Archive for February, 2012
Posted by Lisa Ryujin, MD (a fourth year Ob/Gyn resident from Kaiser Permanente Oakland reflecting on on her global health elective in Daet, Philippines with Bay Area Surgical Mission).
I came to the Philippines unsure about how I would feel about a trip concentrating on providing surgery. However, over the course of my time here, I have realized that providing these services to those who did not have the means sometimes meant changing lives. One of the residents and I would stay up late and discuss the ethics of the surgeries, making sure that we were supervised and performing the same roles that we had in the USA. We talked about the responsibility that we felt for our post operative outcomes and how important morning and evening rounds were in making sure our patients were well taken care of. My attending and I were talking about the ‘magical post operative day 2′ and how happy and pain free the patients were. They asked to take pictures with us and took the post operative medications with huge smiles. We also talked about how wonderful it was to work with the Filipino nurses an the familiarity of our own nurses. They worked together as a team, and at the end of the day, the patients always came first.
I’m so grateful that I was able to participate in such a wonderful group effort, it was a true pleasure, and I can’t wait to come back!
I had the pleasure to travel to Nicaragua in January of 2012. The trip was partially funded by the Kaiser Permanente Northern California Residency Program Global Health Program.
There were 9 physicians, 1 physician assistant and one registered nurse on the trip. Most of the other physicians had been on prior global health experiences, many of them to this particular region of Nicaragua. The trip organizer, Dr. Anthony Valdini, is a faculty member at the Lawrence Family Medicine Residency Training Program in Lawrence, MA. He has been to Siuna and surrounding communities annually on global health projects for the past 8 years. Several of the physicians were either current or past family medicine residents in Lawrence, MA.
We partnered with a non-governmental organization called Bridges to Community (BTC). BTC is a non-profit whose mission is to “build a more just and sustainable world through service learning and community development by engaging volunteers to work in developing countries–building community and changing lives.” With offices in New York State, they currently offer many programs in Nicaragua exclusively with plans to spread to the Dominican Republic in the near future. Medical trips are only a subset of the work they do. They help to arrange logistics such as food, lodging, transportation and community liaisons during medical brigades.
The area of Nicaragua we traveled to was outside of the town of Siuna in the Regional Autonomous Region of the North Atlantic (RAAN) to a community called Mongallo. While there we staying with a local family, the Trujillos.
Interestingly, there has been tremendous change in both the country of Nicaragua and the area of Siuna in the preceding years. The availability of electricity on a regular basis had spawned increased usage of cellular telephones, cable and satellite television. Infrastructure is still poor. Medications and medical services are available, but too costly and/or scarce to be widely or regularly available.
Once we arrived to the community of Mongallo, we set up at our “home” clinic at a regional health outpost usually staffed by a registered nurse. We had purchased medications and brought supplies with us from the United States. With the assistance of local health leaders from each nearby community, residents were instructed to come to the clinic to be seen by a health care professional. Once the word of our arrival spread, people were coming from several hours away to be seen. Additionally, we operated “field” clinics to communities further afield. These communities tended to have less infrastructure and more acute illness, many times preventing travelling to the regional hospital in Siuna. In addition to seeing patients, we helped to educate some of the local health leaders.
We saw a wide breadth of illness in Nicaragua. Many healthy people with musculoskeletal pain, parasitosis, dehydration, anemia, malnutrition. As Nicaragua has a very high birth rate, we saw many pregnant women. We also saw some hypertension, diabetes mellitus, coronary artery disease and other chronic diseases. When appropriate we offered medication, education or procedures to the patients. Follow up was to be obtained either by the nurse at our health outpost or the regional hospital. In cases where further testing or treatment was necessary, we would write a brief letter to the regional hospital. According to the team members who were returning, there was a notable decrease in acute medical conditions and increase in chronic conditions compared with prior years.
After one and a half weeks of clinic work, we traveled back to Managua, then on to a coastal community for several days of relaxation prior to returning home. While there, in addition to relaxing, we discussed our work in Mongallo and how it could be improved in the coming years. We discussed how to make our impact more meaningful and lasting. After much discussion, we started planning a 5-year strategic plan with goals for sustained improvement. We agreed on the need for an increased presence in the community, and hope to increase the frequency of medical brigades trips to the community of Mongallo. We also worked on the creation of a “Field guide” to document all aspects of setting up our field clinics, including a pharmocopia, common and dangerous pathology, procedures, equipment and logistics.
Now that I have returned to the United States, I am already planning my next global health experience and assist/encourage other residents in their own global health projects. Additionally, I will be co-presenting a Department of Medicine Grand Rounds in the spring on my global health experience.
Hadia and I just completed our second week at Clinica Esperanza. Our attending pediatrician was gone for 4 days (as there was a ventilator course for the new pediatric hospital) so aside from a family medicine attending with a rather busy schedule, we were on our own. The most interesting case I saw this week was one I was relieved that I consulted him on, as it turned out to be a case of Strongyloides! We also saw a case of Chickenpox this week; unfortunately families are told their kids “have had all their vaccinations” so this girl’s mother was puzzled as to how her child developed chicken pox when she had been “fully” vaccinated. We later discovered after talking to our attending that the place she was immunized at doesn’t carry the varicella vaccine even though it does exist on the island.
It’s impressive to me how many children we see for colds and other viral syndromes when families are waiting so many hours to be seen. I’m told some families come in as early as 5:00 AM to get a spot and the earliest we start seeing patients is 8 AM. By the time we show up to work, the indoor and outdoor waiting areas are pretty full. After learning more about the prevalence of mortality from pneumonia and diarrhea in developing countries, I now have a better understanding of why patients must present for what seem to be rather benign illnesses. Interestingly, one of my families presented again this week after I saw them for a URI last week. She said she took her baby to the hospital for her 6-month vaccines the prior day and they said the baby had noisy breathing and was too sick to receive the vaccines. They sent her home with loratadine and PO albuterol! She did not feel comfortable giving them and returned to see what our thoughts were, at which time the baby sounded great and was afebrile; we advised against either medication and to proceed with the vaccines the next day. Fortunately, Honduras has been quite strict about making sure children have their vaccines so we don’t have to really convince families to get them done(especially since we mostly just carry the flu vaccine for high-risk individuals and have to send them off-site). It felt nice to know she trusted us and didn’t want to give her child any medications she was unfamiliar with without checking with us.
This week there is also an Emergency Room doctor from the US who visits the clinic about half of each year so it has been nice to see what his take is on some of the local practices. I also enjoy working with the pediatrician and having the chance to exchange stories about how we each manage certain conditions in our respective countries and teaching each other our respective languages. I continue to learn about alternatives for medications we would like to use but don’t have; fortunately many rather young kids swallow pills out here but sometimes we have them just crush the adult pills if they can’t. We also can send them to a pharmacy with a prescription if it’s something we don’t carry but they may not be able to afford it.
We just had our second and last weekend to enjoy the beautiful island; it has been rather hot and humid but fortunately it looks like the rainy season is finally over for the year!
Yesterday was the hardest day of our mission. Our first case was a suspected endometrial cancer, and when we finished the surgery, we cut open the uterus and confirmed, but there was not time to stop, we had other cases waiting. The next case was a 26 week sized uterus who wanted a myomectomy to preserve her fertility, another hard case. Then, simple appearing ovarian cyst removal that ended up being ovarian cancer. We had to pause and think of our mission, do no harm, we had not consented her for a hysterectomy, and her spinal anesthesia was quickly running out. One of the local nurses ran out of the operating room to find the patient’s mother to ask for permission to take the uterus and the ovaries with the hope of low stage an cure. We waited as the patient got more uncomfortable. By the time the nurse came back to give us the permission, we had almost run out of anesthesia making the surgery impossible. The anesthesia crew was wonderful and put her under general anesthesia and we completed the case. The last case was difficult - 18 cm bilateral ovarian cysts. After a long day, we had to go round and I had to sit down with two patients and their families and tell them that they had cancer, with a translator, in a foreign context. It was one of the hardest days of residency and it and it made me respect and wish for our oncologists.
After the discussions with the families I rounded on the rest of the patients and took a shuttle home. It was a hard day and I fell asleep immediately.
This morning when I woke up and went to round before our surgical cases, I was amazed how wonderful they were doing. Even though it’s been exhausting, it’s been one of the best times I’ve had in medicine.
One piece of advice for anyone else going there to work, is to really brush up on your IV placement and blood drawing skills if it’s not one of your strongest areas. I have never really been very good at placing IVs in small children. While my pediatric program of course has requirements and time built into our training so that we learn how to do this, there has never been much pressure to get really good at it, since there is always a nurse or phlebotomist to do these things for you. Since I don’t naturally love putting in IVs like some other residents, I haven’t perfected the skill. In Jamaica, however, the doctors draw all of the blood and place all the IVs, so I’ve actually gotten much better by necessity! I was also surprised to learn, that the GPs here, although I knew they saw all ages, actually do some surgeries as well. One doctor at Port Maria said he will do “simple” procedures like appendectomies or inguinal hernia repairs himself, but prefers to only assist on more difficult operations like a biliary atresia repair. He has of course received specific training in surgery as part of his medical training, but I was impressed. At least I can do my own I&Ds and laceration repairs!
The rotation was challenging at times, and looking back it seems that the first and last weeks were the toughest. The first week, of course, because I was getting used to how to treat patients in a different medical system. The last partly because I was, by that time, feeling homesick. The other difficulty was brought on by a discussion I had the end of my 3rd week with Dr. Ramos and I had some realizations about things I had been experiencing that for a while made me feel somewhat depressed. I had grown used to patients and their parents answering everything I said with “Yes Miss.” I tried my best to give education and explanations at the end of each visit and always ended with, “Do you have any questions?” Very rarely would anyone actually ask a question, and most times they would respond with a little giggle or chuckle, followed by “No.” I told this to Dr. Ramos, and he replied, “Well how can they ask a question when they didn’t understand anything you just said.” Excellent point. Even at home, at times it is difficult to explain to a parent what is going on with their child in terms they fully understand, trying to find the words in lay terms while trying to provide necessary education. But in Jamaica, one also has to deal with a language barrier. Even though I had gotten better at understanding the mix of usually broken English and Patwa that most people speak, I also had to ask them when I don’t understand. Could they repeat, or tell me in a different way. But rarely would a parent ask me to do the same. I shouldn’t have assumed they could understand my English. I came to realize that just because they did not have questions or nodded their heads and said, “Yes Miss,” in a lot of cases it probably had nothing to do with whether they actually understood or not. What a doctor says goes, and most Jamaicans would never speak up to say they couldn’t understand me. There is also another aspect, it seems that a lot of time the people just don’t listen to what you say. I would be asked a question, and then as I proceeded to answer they would either start talking about something else, or a few times even got up to leave the office. Anyway, after I realized all this about 3 weeks into my time here, I felt a bit helpless, wondered how much good I had been doing besides just writing a prescription when needed. When a mother comes in with her baby worried because that baby is having reflux (that is not in need of medication), the whole key is helping her to understand what is happening to her baby and why and when it will get better. That is whole point of reassurance, education is the biggest part of it, knowing what is “normal” and what is cause for concern. But after a couple days, I just accepted that this is part of learning and part of working in an unfamiliar culture. It has been an amazing learning opportunity. I hope I can take this experience and become a better listener and a better educator for all people. It has been a very important lesson for me.
Overall, I hope that this whole experience will make me a better clinician in all aspects, as well as improve my cultural competence. I am truly grateful for the opportunity!
I encourage other physicians to take advantage of this opportunity as well. The Issa Trust Foundation has room for 2 physicians here all year round! It would so wonderful if there were always pediatricians there, a consistent presence to serve the children here so they receive appropriate follow-up and care. You will be challenged, you will have fun, and you will leave feeling rewarded. The accommodations here are out of this world! When you have off time, which is every night and the weekends, it is wonderful to be at Tower Isle where you always have great food and entertainment, and can always relax on the beach and read a book, as I so often did after work. There are many opportunities for trips outside the resort if you wish to join them. Please, take advantage of this exciting opportunity to become a better clinician while helping the children of St. Mary and Portland!
So a HUGE thank you to everyone at the Issa Trust Foundation, all the many physicians and nurses I had the pleasure of working with in Jamaica, and to Kaiser Permanente for allowing me the time to have this experience! I plan on returning soon . . .
Hadia and I have just finished our first week on the beautiful island of Roatan, Honduras. We are working at Clinica Esperanza, or “Ms. Peggy’s clinic” as it is often better known on the island, referring to the nurse whose vision it was to create a clinic for the underserved residents of Roatan and has worked very hard to make it a reality. While the outpatient clinic opened nearly 5 years ago, a new pediatric inpatient unit has recently opened and this week 2 patients were admitted for dehydration; prior to that, the closest inpatient unit was within a hospital that does not even have running water. There is also a newly opened birthing unit, where there was a successful delivery this week.
Managing a clinic with limited resources has been challenging yet educational, as I have to often seek alternatives to my usual care. Sometimes I cannot offer an immediate solution as it requires a service not offered at our clinic(or possibly the entire island!) or one that exceeds the patient’s ability to pay for it. Clinica Esperanza has definitely exceeded my expectations; I have found a much larger range and quantity of medications available than I had expected to and we have a visiting lab tech who performs simple lab tests as well. We also have the luxury of having a basic electronic charting system, though they are still working out some kinks. As the pictures had suggested on their website, the clinic is clean and has nicely painted walls (with otoscopes/ophthalmoscopes mounted on them in both of the pediatric rooms!).
There are many Honduran patients(of whom the great majority do not speak English) and some English-speaking islanders as well. Many of the Honduran patients come from a nearby village of about 4,000 people referred to as “La Colonia,” where immigrants from the mainland live with limited water and electricity. The clinic has a Honduran pediatrician, Dr. Solis, who is very friendly and available to answer questions about the local practice of medicine. He doesn’t speak much English so, while I am rather fluent in Spanish, interacting with him and my patients has helped me better learn how to think and communicate in medical Spanish. I have also been learning tropical medicine and becoming quite familiar with patients wanting to “desparasitar,” a frequent chief complaint that wins them a dose of albendazole and often a one-month supply of multi-vitamins. On Friday alone I had 2 patients with GI parasites(either seen by the parent or confirmed on labs)!
Living about 10 minutes away from our clinic has really taught me how much we take simple things like roads for granted, as we often end up taking taxis for only part of our route given how rough the roads are. There is one major paved road to clinic and the rest is dirt roads, which have been a bit challenging between the tropical rainy weather we intermittently experience and ongoing construction. I feel grateful to have running water and electricity at both my home and in clinic.
It has been an exciting trip so far and we have found the people here to be very friendly and welcoming; I am looking forward to seeing what the next week holds in store for us!
Naturally, I get a bit nervous when I am about to experience something new. So when I embarked on this journey, to a country I knew little about and my very limited Spanish, you could say I was a little apprehensive. However, as soon as Neelu, my co-resident and I arrived in Roatan, my mind was placed at ease when we were greeted by a smiling, energetic Ms. Peggy, who had an air of confidence that was contagious. As Ms. Peggy, the founder of Clinica Esperanza drove us to our residence, I tried to acquaint myself to this beautifully lush island, which has one main road running like a spine from one end to the other end of the island. The dirt roads that branched off the main road told a story of their own. Ms. Peggy’s home was off the main road in Sandy Bay, which was a humble place nestled in an impoverished neighborhood. We were greeted by small children running barefoot alongside our truck. Everyone seemed to know Ms. Peggy and their gratitude was apparent in their demeanor towards us, thanking us for being here even before we had set foot in the clinic.
The next day, Neelu and I took a taxi from our residence on the West End, which was quite the rugged ride as it made its way through the bumpy dirt road, ridden with mud puddles from the sporadic downpours, to the clinic. After about 10 minutes, we were dropped off in front of a two story maize yellow building with a long line of patients waiting in front. It reminded me of the long queue of pregnant women patiently waiting from dawn to dusk at the maternity hospital in Kabul, Afghanistan, where I had done research 5 years ago. I recalled the dire conditions in the maternity hospital where there was no running water, latex gloves, or a working autoclave to sterilize instruments. Only, I was surprised to find that this clinic was clean, had running water, electricity with a backup generator, and a pharmacy with neatly labeled shelves stacked with a variety of drugs. The exam rooms were not that different than the ones I was used to in the United States. Each exam room had an exam table, instruments needed for a general exam, a sink for hand washing, and even a computer with a simplified EMR system that had its flaws but nonetheless impressive given some hospitals in the US still use paper records. I was told that this was by far one of the best and well reputed clinics on the island.
I was given my own exam room and the day began with patients pouring in, first come first serve, many arriving before sunrise. Most of the chief complaints were not that different from the ones I see back home: diarrhea, vomiting, fever, colds, and rashes to name a few. Impetigo seems to be fairly common on the island given the humid weather, crowding, and poverty; however, I was surprised by the severity of presentation. One child had large crusted lesions all over his body. In contrast to the US, many parents request vitamins and empiric antiparasite therapy. At first I was skeptical about liberally prescribing antiparasitics, but soon learned that the standard of practice here is largely experience based and seems to work well for the most part. Patients are treated with albendazole or piperazine anytime a parent asks for treatment or about three times a year to decrease the parasite load as most can be asymptomatic.
We had our first newborn on our fourth day at the new Birthing Center at the Clinica, a presumed 37 weeker with shoulder dystocia who was delivered by significant traction on the left arm. Neelu and I were asked to assess the infant. Fortunately, the infant was vigorous with reassuring APGAR scores and without any concerning findings. It was both exciting and a relief to all to have a successful delivery. I am looking forward to learning more about the Honduran people, seeing diverse pathology, and working with the staff here.
It was a long 14 hours from San Francisco to Manila, and then one and a half hours to Legaspi and then 4 hours by bus to Daet. It took two full days to set up the operating room and today we had our first day in the operating room. There are two operating tables per operating room, only one anesthesia machine. We have been operating side by side and since we operate in the pelvis, we have been doing our hysterectomies under spinal anesthesia. It isn’t that hard to get used to, we operate on cesarean sections while they are still awake, but it’s just another layer that makes operating here a little foreign. But it’s been incredible what we are able to offer and how wonderful the staff has been. All our efforts revolve solely around patient care, what an amazing experience to share with the fantastic Kaiser team!
I spent a month in Jamaica, parish of St. Mary, working in several hospital clinics. It was hard coming from working in the American medical system to working in the Jamaican medical system, but it got easier everyday. I had the opportunity to see many patients and work with many wonderful physicians. Our goals as physicians both there in Jamaica and here in America are the same, to do what is best for our patients, we just get there in different ways sometimes.
My weeks began at Port Maria Hospital. The kids that generally showed up for regular clinic that day got funneled to me, or were sent from A&E (the ED), lots of general complaints. The first patient the A&E doc sent me was a consult to rule out leishmaniasis. What do I know about leishmaniasis? I work in California! So I said, “Give me a minute,” got out my atlas of tropical diseases, and read up quickly. Then I was able to say with some certainty that the child did not have leishmaniasis. But that’s how a lot of my experiences were, learning through doing and seeing. I saw the typical childhood problems that I see so often here at home: asthma, eczema, otitis, pharyngitis, and cellulitis. I also saw things that I have never seen before, but now have seen several times and feel confident in my diagnosis, such as miliaria crystallina. So many babies at their well checks seem to have developed it, and at first I wasn’t sure what I was seeing, but after looking it up on the internet (at night after clinic – no wifi or computers there) and seeing it over and over again, I can now confidently tell parents what it is and offer reassurance.
I am also visiting Annotto Bay Hospital in the middle of my weeks. There I see patients and participate in ward rounds, as well as being in the pediatric clinic where I see kids with problems that are followed by the pediatrician there, Dr. Ramos. More asthma, anemia, and some follow-ups post discharge from the hospital. On the inpatient side the majority of the patients I saw were neonates with suspected sepsis or risk factors. Since it is very difficult to get cultures here (they must be sent to Kingston and most of the time never make it there due to transportation problems or make it there too late to be useful for making treatment decisions), most babies with any suspicion, those who would be a 48 hours rule out in the states, get a full 5 day course of IV antibiotics and then are sent home on orals.
On Fridays I make the 2+ hour ride (thanks meclizine!) to Port Anotonio Hospital in the parish of Portland, where I visit the wards and then go to clinic. Here they do not have a pediatrician at all, but the general physicians round on the patients on the ward.
There were so many interesting cultural things to be learned as well. I quickly heard about black dressing, which is tar based, an all-purpose salve for infections and the like. It took me a while to figure out what the mothers were talking about when they said the baby had “coal” (not sure how they spell it!) in his emesis or diarrhea, but I realized they meant mucus. I asked my patient’s parents a lot of questions about things like this as you can learn so much from them about attitudes toward health and nutrition and home remedies used.
One thing I had to get used to there is that I am always “Dr. Westman,” not “Amy,” at least at the hospital. Here at Kaiser I am on a first name basis with everyone in my program, from interns to attendings and administrators. But in Jamaica, it is more formal. A doctor is always “Dr. . .” and a nurse is always “Nurse . . .” The other doctors and even the interns introduce themselves as “Dr . . .” and I’ve noticed that even when they drop the doctor part, others refer to them by their last name only.
Another thing that just goes with the territory here, and I presume for all global health rotations or missions, is that you just need to relax and go with the flow. Things are not as tightly regimented and scheduled there as in America, but everything gets taken care of in the end. The patients show up at 8am and register first come, first serve, but will wait all day to be seen, no appointment times. You, as a volunteer there, will always have someone to drive you to and from the hospitals and clinics, but it may not be the same person and they may not pick you up at the expected time. But you will get there and back safely! The doctors mentioned in the orientation packets may not be around, but there is always someone there to help with any questions. Even if there aren’t many clinic patients one day (my wide range has been from 2 to 30, but on average about 20), you can always find other ways to help out like seeing patients in A&E. Just go with the flow, and everything will work out. One of the big things I’ve learned in my time there!
There are so many reasons that residents are interested in participating in global health projects. I have wanted to be a part of the development of clinics, medical education and self sustainability of medical facilities that are coming into their own. I have also been interested in the way medicine is practiced around the world, the different expectations that patients have of their physicians, and how we can better deliver quality health care. I have always learned much more than I have taught, and it has given me insight to different parts of the world. Up until this trip to the Philippines, I have focused on facility and medical personnel development, and much less with patient care.
In the past I have been hesitant to go on a surgical ‘mission.’ I thought that most places, even rural places, have physicians that provide wonderful medical care, and by going in and doing surgeries in places where there were local surgeons, we would undermine their skills. I also believe, that as a surgeon, you are responsible for surgical complications, and with short surgical missions, we are unable to deal with the possible complications of our surgeries. During past (Vietnam and Kenya) medical trips, I have never declined to participate in a surgery when the local surgeons have requested assistance, but when I did participate, it was clear how key communication during surgery is. In Vietnam, the names of the surgical instruments were in French, so even when I asked for standard instruments, the scrub would look at me bewildered. We take so many things for granted in our operating rooms, our wonderful anesthesiologists and CRNAs, our circulators and nurses and EVS make our jobs run smoothly.
At the last Global Health Educational Consortium, in Montreal, there was a session on the ethics of surgical care abroad. I attended, as I was interested to see the latest updates, papers and innovations. The West African College of Surgeons made a plea for more surgical missions. They said that in the major cities, there was a large concentration of surgeons, but in the rural areas, there may be facilities, but no doctors to staff the operating rooms. A Rwandan surgeon stood up and reported that after the 1995 genocide in Rwanda, there were a total of 5 surgeons and 2 anesthesiologists left in the country, today, there are still only 30 surgeons and 12 anesthesiologist to serve a population of 11 million.
Organizations like BASM (Bay Area Surgical Mission) are able to provide free surgical procedures in a place where all surgeries are a fee for service. And organizations like Doctors without Borders and Relief International, are able to offer surgical services to places in crisis. This is a wonderful temporary solution while simultaneously working on medical education, community development and self sustainability.
I am grateful to be able to go on my first trip, solely dedicated to providing surgical care, with people from BASM. A team that I have worked with every day at Kaiser Permanente in Oakland, a team that I love and trust, it will be a fantastic (and exhausting) opportunity to focus on patient care together. I am so happy to have talked with these surgeons from Rwanda, who had expanded my understanding of needs in other countries.
We fly out tomorrow for a 3 day journey to our final destination in Daet, Philippines. More to come!