We've written about the emergency obstetrics training courses before. ALSO (Advanced Life Support in Obstetrics) as it is called, has been one of the most effective, interesting, and sustainable projects we have done in Tanzania.
As all health care providers know, it is one thing to read about uncontrolled bleeding and how to treat it; it is immensely more helpful if you can practice how to treat the bleeding. Especially with your peers, and in a non-threatening situation.
Comparing our ALSO course with the typical emergency obstetrics course offered in Tanzania:
Our ALSO vs. typical course
1. We go to provider’s hospital vs 1. Providers are taken to an outside location
2. Course lasts 2-3 days vs. 2. Course lasts 3 weeks
3. Mostly hands-on, role-playing vs. 3. Mostly lectures, talks
4. Costs ~$130 per provider vs. 4. Costs ~$1200 per provider
5. Each participant can become vs. 5. Usually instructors prearranged
an instructor based on evaluation
6. Evidence-based information vs. 6. Sometimes evidence-based information
It is easier to learn emergency obstetrics training in your own hospital, in just 2-3 days, with your colleagues practicing with you. It is more effective to have instructors who can explain things in English and Swahili. Because of these methods, the ALSO course is a cost-effective training- funded exclusively by individuals (through the Blue Jean Ball funds) and the local Tanzanian hospitals.
In this video, you hear from two KCMC midwives who first were ALSO course participants, and then became instructors. They give examples of how some simple techniques have been able to help them save lives.
Thanks to Dr. Puri, our current global health fellow, we have 4 ALSO courses scheduled in the next month, with more than 100 providers planning to attend.
Thursday, November 18, 2010
Wednesday, October 20, 2010
It has been a while.
It has been 8 months since our last blog. A few of us were returning to the US, and so we had a lot of projects to complete, teaching to do, research to wrap up, and friends to say goodbye to.
Although Jeff and I are back in America, we plan to continue projects initiated 2 years ago through our colleagues who are still in Moshi, including Ruchi, the Global Health Fellow for the year. Jeff will return to East Africa multiple times this year to continue projects in person.
We also plan to write more. And now that we have access to high speed internet with some computer virus protection, we will finally post some pictures. We will also continue to write about the many challenges, surprises and rewards experienced by our team in Tanzania. We continue to need the support of everyone who has helped us before, through the Blue Jean Ball, and I hope that some of our stories and pictures will be able to show you why.
Below is the introductory part of the video for the Blue Jean Ball fundraiser held February 2010.
Sunday, February 21, 2010
Thank You
To all the wonderful people who volunteered and attended the Blue Jean Ball on Saturday despite the snow and cold: you are amazing. To all the people unable to attend, but who have donated their time, or resources, or money: you are also amazing.
Your efforts affect a wide population that encompasses the Northern Zone of Tanzania. Since KCMC hospital is 1 of only 4 Referral Hospitals for the entire country of 40 million, it officially serves as the hospital of last resort for a population of 15 million people (and also the Kenyan villagers who live right across the border). We have seen patients come from Zanzibar, from Kenya and from the Ugandan border based on the reputation of KCMC hospital. The reality of KCMC is that it has knowledgeable specialists and intensive care possibilities, but frequently lacks the most basic resources such as functioning hemoglobin machines, or blood in the blood bank, or patient gowns for surgery.
None of this is new information, and all of our previous blogs have touched on different aspects of working in low-resource situations. But the one thing that keeps us optimistic is our Duke team's ability to contribute to women's' and newborn's health care.
And on Saturday, 350 people attended and 125 volunteered at (and countless others donated to) an event to raise funds for people that they will never meet.
Because of you:
1. There are women and babies alive in Tanzania who otherwise would not have survived. Due to donations of:
*Ambu bags to resuscitate babies
*Medications to save laboring mothers lives (to treat preeclampsia, postpartum hemorrhage, infections)
*Money for intensive courses on managing emergency obstetrics and newborn resuscitation that have trained more than 255 people in Tanzania so far
2. There are women who have new-found hope in a healthy life. Due to donations: *Allowing doctors (such as Jeff, Masenga, the global health residents) to travel to rural areas to perform fistula surgeries
*Providing women with fistula funds to travel to KCMC and get treated
*Providing women with cancer funds to travel to the only cancer center in Tanzania- located 600 miles away.
*Providing funds for fistula patient's families or nurses to accompany them for support;
* In surgical equipment and supplies to perform more complex surgeries.
3. The doctors and nurses at KCMC and other hospitals in the Kilimanjaro Region have more chances to be empowered. Due to donations of:
*Stipends that allow local midwives and doctors to teach the emergency obstetrics courses to other Tanzanians. Our research has shown that instructors retain their knowledge of emergency obstetrics better.
*Scholarships to allow our local KCMC colleagues to attend important international and national meetings for continuing education as well as disseminating best-practices
*Medical books and supplies that are not available (or are prohibitively expensive) locally, given to colleagues who demonstrate initiative in patient care.
4. Patients have something to smile about. Due to donations of:
*Infant blankets and caps, handmade by people in the US! Sometimes the only gift the baby will have.
*Hundreds of infant caps donated by a North Carolina company, kept the heads warm of so many newborns.
*Money, the poorest patients have received personal items that they could never afford, such as clothes and hygiene items.
Thank you
Sumera
Your efforts affect a wide population that encompasses the Northern Zone of Tanzania. Since KCMC hospital is 1 of only 4 Referral Hospitals for the entire country of 40 million, it officially serves as the hospital of last resort for a population of 15 million people (and also the Kenyan villagers who live right across the border). We have seen patients come from Zanzibar, from Kenya and from the Ugandan border based on the reputation of KCMC hospital. The reality of KCMC is that it has knowledgeable specialists and intensive care possibilities, but frequently lacks the most basic resources such as functioning hemoglobin machines, or blood in the blood bank, or patient gowns for surgery.
None of this is new information, and all of our previous blogs have touched on different aspects of working in low-resource situations. But the one thing that keeps us optimistic is our Duke team's ability to contribute to women's' and newborn's health care.
And on Saturday, 350 people attended and 125 volunteered at (and countless others donated to) an event to raise funds for people that they will never meet.
Because of you:
1. There are women and babies alive in Tanzania who otherwise would not have survived. Due to donations of:
*Ambu bags to resuscitate babies
*Medications to save laboring mothers lives (to treat preeclampsia, postpartum hemorrhage, infections)
*Money for intensive courses on managing emergency obstetrics and newborn resuscitation that have trained more than 255 people in Tanzania so far
2. There are women who have new-found hope in a healthy life. Due to donations: *Allowing doctors (such as Jeff, Masenga, the global health residents) to travel to rural areas to perform fistula surgeries
*Providing women with fistula funds to travel to KCMC and get treated
*Providing women with cancer funds to travel to the only cancer center in Tanzania- located 600 miles away.
*Providing funds for fistula patient's families or nurses to accompany them for support;
* In surgical equipment and supplies to perform more complex surgeries.
3. The doctors and nurses at KCMC and other hospitals in the Kilimanjaro Region have more chances to be empowered. Due to donations of:
*Stipends that allow local midwives and doctors to teach the emergency obstetrics courses to other Tanzanians. Our research has shown that instructors retain their knowledge of emergency obstetrics better.
*Scholarships to allow our local KCMC colleagues to attend important international and national meetings for continuing education as well as disseminating best-practices
*Medical books and supplies that are not available (or are prohibitively expensive) locally, given to colleagues who demonstrate initiative in patient care.
4. Patients have something to smile about. Due to donations of:
*Infant blankets and caps, handmade by people in the US! Sometimes the only gift the baby will have.
*Hundreds of infant caps donated by a North Carolina company, kept the heads warm of so many newborns.
*Money, the poorest patients have received personal items that they could never afford, such as clothes and hygiene items.
Thank you
Sumera
Thursday, February 11, 2010
The baby died after the uterus ruptured. Or maybe the baby died first, setting off the cascade of events leading to the uterine rupture. It's difficult to know the exact story. The patient, E., went to the first hospital after she started having abdominal pain and vaginal bleeding. She wasn’t sure if the abdominal pain was normal labor-related or a worrisome sign, since this was her first baby. She had not felt her baby move for a week.
E. was referred to KCMC for the vaginal bleeding and concerns about placental abruption (but without a referral form we can’t tell if they ever heard fetal heart tones).
What is known is that on admission to KCMC, a lack of fetal heart beats led the staff to do an ultrasound which showed a murky picture with possible placenta previa and placental abruption, but definitely no fetal heart beat. An emergency c-section was called, but first some blood had to be found from the blood bank (because of 2 days of vaginal bleeding). Since a hemoglobin level could take 24 hours for the lab to process, E’s anemia was diagnosed clinically.
During c-section, the chief resident (Zuhura) surprisingly found a ruptured uterus, a dead baby of a healthy size (about 7 pounds) floating in the abdomen along with its placenta, and about 1 liter of blood. She called Jeff to assist, but she handled the emergency well, and E’s vital signs were stabilized. The tough question for Jeff was whether to stitch the uterus back together, or remove the uterus by hysterectomy. E. is a young lady on her 1st pregnancy, and since she could not be asked her thoughts while under general anesthesia, Jeff decided to err on the side of fertility and keep the uterus in place.
E. is doing well today, with her fever resolving and in less pain. By now she knows that her baby has died, although we don’t know when or for what reason.
E’s story is one reason that the residents have instituted a Stillbirth Audit with our help. We plan to collect data on babies who died before admission, during labor or immediately after delivery. We plan to do it within 24 hours of the event, so that the history is fresh in the minds of providers. The entire obstetric staff is behind this initiative, because evaluating the problem is the first step in creating long-lasting and effective interventions to solve the problem.
It is a start.
Sumera
E. was referred to KCMC for the vaginal bleeding and concerns about placental abruption (but without a referral form we can’t tell if they ever heard fetal heart tones).
What is known is that on admission to KCMC, a lack of fetal heart beats led the staff to do an ultrasound which showed a murky picture with possible placenta previa and placental abruption, but definitely no fetal heart beat. An emergency c-section was called, but first some blood had to be found from the blood bank (because of 2 days of vaginal bleeding). Since a hemoglobin level could take 24 hours for the lab to process, E’s anemia was diagnosed clinically.
During c-section, the chief resident (Zuhura) surprisingly found a ruptured uterus, a dead baby of a healthy size (about 7 pounds) floating in the abdomen along with its placenta, and about 1 liter of blood. She called Jeff to assist, but she handled the emergency well, and E’s vital signs were stabilized. The tough question for Jeff was whether to stitch the uterus back together, or remove the uterus by hysterectomy. E. is a young lady on her 1st pregnancy, and since she could not be asked her thoughts while under general anesthesia, Jeff decided to err on the side of fertility and keep the uterus in place.
E. is doing well today, with her fever resolving and in less pain. By now she knows that her baby has died, although we don’t know when or for what reason.
E’s story is one reason that the residents have instituted a Stillbirth Audit with our help. We plan to collect data on babies who died before admission, during labor or immediately after delivery. We plan to do it within 24 hours of the event, so that the history is fresh in the minds of providers. The entire obstetric staff is behind this initiative, because evaluating the problem is the first step in creating long-lasting and effective interventions to solve the problem.
It is a start.
Sumera
Wednesday, January 20, 2010
Courage
Courage
Bravery, guts, nerve, valor, daring, audacity…….
Some people seem to come by courage naturally. Some create a false image of courage for the outside world to see yet suffer greatly on the inside. For some, courage comes involuntarily as it is thrust upon them. In these people we see indomitable spirits from which we all can learn. Take F.N. who has been with us now for a year in the hospital. She was 16 when she became pregnant and delivered her first and only baby that she will ever deliver and it was dead. She had obstructed labor like so many other woman and did not have access to emergency obstetrics care and labored at home for 2 days. She experienced such a horrific injury to the soft tissues of her pelvis from compression of the fetal head that we were unable to even attempt a traditional fistula repair. She was one of a handful that we cannot attempt a repair with a relatively safe, quick vaginal surgery. She had both a vesicovaginal and a rectovaginal fistula and leaked urine and stool constantly. When we saw her on an AMREF (www.amref.org) fistula outreach surgery week, she was malnourished, lethargic, depressed. She had the stench of someone who lays in their own concentrated waste for days with no one to attend to them. Her skin was broken down from the constant wetness and she had deep, painful ulcerations of the labia and buttocks. She had nearly given up hope, abandoned by her family. With Dr. Masenga’s guidance and help from funds from the Blue Jean Ball donations, we transported F.N. to KCMC for care. After countless examinations and tests it was concluded that the Urologists would assume her care because of the complexity of her condition. Despite valiant attempts at diverting the flow of stool and urine and 5 separate surgeries, she had a recurrence of her rectovaginal fistula and because her urine had been diverted in to her colon, she was having stool and urine leaking constantly through the same residual hole in her vagina. One year in the hospital and no hope in site, but she had regained an ever present smile and sense of humor that belied her wretched state.
One last desperate attempt at repair: She arrived in the operating theatre that morning with her usual calm, determined smile, without a hint of anxiety or worry which most of us would have. After so many surgeries, she had very few iv sites and served more as a pin cushion for the anesthetists. Two failed spinal anesthesia attempts added insult to injury. As she lay there after her second spinal attempt and her 7th painful iv start the urine and residual stool from the bowel preparation filled the canvas on which she lay and because of her positioning ran up and around her head. It was disgusting to watch and we hastened to clean her up and apologize for the mess, but she just patiently smiled and reassured us that she was ok as she finally went off to sleep with general anesthesia. What kind of person can endure this level of prolonged suffering and still hold her head high the next day and smile, laugh and walk the corridors of her familiar hospital with her fistula friends? A woman with courage beyond measure and one from whom I will always be grateful for teaching me about humility and equanimity in a way greater than any doctor could ever teach.
Bravery, guts, nerve, valor, daring, audacity…….
Some people seem to come by courage naturally. Some create a false image of courage for the outside world to see yet suffer greatly on the inside. For some, courage comes involuntarily as it is thrust upon them. In these people we see indomitable spirits from which we all can learn. Take F.N. who has been with us now for a year in the hospital. She was 16 when she became pregnant and delivered her first and only baby that she will ever deliver and it was dead. She had obstructed labor like so many other woman and did not have access to emergency obstetrics care and labored at home for 2 days. She experienced such a horrific injury to the soft tissues of her pelvis from compression of the fetal head that we were unable to even attempt a traditional fistula repair. She was one of a handful that we cannot attempt a repair with a relatively safe, quick vaginal surgery. She had both a vesicovaginal and a rectovaginal fistula and leaked urine and stool constantly. When we saw her on an AMREF (www.amref.org) fistula outreach surgery week, she was malnourished, lethargic, depressed. She had the stench of someone who lays in their own concentrated waste for days with no one to attend to them. Her skin was broken down from the constant wetness and she had deep, painful ulcerations of the labia and buttocks. She had nearly given up hope, abandoned by her family. With Dr. Masenga’s guidance and help from funds from the Blue Jean Ball donations, we transported F.N. to KCMC for care. After countless examinations and tests it was concluded that the Urologists would assume her care because of the complexity of her condition. Despite valiant attempts at diverting the flow of stool and urine and 5 separate surgeries, she had a recurrence of her rectovaginal fistula and because her urine had been diverted in to her colon, she was having stool and urine leaking constantly through the same residual hole in her vagina. One year in the hospital and no hope in site, but she had regained an ever present smile and sense of humor that belied her wretched state.
One last desperate attempt at repair: She arrived in the operating theatre that morning with her usual calm, determined smile, without a hint of anxiety or worry which most of us would have. After so many surgeries, she had very few iv sites and served more as a pin cushion for the anesthetists. Two failed spinal anesthesia attempts added insult to injury. As she lay there after her second spinal attempt and her 7th painful iv start the urine and residual stool from the bowel preparation filled the canvas on which she lay and because of her positioning ran up and around her head. It was disgusting to watch and we hastened to clean her up and apologize for the mess, but she just patiently smiled and reassured us that she was ok as she finally went off to sleep with general anesthesia. What kind of person can endure this level of prolonged suffering and still hold her head high the next day and smile, laugh and walk the corridors of her familiar hospital with her fistula friends? A woman with courage beyond measure and one from whom I will always be grateful for teaching me about humility and equanimity in a way greater than any doctor could ever teach.
Tuesday, December 15, 2009
Community Health and local healing
Andy, a graduate student, and I have been working with the Community Health Department at KCMC to help prepare their MD1's (first year medical students) for their longitudinal community health experience. It is a great idea, and I wish my medical school had offered such an experience....years ago.
The MD1's spend 1 Thursday every week in their 1st 2 years of medical school with the Community Health department. Students are placed in groups and paired with villages in the Kilimanjaro region. Initially, they are required to do a community assessment of their village- interviewing the village health leaders, some families, and the health facility- and form recommendations based on their evaluations. Last week, the students presented their findings, and it was a great way to hear about the villages bordering KCMC hospital. Andy and I had each gone with a group to a specific village, so we had a chance to see 1 village closely.
My village was on the road to Kibosho, a rather large village with 12,000 inhabitants, it contained 7 primary schools, 123 local bars and 2 health dispensaries. We went to visit one dispensary. Dispensaries are the most basic level of health facility, and are ubiquitous. Tanzania has a goal of having 1 dispensary every 5 kilometers. This dispensary was privately run by a church, and contained all the essential parts: outpatient area, pharmacy, lab, 6 inpatient/maternity beds and 1 delivery bed. The dispensary was very clean, but it was also very quiet. The entire hour we were there, we only saw 2 patients come through. The villagers say that private dispensaries are not popular because they charge money for medications and services. Usually it is quite minimal- $1 for medications, $5 for a delivery. But this amount is enough to keep people away. We see this at KCMC hospital, where people don't want to pay the $12 fee for a regular delivery and try to stay at Mawenzie hospital (where it is free).
This village also has a local healer, and we were lucky enough to interview him. He practiced from his home, a nice house with a very nicely manicured lawn and driveway. His entire waiting room was filled, and we (the 4 medical students and I) squeezed into his treatment room the size of a closet with 2 babies, 1 child and their anxious mothers. Local healers practice in different ways- some are herbalists, some are spiritualists and a few are quite frightful (see the recent news of albinos afraid for their lives given the high value of their body parts http://www.timesonline.co.uk/tol/news/world/africa/article6901688.ece ). This local healer used to be an engineer until about 15 years ago when he had a vision, literally. He was driving down a lonely road in central Tanzania when he was forced to pull over by a vision in the sky. This vision told him to start healing people in his village, and he continues to get his treatments through visions. As he was talking with us, he was creating suspensions in bottles (he wouldn't tell us what it was) to give to the babies and child. He gave 1 teaspoon to each, and waited 5 minutes. Then he gave the suspensions to the mothers to take home. I admit I was rather conflicted- especially seeing infants given suspensions of unknown yellow liquids, when it sounded like they had some colic. Should I have offered to evaluate the infants with my western medical background and provided my allopathic-based diagnosis and treatment? Who am I to say that my treatment would work better? It definitely would be less mysterious and more standardized. I was surprised to see the mothers willing to pay $1 to the local healer, but not to the dispensary. The healer was not surprised, and he gave us a few stories of people who failed to be healed despite weeks of therapy at the hospital and who were only cured after visiting him. Of course, this conflict of therapies occurs in the U.S. all the time. My patients would tell me about how their Homeopathic doctor, or their Naturalist finally treated their problem after countless visits to my colleagues had failed. I wonder how many of my patients had similar experiences. I assumed that this local healer would be cheaper, or offer services at nights/weekends, or spend a long time with his patients- none of these were true. But he was definitely a popular alternative to the dispensary, or to the long journey to a larger health facility. With so many health facilities lacking basic medicines, laboratory tests, or essential supplies (like blood pressure cuffs or delivery kits), local healers can be an attractive alternative in health care. As we were leaving at the same time as the patients, we heard the mothers thank the "doctor" for his help.
Sumera
The MD1's spend 1 Thursday every week in their 1st 2 years of medical school with the Community Health department. Students are placed in groups and paired with villages in the Kilimanjaro region. Initially, they are required to do a community assessment of their village- interviewing the village health leaders, some families, and the health facility- and form recommendations based on their evaluations. Last week, the students presented their findings, and it was a great way to hear about the villages bordering KCMC hospital. Andy and I had each gone with a group to a specific village, so we had a chance to see 1 village closely.
My village was on the road to Kibosho, a rather large village with 12,000 inhabitants, it contained 7 primary schools, 123 local bars and 2 health dispensaries. We went to visit one dispensary. Dispensaries are the most basic level of health facility, and are ubiquitous. Tanzania has a goal of having 1 dispensary every 5 kilometers. This dispensary was privately run by a church, and contained all the essential parts: outpatient area, pharmacy, lab, 6 inpatient/maternity beds and 1 delivery bed. The dispensary was very clean, but it was also very quiet. The entire hour we were there, we only saw 2 patients come through. The villagers say that private dispensaries are not popular because they charge money for medications and services. Usually it is quite minimal- $1 for medications, $5 for a delivery. But this amount is enough to keep people away. We see this at KCMC hospital, where people don't want to pay the $12 fee for a regular delivery and try to stay at Mawenzie hospital (where it is free).
This village also has a local healer, and we were lucky enough to interview him. He practiced from his home, a nice house with a very nicely manicured lawn and driveway. His entire waiting room was filled, and we (the 4 medical students and I) squeezed into his treatment room the size of a closet with 2 babies, 1 child and their anxious mothers. Local healers practice in different ways- some are herbalists, some are spiritualists and a few are quite frightful (see the recent news of albinos afraid for their lives given the high value of their body parts http://www.timesonline.co.uk/tol/news/world/africa/article6901688.ece ). This local healer used to be an engineer until about 15 years ago when he had a vision, literally. He was driving down a lonely road in central Tanzania when he was forced to pull over by a vision in the sky. This vision told him to start healing people in his village, and he continues to get his treatments through visions. As he was talking with us, he was creating suspensions in bottles (he wouldn't tell us what it was) to give to the babies and child. He gave 1 teaspoon to each, and waited 5 minutes. Then he gave the suspensions to the mothers to take home. I admit I was rather conflicted- especially seeing infants given suspensions of unknown yellow liquids, when it sounded like they had some colic. Should I have offered to evaluate the infants with my western medical background and provided my allopathic-based diagnosis and treatment? Who am I to say that my treatment would work better? It definitely would be less mysterious and more standardized. I was surprised to see the mothers willing to pay $1 to the local healer, but not to the dispensary. The healer was not surprised, and he gave us a few stories of people who failed to be healed despite weeks of therapy at the hospital and who were only cured after visiting him. Of course, this conflict of therapies occurs in the U.S. all the time. My patients would tell me about how their Homeopathic doctor, or their Naturalist finally treated their problem after countless visits to my colleagues had failed. I wonder how many of my patients had similar experiences. I assumed that this local healer would be cheaper, or offer services at nights/weekends, or spend a long time with his patients- none of these were true. But he was definitely a popular alternative to the dispensary, or to the long journey to a larger health facility. With so many health facilities lacking basic medicines, laboratory tests, or essential supplies (like blood pressure cuffs or delivery kits), local healers can be an attractive alternative in health care. As we were leaving at the same time as the patients, we heard the mothers thank the "doctor" for his help.
Sumera
Brief trip to Rwanda
Jeff had a quick visit to Rwanda recently. It's always helpful to get some perspective on suffering. Here is a brief email received from him:
"I made a quick. somewhat last minute trip to Rwanda with Nathan Thielman to help him with a project on emergency obstetrics teaching here. Yesterday, we visited a few hospitals and also had the oportunity to visit two genocide memorials here in Kigali and in a town close by called Nyamata. I had read of many accounts of the Genocide in 1994, and the smaller ones over the past 40 years that lead up to it. It was something else to ride through the beautiful landscapes here and imagine it strewn with corpses. The world sat by and watched as 1 million people were systematically killed. It was sobering to say the least. We are going to Gisenyi today which is on the border with Congo. We are visiting one of the district hospitals there that has a particularly high maternal mortality rate."
More details to come....
"I made a quick. somewhat last minute trip to Rwanda with Nathan Thielman to help him with a project on emergency obstetrics teaching here. Yesterday, we visited a few hospitals and also had the oportunity to visit two genocide memorials here in Kigali and in a town close by called Nyamata. I had read of many accounts of the Genocide in 1994, and the smaller ones over the past 40 years that lead up to it. It was something else to ride through the beautiful landscapes here and imagine it strewn with corpses. The world sat by and watched as 1 million people were systematically killed. It was sobering to say the least. We are going to Gisenyi today which is on the border with Congo. We are visiting one of the district hospitals there that has a particularly high maternal mortality rate."
More details to come....
Subscribe to:
Posts (Atom)