AMPATH Surgery

by Indiana Institute for Global Health, Inc.
AMPATH Surgery
AMPATH Surgery
AMPATH Surgery
AMPATH Surgery
Dr. Joanna Hunter-Squires
Dr. Joanna Hunter-Squires

 

Surgery impact is continuing on the ground in Kenya with a new IU Surgury Faculty Team Leader!  Dr. JoAnna Hunter-Squires will arrive in Eldoret this month to continue the commitment of Connie Keung and her predecessors.

AMPATH team leaders provide clinical care and teach both Kenyan and North American students while also fulfilling research and administrative responsibilities. They typically serve for one year, though many have continued their involvement with AMPATH for additional years or in other global health leadership roles in both Kenya and at their home institutions.

Incoming surgical team leader Hunter-Squires also lauds the cooperative AMPATH environment. “Health care is challenging everywhere, but I do think that with collaboration, education, and some creativity, we can all make our field, and the lives of our patients better,” she said. Hunter-Squires attended IU School of Medicine and completed her general surgery residency at IU before completing a breast surgical oncology fellowship at Cedars-Sinai in Los Angeles. While at Cedars-Sinai, she worked with Dr. Armando Giuliano, the pioneer of sentinel lymph node biopsy for breast cancer and she hopes to introduce the procedure to her Kenyan colleagues and patients.

Hunter-Squires looks forward to working with her Kenyan colleagues in the MTRH Department of Surgery to develop protocols for improving cancer care. “We plan to start with obstructive jaundice and breast masses, two of the most common diagnoses seen on the surgical ward and clinic,” she said. She will also continue the work of prior surgical team leadership to grow the Advanced Trauma Life Support (ATLS) program throughout western Kenya.

We look forward to sharing more updates as Dr. Hunter-Squires continues this important work! 

 

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Palliative Care is defined by the WHO as “an approach that improves the quality of life of patients and their families facing life-threatening illness through early identification and impeccable assessment and pain treatment of pain and other problems, physical, psychological, and spiritual.” Even before palliative care was officially recognized as an official sub-specialty in 2006, the need for its services on a global scale has been overwhelming. From 2007 to 2018, palliative care has grown on the African continent from 14 institutions to over 70. While such growth is profound, the focus of palliative care is currently narrow and most often in medical oncology. Therefore, many other high-risk patient populations who suffer from high pain and symptom burdens, surgical patients in particular, are left unaddressed.

Surgical disease represents nearly 30% of the global disease burden, and spans 100% of disease sub-categories. Due to limitations in operating room availability, supplies and trained surgeons, even patients who are able to reach the hospital may not receive the care they require. Therefore, patients who are younger, have treatable conditions, and do not require complex surgeries still face high rates of mortality and suffering. It has been shown that early palliative care intervention in surgical patients can decrease complications, improve quality of life, reduce healthcare costs, and increase survival. However, the sheer numbers of patients in need overwhelm the budding, under-staffed and under-resourced palliative care teams present. Therefore, surgical patients are often not linked to palliative care until death is imminent. This leaves patients to not only face astounding health inequality, but they must also do so in the midst of great pain and suffering. 

At MTRH, palliative care is integral to the surgical care delivery.  Many diseases that could have a surgical cure, present late with metastatic disease.  90% of our surgical oncology care is palliative in nature. Rather than curative resection, we perform surgeries to bypass tumors so that patients can be comfortable.  AMPATH surgery has been working closely with the palliative care team to understand the need and deliver the appropriate care.  Your donation will support this effort.  

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AMPATH's surgery team has been busy on many initiatives during the past few months! 

TEAM: (Trauma Evaluation and Management). This is a course for medical students. We have run a course for the medical students here at MTRH and just assisted with a course at Kenyatta University in Nairobi for their graduating 6th year medical students last week. Helen is spearheading a research project evaluating the course in these student populations. She has submitted an abstract to the Association for Surgical Education about our experience at MTRH, and we are waiting to hear if it has been accepted. We will be helping conduct another TEAM course at JKUAT (Jomo Kenyatta University of Agriculture and Technology) at the end of this month.

ATLS: We ran the first course in Eldoret and have continued to assist with courses in Nairobi. We will be presenting our experience with the first ATLS course at the COSECSA meeting in Kigali, Rwanda next month. Our next course in Eldoret will be in February while next week we will be traveling to Nairobi to help with their next course. We are designing a study to evaluate the ATLS experience in Kenya over the last 5 years.

Burns: We had a clinical burn care camp with the team from Eskenazi October 5-11. This included participation in the Burn Society of Kenya National Symposium which was held in Eldoret on October 5. The camp provided surgical care for 23 patients. Educational sessions were held for the surgeons, nurses, and therapists. Additionally, donations of surgical and wound care supplies were made by the team from Eskenazi. We have continued to have weekly multidisciplinary teleconference meetings with the Shoe 4 Africa Burn Team and the Eskenazi team to discuss the patients and follow-up on their care.

 The burn registry has also been initiated following the camp. So far we have enrolled 23 patients in the registry. 

 Trauma Registry: We have rolled out the prospective trauma registry trial at Shoe 4 Africa. We are also beginning to analyze the data from the prospective trial at the adult side of MTRH. We will be presenting an abstract from this data evaluating preventable risk factors in road traffic accidents (i.e. helmets, seatbelts) at the Academic Surgical Congress.

Surgical Oncology: We have begun collaborating with Tenwek Hospital in Bomet, Kenya during our weekly Tumor Board meetings. They are joining via teleconference and both sides are presenting patient cases for discussion. This has facilitated transfer of patients between the two hospitals to seek care provided at one facility and not the other. 

We have also developed standardized data collection forms for our sugical oncology clinic to help make the clinic run more efficiently and standardize the type of information we report on patients. This will help improve their care when they return for surgery as well as help us to collect research data in the future as well. 

Listrunner: We have implemented Listrunner, which is a HIPAA-compliant electronic inpatient census list software which can be used via web browser or mobile app. This allows for a secure method to keep track of our surgical inpatients. It also helps us to organize the list of patients to be presented at our weekly Surgical Oncology Tumor Board. So far it has been adopted by General Surgery, Pediatric Surgery, Burn/Plastic Surgery, and ENT. 

It's been a busy few months and we wish you all well as the holiday season approaches! 

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ATLS trainers and trainees
ATLS trainers and trainees

We're delighted to share that as result of AMPATH surgery's partnership and efforts, the first Advanced Trauma Life Support course was held in Eldoret! 

AMPATH and Moi Teaching and Referral Hospital recently partnered with the Surgical Society of Kenya to conduct the first Advanced Trauma Life Support (ATLS) course in Eldoret to train healthcare providers on the fundamentals of initial assessment and treatment of trauma patients. Sixteen MTRH doctors participated in the course, including consultants, registrars, and medical officers working in general surgery, orthopedic surgery, the casualty department, and OB/GYN. For these doctors, who are often the first to see patients after they arrive at MTRH following a traumatic injury, the knowledge and skills obtained in this course are invaluable.

The three-day ATLS course is the gold standard for trauma care worldwide and took place over July 18-20, 2018. In addition to didactic lessons, ATLS students participate in hands-on training stations where they learned essential skills, from interpreting radiologic findings to performing several life-saving surgical procedures. On the final day, students must pass a written exam and are given a realistic patient scenario, using live simulated patients. There, they must demonstrate the ability to proficiently assess the patient, intervene on any life-threatening injuries, stabilize the patient, and ensure they are directed to definitive treatment.ATLS students practice trauma response skills at stations.

The ATLS course, developed by the American College of Surgeons, was brought to Kenya five years ago through a partnership between the Surgical Society of Kenya and the Kenyan Red Cross Society, with assistance from trauma surgery faculty at Indiana University. Since that time, courses have been held several times a year in Nairobi, under the guidance of Dr. Daniel Ojuka, Country Course Director for Kenya.

This course represents the first official ATLS course in Kenya taught outside of Nairobi. It was made possible through the vision and efforts of Dr. Connie Keung, AMPATH surgical team leader, and Dr. Seno Saruni, a surgeon at MTRH and ATLS Instructor. As they did five years ago in Nairobi, Dr. Clark Simons and Dr. Michelle Laughlin led a team from Indiana University to help conduct the course. 

The next ATLS course in Eldoret is currently scheduled for January 2019. As more Kenyan doctors successfully complete the course and go on to become instructors themselves, Drs. Keung and Saruni hope that these courses will become a more regular offering. Expanding ATLS instruction to providers throughout Kenya will be a significant step in improving the care of those who suffer from traumatic injuries.
Learning proper technique at simulation stations
Learning proper technique at simulation stations

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As Connie gets ready to head back to Eldoret for Year 2 with a new addition to the family, we're pleased to share an exciting update about the AMPATH Surgery program. 

Kyle Carpenter, a General Surgery Resident at the IU School of Medicine, has received a prestigious Fulbright Scholarship that will enhance AMPATH's surgery work - particularly for burn patients. He's headed to Eldoret this month and will stay for a year, working to create the foundation for specialized burn care in Kenya . Here's more information about Kyle's work and motivation.

We look forward to hearing from him this year and how his work will improve surgical care for burn victims in Kenya! And we're grateful for your support to make work like this possible. 

 

_____

"Morning rounds can be somewhat mundane as a surgery resident in the burn unit, but this specific day stood out in late January as the director of the burn unit at Eskenazi Hospital in Indianapolis informed us of a special transfer from Johannesburg, South Africa.   I was intrigued due to my passion for global surgery, but as the story unfolded it highlighted the amazing fortitude of this specific patient and emphasized the need for improved surgical care in Kenya. He was a Kenyan-born British bush pilot who worked for a conservation group, patrolling for elephant poachers in Tsavo national park. On duty one morning early January, a strong wind overturned his plane, causing it to crash and catch on fire. He suffered severe burns from the fire and there was no one nearby. Despite his injuries, he self-extricated from the wreckage and trekked five miles, despite the potential dangers of nearby wild animals, until he was met by another human. From there he was transported by air to a hospital in Nairobi. However, due to limited infrastructure to manage his critical condition from the severe burns, the patient was transferred to Johannesburg. Yet again, he was now being transferred to our care.

While his bravery and courage are commendable, the reality is that most patients in western Kenya do not have access to the resources or connections that made it possible for our patient to receive care in South Africa and at Indiana University. My career goal is to improve access to surgical care in underserved parts of the world, such as western Kenya.

This patient was not my first exposure to the difficulties of providing care for victims of burn injuries in Kenya. As a fourth-year medical student, I had the opportunity to participate in a month-long rotation on the pediatric surgery service at African Inland Church (AIC) Kijabe Hospital in Kenya, a small missionary hospital that serves as a private referral hospital for its region. There, I learned first-hand the frequency and significance of these injuries and the challenges faced by surgeons caring for burn patients in a resource-limited setting. These challenges, along with the rest of my experiences in Kijabe, solidified my passion for a career in global surgery.

I have been pursuing a career in global health since medical school. I was quickly attracted to my school’s robust global health programs. I completed a track of global health electives throughout my four years. Through the National School of Tropical Medicine, I earned a Diploma in Tropical Medicine. The focus of my capstone project was on the burden of road traffic injuries in low- and middle-income countries (LMICs). Choosing to complete an Ethics track of electives as well, I focused my ethics research on global surgery. I devised an ethical framework for measuring competent surgical performance. This tool can be used to determine whether surgeons working in humanitarian and/or global health settings may ethically perform procedures outside the scope of their formal training. Since starting my surgical residency at Indiana University, I have participated in an interdisciplinary global health residency forum along with residents from several different medical specialties. I now have the fortune of serving as my department’s first global surgery research scholar. These experiences have prepared me to meet the challenges of a career in academic global surgery.

Burn injuries in Sub-Saharan Africa account for significant morbidity and mortality. The World Health Organization (WHO) estimates that the worldwide annual death toll due to burns is over 265,000, with burns in LMICs accounting for over 95% of all annual burn deaths.8 An estimated 43,000 people die of burns in Africa every year. In Kenya, burn injuries are associated with significantly higher rates of mortality when compared to other traumatic injuries and they are the leading cause of traumatic injury in patients under the age of 5.This is consistent with other data in Africa, where children die three times as often from burns compared to the world. 

There is a shortage of burn care providers in Sub-Saharan Africa, and in Kenya specifically. Many countries have one or two burn specialists, if any. These providers tend to be located at national referral hospitals in urban centers. Most patients in rural areas of these countries have no access to specialized burn care.

In general, the objective of this study is to better understand the burden of burn injuries in western Kenya as well as the implementation of a validated burn registry at Moi Teaching and Referral Hospital, the national referral hospital in western Kenya.

 Specific Aim #1: To evaluate the capacity and protocols in place for providing care to burn patients at Moi Teaching and Referral Hospital through an objective review of their infrastructure and workflow.

Specific Aim #2: To retrospectively review charts from patients treated for burn injuries over a six-month period from Moi Teaching and Referral Hospital in Eldoret, Kenya, using a validated burn registry data collection form.

Specific Aim #3: To prospectively collect burn injury data over a six month period from Moi Teaching and Referral Hospital using a validated burn registry data collection form. Analysis of this data will help to better understand the burden of burn injuries in western Kenya as well as the challenges and applications of implementing a burn registry in these facilities.

By developing and implementing a burn registry, collection of burn information will be formalized into a validated model. Conducting such a study is a necessary first step in improving the care of west Kenyans injured by burns. Ultimately we hope this study serves as the foundation for creation of a national referral center for specialized burn care at MTRH."

- Kyle Carpenter

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Organization Information

Indiana Institute for Global Health, Inc.

Location: Indianapolis, IN - USA
Website:
Facebook: Facebook Page
Twitter: @ampathkenya
Project Leader:
Connie Keung
Indianapolis, IN United States
$3,515 raised of $50,000 goal
 
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