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AFTER-ACTION REPORTS:
Thailand-Burma March 20-April 5 2007 Dates: (Thailand local): 20 March through 05 April, 2007 Personnel:
Mission Location: Thailand-Burma (Myanmar) border Mission Objectives: 1) Instruction of Module II of four modules of the General Medical Officer (GMO) course; 2) To begin immunization of the children of the internally displaced refugee population of the Karen nation. Background: Refugee Relief International, Inc. has been working with the Karen National Union Committee for Internally Displaced People for 17 years. Our service has encompassed everything from trauma surgery to tropical medicine to teaching. We recently committed to training a general medical practitioner for the internally displaced refugee Karen population. As the Karen are victims of ethnic cleansing by the Burmese military junta, they are stateless and have no opportunity to attend medical school. RRII has designed a 4 module course to be taught over 2 years, taking into consideration the limitations placed on the Karen by terrain, guerrilla warfare, and lack of sophisticated medicine and medical services. In late 2006, some very generous people in Silicon Valley, CA, attended a fund-raiser entitled “Shoot the Children”, in reference to RRII’s attempt to provide shots for the Karen children living in denied areas; children who were dying of communicable childhood diseases. A previous RRII team had established that a “cold chain” could be maintained to keep vaccine viable long enough to get it to the Karen homeland. Enough money was raised to begin the vaccination project. Narrative: Refugee Relief International, Inc. Team 07-1 (minus 1 pax) departed the United States on 19 March and arrived in Thailand at approximately 2345 local. Baggage count correct, the team proceeded to the hotel in Bangkok where it would locate in preparation for the mission. Time in Bangkok was spent in securing the vaccine and supplies necessary to begin the vaccination series for the Karen, and contracting for transportation. The vaccine supplier, not wanting to order the vaccine prior to the arrival of the team, required 2 day’s lead time. Team member Gieseke joined the group in Bangkok on the 3rd day. With a complete team and supplies, the team departed for the NW Thailand border town of Mae Sot.
In Mae Sot, the team rested overnight and replaced ice for the vaccine. Before dawn the next day the team departed for the Area of Operations (AO). After travel by 4WD, boat, and foot, the team reached the AO the following morning. Karen medical counterparts were met and briefed, and work was begun immediately to set up an area to administer the vaccines and an area to teach. Village elders began rounding up families with children. The students for the GMO course checked in.
Within an hour of arrival, the two parts of the RRII team were at work in their respective areas of assignment. The GMO course began with a review of the previous module, and with the help of Karen nurses and medics, the immunizations were begun. Module 2 of four of the GMO
course consisted of courses in Dermatology, Endocrinology, Urology,
the Head/Eyes/Ears/Nose &Throat (HEENT),
and the musculoskeletal system. Prior to the discussion of diagnosis
and treatment, a review of the anatomy and physiology of each system
was conducted. The students were given case scenarios and practice
patients with each block of instruction. The nearby Karen dispensary
was a source of patients to illustrate several types of problems.
The General Medical Officer training program is intended to raise the
Karen practitioners to a new level of competence, but, unfortunately,
not everyone who began the current session of training was able to successfully
complete it. Three students failed to maintain a passing average on their
tests and practical evaluations, and were returned to their duties as
medics.
RRII team members were able to keep a viable “cold chain” for the vaccine for 3 days, enough to dispense all of the vaccine brought to the AO. 512 children were vaccinated with measles, mumps and rubella (MMR) vaccine, and with diphtheria, tetanus, pertussis and hepatitis B (DTP-B). Polio vaccine was also supplied to a limited number, due to limited availability.
After finishing with the vaccinations, the shot team then assisted in the teaching of GMO Module 2. The Karen students who successfully passed the second phase were able to add new skills to their practices, and have begun using them as of this writing. When the instruction was complete for this phase, the team departed the village, reversing its path along the river and through the jungle. Karen logistics turned us over to Thai commercial transportation in Mae Sot. The team returned to Bangkok the day after leaving the field, and returned to the US after a day’s rest. Team Leader’s Comments: RRII Mission 07-1 went very well. Vaccinations were provided to 512 Karen children who have never had any. These are 512 children who will not die of communicable diseases that could have been prevented. The train-up of the Karen GMO candidates is proceeding well, thanks to the dedication of the instructors and the hard work of the students. There is still much to be done. The remaining 2 modules of the GMO course are yet to be taught, and include such topics as trauma, tropical medicine, and sanitation, as well as a course on how to instruct. There are thousands of more children who need the basic series of vaccine, as well as boosters to insure immunity. RRII continues to rely on the support of its donors, without whom we could not continue. The team humbly thanks all those who made this mission possible, and requests your continued support.
Tanzania July 4 – July 14 2006 Mission: To provide surgical services to displaced refugees of the Rwanda civil war and under-served citizens of Tanzania on the border with the People’s Democratic Republic of the Congo. A three-person Refugee Relief International medical team left San Francisco international airport on July 4, 2006. The team arrived at Kilimanjaro Airport (JRO), the evening of July 5,2006. We were met by our ground contact, Tom Lithgow, for assistance with clearing customs. After clearing customs, we were taken to the Arusha hotel. The hotel had kindly donated rooms to the relief team on both arrival and departure.($130 value times 4 rooms total). Tom Lithgow had not been able to find a medical supply house. We went to a small clinic in Arusha that had been built by Tom’s father and was now run by Dr. Arras. Dr. Arras is a Fellow of the Royal College of Surgeons and completed a surgical fellowship in cardio-thoracic surgery in Edinborough, Scotland. Dr. Arras provided us with a case of IV fluid and Cydex chemicals. These were critical to performance of the surgical mission. The following morning we loaded 400 pounds of medical supplies and surgical equipment into our charter aircraft at Arusha airport. The charter company provided the flight to us at cost, $6000 dollars round-trip for a Cessna Caravan. The aircraft landed at a dirt strip at Katavi National Park. We were met by two Land Rovers and off-loaded the team and all our equipment into these vehicles. We then drove five hours to the shore of Lake Tanganyika, to the town of Kipili. The town of Kipili has approximately 500 inhabitants living in
individual mud brick houses. It is right on the shore of Lake Tanganyika.
There is a Moravian mission and a Benedictine monastery just behind
the town. We met the local medical assistant who worked out of one section of the building. He maintains medical records on the villagers, and provides referral services to the regional hospital as well as immunization services and basic medical care. He was assisted by a nurse who lived in the village. The village has two small market stalls with an extremely limited number of items for sale. The water from the lake was tested and found to be completely safe for drinking from both a chemical and bacteriologic standpoint. Village sanitation is by open burning, and use of covered latrines. They are numerous venomous snakes, including puff adders, black mambas, spitting cobras, and king cobras. Five hundred meters beyond the village is a secure warehouse where the construction materials for the Lupita Island resort are stored. The medical supplies were secured at that location, and we then took an open boat to the island, two miles offshore. The resort is under construction and will not be finished until approximately December 2006. We moved into staff quarters with electricity, running water and flush toilets. The following morning, we went into the town of Kipili by boat. We secured out medical gear and went to the clinic. The center room had been designated for our surgery efforts. We cleaned out the dirt from the termites’ overnight activity, and set up our medical and surgical equipment on long tables for easy access. The local village chiefs had been informed several months ago about our impending visit. They selected approximately 250 people with medical problems for review. Each of the chiefs had submitted names and chief complaints. Approximately 100 of these people came the first day to be evaluated. The prior evening, the local medical assistant had received a letter from the district medical officer indicating that our activities were not permitted. The district had been contacted several weeks prior by our ground representative, informing them out of our capabilities and intentions. Because of the contents of the letter, it was clear we could not proceed until we had obtained permission from the regional Medical Officer. We secured our medical gear and returned to the island of Lupita, where the team worked on infrastructure construction, including preparing telephone lines and installation of the security system. Tom made multiple phone calls to regional Medical personnel, and ultimately secured permission for us to proceed with our surgical activities the following morning. The main concern of the regional authorities was that we would not perform general anesthesia with intubation and complex operations for which there was inadequate medical support at the village clinic level. They were reassured about our capabilities with Ketamine anesthesia as well as our extensive experience in these circumstances where operations can be performed with safety and minimal complications. With assistance from our local translator Micha, as well as anesthesia
tech/EMT team member, Katharine, and the assistance of the clinic
nurse, we began the evaluation of the patients. The vast majority
of patients consisted of primary care issues and chronic diseases.
Respectful attention was given to these patients while we attempted
to identify surgical cases among those waiting. At 1 p.m. we began preparations for surgery. The gentleman with the tumor in the buttock was initially selected. His resection was performed with valium intravenous sedation, and local anesthetic. The 7 centimeter tumor was removed, and this was consistent with a complex lipoma, with fibrous features. Blood and fluid precautions were strictly observed. We then broke down the instruments and surgical field and had all instruments cleaned and sterilized in CIDEX. Medical trash was burned in a pit behind the clinic specific for that purpose. The following morning we intended to screen additional patients, and then proceed with surgery on the five-year-old boy with foot drop. However, the previous night, the two neighboring villages were attacked by bandits armed with AK-47 rifles. When we went to the clinic the following morning, one of the villagers who had fought back had been bayoneted in the abdomen. He was at the clinic seeking assistance. The patient had an acute abdomen and an entrance wound near the solar plexus. I immediately prepared him for surgery. A regional medical doctor, Dr. Kasimba, had come to observe this day. Dr. Kasimba is one year out from his fellowship training. He works at the Karenga hospital, which is only 30 minutes away by boat. The hospital has very limited resources, but it is able to do to C-sections and simple emergency surgery, and has inpatient capabilities. Dr. Kasimba and I evaluated the patient and prepared him for exploratory laparotomy. The patient was found to have a penetrating wound into the abdomen, with a small laceration on the superior dome of the liver. There was no penetration of the hollow organs. The patient was washed out, the liver laceration oversewn, and drains placed (foley catheters for improvised drains). He was begun on an antibiotic and was then transferred to the hospital for further intravenous antibiotic therapy and drain management. We supplied him of with two days of intravenous antibiotics. Dr. Kasimba managed the patient over the next several days, and he made a complete recovery. We then proceeded to operate on the boy with the foot deformity and paralysis with a modified Bridal procedure and tendon lengthenings. We were successful in achieving a plantigrade foot he could walk on. We performed additional screening and evaluation the following day. A seven-year-old girl with a direct inguinal hernia was identified. This was surgically corrected that afternoon. A five year old boy, Juma Kulwa of Kipili, with a severe club foot was also identified , but this was our final day for surgery. He was evaluated for surgery on a follow –up mission. Pictures were taken for surgical planning and identification. Carlos Kagia, A 37-year-old man with a painful partial amputation was also identified for a surgical correction the following year. Each day we saw our previous day’s patients or received reports on their status. All patients did well with no wound complications. The villagers were very grateful and presented us with a goat. At the end of the mission, we separated our supplies into those we left pre-positioned on Lupita island in anticipation of a return visit, and to provide fundamental medical resources for the local population. I also left tropical medicine handbooks, out-patient medical treatment guides, and manuals of outpatient orthopedic and plastic surgery. REFUGEE RELIEF INTERNATIONAL MISSION 06-1 In response to a request from the Committee for Internally Displaced People, Karen National Union, a four man team consisting of David Mohler, MD, John Padgett, PA-C, Jeffrey Gieseke, RN, and Matthew Bigge, traveled to the Thai-Burma border to render medical and surgical assistance. The team departed the United States on April 13th, and reached the area of operations on April 16th. Medical and surgical assistance and medical training were conducted at two sites along the Thai-Burma border: one border village north of the Thai town of Umpang, and a new refugee encampment in the jungle next to the Salween River.
Refugee Relief International’s team arrived on the Thai-Burma border to find a group of 900 refuges setting up a camp in the jungle along the Salween River. The shelters were being constructed out of jungle materials: bamboo walls and floors, and leaves for thatched roofs. Some temporary shelters were made from plastic tarp purchased in Thailand. There was already a long bamboo building with open sides, which was functioning as a medical clinic. There a young medic, a graduate of a Refugee Relief International, Inc. course in trauma and basic medicine, was doing his best to treat refugees for malaria, dysentery, dehydration, and exhaustion.
The RRII team identified three surgical candidates in the village near Umpang, and did one hernia repair two cleft lip repairs on children there. Medical problems such as malaria, malnutrition and dysentery were addressed. One patient had been experiencing back pains since escaping from a Burmese Army forced labor gang, where he was made to carry heavy loads on his back up and down mountainous trails. In addition to medical and surgical cases, the RRII team distributed medical supplies to the village nurse at Freedom Clinic #5, and gave instruction in the use of medications supplied by RRII to the clinic. Karen National Liberation Army medics were at the village clinic, and were given combat aid kits, battle dressings, intravenous fluids and other lifesaving materials to enable them to stabilize the wounded in their operational areas inside Burma.
After two days near Umpang, the team moved north to Camp #1, the new camp for the 900 newly created refugees. Access to the camp was gained by an hour by 4WD from the nearest town, then 2 hours by boat, and then a 30 minute walk up a stream to the new camp, set in the jungled mountains. The team brought a great deal of medication, especially IV fluids and ant-dairrheals, as we had been told by our Karen counterparts that dysentery and diarrhea were rampant. Having experience with the Karen, we also knew that 100% of the Karen population in the jungle has malaria (usually P. falciparum), and brought anti-malarials and fever reducers. To address the dehydration and malnutrition certain to be present in refugees who had trekked through the mountains and jungle, rehydration salts and vitamins were included. The Karen Committee for Internally Displaced People (CIDP) had been busy in helping their people set up the camp. Already there were huts hewn out of the jungle, with bamboo and thatch being the building materials. Some plastic tarp was brought in from the nearest Thai town for temporary shelter from the rain, until families could complete their dwellings. The CIDP’s medical representative, Saw Diamond, had already addressed sanitary needs in the camp by supervising the digging of latrines and shipping some Turkish toilets and concrete in to seal them. A small jungle dispensary had already been set up to care for the sick and injured. This was staffed by a graduate of the training conducted by a Refugee Relief International, Inc. team during RRII mission 05-1 (see the report of mission 05-1 on the web site). Medical problems encountered included diarrheal disease and dysentery, malaria, malnutrition and vitamin deficiency, dehydration, parasites, upper respiratory infections, pneumonia, problems associated with pregnancy, filariasis, heart failure, obstructive pulmonary disease, and asthma. The team worked with the Karen medic to address these problems, using the opportunity to do some teaching, and the medications were put to good use. Surgical problems included previous injuries from land mines, burns, and bullets, and hernias of different types: inguinal and umbilical. Dr. Mohler, assisted by the team, performed field surgery on a child with a large umbilical hernia, with good results. The RRII team identified several areas of need, as well as opportunities, and in which future projects and future funding, are essential. They are:
Refuge Relief International, Inc. will work with other organizations and private individuals to attempt to secure funding for a vaccination program for the Karen, and will work with the CIDP medical representatives to implement same. The initial plan is to secure vaccine for common childhood and adult illnesses, as well as cold containers and dry ice, in Bangkok from a medical supply company with whom RRII has an established relationship. The CIDP would identify sites and patients. RRII team members and Karen medical will administer the vaccine and provide records. RRII will contact other agencies to alert them of the need for urgent food relief at Camp One. It is vital that relief agencies in the area with the capability and motivation to help this refugee population come together at this time of urgent need. Financial accounting for this mission will be accomplished by the Team Leader under separate cover. Respectfully Submitted, John E. Padgett, PA-C, Ph.D. REFUGEE RELIEF INTERNATIONAL MISSION 05-01 Background The Karen are an ethnic minority group that has resided in the mountains of western Burma (now called Myanmar by the current regime in Rangoon). A predominantly Christian group, they have been historically persecuted by the Burmese majority, and the military government in Rangoon has waged genocide against them since the British withdrawal in 1947. The Karen resist as best they can, with no outside support. The Refugee Relief International team’s mission was to give refresher training to the medics who are responsible for the great majority of medical care in areas that the Karen occupy.
P.A. Padgett taught medical subjects, while Dr. Padgett conducted a review of trauma management and wound care. Dr. Elliott gave a course in field dentistry and did some dental procedures on patients at Dr. Cynthia Muang’s border hospital. Matthew Padgett assisted as an assistant instructor, dental assistant and logistical coordinator. Medical Training for the Backpack Medics The team paid a courtesy call on Dr. Cynthia Muang, director of the border hospital which treats sick and injured Karen and other ethnic Burmese minorities who can make it to Thailand for treatment. Dr. Muang’s hospital has been the recipient of international recognition for the free care provided to her people. RRII has provided assistance to the hospital in the past, having trained some of its clinicians, and has provided patient care, supplies and equipment to the hospital. The following is a review of the curriculum taught during the refresher course:
In addition to the medicine and equipment mentioned above, upon successful completion of the course each medic was given a new backpack stocked with first aid items to take back to the field. Throughout the training, the medics were attentive, respectful and cooperative. They did not hesitate to participate in practical application of I.V. and suturing skills, and asked pertinent, thoughtful questions of their instructors. To assess student comprehension of the material, questions were asked of the students following blocks of instruction, and they were able to demonstrate competence in the subject matter. Out-Briefing The concept that they wish to develop is one of initial training, followed by an increased levels of competence over a year, and finally a ‘train the trainer’ course, which would enable senior Karen medics to take the training program to their own people in areas under Karen control. The idea envisions four training sessions of approximately 2 weeks in length, with increasing levels of subject matter and competence, culminating in the trainer block. P.A. Chan-Padgett is working on a course curriculum for the requested course to present to the CIDP and the RRII Board of Directors for approval. Following a successful mission, the team returned to the United States on 27 February, 2005. Respectfully submitted, John E. Padgett, PA-C, Ph.D.
Refugee Relief International, Inc.
2995 Woodside Road #400-244 Woodside, CA 94062 email: info@refugeerelief.org |
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The training team consisted of team leader Dr. John Padgett, PA-C, Ph.D.,
a physician assistant and clinical professor with combat experience with
US Special Operations Forces in Viet Nam and Iraq; P.A. Vicki Chan-Padgett,
MPAS, a medical school Program Director and former director of the US Air
Force PA Program; Dr. John Elliott, D.D.S., an Iraq combat veteran and dental
surgeon; and Matthew Padgett, medical student and public health volunteer.
After link-up in Mae Sot, Thailand, with representatives of the Karen CIDP,
the RRII team was transported to its quarters and from there to the training
site near the Thai-Burma border. The 21 mixed male and female students had
previously arrived from their dispensaries and health posts in areas occupied
by the Karen.
To compliment the training, familiarize the students with the medications
available locally, and to assist the medics with obtaining medicine for their
patients, several types of medications were provided by Refugee Relief International,
Inc. These included diuretics, adult and pediatric vitamins, antibiotics,
anti-diarrheals, local anesthetics, analgesics, anti-inflammatories, anti-malarials,
and I.V. solutions. RRII also provided a considerable amount of dressing
material, needles and syringes, I.V. lines, dental material, suture, suture
sets, and other instruments.