Temple Now

Story by Renee Cree, SMC´12

Photography by Alvin Wang

Ariel Marks, a second-year medical student, consults a woman with a large bruise on her leg as a third-year student looks on. The woman could be a grandmother, or una abuela: In her mid-to late 50s, she is petite, with long, grayish-black hair and a warm smile. At Temple University Hospital (TUH), a patient with bruising can often be treated easily and will leave on the road to recovery. But the scene is not unfolding inside a building on North Broad Street—it takes place in a tent, in the middle of a Nicaraguan jungle, in front of an abandoned community center with a dirt floor and no plumbing. Marks is one of a group of Temple medical students deployed to this shantytown outside Nicaragua´s capital, Managua, as a part of the Temple Emergency Action Corps (TEAC). Since 2007, TEAC has traveled to various Central and South American countries to provide medical care to those affected by natural disasters.

Marks and his classmate run several tests on the woman and, after consulting with an attending physician, determine that the cause of her bruising is diabetes. When the abuela learns her diagnosis, she bursts into tears. The disease has killed her husband already. She knows there is a real possibility it will kill her, too.

Six months later and 3,700 miles away, Marks sits in Temple´s gleaming Medical School building, where local residents with diabetes—or those at risk of getting the disease—can receive free nutritional counseling, education, and blood pressure and blood- glucose tests. Marks reflects on his time with the abuela. He looks down and laughs briefly, sadly.

"We tried to explain to her that she could control the disease easily, that she could go to a nearby clinic to see a doctor," he says. "But patients can wait for days at those clinics, and they are often out of whatever medication is needed. She wasn´t present in the moment anymore; she was consumed with the image of her husband in his last months.

"Thankfully, our health system is good enough here that diabetes is something that can be managed," he adds. "But there, it´s scary." He pauses and shakes his head, as though he cannot believe such a situation exists in the 21st century. When he speaks again, his voice is soft. "In the end," he says, "she went home with the knowledge that what happened to her husband would happen to her."

It can be difficult for medical students—especially those in their first or second years with little to no clinical experience—to see people suffer to such a degree from something as easily manageable as diabetes. Marks says he felt overwhelmed by this woman´s situation. But he also says he and his fellow students are buoyed by such encounters. They are helping others and learning all they can in the process.

STUDENTS WITHOUT BORDERS

The idea of a student-run disaster-relief program came about in 2005, in response to Hurricane Katrina. Zoe Maher, MED ´08, then a Temple medical student, watched on television as the storm and flood waters pummeled the New Orleans neighborhood where she had once been a public-school teacher.

That fall, Maher was able to secure initial funding from the Temple University School of Medicine Alumni Association and the Arnold P. Gold Foundation to lead 10 medical students and two doctors on two trips to New Orleans. Maher and her team provided basic medical care and general manpower to residents in the hardest-hit areas of the city.

"The goal of our trips to New Orleans was certainly to help the people in Louisiana," says Maher, now a resident at Temple University Hospital, "but also to eventually help people in other parts of the country and the world." Temple Emergency Action Corps officially launched the following year, and thanks to a grant from the Greenfield Foundation—of which William Greenfield, MED ´69, ´74, is director, and his daugher, Jill Feldman, FOX ´91, is manager—the program was able to expand its efforts outside the U.S. through an annual service-learning trip that takes place during spring break. Thus far, the group has traveled to Bolivia, El Salvador, Panama and Nicaragua.

"About two months before spring break, the group meets to determine a site where it will be most useful," says Manish Garg, associate professor of clinical emergency medicine, associate residency program director at the School of Medicine and TEAC faculty advisor.

"They work to find a contact there—usually with governmental or church groups—to help with the logistics of getting to the site."

As Marks explains, TEAC chose Nicaragua in 2012 because the country is prone to seasonal flooding, which has intensified over the past few years because of extreme weather patterns. And after Haiti, it is the second-poorest nation in the Americas. According to the World Bank, approximately 63 percent of the rural population lives below the poverty line, and close to 20 percent suffers from undernourishment—the highest percentage of the condition in Central America.1 Further, only about 37 percent of the rural population has access to adequate sanitation,2 which can lead to a host of health problems including rashes, parasites, infection and fever.

So rather than grappling with a specific disaster, the country is mired in an ongoing one. The students wanted to help. Over the course of its trip, TEAC treated more than 500 people for conditions ranging from infection to scarlet fever to heart disease to diabetes.

MACGYVER, MD

All medical students are eligible to participate in the service-learning trips, but they must first complete an elective course called TEAC I, during which they are trained in emergency medicine and disaster preparation. Throughout the semester, students participate in workshops to learn skills such as splinting, casting, intubating, inserting IVs and dressing wounds. They also run through ethical role-playing exercises, such as what to do during a mass casualty.

"You get experiences and learn skills through TEAC that you wouldn´t get in a lecture or from a book," says Marks, coordinator of the TEAC Ielective. "It´s a great thing—especially in your first two years of medical school—to learn how to practice medicine in a real-world setting."

Perhaps it gets no more realistic than seeing patients who lack basic healthcare offerings. Faculty advisor Garg recalls an instance during the 2010 trip to El Salvador: The group encountered a young girl who was so badly bowlegged, she could no longer walk. The team was able to craft a brace for her using only Ace bandages and medical tape. The effect was instant—she could walk again.

Also in El Salvador, a boy came to the clinic with a fused frenulum—the strip of skin underneath the tongue that attaches it to the lower jaw. The condition impeded his ability to speak; he could only say "mama" and "papa," and he was falling behind in school. Once Garg snipped the skin, the boy was able to talk again, saying words his parents had never heard him say before."I know it sounds a little grand to say that TEAC can help people walk and talk again," Garg says with a smile. "But in those cases, we did."

READY, GO

Prior to graduating in 2008, Maher led TEAC to Bolivia, where "the first- and second-year students bonded with their older peers and got a powerful hands-on learning experience," she says. "Traveling to areas of disaster allows you to see patients as complete people and to recognize how the challenges people face outside their doctors´ offices can affect their healthcare."

A world away, Katie Guevel has experienced a similar feeling during her visits to Philadelphia´s homeless shelters as part of TEACH, the domestic arm of TEAC (read more). "There are so many things patients have to worry about: ´How am I going to get to my appointment if I don´t have a car? How will I afford my medication?´" she explains. "Meanwhile, all the doctor sees is an empty time slot. It´s important to make the effort to see things from the patient´s perspective."

Whether at home or abroad, Garg says that TEAC offers students the opportunity to think on their feet—which leads them to become better doctors. "It´s important for them to be ready for anything, anytime," he says. "You see it in former paramedics—the ones who have gone through broken floorboards to get to a patient or have put in IVs while in a cramped space, standing on one foot. They are often the best doctors. They know where a patient came from; they know a patient´s whole story.

"I think the new breed of medical resident isn´t satisfied with only practicing in a hospital," he continues. "They want to take that knowledge and apply it to the wider world. The human condition is the same no matter where you go. If you can communicate effectively with your patients, it makes a huge difference in their lives."

(Listen to a news report on the El Salvador trip from WRTI, Temple's NPR affiliate.)

1 Food and Agriculture Organization of the United Nations. "Food Security Indicators 2011—Nicaragua." 2011.

fao.org/fileadmin/templates/ess/documents/food_security_statistics/monitoring_progress_by_country_2003-2005/Nicaragua_e.pdf.

2 UNICEF. "At a Glance—Nicaragua." unicef.org/infobycountry/nicaragua_statistics.html.