Resident Scholar Report: Zambia

Amanda Saltzman, MD
Louisiana State University/Ochsner Clinic Foundation
Lusaka, Zambia
September 26-October 5, 2014
Mentor: Dr. Francis Schneck
Sponsored By: Southeastern Section of the AUA

Through the generous sponsorship provided by the Southeastern Section of the AUA, Amanda Saltzman, MD traveled to Lusaka, Zambia with mentor Francis Schneck, MD to assist during a pediatric urology workshop.  During her visit, Dr. Saltzman was able to provide much-needed urological care to 50 children.

Reporting on her experience, Dr. Saltzman stated:

“We rounded on all the kids for the day in the morning.  There were immediately differences from America.  The first was the open wards and multiple kids per bed.  The shoes at the entry to the ward were also surprising.  Diapers are not supplied by the hospital and are the responsibility of the families, with many using rags or nothing as diapers.  There is an area called “high cost” where kids with insurance are housed. This area has more sheets and each kid has his/her own bed.

“I think our trip was a great success.  We had a great exchange of information with the Zambian urologists and they did a great job learning the reconstructive techniques.  The only disappointing thing about the week was that we had to turn away many kids and families that travelled from far away to seek our help.  However, we passed on our knowledge to the local urologists and they scheduled many of the distal hypospadias to be fixed the week after we left during their ‘jubilee.’

“This trip was my first international medical trip and will not be my last.  I had such a wonderful time meeting new people, seeing how to cope and work with less, appreciating the sophistication of the American medical system and working with such adorable children.  I felt like I helped more children and families during my week in Zambia than I have during my 3 years of residency so far.  The joy on the kids’ faces when they saw us and got toys everyday was priceless.  I can’t wait to go back, hopefully every year!”

Common, Costly, & Critical: January is National Birth Defects Prevention Month

“Birth defects are common, costly, and critical.” is the National Birth Defects Prevention Month theme for January 2014.

Every 4 ½ minutes in the United States, a baby is born with a major birth defect. Birth defects are a leading cause of death among U.S. infants, causing roughly 20% of mortality in the first year of life. Babies born with birth defects are also more likely to have more illness and long term disability than babies without birth defects. National Birth Defects Prevention Month raises awareness about the frequency of birth defects occurring in the United States and the efforts to prevent them. While not all birth defects are preventable, women can do many things to prepare for a healthy pregnancy. The Center for Disease Control suggests:

• Be fit. Eat a healthy diet and work towards a healthy weight before pregnancy.
• Be healthy. Avoid alcohol, tobacco, and illicit drugs. Be sure to consume at least 400 micrograms of folic acid every day before and during early pregnancy.  Work to get health conditions, like diabetes, in control before becoming pregnant.
• Be wise. Visit a health care professional regularly. Consult with your healthcare provider about any medications, including prescription and over-the counter medications and dietary or herbal supplements, before taking them.

Awareness efforts offer hope for reducing the number of birth defects in the future. The National Birth Defects Prevention Network (NBDPN) suggests these additional prevention strategies:

• Manage chronic maternal illnesses such as seizure disorders or phenylketonuria (PKU)
• Avoid toxic substances at work or at home
• Ensure protection against domestic violence
• Know their family history and seek reproductive genetic counseling, if appropriate

Leslie Beres, MSHyg, President of National Birth Defects Prevention Network, said, “It’s also important to remember that many birth defects happen very early during pregnancy, sometimes before a woman even knows she is pregnant, so planning a pregnancy is key and can also help make a difference.”  Managing health conditions and adopting healthy behaviors before becoming pregnant increase a woman’s chances of having a healthy baby.

While approximately 1 in every 33 babies born in the United States has a birth defect, the international birth defect statistics are even more disheartening. According to a March of Dimes report, 6 percent of total births worldwide – almost 8 million children – are born with birth defects, with over 4 million infant deaths occurring annually due to birth defects and preterm birth.

When IVUmed started in 1992, our first programs were dedicated to pediatric urology.  Reproductive and urinary tract malformations are among the most common birth defects affecting children worldwide.

IVUmed addresses the lack of available care through specialized intensive trainings and distance learning opportunities.  Due to continued demand, we have conducted these workshops in over 20 countries since the program first began.

IVUmed has various pediatric urology training workshops scheduled for 2014, including visits to India, Kenya, Ghana, Honduras, Vietnam, Senegal, the West Bank, Mongolia, and Zambia.

Resources for this article:

March of Dimes

Center for Disease Control

National Birth Defects Prevention Network

Pediatric Urology: A Mother’s Experience

This is a personal blog post from a Zambian mother of a little boy born with hypospadias. Brillian Izukanji Kaona generously shares the details of her experience with her local doctors and then of her son being treated by the visiting IVUmed team and the doctors and nurses who were training with them. She shares her perspective here to give hope and encouragement to other mothers of children with similar conditions. We are grateful to hear her perspective to better understand the thoughts and feelings of those we care for through our work Zambia and around the world:

My name is Brillian Izukanji Kaona; I’m aged 31 and live in PHI, Lusaka. I am a single mother of two boys aged ten and three.  I am an entrepreneur in the catering industry. My son was born with hypospadias; I was keen to share my experience especially the important lessons I learnt that I hope other parents with children born with the condition can learn from…

Three days after having been admitted in hospital with pre-eclampsia, I finally left for home with my newborn son, Ninza. The next day, my mother noticed his penis wasn’t straight while bathing him and his urethral opening wasn’t in the right position. During my postnatal visit at Nkwazi Clinic in Lusaka, I asked my doctor to check my son and tell me if he was OK. He advised me to take him to UTH (University Teaching Hospital) where it could be fixed.

The doctor diagnosed my son with hypospadias and said he couldn’t have an operation until he was two. He explained that he’d need two operations: one to cut and make it straight and the other, a year later, to close the hole and open another. Since he was only a month old, I was advised to return him to the hospital when he was older than a year.

A lot of things went through my mind: “What if he dies during operation?”; “What if operation isn’t successful?” ; “What if he grows up like this and becomes the object of women’s mockery?”…

Read more about Brillian and Ninza’s experience here on Brillian’s blog.

All Photos by Brillian Izukanji Kaona.

A Privilege: Final Entry from an IVUmed Nurse in Zambia

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

The last patients of the day seem to wake up more slowly. Often they have been under anesthesia longer, since shorter cases are usually scheduled earliest. I think by the end of the day they are also just more tired and hungry. By 6pm the local nurses and porters are ready to go home to their families, and I am sure are also a little concerned about missing the last bus home.Yesterday, Malasa, one of the nurses, was laughing and trying to wake up the patients. My patient wasn’t interested in waking up until she tugged on his earlobe and said “Boy, do you want to go see your mother?” He sat right up.  Douglas was still not interested in waking up, despite Malasa’s best effort. I told Malasa that I was going to wake her up at home on her day off, and she laughed. Finally, Douglas started to stir. We put a syringe of orange Fanta in his mouth and when the bubbles hit his tongue he startled. Then he began expertly sucking down the Fanta. By 6:30, everyone was on their way home.

So far, today has been pretty upbeat. For morning lecture, the residents played urology jeopardy. Everyone seems pleased with the number of children we have been able to treat.

Throughout the week, one operating room has remained open for emergency pediatric cases. They have ranged from routine appendectomies, removal of foreign bodies, to more complex cases. Yesterday a 5 day old baby was brought in with a malrotated bowel, like a twisted garden hose. By the time of her surgery her entire small intestines was necrotic from loss of circulation. The bowel had to be removed. She would need IV nutrition and ultimately a small bowel transplant, neither of which is available here.We watched her in recovery until she could be transferred to the ICU, where she will stay with her parents and receive comfort care. Today, a one week old premature baby was brought in for closure of gastroschisis, a condition where the stomach or bowel protrudes from the abdomen. In developing countries it is treated initially by suturing a sterile “silo” over the protruding bowel and gradually pushing it back into the abdomen. For this patient they used a sterile IV fluid bag and gradually compressing the end of it, like squeezing a tube of toothpaste. The baby weighed about 2.5 pounds, but was breathing well. It is amazing that he survived this far, but he still has huge obstacles ahead. Still, miracles don’t happen by themselves.

Complex patients and surgeries are scheduled in the beginning of the week so the team is available to deal with complications. Still, we are here to work, so a full day is planned. The last patients are as important as the first, so nobody can afford to let their guard down.

By the end of today we will have treated over thirty children. It’s hard to measure results, though. Certainly numbers of patients treated and people trained are important, but you can’t measure up front how a surgery will affect an individual patient’s life, or what someone has learned from your teaching and your example, and what they will do with their knowledge.In medicine, you work with people and then you both move on. You rarely see the long term results of your work. There are far more built in obstacles than any individual or organization can change, but in the long run change is possible. Johnny Clegg, a South African musician, says in one of his songs that if you want a better future you have to “fetch it” yourself.

It’s also hard to measure the effect on ourselves, but I think it is overwhelmingly positive. At least most people I meet on these ventures want to come back. The imprints of experiences and people stay with you. Working with limited resources teaches you to be appreciative and creative. You learn not to waste your time or energy focusing on what you don’t have.And you learn again and again to regard your work as a privilege.

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:

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.

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.

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

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.

Separate Worlds Brought Together: A Nurse’s Perspective

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.

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.

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…

Board member, Dr. Francis Schneck and daughter, Meghan recognized by local community for service in Zambia

Board member and Medical Services Committee Chair, Dr. Francis Schneck, recently led our workshop in Lusaka, Zambia. His daughter, Meghan, joined the team to help with logistics and interacting with the patients. Her high school field hockey team recognized her off-the-field time was worth it!

Read more: Mt. Lebanon field hockey player helps African mercy mission 

“Repairing the Surgery Deficit”

Zambia currently has 44 licensed surgeons to serve its population of 13 million.  That is less than one surgeon (.33) per 100,000 people.  To put that in perspective, in the United States, there are about 45 surgeons per 100,000 people.  

Next month we have a team of volunteers heading to Lusaka, Zambia to conduct a pediatric urology workshop.  The volunteer experts will work at the University Teaching Hospital there, focusing on training and transferring skills to the local surgeons and professors so that they in turn can train more surgical students.

To read more about this pressing need for surgical training in Zambia, please read this recent article:

Repairing the Surgery Deficit
By SARIKA BANSAL
The New York Times

There are solutions to these problems.  IVUmed is committed to making a difference both in Zambia and throughout the world through surgical education.