On the Pediatrics Ward: Learning in Sri Lanka

1 02 2012

By Holly Stump
Duke Physician Assistant Student

Note: This blog post was originally posted on Sen. Bill Frist’s “Hope Through Healing Hands” Blog. Stump is on a global health rotation in Sri Lanka as a result of a new partnership between the First Global Health Leaders Program, the Duke PA Program and the Duke Global Health Institute. Learn more.

We arrived on the pediatrics ward this Monday, a little less naive and much less shell-shocked. I had grown accustomed to hearing only the whirring of ceiling fans, barking dogs, and the quiet chatter of Sinhalese in place of the traditional mind-numbing beeps and alarms of our medical equipment. I was pleased to see protective screening over the open air hallways, to keep the children from tumbling two stories, and to keep out the birds. It was surprising to see the number of children waiting to be evaluated for possible admission. Nearly all the beds were full, and it seemed as though they were in the habit of converting previous storage closets, consultant lounges, and any available space into treatment areas. The need for even more space remains evident.

We were greeted by Dr. Jayantha, the department head, and were quickly incorporated into rounds. My incredible learning experience began the moment we arrived at the first patient. Rapid fire questions regarding minute details about pneumonia. “Inspect this X-ray, what do you see? What organisms cause the X-ray to appear this way? How do you know? Are you certain? Why is this child’s pneumonia not caused by Klebsiella?” As the only visiting students on the ward, we were not spared! He is a fantastic educator and we were soaking in every piece of information. The ward was full of interesting cases. Kawasaki disease, meningitis, dengue fever, juvenile rheumatoid arthritis, osteogenesis imperfecta, just to name a few. About 25% of our patients that day were hospitalized due to new occurrences or relapses of nephrotic syndrome. Dr. Jayantha explained the incidence is very high here, mostly caused by minimal change in his younger patients. He calls them his “nephrotics” and he holds a special renal clinic for these patients every Wednesday morning, which we attended. Collectively, we saw nearly 50 patients that Wednesday morning with some variation of this syndrome. He has spearheaded a study on his nephrotics over the past 15 years. It will certainly be an interesting read once his results are published.

Regretfully, Friday was our last day on the Peds ward. We were benefited from phenomenal teaching by a handful of consultants who were intent on actively involving their students during rounds. “Palpate this child’s skull, Holly. What do you find?” “An open fontanelle sir,” I responded. “Quickly, in your notebook, write down 3 reasons you may find an open fontanelle in children over the age of 18 months” he demanded. Apparently noting the oppressive heat in the ward, and the obvious sweat forming on my face, he continued, “Quickly, and then we will go snowboarding!” Snowboarding? “I’ll take it,” I said. “Too slow,” was his response. Then he erupted in laughter, gave me a pat on the back and moved on to the next patient. This kind of rousing I was familiar with!

The opportunity to go into the community and provide antenatal care, well child checks, and give immunizations was extended to us by Dr. de Silva in the Department of Community Health. We had been waiting for this! We boarded the bus with 20 medical students from the University of Ruhuna Faculty of Medicine and set out towards a primarily Muslim clinic in Gintota, about 10km from Galle. 10km came and went, then 20km, maybe 30km. There was much discussion between the bus driver, the spotter, and the instructor in charge of this outing. I didn’t need to speak Sinhalese to understand that we were lost! When we finally made it to the road leading to the clinic, the bus was unable to fit, so we walked the final 2km. We walked through tiny villages, past small shops, and many people who hadn’t seen many (or any) fair skinned, light haired women walk past their homes. They were curious, and came off of their porches to watch where our journey would end. It ended at a clinic at the top of a hill, which was closed! A cyclone had badly damaged the structure three weeks prior. We now had to make the trek back down the hill, into the Muslim town, where we were shuttled by a community doctor to the temporary location at a school. 35 moms-to-be and 35 children were seen that day. Although cramped in their temporary clinic, their system worked well.

We visited a Sinhalese clinic a different day this week, which strictly provided antenatal care. We found this to be just as efficiently run, with roughly 60 mothers receiving exams. I was amazed at how integral a role the midwife plays in prenatal care in the villages. She performs all exams, including albumin and blood sugar checks, fundal height measurements, and even listens for fetal heart sounds through a pinard stethoscope! A “pinard” is a cone shaped instrument made of wood, plastic or aluminum, with a second cone at the top through which you are to listen. The fundus and the baby’s head are palpated, pressure is placed at the top of the fundus, and the pinard is placed approximately over the baby’s left shoulder. The provider then places their ear on the top side of the pinard and listens closely (very closely) for fetal heart sounds. Warning: The aforementioned technique may read as an easy procedure; however, after being spoiled by dopplers and fetal ultrasound, this takes much practice and a well trained ear!

I read somewhere that Sri Lanka has been called the “gem” of the Indian Ocean. It is most definitely unique. The people, the food, the language, the landscape, the culture, all novelties to me. Every day is an adventure here, and I am cherishing every one.

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