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Group Reflections on a GEMx Family Medicine Exchange from University of Zimbabwe to University of Kwazulu-Natal

Filed under: GEMx Regional Exchanges GEMx Student Reflections

Post by Nyasha Manyeruke, Leslie Mashayahanya, and Talent Munjombi, medical students at University of Zimbabwe College of Health Sciences who completed a elective exchange at University of Kwazulu-Natal School of Nursing and Public Health (South Africa) through the GEMx-AFREHealth Regional Exchange Partnership.

 

Students selfie in Durban

INTRODUCTION

When we signed up for the GEMx Elective experience in South Africa, we hoped to experience and gain better understanding of the clinical setup in a neighbouring African country and improve our overall clinical skills in preparation for our final year of medical school. We happily report, that the experience exceeded our expectation and broadened our knowledge overally.
Under the supervised guidance of Proffessor Mergan Naidoo, we had an opportunity to rotate in different wards at the hospital, that is- High Care Unit, Out Patients Department, HIV clinic and Accident And Emergency Department. We had multiple opportunities throughout our elective to interact with Family Medicine constultants and Registrars for “one on one” tutorials as well as group tutorials. We also interacted with other members of the clinical team including interns, counsellors and nurses, who taught us and encouraged us to perform certain procedures, such as, drawing blood for investigations, inserting urinary catheters, suturing and so forth. Outside clinical activities at the hospital, we also explored Durban –visiting the beach, shopping malls, indulging in local delicacies, and interacting with fellow Zimbabweans living in South Africa, as well as the other locals we encountered in our day to day activities. We gained a greater appreciation of the multicultural and diverse society that makes up South Africa, Durban in particular, and how this correlates to patient management in the hospital setup.
In this report, we have summarized our elective experience into experiential sections and attached pictures accordingly.

Hospital Clinical Experience
1. Out-Patients Department
We each spent a week attached to the outpatients department, participating in local procedures and guidelines. In our logbooks we had clear learning objectives and subjective measures to assess our progress throughout our elective. We enjoyed ourselves thoroughly, and below in Figure 1.1, the picture illustrates Leslie clerking patients seated on the bench waiting to be served at the Out-patients Department.

MD student looking at papers

2. High Care Unit
We each spent a week attached to the high care unit. We mainly learnt ward management of patients and ward conduct as well as protocol. Besides knowledge learnt on commn ailments in our setting, such as, HIV, TB and Myorcadial infarctions, from the various ward rounds and tutorials,we also assisted the interns in performing their daily ward duties, such as, taking blood, performing lumbar punctures, inserting chest drains and so on, as well as interpreting lab results for investigations. Figure 1.2 below illustrates Talent taking blood from a newly admitted patient, with the assistance of one the nurses.

Students taking care of patient

3.HIV clinic
We each were attached to the HIV clinic for one week, and we mainly participated in patient adherence counselling, reviews, as well as initiation of patients on Antiretroviral medication. We learnt about the importance of the multi disciplinary team and we often assisted the nurses at nearby clinic( gateway clinic) in using the referral system tool effectively in ensuring patients receive the best care. Figure 1.3, is a picture showing Nyasha, standing at the entrance for Gateway clinic.
Student in front of hospital sign

4.Accident and Emergency
We each spent one week at this department. This was a very busy department, it was very interesting learning about the triage system at this hospital and the acute management of patients. We learnt about the importance of time and sharing tasks amongst members of the clinical team in order to manage patients adequately. In figure 1.4, the picture below illustrates Leslie, preparing bloods to be sent to the laboratory for investigation.

5. Other Hospital Related Activities

Talent and Leslie reviewing clinical magazines for updates on recent research findings, new additions to clinical guidelines and for Continuing Medical learning(CME) in the doctor’s tea lounge during some of our lunch breaks.

Students Reviewing Journals

Talent(female) and Leslie, standing in front of college of health sciences building for the University of Kwazulu-Natal. We visited the medical school a few times during our stay and we marveled at the architecture

Talent(female) and Leslie, standing infront of college of health sciences building for the University of Kwazulu-Natal. We visited the medical school a few times during our stay and we marvelled at the architecture

A selfie taken after our GEMx end of elective exercise and discussion with us and Professor Ross( one of the consultants at the hospital. We enjoyed our interactions with him during ward rounds and our various tutorial sessions.

A selfie taken after our GEMx end of elective exercise and discussion with us and Proffessor Ross( one of the consultants at the hospital. We enjoyed our interactions with him during ward rounds and our various tutorial sessions.

As we come to the conclusion of our elective experience, we would like to thank all the people who made this elective experience possible, we thank you for impacting our careers in our fruitful and adventure filled manner. We hope you continue your great work.

THANK YOU
Siyabonga

That was epic: my one month rotation at Universidad Iberoamericana!

Filed under: GEMx Student Reflections

Basel Magdy Abdelmohsen Abdelazeem, Ain Shams University student in front of UNIBE

Basel Magdy Abdelmohsen Abdelazeem

For those who dare to dream, the world spreads out its arms, and for those who aspire to realize their dreams, they conquer the world. This belief has made my family and I walk diverse paths to learn, compete and shine. Due to the continuous strive to chase our passions, we became a family of dreamers.

My name is Basel, Student at Ain Shams University – Faculty of Medicine, Cairo, Egypt. My nickname is Dr. Nobel because My dream is to get the Nobel Award in Medicine in the future Insha’Allah.

Abdel in front of Hospital General de la Plaza de la Salud emergency center

I’ve gone on a lot of electives worldwide, but this was a totally new different experience in the Dominican Republic. My rotation was divided in two hospitals. The first one in Hospital General de la Plaza de la Salud (HGPS) which is a teaching hospital facility and has helped more than 140,000 low-income patients with discounts and waivers of its health treatment plans. I did one week at internal medicine Department both inpatient and outpatient in addition to one week in ICU and Emergency Department.

At the second hospital,Hospital Escuela Dr. Jorge Abraham Hazoury Bahles (INDEN), one of the greatest hospitals in diabetes’ management in Latin America, I went through every aspect in diabetes management starting from the outpatient clinic by ordering basic lab & imaging and adjusting the doses of medication and Insulin up to management of diabetic retinopathy and surgical aspect of the Diabetic foot. It was really an amazing experience.

Abdel with several colleagues in a classroom

Can you imagine that you go through all medical specialties in a month while getting the opportunity to improve your Spanish at the same time?! We had morning case report, grand round, interacted with physicians and residents and finally the awesome UNIBE students  who are all so nice, humble and willing to help you as much as they can. And fortunately, they speak both English and Spanish so you Ain Sham Universcan overcome the language barrier while interacting with the patient.

 

There are seven broad benefits of my rotation there and you should consider them in your next medical rotation.

  • First, I expanded my clinical knowledge and skill set as the style of medicine you’re studying is not universal, nor are the cases you’re familiar with.
  • Second,  I must admit, I was nervous on my first day on the wards. I had no idea what to expect but the doctors made me feel like a part of the team. I found out what I’m made of and strengthened it.
  • Third I made myself more employable as an elective abroad stands out as a badge of durability, resourcefulness, and aptitude.

  • Fourth, traveling is an opportunity to see a part of the world you’ve never seen and might never otherwise consider.
  • Fifth, an elective helped me in building my personal and professional network and if you’re clever about it, you can also build an international network of professional contacts
  • Sixth, I sharpened my language and communication skills, right now I’m confident enough to take history and doing the complete physical examination in Spanish.
  • And finally, it renew my perspective on the worldwide health and I mentioned before my life goal is Nobel award and you should know a little bit about everything in each field in this world and you must know everything about your specialty.

 

Away of medicine, let’s talk about the country and culture.  The Dominican Republic is the most popular tourist destination in the Caribbean region. I traveled a lot, so I learned how to enjoy each country to the most.

Abdel with friends from UNIBE having fun at a bar
This country is awesome if you have the correct company, I mean that you should interact with the real Dominican people and hang out with them. There is an amazing beach here, the old city, jungles– I mean literally– great nature. If you like dancing and drinking we’d definitely have a lot of fun as everyone literally is dancing to Latino music everywhere.,  Don’t forget to visit the Colonial Zone and Punta Cana. And make sure that you eat Dominican food made by locals and ask them to teach you how to dance to Latino music. You will have a lot of fun if you have good communication skills and know a little bit of Spanish.

Abdel with a professor and a colleague

My last word is thank you for everyone who helped me to get this rotation, for every doctor who taught me during the last month, for every student I met there and helped me.

Thank you, Dr. Mejia, Program Manager of HGPS

Thank you, Dr. Ammar Ibrahim, Director General of INDEN

Thank you, Danny, UNIBE Coordinator

Thank you, Eunice Kamami, GEMx Student Engagement Assistant

And Big Thank you to GEMx to giving us these opportunities.

Dermatology in the US

Filed under: GEMx Student Ambassador Network GEMx Student Reflections

Post by Divya Gautam, Student Ambassador at Royal College of Surgeons in Ireland (RCSI) and University College Dublin (UCD) Malaysia Campus has completed an elective exchange at PAGNY in New York City.

Divya Gautam

The aims of this elective were to gain a better understanding of some of the rotations that I am interested in and to narrow down the field in which I hope to specialize as well as to learn how the American healthcare system functions. In medical school, we were unable to achieve a specialized exposure to Dermatology and therefore, this elective was very attractive to me as it offered the opportunity to shadow one of the most established dermatologists in the United States. As an international student in Malaysia, I have gone through most of my clinical years barely scraping the minimum requirement for patient interaction. It is an entirely different experience to be able to converse with a patient about their problems in your first language and be able to counsel a patient directly, instead of through a translator. Another major objective was to be able to work on research with PAGNY, an established organization that is responsible for publishing hundreds of quality papers. Forming contacts within the United States system is extremely vital for me to give myself a chance for furthering my career.

Divya with Dr. Bijan Safai, Dermatologist

Throughout this elective, there were some ups and downs due to the mere timing of the placement as it was around the winter holiday period. There were fluctuations in the number of patients being seen; however, I was, without a doubt able to identify some key differences in the practice of medicine in Malaysia and the USA. I was very happy with the way I was treated as a medical student. When I was rotating from clinic to clinic, I was always introduced as part of the consulting team and was asked for my medical opinion when it came to clinical decision making. Working with the physicians at PAGNY, encouraged me to continue my journey in medicine. I was on the elective with three other students, and during the research segment, we were given the option of being put on existing research or creating our own topic and literature review. We, of course, being extremely ambitious, as medical students are, chose the latter. Our research paper is a cross-cultural literature review on the substance use patterns in the countries that we are from. In my opinion, given the massive burden of substance abuse and dependence on the healthcare systems, globally, this paper can be an asset to warrant further research on intervention and public policy.

Now for some fun stuff—since I grew up in the States and a lot of my friends from boarding school ended up there, I spent a lot of time catching up with old friends and just drinking A LOT of apple cider and eating A LOT of Christmas market food. I could list about a hundred things I fell in love with while I was in Manhattan. The dollar pizzas, the museums, the brunch spots, the convenience of the subway, the musicians and street artists, the hustle and bustle of Wall Street, the fantasy lifestyle on the Upper East Side, the strolls through central park, hearing over 20 different languages on your way home from the clinic, the list goes on and on and on and on!

Divya with Anna, Justin, Maureen, (PAGNY exchange facilitator), and other students at PAGNY

I want to thank GEMx for providing me with this fantastic opportunity. It is rare to carry out an elective in the United States without having given the USMLE, and together with PAGNY, this was made possible. All of the physicians that I worked with were extremely kind and did not hold back on teaching us and guiding us through the rotation. Our research coordinator was always available in case we were having difficulties and provided us with ample resources to aide our monumental task of doing a literature review over a span of 6 weeks.

Overall, it was also a great experience, being able to live in Manhattan and experience the diverse culture of the state of New York—that too during the most wonderful time of the year!. I’m more confident in my decision to practice in the United States as I feel that I understand the structure and inner workings of their healthcare system. I’ve been able to successfully establish a good relationship with practicing physicians that have been kind enough to offer recommendations and continued contact for mentorship.

Take Hold of the Learning Opportunity

Filed under: GEMx Regional Exchanges GEMx Student Reflections

Onthatile Thusi

 

Post by Onthatile Thusi, a medical student from University of the Witwatersrand Faculty of Health Sciences [South-South] who recently completed an elective exchange at the University of Malawi.

The plane cut through the clouds to reveal the first views of Malawi from the sky. The land was patterned with areas of green and brown and scattered housing. The scene was a great contrast to the landscape of Johannesburg which is populated with housing. As the plane began to fall towards the earth the exhilaration rose in my body while the thought of stepping my feet onto to a foreign land soon became a reality.

Queen Elizabeth Central Academic Hospital found in the city of Blantyre, Malawi is the largest referral health facility in the country of Malawi and was the setting of my 4-week elective along with 4 other students from South Africa. I was in the Department of Medicine under the supervision of Dr. Mallewa.  I was placed in the male medical Ward 3b and was welcomed by the team responsible for Bay 2 which consisted of Dr. Lester, an experienced consultant, Dr. Basami a proficient intern, Dr. Pink an enthusiast registrar, and Allan Masapi a friendly and helpful final year medical student. The only directive we were given for the elective was to follow the final year students timetable and we were given the freedom to attend any of the lectures or teachings carried out by the Department of Medicine.

Onthatile Thusi with her colleagues

“You are responsible for your own learning”.

This was a statement repeated to us throughout our second year of study and it is now in this elective experience, that I have come to grasp the significance of this statement. There are numerous opportunities to learn from patients whilst in the wards. The team working in Ward-3b, Bay 2, and the members of the Department of Medicine was willing to impart their knowledge onto the students. However, it was my responsibility to take hold of the learning opportunity and initiate engagement and discussion with every source of knowledge at my disposal. Other than the scheduled final year student lectures, and the bedside teachings carried out during the ward rounds twice a week, learning was often self-directed.

My day at Queens began with student case presentations which I found very valuable. In these case presentations, I saw the theoretical knowledge acquired in medical school come to life through practice.  It is in the discussions of these cases where I learned the value of the art of medicine in a resource-limited setting. Each investigation was challenged for its relevance and utility. The principles imparted in these discussions are some that I hope to apply in my personal practice of medicine in my home country of South Africa that face a number of resource limitations with a similar HIV burden. Following case presentations, were morning ward rounds often done with the intern and joined by the student and consultant twice a week. It is in these ward rounds that I was inspired by the extremely knowledgeable intern Dr. Basami and had the privilege of seeing the art of medicine practiced with efficiency and great proficiency despite the many limitations.  Under the patient guidance of interns and final year students, I was able to carry out a number of my clinical skills and acquire new skills with the encouraging consent of the patient.  It was often that the ward round and ward work was completed before 13:00, and I would find myself with nothing to do the rest of the day. I attempted to shadow an intern in the medical admissions in the Emergency Department or searched the wards for a doctor to have discussions surrounding patient’s cases.

One of the very exciting experiences was at the Grand Ward round which took place once a week. It is in this ward round where ongoing studies at the hospital were presented. Exhilarating discussions were had on the clinical relevance of the study and conclusions were made from the study. Active conversations between departments would take place on how the challenges and recommendations brought forward by the study could be mitigated and implemented. It was exciting to hear the dynamic interactions between professionals that bring tangible change in public health and ultimately improve patient care.

Malawi home

Malawi the warm heart of Africa. The pulse of this heart is felt through the people of Malawi.  The patients I encountered were willing to engage with me and consented to my intention to learn new skills with welcoming eyes. The language was a great obstacle, as most of the patients speak Chichewa, there were very few patients that spoke English. I felt that my opportunity to gain crucial experience in clerking and presenting patients was hindered. This language barrier limited my ability to perform procedures and examinations using a patient-centered approach, as all communication was done through a third party.

The pulse of this warm heart of Africa extended outside the hospital confines. The owners and staff at Home Up guesthouses, our accommodation for the duration of the elective, welcomed our arrival with expectant and cheerful spirits. Throughout our stay, they created a friendly and cozy environment. The staff was eager to help in any regard and provided valuable information to make the most of our experience in Malawi.

The vibrant and energetic spirit of Malawi is reflected in its landscape. We had the privilege of exploring some of the great sites in Malawi. We trekked through the majestic Mount Mulanje, trudged the lush green forestry of Zomba plateau and strolled through the tranquil fields at Satemwa tea plantations.

Views from Zomba Plateau

The friendly people, the warm culture and the exposure to a number of new medical experiences made these 4 weeks greatly fruitful. Despite the delays during the application process and the challenges in securing the funding before my departure, thanks to the diligent work of Mr. Motlhabani and all involved this elective experience was made possible. Each moment has been a true privilege. I have obtained valuable exposure to a wide range of medical conditions, although ideally, I would have enjoyed the chance to rotate through the different medical wards and engage with different doctors. Similarly to South Africa, Malawi has a large HIV burden and through this elective, I learned crucial principles concerning the monitoring of HIV in a resource-limited setting. The greatest personal revelation that I have taken from my 4 weeks in the Department of Medicine, is that true learning comes with an eager and earnest attempt to acquire it. I have retained a great amount of information due to a personal growth desire to gain a greater understanding of the patients I encounter and I hope to continue to grow into an experienced and proficient doctor.

 

My GEMx Elective Added Value to My Medical Career

Filed under: GEMx Regional Exchanges GEMx Student Reflections

Stephen Odiwuor

Post by Stephen Odiwuor, a medical student at Jomo Kenyatta University of Agriculture and Technology, Kenya [MEPI]

I was born around the mid-90s as a son to John Ochieng and Janet Ochieng at home in the middle of the night, with the assistance of a traditional midwife as the only complementary and alternative medicine provider on standby at that critical hour of my birth. My name, Odiwuor, means born at midnight.  I thank God that neither my mother nor I developed perinatal and post-natal complications because had my mother experienced any obstetrics complications, there would be either no ambulance or vehicle to rush us to the nearest health facility except for an old, poorly maintained wheelbarrow that could be easily accessed from the nearest neighbor.

This meant that I had to catch up with the immunizations the vaccines that I should have received at birth, at 6 weeks, at 10 weeks and at 14 weeks later on in the course of my infancy period. In the course of my neonatal period, my mother reports that she developed breast disease, which, after literature review and medical knowledge, I concluded could be either mastitis or breast abscess. I then had to be shifted from exclusive breastfeeding to completely cow milk and that was the end of me with breastfeeding at that tender age before the recommended six months period had elapsed. My parents could not afford the infant formula milk because we were wallowing in the mud and mire of poverty.

At the Zimbabwe Medical Students’ Association annual general meeting (AGM)

In our village, I had to put up with a life that meant learning how to live with malnutrition and, occasionally acute malnutrition and severe malaria due to lack of untreated mosquito nets. My passion to pursue a bachelors in medicine and  a bachelors in surgery course is being driven by these health concerns that I had to survive right from my perinatal period, the immunizations I did not receive according to schedule, the exclusive breastfeeding that I did not get a chance to enjoy, the malnutrition I suffered among other health risks that I faced.  I, therefore, acknowledge the Education Commission for Foreign Medical Graduates (ECFMG) for their Global Educational Exchange in Medicine and the health professions (GEMx) that sponsored my electives at the University of Zimbabwe College of Health Sciences, Parirenyatwa Hospital, that would help me realize my dream of giving back to the community as a doctor by addressing the health challenges that I faced.

It was in early 2017 as I was going about my normal academic obligations at the Jomo Kenyatta University of Agriculture and Technology (JKUAT) school of medicine as a fourth-year bachelor of medicine and bachelor of surgery (MBChB) student when, a bachelor of pharmacy student, whose lecturer is Dr. Karara, the JKUAT GEMx Coordinator, sent me a link about GEMx electives. It was my first time to hear about GEMx so I did not take it with a lot of seriousness that it deserved. After a period of contemplation, I decided to give it a trial. I opened a student account on the website and requested Dr. Karara to confirm my details and accept me in the system since she is the JKUAT GEMx Coordinator which, she did. I then proceeded to start my applications for elective. I applied to Kwame Nkrumah University of Ghana, the University of KwaZulu Natal and the University of Zimbabwe. My electives would be in August and September 2018. University of Zimbabwe College of health sciences accepted my applications after uploading all the requirements for the elective on the system and submitting my applications.

At the Medical and Dental Practitioners’ Council of Zimbabwe (MDPCZ)

I arrived in Zimbabwe on 20th of August 2018 at around midday and went straight to the University of Zimbabwe College of health sciences. To my amazement, the elective department had been waiting for me. After a few minutes of engagement and introduction, I was taken to the building at which I would be hosted for the 42-day period that I would be at Parirenyatwa Hospital for my elective. The awesome reception, the transport around the city and the orientation that I received from the elective department on the first day are among the many things I cannot fail to highlight in bold when talking about my elective experience. I did my clinical elective rotation in internal medicine. Among the things I learned were: The good attitude of the consultants towards both students and patients, the awesome reception by the nursing staff, the interactive sessions we had with the junior registered medical officers, the healthy discussions we had with the final year MBChB students, the vast medical knowledge that I gained during ward rounds and enjoyed the beautiful culture of the Shona community. Generally, it was such a life-changing experience for me. Moreover, I was also able to attend the Zimbabwe Medical Students’ Association (ZiMSA) annual general meeting and Dinner and the Family medicine conference at the University of Zimbabwe College of Health Sciences, Gellfand hall.

GEMx sponsored everything during my elective period. GEMx sponsored my accommodation, my upkeep, my flights to and from Zimbabwe and all other expenses. Special thanks to Mrs. Faith Nawagi, the GEMx Africa Coordinator for the constant counsel and help that she provided for me at every stage of my application, Mrs. Chuma Vunganayi, the elective coordinator at University of Zimbabwe College of Health Sciences and Dr. Monica Karara, the GEMx JKUAT coordinator. I also want to acknowledge and appreciate Dr. Reuben W. Thuo, the Dean school of medicine (SoMED) JKUAT, for the recommendation letters and the support he accorded me towards the application for my elective attachment.

Thank you GEMx, you have added a lot of value to my medical career.

 

 

 

 

Increasing Quality and Accessibility to reach everyone, everywhere

Filed under: GEMx Regional Exchanges GEMx Student Reflections

Nyasha Dzinotyiwei

Post by Nyasha Ronald Herbert Dzinotyiwei, a student from University of Zimbabwe College of Health Sciences [MEPI] who recently completed an elective exchange at Kwame Nkrumah University of Science & Technology

Acknowledgments

I would like to thank the Global Educational Exchange in Medicine (GEMx) for providing opportunities for medical students all over the world to go on exchange programmes. I would also like to thank my school, University of Zimbabwe College of Health Sciences, for selecting me to take part in the programme. I would also like to thank the Kwame Nkrumah University of Science & Technology (KNUST) for accepting my application, as well as Ms. Charlotte Osei Boateng, Bismark Addu-Appiah (the Exchange Officer) for assisting me in settling in. I would also like to thank the medical students at KNUST for welcoming me and making me feel at home. Medase pa!

Experience in Ghana

My experience in Ghana has been awesome. For sure I had never imagined that I was going to experience what I had experienced. I love so many things about Ghana – the rich heritage, the different languages, the traditional dress (called Kente), the food, and the people. More importantly, I also noted the many similarities between Ghana and Zimbabwe.  Moving forward, I can use the different things I learned to make suggestions and improvements in my home country.

Nyasha and his friends

Elective Placement

I took up an elective placement in internal medicine that lasted 4 weeks. I was based at Komfo Anokye Teaching Hospital (KATH), which is the hospital affiliated with the KNUST (Kwame Nkrumah University of Science and Technology). I was placed in 4 different departments: Cardiology, Respiratory Medicine, Nephrology, and Neurology. Each placement in the respective subspecialties lasted 1 week. I had difficulties communicating with patients, as some of them were not comfortable speaking in English.

Nonetheless, I managed to communicate with them, and I managed to examine patients as well.

Adjusting to the hospital set up was not very difficult for me because the teaching styles employed at the hospital were identical to those I was accustomed to back home. One of the major things I learned from my stay in Ghana was the provision of the National Health Insurance Scheme (NHIS), and how it aimed at providing equity in healthcare across economic divides in Ghana. I learned about the strengths & weaknesses of the system and how best the system could be tailored to meet the needs of the population.

Nyasha standing outside of the Emergency Department

The teams I was attached to were the teams that had been on duty at the Accidents & Emergencies section. The system in Ghana differs from that in Zimbabwe. While in Zimbabwe we have firms that have admitting days, in Ghana they have duties in which firms take care of patients in the Accidents & Emergencies Department (Our equivalent of Casualty). Back home, there are about

5 firms which, despite being specialized, admit all patients sent to Internal Medicine. In Ghana, the medicine subspecialties operate independently and therefore cardiology patients only attend to Cardiology patients & consults. It reduces the workload tremendously and I believe it also improves outcomes. I also learned about a triaging system for patients who present to casualty, which divides patients into green, yellow, and red depending on the triaging score, which also estimates the severity of disease/injury.

 

Food

The most intriguing part of my stay in Ghana was the new food. I had never seen such variety in dishes! Ranging from Jollof rice, fried rice, and Waache to Fufu, Omo Tuo, red red, Banku and Kenkey, I had the opportunity to experience a different array of dishes. The food was awesome, and I loved it.

Jollof Rice

Other Experiences

I also had the opportunity to meet many other exchange students who were affiliated with KATH as well: many of whom were from Germany, Finland, Austria, and Nigeria. The experience was very nice and I got to make new friends and learn about their health systems. I also got to know how their medical experiences have been and how they differ from ours. I made friends that I hope to keep for the rest of my life.

I also had the opportunity to travel whilst in Ghana. I went to Cape Coast & Elmina, and while there I visited Cape Coast and St. Georges’ Castles. I learned more about the slave trade, and how the castles were used to detain slaves while waiting for slave merchants to arrive and collect them as they began their journey across the Atlantic Ocean. I also visited Kakum forest while there. I also went to Mole National Park, which is northern Ghana. The environment was different from the one I had already adjusted to in Kumasi. I had a nice time with the elephants J and I also visited the Ancient Mosque in Larabanga, which happens to be the oldest mosque in West Africa

Elephants in the background

Last but not least, I had the opportunity to attend the opening ceremony of the 14th International Federation of Medical Students Associations’ (IFMSA) African Regional Meeting (ARM), which was held for the first time in Ghana and in Kumasi. The 13th edition was held in Zimbabwe, so for me, it was a déjà vu experience. I had the opportunity to meet people from many countries, including my own. The theme for the 14th edition was “Rural and remote healthcare – Increasing quality and accessibility to reach everyone, everywhere”. I was inspired by the address given by the Dean of Public Health, Professor Ellis Owusu-Dabo, whose message was in accordance with WHO recommendations. He highlighted 5 main aspects: providing proper healthcare financing (for which he commended the launching of the national healthcare financing scheme in Ghana); deployment of health personnel to remote hard-to-reach places in countries; availability of essential medicines; compiling health statistics and data (incorporating health informatics), and ensuring quality service delivery

Opening ceremony of the 14th International Federation of Medical Students Associations’ (IFMSA) African Regional Meeting (ARM)

 

Ophthalmology in Mombasa City

Filed under: GEMx Regional Exchanges GEMx Student Reflections

Post by David Mutanga, a student at Mbarara University of Science and Technology [COESCA]

David Mutanga

Introduction

Lighthouse for Christ Eye Centre is located in Mombasa city. Mombasa city is the coastal city of the nation of Kenya which is in East Africa. Basically, Mombasa is known as an island. It has many historical sites such as the Fort Jesus, The big Tusks, the Swahili Arab old town, and the first restaurant in East Africa. This city is an international tourist destination.

Lighthouse for Christ Eye Centre is a modern Eye hospital in Mombasa, located in the coastal region of Kenya. It has ophthalmologists and clinical officers seeing a large volume of patients.

My reason to choose Lighthouse for Christ was that it is among the highest reputable hospitals in Kenya. It is also a good place for training because there is all the equipment’s required for eye check-up (e.g. visual field machine). There is very skilled personnel with Christ love ready to support students on their campus. As a result of all this, the number of patients seen in a day is always high.

Experience during the Elective

During my tenure time at Lighthouse, I had two days in OPD, three days at the theatre every week. Towards the end of the five weeks at the campus, I was given an opportunity to work with an outreach team which took place over 194 km away from Mombasa.

  1. OPD (Out Patient Department)

In OPD, I was working with a team of 6 staff. Amongst the six, I was with three senior ophthalmologists:  one senior OCO and others were technicians. Handling the patients at OPD, I always had someone to consult and there was someone ready to assist me as much as I needed. Because of this, I really have improved my skills in the Visual field and OCT interpretation.

David working with his colleagues.

  1. Surgery

The team in theatre apart from the surgeon is composed of a team of six technicians who are highly skilled. Throughout my time here, I did around 6 small incision cataract surgeries without close supervision and this increased my confidence in surgery.

-A one-week Phaco workshop with an international expert surgeon from U.S.A permitted me to know more about Phaco machines and it was my first time to appreciate that modern technology.

-During this elective, I did my first cryotherapy after excision to a patient with a conjunctival neoplasm.

-The one week outreach to the rural areas was a good experience for me and in fact, now that I’m coming from a rural area, I would wish that will be part of my work when I graduate.

During the one week camp, I was able to see more than 350 patients and around 68 mature cataracts were diagnosed for surgery.

  1. Weekends

Mombasa is a big city with significant recreational sites. I enjoyed the walk on the shore of the Indian Ocean and had memorable days of swimming. Commuting within the city is so easy because there are the three wheel motorcycles known as Tuktuk. You can easily move from one end to the other. Security wise, the city is well beefed up, apart from some areas where you see the streets young and old people. Though a big city, it has some parts of the city that is very clean and some very dirty.

To the South, you cross over to the mainland with a ferry. I tried it and during the peak hour, the passenger ferry boards thousands of people across. From the North, you cross by a Nyali bridge and to the west through a causeway.

David on a camel enjoying his weekend.

  1. Acknowledgments

-To GEMx and COECSA for providing funds to this Elective program.

-To the Medical Director of the Lighthouse Dr. Fredrick Korir (Senior Ophthalmologist – specialized in the Cornea), Dr. Ibrahim Matende (Pediatric Ophthalmologist) and all the staff of Lighthouse.

-To the Department of Ophthalmology Mbarara University of Science and Technology.

Growing as an Individual

Filed under: GEMx Regional Exchanges GEMx Student Reflections

Post by Rumbidzai Mupfuti, MBChB student at the University of Zimbabwe College of Health Sciences taking an elective exchange to University of Kwazulu-Natal School of Nursing and Public Health.

My name is Rumbidzai Mupfuti, I’m a 23-year-old lady, currently in my final year doing MBChB at the University of Zimbabwe. Like most people, during my 4th year, I was super excited about participating in an elective but to be honest my excitement was mostly to do with the hype of getting to leave the country and going for a tourist adventure. At my medical school, we always had elective day sometime in April and medical students would share their different destinations and their encounters. When I started my 4th year, I had all sorts of plans to go do my elective overseas because I had always dreamt of doing my elective in a first world country. Finally, it was my turn to have an amazing experience I’d always thought about.

In January of 2017, I started applying to many universities abroad and talked to my predecessors on how I could approach. I had already made all my budgets for the various destinations I hoped for and had started looking for sponsorships. With all the enthusiasm I had, sadly it was now June and still, I was far away from landing any of my dream destinations.

It was just one day, as I was strolling with a friend and she mentioned GEMx…to be honest I had just heard of it briefly, as our faculty office was encouraging people to apply but I never put it to mind since I didn’t have much knowledge about it. So my friend, Tinashe, shared a little bit more about GEMx and I remember going home that day with so many questions about, why I wanted to go for an elective and what my expectations were in relation with my future goals within the medical fraternity.

GEMx was a fairly new thing at my medical school; it had been running for a few years. However, going through the GEMx website I realized how this experience would make me grow as an individual and give me an opportunity to learn more about the health care in surrounding nations, and there was no better time than NOW!

Looking back, I’m grateful I had that conversation because it gave me a different view and bigger picture towards elective attachment. It was as if I had a whole new view…..yes my dream was to do my elective overseas but I still failed to answer the why and how it would help me as a health practitioner and my goal. I realized that I’m very passionate about Global Health particularly in Africa as a whole…. so to cut the long story short, my heart was here, home in Africa.

So given the few months that were left I pursued my GEMx application, and fortunately I was selected as part of the 3 students from my medical school. I was excited and expectant to be visiting our neighbors, South Africa in the beautiful city of Durban.

Travel

We traveled from Harare to Durban by air.  It was a fairly short journey approximately 4 hours and connected in Johannesburg. Upon our arrival in Durban, it was one of the best experiences. If I was asked to describe Durban in a few words I would say, “CULTURAL EXPLOSION!!!” A place which is multi-racial with so much energy and a warm breeze climate. We were welcomed with love, with a lovely lady, Viv who we stayed with for the whole 4 weeks in the lovely neighborhood of Wentworth. With all the love she showed us, this became a second home for us.

Rue with her friends

Hospital Experience

We were nervous about our first day of elective at Wentworth Hospital. All sorts of questions were running through our heads: where we would fit in or even adjust? I remember our first day, we got lost initially but eventually found our way and we were welcomed by our coordinator, Dr. Naidoo. He was the head of Family Medicine at the hospital and he guided us through step by step concerning our 4 weeks attachment in Family Medicine where we got to rotate through Accident and Emergency, Medical ward, Chronic and Acute OPD and the HIV clinic. We had such an amazing team at Wentworth Hospital, from the doctors, nurses, and staff. They treated us like fellow colleagues.

As I said earlier, Durban is a multiracial city and served as an educational time. It was great meeting and learning from different people’s clinical experience and the fact that despite the different backgrounds they all worked as one unit towards providing the best medical care they could give to their community. This gave me a whole different view, as I noticed that we share the same disease burden i.e HIV and its associated infections and non-communicable diseases. This made me appreciate and understand that the different disease burdens and health resource challenges we encounter in my nation go beyond our borders and the first is ours together and through interactions like these and even at a bigger scale can help stop the fight against the various disease burdens in Africa. I also noted a lot of similarities in the health protocols and the differences motivated me and gave me ideas that maybe one day would love to see being implemented back in my home country.

During our 4 week attachment, we got an opportunity to do a Quality Improvement Project on Primary prevention of chronic illnesses. I got to appreciate the importance of teamwork, as it gave us an opportunity to interact with different staff of the hospital and patients giving us insight on the importance of both health practitioners and patients in our efforts as a whole continent to improve our health in Africa as a whole. Lastly, we got an opportunity to visit a government tertiary(specialist) hospital in Durban, Albert Nkosi Hospital. It was an unforgettable experience, I appreciated how people were able to access specialist care equally regardless of different economic background. This moved me, and I thought this was a positive step towards achieving Global Health Access to Africa as a whole. I can go on and on but words can never fully describe how this experience changed my view towards health and motivation towards my career goals…Not forgetting the fun bit of Durban in conclusion, we couldn’t have missed that too

Out and About

So Durban is a tourist city with so much more to show. I can say we got a glimpse of so much great stuff there is to see in Durban…the “CULTURAL EXPLOSION” makes Durban a city full of life and love!!! We got an opportunity to tour around the city Centre and got to know a bit of history about how the city came about. Not forgetting the amazing experience at Ushaka Marine World, we got an opportunity to see one of the largest aquarium, had dolphin shows and a whole lot of activities. we also toured to Moses Madhiba Stadium were also got a glimpse of the huge stadium. We also to see a glimpse of the huge malls, the Pavilion and Gateway Malls and last but not least, because of the vast Indian Ocean, we had unlimited opportunities to swim through the warm ocean currents.

Dolphin show


Looking back, I never imagined that I would have done my attachment in South Africa but now reflecting upon my journey towards SA, I’m grateful for the opportunity I got to do my elective there. In summary, this was a priceless experience with a whole full package and I’m forever grateful for the opportunity GEMx gave us to learn and develop our leadership skills as future doctors towards the effort of building healthy communities.

Rumbidzai, Zimbabwe

My Elective Exchange at The University of Zimbabwe College of Health Sciences

Filed under: GEMx Regional Exchanges GEMx Student Reflections

Joy Kinya Kimathi

Post by Joy Kinya Kimathi, a 5th-year medical student at Jomo Kenyatta University of Agriculture and Technology in Kenya who has completed an elective exchange at the University of Zimbabwe College of Health Sciences.

I was granted an opportunity to participate in an elective program in the University of Zimbabwe at the Parirenyatwa Group of Hospitals in Zimbabwe, from the 20th of August to 30th September, 2018 by GEMx. I found this as a great opportunity to learn, a stupendous chance to mingle with new people, explore a new culture, food, and new places. It’s worth noting that Zimbabwe is a vibrant country whose occupants mainly speak Shona and Ndebele, and are amazingly hospitable.

 

Reception and Accommodation

On arrival at Zimbabwe, I was treated to a very warm reception by the University of Zimbabwe elective office. We were 2 students from Kenya at the time of my elective. Throughout my stay in Zimbabwe, I was accommodated at the Medical residence elective flat within Parirenyatwa hospital grounds. This was a very convenient spot to access the hospital, and I wish to pass my gratitude to the Accommodation office at the University of Zimbabwe for this consideration.

At the Medical and Dental Practitioners Council of Zimbabwe (MPCZ).

Academics

As a prerequisite to working in any clinical area within Zimbabwe, one needs to register with the Medical and Dental Practitioners Council of Zimbabwe (MPCZ). This was one of the first exercises that I embarked on just after settling down. The elective office was kind enough to offer transport to the Board’s premises to register with them.

Clinical Areas

Being a very adventurous person, I explored various departments within the hospital during my elective. These included: Medical Ward, Hematology Department, Urology Department, Oncology Department. I have to admit that I had an awesome learning experience within the institution. The consultants were very enthusiastic and more than ready to impart their knowledge and skills to me. Special thanks to Dr. Marejela (Consultant Physician), for his well-researched discussions crowned with a special sense of humor. Being in your ward round was something each of us looked forward to every single day.

Special thanks to Dr. Mberi (Hematologist Consultant) together with the whole Hematology team, for your dedication to teaching me. Lots of gratitude Dr. Chikore for teaching me how to administer Chemotherapy.

At the Hematology Laboratory

It was a great honor to work with Mr. Dube (Consultant Urologist). His austereness kept us on our toes bringing out the best in us. A shout out to the Oncology team for being one of the most amazing teams to ever work with. I was able to participate in cancer diagnosis, staging, planning of management, radiotherapy, brachytherapy and chemotherapy sessions. Above all the team got to include me in most of their social events making me feel at home.

The junior doctors (JrMOs) in all the departments I rotated in, occupy a special part in my heart. They were not only colleagues but also mentors and probably the greatest friends I’ll ever make within such a short period of time. They shared with me tips on how to navigate around Zimbabwe and were really great chaperones.

In a nutshell, the academic part of my elective was marked with new amazing and interesting exposures. Of special note is the fact that the whole experience sparked in me, a special interest in oncology, a field that I had never ever considered prior to my elective.

Interacting with local students ZiMSA dinner

Social

Over my stay in Zimbabwe, I got to visit many astounding places. It all began with a tour around the University of Zimbabwe main campus. The institution is located in a vast piece of land, in an exquisitely serene environment at Harare.

Some of my major highlights were: A visit to the agricultural showground, visiting the National Gallery of Zimbabwe, Grabbing lunch and dinner with the Zimbabwe Medical Students Associations (ZiMSA), and visiting the Bally Vaughn Animal Sanctuary

Challenges

Zimbabwe cash crises:

I found myself in the middle of a Zimbabwe Cash crisis right from the time I landed at the airport. The challenge was brought by the fact that I couldn’t withdraw any money from the banks due to acute cash shortage within the country. This was a very unique challenge that I had never anticipated at all. To add insult to injury, some of the swipe machines in the country were not compatible with my visa cards making it almost impossible to pay for accommodation as well as the Board fee. However, I would like to take this chance to thank the UZ elective office for being patient and resourceful in handling any new challenge that came up.

At this juncture, I would also like to pass my heartfelt gratitude to the Kenyan Embassy in Zimbabwe. They went out of their way to enable us to get Hard Cash when all our efforts had hit the wall. God bless you richly.

Photo at the Kenyan Embassy

Lesson Learnt

To any student planning to travel out of their country, make a habit of getting in touch with your embassy on the intended country of travel before leaving your country. Let your embassy advise you accordingly pertaining your travel expectations and expected challenges. This will help with your planning and cushion you from any unanticipated shock.

Conclusion

My trip was amazing. In the beginning, I faced a few strains, but I still got the best out of this elective both academically, socially, and culturally. I greatly appreciate the opportunity afforded to me by GEMx team. I wish to thank everyone who went out of their way to ensure that I had the time of my life. The GEMx initiative is a great one, and I take this opportunity to encourage more and more students to enroll and be part of it.

Orthopaedics and Traumatology at CES Universidad, Medellin, Colombia

Filed under: GEMx Student Ambassador Network GEMx Student Reflections

Post by Jack Dunne,  Student Ambassador at National University of Ireland (NUI), Galway who has completed an elective exchange at Universidad CES Escuela de Medicina.

Jack Dunne

Why Medellin, Colombia?

I wanted to explore my interests in trauma medicine. Ireland lacks trauma as a specialty, so an elective abroad offered me the only opportunity to experience it. I looked for a location that offered this practical experience but also one that offered cultural and travel opportunities. I read positive reports on Colombian hospital electives. The reports detailed a practical and intensive environment, where the standout point for students was that it had been very rewarding.

I chose Medellin simply based on the many positive touristy accounts I heard of it.

 

The Application Procedure

I Google searched Universities in Medellin and found various websites and email addresses. I came across CES Universidad and the organizer there was very prompt and helpful in her replies. I then noticed it was a GEMx University, so I made my application through the GEMx portal, rather than through the CES portal, and this saved me the cost of fees. Winning straight off the bat! Overall, the application procedure was very straightforward, I just needed the usual documents (letter of recommendation, grade transcripts etc).

View of Colombia PC: @baermannfelix

CES Universidad

CES Universidad is a small private university in Medellin, based in the leafy ‘El Poblado’ suburb. On the CES University application page on the GEMx website, you have 2 hospital options for each specialty available, CES Clinica or a General Hospital. I chose CES Clinica, just on the flip of a coin, and can only comment on that.

Streets of Colombia

I was very happy with CES Universidad. The programme was run professionally; I had an orientation before beginning and was also brought on a guided graffiti tour with other exchange students. The hospital knew I was coming was used to taking foreign students and had preassigned me to a doctor.

I initially assumed I would be placed in Clinica CES, a hospital close to the city centre of Medellin, however there all multiple ‘Clinica’s’ for medical students across the city and I ended up in a hospital called Clinica Del Norte. The hospital was actually in Bello, a suburb of Medellin. It’s a private hospital and has various different specialties and 4 theatres. It’s close to a busy commercial centre and the public metro station, Niquia.

Accommodation

Airbnb

It’s hard to judge an area you’ve never been to, halfway across the world, so I decided to figure out accommodation once I arrived, had spoken to people, and could ‘feel out’ the place. Don’t stay in a hostel if you’re doing clinical rotations (as I considered), that’s the 1st piece of advice. Colombians I asked said accommodation is advertised either on Facebook or through the grapevine. Hence, there’s only Airbnb available if you’re looking for a short-term rental. There’s tons of availability though. No tourists stay in Bello so every Airbnb was available for however long I wanted to stay. My advice would be to find accommodation for the 1st few days and then revaluate. I actually got lucky in that I had an Airbnb for 3 days, then met someone with a room to rent out and got a great deal, close to the hospital.
In Bello, Airbnb might set you back €12 a night, while finding local rent generally goes for $400,000-$500,000pesos (€115-€140) a month. Closer to Medellin city centre, however, the rent can be much higher: $600,000-$800,000pesos.

 

airbnb

Orthopaedics and Traumatology

Traumatology, in this case, was essentially an orthopaedic doctor based in the Emergency Department. In Ireland, orthopaedic doctors would be on call and required to come down to the Emergency Department. But there are so many orthopaedic cases in some hospitals, it’s far more efficient just to station an orthopaedic doctor there.

Clinica Del Norte is a private hospital for patients with good insurance, and this really dictates the patient cases that walk through the hospital doors. The vast majority of patients I saw were involved in low speed, minor trauma, motorcycle accidents. Know your bone anatomy of the upper and lower limbs as they’ll be your bread and butter for the 4 weeks. Though there were some polytrauma/major trauma cases, such as pelvic fractures and cranial fractures which I got to view/assist in. As I was based in the Emergency Department, I got to view/assist in many other cases, for example, a resuscitation case and a patient with a ventricular tachycardia. If you want to see big trauma, with gunshots and stab wounds, all the Hollywood gore of very sick patients, going to a public hospital is what you need to sign up to, according to the staff in CDN.  There is something to be said though for the less hectic, private hospital clinical rotation, especially when you don’t speak fluent Spanish.

I got a lot of practical experience from my time in CDN:

  • Doing various types of casts, splints
  • Suturing for various cuts/wounds
  • Intramuscular Injections
  • Digit ring blocks
  • Venous catheters
  • Urinary catheters
  • Taking blood from veins
  • Resuscitation procedures
  • Pelvic fracture stabilization
  • Shoulder relocation

 

The big piece of advice I’d give is don’t come over without knowing how to put on sterile gloves, wash your hands, and scrub in (your sterile techniques, essentially). I was most taken aback by the attitudes of the doctors and nurses towards medical students getting involved. I was never turned away from doing a procedure and was actively encouraged to try my hand wherever an opportunity presented itself. The staff was happy to teach the procedure and to patiently guide me through it.

Typical Day

7 am: starts and finishing at 6 pm most days, Monday to Friday. Weekends off for Orthopaedic students, not for emergency medicine students.

7 am: Reviewing the cases with students and doctors. Received teaching throughout the cases.

9 am: Go see the patients and do any of the tasks e.g. casts.

10 am: Teaching on a specific topic.

11 am: Go see patients on the wards/do any practical tasks/write up patient notes.

Lunch for an hour.

1pm-6pm: Based in the Emergency Department and seeing patients that came in/writing up notes.

CES Universidad

Orthopaedic Surgery

I expressed my interest to see orthopaedic surgery, and one of the students mentioned it to the doctor who then happily brought me along to theatre with him, making me feel very welcome. I got to scrub in, assist and close on all the operations they performed. The consultant would then struggle with his English to teach me what was happening in the surgery, which I really appreciated.

I got to see rotator cuff repairs, internal fixation of the tibia and LCA repairs.

Other Students

The Colombian students on the placement were lovely and helped me a great deal both with my medical knowledge and with my struggling Spanish.
I was also lucky in having another native English-speaking student from New Zealand there.

Colorful houses in Colombia

Spanish Requirement

CES Universidad doesn’t require a Spanish competency certificate, however, this may change after my stint there.  I would advise practicing your Spanish as soon as you make the decision to go to Colombia. It would take a high B1/B2 level in order to work competently and at least somewhat independently in the hospital.

Orthopaedics, however, is an ideal rotation for those with less Spanish ability. You need far less medical Spanish, and the nuances of a medical history aren’t as relevant.
Still, you should make a decent attempt at learning all the relevant vocabulary in order to get the most out of the elective

Things For Eager Students
Learn lots of medical Spanish and improve your all-round conversing Spanish.
How to type up a history in Spanish.

Graffiti tour

Tourist Activities

I was fairly wrecked by the time the weekends rolled around, and I imagine you will be too. Probably best not to plan your weekends down to a T, to try and cram in as much culture as 48hours allows. I’d recommend allowing time to travel before or after for a couple of weeks. I arrived in Colombia early and did my traveling in the 4 weeks before I started in the hospital. There are tons to do, and it would be disappointing to leave without thinking you made a least a decent crack at ticking off the touristy stuff.
If somehow stuck with weekends, however, Medellin has lots to offer. The nightlife is great (I got to go out with the Colombian students which was a lot of fun).
The graffiti tour I’d recommend. Taking the cable cars around the city was cool. There’s a walking tour of the city which was OK (you might as well do it, but don’t rush to tick it off). Paragliding was by far the highlight of Medellin for me. Super cheap (130,000pesos) and you get to soar in the winds on Medellin, with a panoramic view of the city.

Safety of the city

I feel tourists love to downplay the safety of Medellin, based on their own well worn, insulated paths through the city. Medellin is still a city that can be dangerous in every zone, and there are places non-locals should never go. I’ve read often that if you ‘use common sense you’ll be fine.’ However, common sense in Medellin differs vastly from common sense in a European city. For example, you shouldn’t flaunt your wealth, or take out your phone in public, regardless of the time of day. No zones are safe to walk around in late at night, so take Uber where possible. Be very cautious of your drinks on nights out, and be very skeptical of anyone showing interest in you on a night out.
All in all, I never experienced any problems or frightening experiences, and I would have no hesitations about returning or encouraging my friends to visit.
It’s highly recommended though to read up on the do’s/don’ts, the common pitfalls, and dangers, and to have backup plans if an unfortunate situation arises.

Graffiti Tour

Costs

There were no hospital/university costs for the elective, and I got a free lunch every day, so technically I was making money!
My accommodation was €165 for a month.
Food per day was maybe €15, including breakfast, the free lunch at the hospital and a nice meal in a restaurant that night.
For food, transport, and accommodation, Colombia is cheap. However, any ‘western’ goods (electronics, clothes, food brands) will be far more expensive than in Europe.

Overall

I would highly recommend doing a traumatology rotation at CES Universidad. The practical experience amongst such warm and friendly people has been so memorable. I thoroughly enjoyed my time both at the hospital and around Medellin.

Jack Dunne standing in front of the street

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