Archive for June, 2010
Upon arrival at the airport in Managua, we were warmly greeted with a big sign and everlasting hospitality. We stayed in Jinotega, a small town in the mountains two hours north of Managua.
The next morning we saw over 40 patients in clinic and scheduled many of them for surgeries including exploratory laparotomies for newly diagnosed pelvic masses, hysterectomies, surgery for prolapse as well as incontinence procedures. We wasted no time and started the surgeries on our first day. I was challenged clinically in ways I’ve never considered. Limited by resources, we had to think about what materials were necessary so we could be as strategic as possible with the limited equipment we had. We often found ourselves improvising throughout the procedures and our time in clinic. Scant light, limited suture supply, minimal suction, and with basic instruments I quickly became thankful for all the materials we easily take for granted as surgeons in the U.S. “We simply do the best we can with what we have,” Dr. Sklar, my mentor, often reminded me throughout the trip, one time when the lights and power in the operating room went out in the middle of a doing a hysterectomy.
The patients are forever memorable. For all the major procedures we used spinal anesthesia and out of almost 40 surgeries completed on this 10-day mission, there were no pain issues. I can still vividly recall the smiles on their faces as they lined up in the late evening after we had finished a full day of surgery so that we could evaluate them in the clinic. Women who traveled 6-8 hours by several bus routes were quick to wrap their arms around us and embrace us with gratitude and a warm welcome to their community. Their smiles persisted immediately postoperative and every morning as we rounded on the patients. I will never forget their smiles.
Despite the language barrier and the cultural differences, I was able to form relationships with the people in the community. The little children whose mothers worked in the clinic spent hours there and were quick to befriend us. At any given break, I ran to play with the kids. They taught me games and songs and seeing them day after day it was impossible to not become attached. The local physicians ate lunch with us daily and we shared personal stories, cultural experiences, and clinical advice. It was impossible to not notice that despite how little they have as far as monetary things they are spiritually complete. I was envious of the sense of community and love that is disappearing in the major cities in the U.S.
One night we took a stroll around the village to learn more about the city and people of San Rafael del Norte, which is where the hospital was situated. We walked up a hill to the town’s cathedral. It was simple yet magnificent and we enjoyed one of their ceremonies. As I looked around the church it was striking to witness how these people are full of so much love and happiness. They hold each others hands in church, walk in the streets late at night, children play soccer outside at all hours, all the doors to their houses are wide open all day so as to welcome neighbors, couples walk holding hands, and everyone is smiling.
On the last day of our trip everyone involved in the mission and clinic threw us a celebratory dinner. Over 40 people attended and the room was full of warmth and appreciation both on behalf of the local physicians who worked with us, the ancillary staff, and me and the other two visiting physicians. Being privileged to be a part of a smaller medical mission with only two other physicians, I was able to be involved first hand in leading a medical mission. I learned that to make the most of a medical mission it is important to: 1) be flexible, 2) be willing to work with the local staff and 3) remember that you are a visitor…culturally and professionally. I am forever thankful to Dr. Diane Sklar for being a role model and taking me under her wing as she showed me the ropes to spearhead a medical mission. A flame has been ignited within me to be involved in more medical missions in the future as a new passion in me has surfaced.
Posted by Rachel Ng, MD (a second year Internal Medicine resident from Kaiser Permanente, San Francisco serving a global health elective at John F. Kennedy Memorial Medical Center in Monrovia, Liberia through the Yale/Stanford Johnson & Johnson Global Health Scholars Program).
Half way through the rotation—time is passing quickly!
Answers to last post’s images:
-CXR #1: miliary tuberculosis
-CXR #2: tuberculosis pneumonia. The film is rotated. There is pleural thickening vs. loculated pleural effusion on left lower lung field. And other gross abnormalities….?!
This past weekend was marked by coming and going of new volunteers. While our guys from the Hospitals of Hope left, we surprisingly received a team of surgeons along with a couple of emergency medicine residents. It was a great addition of much needed skills to help out with the many trauma, tumor, and infectious cases.
Meanwhile, midweek on March 10, 2010 was an observed holiday—Decoration Day. Much like Memorial Day in the U.S., this holiday was a time to remember the dead—the many people who had fallen during the war. Near downtown is a huge public cemetery.
The rest of the week continued to be challenging with lack of manpower, varied and new pathology including tetanus and ascaris, my patient panel with growing number of liver disease patients, etc. The x-ray situation continued to present many setbacks of patients unable to pay upfront for x-rays. Or else if they qualified for free xrays, then it was a matter of not being able to find the stamp of approval for their free x-rays (HIV patients receive free medical care under the Clinton Foundation, after their initial diagnosis and registration into the infectious disease clinic). Or else, pushbacks from technicians about not having enough films. Etc. etc. etc.
Let me say however that despite situations being grim, not all is lost, and really not as depressing and whiny as my blogs may be sounding. Despite not being to run successful codes here for now, there have still been many miraculous and beautiful moments. The gentleman whom I mentioned in my previous blog is about to be discharged, as well as the boy who came in with tetanus—originally so spastic as to resemble almost status epilepticus—now ready to go home and walking on his own. Healing and cures do occur.
And thus, another week went by. Over the weekend, I had some time to get to know more the land and people here. There is also almost a sense of renewed innocence in the city—one that comes from hope after the war? I have not heard much war stories from the people around me, but as I have read before, it was truly a time when “hell on earth” existed. If so, I can understand…who would want to retell and re-live that experience, even verbally. And so, Reconstruction continues.
This weekend also included a visit to the National Liberian Museum. I believe there is a small little blurb about it in the Lonely Planet chapter on Liberia. The exterior of the museum building was colonial appearing. However, as I stepped inside, I found a large room sparsely filled with scattered items. It was pretty sad at first sight. Nevertheless, my friends and I struck up a conversation with a tour guide who met us at the door. Systematically, he showed us significant wooden furniture pieces belong to the country’s past presidents. We also saw old currency—thin metal sticks of varying lengths, made from iron, bronze, or gold, twisted at both ends—used before the introduction of the Liberian paper dollar. I can’t imagine trying to carry those things around. Other items around the room included a very old flag (Monrovia used to be called Christopolos or “city of Christ” and the very first flag of Liberia was with a cross on it. Later the capital was changed to its present name, after US President Monroe.), masks, clothing, and couple of communication drum (back in the days before telecommunication existed, people were called to the town center via communication drums placed strategically at interval distances away from town and as one drummer hears the original drum sound, he would hit his drum, and so on).
At the very end of our tour, we had a nice little traditional African music concert with the xylophone and samba drum .
Posted by Kate Pettit, MD (a second year Ob/Gyn resident from Kaiser Permanente, San Francisco serving a global health elective at The Matibabu Foundation in Ugenya, Kenya).
The first day I arrived in Kenya was a blur. I was lost somewhere between the traffic, grilled cheese, and noise of Nairobi and the bumpy roads, gorgeous landscape and peaceful quiet of Ukwala. When I finally reached my “home” in Kenya, I was met by an incredibly kind family, who offered me a room in their home, lots of green vegetables and wonderful stories. I was exhausted and Lucy led me to a friendly room with a bright blue mosquito net and old World Cup soccer pictures and articles taped to the walls. I had always wanted one of those four-poster princess beds as a little girl and I smiled, the blue net draping from the ceiling was pretty close.
I woke up the next day to what sounded like 55 roosters crowing outside my window. It had been pretty dark when I had finally arrived at the house, so I hadn’t appreciated the fact that there was an amazing virtual farm right outside my window. I peaked out and saw chickens, cows, and some goats, all making their morning rounds. I padded to the bathroom and met Lucy just outside. She gave me a bathroom tour and had just brought warm water for me to bathe. I took my big bucket of water and my small bucket to dump said water on my head and managed to keep most of the water from seeping out the door, quite an accomplishment for my first inside bucket shower. In the next couple days, I would sneak in to shower and just use cold water because it would wake me up faster and I didn’t want to waste the family’s warm water. I am from Washington and I used to swim in Puget Sound, so a bucket of cold water on my head was something that felt like home.
I sat down for breakfast the first day to one of the most delightful traditions in Kenya – amazing hot tea. It is a mixture of sweetness and warm milk and spiced tea that tastes good any time of day, from the breakfast table to the middle of a busy clinic. It is always offered and thankfully, no one ever lets you decline. I have tried to recreate it after returning to the U.S., and sadly, have not come close.
After breakfast, I walked down the road to clinic. Each of the children I passed screamed “Mzungu” followed by “how are you” with different intonations. Mzungu refers to people of European descent and the children will repeat it incessantly every time they spot you and “how are you” is something that is yelled almost like a cheer. When you respond, “fine, how are you,” they will often run away and giggle. I never tired of this exchange, no matter how many times it happened each day.
When I arrived at the Matibabu clinic, I was again met with kindness. I spent the first day working with one of the clinical officers, learning the ways of the clinic. She was great in taking time to explain each of the patients’ cases as I could not follow the Swahili or Luo words flowing back and forth. There were definite recurring themes – malaria, diarrheal illnesses, and often, all of this in the context of HIV.
The next several days in clinic, I began to work on my own with a translator with the clinical officer available for questions. I found myself seeing patients that brought me back to the tropical diseases of medical school. One child came in with a diffuse rash and a fever. The rash was somewhat unusual. I started the exam with how I had seen the Kenyan clinical officers starting, but first looking at the baby’s eyes. Right away, I noticed they were red and weeping. I looked again up at his rash. Then I had one of those “aha medical school moments” when somehow something you have read once upon a time springs up for you from some deep part of your brain. Cough, coryza, and conjunctivitis – the three C’s of measles. I quickly asked the mom to wait one moment and I would be right back. I walked out of the small clinic room to ask one of the clinical officers to confirm the diagnoses and they were of course unimpressed, having seen this many times before. I on the other hand was initially nervous (I stupidly first thought I would contract it from him, but then remember the M of MMR vaccine) and then fascinated. The little boy left with just pain medicine and a very strong mother to carry him all the way home.
My second week in Kenya was spent in Siaya, a small town about an hour from Ukwala, where the district hospital was located. This was the only hospital in the area and many patients traveled from far away even while they were very sick. The stories from Siaya were countless, but more than anything, I remember faces. I remember Sarah, with her gentle whispers in English and with such a bad pelvic infection that surgery left her with no chance of childbearing. Yet, she walked the day after her surgery to get some tea with her adopted mother like nothing had happened. I remember Jane who was only 30 years old and had a mass that was likely advanced cervical cancer, found too late. Her hematocrit was only 15, so low we could not even operate to take a biopsy and still, when we walked by, she would smile and wave out the window. I remember Susan, who had had polio and also had HIV and could not walk without support and needed a friend’s bicycle rack to travel more than 20 feet. She waited all day for her appointment and even translated for others in line at clinic. I left each day incredibly impressed with the strength of these women, both physically and emotionally. I was in awe.
At the end of my trip, I traveled back on the same bumpy roads upon which I had come with a sense of patience, appreciation and hope that will stay with me for a long time to come.
** All names of patients have been changed for privacy.
Posted by Irene Mason, MD (a third year Ob/Gyn resident from Kaiser Permanente, Santa Clara serving a global health elective at The Matibabu Foundation in Ugenya, Kenya).
I spent 2 weeks at the Siaya District Hospital in western Kenya through the Matibabu Foundation. Although Matibabu does not strictly work at the hospital, they were able to set up a surgical rotation for us. I went with Dr. Philip Miller, a recently retired Kaiser Ob/Gyn physician.
Upon arrival in Nairobi, we had an orientation to the Matibabu Foundation with Dan Ogola, a co-founder, and learned about the beginnings of the Foundation as well as the vision for its future.
Having made our way to Kisumu and beyond into the rural areas of western Kenya, we were embraced by the Matibabu clinic staff and given a tour of their facilities. One of their nurses, Celestine, was gracious enough to be our liaison during our time at the district hospital.
Upon our arrival to the hospital, we were given a tour of the operating theatre, the outpatient clinics, the female wards as well as the ancillary services. Several patients had been lined up for us as surgical candidates and were already admitted to the wards. We reviewed their records, examined them and discussed the indications for their surgeries.
The following day and into the first week we proceeded to perform hysterectomies. For 80% of these women, the indication for surgery was very large uterine fibroids which caused excessive bleeding and pelvic pain. The other 20% consisted of large ovarian tumors and uterine prolapse. We were consulted on 1 young lady who had HIV as well as advanced cervical cancer (manifesting as vaginal bleeding) for which she needed multiple blood transfusions. We made our recommendations for treatment, which did not include our performing a hysterectomy. We did not feel that we had the back-up in the event of massive blood loss or the need for an intensive care unit. We also performed one minor procedure- removal of a cervical polyp which was likely benign.
During any down time we had in-between cases, we consulted on other women who also had large uterine fibroids for which we set up surgery for the following week. I also had the opportunity to help conduct the GYN clinic. There we saw women for their postoperative visit, chronic pelvic pain, pelvic inflammatory disease and uterine fibroids.
Our preoperative work-up for these women would be a complete blood count, an ultrasound if needed and a good history and physical exam. We noticed that most women were chronically anemic, although asymptomatic, likely from years of malaria infection. Very few women needed blood transfusions. Only 2 of our 10 patients needed blood transfusions. We followed our patients in the postoperative period and managed their hospital care and eventual discharge.
I found the other surgeons and OR staff to be very helpful. I have great respect for these healthcare workers as they have many obstacles to overcome as they attempt to provide the best care they can for these patients.
Overall, I had a fabulous experience. The keys my good experience are: 1) having an open mind about what healthcare is like in a developing nation 2) only doing what is within your means with the tools you have- which is often much less than you are used to in the U.S. 3) creating good working relationships with the local staff 4) being prepared in terms of bringing many of the surgical supplies you may need 5) remaining positive about your experience.