INMED Blogs

Could You Deliver This Baby?

You are in Mozambique volunteering at a birthing center. The midwives are entirely African nationals who will have no backup once you depart. One evening reflecting on this fact you determine to vigilantly transfer your skills to permanent staff. At that moment a voice comes from the door, “The baby will not come down and the heartbeat is falling!”

You trot to the birthing center to find two midwives surrounding a young lady. Her uterus is term in size and the fetal heart rate is 90. This is her second vaginal delivery, her cervix is fully dilated, and she has been pushing for four hours – far longer than to be expected.

You explain to the midwives to be cautious, for this woman is at increased risk for ALL but which ONE of the following?

A Postpartum infection
B Postpartum hemorrhage
C Lacerations of the birth canal
D Shoulder dystocia
E Preeclampsia

Please select your answer before reading on to the explanation to this intriguing question of clinical wisdom. The correct answer is E. Preeclampsia, also called toxemia of pregnancy, is a disorder of late pregnancy characterized by hypertension, edema, and proteinuria. Risk factors for preeclampsia include first delivery and multiple gestation, but not prolonged labor. Postpartum infection, postpartum hemorrhage, lacerations of the birth canal, and shoulder dystocia are all commonly associated with prolonger second stage of labor – the interval between full cervical dilatation and delivery.

You recommend draining the bladder with a catheter to open the birth canal. You also call for administration of oxygen, which remarkably is indeed available. The fetal heart rate rises to 130 between contractions. The baby begins to descend with the mother’s forceful pushing and minutes later the head is delivered. The mother continues to push. The midwife applies gentle traction on the head but the head will not further descend.

At this moment you recommend which ONE of the following actions?

A Administration of IV oxytocin
B Application of suprapubic pressure
C Application of increased traction on the fetal head
D Symphesiotomy
E Replacement of the fetal head into the uterus

Please select your answer before reading on to the explanation to this, another intriguing question of clinical insight. The correct answer is B. This complication is shoulder dystocia. It is caused by impaction of the fetal shoulder against the maternal pubis. Increasing uterine pressure via oxytocin or increasing traction of the fetal head will not relieve the impaction and may lead to serious injury of the infant. Effective management of shoulder dystocia calls for specified maneuvers that include suprapubic pressure to compress the impacted shoulder, internal rotation of the impacted shoulder, and extreme flexion of the mother’s legs at the hips. Symphysiotomy and replacement of the fetal head into the uterus (anesthesia required) are maneuvers of last resort.

Shoulder dystocia can be one of the most frightening delivery room emergencies. Yet basic maneuvers usually lead to successful delivery. Attaining such skills is well within the capability of primary care providers, and transferring these skills is one of the most effective roles for international healthcare volunteers. Please join us at the Exploring Medical Missions Conference for an introduction to managing such common delivery room emergencies, and other skills essential in serving forgotten people.

INMED International Medicine & Public Health, 2nd Edition

Extraordinary numbers of individuals and families are forgotten: the poor, unemployed, minorities,  immigrants, and people separated by geographical barriers. Healthcare professionals who serve forgotten people regularly discover that their training prepared them inadequately. INMED International Medicine & Public Health, first published in 2007, is a recognized, leading resource for people engaged in global health. The second edition, which I edited over a two-year period, is a 404-page full-color book addressing international public health, diseases of poverty, low-resource HIV care, cross-cultural competency, and international health leadership. Please check out the book sample at http://inmed.us/resources/books.asp#INMED

Parallel online, self-paced courses correspond to each chapter of the book, and provide interactive learning experiences and continuing education credit. But read carefully. The interactive questions can be tricky! Learn more at http://inmed.us/self-paced_courses.asp

Could You Resuscitate This Newborn?

You are in Burma teaching Helping Babies Breathe - a newborn resuscitation curriculum for resource-limited settings. Your venue is a Burmese national hospital with an assembly of excited nurses and midwives. But your presentation is suddenly interrupted by an urgent call from the postpartum floor: “What have a baby who is not breathing.”

You scurry to the ward to find a full-term newborn just minutes since birth. He appears listless, cyanotic, and with grunting respirations. With each gasp his chest caves in. Your anxious learners watch as you palpate the umbilical cord and announce the pulse rate is less than 60 beats per minute. You anticipate that the most likely cause of this baby’s distress is:

A Diaphragmatic hernia
B Hypoglycemia
C Transient tachypnea of the newborn
D Pneumonia
E Pneumothorax

Please select the most correct answer before you continue reading. The correct answer is C. Transient tachypnea of the newborn (TTN) is the most common cause of neonatal respiratory distress, constituting more than 40 percent of cases throughout the world. TTN is a lung disorder characterized by pulmonary edema resulting from delayed resorption of fetal alveolar fluid. Diaphragmatic hernia, hypoglycemia, pneumonia and pneumothorax are potential but relatively uncommon causes of newborn distress among term infants.

You immediately instruct your students to aggressively dry the infant. You then call for oxygen, but are told that the O2 calendars along the wall are all empty. Borrowing a stethoscope, a quick auscultation of the chest reveals coarse but present lung sounds throughout. Your next immediate step in the management of this infant is to:

A Begin an intravenous infusion of normal saline
B Provide artificial ventilation with a bag and mask apparatus
C Administer epinephrine subcutaneously
D Request a chest radiograph
E Begin gavage feedings

Please select the most correct answer before you continue reading. The correct answer is B. The immediate treatment for neonatal respiratory distress due to TTN or most any other cause is assurance of adequate ventilation, most commonly with a bag and mask apparatus. Room air or supplemental oxygen administered in this way usually results in rapid improvement in a newborn’s status. Less urgent interventions include chest radiography to differentiate causes of respiratory distress, and intravenous normal saline and gavage feeds for provision of fluids and nutrition. Epinephrine administer is rarely indicated in neonatal resuscitation.

Neonatal respiratory distress is one of the most devastating and preventable causes of death in the world’s poorest communities. In response, the American Academy of Pediatrics launched the Helping Babies Breathe educational program. Join us on June 1-2 at the Exploring Medical Missions Conference for Helping Babies Breathe instruction. You too could become a Helping Babies Breathe teacher, and transfer these life-saving skills to healthcare providers around the globe.

INMED Intensive Courses - See One. Do One. Teach One

What makes for effective medical education? In the clinical setting we often speak of, “See one. Do one. Teach one.” It’s learning via role modeling, active participation, and skill transfer. Enter the INMED International Medicine and Public Health Intensive Courses… Just days ago we concluded the fifth round of these courses. Hours of lectures? Worse yet, hours of videoed lectures?

No. By contrast, today’s INMED Intensive courses include an interactive online segment followed in-classroom sessions that develop skills in casting/splinting, obstetrical complications, suturing, interosseous infusion, newborn resuscitation, community health surveying, cross-cultural competency, and sticky clinical case studies. Come “see one” with us. Next “do one” under supervision at an INMED training site. Then “teach one” for the benefit of local healthcare providers who will continue to care for their own.

My Children Cry “We Will Die”

“Theirs is unbearable pain: mothers and fathers recounting their helplessness to alleviate the hunger of their children – hunger often compounded by the rigors of malaria, breathlessness of pneumonia, and lethargy of prolonged malnutrition. I scramble to offer assistance, but there is no end to their need. The difficulty is knowing how to help most effectively.”

Charlotte White, a nurse practitioner from Wichita, lives in Tanzania. She took seriously the challenge of African healthcare by participating in the INMED International Medicine & Public Health Intensive Course. “I realized I have so much to learn about the people I want to serve. It is very tempting for us as western-schooled healthcare providers to think our way of doing things is the only way - or at least the best way. This approach really doesn’t work.”

I was trained to rely upon modern technology, for example, for diagnosis. But here the only tools are history and a good physical assessment. And just because I’m a healthcare professional, does not mean I am automatically trusted. Here among the Maasai people we begin by building relationships with leaders of villages, tribes and districts. This requires ample time, patience, language learning, and communicating the humanness of caring. The women in this culture have very difficult lives, but only now am I able to visit women and offer education about nutrition, hygiene, and small micro-enterprise projects.

“And what about relieving the hunger that causes parents to fear their children’s death? This compels us to focus on community development – a subject we barely touched in graduate school. Our health intervention in Tanzania includes vegetable gardening, accessing safe drinking water, and encouraging Tanzania pastors who teach their people biblical virtues that also improve their health. Our approach is holistic.

“We must always be humble students of the culture if we aim to relieve and prevent suffering. The INMED staff did a great job of integrating these truths into the INMED International Medicine & Public Health Intensive Course. As a result of those weeks of study and skill stations I feel more prepared to take on the challenges I face everyday in Tanzania. I am hopeful that you who are passionate about international health and medical missions will take advantage of this course so that one day no one must hear their children cry ‘We will die.’”

Charlotte White and her husband Thane are located in the city of Arusha, Tanzania – directly south of Nairobi in East Africa. Thane is engaged in micro-enterprise and water development, while Charlotte leads health and family innovations in this region racked by HIV/AIDS. They both are actively learning Swahili. Please follow their progress at http://web.me.com/oursafari and discover how you can undergird their exemplary service.

What Will Be Your Legacy?

It is human nature to step up to a challenge. What challenge will you choose? It is also human nature to defend. Whom will you defend? Most all of us in healthcare have dreamed of doing something bold. Why don’t we follow through?

Here’s the reasons I hear most often: “I don’t know those diseases, Don’t I need malpractice insurance? Isn’t it dangerous? I don’t speak another language, I don’t understand their culture, Financially I can’t afford it, I’m in debt, I don’t have enough free time, I’m not a spiritual person, My parents won’t approve, My children can’t come, I can’t make any difference, and, I don’t know where to begin.”

I could share with you a rebuttal for each of these concerns. But let me simply reply by asking, What will be your legacy? When your friend and your children speak of you, for what do you most wish to be remembered? As a man or woman to dodged to live another comfortable day? Or as the rare, exemplary individual who not only felt inspire, but mobilized to action?

What’s The Role Of INMED’s CEO?

Like any number of us who oversee organizations, businesses or institutions, I grapple constantly with dreams and demands that far exceed my capacity to fulfill or to manage. And like many of my colleagues, I find some reassurance in regularly remembering just what is my role as CEO.

In one phrase, the INMED CEO must be an exemplary role model. A credible leader is one who first leads by example. Isn’t this what was on Jesus heart when He declared, “Anyone who wants to be first must be the very last, and the servant of all” (Mark 9:35), and isn’t this what you and I decry when we behold a superior who defames the very actions he demands of his followers?

On this basis the INMED CEO then provides:

• OVERSIGHT of all INMED activities

• PROMOTION of INMED offerings

• FUNDING of INMED activities

• INNOVATION of new activities that fulfill INMED’s mission

• SERVICE, particularly in direct teaching and healthcare

Do you make a habit of praying for some individuals? If so, would you consider upholding me in this important way - that I would prove to be exemplary and faithful in my role.

“Global Health” or “International Medicine”?

Well-meaning people continually inquire about the terminology associated with global health. Their inquiry is not just hair-splitting. Terminology may be subtlety different, and yet the meanings conveyed be profoundly divergent. And so consider these terms:  global health, international health, international public health, and international medicine.

In common usage,  global health and international health best refer to the overall health status of the people being considered. These people may be wealthy or advantages, or impoverished. Leaders in this field usually focus on the needs of people who are most disadvantaged, for enormous wealth and knowledge benefit the world’s affluent people, while some three billion persons subsist on less than US $2.50 per day. Global health and international health tend to focus on the factors of economics, literacy, education and public policy, in addition to more traditional ‘health’ factors.

International public health and international medicine, by contrast, are fields that focus more on the roles of the disciplines of public health and medicine, and on how these disciplines interface for the benefit of disadvantaged people.

The caution I constantly urge for people in the fields of  international public health and international medicine is that they do not allow their disciple itself to limited the actions or innovations that may be necessary to succeed in the overall goal of health improvement. Hence,  global health or international health should remain the goal of us all, regardless of training or discipline.

From Inspiration To Mobilization

Rapid-fire rifle shots grew closer, echoing from each direction. The cadence of explosions increased, accompanied by shouting just outside in the streets. Inside Dr. Steve Foster, keynote speaker at the 2012 INMED Exploring Medical Missions Conference, and his colleague Darrel Hockersmith barred the metal door and grappled in the darkness for protection from flying shrapnel. Sheltered in a corner they breathed a joint sigh of relief. But this was short lived.

Hammering emanated from the front door, along by the demand “Abra a porta ou vamos matar todo lá dentro!” Foster edged toward entry just as the door burst open. Soldiers shoved inside, very young men carrying weapons as large as themselves. They forced Foster and Hockersmith to the floor. Hovering over their faces with his pistol, the muscular captain pronounced sentence, “You are a Russian spy. The penalty for spying is instant execution!” He pressed his gun closer. “Tell me, Dr. Foster, why are you really in Angola?”

Steve Foster inched upward, made contact with every eye in the room, and addressed them all. “I am actually a surgery resident in Canada at the University of Toronto. But while enjoying every comfort of modern life, I can not but attune my ears to the bloodshed accompanying your civil war here in Africa.”

The stone-faced captain gazed at Dr. Foster in disbelief and demanded, “Tell me who is paying you?”

“No one,” replied Foster, “in fact, it’s my friends and personal savings that finance the medical care I’m providing your people. Earlier today I repaired the landmine injury suffered by a young man,” explained Foster inquisitively. “Perhaps he was your own cousin?”

“This is unbelievable,” replied the captain in a more consolatory tone. He lowered his gun slightly. “Many people have good intentions or contribute a little to a good cause. But what would motivate a person of your stature to take mortal risks to serve in a country of such chaos as Angola?”

Dr. Foster looked on the captain sincerely, “I envision the day when I’ll stand before God and account for my life. How can I say that I chose self-indulgence while other people, no matter how far removed, are struggling to survive?”

Disarmed, the captain motioned to his cadets to exit the house. “I mobilize my men for combat. But you are mobilized for virtue. I shall not trouble you again.”

On June 1st Dr. Steve Foster will address “From Inspiration To Mobilization” at the INMED Exploring Medical Missions Conference. Who is inspiring your life? Which virtue is your theme? For what mission are you mobilizing?

Babies In Dumpsters & A Moral Imperative

Marek Banas, a medical student at Lincoln Memorial University, just returned from her INMED service-learning experience at The Surgery, a general practice clinic in Kampala, capital of Uganda. “The Surgery is potentially the best clinic in Uganda,” she writes. “People who did not have a conclusive diagnosis came from all over Uganda as well as neighboring countries to be helped by The Surgery doctors.”

Marek continues, “Patients included wealthy Ugandans, tourists, expatriates… and abandoned infants - who were on occasion brought into The Surgery after being found on the street or in dumpsters.”

Many healthcare professionals are enamored with the possibility of international service. Yet relatively few ultimately make this a part of their career. In reply to what motivates her, Marek says, “My desire to help the marginalized people springs from a moral imperative I found in myself years ago. I feel I have been lucky in life and it is my responsibility to share my fortune with the forgotten ones.”