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325 Bags of Cement Later, Antonio Fernandez, Builds a Basketball Court in Peru

Antonio Fernandez is a national proposal consultant with Kaiser Permanente. Last month, Antonio and 12 of his Kaiser Permanente colleagues traveled to Cerro Blanco, Peru to build basketball courts for Courts for Kids, a non-profit organization that partners with local communities to provide athletic opportunities for children.
We arrived in the village of Cerro Blanco, Peru on Saturday, August 16th, after more than eight hours in flights and a two-hour bus ride. Our group was met by Chris Cobb, the director from Courts for Kids, and a few Peace Corps volunteers, led by Kristen Jackson. We stepped off the bus and were greeted by the Group with workerspeople of the town, who were lined up waiting for us, with big hugs and even kisses on the cheek. No one in the town spoke English. The Courts for Kids group would be relying heavily on about four people to translate any communication that took place all week long.

We were well fed all week long. I heard that the village didn’t have a lot of funds to put towards the court, so much of their contribution came in the form of feeding our group and providing a lot of manual labor. Most of the food I believe, especially the meat, was raised right on the farm where we stayed. We ate meat almost every meal, which we heard was not common in developing countries like Peru. On one of the days, our volunteers Kathy Pantele and Angelica Velasco pitched in and made ceviche, a seafood dish wStove (Medium)ith its origins in Peru.

The morning following our arrival, the volunteers were up and ready to work at 9 a.m. After a minor setback—not having gasoline for the cement-mixer—the group finally started moving cement at about 10:30 and by noon we had finished the first square. The 25×30 meter court consisted of approximately 65 squares.   At the pace we started out at, it looked like we might get ten squares done by the end of the week.

Halfway through the week we found out that the contractor, the people of the village and almost anyone who lived in the immediate area and knew about the court didn’t believe that a group of volunteers would ever finish a court in a week. I never had a doubt. I have done many volunteer projects with Kaiser Permanente employees and I know that they always show up and give everything they have and then a little bit more. This group was no different.

By the end of Monday we had completed 17 more squares. After two half days of IMG_5473 (Medium)work, the group was nearly halfway done with the whole court. The energy at the end of the day was high and the group bragged about its work. We talked about the idea of being able to maybe finish by mid-week.

On Wednesday, I was totally bummed because I contracted some sort of a stomach bug. However, thanks to the marvels of modern medicine, by late Thursday morning I was back up on my feet again. I even jumped in and helped the group as we began to fill the last few squares. I found out quickly though that whatever bacteria I contracted, I was pretty well wiped out still. After about an hour of tough manual labor I stepped aside and let the healthier volunteers do the work.

Completed court with mayorsThe court was completed by Friday. Not only did we finish a court that was about one-quarter bigger than it was supposed to be, but we did it in only two and a half days’ time. Well, really five half-days. For most of the volunteers on the trip, I joked, “It was the toughest half a week most of us ever worked in our lives.”

Our statistics for the week included the following:

  • We emptied nearly 325 bags of cement, which weighed about 100 pounds each.
  • Each batch of cement filled about eight wheelbarrows. Each square needed about five batches.
  • I estimated that we also dumped approximately 1950 buckets of the sand and rocks, each bucket weighing probably close to 50 pounds, and almost 650 buckets of water.
  • In the end, we emptied about 2600 wheelbarrow loads of mixed cement.

For most of the volunteers, it was the hardest week of manual labor they have ever worked.IMG_5834 (Medium)

The first week back from the Peru I was stuck in existential crises mode like I usually am after going on a volunteer trip. I often pondered the previous week’s events and wondered what impact I made and if it was enough. It finally came to me after a few days of running it over and over in my head. The court was only one of the things that could have a big impact on the village. The new court might help generate some money to bring much needed improvements to the village. It could also attract others to come and live there, building a bigger community. It will definitely be a great place for the kids to play safely and for the community to hold events.

What came to me as I thought about what else might change the village was the story about a group of volunteers who showed up from thousands of miles away and gave themselves selflessly to a cause, asking for nothing in return.

After the trip, I asked some of our volunteers to reflect on how it affected them. Here is what they had to say:

Denise Dorado, is a Mammography Technologist at our Santa Clarita Medical Offices.“This was my very first volunteer trip of any kind and I must say I’ve learned I truly do feel a balance in my life when I help others. My job consist of helping others but there is nothing in this world like actually paying out of your own pocket to help others and in return receive smiles, hugs, laughter, joy.”

Ly P. Rivera, is a Change Management and Communications Analyst with our Pleasanton Medical Offices. “This trip incited my passion for altruism and, thus, I have decided with my family, that every vacation will be merged with a service project, as social needs exist almost anywhere at different scales.”

Donating supplies to the school

Thomas Kaschak, DPM, and Colleagues Serve in Da Nang, Vietnam

Note: Thomas Kaschak, DPM,  a podiatric surgeon at Kaiser Permanente Fresno (Calif.) Medical Center,  is in Da Nang, Vietnam, with several colleagues on a relief mission for the Vietnam Medical Project. Among his colleagues on the mission is Ben Cullen, DPM, a third-year resident at Kaiser Permanente Medical Center in Fremont. Below is Dr. Kaschak’s first dispatch. A dispatch from Dr. Cullen follows, and then a second dispatch from Dr. Kaschak that he sent as he was in transit back to the United States.

July 27, 2012

Hello to all readers:

Tom Kaschak writing here from the Da Nang Orthopedic and Rehabilitation Hospital in beautiful downtown Da Nang, Vietnam.  Challenges to internet access led to delay in reporting sooner, but nice to be finally up and going.

Our group arrived in Da Nang Saturday, July 21.  We enjoyed 2 days of R&R before starting our busy clinical/surgical schedule which would take us through the end of this year’s tour.  Joining me again this year is my wonderful and supportive wife Cissy, Dr. Glenn Weinraub makes his second appearance with his resident Dr. Ben Cullen accompanying him from Kaiser Permanente Hayward Medical Center, along with Dr. Annie Nguyentat from the Kaiser Permanente San Francisco Bay Area Foot and Ankle Residency Program.  Dr. Joe Smith makes his first return to Da Nang since his deployment during the “American” War in 1969.  He joins us from Kaiser Permanente Fontana Medical Center.  Chi Lan Ly, an inpatient pharmacist joins me from my home base in Fresno, along with her lovely daughter Kelsey Mott.

We arrived through the new Da Nang Airport Terminal, opened just a few months ago.  Greeting us was a large group of friends and colleagues from the Center.  It is always great to see so many familiar smiling faces as we leave the terminal to begin our annual adventure.

Da Nang has gone through so many changes over the 14 years we have been visiting this town.  In 1998, Da Nang was truly a “third-world” city with mostly old, weathered buildings, torn up roads, and streets crowded with bicycles and motorbikes.  Looking across the Song Han (Han River) from the Central Market was a view of palm trees, jungle and small huts on stilts.  Today, that same vantage point looks out to large hotels, condominiums, and brightly lit billboards. Although motos (motorbikes) still rule the road, cars are becoming more popular.  Hopefully they’ll remain in the minority, since nothing would move if they completely replaced the bikes.

Only two bridges crossed the water in those early years; one built by the French and the other we Americans built during the war.  A third was constructed about 8 years ago and another just last year.  Now, those original two are being replaced and three more are under construction.  Quite a bit of investment in infrastructure in this emerging economy.

We came again bearing supplies and equipment to help make patient care a little easier.  I had hoped to bring two decommissioned tourniquet systems promised to me regularly over the last several years, but, unfortunately, because of restrictive donation policies, this badly needed donation was denied.  Oh well, try again next year.  Still, we were able to collect some medical supplies as well as “souvenirs” such as crayons, coloring books, sunglasses, lollipops and the like, quite popular with the kids, but moms, dads, and even grandparents line up enthusiastically for the goodies.

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Monday was quite a busy day in clinic.  We evaluated about 40 patients, enough to keep us busy in surgery for the remainder of our visit.  We see mostly congenital deformities such as clubfeet in many and varied forms, old injuries, some still carried from the war, lower extremity effects from cerebral palsy, and fortunately now more rarely, polio.

Surgery began on Tuesday with about seven cases scheduled. Not an overwhelming number of cases, but most were quite long and difficult.  The new hospital has three operating rooms, but we mostly use the main OR, which curiously still has two tables side-by-side, a holdover from the days when we worked in the old surgery building – more like a slightly oversized garage outfitted like an operating room.  In those earlier days, it was indeed a necessity.  One anesthetist, Bac Si Sy, managed the two tables, monitoring the patients with nothing more than a blood pressure cuff and a stethoscope.  As he induced spinal anesthesia on one table, the woman who tidied up the room helped “bag” the sedated patient on the adjacent table to keep them breathing – the process had us holding our breath!  He now has quite a bit of help, but those side-by-side tables remain.

Each day presented more challenges both in surgery and clinic.  Dr. Weinraub shared his expertise with the residents and the surgeons from the Center.  The chief orthopedic surgeon is a quiet, unassuming, very bright and talented surgeon, Bac Si Do Van Thanh (Dr. Thanh).

Bac Si Thanh began his career at the hospital in 1999. Then, he spoke no English and was reluctant “accept the knife” in training.  Within a year, he spoke English fluently, and was on the road to becoming the exceptional surgeon he is now.  Proudly, he now instructs us, but we do still trade surgical “pearls”.

Thanh had several opportunities to study in the USA over the years, and he has really taken the knowledge and skills he learned and ran with it.  Here in Vietnam, he has developed the reputation as being the expert in the “Ponseti” method of casting infants born with clubfeet.  Thanh studied with Dr. Ponsetti in Iowa in 2006.  Dr. Ponseti was even then in his mid-90s, practicing and instructing as enthusiastically as ever.  Sadly, he passed away not long after.

Friday, July 27, was an historic day in Da Nang.  Under the careful hands and watchful eyes of Dr. Weinraub, Thanh helped perform the first ever ankle arthroscopy in Da Nang with Dr. Cullen assisting.  Thanh’s younger protege, Bac Si Vu, also had an opportunity to “take the scope” as well.  Dr. Annie Nguyentat, Chi Ly, Kelsey Mott, my wife Cissy and I joined the entire surgical staff as we crowded into the surgical suite to witness this historic event.

We have developed wonderful and enduring friendships here in Da Nang.  We feel and are treated more like family rather than just visitors.  Each evening, we are invited out to dine with our hosts.  The hospital director, Mr. Hoang Van Cuc, gathers us together to share a sumptuous dinner on our arrival and before we depart.  The other evenings it is the staff and our coworkers here that invite us out.  We reciprocate on the nights they have no plans for us.  We’ve become quite fond of Vietnamese food, and cherish the evenings’ fare.  We just can’t find food of such flavor and quality (and quantity) in the states.

I invited the residents and  Drs. Smith and Weinraub to contribute to this blog and share their thoughts and experiences as well.  I’ll try to send off one more before the visit ends next week.   Stay tuned.


Dr. Cullen’s dispatch:

July 28, 2012

I have never been to Asia, or on a medical mission, so I didn’t know what to expect on this trip to Vietnam. One of my attending physicians (Dr. Glenn Weinraub) mentioned the trip in passing a few months ago, and from how he described it, it sounded like a once in a lifetime opportunity to experience health care in a completely different environment, with a variety of pathology unlike any I would ever encounter during residency.

This trip has not disappointed.

From the moment our flight arrived in Da Nang, I have been immersed in a completely different world from anything I have ever experienced. Different language, different clothing, different food, etc. But beyond the cultural differences, the pathology we have seen in clinic is almost unreal. Babies with complex congenital deformities, adults with major trauma, degenerated joints, people walking with the top of their feet hitting the ground, and most of these people basically being crippled by their condition and living with it for several years. Stuff that we read about in textbooks, but don’t ever encounter in modern America.

The clinical and surgical side of things has been incredibly rewarding and eye-opening. Patients were lined up out the door, coming from all across the country for evaluations and treatment. We saw patients in rapid-fire succession on Monday, planning out the surgical procedures for the rest of the week. Then Tuesday through Friday it was surgery all day, with a variety of surgeries that I will probably only see a handful of times the rest of residency, from pantalar arthrodeses to macrodactyly and polydactyly, club foot and flatfoot surgery. As the latest technological advances we are accustomed to in the United States are not available here, we have been forced to adapt to not having up-to-date fixation, intraoperative flouroscopy, or high-quality instrumentation. Being able to be flexible here will undoubtedly help me to get out of tough situations in future surgeries in the event things don’t go exactly as planned.

Our hosts were extremely hospitable, taking great care to make us feel welcome and comfortable throughout the trip. We talked about differences in healthcare and cultural styles, and found common ground in our values and hobbies. At the final dinner, we celebrated an incredible week of making a huge difference in the lives of the patients we treated and advancing the ties between our two programs, with a look to the future and how the event can be made even better next year.

This has truly been a life-changing week for me, one that will positively influence the rest of my career. I feel extremely fortunate and humbled to have been a part of this trip, and I cannot thank Dr Kaschak, Dr Weinraub, or the rest of the team enough for enabling me to be involved. This project will undoubtedly continue to be mutually beneficial for all parties involved under the sound guidance of Dr Kaschak, and I already envy the experiences of future residents who are lucky enough to participate in future trips.

Ben Cullen, DPM
Kaiser Permanente Hayward Medical Center
Below is Dr. Kaschak’s final dispatch, sent en route home.

August 1, 2012

Tom Kaschak here again with the Vietnam Medical Project writing from the Hong Kong Airport, where my wife and I get to “time travel” today.  We leave for SFO just after midnight, August 1, and arrive in San Francisco one month earlier, at 10 p.m. July 31.  Cool!

The trip was quite wonderful this year – and quite busy.  Even as I was leaving for  Da Nang Airport, I was asked to stop by the hospital to evaluate a few patients.  Nothing too complicated, but working right up to the last minute.  Just as we like!

Our final unofficial evening was an event to be remembered for sure.  As in previous years, the entire surgical staff treated us out to a night of delicious Vietnamese cuisine, generous libations, and the company of new and old friends.  It was truly an experience.

Clinic and surgery are quite professional and focused, but after hours, for those not on-call, evenings are to be enjoyed and shared with friends and coworkers.  The surgical staff is extremely dedicated to their profession, and care for the patients is exemplary.  They take their jobs quite seriously and want to make the physician’s/surgeons’s jobs as easy and uncomplicated as possible.  Long hours are not uncommon and no complaints are submitted.  In surgery, the assistants strive to learn each surgeon’s manner, technique, and expectations, and their needs are met and exceeded.  Instruments are handed to us before we know we need them!   It is an honor to work with such dedicated, caring and professional people.

The clinic director, Mr. Haong Van Cuc, Bac Si (Doctors) Thanh, Ky, Tuan, Vu and Sy, were all quite appreciative of our visit.  They really don’t need us there anymore – these surgeons have developed skills and have experience far beyond what we can offer, but they do indeed appreciate the helping hand and any supplies and equipment we could bring.  As I mentioned in my previous blog though, there are those many clinical and surgical “pearls” we exchange that add up to allow for an easier time in surgery.

An exit poll of all participants this year was overwhelmingly positive.  An excellent time and experience was had by all.  All declare they will visit again soon – hopefully again next year, and hopefully this will become a regular event for everyone.  I want to thank my wife Cissy, Drs. Glenn Weinraub, Annie Nguyentat, Ben Cullen and Joe Smith, Inpatient Pharmacist Chi Lan Ly and her daughter, Kelsey Mott, for making this such a wonderful and memorable year.  And thanks to our outstanding hosts and all of the wonderful patients who are so respectful and appreciative of our work.

Stay tuned for VMP 2013!

Tom Kaschak, DPM
Kaiser Permanente Fresno Medical Center
Director, Vietnam Medical Project

Nandini Bakshi, MD, Blogs from Phnom Penh, Cambodia

Editor’s note: Nandini Bakshi, MD, is a neurologist at Kaiser Permanente Antioch (Calif. ) Medical Center. She is serving in Phnom Penh, Cambodia, with the Kaiser Global Health Program on behalf of the Sihanouk Hospital Center of Hope in Phnom Penh.

Day 2 in Phnom Penh: So far it has been as expected although I was struck by the lack of resources, even relative to other counties in Southeast Asia that I have visited. I spent some time at Sihanouk these past couple of days though work there has come to a near standstill due to a lack of funding. (One of the primary relief organizations supporting the hospital is based in Japan and thus its resources have been put to work there following the catastrophic earthquakes there earlier this year.)

People are warm and friendly. They would like teaching to continue and are  happy to have me teach.  Next week I have two lectures per day scheduled plus seeing any case they want to present to me. They presented a case of a  HIV-positive young man who had a sudden neurologic decline and is being treated for presumptive toxo, though he could have central nervous system lymphoma or just about anything else.

Thanks to Dr. Suzy Fitzgerald, I made contact with Tola Hok, a neurologist who works at Preah Kossamak Hospital nearby. She did her residency in France and is one of six neurologists in the country, all recently trained in France and all work in Phnom Penh.

Kossamak is a public teaching hospital and serves people for a nominal fee. There is no CT scanner or EEG machine at the hospital.  The entire country has one EEG machine and though Dr.  Hok trained in epilepsy in France, she is not able to keep up her skill. She asked me to do a talk for the medical students, so yesterday I spoke about stroke to approximately 70 medical students. Their English proficiency is limited so Dr. Hok translated for me. The students asked
questions and were energetic and motivated, for the most part.
They would like me to do a lecture every day at Kossamak so I expect to
be busy the next week. It has been good to have overlapped with Rody
Yoshinaka, who leaves tomorrow.  Rody has been busy teaching endoscopy
and seeing GI cases.
This weekend I head off to Siem Reap for temple hopping, if the rain will allow.
More later,

Nandini Bakshi MD
Kaiser Permanente Antioch Medical Center

Dr. Hernando Garzon’s Reflections on Nigeria

Note: Hernando Garzon,  MD, an emergency medicine physician at Kaiser Permanente in Sacramento, served recently in Nigeria at the request of Medicins Sans Frontieres / Doctors Without Borders.  Dr. Garzon’s timely and evocative emails from Haiti in 2010 largely spurred the creation of the Dispatches From Haiti blog.  His deployment to Nigeria earlier this year preceded the launch of this blog; with his permission, we’ve repurposed excerpts of his notes back to family and friends, and his photos.

January 11

MSF (Medicins Sans Frontieres / Doctors Without Borders) has requested that I go on an exploratory mission for up to 3 weeks to Jos, Nigeria, for escalating religious violence there.  I expect to leave Thursday evening.

Since beginning a relationship with them, we have seven E.M. physicians rostered for the KP-MSF Emergency team, and have sent four of those physicians on three separate missions.

We also have said “no” to them for several mission for which we could not provide a physician due to scheduling.  This opportunity in Nigeria is specifically for an “exploratory mission” and requires someone with enough field experience to make decisions about security and deploying personnel and material resources.  Participating in this mission will further strengthen our relationship with MSF, and increases the role our physicians play in leadership positions with MSF.

If the violence continues, I expect to be making decisions about establishing and running a trauma care facility.  I expect to be gone through Feb 8, but, as usual, may have intermittent electronic access.  More details to follow.

January 25

Have visited two (Christian) hospitals, Muslim neighborhoods, two (Muslim run) clinics, Health Ministry, army general, and a few other things.  Movements, even during the day, are a bit calculated, and we’ve had to cancel or reschedule certain appointments due to ‘unsafe to go there’ conditions.

Still have a host of other hospital, clinic, and community leader visits planned.  Before even doing any kind of health needs assessment, there are a host of logistical issues and questions that need to be addressed:

  • Exact location of public, Christian, and Muslim health service points and their capability (hospital, clinic, dispensary, or chemist) (thank goodness for having GPS skills);
  • Cultural and geographic barriers to access that care (are Muslims comfortable going to Christian health centers and vice versa? Do people feel safe traveling to these health centers when security is an issue?);
  • How does the health system work (if at all) and how is it paid for? A bit of a large task for a city of about 500,000 people with terrible health system management and record keeping.

So far, the answers are not promising, but expected – No emergency transport system exists, baseline level of health care practitioner training woefully low (many in prior clashes simply bled to death from lack of basic care even in health facilities); once injured, people do not feel safe to travel for care or go to the closest (frequently ill-equipped place), and so on.

Only a few weeks left to figure it all out and make recommendations how MSF-B can best make a meaningful intervention.

Perhaps images (slideshow below) of what I have seen will give you better perspective.

February 2

This past weekend there were at least 14 killed and we were largely restricted to our compound for security reasons.  Lost about 3 days to work.  Still doing assessment, but looking to pull together the first ever meeting of all hospitals and clinics before we leave.

February 4

The end is in sight. Am making final and follow-up visits.  Have started to write a final report (up to 25 pages so far).  Operations Chief for MSF-Belgium is presenting a preliminary proposal to all MSF heads at a meeting in Paris today.  Key meeting with leaders of all health care facilities next week.

Found a hospital with a high-speed internet connection to make maps of this area.

More inspired by color today.  Hope the images give some idea of this world.

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February 10

Our last full day in Jos culminated with the first-ever gathering of physician and management leadership from all hospitals and most clinics in Jos, as a preliminary meeting to form a regional Emergency Preparedness Committee.  A very helpful start to a long-term process here. Large report with proposal for further MSF participation is essentially complete and is to be presented to MSF operations leadership in Brussels.

I begin a long trip back today, first to Abuja, then a stop for a ‘debrief’ with the MSF offices, and finally home early next week.

The attached photo (just one this time) is from the early part of my trip.  I have looked at it often as a reminder of the hope that drives much of this work.

Peace,

Hernando

Dr. Jack Cochran Returns From Tanzania

Note: Jack Cochran, MD, FACS, is executive director of The Permanente Federation, which represents the national interests of the regional Permanente Medical Groups, which employ 15,000 physicians who care for 8.6 million Kaiser Permanente members. He has traveled regularly to Tanzania for the past 23 years on behalf of Global Health Ministries to provide free surgeries to children/adults with congenital deformities. He traveled there again in February and provided this dispatch:

Just a quick update on our trip to Arusha, Tanzania, which included one other surgeon from the Colorado Permanente Medical Group. Our team of four surgeons did 121 surgeries for the week, of which approximately 76 were ‘major cases.’ We saw a lot of cleft lip/palate and other congenital deformities, burn scar contractures (many very disfiguring), and a variety of tumors and traumatic deformities. We operated 12 hours a day and I was gratified  to carry my load!!   I look forward to next year and keeping my commitment to the group.

Two positive changes are the really high level of training and skill that the young Tanzanian physicians are getting today.  Many are truly world class. Second , the number and skill of young women becoming physicians…a much needed and welcome evolution.
A negative is that trauma is now a more common reason for hospital admission than malaria in spite of a high prevalence of malaria. The reason is the recent boom in motorcycles in the country. They have gone from virtually nonexistent to being everywhere in the past 2 years. The number of motorcycle accidents is truly disturbing and will be another hit on well-being and productivity for too many young Tanzanians.

Jack Cochran, MD, FACS