Our last day of the course, and the morning prayers were tinged with sadness. It’s been a fantastic two weeks, and I’ve made lots of genuine friends. I’m really going to miss going back to real life…

Dermatology

Claire Fuller gave us our final topic session of the week, based on many years of experience in both the UK and East Africa.

The WHO is working with the Gates Foundation to run a Global Burden of Disease statistics measuring. 600 million cases of scabies worldwide. In the developing world, skin disease is the second commonest reason for attending primary care – but people are still far less likely to attend if they have a rash compared to other types of pathology.

As in many other areas, traditional healers cause many problems – their treatment for lymphoedema is to puncture the legs multiple times to let the fluid out. Sadly, this leaves the door wide open for infection.

Dermatological Examination

Important features to have.

• Suitable location for skin examination
• Satisfactory light
• Examine patient all over – check mouth, nails, scalp, feet, genitalia.
• Distribution of lesions.

The problem is, because don’t want to strip off because the clinic is full of people and no privacy, but then you take them down to the cupboard, and its too dark to see.

Bacterial skin disease

Very commonly this will be impetigo – yellow crust to blisters, generally around nose and mouth.

1. They need to wash the skin – with clean waters and disinfectants. Remove crusts, debris and necrotic tissues.
2. Apply antimicrobial preparation – herbal, honey, hydrogen perocide, chlorhexidine, topical antibiotic.
3. Oral antibiotics – flucloxacillin, erythromycin.

Eczema

Eczema is very common in the developing world. Can be especially aggressive in African skin. Rather than simply affecting the flexures, it can affect the whole trunk, and can cause very high levels of inflammation, which leaves hypopigmentation after resolution.

Often needs emollients and dermovate.

Tinea

Scaly round rashes on arms or trunk related to ring worm. Can be treated with topical antifungals. However, tinea capitis – affecting the scalp – will need systemic antifungals. (See image above on right)

Pyoderma, scabies and renal damage

There is an established association between scabies and pyoderma. In those with scabies + pyoderma, 5-10% will have visible haematuria: so it should be treated.

80% of dermatology consists of 8-10 common diseases. If it smells like pyoderma, it probably is.

Medical implications of skin-lightening products

These can cause local damage, with inflammation and awful stretch marks. In Malawi, around 5-10% of people attending our clinic had problems related to these creams.

Patients will deny using the products, so you have to say “I’ve heard that people who use these creams get these problems”, letting them save face.

HIV/AIDS

Having a skin disease is a risk factor for having HIV, from evidence in Tanzania. Multiple dermatoses is quite specific for low CD4 count. In one study, 88% of adolescents with HIV had a skin disease.

The best way to treat the HIV associated dermatopathology such as Kaposi’s Sarcoma is to treat the HIV.

Ulcers

1. Treat underlying cause.
2. Keep clean without dirsupting healing (antiseptic soaks, water fit for drinking is fit for wound case)
3. Treat secondary infection
4. Greasy covering prevents adhesion and good for pain relief.
5. Compression is very helpful.

Removing suspicious lesions

Podoconiosis

Known as “Podo” – one of the forms of elephantisis. Seen in the highlands of tropical countries with lots of bare feet in muddy professions.

Skin swells and becomes woody and hard. Smells insanely awful. Basically an end stage lymphoedema.

Usually can be dramatically improved with frequent washing and antiseptic. Get children to wear shoes, prevents the condition occuring.

Our scheme in Ethiopia has led to all who are treated being invited to join the team to teach others. 30,000 have now been treated in the scheme!

Teaching… a workshop

Our closing session was from Vicky Lavy, talking us through the wonderful art of teaching, a key tool for all of us, especially in the developing world.

Many of us have done a fair amount of teaching. As a group we came up with lots of words beginning with E, about the important things that teaching needs to achieve:

• Enable
• Enthuse
• Educate
• Empower
• Entertain
• Encourage
• Exchange
• Effect (on patient care)
• Everlasting (sustainability)

What makes a good teacher?

• Clear + interesting
• Acting
• Inventive
• Honesty
• Inventive
• Relevance
• Love for the subject
• Audience
• Approachable
• Knowledge + Preparation
• Experiment

Teaching tools

There are millions of different teaching styles: Participation, Lectures, Scenarios, Practicals, Groups, Role play, Mentoring, Informal, Teach others, Drama & Song, Quiz, Stories, Bed side, Shared consultations, Video, Books, Online, Visual stuff, Thought exercise, Buzz groups.

One week after a lecture, evidence shows that people often only remember around 20% of the information.

Some of these are very effective in developing settings, others not so well. Generally, developing world cultures are used to very didactic of teaching, which means they can learn by rote, but are not well versed in problem solving.

However, once they get used to small groups, which can take some time, they find them useful also. Good to tell people they can use their own language in the groups.

“I was doing some teaching in china, and trying to ask questions, and just getting blank faces. However, over the 3 days, the group slowly opened up, talking about patient cases. By the end, I found they were very engaged.”

• Dealing with wrong answers - Important to a) not embarrass people, but also b) correct dangerous treatment ideas.
• Breaking up teaching sessions is valuable - to keep people awake. Having a buzz group session between talks is helpful. A buzz group is where someone turns to their neighbour and briefly discusses an issue
• Visual aids – showing pictures, to tell stories. One teacher on this course has showed us the manacles used to hold psychiatric patients to the wall. That kept us awake!

Case example: Teaching student nurses in Uganda about immunisation within 1 hour

We broke into lots of pairs and tried to come up with teaching sessions. Then fed back to the group. Huge variation in styles and approaches. Some groups taught basic practical skills, some came up with dramas, some had very ambitious plans to teach a much more holistic community engagement approach.

Closing

Ian’s closing remarks: God did not make us to cope with burdens on our own. Jesus sent people out two by two, not individually. We need to share our burdens together.

We then all held hands and closed in prayer together.

And that’s all folks. Sad to feel we are at an end, but I’ve definitely never enjoyed a medical course, or generally teaching so much. I’d like to give some huge thanks to Vicky and Ian, and the whole of the CMF team. Bless you all!

I had a massive lie in today, and then discovered that the traffic at 8:15 around London is rather horrendous. Happily, arrived only 5 minutes late, in time for…

Towards culturally competent care

Mary Hopper talked to us again, this time looking at the impact of not understanding culture on care…

There has been lots of awareness throughout the course about the impact of culture. Most of the speakers through the last two weeks have mentioned the shocks and surprises of moving between the developed and developing world.

We all contributed things we’ve experienced in different cultures we were not expecting:

• Less personal space: people just turning up at our house.
• Less confidentiality.
• Personal questions: asking things polite British society doesn’t accept.
• Different expectations.
• Facial expressions.
• Time.
• Hierarchy of generations/roles.
• Fatalism.
• Family values.

To many people, not complying with their culture is not an option.

I’ve had people who have come to me, and decided they want to accept Jesus. They’ve become Christians, and then said to me “Now I can’t go home”. Breaking cultural norms can lead to beatings, ostracising, deaths…

Culture has 3 layers

1. Outer layer – artefacts and products.
2. Middle layer – norms and values.
3. Inner layer – laws, generational beliefs.

“It was not the women’s ignorance but their intelligence that led to their refusal to adapt or abandon certain habits. They sought to understand the reason for such changes in terms that made sense to them. Not all those put forward by the health care worker did.”
Currer 1986 

The impact of culture on healthcare can be huge. Pre natal sex selection, communication styles, work force issues, birth marriage and death rituals, issues of consent, organ donation.

Ask yourself the question: Who are you? Where do you get your identity, beliefs, values, skills from? Ethnocentricity is the feeling of “I’m right, you’re wrong”. The feeling that your idea of culture is correct and needs to be taught to others.

We need to challenge ourselves; sometimes the correct thing to do is the culture that has been there for years, not our shiny Western ideas.

Women: Key Issues

• Stewardship of natural resources – women may be in charge of securing food, water, fuel and overseeing family health and diet.
• Reproductive health – issues re-morbitity, expectations of role and childbearing. Could be seen as coercion/force. Infertility is a hugely ostracising problem in some cultures, as is having a female baby.
• Economic empowerment – more women than men live in poverty. potential for economic disparity, less access to food, essential resource for living, property ownership.
• Education empowerment - women do not have access to education: linked to child mortality.

Sociocentricity and Egocentricity is the contrast of being society centred or self centred. The former is often modelled in developing world cultures, with tribes and villages central, rather than the Western individualism. It can be argued that the Socio model is more modelled in Biblical theology and morality: the concern is that there also a huge potential for individuals to be disadvantaged within it.

If used well, Sociocentricity, can be empowering for individuals and communities: its another situation where cultural sensitivity can help us to improve current systems, rather than trying to implant our own.

“We had condom education in our village, and the men came, and demonstrated placing a condom onto a stick. Rather than seeing the example in the spirit it was intended, many people in the village started placing condoms onto sticks.”

Wherever we go, we need to consider: how culturally sensitive are we being, and how can we help by providing culturally appropriate care.

Workshops

The rest of the day involved workshops of Contraception, Gynaecology case studies  & Gynaecology Emergencies. It was great, and very interactive, but sadly not terribly conducive to note taking.

They also told us about Swinfen Charitable Trust, who provide an international medical advice service for professionals – very useful in the field!

After a late night gig in London, I had a rather late night, followed by getting up at 6am to prepare for speaking at the early morning prayer meeting. I also washed everyone’s feet, which was a real honour for me. The upshot of all this was that I didn’t do my preparatory homework for today’s sessions, so apologies if it seems a bit sparse.

Women’s Health in the Developing World.

The first talk of the day came from Christine Edwards, with a talk based on many years of experience in fistula surgery in Bangladesh. 

• There are 360,000 women dying because of childbirth each year.
• There are 2 million newborns dying within the first 24 hours per year.
• There are 2.6 million avoidable stillbirths per year.
• 2 million unplanned pregnancies per year.
• 70,000 deaths due to abortion per year.

Birth complications means many women end up with fistulas that leak urine and faeces continuously. Women are socially ostracised – we watched the story of a lady called Mastula, and her experience of her life being turned upside down by a fistula.

Lifetime risk of dying from childbirth and pregnancy. In the west it is 1 in 4300. In Afghanistan, it is 1 in 11.

In the UK in 1930, maternal mortality rates were similar to the developing now. The UK changed due to 4 changes in services & skills:

1. Midwifery care
2. Blood transfusion
3. Caesarean section
4. Antibiotics

3 delays

It is felt that there are three areas of delay that cause many of these deaths: delay in deciding to seek care (due to socio-cultural constraints, values put on women, beliefs related to pregnancy, traditions, non medical attributed causes), delay in reaching facility (financial constraints, poor transportation, no local facility) & delay in recieving care(Lack of staff (24/7), training, equipment, drugs and money).

92% of Bangladesh births are at home, with 89% totally unattended by health care providers. We worked at the only hospital in Bangladesh (population 160 million) that had an obstetric service available 24/7.

What is needed?

1. Increase in the value put on women by society/ community
2. Increase in community awareness of danger signs and preparedness
3. Increase in the community’s  confidence in EOC (Essential obstetric care) facilities
4. increase in comprehensive and in basic EOC facilities
5. Increase in skilled personnel in an integrated system

LAMB approach

The LAMB hospital is a mission hospital in Bangladesh. Find out more at LHCF.org.uk.

Bible studies for all staff on created in His image, and violence against women. Teaching on how New Testament teaching on how a husband should treat his wife – “husband ought to love his wife as he loves his own body“.

We’ve seen a drastic effect: people working through the verses together: Christians, Muslims, Hindu, all reading the Bible together, and together coming to an understanding of how things should be.

We work with traditional healthcare attendants, giving them some simple points of when they need to refer to the hospital – the WHO feels this is not an effective policy worldwide, but we find it has been helpful in our area. We also train our own community skilled birth attendants, who receive 6 months training, then return to their villages..

Involvement of mother-in-laws and husbands, as decision makers, is very important; mothers will often agree with all our plans, but do not have the authority to make it happen.

That makes this the third day on this course where mother-in-laws have been recognised as an international threat to health. The hospital uses the community to pay for itself. Subsidies are provided for those who cannot afford. Households donate 1 tk per month (less than 1p), with further donations at religious festivals. We have advanced trained midwifes and advanced anaesthetic assistants – an area of contention at the moment. However, having audited our anaesthetic assistants, we have had no deaths directly due to anaesthesia in 5 years.Appropriate review definitely improves our service quality:

• “No blame”, confidential meetings
• Facilitates interdepartmental communication & teamwork
• Addresses areas for improvement
• Regular review of protocols
• Saving Newborn Lives initiative – pilot project in PNDA
• ‘Verbal autopsy’ of all maternal and child deaths in the community

Birth basics

I joined the “Basics” rather than “Advanced” Obstetrics workshop, which was being taught by Mary Hopper, who spoke on Saturday.

Some useful bits and pieces

• Grandmultigravida – more than 5 births.

“In Zimbabwe, we had one lady who was having her 23rd baby. In the next bed, we had her daughter, who was also having a granddaughter for our original patient!”

• Due date can be calculated: add 5 days and 9 months to the beginning of the last period.
• Foetal heart rate should around 130-140 – in the absence of other tools, using a loo roll over where you think the shoulder of the foetus is.
• Amniotic fluid should be around a litre, and should be strawberry coloured. Polyhydramnios (too much) is often seen in twins, pre-eclampsia, and seems to be more common in congenital abnormalities. Oligohydramnios (too bad), if bad, can lead to baby being held in uterus by adhesions.

Stages of Labour:

Onset of labour: from start of contractions until the cervix is completely dilated. Make a peace sign with your index and middle fingers: the distance between fingertips is around 10cm. The cervix generally progresses at around 1 cm an hour.

Our nurses in Zimbabwe couldn’t say ‘dilated’, so they would run and find me and say ‘The patient is fully delighted!’.

Second stage of labour: from full dilation to delivery of the baby. Once the woman feels she is ready to push, check the cervix.

Third stage of labour: from delivery of baby to delivery of placenta. Breastfeeding releases oxytocin, which will speed this up. Usually takes up to an hour.

Presentation, Lie & Position

1. Presentation – what is near the cervix: cephalic presentation, shoulder presentation, breach presentation.
2. Lie – Longitudinal or transverse.
3. Position – Commonest is OA – occipito-anterior. This means the back of the baby’s head is at the front of the mother. OP is the reverse of this, the occipital region of the baby’s head faces backwards. Often, OA you will easily be able to palpate the back of the baby in the abdomen, and mum will say the kicking is mostly to the sides. OP, you won’t easily palpate the back, and mum will say that kicking is all over the place.

Cord Prolapse

If a cord is visible before the baby, it often means the cord has come out, which means it can get stuck, with the baby squashing it, giving the baby hypoxia. Push the baby back in vaginally with your fingers, and get mum on hands and knees with head down.

Is the cord still vibrating? If not, baby is dead. Very occasionally, the cord can start vibrating again once you apply pressure. If the baby is dead, you need to deliver it, but there is no time pressure beyond keeping mum well.

Shoulder distocia

Baby gets it shoulder stuck in the pelvis vertically. You need HELPERRS!

Help – call for help.
Episiotomy.
Lift the legs.
Suprapubic Pressure.
Enter vagina – to try to turn the baby.
Remove posterior arm – try to deliver arm through the vagina.
Rotate the mother onto all fours.
Symphesiotomy if not resolved – pop in a solid catheter, so you can move the urethra out of the midline, then cut through the synthesis pubis and pull out the baby.

Sepsis

Our first afternoon session was with Jacqui Hill, who has been in Afghanistan for the last 3 years, working in Obs & Gynae…

Sepsis is a huge killer in maternal deaths – even in the UK, there were 43 maternal deaths in the last 3 years from sepsis, 13 from Group A Streptoccus/

• Sepsis is a systemic infection.
• Severe sepsis is sepsis with organ dysfunction. (40% mortality in pregnancy)
• Septic shock is sepsis with hypotension. (60% mortality in pregnancy)

Sepsis is dangerous in pregnancy, because the woman is under a lot of physical duress, so has more susceptibility, and pathology presents abnormally, so is picked up late.

The evidence shows that the most important treatment is to get antibiotics into the patient.

Chorioamnionitis

A pregnancy specific sepsis can be chorioamnionitis. This occurs from rupture of membranes early, leading to infection in the amniotic fluids.

With cases of chorioamnionitis, delivering the baby is going to be better for both the child and the mother. Non delivered foetal survival rates are almost non existent.

Inducing a birth is usually done with medication or pessaries in the UK. One thing you can do in the developing world. Putting a catheter into the cervical os: you inflate the balloon to start stimulating the cervix. Also give an oxytocin IV infusion.

We also had session on haemorrhage and eclampsia. I failed to get many notes, but they were awesome! Then I went for a curry and finally got Peshwari chips for the first time!

Driving round the North Circular via the world’s most awful roundabout meant that I nearly didn’t make it to the course this morning. Happily though, I avoiding the lorry that tried to crush me by changing lanes without indicating, and I arrived ready for a day of #…

Trauma Overview

Our first talk came from Chris Lavy, husband of Vicky Lavy, who runs the course. He explained that the reason for his haggard experience was her being away for a week, leaving him alone with the children.

The USA have nearly 1% of the population having an operation each year, whereas in Guyana that figure is 0.002%. There are 1700 surgeons per 100,000 population in the UK, whereas in Ethiopa that figure is around 1 per 100,000.

When I work in London, I don’t even recognise all the other surgical consultants in my hospital. When we lived in Malawi I knew the names, birthdays and spouses of every surgeon in the country.

16% of the global burden of disease is injuries, so we need to take it seriously. The Primary Trauma Care course is basically a very low cost of the ATLS course.

Fractures & Joint Injuries

In the West, it has become common to treat fractures operatively, but in the developing world, conservative treatment is better since it is cheaper, and doesn’t rely on having equipment, with much lower risk of infection.

Fracture treatment:

1. Assess fracture, circulation and nerves.
2. Reduce the fracture
3. Hold or support it until united
4. Encourage movement at all stages.

Remember most fractures will heal without your help.

Fracture healing:

Union = bone moves as one
Consolidation = back to normal strength
Remodelling = returning to normal shape
Non union = still mobile at 6 months.
Mal union = healed in the wrong position.

How long do fractures take to unite?

• 2-3 weeks if metaphyseal eg wrists
• 4 weeks for oblique forearm fracture
• Add 2 if transverse
• Add 2 if lower limb.

Children heal much faster.

Common fractures:

These are all conservative solutions, rather than operative

• Clavicle - put in a sling.
• Humeral - back slab or sling. Encourage elbow movements.
• Supracondylar (see above on right) – forearm traction for several day until swelling gone, then treat in sling.
• Olecranon - sling.
• Radial - plaster of paris potting.
• Metacarpal – no fixing, just regularly flex and make a fist.
• Femoral - traction – raise foot of bed and hang traction off end of bed.
• Tibial – above knee cast for 4 weeks, then below knee walking cast if stable enough. If unstable, will need traction.
• Ankle – plaster of paris pot, will need replastering in around 7 day, since the ankle is almost always swollen.

Don’t forget exercises to stop everything stiffening up!

Open fractures:

Tropical Orthopaedics

Tea break finished, it was time to meet Alan Norrish, and his encyclopaedic knowledge of using drills on people in hot places…

Some Ugandan studies: 3% of all surgical procedures ended up with osteomyelitis, and 18% of paediatric hospital days was related to joint and bone infection.

In the developing world resources are short, so the focus goes on injuries with blood and bones all over the place, rather than long standing musculoskeletal problems that cause a lot of morbidity.

Often there is not enough time or money to operate, but sometimes Alan has found this website rather helpful for giving patients helpful exercises.

Childhood limb specific disorders

Failure of formation

Hemimelia (picture above right) is missing bones or parts of bones:

• Missing fibula
• Missing tibia (autosomnal dominant)
• Missing radius (causes clubbed hand)
• Missing fingers (claw hand)

Failure of separation

• Most common is syndactyly of the fingers and toes.
• Can be simple with bones separate, or complex with bones combined.

Duplication

• Normally extra fingers and toes.

Amniotic constriction bands

• Need removing before the child grows, as get tighter

Undergrowth of bones

• Shortened femur.

Systemic Congenital Conditions

• Osteogenesis imperfecta
• Fibrodysplasia ossificans progressivica.
• Cerebral palsy

Some people spend all their money trying to find a resolution to a long term problem, and sometimes the best you can do is tell them there is no cure, and then they can spend the money on useful things for their life.

Club feet:

• Common in developing world – 1:1000 births.
• Use serial casting in under 3 years
• 3 years to 8 year, needs soft tissue surgery
• 8 years olds onwards need bone surgery.

Osteomyelitis:

• Acute, treatable with antibiotics
• Chronic, will need bone debridement, very difficult to cure.

TB of bones and joints:

• Often present without pulmonary TB.
• Triple therapy is treatment.

Burns & bites:

• Elevate limb and splint joints in functional position.
• The skin can cause a contracture of scar tissue that needs cutting, or serial casting to prevent it limited movement.

Neck injuries:

1. Go and hold the neck. It will increase awareness of the neck to other staff.
2. Rigid collar.
3. Log rolls for moving patient.
4. If facet joint dislocation, you can perform head traction!

Burns

It turns out that I am not very good a paying attention to lectures for 8 days in a row. Eyes practically closed, I grab a coffee with ten sugars in time for the final talk of the morning with Sarah Tucker…

Our three key aims with treating burns in a resource poor setting are survival, prevention of disability and effective use of resources.

We did an audit in Nepal that showed that in six years, no one had survived 40% burns on our burn unit.

Painful as it is to say, this means that it was unlikely to be worth the heavy investment in resources treating people with this level of fatal wound. Burns patients die from injection – sadly we had to make the decision to treat anyone with more than 60% palliatively.

Severity of Burns

To assess percentage coverage, we use the rule of 9s – click the image on the right for more information.

The best way of finding out depth of a burn is to see how quickly it heals. Anything that heals in less than 2 weeks is superficial, longer is deep.

Treating Burns

You need to perform escarotomies if any circumferential full thickness burns to the limbs, chest or neck, to prevent contractures.

The burn needs to be scrubbed clean, especially if any foreign bodies or chemicals. The burn will need to be scrubbed every few days, this removes dead skin, leaving healthy tissue.

The Ideal Burns Dressing

My pet hate is people arriving from the West with boxes of dressings, that everyone leaps on, gets very excited about, and then runs out. Much better to teach everyone to make local solutions that work well.

• Clean
• Available and sustainable
• Cheap
• Non adherent
• Reduced need for analgesia
• Reduced need for changing
• Antiseptic

We started to use banana leaves for burns dressings. They can be autoclaved, boiled and sterilised. They are non adherent. They work better than silicone dressings.

I showed the banana leave dressings to our nurses, then went away for two weeks. When I came back, they had visited all the trees in the area, autoclaved leaves and filled the fridge with them of their own volition – that’s how noticeable a difference they made to the nurses.

Preventing contractures.

If burns are across joints, and the joint is held out straight, inflammation, then scar tissue will cause contractures, which will cause functional problems in future.

There are some finer points, but generally the Edinburgh position (on the right) will prevent the hand losing functionality.

If there are burns on the inside of the hand, you will need to release the splint at night, or splint it straight at night to prevent this.

Practical Skills Workshop

The afternoon was an exciting blend of Plaster of Paris, Disolocations and traction, Skin grafting and Physio sessions. Afraid there’s not much I can say about them – you had to be there! Since you weren’t, you did miss me accidentally removing the skin on my knuckle whilst practicing taking a skin draft on an orange.

After a glorious day off, where I mostly read books and used a petrol strimmer to utterly destroy a number of stinging nettles, I returned to the lovely Oak Hill College for the start of week two…

Anaesthetics

Our first talk today was from Hilary Edgcombe, who started with photos of an elephant and a boa constrictor under anaesthetic, which was cool.

Anaesthesia is the absense of sensation: so this includes local and general anaesthesia.

General perspective on world anaesthesia:

• Good anaesthesia is
• Safe
• Comfortable for the paatient
• Comfortable for the surgeon
• Preferably simple, economical and fast

11% of world’s disability-adjusted life years are lost due to conditions amenable to surgery. Safe anaesthesia is necessary for surgical care.

Safe anaesthesia is not available worldwide:

• In the UK, anaesthesia related mortality is 1 per 185000
• Malawi central hospital: 1 per 504
• Togo teaching hospital 1 per 133
• South Africa: 1 in 4 maternal deaths anaesthesia related: 90% avoidable

Key causes of anaesthesia related mortality:

Of 41 anaesthetic clinical officers in Malawi, 5 had seen a failed intubation. 2 had seen a case of pulmonary aspiration. 9 had seen a case of high spinal (requiring intubation)… in the preceding week!

A lot of this is due to lack of equipment – in one study in Uganda, only 23% hospitals had enough equipment to safely anaesthetise an adult, 12% enough to manage a child and 6% enough to do a C-section.

Golden rules for Anaesthesia

1. Pre-assess your patient: to optimise their condition, to make a sensible plan, explain/allay fears/concerns.
2. Know your equipment.
3. Work out what you expect to happen when:
   your anaesthetic,
   encounters your patient,
   with their surgical problem,
   and their other comorbidities
4. Do a bit of catastrophising: formulate plan B, plan C.
5. Monitor your patient: ideally HR, BP, pulse oximetry, and end tidal CO2. Worst case, make sure you are looking at and feeling the patient.
6. Remember recovery.
7. Don’t get into trouble you can’t get out of: if you think the airway will be difficult, don’t stop the patient breathing, etc.

Pulse Oximetry

Hilary then showed us a video about an exciting push to get pulse oximetry machines worldwide:

Oxygen sources and delivery

For the sick patient (who needs more oxygen or who can’t get it to their cells effectively), or for some anaesthetic techniques, oxygen is helpful. It can be difficult getting hold of O2 in the developing world for logistical reasons.

She shared a story of a patient who died due to the oxygen cylinders being full of NO2, and another of a paedriatic ward that had a 2,000 litre cylinder that they used with neonates with no pressure control, so the babies were practically being inflated by the force of gas…

Pipes:

• Lucky you!

Cylinders:

• Money – expensive
• Logistics
• Safety – have they been maintained?
• Safety – which gas?
• Safety – what pressure?
• Safety – traumatic injury?
• Duration

Concentrators:

Ketamine

Ketamine is a super drug, its a hypnotic, analgesic, amnesic. It is not a muscle relaxant. It has some weird effects, since it can lead to patients have their eyes open throughout, and causes emergence delirium (the reason we don’t use it in UK).

Other key points, some positive, some negative:

• Tend not to end up hypotensive – slight rise in BP, HR and RR.
• Patients tend to maintain their own airways.
• Probably the least dangerous anaesthetic to use.
• Can cause laryngospasm due to hypersalivation, but less commonly than thiopentone.
• Can cross the placenta, giving you a spaced out baby.

Key Ketamine Safety Points

An introduction to spinal anaesthesia.

A local anaesthetic block of all the nerve exiting the spinal cord below a particular level. Low risk – but not “no risk”.

In an adult, the spinal cord ends around L1/L2, so going in below that, you are unlikely to hit the spinal cord.

There are two types of any spinal drug. Normal, and heavy – the normal types are roughly the same weight as CSF. The heavy types are mixed with glucose, and obey gravity going low. However, due to the lumber lordosis, if you give someone a heavy drug and lay them down immediately, the agent can pool in the thoracic region – see diagram on right.

Common local anaesthetics: lidocaine, bupivacaine, tetracaine. Need to know relative baricity and appropriate doses for the drug. Exclude preservatives: since they can cause neurotoxicity.

In the West, we tend to give some opiates with the spinal, but this is not something generally done in the developing world.

Problems with Spinals:

Immediate

• Block doesn’t work.
• High spinal (cardiovascular compromise)
• Very high spinal (cardiovascular & respiratory compromise)
• Total spinal (cardiovascular, respiratory and CNS compromise)

Early

• Headache

Late

• Haematoma
• Infection
• Ongoing nerve damage

Contraindications

You need:

1. IV access and fluids
2. Some sort of vasopressor and atropine
3. Someone to monitor the patient
4. Resuscitation equipment
5. Position the patient well, and use aseptic technique
6. To look for delayed hypotension

There is a free Developing Anaesthesia Textbook available at www.developinganaesthesia.org

Surgery for the non-surgeon

John Rennie and Colin Binks shared the next talks about surgical matters. They both apologised for the dwindling capacities of their ageing neurones, but assured us that with enough prompting they would be able to recall the more important arteries, etc.

“You must take your bible, your toothbrush, your anti-malarials and the Textbook of Primary Surgery. It’s brilliant, full of pictures, and perfect for those of you who are far more comfortable cutting sausages than cranial burr holes”.

Acute abdomen

Does my patient need surgery NOW?

• Bleeding (immediately)
• Strangulated bowel (need to stabilise patient first).
• Peritonitis – perforation, pus (need to stabilise patient first).

Does my patient need surgery at some time?

• Think: what resuscitation or other treatment is needed whilst observing?
• Can I do the surgery?
• Action: Active observation/resuscitation/refer.

Does my patient definitely not need surgery?

• Respiratory problems – basal pneumonia
• Gut problems – gastroenteritis or ileus
• General illness – diabetes, viral infections, uraemia, sickle-cell crisis
• “Surgical” – cholelithiasis, pancreatitis
• Gynae – ovulation pain, salpingitis
• Nerve pain – herpes zoster

Fluid Resuscitation

• Clinical assessment: if a little dry, potentially 5% dehydration, with very shut down, sunken cheeks, 10%.
• Deficit (ml) = % dehydration x Wt (kg) x 10
• This is 7000 ml for 10% dehydration in 70 kg adult and 1000 ml in a 10 kg child.
• Use N-saline or Ringer’s lactate for deficit
• Resuscitation for fluid deficit will normally take 3-5 hours to optimise patient’s condition.
• Patients with active bleeding need surgery as soon as possible.

How to find a perforation in the developing world…

• CT scan – unavailable
• Bowel sounds – unreliable
• Rebound tenderness – unreliable
• Loss of liver dullness – a valuable, underused resource. Air in abdomen will reduce dullness on percussion.

In Uganda, there are currently 27 surgeons for 10 million people. Last year in Ethiopia, there was only one new surgical graduate in the whole country.

Differential for Acute Abdomen

How to Operate for Dummies (AKA Medics)

1. Get a nice sharp knife.
2. Cut through the midline.
3. Go through the fat.
4. Carefully cut through the rectus sheath.
5. Cut through the peritoneum, hold it aside from some clips.
6. There will be a big woosh of horrible contents, if there has been a perforation.
7. If there is bowel contents in there, use some sterile water to wash it out. If you haven’t got that, tap water is an awful lot cleaner than what is already in there.
8. Find the hole in the bowel.
9. Gentle drag the omentum over the hole, and put some big loose stitches around it.
10. Leave a drain in the abdomen, through a separate hole.
11. Using some strong nylon, take all the layers together and close in a mass closure technique. If you have no strong thread, buy some fishing line and sterilise it.
12. Put some loose sutures in the skin, closing it properly a few days later.
13. Fill them with antibiotics.

“You can do good surgery without electricity, although it is rather nice to have a lightbulb…”

Popping in a chest drain

1. Use clinical signs to ascertain which side.
2. Use some local anaesthetic all the way through – which then tells you that you are in the right place.
3. Wait several minutes
4. 5th intercostal space, mid-axillary line.
5. Go just above the rib – because the vessels hang underneath the ribs.
6. Make a small cut with a scalpel, then push through a Spencer Wells (see right).
7. You will go through skin, then fat, then pleural.
8. Open the forceps, and pop your tube through the gap.
9. There will be pus, fluid or air that comes out.
10. Put the other end of the tube under a water seal.
11. Keep the underwater seal lower than the patient.

Suprapubic catheter

1. Needs a full bladder, dull on percussion.
2. Find the point an inch or so above the pubic tubercle, in the midline.
3. Pop in lots of local anaesthetic.
4. Make a small vertical incision – just 2 inches high – but add another inch for each depth of fat in obese people.
5. Dissect down through the fat to the lineo alba – a white line down the midline.
6. Carefully slice this in half, then hold the two sides apart.
7. If there is any gut in the way, push it aside.
8. Make a very small cut, and pop a Foley Catheter through the wall of the bladder.
9. Stitch it in place.

Ascitic tap

1. Lay patient on side.
2. Measure 5 or 6 inches from the midline laterally, avoiding rectus sheath.
3. Pop it in.

Practical Sessions

After lunch, we had an afternoon of practical workshops with the team from this morning. My spinal actually worked!

Performing a spinal

We had a practice at both upright and lateral spinals on some models. Rarely, I didn’t hit spinous processes, and got loads of juice out, and popped some in! Good times…

Wound management

• Wash out the joint, especially if there is debris in the wound.
• Deal with it within 6 hours, to prevent infection.
• Use anaesthesia.
• Examine blood supply, nerves, tendons, other structures.
• Bone chips should be removed from trauma wounds.
• Tendons and nerves should be tied end to end with silk stitches, and keep the wound moist.
• Give tetanus prophylaxis.

You would often not stitch the wound after you have debrided it, since you need to allow muck to escape. Different areas of the body will have different rules: click picture on right for more details.

• Primary Suture – immediate closing
• Delayed Primary Suture – delayed closing after 3-5 days.
• Secondary Closure – often for older wounds that have began to heal themselves through granulation, and may need skin grafting.

There was also a fantastic Dentistry Basics session, which involved pulling teeth from a pig, and a Suturing Basics session. By the end of the day, I was definitely very ready for a curry. Which was lucky, since I was about to go to the East End for one.

I cycled today! 14 miles on my dad’s mountain bike. Excellent practice for a potential 26 mile cycle to Skegness on my next rotation. I decided that this exertion deserved a reward with a croissant, before the morning session began…

Caring for the carers

Mary Hopper has lived and worked in Rhodesia/Zimbabwe and South Africa for many years, and also runs a counselling and trauma workshop for those working in resource poor settings.

Elijah was afraid and ran for his life. When he came to Beersheba in Judah, he left his servant there, while he himself went a day’s journey into the wilderness.

He came to a broom bush, sat down under it and prayed that he might die. “I have had enough, Lord,” he said. “Take my life”.
1 Kings 19 

Following this, God strengthened Elijah, takes him to a quiet place, given a word of encouragement: and then gives him another difficult job to do.

The passage from Kings is a word to those who have grown wearing in well doing. Also a word to those who think that this will never happen to them. Huge list of people who have shown stress in history: Jeremiah, David, Charles Spurgeon, Martin Luther

Stress

Both acute and chronic stress have physiological effects. Its a common problem in the field of world mission. 20% have taken anti-depressants since becoming missionaries.

46% of missionaries suffer psychological problems (mainly depression) - their home organisations only knew of about 7.5%.

What can cause stress and burnout in resource poor settings?

• Frustration
• Feelings of inadequacy
• Busyness and tiredness
• Conflict within teams
• Cultural differences
• Language barriers
• Distance from local church – no fellowship
• Sad spouse, stuck at home
• Personal healthcare issues

Greenhouse effect: a plant in a greenhouse in the UK won’t grow out of control. Pop it into the Congo jungle, and it will grow out of control. Social conventions in the UK can reign back behaviours: drinking too much, driving, marriage problems. etc – without that control, it can worsen abroad.

Children especially can find returning home to the very civilised culture in the UK very difficult. No one at school will understand the freedom of running around barefoot under the sun. Studies show that children struggle with moves most, especially when they have to leave friends behind.

Single women can have problems: cultural expectations are often that must be prostitutes.

Further problems

• Questioning the meaning of life
• Loss of purpose
• Loss of hope
• Changes in beliefs
• Doubts
• Giving up faith
• Anger
• Feeling far from God

“I felt as if my life had ended; I just had to do things for other people; I couldn’t do enough for them.”

It is normal to feel low/disorientated when adjusting to a new culture. People who accept this is normal, and seek support, soon start to feel normal.

What is our theology of suffering and poverty?

When surrounded by dying and suffereing, how do you respond to “How can there be a God, if all this is happening?!”

“When working in a relief programme and witnessing a lot of death, poverty and suffering, I found my spiritual beliefs gave me a lot of comfort, and helped me “lay it all to rest” in my head.”

“Are you tired? Worn out? Burned out on religion? Come to me. Get away with me and you’ll recover your life. I’ll show you how to take a real rest. Walk with me and work with me—watch how I do it. Learn the unforced rhythms of grace. I won’t lay anything heavy or ill-fitting on you. Keep company with me and you’ll learn to live freely and lightly.”
Matthew 11:28-30

Helping yourself: Prevention

• Take a day off every week.
• The Sabbath principle
• Don’t overwork – do a Bible study on when Jesus said “no”, or didn’t meet needs”
• Do things you enjoy
• Have an attitude of gratitude

Savour the culture!

Mary has learnt far more from the people culturally in her area than she’s ever taught them. Coming home can be difficult because we have changed. She is no longer English – she is Shonglish: Shona and English. You come back, and you bring both cultures with you. One story she told us was very revealing:

“When I first went to Rhodesia, I still liked men to allow me to walk through doors first. There was one paramedic who seemed very rude – sometimes he would push me out of the way! One day, I confronted him, ‘Why are you so rude?’.

He explained, ‘In this land, I am the man, I must be first through the door. If I am first through the door, it is me who will be shot, it is me who will be blown up by the landmine.’

This rather turned my theology of manners upside down!”

Sabbath living

It is good to try to live out a Sabbath principle, even if we can’t necessarily have a set day each week.

God has called us to be a living sacrifice, so there will be times where we do have to work very hard, at the same time there are periods where he takes us behind still waters, times to get up on the mountain out of the crowds.

God has also called us to be members of a body – teamwork is an integral part of sharing a workload, jointly serving.

Managing teams across cultures

Standing barefoot in the sun for 20 minutes made me feel ready to sleep in the sun, but before that, we had Jane Bates heading up our final session for the weekend.

Cultural intelligence is a valuable skill, since our personal cultural situation so affecst the way we think, live and relate to one another. Jane shared some of the insight she has to this as a half Indian woman, raised in the UK by an English mother, and currently working in Malawi.

A simple model of different culture: our Prime Minister is the leader of our country, in Malawi, the President Joyce Banda is called the Mother of the Nation.

• How do people greet each other?
• How do people behave when they disagree with each other?
• How do people behave when they disagree with you?
• Do people publicly question/teach one another?

“A fish only discovers its need for water when it is no longer in it.”

We all have our own culture, but we may not recognise it until we are out of it.

Going beneath the surface

There are different layers of culture: “tip of the iceberg” culture is anything you can perceive with your five senses. Such as clothing, temperature, geography, smells. But its the deeper things that will affect your relationships more:

• opinions, viewpoints & attitudes
• philosophies & values
• convictions
• rules about relationships
• attitudes to time
• how the individual fits into society
• role of the family
• different role expectations
• fear of losing face
• attitudes to money & corruption

Case studies

What is your response, and what cultural issues may you need to consider?

You are part of a team of a team about to set out for a community visit and are waiting for team members to arrive. The last member of the team is over an hour late and gives no excuse on arrival.

• “Initially I found this very frustrating, but as time passed, I settled into their culture and became more late myself. Important meetings, I would tell them an hour earlier than I actually wanted them there.”

As team leader your office manager is one week overdue in submitting a report for donor funds. The donors are hassling you for the report.

• “Frustration”
• Cultural clash from donor expectation

The hospital you work at has run out of oral liquid morphine. Last week your staff went to the pharmacy to get distilled water, and you contacted the pharmacy warning them of this impending shortage.

• Frustration, understanding of problems with electricity.
• Increase your stocks – create buffers.
• Perhaps the pharmacist is not aware of pain being caused.

Overseas donors question why you have failed to extend the contacts of one of your staff members who they found ‘warm and personable’ on their recent visit.

• Everyone can have several different faces.
• Discussing problems, differences in living and working with people rather than seeing them on a visit.
• Important to have knowledge local labour laws and local contracts.

A visiting foreign doctor in the department of which you are head has one month left on his contract. He disappears and emails a week later saying that he has “decided to get some experience in accident and emergency before he leaves”.

• Considering his own advancement over his responsibilities. 
• Need to look at the contract.
• “?He is avoiding anyone losing face: if he came to me to ask for more experience, and I couldn’t provide it, then I’d be losing face”.

Your team refuse to go into the field unless you provide money a cold drink and a daily allowance.

• Assess the normal amounts and behaviour.
• Definitely provide a drink.
• Bargain 

Patient on the ward is the wife of one of your staff team. She has tested positive for HIV but only you are aware of this result.

You get back from two weeks leave to find that only two home visits have been done instead of the usual 8-10.

You are planning to do an HIV awareness campaign in a local community. Your staff workers return from their day’s visit saying they failed to do the activity as religious leaders “refused permission”.

Your staff team are regularly seeing and treating relatives of staff with general health issues regularly during time for your palliative care clinic.

Within your team, rumours have reached you (from a senior team member) that another staff member is having a sexual relationship with one of her immediate juniors. The junior staff member is about to come up for his appraisal.

Keys for managing a team:

Lead by example

Teach forward planning

Delegate

Transparent process of recruitment and selection

Train those starting work

Fixing salaraies and offering incentives

Seek opportunities for professional development

Team building get togethers

This marked the first day I arrived early enough to

Introduction to Paediatrics Abroad

The first step today was a presentation from the energetic Ian Spillman, with piles of horrific statistics. Sadly, as he said, behind the statistics are real children…

We live in a world of difference. For many families, feeding is a case of “have the rains come?”. 40% of under five deaths are neonatal. If you improve sanitation, you see ~25% improved in under 5 mortality. The most common causes of death are diarrhoea, birth asphyxiation, diarrhoea and malnutrition.

In Malawi, half of all mothers have had at least one child die.

He shared a story of a 1 week old in Uganda that had been 3.5kg at birth, and 2.5kg on presentation. They waited a week, with this child vomiting every feed. The family, both parents teachers, had been to a traditional healer, instead of seeking health care support. There is a cultural problem, complicated all our medical efforts.

One UN Millennium Development goal was to see a reduction by two thirds in child mortality between 1990 – 2015. We are currently about halfway there…

Resus key practical skills

Ian then showed us clips of a video from a APLS course. Key points:

• We saw expiratory grunts, pertussus, inspiratory stridor, don’t forget systemic causes – heart failure, acidosis, ketoacidosis.
• With a neonate, you need to dry the baby immediately.
• Umbilical vein catheterisation. Open it up with forceps, insert a pre-flushed saline catheter and tape in place. You can still access the umbilical vein up to around 7 days.
• Interosseus is inserted into the tibia around 3cm below the top of the tibia, medial to the tibial tuberocity. Ideally used for resus, allowing you to gain venus access.

Care of the Newborn

The next talk was from Hannah Blencowe, speaking on neonatology in resource poor settings.

Globally around 135 million births each year, with around 57% in  health facility. The evidence is that birth in a health facility may be safer… but this isn’t really feasible in all settings.

Whilst worldwide, the under 5 mortality rate is dropping steadily, the newborn percentage of that is fairly static: we are getting better at treating the under 5s, but not neonates.

The top 3 causes of death are preterm birth complications, neonatal infection and birth asphyxia.

The majority of neonatal deaths are at home. This is due to delay in 3 areas, only one of which is medical:

1. Delay in recognition and decision to seek care.
2. Delay in transport to care.
3. Delay in receiving quality care.

Resuscitation of babies

• 136 million – normal.
• 10 million – need rubbing and drying to stimulate breathing.
• 6 million – needs respiratory support with bag and mask ventilation.
• <1 million – need advanced neonatal support.

More hospitals in developing countries have neonatal resus equipment than staff trained in neonatal rescucitation. Training would save far more lives than buying new shiny machines.

Many neonates brought in have hypothermia to some degree – some studies in the developing world show a prevalence of 60-90%. Incubators are expensive and can cause infection – the best initial treatment is kangaroo care – baby skin on skin with mother, wrapped in a blanket. Using this for stable babies frees up resources for the more unwell children.

Early and regular breastfeeding is vital. Some hospitals have closed neonatal wards that only allow mothers in every 3 hours, and if they miss their slot, they aren’t allowed in and the baby is fed with water and glucose instead: this should not be encouraged.

Hygiene is important, especially in hospital. Many washing, clean facilities, washing the patient, etc. However, cord care is valuable also, and the recommendations are changing to cord care with chlorhexidine. Remove cannula if not needed, since can be a key focus for infection.

Ideally primary care transfers and patient self referrals to hospital need to increase. However, if this happens, most developing world hospitals will struggle to cope.

Integrated Management of Child Illness & Triage

Next up to the plate was James Bunn, teaching us about the tool of IMCI, for implementing an integrated approach in order to impact child health.

Integrated Management of Child Illness (IMCI) was started in 1997, and has 3 components :

• To improve case management skills of health workers
• Health care system improvements
• To improve  family and community practices

More than 8 million children die each year from just 5 causes. Pneumonia, Diarrhoea, Measles, Malaria, Malnutrition.

Some studies now show that healthcare workers, if using a simple clinical syndromic approach to these key conditions, can provide an equal quality of care as doctor to 50% of patients – sometimes better.

A pneumonia traffic light system:

• Normal RR – no pneumonia: simple remedies.
• Raised respiratory rate - pneumonia: give antibiotics.
• Subcostal indrawing - severe pneumonia: refer, admit, or give parenteral ABx.

(Inabilty to feed, stridor, convulsions, reduced conscious level, malnutrition are all red flag features too)

Whilst IMCI hasn’t been as successful as hoped, it has shown that there have been systemic changes in practice, which has improved outcomes. For example, the evidence showed that after training, staff were going back to their healthcare offices, and attempting to rectify lack of resources, diagnosing more successfully, and assessing better. This did reduce over time, but still clearly showed an improvement.

IMCI can reduce overall costs of treatment despite actually providing a more comprehensive care for the child.

One study in Pakistan, they made of doctors use an IMCI protocol, instead of providing individualised treatment to each patient. The doctors hated this: but they saw their survival rate from Pneumonia increase from 91% to 96%, whilst also seeing their ABx use drop from 52% to 19%!

In other words: you don’t need a stethoscope to diagnose pneumonia.

The problem with IMCI (and all good health care) is it needs frequent retraining. The courses take 11 days. Obviously, this is expensive and so needs.  icatt-training.org

Triage

Emergency Triage, Assessment and Triage (ETAT) is a process of triaging queues in clinics, to walk around and check for red flag signs regularly, bringing people to the front of the queue in order of priority. With small amounts of training, a low level healthcare worker can provide this service.

Case Studies of Paediatrics

After a practical session involving practising interosseus fluids, infant bag and mask and umbilical cannulation, we had some lunch, then returned for some intriguing case presentations from Ian Spillman. 

He took us through a number of conditions in children, that we never see in the West due to screening, folic acid in food, etc:

• Dehydration
• Imperforate Anus in Downs
• Hydrops
• Spina bifida
• Gastroshisis
• Haemorrhagic disease of the newborn
• Albinism
• Ilial performation in typhoid.
• Pott’s disease
• Cardiac Failure
• Hypothryoidism

Beware the damage from traditional healers: some things they use cause blindness, increased infections.
Neglect causes problems, with clubbed feet, neglected osteomyelitis, non healed bones.

Seminars & Case Studies

We worked through some IMCI case studies next with Mark, and then some neonatal case studies with Hannah.

Jaundiced baby – if occurs in first 24 hours of life, always pathological. Common causes haemolysis, infection – syphillis. Treat quickly with light therapy, either phototherapy with special bulb, or put near window. Also use fluids. Aiming to prevent Kernicterus.

Floppy, apnoeic baby after a 3 day labour. ?Sepsis, ?Hypoxic damage. Check hypoglycaemic, with ABx: Pen & Gent. Replace fluids, get breast feeding as soon as possible. If starts feeding, higher survival rate.

Malnutrition

After this, we had a final talk from Marko Kerac on Malnutrition. The AC was on full, and I had coffee, so there was at least a tiny chance I would stay awake…

Causes of Malnutrition

Over 50% of developing children are stunted, wasted or underweight. This causes cycles, since it leads to stunted adults, who have deficient babies, who becomes affected adults, who become… etc.

Being malnourished makes conditions worse, worsens mortality and morbidity. See the picture in the IMCI template – it underpins all the child mortality..

Zinc and Vitamin A deficiency kills nearly 1 million children worldwide. Why can’t we resolve this?

Levels and types of Malnutrition

An upper arm circumference (MUAC) of less than 11cm in a 6 month to 5 years child implies dangerously underweight.

• Marasmus: wasting malnutrition. Generally wasted, thin arms (MUAC), thin face, “old man”, ribs visible, sunken eyes, lack of skin turgor.
• Kwashiorkor: oedematous malnutrition. Bilateral pitting oedema, englarged liver, angular chelitis.

Remember the Car

The basic of therapeutic supplementation is to remember a car. If your car is stuck, you can’t just start at 60 and drive off – you need to work up the gears.

In someone chronically malnourished, all their body systems have slowed down: low stroke volume, low renal function, low gastric motility, etc. You need to start feeding them very slowly, or the car will stall, eg. the patient will become overloaded. Their appetitie will slowly return, and this is helpful: it is a good sign that their other body systems are catching up: so you can rev the engine!

Start with an inpatient stabilization, followed by outpatient therapeutic feeds, then outpatient supplementary feeds, as the car becomes able to drive itself.

Community treatment

Mum’s prefer community based approach, takes the workload away from the ward. Some places have managed to make an locally sourced peanut butter based ready to eat nutrition.

UNICEF can help provide ready to eat nutritional supplementation. The Emergency Nutrition Network is an excellent resource to use to ask questions.

It’s all very well worrying about breast feeding passing on HIV. But what’s the point in being HIV free if you are dead?

Important to breast feed babies – dying from malnourishment is not a successful outcome – HIV Free Survival, not just HIV Free.