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11 Articles in Volume 13, Issue #8
Ask the Expert: Intranasal Ketamine for Migraine Therapy
Assessment and Treatment of Neuropathic Pain
Diabetes & PAD: Diagnosis, Prevention, and Treatment Paradigms
Editor's Memo: Chronic Low Back Pain: Bringing Back A Forgotten Treatment
Evaluation and Treatment of Chemo- or Radiation-Induced Painful Complications
Guide to Implantable Devices for Intrathecal Therapy
Is Buprenorphine a ‘Partial Agonist’? Preclinical and Clinical Evidence
Letters to the Editor: Hormones and Genetic Testing
Pain Management in Kenya: A Team Experience
PROP versus PROMPT: FDA Speaks
Use of Ultrasound in Detection Of Rotator Cuff Tears

Pain Management in Kenya: A Team Experience

Pain management can be challenging under any circumstances, but imagine the challenges facing clinicians at an orphanage in Africa. This article describes the experience of a team of Canadian health care professionals, and the lessons they learned.

A team of Canadian health care professionals travelled to Kenya to volunteer at a remote facility. This article describes the challenges in providing pain management services at the medical clinic in an established Kenyan orphanage (Mully Children’s Family Charitable Foundation) during the summer of 2013. Such experiences contrast the differences in health care needs and resources between North America and Africa, and also highlight the opportunities for pain physicians to broaden their understanding and expertise in this field.

The Orphanage

Mully Children’s Family (MCF) is a charitable Christian orphanage founded by Dr. Charles Mulli in Eldoret, Kenya. Since 1989, MCF has rescued street kids, orphans (including those with HIV), and single teenage mothers and their children. In that time, more than 6,000 children have been rescued and rehabilitated. Services provided for these children include food, shelter, education, and support—much of this dependent on charitable donations. Free medical services also are provided for adults and children in local neighboring communities.

On June 28, 2013, the authors were part of a team of 34 volunteers (33 Canadian and 1 American) who worked at MCF Ndalani, 2.5 hours east of Nairobi, for 2 weeks. The team included 21 adults—including two physicians, one dentist, one physical therapist/nutritionist, one pharmacist, four information technology experts, three mothers who helped in triage, and 13 children and young adults—several of whom were high school/university or pre-med students. After an 18-hour flight, our first few days involved orientation and touring of the extensive facilities, which includes a farm in Yatta as well as school classrooms and a baby orphanage. During this time, our team adjusted to the local climate and diet.

Over the subsequent 10 clinical days, we saw 2,510 patients. The breakdown of patients seen is summarized in Table 1. It took villagers anywhere from 30 minutes to 4.5 hours to walk to the clinic. Some patients traveled by motorcycle for up to 3 hours to reach the clinic.

Diseases and Conditions Treated

The majority of pain complaints (80%) were caused by chronic infectious diseases including typhoid, malaria, brucellosis, amebiasis, and giardiasis. Typhoid patients typically described gastrointestinal pain, including lower abdominal bloating, early satiety, and chronic constipation. Malaria patients classically described headaches and joint pains accompanied by intermittent fever and chills as well as night sweats. Brucellosis patients described severe back pain with widespread aches and pains and/or numbness. A simple algorithm was used:

  • fever + headache, think malaria (treat with artemether-lumefantrine or quinine)
  • fever + irritable bowel symptoms, think typhoid (treat with norfloxacin)
  • fever + fibromyalgia symptoms, think brucellosis (treat with doxy-cycline or trimethoprim and sulfamethoxazole)

Approximately 20% of patients presented only with localized pain due to repetitive strain. These injuries included plantar fasciitis and knee osteoarthritis (Figures 1 and 2) from prolonged weight-bearing, head-neck pain from patients carrying heavy firewood on their shoulders, and vertebral subluxations that responded to manipulation therapy by Linda Finn, PT, ND (Figure 3).

A few patients (1%) had neuropathic pain resulting from post-traumatic amputations (Figure 4) or burn injuries and classic findings of brush allodynia. It was difficult to administer the Douleur Neuropathique 4 (DN4) questionnaire due to translation problems.

A number of patients (1%) presented with acute traumatic pain (occurring within 2 weeks of presentation) resulting from fractures or sports injuries (Figure 5). One of these cases involved a teenager with knee effusion from a karate injury, in whom 50 mL of serous fluid was aspirated twice.

Spastic diplegia was seen in a 2-year-old patient with probable birth trauma and cerebral palsy (Figure 6). This patient was injected with incobotulinum toxin A to reduce the equinovarus deformity of the feet. This injection also was administered to an adult with cervical dystonia.

Comorbidities included uncontrolled hypertension in 10% to 20% of patients, with the highest recorded blood pressure being 250/110 mmHg. Some patients also had diabetes as confirmed using glucometer testing. Three patients who presented with abdominal pain were unaware that they were at least 7 months pregnant.

Procedures Performed

Medical procedures performed by our team included pelvic exams for vaginosis and pelvic inflammatory disease, prostate exams for painful urination, catheterization for urinary retention, and silver nitrate application for epistaxis in a child. In addition, 2 children required extraction of painful foreign bodies (eg, corn) in the nose, one of which was difficult even with administration of intravenous diazepam sedation. A simple suggestion to sniff black pepper was the solution and the child sneezed out the corn. Another case involving a deep intra-aural foreign body had to be sent to a Nairobi hospital for intervention.

One emergent older female was brought in unconscious, but with intact vitals. A positive sign of conversion disorder was noted (hand lifted up over her face would not strike her face when released). She later regained consciousness and improved after given dextrose 10% in water orally via syringe, suggesting that she was possibly hypoglycemic and/or prediabetic.

Several cases of advanced cancer were seen, including inflammatory breast carcinoma that rendered the affected breast twice the size of the nonaffected breast, and squamous cell cancer of the scalp with a lump measuring 4 inches. Another patient had marked scrotal swelling the size of a grapefruit that did not transilluminate (probable elephantiasis). Surgery at the hospital was recommended but declined by this patient.

All patients were pleasant, respectful, and grateful to be seen. No patients had any complaints or grievances against the staff for having had to wait in the triage holding area for several hours. As a courtesy, MCF provided free lunch for all patients and their children. Triage also tried to first attend to those patients who had walked 3 to 4 hours so they could get back home safely before dusk.

Recommendations For Improving Pain Care In Rural Kenya

All patient intake forms were handwritten with the use of translators helping the triage team. The first clinical day was hectic as there was a learning process involved in understanding key tropical disease presentations. In the future, clinics that incorporate computerization of medical records would benefit from tracking previous prescriptions and response to prescriptions as well as comorbid conditions. One patient with early sepsis complicating chronic dialysis was treated with intravenous ceftriaxone, but was not able to afford the cost of travel needed for the recommended 3 dialyses per week. This history became apparent later after discussion with local staff.

Another drawback was limited laboratory testing resources. If every patient with equivocal symptoms was tested, as was done in the first few days, then the clinic would run late into the evening hours. For example, a brucellosis or typhoid test would take 45 minutes to get results. Expanded laboratory resources to aid in diagnoses and appropriate antibiotic prescriptions would be more helpful than “best guesswork” diagnoses. Laboratory testing feedback also helped our clinicians further refine their clinical diagnostic skills.

Annie Ngan, BScPhm, was able to liaise with Health Partners International to purchase medications at a lower cost for the villagers and also liaise with local pharmacies in the purchase of more medications when they ran out. A detailed inventory recording medication requirements, including pain medications, would help future teams prepare for this type of clinic. In our experience, we ran out of duloxetine (Cymbalta) for neuropathic pain (amitriptyline was well-stocked) and celecoxib (Celebrex) for rheumatoid arthritis (naproxen was well-stocked). In addition, antibiotic and anti-parasitic drugs were exhausted rapidly, including limited supplies of praziquantel for schistosomiasis. With cross-border restrictions, use of opioid and cannabinoid pain medications was not feasible.

Willa Chu, DDS, spearheaded the mission to get medical supply donations from organizations such as the Henry Schein Cares Foundation. With her dental team, Dr. Chu managed 233 patients and performed several difficult extraction cases, often working into the late hours (Figure 7). Thermometers and batteries were in high demand. After seeing hundreds of patients, there was a breakdown in equipment. Support in medical equipment provision and maintenance is therefore critical. Douglas Harvey, our dental equipment technician, helped repair medical equipment and, along with Jim Finn, was able to select appropriate electrical adaptors for use of the otoscope/ophthalmoscope (after one was blown when inserted into an outlet).

A final recommendation is to train support staff and students in helping out with the streamlined care of patients. A flow chart was developed by the third day that helped prepare for the busiest clinic day (typically Fridays) when 348 medical patients were seen in a 9-hour period. At one point, five pre-med students were seeing patients using the flow chart approach, taking histories and in select cases ordering laboratory tests. Supervising physicians then carried out the final diagnoses, confirmatory physical examinations (when needed), and medication prescribing.

Learning Points

This type of medical care does carry risks. One member of the team experienced a needle-stick injury from a patient with confirmed HIV. HIV prophylaxis travel kits were available and treatment was initiated within the necessary 72-hour period. Avoidance of needle-stick injuries requires strict adherence to safety protocols and not rushing the treatment of any patient. For example, it is important to take time in palpation, proper positioning, and lighting and to ensure patient compliance. If the patient is too anxious or fearful (which was seen with 3 patients), do not inject! Also, capping of needles should be done with a hemostat with proper disposal in a sharps container. More superficial injections were done using the donated 1-inch safety capped needles.

Preparation for work in such areas also requires prophylaxis against infectious disease. Besides immunization requirements (including against yellow fever), our team took medications to minimize the risk of malaria (such as atovaquone [Mepron] and atovaquone and proguanil HCl [Malarone]) beginning 3 days prior to trip, daily during the trip, and 3 to 5 days after the trip. It was also necessary to avoid drinking tap water and eating any uncooked fruits or vegetables in endemic areas to prevent the risk of typhoid or travelers’ diarrhea. Gowning/gloving up was necessary—particularly when treating patients in areas at high risk for tuberculosis and HIV. We ran out of gowns, gloves, and masks towards the end of the trip. We often did not use N95 masks as they were too uncomfortable in the hot crowded rooms, which did not have air conditioning.

Longer-term care ultimately requires more than patchwork type medicine. Education is still a key part of pain management and should include information on medication use, appropriate post-treatment exercise, and lifestyle modification. For example, an acute inflamed knee effusion requires rest (unlike the patient who went right back to activity and required a repeat aspiration the next day). Exercise to correct postural imbalances requires time and teaching. Likewise education to prevent communicable and infectious disease is key for long-term pain relief.

Copies of medical licenses or Doctor of Medicine degrees are usually required. Clinic preparation, such as reviewing notes on tropical medicine, also would qualify as a personal learning project for accreditation/re-certification purposes. This could include downloading and studying information on the most common diseases in the target area. Updated certification in cardiopulmonary resuscitation and/or advanced cardiovascular life support also would be appropriate.

These key learning points also apply to practice in North America, particularly with immigrant populations, homeless people, and street youth seen in our larger urban centers.

Summary

For pain management specialists who would like to expand their knowledge base and enhance their overall medical practice skills, consider doing a 2-week or longer medical mission trip in a country such as Kenya. From the post-missions debriefing, it was noted that all of the team (Figure 8), including the children and young adults, reported having a broader experience and perspective of healthcare in the world. The Kenyan children and their caregivers/teachers at the orphanage were truly an inspiration in their courage, courtesy, and commitment toward education for a better society.

For more information, contact www.MCFCF.org or Randy Chinn at randy@foglightsearch.com. For medical information, please visit Dr. Ko’s websites at www.DrKoPRP.com (videos and articles) and www.drkobig5.com (The Big 5 handbook to help chronic pain patients).

Last updated on: July 26, 2019
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