Having been invited by Dr. Steve to join him and the Navajeevana team for their outstation visit, I packet my bags for our 4 day trip, and prepared myself for the 10 hour journey. Although the distance is not great as the crow flies, it takes a long time due to the constant reclaiming of roadways by the jungle and flooding. I was told to bring my original passport, and prepare for what would be a constant string of special task force (STF) checkpoints. The STF is a military police force charged with weeding out LTTE along a series of checkpoints on major roadways. We passed through an area that was supposed to be populated with elephants, but unfortunately we didn't see any. We took turns sitting up front to "flash our white skin" and pass quickly through checkpoints.
Navajeevana outstation program was started after the tsunami of 2004 - focusing on relief oriented medical care. After the large influx of relief organizations, it quickly became apparent that the true need was community development and health education to foster a sustainable program of health improvement. The solution was CHE, or community health education programs. Funded by Samaritan's Purse, the CHE program goes into villages and helps them to improve the health of their community utilizing their people and resources.
Each district has a group of village representatives that elects people from each village to become trainers. These elected trainers go through an intensive education program on how to teach people in their village all sorts of public health and community medicine related topics. After they graduate from the program, they go back to their village and teach their people about sanitation & hygiene, safe cooking, dental care, nutrition, family planning, community development, etc. They learn how to prepare lessons, dramas, and skits using things they are likely to have in their village. They also receive basic first aid training and learn to cope with most day to day medical issues. Upon arriving at our destination in outstation, I was able to tag along on one of the CHE education sessions and see for myself how this program works.
In outstation, the group travels by marked ambulance. The interesting thing is that there is no requirement for ambulances. Anybody can buy an ambulance, and with no training, start charging people for transportation. Our driver had some experience in driving long/heavy vehicles, but the rest of the crew had no formal training. Two of the staff had prior experience as "gentle nurses" - something akin to a nurses aid or LPN. The reason for having the ambulance is that it makes it a less likely target, and smooths security checkpoints. LTTE is less likely to set of a claymore mine if the vehicle is marked.
Claymore mines are elevated, remote triggered mines set up on the roadside, and often stuffed with ball bearings and other various shrapnel. They are designed to maim and injure as many people as possible, using up as many resources as possible caring and transporting the wounded. They can be seen stuffed in trees, or in roadside stumps covered with black plastic. At one of the gas stations I saw a mine removal team - probably keeping very busy.
The War has now been going on for over 20 years, erupting in the early 1980s. With most of the Tamils living in the North and East, these zones of transition to the predominately Sinhalese inhabited South and West mark the highest hit areas of tit-for-tat conflict. Ruins of homes, set aflame and riddled with bullets, can be seen amidst the new post-tsunami construction. They serve as eerie reminders of past conflicts, and portray what is undoubtedly happening now in the North. Anywhere outside of Colombo, army and STF guards line the roadside, spaced every couple hundred feet or so, equipped with their AK-47 and drab camo costume.
If one gets distracted by the beautiful scenery or playing children, it is not long before another soldier brings your mind back to reality - a stark contrast of hell and the garden of Eden.
On route to our destination, we stopped off at Handicap International, an organization kept busy building prosthetic limbs and wheelchairs - largely due to the landmines. We needed to pick up a wheelchair for a 12 year old paraplegic boy who injured his back after a fall. The holding room of Handicap International had a rack, filled with legs. It was again an unfortunate reminder of what some people had been dealing with their entire lives. The recipient of this new wheelchair, however, was not a tragedy of war. He had fallen from a height and fractured his T-spine. He now has no use of his lower legs and limited bowl and bladder function. His family can not afford a bed for him, so he sleeps on the concrete floor of their wood and sheet metal shack.
He is chronically suffering from pressure ulcers, and has dramatically increased muscle tone with constant spasms. His life is so miserable he has attempted suicide several times. In the Sri Lankan culture, if someone is unable to work due to an injury or disability, they cannot survive and will not marry. From their point of view, their life is already over. Navajeevana is 'loaning' him a wheelchair, working on better sleeping arrangements, using the ambulance to transport him to all his clinic appointments, and sending home nurses to treat his ulcers and provide twice weekly physical therapy.
After the tsunami of 2004, NGO support came to Sri Lanka in a major way. Probably one of the biggest players was World Vision. Their signs can be seen on rebuilt villages, playgrounds, and transport vehicles. Because many of the NGOs responding after the tsunami were Christian, they had to deall with the constant hastle of the local government, constantly changing rules, and import taxes. Many organizations did their best to get resources to the people who needed them most. Some, however, got fed up and left the country.
There are a few post-tsunami reconstruction communities that are not inhabited. The builders did not first consult locals and subsequently built the houses in a manner that offended people. Sri Lankans have a superstitous tendency. If the ratio of doors to windows is not correct, the home is cursed and it is better to sleep in the dirt than in the cursed house.
In addition to NGOs, the United Nations has a constant presence in the East and North. They are monitoring the humanitarian situation in Sri Lanka, and branch organizations such as the United Nations International Children' Emergency Fund (UNICEF) are helping the country recuperate with community based interventions to improve health and education. Signs and painted flags on water collection tanks help identify the nationality of the relief team.
With the medical team and the ambulance, we made rounds to two pre-teen boys, both paraplegic. One needed to go to the hospital and be admitted - just to have a chest XR. We pulled into the ambulance bay of the base hospital (one step lower than a large teaching hospital). We opened the door and were greeted by a concrete floor and crowded waiting room. We unloaded our patient (by picking him up and carrying him out of the ambulance) and placed him in a wheelchair. Afterward, the ambulance attendant complained that his back was "paining" him.
Before our patient could be admited, he first needed to have his XR order re-written by the outpatient department medical officer (OPD). This is a person with a total of 4 years training out of highschool - the mainstay of Sri Lanka primary care. She signed the order, and we wheeled our patient off to "Ward 1" - a med/surg ward in the "nice" part of the hospital. This open room featred a double row of opposing metal frame beds. The rails were rusted and slowly trying to undo their making and join the recycled nature of the jungle outside. The beds featured cloth covered mats, displaying the various humors of the prior patient. One could imagine what took place hours before one's arriving by the color and location of the stain. We pulled up the wheelchair next to the designated bed, and our medical attendant bent over and lifted the boy (using his back) into the bed. We left him with his sister to care for him. If he became hungry, a small snack shack was outside the hospital, ready to sell junk food to hungry hospital patients. The wooden shelves adjacent to each hospital bed were covered with soda, chips, and various Lankan junk food snacks provided by family members to feed their ailing loved ones. There is no food provided in the hospital. Even if it was, most people would fear the food more than the disease bringing them to the hospital in the first place.
As we returned to the ambulance bay to depart, I poked my head into the accident treatment unit, or ATU. This is the emergency department equivalent in Sri Lanka. This unit is staffed mainly by 2 nurses, with medical officers to help out with new incoming patients. At the national hospital (where most major trauma goes in Colombo), most patients are seen by MOs, but general surgery and anesthesia residents are available to help with critically inured patients. To my surprise, the ledge at the head of each bed had a monitor. These beds were covered in plastic and kept around the corner out of the normal view of the public.
A tray lay in the washing sink with various surgical instruments - later shaken off and placed back on the white cloth ready for possibly the next patient. Plastic bins sit on the nurses table with various glass vials of parenteral medications. A single patient lay in the corner of the ATU - likely waiting for admission to the ward. In Sri Lanka, there is no specialty training for emergency medicine, or 'accident care.'
The next day we wanted to focus on training the medical stuff. After having the 'ride along' the day before to see how they conduct their transports, I had little difficulty brainstorming where to begin. Having only 4 hours to work with, I adapted the EMT textbook into a single handout with an emphasis placed on personal protection. We discussed driving safety and using the ambulance's lights and sirens to warn traffic. When asked, every member of the team though it reasonable to go into conflict zones, burning buildings, and raging rivers. We addressed the concept that patients will have bad days, but they (as rescuers) never should... it is the patient's bad day not theirs. This was a new concept, but I think it caught on. In conjunction with safety was personal protection equipment and hygiene.
Washing hands before working with a patient, and using gloves/goggles/mask to protect yourself from contaminated materials was again a relatively unexplored concept. We practiced making splints out of common garbage - cardboard, lawn-care materials, duct tape, etc. And then the capstone... proper lifting and transfer techniques. We learned to transfer from chair to wheelchair, floor to chair, bed to chair, and chair to stretcher, stretcher to bed, and wheelchair to bed. After they had mastered this, we practiced loading and unloading the stretcher from the ambulance. When this was done, we did a scenario, as though we were transporting our patient from yesterday.
By the end of the practice session, they were protecting themselves, taking safety precautions, and properly loading and transporting patients by the same standards as in the states. We topped off the day with a practice scenario - Dr. Steve had a scooter crash. They had to stabilize his spine, safely remove his helmet, protect his airway, splint his broken arm, then load him into the ambulance for transport. Everyone had a fun time. They later told me that they now might possibly be the best trained ambulance crew in the region.
Having been invited by Dr. Steve to join him and the Navajeevana team for their outstation visit, I packet my bags for our 4 day trip, and prepared myself for the 10 hour journey. Although the distance is not great as the crow flies, it takes a long time due to the constant reclaiming of roadways by the jungle and flooding. I was told to bring my original passport, and prepare for what would be a constant string of special task force (STF) checkpoints. The STF is a military police force charged with weeding out LTTE along a series of checkpoints on major roadways. We passed through an area that was supposed to be populated with elephants, but unfortunately we didn't see any. We took turns sitting up front to "flash our white skin" and pass quickly through checkpoints.
Navajeevana outstation program was started after the tsunami of 2004 - focusing on relief oriented medical care. After the large influx of relief organizations, it quickly became apparent that the true need was community development and health education to foster a sustainable program of health improvement. The solution was CHE, or community health education programs. Funded by Samaritan's Purse, the CHE program goes into villages and helps them to improve the health of their community utilizing their people and resources. 
Each district has a group of village representatives that elects people from each village to become trainers. These elected trainers go through an intensive education program on how to teach people in their village all sorts of public health and community medicine related topics. After they graduate from the program, they go back to their village and teach their people about sanitation & hygiene, safe cooking, dental care, nutrition, family planning, community development, etc. They learn how to prepare lessons, dramas, and skits using things they are likely to have in their village. They also receive basic first aid training and learn to cope with most day to day medical issues. Upon arriving at our destination in outstation, I was able to tag along on one of the CHE education sessions and see for myself how this program works.
In outstation, the group travels by marked ambulance. The interesting thing is that there is no requirement for ambulances. Anybody can buy an ambulance, and with no training, start charging people for transportation. Our driver had some experience in driving long/heavy vehicles, but the rest of the crew had no formal training. Two of the staff had prior experience as "gentle nurses" - something akin to a nurses aid or LPN. The reason for having the ambulance is that it makes it a less likely target, and smooths security checkpoints. LTTE is less likely to set of a claymore mine if the vehicle is marked. 
Claymore mines are elevated, remote triggered mines set up on the roadside, and often stuffed with ball bearings and other various shrapnel. They are designed to maim and injure as many people as possible, using up as many resources as possible caring and transporting the wounded. They can be seen stuffed in trees, or in roadside stumps covered with black plastic. At one of the gas stations I saw a mine removal team - probably keeping very busy.
The War has now been going on for over 20 years, erupting in the early 1980s. With most of the Tamils living in the North and East, these zones of transition to the predominately Sinhalese inhabited South and West mark the highest hit areas of tit-for-tat conflict. Ruins of homes, set aflame and riddled with bullets, can be seen amidst the new post-tsunami construction. They serve as eerie reminders of past conflicts, and portray what is undoubtedly happening now in the North. Anywhere outside of Colombo, army and STF guards line the roadside, spaced every couple hundred feet or so, equipped with their AK-47 and drab camo costume. 
If one gets distracted by the beautiful scenery or playing children, it is not long before another soldier brings your mind back to reality - a stark contrast of hell and the garden of Eden.
On route to our destination, we stopped off at Handicap International, an organization kept busy building prosthetic limbs and wheelchairs - largely due to the landmines. We needed to pick up a wheelchair for a 12 year old paraplegic boy who injured his back after a fall. The holding room of Handicap International had a rack, filled with legs. It was again an unfortunate reminder of what some people had been dealing with their entire lives. The recipient of this new wheelchair, however, was not a tragedy of war. He had fallen from a height and fractured his T-spine. He now has no use of his lower legs and limited bowl and bladder function. His family can not afford a bed for him, so he sleeps on the concrete floor of their wood and sheet metal shack. 
He is chronically suffering from pressure ulcers, and has dramatically increased muscle tone with constant spasms. His life is so miserable he has attempted suicide several times. In the Sri Lankan culture, if someone is unable to work due to an injury or disability, they cannot survive and will not marry. From their point of view, their life is already over. Navajeevana is 'loaning' him a wheelchair, working on better sleeping arrangements, using the ambulance to transport him to all his clinic appointments, and sending home nurses to treat his ulcers and provide twice weekly physical therapy.
After the tsunami of 2004, NGO support came to Sri Lanka in a major way. Probably one of the biggest players was World Vision. Their signs can be seen on rebuilt villages, playgrounds, and transport vehicles. Because many of the NGOs responding after the tsunami were Christian, they had to deall with the constant hastle of the local government, constantly changing rules, and import taxes. Many organizations did their best to get resources to the people who needed them most. Some, however, got fed up and left the country. 
There are a few post-tsunami reconstruction communities that are not inhabited. The builders did not first consult locals and subsequently built the houses in a manner that offended people. Sri Lankans have a superstitous tendency. If the ratio of doors to windows is not correct, the home is cursed and it is better to sleep in the dirt than in the cursed house.
In addition to NGOs, the United Nations has a constant presence in the East and North. They are monitoring the humanitarian situation in Sri Lanka, and branch organizations such as the United Nations International Children' Emergency Fund (UNICEF) are helping the country recuperate with community based interventions to improve health and education. Signs and painted flags on water collection tanks help identify the nationality of the relief team.
With the medical team and the ambulance, we made rounds to two pre-teen boys, both paraplegic. One needed to go to the hospital and be admitted - just to have a chest XR. We pulled into the ambulance bay of the base hospital (one step lower than a large teaching hospital). We opened the door and were greeted by a concrete floor and crowded waiting room. We unloaded our patient (by picking him up and carrying him out of the ambulance) and placed him in a wheelchair. Afterward, the ambulance attendant complained that his back was "paining" him. 
Before our patient could be admited, he first needed to have his XR order re-written by the outpatient department medical officer (OPD). This is a person with a total of 4 years training out of highschool - the mainstay of Sri Lanka primary care. She signed the order, and we wheeled our patient off to "Ward 1" - a med/surg ward in the "nice" part of the hospital. This open room featred a double row of opposing metal frame beds. The rails were rusted and slowly trying to undo their making and join the recycled nature of the jungle outside. The beds featured cloth covered mats, displaying the various humors of the prior patient. One could imagine what took place hours before one's arriving by the color and location of the stain. We pulled up the wheelchair next to the designated bed, and our medical attendant bent over and lifted the boy (using his back) into the bed. We left him with his sister to care for him. If he became hungry, a small snack shack was outside the hospital, ready to sell junk food to hungry hospital patients. The wooden shelves adjacent to each hospital bed were covered with soda, chips, and various Lankan junk food snacks provided by family members to feed their ailing loved ones. There is no food provided in the hospital. Even if it was, most people would fear the food more than the disease bringing them to the hospital in the first place.
As we returned to the ambulance bay to depart, I poked my head into the accident treatment unit, or ATU. This is the emergency department equivalent in Sri Lanka. This unit is staffed mainly by 2 nurses, with medical officers to help out with new incoming patients. At the national hospital (where most major trauma goes in Colombo), most patients are seen by MOs, but general surgery and anesthesia residents are available to help with critically inured patients. To my surprise, the ledge at the head of each bed had a monitor. These beds were covered in plastic and kept around the corner out of the normal view of the public. 
A tray lay in the washing sink with various surgical instruments - later shaken off and placed back on the white cloth ready for possibly the next patient. Plastic bins sit on the nurses table with various glass vials of parenteral medications. A single patient lay in the corner of the ATU - likely waiting for admission to the ward. In Sri Lanka, there is no specialty training for emergency medicine, or 'accident care.'
The next day we wanted to focus on training the medical stuff. After having the 'ride along' the day before to see how they conduct their transports, I had little difficulty brainstorming where to begin. Having only 4 hours to work with, I adapted the EMT textbook into a single handout with an emphasis placed on personal protection. We discussed driving safety and using the ambulance's lights and sirens to warn traffic. When asked, every member of the team though it reasonable to go into conflict zones, burning buildings, and raging rivers. We addressed the concept that patients will have bad days, but they (as rescuers) never should... it is the patient's bad day not theirs. This was a new concept, but I think it caught on. In conjunction with safety was personal protection equipment and hygiene. 
Washing hands before working with a patient, and using gloves/goggles/mask to protect yourself from contaminated materials was again a relatively unexplored concept. We practiced making splints out of common garbage - cardboard, lawn-care materials, duct tape, etc. And then the capstone... proper lifting and transfer techniques. We learned to transfer from chair to wheelchair, floor to chair, bed to chair, and chair to stretcher, stretcher to bed, and wheelchair to bed. After they had mastered this, we practiced loading and unloading the stretcher from the ambulance. When this was done, we did a scenario, as though we were transporting our patient from yesterday. 
By the end of the practice session, they were protecting themselves, taking safety precautions, and properly loading and transporting patients by the same standards as in the states. We topped off the day with a practice scenario - Dr. Steve had a scooter crash. They had to stabilize his spine, safely remove his helmet, protect his airway, splint his broken arm, then load him into the ambulance for transport. Everyone had a fun time. They later told me that they now might possibly be the best trained ambulance crew in the region.
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