MS-IV students complete international rotation in Liberia

“Our mission at CUSOM is to train physicians to fill the health care gaps in our country, namely rural America. To do that, our graduates must learn how to function with limited resources and thus rely more on clinical skills. What better place to perfect their clinical skills than where there are no resources except those skills.” - Joseph Cacioppo, DO, Chair of the Department of Community and Global Health.

Campbell Medicine students have many incredible opportunities throughout their medical school career to train and serve in rural and underserved community settings both locally and around the world. The Campbell Medicine Department of Community and Global Health leads students on 4 to 5 international mission trips per year in addition to multiple local outreach clinics each year. They travel regularly to Guatemala, Ecuador, Jamaica, and Armenia.

Third and fourth year students also have the unique opportunity to complete a 4-week rotation in several hospitals around the world. Students have traveled to Bolivia, Ecuador, Jamaica, India, Liberia, Angola, and Nicaragua to mention a few.

We had the opportunity to talk with several students along with Dr. Joe and Mr. Doug Short, administrative director of the Department of Community and Global Health, about their personal experiences abroad and how it has impacted their medical school journey and future careers in medicine.

Autumn Bass, Claire Morley and Amelia Johnston (now fourth-year students) spent the first month of their third-year rotations at ELWA Hospital in Monrovia, Liberia in fall 2019.

Autumn Bass (MS-IV) and Amelia Johnston (MS-IV) spent a month in Monrovia, Liberia in West Africa in fall 2019 at the beginning of their third year. It was actually their very first rotation following Sim month. Liberia is about the size of Tennessee and sits on the coast of the Atlantic Ocean. It’s bordered by Sierra Leone, Guinea, and Cote d’lvoire.

Liberia is ranked 181/189 on the human development index 2018 (one of the least developed nations in the world) and is one of highest nations suffering from malnutrition. Ninetyfour percent of Liberian people live on less than $2 per day.

CAMPBELL MEDICINE: Did you select your specific location and why?

AUTUMN: Initially, we (Autumn, Amelia, and another med student - Claire Morley) were trying to go to Haiti for the month. Haiti then entered into a state of civil unrest the summer prior to us leaving, so this sent us on a “pop-corn” search across the world for a site that was willing to take 3 third-year medical students! We went from Haiti to Angola to Malawi to India to Nepal and finally to Liberia!

Long story short, Liberia fit our desire to serve in a place that was truly struggling. We all 3 wanted to be pulled from our comfort zones during this experience, and Liberia definitely was the perfect match.

Our second day was what would become a typical day at the hospital, which looked something like this:

Personally, I (Autumn) was initially very nervous to make the leap across the Atlantic. Prior to Liberia, I had served on medical missions throughout central and south America, but I was unsure if I was ”ready” to make the leap across the pond so to speak. In addition to that, I really loved working with the people and communities throughout central/south America! The healthcare need is there, and I have so much respect for the work ethic, the hospitality, and the lifestyle of the people I have treated in those nations. So, I was nervous about starting in a very new part of the world. Honestly, I found solace in the fact that the Liberian language is English! What I didn’t realize, was the dialect and difference in the sentence structure actually makes it sound completely foreign to our ears (I.E. We had translators).

**AMELIA has also been on a short-term mission trip with CUSOM to Ecuador.

ABOVE: Claire, Autumn and Amelia with Dr. Joe (chair of the Dept. of Community and Global Health at CUSOM).

CAMPBELL MEDICINE: Describe your rotation experience (from a medical student perspective and a personal perspective - although I'm sure they overlap quite a bit).

AUTUMN: Med student perspective: My literal first impression was just information overload!

Our first day in-country was actually spent settling-in from the 2 day trip (3 countries) it took to get there. We had to get phones and learn how to shop, we had to get Liberian money because the dollar was worth so much more over there, if you used it, it was hard for markets to give you change (they wouldn't have enough).

A typical day at the hospital

• We were picked up by Dr. Sacra (one of the western physicians who contracted Ebola in the 2014 outbreak, he’s lived in Liberia for close to 30 years I think, his Antibodies were used to develop the vaccine used in future Ebola outbreaks <-- kind of a rockstar) at 6:30am sharp and go to the hospital for morning chapel! All hospital personnel and patients we’re encouraged to go each morning for worship. These mornings were beautiful, the songs were all acapella and the rhythm was kept by each person clapping different but cohesive beats…it was awesome.

• At 7:00, it was time for "morning report". All residents and physicians would meet in a room and discuss the events that occurred overnight. Most nights the entire ELWA hospital was covered by a resident which is literally insane, but during these mornings we discuss certain cases that were concerning, number of deaths overnight, number of births, any concerning ED cases, etc. Morning report lasted about 1 hour.

• After this, we all broke off and went to whatever “Ward” we were assigned too: ED for 2 weeks and the Pediatric ward for 2 weeks.

• We always started with patient rounding … this is where it may help to have a phone call because the ward experience is where there was the most distinctive difference in developed vs. developing nations.

• After rounding on your wards, the rest of the day was filled with managing and treating patients, seeing new patients in the ED, adjusting medication regimens, doing ultrasounds, adjusting kids make-shift bubble CPAP device, working in the malnutrition clinic assessing kids, evaluating comatose patients, trying to find the needed equipment for patients who needed oxygen or suctioning was next to impossible, tracking down lab tests, cleaning wounds, looking at images, and then the best part of course was simply working with the patient and their incredibly scared families. Speaking with them and reassuring them. Trying to explain what is happening to try and reduce the fear was crucial. Busch-medicine, herbal medicine, or Joe-schmo from the pharmacy in the side of the road are much cheaper and are very common ways people in Liberia get ”treatment” for whatever they have. People fear hospitals and they are scared to go to them largely because of the Ebola situation.

• If we had time, around 12 or 1 we would grab a quick lunch that was prepared on-site by the hospital cooks. Normally this was rice and some type of ”soup” to put on top. Meat was few and far between, rice was the thing that filled you up, but the vegetables were amazing (casava, pumpkin greens, etc.)

• The rest of the day was filled with much of the same things, including intakes from the ED, or helping discharge families, etc.

• At around 6:00, 6:30pm the 2 other girls and I would meet up and walk home. Make dinner, do whatever homework, walk the beach out front of our house, and then go to bed!

Personal perspective: Sensory overload is the only way I can really describe it. To put it plainly, the hospital experience was incredibly taxing mentally on myself and the two girls I went with. Death is all too prevalent and common there. I worked in EMS for 6ish years, and I saw double the amount of deaths I did in the first 2 weeks in Liberia than in the 6 years in the US. People are INCREDIBLY sick, disease states are incredibly progressed by the time they come to the hospital, malnourishment is everywhere, malaria is like the common cold, sexually transmitted infectious diseases, Tuberculosis, tetanus infections, incredibly severe burns, cancer…you name it, I feel like we saw it during our time there.

It was a lot to intake and digest each day, so yes, it was incredibly tough, but also very much worth it.

I literally think about ELWA and the people who work there and the patients I was privileged to treat every single day. The girls and I, on our walk home from the hospitals, would use that time as our time to decompress and vent. It was an unspoken rule that, this is what this walk home was for until we turned the final corner of our walk, and we could see the ocean…the ocean is a very therapeutic place, so to have that at our disposal was incredibly beneficial for our state of mind.

In addition to having each other to lean on, everyone at ELWA, SIM personnel and Samaritan’s purse volunteers were all so incredibly kind to us. They were very welcoming and definitely always checked in on us, took us off compound a couple days to go get ice cream or shop or eat at a restaurant!

As the days progressed, we definitely began to settle into a rhythm a bit more, but initially it was very intense.

We also didn’t have great WIFI, so we couldn't really reach our families. The time zones were 6 hours apart, so that added to the difficulty a bit as well.

Community children at the field clinic.

AMELIA – Med student perspective: I think it's really hard for a third-year, at the beginning of their clerkships - when they've only been taught medicine in a Western setting - to go to a third-world country. It’s tough. You kind of have to set expectations aside and just go with it. Take in the cultural aspects and be open to so many different things. It was difficult, and it was very eye-opening, but it was a great experience because we didn’t know what to expect.

Because we’re from a different part of the world, [the healthcare workers] want to show us a little bit about how things are done there. At this hospital, a lot of the doctors were missionaries that were from other parts of the country. We also worked with Liberian doctors as well as people from Kenya and Wales. It was like learning medicine from everywhere, and it was really interesting. Some of them would just sit down and say, “all right, here are 10 topics that I want you to go home and look at, and then we're going to talk about them” … and that's something that would happen here [in America - during a regular rotation]. And then there are others who just kind of throw you in and see what happens!

So it was kind of similar to what you would expect on your clerkships here, except because we were the first med students there, there was a little more uncertainty. Initial thoughts like, 'what can a med student do over in a third world country?' But, I learned a lot – there are so many life-saving options we have here [in America] that they don’t have [in Liberia]. It’s really difficult to accept that when treating and caring for patients there.

The educational experience was also different. It’s more about learning what you can do for those patients at that time, and adapting, and being open to cultural diversity, and accepting. Learning to let some things go that you aren't used to. It’s a teaching hospital with residents, so we did rounds and regular patient care, etc., but it was hard. It was definitely still fun though!

Personal perspective: When I felt called to medicine, I always knew that I was called to more than just my own community, wherever I ended up. So, I wanted to start experiencing it, and that's when I did my first mission trip. I loved it, and I had this thought that I really wanted to do more long-term missions or at least serve somewhere that I would come back to continually. So, I wanted to gain experience at a longer term mission trip since it was a month long, instead of two weeks.

I went to see how I would do because it can be really emotionally heavy. I wanted to start small and grow bigger and just see where that takes me and my medical journey because I really want to do missions with whatever field I end up in. That was “my why” in the first place.

Community children at the field clinic.

CAMPBELL MEDICINE: What are a few key things you learned/took away from your trip?

AUTUMN:

• We (as humans) have WAY more similarities than we have differences.

• Verbal language is not the only way to communicate effectively.

• Regardless of our circumstances, you can always choose joy and always find things to feel blessed/ thankful.

• Never underestimate the power of prayer and miracles actually do happen.

• Never underestimate the power of adaptability.

AMELIA: Liberia is one of the poorest countries in the world, so it was in a very raw area. We had guards outside our door - but it was what we wanted to experience. We wanted to be in an area that was still safe, but where we could get something really deep from our experience by living and serving in a very [non-westernized culture].

And I think the initial expectations vs. what’s actually happening is also hard. I think people have this idea that it's a really fun experience - but there's a lot more to it, and there's a huge emotional weight to it. Even on my own trip, I had emotional up and downs: 'This is hard!' I'm not sure how people do this' - thoughts like that. I think you have to be able to adapt and accept cultural differences and for some people that's hard. I think after experiencing some of this and you still have a strong desire to do it, then you know it’s more of a right for you kind of a thing.

And I think spirituality also like plays a huge role, which isn't something we're always allowed to talk about, but if spiritually you feel called to it from your specific religion, I think that also really helps play a big part if you feel like that is the path that's laid out for you. A lot of us [from Campbell] that go on these bigger missions, [exploring a spiritual calling is] the reason why, and it really helps. And it also helps you to be able to let go of what's heavy about the trip - you have a way to vent about it - pray about it.

CAMPBELL MEDICINE: What would you say to medical students considering international rotations and/or medical outreach opportunities?

AUTUMN:

• Always ask yourself why you are considering medical missions or outreach. Always know your why or your motive behind ”the urge”. Your ”why” often can shape your experience.

• If you are interested, the most helpful thing to do is speak to someone who has either been to that country or who is familiar with medical missions. They can clarify questions, help shape your expectations, help give you fundraising tips, etc.

• Always know what vaccinations you need prior to signing up because they are expensive and there are certain timing intervals that have to be accounted for.

• Planning is everything in medical missions, but adaptability is huge.

AMELIA: You are bringing hope and faith to that community and just being there for them, respecting them, and trying to learn their culture. I think the biggest thing to take away is that along with treating and caring for patients, you’re also learning about a new culture and how things work for them and what you can do to serve them. Take the time to learn about global missions and what it's all about.

It’s not just about saving every life out there. Taking the time to be with another culture helps you when you come home to have a better sense of working with a patient that is not the same culture or religion as you, etc. I feel like that that's like the biggest thing I'd want med students to know if they want to do missions. It's totally okay for it to just be a mess sometimes. And our trip had some messy spots, but we’re happy to talk about those. I think they made a big impact and put a lot of things in perspective for us.

- SHELLEY HOBBS