukwala.
We traveled to Kisumu via Kenya airlines and immediately drove to Siaya District Hospital where we had a tour of the facilities. While walking through the hallways, women came up to us with their pelvic ultrasound images asking us for advice and surgery. Even though it was a Monday (and not the GYN clinic day), we opened an impromptu clinic and started seeing women and booking them for surgeries. Then we continued on to a tour to Ukwala to see The Matibabu Clinic as well as the new Matibabu Hospital under construction.
Our first day at Siaya Hospital for the Tuesday GYN clinic started with a tall stack of charts and women waiting in the halls for us. We saw so many women I lost track of the number (perhaps 30-40?). We saw women with leiomyomata and uteri extending to the xiphoid as well as 4 women with advanced cervical cancer. Women do not receive regular cervical cancer screenings here due to lack of medical providers and education. It highlights the importance of cervical cancer screening, as we see so few advanced cervical cancer cases in the United States.
The following Tuesday, we again saw GYN patients in clinic. It’s amazing to me that they knew about our coming in advance and waiting for these particular clinic days to come to the hospital in hopes of having a surgery. There is only one trained obstetrician/gynecologist at the Siaya District Hospital. The other medical officers are essentially residents who teach themselves how to do cesarean deliveries and appendectomies so anyone who needs a hysterectomy or other specialized surgery has to wait for the one day a week that the surgeon operates. The overwhelming ratio of one gynecologist to an entire district of women highlights the need of the community for more surgeons.
We saw a woman with the complaint of copious vaginal discharge and bleeding and stated that a “white doctor” put something inside her vagina 2-3 years ago. Turns out she had not removed her pessary during all that time!
On our first OR day, we found out a laboring woman had died and had a perimortem cesarean delivery earlier that morning and the staff was still shaken from that event. We did an emergent cesarean delivery for a woman who had been laboring at home with a history of prior cesarean delivery in August 2010. She was taken to another hospital and turned away because of her bleeding and lack of blood products available. She was then brought to Siaya District Hospital for surgery and cesarean delivery was done for posterior uterine rupture. Her hemoglobin was 4.1 g/dL and she had large blood clots in her abdomen. Given the prolonged amount of time between uterine rupture and surgery, the infant did not survive. We also did an ovarian cystectomy for “Millicent” and noted significant tubal scarring which may have been causing her pelvic pain.
We had 2 more OR days while at Siaya District Hospital and performed some hysterectomies, myomectomies, and then ruptured a large tubo-ovarian abscess in an HIV positive woman.
I have to admit, I was completely unprepared for operating in Kenya. The availability of instruments, sutures, and staff is limited and many items that we consider single-use are used multiple times. It made me deeply appreciative of the equipment and OR staff that we have in the U.S.
I went to The Matibabu Clinic in Ukwala later in the week and spent time seeing patients. I had never seen a patient with malaria and I got the chance to see many! We went to a children’s club in the afternoon and talked about de-worming. We handed our albendazole to adults and children as well as USAID food/milk and vegetable seeds to the families.
I did two cervical cancer screening days with the community health workers and midwives and discussed cervical cancer education while I was volunteering with Matibabu, which was one of my favorite parts of my experience. In many ways, giving women education about their health and how to initiate change is an enormously empowering act, and it is a way that volunteers can profound impact the lives of many. There are only so many women that you can operate on or see in clinic but knowledge can be passed among women in a community indefinitely.
My experience in Kenya was one filled with gaining more clinical knowledge about OB/GYN in addition to learning about medical care in rural Kenya. The work I did there is small in comparison to the knowledge and experience that I gained from the patients I saw and the health workers I met. I saw advanced disease that is luckily rare in the U.S. due to our medical system and patients’ knowledge about their health, and it highlights the privilege we have in taking care of our patients here. I am grateful for the opportunity to volunteer with a community driven health center like Matibabu/Tiba Foundation during my residency training in OB/GYN, and it has given new purpose to my work here as well as my future goals to volunteer internationally.
Clinica Esperanza
Posted by Jillian Main, MD (a second year Ob/Gyn resident from Kaiser Permanente, San Francisco serving a global health elective at Clinica Esperanza in Roatan, Honduras).
Upon arrival to Clinica Esperanza, I was impressed with how new and fully stocked the clinic was. I have worked at clinics in Guatemala, Mexico, and Ecuador, and this was by far the most modern and comfortable. There were ample gloves, hand gel, towels, gowns, medications and medical supplies, which led to a safe practicing environment for both the patients and practitioners.
The patient population was made up mostly of the local colonies of the poor immigrants who settled on the islands after the major Honduras hurricanes. These “towns” are called “La Colonias.” The average income is about $3,200 per family/year and they have very little access to healthcare. There is one public hospital, at which I had the opportunity to work, and it has virtually no financial support. There is no drinking water, toilet paper, or soap, and the wards are made up of 8-10 people in a room of beds without curtains. It only costs the patients fifty cents per visit, but they may end up waiting all day without ever seeing the doctor. Therefore, there is a huge local support for Clinica Esperanza.
My experience was mostly based in the clinic. They have a new Labor and Delivery (L&D) ward, which is still awaiting licensing, so it is not yet open. I worked from 8 am – 2 pm daily, seeing both routine gyn and obstetric patients, but also the more sub-specialized Ob/Gyn patients. I managed many teen pregnancies, gestational diabetes, pregnancies complicated by malaria, multiple missed abortions and outpatient management of pyelonephritis in pregnancy. I also saw several patients with secondary amenorrhea, in which I had to decide if a certain lab, which would I would normally reflexively order in the US, was worth the cost of one month’s salary. I had to rely on my history and physical to make the diagnoses and could only use labs as supplementary.
There is a strong need for women’s healthcare and advocacy in Honduras and I hope I was able to educate both the patients and the permanent clinic employees on how to better address these issues. I plan on working from the US to help involve a clinic based Ob/Gyn attending for more difficult cases and to help organize the infrastructure of the L&D. I plan on returning next March during my elective time to continue these goals. It was overall a great experience and one I would recommend to any second year or above Ob/Gyn resident.
Weeks 3 & 4 – Port Maria and Port Antonio
Posted by Chung Lee, MD (a third year pediatric resident from Kaiser Permanente, Oakland serving a global health elective at Issa Trust Foundation in Ocho Rios, Jamaica).
5/31/11
Port Antonio
My last week of Port Antonio Hospital was a slow day on the ward as well as clinic, having only 2 patients to be seen in clinic which was a contrast to the previous week which had us working with no breaks up until the moment we left. One was a young girl I diagnosed with inguinal hernia and referred to the Surgeon down the hall and the other was a 7 month old baby who was unable to make it to the appointment but had been referred for evaluation for achondroplasia. I listened to the social worker who was there representing the mother and she explained how the mother had come several weeks to see a pediatrician but that the weeks she had come, there were no pediatricians available and today both were unable to make it due to a complicated social situation. The baby was apparently disproportionate in size with short extremities and a description that fit but had not been formally seen or diagnosed with a genetic condition. Of note, there are also no medical geneticists on the island in addition to other pediatric subspecialties.
On the way back from Port Antonio, the Ministry of Health employee who was kind enough to drive me back the two hours back to the resort explained to me all of the different type of plants and fruit trees lining the road ranging from banana trees, breadfruit trees, mango trees, and ackee trees. I expressed my interest in trying ackee and saltfish which is a national Jamaican dish. He stated the dish was delicious with breadfruit, but he warned me that ackee that is picked too early can be poisonous. Other people who call this dish the Jamaican Rundown, told me that one has to be careful about who you buy your ackee from but that the dish is very delicious. I asked one of the doctors at Annotto Bay about this, and she told me there was recently an outbreak in ackee poisonings this past year with a spike in the number of cases. Due to ingestion of ackee that has not fully matured, the toxin Hypoglycin will lead to hypoglycemia and symptoms of vomiting, stomach cramps, and diarrhea and in severe rare cases, coma or death. I found this useful information to know and has somewhat dampened my curiosity in trying this fruit.
Ackee fruit
The next two weeks at Port Maria were busy and a week after the departure of my wonderful colleague Dr. Hack, I found myself incredibly busy seeing 26 patients in clinic one day from 9 AM to 4PM. I realized how just like at the end of any rotation, you start feeling comfortable with how things are run right when it’s about time to leave. One of my more complicated cases was a preadolescent boy diagnosed several months ago with HIV but who was not aware about his diagnosis. He came in with 3 weeks of cough and a rash which looked like tinea versicolor. I obtained a chest xray which revealed an infiltrate, keeping in mind that the mother stated he had been on several weeks of an antibiotic which finished a week ago, but now was not on any medications and that his first appointment to discuss his condition was next month. None of this information was located in my paper chart and without any previous labs or other information about which antibiotic he previously was on, I discussed a plan of care with the ER doctor who knew him well and sent him to the A&E for further work-up including a CBC, viral load, CD4 count and initiation of antibiotics.
The rest of my clinic visits at Port Maria in the last two weeks were the same ranging from well checks, scabies, deworming, a variety of skin rashes and referrals to other hospitals for conditions requiring surgical intervention. Three medications that I felt helpful to know were Tropovite Vitamin Drops which contain Vitamin D, Hemafed which contains iron, and Rid Cream for scabies and lice. I would ask to peruse the pharmacy counters before clinic on days I had time because knowing which medications were available in the pharmacy is invaluable to avoid having families paying out of pocket for medications at private pharmacies when alternatives can be easily picked up at no cost here.
Another thing I take for granted in the states are scheduled appointments. I find it hard to take breaks knowing that patients arrive at 9 or 10 in the morning for an appointment. Once a parent even pretended his son was another patient so that he could be seen earlier and I only discovered this after the parent of the actual child asked why they had not been seen yet. Due to this, I have made it a habit of asking the parent the child’s birthdate before starting the visit. I’ve also gotten used to adults randomly walking into my room, even in the middle of a child well check, and start telling me their ailments. I always have to gently cut them off and explain to them that the family practitioner across the hall can aid them and that they have to wait for their turn.
Long lines
Here are a couple of photos of 2 adorable children seen in the clinic: (written consent obtained from parents).
Week 2 – Annotto Bay and Port Antonio
Posted by Chung Lee, MD (a third year pediatric resident from Kaiser Permanente, Oakland serving a global health elective at Issa Trust Foundation in Ocho Rios, Jamaica).
5/27/11
During the second week of our stay, I enjoyed rounding with Dr. Fisher and the ward team on the inpatient service. There were several interesting cases ranging from rule out kawasaki disease, seizure disorders, and asthma exacerbations. There was one case where a parent believed that bad spirits were causing the medical disorder, and did not believe giving the anti-epileptic medications recommended to treat the disorder would help, asking instead to take her child out of the hospital to see a medicine man that day. One of the doctors and an ambulance worker explained to me that there are people with voodoo beliefs and they can be suspicious of medical treatment, preferring to go instead to those they believe can make the bad spirits go away. This can present as a challenge for medical doctors who are trying to give a child the medical treatment they need and to educate a parent about the condition.
The following day, we had a short clinic day where I saw several well checks, a follow-up for sickle-cell disease, and a girl diagnosed and treated for kawasaki disease whose coronary aneurysm had resolved and was getting ready to graduate the clinic. I was surprised to hear that there was no clinic in the afternoon, and then was informed of a special event that afternoon where the ISSA Trust Foundation was donating incubators and a combination incubator and ventilator to Annotto Bay! Everyone was very excited because this equipment would help improve the care of premature babies in keeping them warm instead of having to improvise by wrapping them in cotton which is not as effective in maintaining their temperature. It was a very exciting day for Annotto Bay!
Here is a link to an article about the event ~ Incubators for Annotto Bay.
The following day, we headed towards Port Antonio, which was a 2 hour drive. We were very thankful for the kind employees who drove us back and forth to this hospital where there are no pediatricians. We helped run rounds where we saw a sick baby with abnormal electrolytes and a boy with sickle-cell pain crisis and acute chest syndrome. We made recommendations to get a CBC, BCx, CXR, and give oxygen and were concerned enough about the progression of one of the children that we called over to Annotto Bay for a possible transfer. I was informed later that the baby’s electrolytes normalized, but the patient with sickle-cell ended up having to be transferred to Bustamante. It is nice to know that we can easily call the ward team or Dr. Ramos with any questions about patients who give us reason to be concerned. One thing that struck me after having rounded on the patient with sickle-cell was that there are no pediatric subspecialists on the island particularly hematologist-oncologists. That is still a fact that I am trying to digest.
Afterwards, we attended to clinic and did not eat lunch in order to see all the patients there. We ended up having to split one room which felt chaotic but were able to see everyone by the time we had to leave. Overall, we agreed that there seems to be a great need for pediatricians at Port Antonio and were thankful for the experience to participate in the care of children there.
Port Antonio Ward
That weekend, we had the pleasure of having dinner with Diane Pollard, Dr. McConkey, her husband, and two Biomed volunteers. It was such an inspiration to hear their ideas and new developments coming in the future for the hospitals and the rotation that will make a positive impact by improving pediatric care. During my experience here, I have had times where I initially felt powerless as a physician when certain resources were not available, but after these weeks, I realize it is empowering to know that one can help out by donating needed resources, spreading awareness, or volunteering.
After a long busy week, we were able to enjoy Jamaica by going bobsledding and ziplining through the Jamaican Rainforest at Magic Mountain in Ocho Rios. Here is a beautiful view from a sky lift showing the coast.
Hello again from Jamaica!
Posted by Chung Lee, MD (a third year pediatric resident from Kaiser Permanente, Oakland serving a global health elective at Issa Trust Foundation in Ocho Rios, Jamaica).
5/15/11
This week began with two days in Port Maria, with my colleague spending time in the A&E while I worked in the clinic. Here’s a photo of the front of the clinic. Each day we arrived to a line of people who have been there since 8 am waiting for clinic to open. It seems to be first come, first served with the clinic starting at 9 am.
It was Child’s Day on Tuesday so we got to see the children for their well checks. While seeing babies, I found a measuring tape useful to have since we measure the length and head circumference of each baby ourselves. I looked up each growth percentile in my Harriet Lane Handbook to ensure that the babies were growing well. There aren’t growth charts in all of the paper chart files due to resources, so we document everything by percentile in the paper charts, which is helpful for the next person who sees them in terms of following a growth trend. Also, if you think a baby is jaundiced and you want a bilirubin level, after 11 AM you would have to draw it yourself in clinic and have it dropped off at the lab. I was really surprised to hear from the lab how much blood is actually needed for a bili draw as the lab or nurses usually draw it at my home institution. Dr. San and Dr. Win have been a great help in asking questions about what is available in the pharmacy here and what is used to treat patients for certain diseases. The cases we saw ranged from scabies to viral gastroenteritis to parental concerns about worms.
One thing I take for granted in the states are strep swabs. In the states, if you hear a complaint of sore throat and suspect strep, you can get a strep screen and if it’s a positive treat, which is important to prevent the complication of rheumatic fever. Here, there is no rapid strep screen so if you suspect, you treat. Dr. Win told us that there have been cases of rheumatic fever this past year and it reminded me of the child I saw last week who was being treated with month shots of penicillin for the past year after being diagnosed with rheumatic fever. I have only seen one case in the states of Rheumatic Fever and here it is definitely more prevalent.
On the second day of clinic, I saw this adorable 2 year old boy who had right periorbital cellulitis with bilateral bacterial conjunctivitis. I had the child admitted for IV antibiotics and observation and found out from the other ER doctors to refer him to A&E for admission. Port Maria also has a ward which we haven’t seen yet and I assume he went there since I did not see him the following day at Annoto Bay. One of the benefits of having electronic medical records back at home is being able to follow up on kids to ensure that they are seen and admitted.
After a busy day at the clinic, we have our 30 minute drive back to the resort. Here is a view of driving through Port Maria where you can see different stores and daily life.
At the end of the day, it is always so nice to come back to the resort. We have been welcomed by such friendly people and my colleague and I are always amazed of the beauty of this country.
Week 1 Welcome to Jamaica
Posted by Chung Lee, MD (a third year pediatric resident from Kaiser Permanente, Oakland serving a global health elective at Issa Trust Foundation in Ocho Rios, Jamaica).
5/5/11
Hello from Jamaica! It has been a wonderful first week and after getting settled in, we started our first day of clinic this Tuesday at Port Maria’s clinic and A&E department. We split up our time between the A&E and clinic but the ED was slow with not much pediatric cases so we both ended up working the clinic which was busy with pediatric patients. I ended up seeing 9 patients or so the first day and it was pretty busy in the morning! One difference I noticed was the lab is open in the morning for several hours and if you miss that window, you have to draw your own labs which we ended up having to do. A CBC is fast to run with results in 10 minutes, but we sent for coags which ended up being a send out and can take 3-4 days and cultures even longer. It makes you really think about whether you really need those labs and how to manage your patient, given your clinical judgement, knowing that it may take a while for labs to come back. I saw several gastroenteritis cases, a primary herpes gingivostomatitis, asthma exacerbations, and well checks. It all seemed similar to urgent care clinic that I see back in the States. In the beginning of the day, there was a long line outside of the clinic but by the afternoon we were able to finish seeing everyone. Week 1 – welcome to Jamaica 
The next day we went to Annoto Bay Health Center and participated in rounds on the ward. The set up had all the beds and cribs in one room with a mixture of pediatric ward, NICU, and well baby! I was really impressed by the rounding, the residents, and Dr. Ramos whose teaching was thorough and engaging. There were interesting cases from r/o sepsis, r/o ITP, RDS, IDM to discuss and it was basically sit down rounds. There is also a need for certain medical equipment including neonatal blood pressure cuffs which the physicians are working on getting and hopefully will come soon.
Today we had clinic at Annoto Bay Clinic and again saw a huge line of patients until everyone was seen. I saw a kid for a well check with a h/o rheumatic fever which is more prevalent here in Jamaica, as well as newborn well checks and urgent care visits. I did spend time making sure to give dental education for my patients during their well checks since there is not as much access to dentists here. It has so far been an amazing experience thus far and we have been so grateful for this opportunity!
Monrovia: conclusion (Spring 2010)
Posted by Rachel Ng, MD (a third year Internal Medicine resident from Kaiser Permanente, San Francisco who served, in Spring 2010, a global health elective at John F. Kennedy Memorial Medical Center in Monrovia, Liberia through the Yale/Stanford Johnson & Johnson Global Health Scholars Program).
It’s been over a year since my return from Liberia. As I approach the end of my residency training, my Liberia trip will definitely be one of the unforgettable highlights of the past 3 years. Again, I am so thankful for the incredible opportunity and support from the Kaiser Global Health Program and Yale/Stanford Johnson and Johnson Global Health Scholars Program. I hope that the medical students and residents reading this blog (and even non medical readers) will seriously consider doing an international elective, medical missions, or some kind of volunteering trip abroad that will truly enrich your practice as a clinician. Thank you also to other current KP residents for sharing all of your memorable stories and experiences of times abroad.
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| Aerial view of Liberia |
This will be my last official blog about my Liberia trip that took place during Spring 2010. In my last entry, I left off at the part of my trip where my teammates and I had the honor to meet with Liberia President Ellen Johnson-Sirleaf. Thereafter, we also briefly traveled off the beaten track to marvel at the beautiful land and seascape of Robertsport.
The final 2 weeks
So it was, energized and ready to head back to the hospital for the final 2 weeks of my trip. Knowing that the remaining time will pass quickly, I treasured, even more so, each moment of working with the staff I have come to know dearly and of seeing the patients whose conditions were now more familiar to me despite not having the diagnostic tools so easily at my disposal as I would have back at home. My patient panel had grown to become a TB service with pleural effusion +/- chest tubes, advance liver disease, pneumonia, cellulitis, and HIV w/ a few presenting with kaposi’s…seemingly not a very good outlook. And some patients inevitably died. However by that time, I had come to terms with the limitations of what the system could provide. And systems issues take time to change. Thus in a setting of what I have termed “medical poverty” (vs. “medical abundance” whereby there is more than enough of the basic medical support in infrastructure, persons, and supplies to treat all general medical conditions)—and similar to what many other residents on the KP Global Health Blog have already noted on the theme of limitations and humility—there is the realization that the art of medicine goes so much more beyond simply offering curative treatment. How much more can be offered by compassion, a listening ear, and the human touch. Below are a few more anecdotes.
My first hospice patient
In the middle of the night, an old man was admitted onto the hospital ward, accompanied by his young son. The patient had apparently not been eating well for the past week or so and was then very weak and confused. He had also stopped urinating for many days. Long story short, renal failure was suspected with major electrolyte abnormalities. No labs available. Hemodialysis did not exist. Patient was treated under comfort measures only and passed away the next day.
Events are perhaps not as scary when it is expected and not a surprise. And somehow, I felt more at peace with his death than any other I had encountered up until then (though still, any patient’s death is never “easy to deal with”). It led me to think how much good could potentially come out of a palliative care service/hospice at the hospital and community. If we cannot cure them of their diseases, at least we can lessen their suffering and preserve their dignity at the end of life.
The prisoner’s pain
Only a few times in my training have I treated prisoners who were still serving their sentence, sometimes handcuffed, and under the watch of nearby guards as they come into the hospital for treatment. This patient came to the hospital with right upper quadrant abdominal pain and a known history of hepatitis C. He was treated for acute hepatitis. As he clinically improved, he however continued to complain of mild lingering pain despite pain medicines given. Upon further questioning, it turned out he did not want to return to prison and thus had hope to delay his discharge but complaining of pain. Being such a subjective experience, he still very well could have had pain, but likely, it was another sort of pain he had—one related to the trauma and injustice he had experienced—per his account. And thus, what I did offer was a listening ear to hear out his story and offering hope and comfort as best as one human being could offer to another fellow human being while in one of life’s troughs. Unfortunately for this prisoner, because he was clinically improved and his acute abdominal pain was resolved, he had to be discharged back to prison.
The NGO community
Every so often, the NGO community in Monrovia would come together at a chosen restaurant for a game night. A fee is paid by each participating group that ultimately goes to the winner’s charity/NGO of choice. Typical of any city that has undergone unrest requiring UN involvement, the capital city was infiltrated with NGOs. Within a 5 blocks radius around the hospital, there must have been at least over 30 NGO offices dotting every street corner. During my time there, the Spain MSF (doctors without borders) announced their planned withdrawal from the country. Often times, the hardest part after a country crisis is not the acute stabilization but instead, the long term rebuilding of a community/nation whereby it once again becomes self maintaining/self-sufficient. Think of all the attention Haiti received after the earthquake. Where do things stand now?
Acupuncture
Somewhat conspicuous in their operation around the hospital, was a group of medical professionals from China. They came during a hospital development phase when medical teams from other countries came to help out. Of the different teams, they stayed behind and opened a clinic in the city offering treatments of acupuncture, moxibustion, and other traditional Chinese medicine remedies. One of the doctors on that team gave an interesting grand rounds presentation on meridians and acupoints. The speaker claimed that there were apparently over 600 diseases of internal medicine, pediatrics, ob/gyn, and ENT (ear, nose, throat) that could be treated with acupuncture! Of all places in the world, what a pleasant surprise to find the use of complementary/alternative medicine when traditional allopathic medicine can only offer so much.
Marshall Island
Another off the beaten track activity. My teammates and I ventured through near 2 hours of absurdly rugged dirt roads to the infamous Marshall Island. Our interest in this place was based on a just-as-ridiculous mythical story of the “one arm ape” that lived one of the islands. Scientists use to conduct animal experimentation on these islands. However, during the civil war, the scientists fled and the apes remained. At this point, the story became a bit muddled for me. It was not clear whether the one arm ape came about due to a scientific experiment gone wrong or that the ape unfortunately caught a grenade-having mistaken it for food. Anyhow, fortunately we did not catch sight of any apes missing any limbs. They were quite huge—size of 2.5 to 3 average-sized man put together! I’m glad they were friendly.
Heading home
And finally, the bittersweet day of my departure from Liberia had arrived.
Some of my final thoughts that day as I remember and looking back at my journal entry that day:
1) Next project: think about how to start an adult chronic condition clinic there (for ongoing hypertension, stroke, diabetes patients)
2) Would love to start an inpatient rehab program
3) Maybe in the future…hospice/palliative care service?
Thank you to my teammates, local colleagues, to the patients and their families, and many new friends met along the way, for making my experience as enriching as it was and for helping me see the beauty, strength, and hope of the land and people despite all challenges.
Hope to see you sometime again, Liberia!
Kendeja Beach
By the Lake
February 2011
Posted by Kathleen Chin, MD (a fourth year Ob/Gyn resident from Kaiser Permanente Oakland serving a global health elective at Hospitalito Atitlán in Santiago Atitlán, Guatemala.
The plane flight seemed short in comparison to the windy drive through the mountains to the beautiful lakeside village of Santiago Atitlan. I read through the volunteer orientation manual that had been emailed to me before departing from San Francisco and looked forward to meeting the hospital staff. On my first day of volunteering, I strolled a quarter of a mile down the street, with a short-cut through the coffee bean plants, to the recently constructed Hospitalito Atitlan (a beautiful building that was recently erected due to mud slides that destroyed the previous Hospitalito). Morning rounds took place promptly at 7:30 am and I was introduced to local hospital staff and other international volunteers. It was amazing to see how many health professional volunteers from various cities in the US and other countries abroad had congregated in this remote village in Guatemala to help the community.
My first day was spent orienting myself to the clinic: learning how the clinic flow worked, figuring out the buttons in Spanish on the ultrasound machine, becoming re-familiar with the traditional “spatula and spray” pap smears, and trying to recall basic Spanish phrases I learned from my brief medical school Spanish class. A medical student would typically accompany me in clinic and assist with the Spanish-to-English interpretation, however often the patient and her family members only spoke the local dialect of Tz’utujil so we would patiently wait for one of the hospital staff to help us with the Spanish to Tz’utujil translation. I found the majority of the hospital staff had many roles, such as the pharmacist whose responsibilities also included assisting patients with their follow-up appointments and billing.
The second day on the job I was assigned to OB specialty clinic but a pregnant patient arrived in labor and her baby was breech by ultrasound. Most prenatal patients plan to deliver at home, but this patient was told during her prenatal care to come in to the hospital due to the unstable lie of the fetus. We consented her for a Cesarean section. The operating room was spotless. Her surgery and recovery were uncomplicated and she went home on post-op day two with her healthy baby boy.
Three weeks passed more quickly than I imagined and I learned what the true meaning of hard work is from the Guatemalan women I cared for. It was a wonderful experience learning about the beautiful culture and community that focuses on the family as a unit. I hope to return to Guatemala at some point in the future.
