Posts tagged ‘global health’
Posted by Zack Gangwer, DPM (a PGY-3 and Chief Resident at San Francisco Bay Area Foot and Ankle Residency program based at Kaiser Permanente, Oakland, California while on rotation in Ica, Peru with Operation Rainbow.)
I had the privilege of serving the people of Ica, Peru on my medical mission. I traveled with Operation Rainbow, a fantastic organization based out of Oakland, CA who provides orthopedic care to children in developing countries around the world. Our team was led by the fearless Todd Lincoln MD, orthopedic spine specialist from Kaiser Oakland. The team was comprised of volunteer physicians, resident, CRNA’s, nurses, surgical techs, and translators. Many of the volunteers work for Kaiser Permanente, including the orthopedic surgeons: Todd Lincoln MD Kaiser Oakland; Theodore Bucklin MD Kaiser Santa Clara; David Godley MD Kaiser San Jose, and Kip Wilkins MD Kaiser Modesto.
Ica, Peru is a city southeast of the capital Lima, and is the capital of the Ica region. It is a land lush in agriculture and wineries. It was devastated by the magnitude 8.0 earthquake that struck in 2007. Part of the destruction included the regional hospital where we were now traveling to provide free pediatric orthopedic care. As such, it had been reconstructed into a modern, beautiful facility.
The health system in Peru has both public private sectors. The public sector has two types of national insurance. First, Seguro Integral de Salud (SIS) is provided by the Peruvian Ministry of Health (Ministerio de Salud, or MINSA). SIS is comparable to Medicaid or Medical in the United States. The second type of national insurance is EsSalud and is provided via employment for working families and individuals. It is equivalent to US employment plans, administered nationwide.
In addition, MINSA (Ministry of Health) mandates certain public hospitals (e.g. Hospital Regional) that offer healthcare services regardless of insurance coverage. At these public hospitals, the government provides health care to the uninsured population in exchange for a fee of variable amounts under the discretion of the individual hospitals. Our services were to be provided at the Hospital Regional de Ica.
There were some interesting and eye opening facets of healthcare in Peru that I did not expect. Despite the actual care offered being gratis, the patients were expected to contribute by purchasing their own implants; otherwise conservative care would be the treatment plan. One patient we saw was a 32 year old female who was in an motor vehicle accident, and suffered a distal femur fracture. When we met her, she had been lying in an ED bed for 5 days. She did not have the money to purchase the recommended plate and screws, and therefore could not be treated operatively. Fortunately we were able to donate the implants and perform her operation.
Part of the adventure is getting to the site. I awoke at 330 am to catch the earliest possible BART to SFO. A few hours later, once the fifty or so 50 lb. duffle bags containing the anesthesia and orthopedic equipment are checked in you are allowed to enter the airport and await your flight. We arrived in Lima, Peru via Dallas 12 hours later. After spending the night in Lima, we made the 4 hour bus ride down to Ica.
The breadth and depth of pathology was impressive, some of which we could not offer any surgical relief. We saw various deformities ranging from congenital defects such as limb deformities and malformations, polydactyly (too many digits) macrodactyly (giant toe) to musculoskeletal problems commonly encountered with cerebral palsy. From a foot perspective (I am a foot and ankle surgeon) I saw club foot in a variety of stages, polydactyly, brachymetatarsia (short metatarsals), and macrodactyly. There was no shortage of pathology, and nowhere near enough time to help everyone we would have liked.
International medical missions come with plenty of uncertainty and change, and adaptability is a chief characteristic required. We planned to have an all day clinic our 1st day. However, the trip was advertised to the local people as a half day clinic daily beginning THE DAY AFTER we had planned. Fortunately, we saw a fair amount of people the first day but still had to adapt our daily plans to accommodate a daily clinic.
Our days typically began around 0630 with breakfast. We arrived at the hospital around 0730 with surgery planned to begin at 0800. We operated all day, sometimes until 9 pm. My main responsibility was to assist on the clubfoot cases with Dr. David Godley MD from Santa Teresa Kaiser. He is an excellent surgeon, with vast experience in both pediatrics and medical missions. Some of the more difficult club foot cases took us the majority of a day to perform.
Much of the surgery performed was related to cerebral palsy and different tendon releases and transfers with the goal of a more normal gait. We also saw a smattering of trauma including the aforementioned femur fracture. Our team also put in the first total hip replacement ever performed at the regional hospital. Aside from our work, we consulted on a variety of cases and offered our experience if no intervention on our part was possible.
At the end of the weeks’ work, our group split as some went to experience Machu Pichu, and the rest of us snapped back to reality. The need for adaptability again reared its head as we were preparing to go home. From issues at customs with baggage to some problems with “fossils in your suitcase” (actually, it is just bone allograft). In the end, we all made it back in one piece.
The greatest experiences I took away from the trip were:
- The ability to serve people who otherwise would not receive the care they needed.
- The opportunity to raise the level of care locally by teaching local surgeons.
- The relationships made with those who serve along side you in the trenches.
I have previously volunteered in Guatemala, and now in Peru. International medical volunteerism is a labor of love. I personally feel that you almost always get back as much as you give in service, and this is no different. It is not a tourist trip, and long hours and hard work are to be expected. There are not many more gratifying experiences I have had in my life. I look forward to future service both nationally and abroad as I move forward in my medical career. I will always remember Peru and it will hold a special place in my heart as my first surgical mission abroad.
I was fortunate enough to participate in a surgical mission to Quito, Ecuador from April 19-27, 2013.
One of my favorite quotes is from Harun Yahya: ” I always wonder why birds stay in the same place when they can fly anywhere in the world. Then I ask myself the same question.”
Kaiser is a unique surgical residency program because residents at all levels are encouraged to participate in global health efforts. As a second year resident in the Department of Head and Neck Surgery (“HNS”), I was able to participate in a surgical mission this year through the support of my Department as well as Kaiser’s Global Health Program.
The HNS residency program provides the opportunity to develop a set of skills that can touch people’s lives in incredible ways. Few things are more gratifying than sharing our skillset as physicians and surgeons with people who are in need of surgical intervention but either cannot afford it or do not have access to the type of surgical expertise that is needed. Taking our efforts abroad is one of the ways we can give back and help people who otherwise would not be able to experience our resources and services.
One of the things that struck me was the incredible coordination of effort that was necessary to make our surgeries abroad possible. Our team spent countless hours planning, gathering supplies and equipment, packing, and ultimately transporting our entire operating room setup to Ecuador. We were responsible for bringing all the essentials that we might need from Anesthesia monitors to surgical tools to medications and surgical dressings. Our team from Kaiser, along with generous donations from several individuals, made this possible.
We arrived at our hotel in Quito around 2:00 a.m on Sunday morning. We stayed in the old town neighborhood, a historic region of the city and a draw for visitors because of its cultural beauty and the number of activities and notable sites concentrated in the area. We finally made it to bed around 3:00 a.m. and were up for breakfast at 6:30 a.m. – a beautiful spread of toast, fruit, and eggs. After eating, we boarded a large bus for the 45-minute ride to Hospital Padre Carollo, where we would be operating.
Hospital Padre Carollo is run by a foundation known as Tierra Nueva. Tierra Nueva is a large nonprofit organization founded by the late Father José Carollo. Father Carollo was a relentless advocate for the poor, and he began Tierra Nueva as a social services center for Quito’s poorest citizens. There is a beautiful saying posted on the front of the hospital that can be seen by all as they pass by – “ Un Canto A La Vida” – which means “A Song of Life” or “An Ode to Life.”
Our first day at the hospital was used to set up a busy pre-operative clinic and unpack our supplies. While the surgeons met countless patients and consented patients for surgery for the week, the OR staff organized our equipment and stocked the operating rooms that we would be using. Patients waited for hours as we addressed each surgical issue, screening candidates for thyroid surgery, parotid surgery, tonsillectomies and adenoidectomies, and ear surgery to name a few. At the end of a long day, the team was ready for food and rest. After the bus ride to the hotel, we had supper at a local restaurant where adventurous members of the team tried the local “qui”, or roast guinnea pig.
The surgeries began on Monday morning. It was inspiring to see our nursing staff and anest
esia colleagues set up the ORs and successfully cope with the limited supplies available to us. What an incredible job they did! Since the local surgical teams were operating at the same time, we were very conscientious to respect their OR rules and protocols. Things as simple as where we could and couldn’t wear scrubs and when our shoes had to be covered took adjustment but we soon fell into the flow.
Between cases, additional patients would arrive and we would evaluate them. A case that stands out in my mind was a young man who had a left sided nasal obstruction after suffering several blows to the face over a year before. He was jumped by robbers, who took his belongings and hit him in the face, fracturing his nasal bones and collapsing the left side of his nose. His nasal defect was obvious in looking at his outward appearance, but his real complaint was the difficulty he had in breathing. He reported that it was interfering with his sleep and making it challenging to be active. We signed him up for a septorhinoplasty to correct the nasal collapse, straighten his septum, and try to restore a more normal looking nose. The patient was thrilled that we would be able to help him.
The morning that the patient was scheduled to undergo surgery, we saw him in the hallway and he beckoned us aside. Via interpreter, he explained that his wife had been scheduled to undergo a hernia repair the day before but given the large volume of general surgery cases, her surgery had been postponed until today. The patient described how he wanted to be there for his wife after her surgery and as a result was willing to sacrifice his own procedure. He didn’t feel like he could proceed with his surgery and still be there to take care of his wife when she came out of the OR. We offered him surgery the following day – his wife would be discharged by that time and he could get the care he needed. Looking down, he described how his job would not allow him to miss another day. We discussed that it might be months or years before another Head and Neck Surgery team is able to return and see him. He nodded his head in understanding. He had made it all the way to the hospital, sought our care and surgical expertise, and eventually had to forgo the needed procedure. Unfortunately, there is only so much we can do to help.
My experience with this patient illustrates that there are indeed limitations to our outreach efforts. Many patients will go unseen secondary to issues with access and time from both the patients’ and the surgeons’ perspectives. While we do our best, there will always be the need for more health care services. I believe, however, that this should serve as motivation and not discouragement. My experiences in Ecuador leave me eagerly anticipating my next surgical mission trip. The experience has helped put my training and practice into perspective and I think it is an integral part of our training as residents. I would like to thank the Kaiser Global Health Foundation, all of my faculty mentors, and the volunteer team who participated for their support.
Da Nang General Hospital and Da Nang Orthopedic and Rehabiliation Hospital – Da Nang Vietnam – Stutee Khandelwal, MD
Posted by Stutee Khandelwal, MD (a third year Internal Medicine/MPH resident from Kaiser Permanente, Oakland while on a global health elective in Da Nang, Vietnam at Da Nang General Hospital and Da Nang Orthopedic and Rehabilitation Hospital).
I was the second KP internal medicine resident to go to DaNang General Hospital in Vietnam (see Dhruv Verma’s blog as well). The rotation was initially set up for the orthopedic and rehabilitation hospital, but is now being expanded to include the Da Nang General hospital.
June 27-July 2: Rehabilitation, Podiatry
My start at Da Nang General Hospital was delayed due to paperwork so I accompanied my KP attending (a podiatrist) at the rehabilitation hospital for the first week. There I saw a variety of cases such as strokes (hemorrhagic> ischemic), Sudeck’s dystrophy, unrepaired congenital valvular defects leading to strokes, Beri-Beri leading to peripheral neuropathy in an alcoholic and so on. I exchanged ideas on diagnosis and management with the PMNR physicians. However most times they did not have medical records of the patient and did not know details of the previous hospitalization leading up to rehabilitation. One of the days, I led a rapid response on a patient with hypertensive urgency without any continuous cardiac or pulse ox monitoring and where the patient’s family member had to run and get nitroglycerin from the pharmacy outside!
One day I accompanied the podiatry team and we saw close to 50 cases in 8 hours in the outpatient clinic. The pathology ranged from congenital defects such as fibular hemimelia to war injuries with residual shrapnel in soft tissue, to motorbike and work accidents. We saw lots of cerebral palsy, few chronic osteomyelitis (decades of drainage and pain), poorly healed fractures, a case of TB in the foot and possible case of polio (we speculated based on history that the patient possibly had an attack of acute polio leaving her with residual weakness and paralysis). I provided the pre op evaluation where the H&P sometimes changed the management for example, a case of an elderly man with chronic osteomyelitis whose limb could be salvaged as long he had a good post op follow up and home wound care, however I found out that he lived 150Km away, so we decided on a BKA instead. I would provide alternate diagnosis for a foot drop such as neuropathy based on my exam, request blood work and MRIs, and ultrasounds. It turned out to be a multidisciplinary approach as there were physical therapists from the US as well.
The next couple of days I scrubbed into the OR and observed the podiatrists work with minimal tools and anesthesia support. I performed a soft tissue mass excision from the foot under the supervision of my attending and was very impressed with the surgical assistants in the OR. The physicians spoke some broken English but the Google translator app on my phone came in very handy.
July 3- July 6: ED
The ED was a very high volume (up to 250 patients a day), efficiently run department where all the staff operates in one hall, all the patients are on gurneys side by side and physicians see them in less than 5 minutes, order labs and imaging and based on the results quickly transfer them to specialty departments. Registration, insurance and billing, nursing orders, physician note writing- all happens right then and there behind a long desk. I saw an immense variety of cases- trauma, various crush injuries, GI and pulmonary infections, pneumothoraces, SVT (use of ocular massage), poisoning (use of gastric lavage), panic attacks, and major depression and so on. There was only one “red room” with limited resources, for example, antibiotics were not given, nitroglycerin was not given for chest pain, intubation was deferred to the ICU unless absolutely necessary. The ED physicians worked in teams and took turns to do overnight call. Evening and nights were the highest volume due to lots of motorbike accidents especially combined with intoxication. I was very impressed with the promptness of consultants coming down to the ED and making their recommendations. All the on call physicians stayed in the hospital and since there weren’t any residents, I got to interact with the senior physicians and chiefs of the departments, who were all quite approachable and friendly. While I was there, a group of French students were also shadowing and I took the opportunity to do some bedside teaching with them.
July 7-11: Cardiology
Cardiology was the largest inpatient department in the hospital. Any patient with a cardiac history (active or not) was sent to cardiology, be it for a UTI or for a pneumonia. The cardiology chief was very welcoming and did some one on one bedside teaching with me. I followed a few patients during my time there- endocarditis with Janeway lesions and splinter hemorrhages, post partum cardiomyopathy, stroke, and acute fulminant liver failure. I vividly remember the extensive use of acupuncture inpatient for stroke rehabilitation. Another highlight of my inpatient experience was watching how efficiently all the appropriate disciplines worked together to discuss a case of renal failure in a patient with endocarditis, where an infarct was seen on CT. The cardiology chief arranged for a meeting the next day and all the heads of the departments- ID, Renal, Radiology, Pharmacy, General Surgery and Vascular surgery came together and took turns to give their opinions and came to a consensus on the management in less than an hour. I also toured the cath lab, echocardiography, pediatric CT surgery departments. One day after work, I shadowed the cardiology chief in his private clinic where he see saw the whole spectrum of internal medicine ranging from ultrasound diagnosis of worm infestation in the GI tract to cervical arthritis. He even took X-rays on his own, had a small laboratory and IV set up in the back!
July 12: Infectious Disease and field trip
On one of the free days, I visited the ID department where I saw several cases of dengue, rare cases of chronic TB meningitis and crytococcal meningitis. In the afternoon, the French students and I took a tour of the neighboring hospitals- women and children, cancer hospital, and I also visited the lab services at DaNang General. I was impressed with the technology, the work ethic of the staff, the cordial and courteous nature of the people in general.
July 13- July 16: ICU
The ICU was a busy place with at least 20-40 active patients at a time, aside from several chronic ventilator patients such as those with Lou Gehrig’s disease, and another 20-30 “TCU” level patients. The pathology was fascinating- various manifestations of TB, poisonings (rat poison, snake venom, insecticide, neurotoxins) as suicide attempts among men and women from the rural areas, burkholderia pneumonia in a farmer, VRE urosepsis, and one fascinating case of locked in syndrome due to a snake bite. The physicians worked on a 3 day overnight call schedule. There wasn’t a hierarchy, every one there is a “doctor” whether a fresh graduate of medical school or a seasoned physician with decades of experience. The ICU chief was a very dynamic and smart physician with training from the US, so I would often discuss cases with him. He led teaching rounds if there was time, I was asked to present articles or short reviews of topics. I accompanied the physicians on consults to other departments, looked up articles, and found out that UpToDate was a quite precious and highly regarded commodity over there. I also attempted a lumbar puncture and watched a central line being placed with judicious use of basic equipment and minimal waste being generated.
An unforgettable experience was witnessing code blue in the ID department on a 92yr old man with meningitis. Shockingly, not all departments have a crash cart, so we were limited in what we could do and the patient did not survive. Code status wasn’t really discussed on admission or even during the ICU stay until the physicians inform the family members of a dire prognosis. In most cases, the family understood and waited till an auspicious day to take the patient home.
Travel: On Sundays, I took short trips to nearby tourist spots such as Lady Buddha, Marble mountain, MySon Holyland, Hue City, Hoi An and an overnight trip to Ha Long Bay on my way back to the US. These sites were beautiful, each with its unique architecture and history, and some with breathtaking landscape like Ha Long Bay. I met other travelers and travelled in groups by taxi.
Climate: It was very hot all day and night, usually around 90-100 degrees. Sun screen, cotton and linen clothing came in handy and I kept myself well hydrated.
Food: Challenging since I was vegetarian, but if you like seafood and meat, tons of great and cheap options. Luckily I never fell sick even with roadside foods (thanks to growing up in India!). The physicians I met were very kind and took me for coffee/dessert after work or even invited me to their homes.
Stay: I stayed in a hotel near the beach (about 6 Km away from the hospital). While it was a nice and relaxing, I would recommend staying closer to the hospital, so that you can do late or overnight night shifts. Hotels in the city tend to cheaper too. Also, there are lot of restaurants, shops, and things to do in the city.
I will always remember this wonderful and unique experience in Vietnam and highly recommend it to any resident interested in a global health elective.
Posted by Kathryn Gunnison, MD (a third year OBGYN resident from Kaiser Permanente, Santa Clara while on a global health elective in Yaounde, Cameroon with Prevention International: No Cervical Cancer PINCC).
I arrived in Yaounde, Cameroon late on Sunday evening after many hours of travel from the bay area. I was exhausted but anxious to begin my work with Prevention International: No Cervical Cancer (PINCC). PINCC is an organization that provides training of local health care providers in visual inspection with acetic acid (VIA) to identify and treat pre-cancerous cervical lesions. Over the course of several trips to the same location, PINCC aims to certify local providers in VIA , cryotherapy and LEEP in order to provide cervical cancer screening and treatment to a previously unscreened population. The goals of PINCC were of particular interest to me. I loved the idea of passing on clinical knowledge and skills to local providers so that they would eventually be able to function independently. This trip was PINCC’s first to Cameroon so there were many unknowns for our trip director, Carol. We had no idea what to expect in terms of clinic conditions, trainees or patients.
On Monday morning we arrived at our first clinic site, Bethesda Hospital in Yaounde. It was a small open air hospital on the outskirts of town. The grounds were well kept and the staff was friendly and welcoming. We were given 3 small rooms to run our training clinic. Gyn beds were not available. The three beds with foot stirrups for pelvic exams were to remain on Labor and delivery. There was no running water that day and the electricity was somewhat temperamental Our team, which consisted of three resident physicians and three support staff members, got to work unpacking supplies and setting up exam rooms while Dr. Miskell, our medical director, met and began teaching the trainees. After several hours of set-up, including construction of “under buttock lifts” from folded and taped together surgical drapes, a blessing of our team by a highly regarded Baptist minister (we quickly learned that many Cameroonians were very religious and many organizations religiously affiliated), we finally met our trainees and began to see patients.
The trainees consisted of local nurses, a lab technician, several first year residents, a nurse’s assistant and two nurses who had traveled 12 hours from the northern region of Cameroon specifically for our program. We quickly learned that many of our trainees were primarily French speaking and a vast majority had never done a speculum exam. They were divided in to groups, each assigned to one resident physician. My group on that first day was excited and eager to learn. I guided them through their first pelvic exams, finding the cervix, identifying the squamo-columnar junction and reviewing the basic principles of VIA. Our patients were extremely kind and grateful. Most had never had a speculum exam before but were very calm and tolerant of any discomfort. After we completed exams many patients thanked us for their screening but also thanked me for coming to their country to help their people. It made me really appreciate the resources that we have in the United States for cervical cancer screening and reinforced my desire to provide cervical cancer screening for women throughout the world.
I had spent a lot of time with one of the nurses who had traveled from the northern region of Cameroon for the program. I was particularly impressed with her clinical skills and kind way with patients. She very quickly picked up the skills needed for VIA. It was gratifying to know that I had played a significant role in training such a capable young woman who could provide screening to women in a rural area of Cameroon.
As the week continued the trainees made excellent progress. When it came time to say goodbye, the PINCC volunteer group felt that we had established a strong foundation in Yaounde for the clinic to continue. PINCC plans to visit Yaounde in January 2014.
Our next stop was a short visit to Kumba, a smaller town in the more humid, jungle-like area of Cameroon. After an eight hour van ride, we arrived late on Saturday. We began working in the WeCare women’s clinic in an area of Kumba called “Kumba 2” that Monday. Conditions in the clinic were poor. There was no running water, exam rooms were hot and poorly ventilated. We worked hard with the trainees to establish screening at this clinic in just two days. PINCC will return to Kumba in January of 2014 for a full week.
I thoroughly enjoyed my trip to Cameroon with PINCC. I learned a lot about the people and the culture. In addition I was able to share my own clinical knowledge with medical providers, which will eventually allow local women to be screened for cervical cancer.
My name is Maylynn Tam and I am privileged to be a third year podiatry resident for Kaiser in Vallejo, CA where I am learning to treat an array of foot and ankle pathology both conservatively and surgically. I traveled to Da Nang, Vietnam to be a part of the Kaiser Global Health Project (KGHP)at Da Nang Orthopedic and Rehabilitation Hospital (DNORH) during July 2013.
I first learned of the KGHP through a group of Kaiser Podiatrists who have been traveling to the DNORH and working with Dr. Thanh, the chief of orthopedic surgery there for over a decade. Each year Dr. Thanh has been setting aside his most challenging and puzzling patients so that they can be treated during our annual visit. Over time the visit from Kaiser has gained notoriety in the community and now the project draws patients from all over Vietnam, who hope have an exam from an American specialist. Many of the patients travel by scooter from small remote villages and wait for hours with no idea when, or if, they can be seen by a doctor.
Vietnam, although now an open market, is still a communist country and still very much reeling from the effects of economic upheaval, political corruption, not to mention the immense physical and emotional losses and injuries of the Vietnam War, which took place only decades ago. Most villages outside the major cities have very little access to health care or public health education and many of the patients we treated had pathology related to chronic diseases that were partially, incorrectly or completely undiagnosed.
As soon as I arrived to the hospital it was an immediate shock. My clinic experience in Da Nang simply trumped any foot or ankle pathology I have ever seen in America. The open-air hospital design meant we were all subjected to the 90F heat and 90% humidity. With only fans to cool us, we examined patients in a room that contained just a hospital bed and a desk. The patients arrived with high hopes and were often accompanied by many family members. I was worried about how the language barrier and the lack of history, medical charts, or advanced imaging would play into our success or failure of each meeting, but it surprisingly was a minor factor. We learned to maximize each appointment by spending the majority of the time touching, palpating and observing rather than reading a chart or looking at an image on a screen.
The outpouring of gratitude from the patient and their family was overwhelming. And the thankfulness from the patient when they were told they could have an operation and possibly be improved was a pure visceral emotion. During those days I was reminded that we mainly differ in our cultures and beliefs, but if you pay attention to our basic needs or an expression of joy, pain or gratefulness, we are all humans- all much more similar than we realize.
My experience in the operating room was equally as shocking. There were no shoe or hat covers, rather everyone wears re-useable rubber clogs and cloth hats designated for the operating area. The area to scrub had one sink where disposable scrub brushes that were donated from the US were recycled until they fell apart. During surgery an intra-operative X-ray was not usually available, as opposed to in the US where most hospitals have them at their disposal. My favorite memory was the absence of perfectly organized racks of screws– and instead we simply picked the screw that seemed about the right size from a potpourri of hardware that has been sterilized in a bucket.
During my trip I learned so much, but the most resounding lesson was definitely how much you can do with with so little. From the hospital and limited resources in the operating room, to witnessing the resilience and determination of the Vietnamese people, my trip was a testament to the power of resourcefulness.
I also learned to rely much more on my hands and observational skills to understand the patients. Without much imaging or history available, I learned that developing solutions for complex surgical problems was much more about recognizing and comprehending basic problems in deformity and how to fix them with basic strategies.
My goal when participating in the Kaiser Global Health Project was to aid the Vietnamese community with my knowledge and skills to help them in whatever way I could. What I ended up having was an experience that forever has changed my skills as a doctor and my heart as a human being. I am so fortunate to be able to have had such an amazing learning experience!
Posted by Gabriel VanGompel, DPM (a third year Podiatric Surgical resident from Kaiser Permanente, Hayward while on a global health elective in Da Nang, Vietnam at and Da Nang Orthopedic and Rehabilitation Hospital).
Looking back on the cases we were involved with this week, we were able to see a wide variety of pathologies. There were five pediatric patients with varying degrees of Cerebral Palsy. Working with the orthopedic surgeons we did a number of releases ranging from adductor muscles in the thigh to hamstring and gastroc lengthening’s. Thank you Dr. Vu for your instruction in these areas. These kids are resilient as represented in their pictures. Although they have bilateral full length cases on, they could not be happier. (See Picture Below)
We were surprised by the number of arthroscopic cases being performed. The orthopedic department is performing 2-4 arthroscopic knee procedures per week. To my knowledge this is one if not the only facilities in Vietnam to be performing this procedure. They have become proficient at this, but have yet to touch an ankle scope. We line up 3 ankle scopes for the week and saw some interesting pathology. The last ankle scope we did was on Friday. This gentleman turned out to have the largest osteophyte both on the anterior tibia and dorsal talus we have ever seen. With a history of rheumatoid arthritis let’s just say the joint was difficult to navigate. Non-the-less Dr. Tanh and Dr. Vu took their turns driving with the arthroscope in the ankle for the first time. Under the supervision of Dr. Weinraub they had an excellent training experience and hopefully will now have the confidence to perform ankle arthroscopy.
Dr. Tanh’s constant pursuit for knowledge has brought him around the world acquiring valuable knowledge and skills to be used in the orthopedic dept. As mentioned before knee arthroscopy with arthroscopic ACL repair is now being routinely performed. More relevant to the foot and ankle is the use of the Ponseti method for treatment of pediatric club foot. Dr. Tanh had the opportunity to travel to Iowa and work with Dr. Ponseti to learn this technique. It has made a huge impact on the incidence of neglected club foot. As compared to years past there was no soft tissue release procedures performed. One talectomy procedure was done on a young girl (Girl wearing the pink rabbit shirt below).
Despite the lack of equipment and preoperative antibiotics the relative complication of post-operative infection in Da Nang is low. We reviewed with Dr. Tanh his experience with this problem over the past year and came to the conclusion that their post-operative infection rate was around 2-3%. This is comparable with the U.S. rate of post-operative infection which has been quoted to be from 2-20%. This is pretty amazing given the conditions they operate in. If you think about the amount of prevention used in the U.S. for this complication and the amount of waste it produces and then compare it to the former situation, we are doing something wrong.
The last 24 hours of the trip were some of the best time spent. As we wrapped up our business at the hospital we planned for our final meals and trips while in Vietnam. I set out on the Saturday morning to explore the town of Hoi An, south of Da Nang. It was a wonderful experience. I was pulled in by a tailor who talked me into having two dress shirts custom made. Giving them a time frame of 1.5 hours, as I needed to return to Da Nang on a shuttle, they were able to turn pieces of plain material into two amazing shirts. Exchanging stories, smiles and hugs the experience was great.
Making my way back to Da Nang, Jamie and I rendezvoused at the resort to log some time on the beach. The most difficult thing was to move our lounge chairs ever hour or so to keep out of the sun. Awesome! Later Minh, Dr. Weinraub, Jamie and I met up for a final dinner at a place downtown that Minh had picked out. The honey chicken was great! As we went our separate ways after dinner a feeling of accomplishment and happiness came over me.
The relationships I made during the trip are lasting and unforgettable. Put together by coincidence it is amazing to witness and be a part of such a unique situation. I have made friends with some of the best people I have ever met and will never forget. I hope to return soon.
Posted by Gabriel VanGompel, DPM (a third year Podiatric Surgical resident from Kaiser Permanente, Hayward while on a global health elective in Da Nang, Vietnam at and Da Nang Orthopedic and Rehabilitation Hospital).
The past two days have been an eye opening experience. From the moment of walking in the front door of Da Nang’s orthopedic hospital, the cultural aspect of the patients and staff has been obvious. Patients line the halls waiting to be seen. The physicians work tirelessly trying to accommodate the endless stream of patients. The courtesy and respect perceived from everyone in the hospital give this place a warm homey feeling.
The pathology seen here is astounding. There was a fair number of mal-reduced fractures most notably calcaneal and lisfranc injuries which presented to the clinic. A number of these patients did not seek care after the injury and now presented complaining of limiting pain and deformity. The cultural mindset of people seeking care for injuries is much different than in the U.S. The walk-it-off mentality is very common. If only the message could be spread for these patients to seek care immediately a lot of these painful deformities may be prevented.
The pediatric patients seen in clinic are both warming and heartbreaking. The number of club feet and other deformities, rarely if at all mentioned in the literature, is never ending. Many patients can be treated, but there are those who will not benefit from any type of treatment. It is these kids that your heart goes out to. They have made a permanent imprint on my heart.
It is a gratifying experience to use the knowledge acquired through years of training to restore these patients’ painful deformities back to a functional limb. This is the stuff that made you want to pursue medicine.
Vietnam Showers Lead to a Perfect Night on the Town
After finishing surgery around 4:30 pm we headed out into the lobby and ran into a patient who had suffered a severe Pilon type fracture of her LEFT lower extremity. She had been treated with an external fixator, but had no attention paid to the fracture dislocation of the ankle joint. As a result, her foot and ankle were now beginning to appear deformed and she complained of swelling and pain with ambulation. After our hall-side visit we instructed her to remain non-weight bearing until Friday when we will take her to surgery. She should not have a problem with this as the wheel chair she was in looked like it was designed to climb a mountain!
As we proceeded outside we happened to catch a glimpse out of the corner of our eye of some dark clouds and what appeared to be rain off in the distance. Paying it no mind we ventured out into the city of Da Nang toward a Spa which was only a few blocks away. We Californians were ignorant to the fact that in the tropics tropical storms are very common and last only briefly, but deliver a massive amount of rain. About half way to the spa we felt the first drops. This soon developed into a steady downpour and then sheet and bucks of rain stronger than your shower head. By this time we were sprinting down the street toward the spa. Turning around we noticed Dr. Weinraub was missing. We found out later that due to his sandals he had to stop at the first building he could to get shelter. This turned out to be the Russian consulate. Good timing as the consul car pulled up and its dignitaries walked in. After essentially taking a shower in the elements we made it to the spa and were able to enjoy a perfect massage.
We then met Minh, an orthopedic resident, at his favorite egg-crepe place in the city. We could not find this place again if we tried. It was at the end of a narrow alley off a street you could never pronounce and would likely drive right by. The food was amazing! Chicken satay, I think… put in a rice paper along with veggies and peanut sauce made for one heck of dining experience. Our trusted guide Minh also recommended we try his patented “Grenadine” drink. This consisted of a local French style beer along with strawberry soda. Delicious! This day was one of those you won’t forget. Thanks everyone.
Angkor Hospital for Children (AHC) — Siem Reap, Cambodia
and The Lake Clinic — Tonlé Sap Lake, Cambodia
Posted by Meg Rothman, DO a second year Pediatric resident from Kaiser, Oakland while on a global health elective in Cambodia
Angkor Hospital for Children : A Pediatric Teaching Hospital
I landed in Siem Reap, Cambodia on May 6, 2013 to volunteer at Angkor Hospital for Children (AHC). AHC is a nonprofit pediatric teaching hospital. It was founded in 1999 by Kenro Izu, a Japanese-American photographer who came to Cambodia to photograph the nearby UNESCO World Heritage Site and historical religious shrine Angkor Wat. His visit inspired him to do something to help the children of the area. Public health and medical care in Cambodia is burdened by the legacy of the country’s long history of war and political struggle. Many basic needs remain unmet: clean water, sanitation, education, transportation, and communication are unavailable in many areas of Cambodia, both rural and urban. Health care is provided by a network of government hospitals and clinics, NGO hospitals and private clinics. There are also traditional healers and lay midwives. The quality of care varies widely, and resources, even in the best hospitals, are limited.
Angkor Hospital for Children extends most of a city block on a vibrant commercial strip in Siem Reap. When I approached the hospital for the first time, I had to weave a path through a line of parked motorbikes and streetfood vendors. The perimeter fence is painted a cheerful green, and every gate is attended by guards. Inside I found an open play area where one young boy chased another across the concrete. As a pediatric resident, I felt an immediate sense of familiarity in this child-centered environment.
The hospital grounds comprise a thoughtfully laid out complex of pale yellow and white stucco buildings with red tile roofs reminiscent of buildings in California. The walkways, both indoors and out, are dotted with benches on which caregivers and children slept, ate, played, cried — and waited. An oral rehydration area stands near an outdoor triage station. In an adjacent cooking pavilion set up for families to use, pots of porridge bubbled, and free produce and nutritional instruction were provided. The facility maintains an outpatient clinic, inpatient ward, ER/ICU, OR, dental and eye clinics, physical therapy and social work departments. There is no dedicated neonatal unit, though plans to develop a NICU are being discussed. Surveying the landscape, I could see that AHC presented an overwhelmingly positive and functional environment.
AHC trains pediatric residents in a three-year program. Most attend medical school in Cambodia, although a few study abroad in places such as Vietnam, the Phillipines and Russia. Residents perform the same functions as residents in the United States; they round on patients, discuss plans with their attendings, write progress notes and orders, serve as the primary contact people for patients and families, and attend daily didactics. They work both day and night, maxing out their hours at about 60 each week. Like residents in the US, they forge close working relationships, drink caffeinated beverages (tea instead of coffee) to stay awake through the long hours and get sleepy during late-afternoon PowerPoint presentations. Many carry smartphones. The residents welcomed me and I felt at ease working alongside them. A pervasive attitude of calm kept stress at the hospital to a minimum.
My idea of what it meant to be a volunteer evolved over the month I was there. I learned far more than I contributed, which is what AHC expects. Rather than take the lead, resident volunteers are invited to observe, build relationships with Cambodian residents and attendings, and examine and read about patients and their diseases. As I engaged in these integrating activities, a sense of trust developed between me and the staff. Eventually, I was offering my clinical reasoning and doing some teaching.
I spent the first week in the inpatient department known as the IPD. It consists of a 30-bed open pediatric ward, two isolation rooms and a four-bed neonatal unit. At first, I saw the ward as a hot, humid cacophony of crying children. (The hospital is cooled only by fans, which means the temperature and humidity can reach 100-plus degrees with 85 percent humidity.) Most families come from remote rural areas, so they sleep at the hospital for the duration of the admission. A covered outdoor daytime waiting area doubles as sleeping quarters at night.
During my first few days in the IPD, along with rare congenital syndromes and life-threatening infectious diseases, I saw familiar pediatric problems such as pneumonia, asthma exacerbations and impetigo. Malnutrition and lack of access to routine outpatient care exacerbated these common pediatric conditions. A 9-month-old boy came in for a weeping and crusty whole-body rash. His mother had taken him to a traditional healer, who, as it was explained to me, had rubbed a medicinal plant all over his upper torso. His chest and back were abraded and infected. We cultured the rash and confirmed that it was staph aureus; the child had a severe case of impetigo. This was a severe presentation of a familiar diagnosis. Over the following days, his mother and father stayed with him in his isolation room, bathing him and keeping him calm. Gradually, with IV and topical antibiotics his skin healed.
I met many patients with diseases I had never seen before. A 1½-year-old girl with severe malnutrition had been on the ward for three weeks when I first saw her. She weighed 5 kg and was severely developmentally delayed. I offered her the rainbow-colored metal bell of my pediatric stethoscope for exploration. She dropped the bell just as quickly as she reached for it, her wasted muscles collapsing under the weight. Despite treatment of her malnutrition according to World Health Organization standards, she struggled to gain weight. While in the hospital she had acquired and recovered from a respiratory viral infection and had intermittent diarrhea. She had gained and lost 100 grams here and there, but at the three week mark she was back at her admission weight. Her family, poor and from a rural area far away, had been living at the hospital during this time. Her mother took turns with her father at the bedside, as the patient’s 3-year-old sister ran barefoot around the ward throughout the day.
A 3-year-old girl with a trifecta of MRSA vaginitis, salmonella non-typhi septicemia and giardiasis was understandably miserable. Part of her treatment was topical vaginal Betadine three times a day. When I went to look for her in one of the few isolation rooms on the ward, she wasn’t there. It was common for parents to carry patients outside for a change of scenery. The nurse tracked them down in the cooking area. I approached her as gently as I could, starting with a cardiac exam. She screamed and kicked me.
I encountered patients with many infectious diseases. Two infectious disease I had not heard of before were EV-71 and Chikungunya disease. Chikungunya is a viral disease spread by mosquitoes. It causes fever and severe joint pain and potentially muscle pain, headache, nausea, fatigue and rash. Care is supportive and the disease is not usually fatal. The word “chikungunya” is derived from the Tanzanian Kimakonde language and means “to become contorted,” describing the stooped appearance of sufferers experiencing joint pain. EV71 is a common cause of hand, foot and mouth disease in children, and most patients recover within four to six days. However, severe neurologic complications, such as acute encephalitis and polio-like paralysis, can develop in some patients.
I was able to sit in on a hospital-wide conference similar to what we would call morbidity and mortality conference. A resident presented the case of a boy who had recently died at AHC after being treated for disseminated intravascular coagulation and shock. It was presumed that he had dengue hemorrhagic fever, an infectious disease for which the seasonal epidemic was just beginning.
While at AHC I met Claudia Tuner, MD, PhD a British research pediatrician and clinical microbiologist. I assisted with data collection for two of her current research projects, both involving retrospective record reviews. One study aims to identify the causes of morbidity and mortality for neonates admitted to AHC between January 2010 to 31st December 2012. The other aims to characterize outcomes of critical care transports between the AHC satellite clinic. I spent two days at the satellite clinic, in the rural village of Sotnikum, 35km from the city of Siem Reap, reviewing charts of critically ill infants. I was struck by how many times I came across a chart that was marked with the words ‘hopeless case’.
I spent much of my last week at Angkor Hospital for Children in the outpatient department, which sees 500 patients on a busy day. Space is limited and small examining rooms are sometimes shared by two physicians.
Part of AHC’s strategy is to defer the provision of primary care services, such as routine childhood vaccinations, to the government health centers when possible. Their aim is to avoid developing an NGO health care system that runs parallel to the public system. Instead they want to encourage the emergence of more comprehensive government health centers.
The hospital prohibits volunteers from taking photographs inside the hospital. AHC wisely puts patient and family privacy over the curiosity and interest of visitors. The photographs of AHC that accompany this blog are from an archive of photographs from past volunteers and staff. AHC does not offer tours of the hospital to the general public. Their policy contrasts with that of some local organizations, including some orphanages, which offer tours and photo ops to tourists and are considered by many to be exploitative.
The Lake Clinic
I also spent three days volunteering with The Lake Clinic (TLC), a floating/mobile health clinic that brings basic health care to people living on the Tonlé Sap lake. Aside from these periodic visits from the floating/mobile health clinic, these people do not otherwise have access to medical care – preventive or therapeutic. The Tonlé Sap is a combined lake and river system in Cambodia that is also the largest body of water in Southeast Asia. The surface area of the lake swells from 2,700 to 16,000 square kilometers during monsoon season. I traveled by van with the clinic team from Siem Reap to the village of Kompong Khleang, where we then boarded a boat. We cruised down a river of the same name to reach the Tonlé Sap Lake, eventually arriving at the floating village of Peambang. Here, we spent three days providing walk-in urgent care from The Lake Clinic (TLC). The medical team consisted of family physician Dr. Hun Thourida (Rida), pediatric nurse Uk Savaan and a midwife.
On our first morning, a 13-year-old boy came to the clinic seeking treatment for a puncture wound. At 3 a.m., while he was out fishing, a hook had caught his right upper arm and bit into his bicep. A heavy fish had been attached to the line at the time the hook punctured his arm. He was quiet during the examination, though he appeared to be in pain. I suggested a tetanus shot but quickly learned TLC doesn’t have the capacity to refrigerate vaccines and that it is prohibitively expensive for the patient to travel across the lake for an inoculation. Fresh blood seeped slowly from his wound, which was deep but only about 1 cm in length. Dr. Rida and I attended to the wound. We gave him wound care instructions and asked him to return the following week for suture removal. I thought about how hard it would be to keep that arm clean and dry in this environment.
Later that morning, a boat approached carrying two adults and two children. A man sat crouched in the front of the boat. He looked ill — very thin, with large sunken eyes and taut shiny skin. Our gaze locked for several seconds as the boat glided across the water toward the clinic. Although he was only 46 years old, he appeared to be 75.
The man had recently been discharged from a city hospital. He had no medications or medical records with him. Dr. Rida, who saw the patient, wasn’t sure exactly what he had been treated for. His heart and lungs sounded normal, and he had no fever. She was unable to perform any labs tests. That night, as I tried to fall asleep on a cot under the mosquito netting, a woman’s voice called out over a loudspeaker somewhere in the village. The sound carried easily over the water. For a couple of hours, she sang and chanted. A man’s chanting voice eventually replaced hers. In the morning, I learned the announcement had been a death notice. The 46-year-old man I had seen in the boat had died. Later that morning, I smelled the smoke from the nearby pyre as it drifted into the clinic.
Volunteering is a generous term to describe what I did in Cambodia. This was my first experience in international medical work. I knew nothing about the culture, did not speak the local language and had never seen many of the diseases the patients brought to us. As a volunteer it seemed that I took more than I brought. Angkor Hospital for Children invested in my education, and I can only hope that what I contributed in return was useful enough to make the visit worthwhile to my hosts. My month in Cambodia is already affecting my practice in Oakland. I know that physical exam is paramount. I am thinking about how to streamline my diagnostic process. I know I’ve been changed by this work and am grateful for the opportunity that it provided.
Reflection of my experience in Nepal
Nepal is a country like no other that I’ve been to. Kathmandu, the capital of Nepal, is home to roughly 3 million people and is the most urban city in their country. Walking the streets of Kathmandu, you get a true sense of what it is like to be in a developing country. There is one main road circling the city, which is one of the only road that is paved; however, there are no dividers on the road to form traffic lanes or even to separate the side of oncoming traffic. Traffic lights are non-existent. There is a constant haziness in the air from the inevitable dust and smog. Pedestrians do not have the luxury of walking on a sidewalk—you must keep your eyes darting between vehicular traffic and the ground you walk on to avoid cars and motorcycles from colliding into your path or tripping over the rubble, uneven stepping grounds and trash. Stray cows and goats share the road you walk on. Walking down the main road, you pass by many dilapidated buildings housing multiple families in a single room. Groceries are purchased from stands with rusted metal roofs held down by stone and buggy carts along the roads. Fresh fish and meat infested with flies are strewn across wooden tables. About every few miles, there are ditches with faucets protruding from brick walls with running water. Everyday, hoards of people are there washing their hair, their clothes, and always a line of people with big plastic or metal containers to bring their only source of water back to their homes. Almost all areas of Nepal, including rural villages, have access to electricity. However, the ability to generate enough electricity throughout the country remains a major issue. As a temporary fix, the entire country undergoes scheduled power outages daily. Being the central area of commerce in Kathmandu, power outages occur twice a day for 5-6 hours each time. Outside of Kathmandu, power outages can occur anywhere from 3 to 5 times per day for hours at a time.
Helping Hands Community Hospital is located within the center of Kathmandu. It is a private hospital that charges patients 50-75% less than the cost for medical services compared to other private hospitals. My first day there, I learned a great deal about their healthcare system and access to medical care. There are only several government hospitals scattered throughout Kathmandu and a few other major cities with virtually none that exist in the rural areas. There is no insurance system in Nepal, but fees for government hospitals are hugely subsidized so that the cost for services are very low and affordable, even for the lower economic class. However, the wait time for medical care is unreal and the conditions of the hospitals are well below par. Those that live in rural areas typically travel a day or two by foot, followed by another daylong bus ride or a flight into Kathmandu if they can afford it. In the emergency rooms, it takes days to be seen, and it is through here that the assessment must be made to determine if hospital admission is necessary. Once hospitalized, all medications and supplies including syringes, gauze, etc. must be purchased by their family members. For those that require surgery, family members must go to the blood bank and purchase 2 units of blood the day before the surgery. Sometimes it becomes a matter of cost that the family cannot afford, or a shortage of the patient’s blood type, leaving the family members literally crying and begging at the doorstep of the blood bank. But, obtaining blood products is only a minor obstacle. The hospital facilities simply do not have enough manpower and rooms available to accommodate those that require medical attention. Thus, the wait time for any surgical procedure can take days, months or even years. When I posed the question, “If a patient’s condition is evaluated to be serious enough to require surgical intervention, how can the patient survive waiting even days?” The doctor I asked shrugged and chuckled hesitantly, acknowledging that access to medical care is a huge problem for middle class citizens and below, but unfortunately, it remains the course for many people with many patients dying during this process. Those that have the financial means can go to private hospitals for faster access to care.
My experience as a gynecologist at Helping Hands Hospital was a huge eye-opener to the issues surrounding women’s health and the way medicine is practiced in Nepal. All of the physicians that serve at this hospital are all volunteer physicians that come and see patients either before or after their main responsibilities at their respective hospitals. Outpatient clinic hours vary between 2 to 4 hours daily with office times that change on a daily basis. The clinic consists of a single room with a metal sink, a desk, an exam table behind a curtain, and several stools. Patient privacy is not a common practice. There can be up to 3 patients in the tiny room at one time along with random family members—the attending is obtaining the history of one patient, the next patient is sitting in a chair waiting her turn, while I perform a pelvic exam on the patient we just interviewed behind the curtain. At most 5 minutes is spent on each patient in total, which leaves virtually no time for counseling. The patient virtually has seconds to ask the questions that she has before her opportunity is lost and our attention has moved on to the next patient. The attending writes a progress note in a paper booklet along with the recommendations (lab tests, prescriptions, etc.), which is kept by the patient. The hospital only has a registration log of when the patient was seen, but keeps no medical file of the patient. It is up to the patient to purchase the recommended medications from the pharmacy and perform the recommended tests. It is also up to the patient to return with their lab or imaging results to be reviewed by the physician. Definitive surgical treatment is often the recommendations of the gynecologists for fibroids, abnormal bleeding after completion of childbearing, pelvic organ prolapse, etc. When I asked why the patient is not counseled on the option for medical management, most attendings have told me that lack of follow up care is the main reason. Most women either will not return for follow up as advised due to cost of office visits, or they come from villages far away without easy access to pharmacies for medications and continued medical care. For those same reasons, as well as the lack of resources within the hospital to provide quick definitive diagnostic testing, many patients are over-treated for conditions that they likely do not have. For example, women that come in with a complaint of vaginal discharge and itching will often be treated for pelvic inflammatory disease, yeast infection, and parasitic infections, even if their physical exam findings do not overtly support these diagnoses. Again, the reason for such practice revolves around many patients either unwilling to or unable to pay for diagnostic tests and then having to spend more time and money to return for follow up afterwards.
As for prenatal patients, most will have a first and second trimester ultrasound for dating and anatomy screening, and the usual prenatal labs. Every patient receives a tetanus booster and one dose of anti-parasitic medication during their second trimester. Fetal heart tones are assessed with a stethoscope through the patient’s abdomen, and feeling the location of the fundus assessed fetal growth. Fetal presentation is assessed by palpation and only assessed by ultrasound if the physician did not feel confident about palpating the head in within the maternal pelvis. Elective primary cesarean sections are quite common due to fear of labor pain, since pain management during labor is not available at this particular hospital. If a patient complained of contraction pains between 39 to 40 weeks, they were often admitted to the hospital for observation overnight and then induced if they did not progress into labor spontaneously. Again, this common practice is due to lack of access to medical facilities and the inability for patients to return repeatedly for labor checks. For these reasons, evidence-based medicine was rarely practiced.
There were two operating rooms that were separated by a glass wall, thus patient privacy was non-existent. Everyone in the operating room changed into scrubs and “OR slippers,” thus toes remained exposed. Those that scrubbed in wore fabric gowns and masks without any protective eyewear. Equipment that is normally disposed of were “sterilized” and reused, such as suction tubing and MVA cannulas. Makeshift baby warmers were put together in the OR during cesarean sections with a portable electric wire-grated heater directed onto baby blankets and towels. Almost all patients received 5-7 days of broad-spectrum antibiotics postoperatively regardless of the type of surgery they received due to the sanitation conditions and overcrowding of the inpatient wards. During times when the scheduled daily power outages were in effect mid-procedure and the power generator had not kicked in yet, we would continue the operation under guidance by flashlight. When a patient presented for a cesarean section, there were no baby warmers in the OR. Instead, a large portable metal heater propped up on a table pointing towards blankets and towels to be used for the delivery became the makeshift baby warmer. What I learned the most in the OR was how to be as least wasteful as possible since the patient has to purchase all of the materials used during surgery. Instrument tying was used to conserve suture, gauze was rinsed with warm saline and wrung out to be reused for dabbing blood.
One of my most memorable and rewarding experiences is from the free women’s health clinic hosted by us medical volunteers through the Mountain Fund at a local daycare center/school named, “Orchid Garden.” This daycare center is a very special one because it was built from the vision of a woman named Bina Basnet, who did not want children to be abandoned, but to have a place where children will be safe, well taken care of and educated while their mothers were at work. Thus, she became the founder of Orchid Garden, which is a non-profit center that accepts children from the age of 6 months to 8 years, and with classrooms from pre-K to grade 2. In total, there are almost 900 children at this center, with 150 children that attend grade 3 at outside schools from funding through the Orchid Garden. At the women’s health clinic we hosted, we saw and treated over 35 women for various conditions such as dysmenorrhea, menorrhagia, vaginal itching, abnormal discharge, abdominal pain, and pelvic organ prolapse. Those that required inpatient evaluation were referred to Helping Hands Hospital. Our exam rooms consisted of two school desks covered with sheets and a mini-mattress, with the two exam tables separated by a bedsheets tied to support beams near the ceiling. Our speculums had to be soaked in a sterilization solution for 45 mins before use on the next patient. The staff from Orchid Garden and local Nepali girls from the Mountain fund served as our translators. Because of the language barrier, each patient took at least 30 mins to assess. But, in the end, the patients were extremely grateful of our services and left with ear to ear smiles with free medications appropriate for their condition which they otherwise would not have been able to afford.
Words can only partially describe how rewarding and fulfilling it was to spend an extended period of time practicing medicine in a developing country. I feel so blessed to have had this opportunity during my residency training to go abroad for an educational experience. It has allowed me to reflect on how fortunate we are to have the resources we have to provide such advanced quality of care for our patients here. I have also learned to appreciate the fundamental things that we have that I surely never thought twice about before—adequate lighting, running water, protective personal equipment, private patient rooms, disposable equipment… and the list goes on and on. If I have the opportunity again to go abroad and provide medical care, I would jump at that chance as it is nothing short of a unique experience that offers insight on the world and within oneself. This experience has also reminded me of the reasons why I chose a career in medicine, which has strengthened my personal mission to provide the most compassionate care I possibly can as a doctor, and as a human being.
For this global health elective, I was fortunate enough to go back to the same hospital in Nicaragua as I went to last year. One of our OBGYN attendings, does multiple international surgical missions each year. We went to Jinotega, Nicaragua with one Kaiser Permanente San Francisco anesthesiologist last year for one week and did GYN surgery with a program called Avodec. This year, she was able to coordinate though the same program to bring two OBGYN attendings, two anesthesiologists and two GYN residents. We had two ORs and were able to see/operate on double the number of patients we had last year. We flew out on a red-eye Friday after work, set up the ORs and organized our 6 boxes of supplies/equipment on Saturday, and began our triage on Sunday. We did H&Ps and full pre-op exams on over 100 patients, working in two rooms. Monday, we began operating and operated all day for the remainder of the week. We completed mostly vaginal surgery with only three abdominal ovarian cystectomies. Our patients stayed in one ward of the hospital with Avodec hired MDs and RNs and we saw our patients in both the morning and evening. We also worked with several of the Jinotegan Urologists and Gynecologists- having them scrub into cases and having them do some of procedures for education. It was a tiring but very rewarding experience. The patients were in such need of surgery and so appreciative for their care. It was motivating and inspiring.