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Urology and Children: A Nurse’s Perspective

The continued account of IVUmed volunteer recovery nurse, Michael Felber, regarding his recent IVUmed humanitarian service in Zambia, shared from his travel journal:

 

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IVUmed missions have a focus on education. There is very little fanfare and the only visitors to the hospital are other doctors and medical students. The operating rooms are usually full of observers and IVUmed surgeons and anesthesiologists work together.

 

Many of the surgeries this week have been revisions of previous surgeries. Pediatric urology as a specialty doesn’t exist as a standalone specialty in most of the developing world. Children need different techniques and different care than adults do though, so specialized training is needed. It’s a dilemma for IVU. The best way to teach doctors surgical techniques is with primary surgeries, allowing them to learn how to do surgeries that won’t require a redo. At the same time, you can’t ignore the needs of children who are living with bad outcomes from previous surgeries.

 

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One of the common procedures is a hypospadias repair, a relatively common birth defect where the opening of the urethra is on the shaft or base of the penis instead of the tip. It is typically treated in infancy in the developed world. The implications depend on where the hypospadias is. If the urethra empties on the distal (tip) end the child may not be able to urinate straight, but otherwise function normally. If it is proximal (base of the penis), the penis will not be able to straighten. The child may not be able to urinate while standing, and eventually will not have normal fertility. The surgery to repair a hypospadias takes a couple of hours. The urethra is reconstructed to the tip of the penis, and the skin is closed with a graft, usually from the foreskin. The child has a catheter in place while healing. Probably the most common complication that occurs after surgery is the formation of a fistula. Instead of healing completely along the suture line, a second opening forms from the urethra to the shaft of the penis. The child will not urinate in a normal single stream and may “leak” urine after emptying his bladder. Repairing is complicated by excessive scar tissue or a shortage of soft, healthy skin available for grafting.

 

Another problem that requires surgical treatment is the formation of posterior urethral valves. Normally urine empties from the bladder through the urethra. Posterior urethral valves are malformed tissues that block this flow of urine, only allowing it to leak out under very high pressure. Children with this condition have chronically full bladders. The pressure forces urine into the ureters, which empty urine from the kidneys to the bladder. The additional pressure restricts blood flow to the kidneys, preventing normal growth and eventually starving the kidneys of oxygenated blood. In the short term children with this condition are incontinent. Over time they develop kidney failure. Surgical repair of post urethral valves requires specialized techniques and equipment. In countries where these are not available, the treatment may involve creating an opening from the abdomen to the bladder and placing a tube attached to a drainage bag. This relieves the pressure on the child’s bladder but greatly increases the risk of bladder infections and bladder cancer. Tubes and drainage bags need to be replaced frequently and urine can leak from the opening, and the associated shame and isolation impedes normal social development. In addition to teaching surgical techniques, IVU donates necessary equipment for this repair and teaches techniques that can be done with local resources and equipment.

 

The most complex treatment is for bladder exstrophy, a condition that results from insufficient room in the pelvis for the bladder. Instead it tries to form outside the abdomen, leaving an opening that drains urine continuously. The implications are complete incontinence, and heightened risk of abdominal cancer and infection. Surgical treatment requires reshaping the pelvis to accommodate the bladder, and reconstructing and reforming the bladder using grafts from other tissue. Because of the complexity, surgical reconstructions are often done in stages.   

 All of these conditions have significant impacts on the lives of children and their families. The suffering they cause is often discreet. Urological defects tend to be hidden behind a wall of shame and often these children are ostracized socially, and are unable to find employment or get married as adults. I think in the end all of these conditions affect people’s most basic sense of dignity.

 The last two patients are in the operating rooms.  One more day left.  It feels like I have been here much longer than a week, though.

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Zambia Blog: A Kind Word and a Smile

The continued account of IVUmed volunteer recovery nurse, Michael Felber, regarding his recent IVUmed humanitarian service in Zambia, shared from his travel journal

 

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We are on the fourth day, a beautiful, warm day. Surgeries are going well.

 

The nurses’ strike is still officially going on, but more nurses are trickling in. This morning there was no running water in the hospital. Luckily the surgical instruments had already been sterilized. There is a large blue tank of water with a spigot for hand washing. By the end of the morning the water was running again. People just sort of go with the flow here.

 

David was a very nice 8 year old boy who had surgery this morning. He was frightened as he went to sleep, but tried mightily not to cry. He held it together until the mask went on, then struggled and cried out “I am dying!”  In recovery he woke up with a smile. He was mildly pleased when we brought him toys, but when I gave him a banana he just about jumped off his cart with excitement.

 

There is the usual big city traffic on the way in to the hospital, but it is quiet. I haven’t heard a car horn since I got here, unlike other countries where the horn is a substitute for a brake. People here are exceedingly polite. Zambia is a poor country, with 50% unemployment. But so far, unlike many other countries I have visited, the people standing in traffic selling newspapers, cell phone minutes, and candy have been adults.

 

The University Teaching Hospital of Zambia, our host, is an 1800 bed facility. When you walk on the wards, you see that all the beds are full, and more patients are sleeping on the floor.

Someone called me Sister yesterday. I guess there aren’t too many men in nursing here. A couple of the surgeons were discussing starting an internet teaching program that would use video to teach urological surgery techniques. You could say live “streaming” video…

In the United Kingdom 10% of available food is wasted. I imagine the figure for the US is the same or worse. It would be enough to feed the entire population of Zambia. Fasting for surgery is tricky here. Kids are often chronically hungry to begin with. After surgeries their blood sugars are low. We had a two year old who was in surgery for 6 hours. We mixed our own intravenous dextrose solution, and when he woke up we fed him orange Fanta with a syringe. Not quite a breast, but he liked it.

I love watching the porters with the patients here. They do all the patient transport. They seem to always have a kind word and a smile, and can often calm a frightened child just with their presence. On Sunday I noticed an iron on one of the stretchers in the recovery room. It seemed out of place, but it isn’t. Nobody is allowed to wear scrubs or shoes that have been outside the operating room area, so they wash and iron their scrubs here.

 

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FGM, the prevalence

Governments and religious groups denounce it, treaties and bills have been signed against it, organizations and activists worldwide protest it; yet 140 million women young and old worldwide suffer from it. Female genital mutilation (FGM) continues to have desolate effects on the progress of Women’s Rights and Healthcare worldwide.

“The practice of female circumcision is rooted in gender inequality, cultural identity, and notions of purity, modesty, beauty, status and honor. The practice has been continuing in Africa because of cultural, tribal and religious factors that vary from country to country.

“Reasons for the continuation and perpetuation linked to FGM include many myths and false misperceptions…”

Continue to read this in-depth article published by the African Journal of Urology here.

Urological conditions and traumas, including FGM, have tremendous social and cultural implications. Challenges arise in promoting awareness of their detrimental effects.  A picture of a saddened face does not describe the emotional, psychological, social and physical effects of urological conditions and traumas. The beautiful African-print fabric draped over an injured woman’s body can hide the burdens of FGM, vesico-vaginal fistula, or the inability to bear children.

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Separate Worlds Brought Together: A Nurse’s Perspective

The continued account of IVUmed volunteer recovery nurse, Michael Felber, regarding his recent IVUmed humanitarian service in Zambia, shared from his travel journal:
“We  are on the third day of surgeries. We wake up at 6, have breakfast, and drive to the hospital. Each day begins with a lecture or presentation for the Zambian residents and staff. Surgical cases so far have taken 1 to 6 hours. The rooms are run very efficiently, but time is spent teaching local surgeons and anesthesiologists with each surgical procedure.  The focus of IVUmed missions is on education, with the goal of each site having enough trained personnel to be self sufficient. Usually the first 10 minutes are the busiest, when the children are still asleep and needing close monitoring. If there are respiratory problems they tend to happen in time. Usually giving a little supplemental oxygen or repositioning their head is all that is needed to help them. When they are breathing on their own without extra oxygen we take out their IVs, using a little of the blood to screen for malaria. We make sure catheters and stents are in place and well secured, and they rejoin their parents.  At the end of the day we check on the patients on the floor.
The children here are very quiet and usually shy when  they  first meet us, but  when they are ready they have beautiful smiles.  We have toys and coloring books and Beanie Babies, which are given in pre-op and recovery.  They often seem bewildered by the toys at first. They seem pleased to have them but don’t get overly excited. What seems to matter to kids here are their parents and siblings and playmates.  Yesterday Sandra, a beautiful 4 year old girl, waited in recovery for us for her cystoscopy. She was quiet and a little withdrawn at first, but watched everything and everyone intently. I gave her a small stuffed animal. She nodded at me and took it, but remained quiet.  Pam, my partner in recovery, gave her a coloring book and some crayons. She looked at the crayons quizzically. We put them in her hand and showed her how to color. It took her a little while to get the hang of it, but soon she was filling up the page on her coloring book. She didn’t actually smile until we brought out the bubbles, though. She reached out to them and laughed when they broke on her hand, and loved blowing through the wand and watching them form. Gift, the porter and OR tech, arrived to bring her into the operating room. He spent a minute admiring her coloring, and then as he wheeled her out whispered to her “Say goodbye to them”.  Sandra smiled and waved.
The field of pediatric urology is very limited in the developing world, even though the need is enormous. This is my fourth experience working with IVUmed. In addition to urology, I often volunteer on missions that treat cleft lips and palates. Between the two, urological defects are usually more hidden, but the shame and debilitation are equally or more significant. Children with conditions that cause chronic urinary incontinence are often unable to go to school. When they mature into adulthood they face problems getting married, which in poor countries is often crucial to economic and social stability. Many urological problems ultimately result in cancer of the bladder or kidney failure, and people’s identity and sense of autonomy are closely tied to their gender, their sexuality, and their mastery of their own bodily functions.
There is a very basic need for human dignity. I think one thing parents all over the world have  in common is wanting a better life for their children. People all over the world seek acceptance in their families and societies, but the opportunities are not the  same for everyone.  How likely you are to have a long and healthy life is not just affected by your lifestyle choices. Where you are born and live matters greatly, especially for people who are not fortunate enough to begin life without the burden of a birth defect. There have been incredible advances in medical science in the last 100 years, and even in my lifetime, but the problem of ensuring access to the benefits of those advances  has proven to be much more perplexing.

In many ways the patients and staff here are a worlds apart from my own life experience. I sense that gulf every time I meet a new child, and see the shyness in their eyes. There is so much about their lives that I don’t know, but we all have the same need for acceptance, the same connections to our loved ones, and the same anatomy and physiology. We are in the end more alike and connected than different and separate.

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The Biggest Favor: One Nurse in Zambia

IVUmed volunteer recovery nurse, Michael Felber, recently returned from an IVUmed trip to Zambia. He blogged about his experiences while in the field and has graciously allowed us to share some of his content on our blog. IVUmed is grateful to Michael for his service and to all of the nurses and physicians who join us in bringing quality urological care and education to those who need it most.

 

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If you ever take an airplane ride over the Sahara desert, try to get a window seat. The landscape is spectacular, with mountains and river beds that look like giant veins. Three days into my time in Zambia I can still picture it in my mind.

You have to take care of yourself. Dehydration sneaks up on you after a few days, between the long days and the heat. You have to drink whether you are thirsty or not. The same kids who were playing a wild game of soccer with a plastic bottle during screening are quiet and shy in pre op and recovery. We are screening all the patients for malaria with a simple blood test that uses a tiny drop of blood on test paper. We initially did finger sticks – then we figured out you could wait until you took out their IVs, and grab the blood before putting on a Band Aid.

 Nurses here are called “Sister”. It is a term that carries some respect. I am not sure if there is a similar title for men. There is a nurses’ strike at the hospital. Somehow people manage. Families do a great deal of the patient care anyway, but scheduled surgeries (not from IVU) have been cancelled. It can take a while to get patients onto the post op wards because they are short staffed.

There are several Eastern European and Russian doctors here. During the cold war, the Soviet Union sent health care workers here as part of their foreign aid. Many of them liked it here so much that they stayed. They still come here, now as private contractors. Our local coordinator is Serbian. His father-in-law was sent here 30 years ago by the Yugosalvian government as a punishment for applying for a visa to study in the United States. Now he says sending him here is the biggest favor anyone did for him.

 

I am posting this from under my mosquito netting because I saw a spider as big as the palm of my hand on the wall above my bed, and it got away…

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Open House For Nurses:

 

IVUmed invites you to attend a volunteering open house for nurses:

  • Learn about where IVUmed serves around the world
  • Hear current IVUmed partners share personal experiences of volunteering with IVUmed
  • Discuss the logistics and rewards of humanitarian medical service with IVUmed staff
  • Discover current opportunities to teach fellow physicians and bringing quality surgical care to resource-poor communities worldwide!

 

Open House For Nurses:

October 24, 2013

6pm – 8pm

1393 E. South Temple, Salt Lake City

 

Refreshments provided.

 

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IVUmed is dedicated to building urological capacity in resource-poor areas of the world. Nurses are crucial to the education and service we provide and are invited to join IVUmed medical teams to improve care in resource-limited parts of the world. For more information, please visit our website: www.ivumed.org or contact Amy at amy@ivumed.org.

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Open House For Anesthesiologists

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IVUmed invites you to attend a volunteering open house for anesthesiologists:

• Learn about where IVUmed serves around the world
• Hear current IVUmed partners share personal experiences of volunteering with IVUmed
• Discuss the logistics and rewards of humanitarian medical service with IVUmed staff
• Discover current opportunities to teach fellow physicians and bringing quality surgical care to resource-poor communities worldwide!


October 10, 2013

6pm – 8pm

1393 E. South Temple, Salt Lake City

Refreshments provided.

IVUmed is dedicated to building urological capacity in resource-poor areas of the world. Anesthesiology providers and nurses are crucial to the education and service we provide and are invited to join IVUmed medical teams to improve care in resource-limited parts of the world. For more information, please visit our website: www.ivumed.org or contact Amy at amy@ivumed.org.
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IVUmed is committed to making quality urological care available to people worldwide.