Diabetes Program Underway To Prevent Threats to Life

With more than 30 percent of adults in the Line Islands of Kiribati suffering with Type 2 Diabetes and its life-threatening effects, Pacific Islands Medical Aid is undertaking its largest program yet.

Under the leadership of Diabetes Team leader and endocrinologist Dr. Elizabeth Beale from the University of Southern California, we are making regular visits to Christmas Island (Kiritimati) to treat the disease, hire and train local aides to assess issues before they become life threatening, in concert with the Kiribati Ministry of Health and it’s medical officer, Dr. Teraira Bangao.

Under the program, we have now hired two nurse’s aides to work throughout the island exclusively to monitor and assess diabetes patients.

Our great volunteer podiatric physician and surgeon, Dr. Julie Chatigny, chief executive officer and president of Central Coast Foot and Ankle Specialists in Templeton, California, has just returned from Christmas Island on this, her third trip there, to begin training the newly-hired aides and advance educational awareness.

– Here is her report –

By Dr. Julie Chatigny, DPM, AACFA

Kiritimati Island
January, 2019

It’s the beginning of something bigger…

On this third trip to Kiritimati, I was able to meet and train two new Diabetes Community Workers (DCW) to perform diabetic foot examinations with the intent to decrease limb and life-threatening foot wounds and prevent amputations.

Thanks to Carlton Smith, president of Pacific Islands Medical Aid, the amazing doctors and researchers at USC, the Kiribati Ministries of Health, the doctors and staff on Kiritimati island, and the philanthropic donation from Mr. Atul Dhubalia, the Diabetic Foot program has begun.

Upon arrival to the island, I was pleasantly surprised to find the diabetic foot examination handouts that were provided at the trip in August, 2018 were hanging on the wall at the front desk at the Ronton hospital.

     

Meet the new Diabetes Community Workers (DCWs) Tanoataake (Tanny) and Teraka.

We spent Thursday, January 24 at the Ronton hospital teaching and examining patients during the weekly diabetes clinic. Tanny was new to medical care, but was quick to learn the medical terms and the importance of the diabetic foot examination. I donated a laptop computer, and Tanny and I sat together and created a database to keep track of all of the foot examinations that would be performed.

Friday, January 25 began with patient rounds and meeting Teraka, the DCW. Tanny and Teraka joined us for patient rounds to experience patient care and see the results of diabetic foot infections on patients who did not seek medical treatment in a timely manner. It just so happened that Dr. John and I performed surgery for a diabetic foot infection on Teraka’s mother that morning. This made Teraka’s new job very real, and he quickly understood the importance of what he was taking on.

 

   

On arrival to the island, I presented Dr. John with a gift only a surgeon could love: new, sharp osteotomes and heavy mallets. He was thrilled.

    

The rest of Friday Tanny and Teraka practiced performing foot examinations on the hospital staff and gathering information for the database.

Monday, January 28
Dr. John, Tanny, Teraka, and I drove the London Clinic where we introduced Tanny and Teraka to and talked with the head nurse. We discussed what the DCWs would be doing and the importance of their work. She was happy to accommodate the two DCWs and even agreed to change the diabetic clinic from Thursdays to Wednesdays so that Tanny and Teraka could be present.

Next, we drove to the Banana clinic. Teraka and Tanny were introduced to the head nurse and they discussed their new jobs and the importance of diabetic foot examinations and patient education. Since Teraka resides in Banana, he would be the DCW assigned to the Banana clinic on Monday and Tuesdays.

    

While in Banana, we also went out in the Community to locate a few of Dr. John’s patients who had not been seen in the diabetic clinic in a timely manner. We were able to locate and assess two people. This woman below had a blood glucose that was so high that it would not even register on the glucometer. She was transported back to the Banana clinic where she was to receive a saline bolus and insulin.

Tuesday, January 29
The morning Dr. John, Tanny, and I drove to Tabwakea clinic. We introduced Tanny and discussed his new job and importance of the diabetic foot examination and patient education. Since Tanny resides in Tabwakea, he would be seeing patients at the clinic on Mondays and Tuesdays.

At lunchtime, the wonderful doctors and hospital staff provided me with a “Good-bye” lunch so that I would not have to dance by myself at an evening party. The trip was a huge success. The Diabetes program is off and running with two new DCWs.

    

Next steps…

Once Tanny and Teraka are comfortable with their new job duties, we plan to expand their duties by:

  • Adding in the school children’s heights and weights.
  • Pending further IRB approval, we would like to get fasting or random glucose measurements as well.
  • Adding nail and callus reductions (that will need to be taught on-site during another trip)

Another Shriners Miracle

Little six-year-old Raebine Tibweana has just returned home to Christmas Island in Kiribati after more than two months at Shriners Hospital for Children in Honolulu, where she underwent successful surgeries for two displaced hips and treatment for involuntary muscle contractions.

“It’s another miracle performed by the wonderful physicians and nurses at Shriners Hospital in Honolulu,” said Carlton Smith, president of Pacific Islands Medical Aid, Inc. (PIMA) “She’s on her way to recovery and will return to Honolulu in a year’s time for reevaluation,” he said.

Tebweana and other children from the isolated central Pacific nation of Kiribati needing orthopedic intervention come to Honolulu as a result of a special agreement between Shriners, PIMA and the Kiribati Ministry of Health, Carlton said.

Under this worthwhile program, Shriners sends physicians to Kiribati once a year to examine needy children and place them on a priority list for help. Shriners provides all medical care without cost, under the direction of chief of staff Dr. Craig Ono.

The Kiribati Ministry of Health pays for round-trip airfare for the child and chaperone (most often a parent), and PIMA takes care of visa fees and provides all necessary housing, transportation and translation services on Honolulu.

New Diabetes Program To Hit Devastating Island Epidemic

By Dr. Elizabeth Beale, M.D., MRCP

Treatment Underway: Pacific Islands Medical Aid volunteer diabetologist Dr. Elizabeth Beale, University of Southern California professor, ( second from right ), begins treatment instructions on diabetic patient with the help of the local island doctor and nurses.

Treatment Underway: Pacific Islands Medical Aid volunteer diabetologist Dr. Elizabeth Beale, University of Southern California professor, ( second from right ), begins treatment instructions on diabetic patient with the help of the local island doctor and nurses.

We are pleased to announce the launch of the Pacific Islands Medical Aid Kiritimati Diabetes Program, to provide year-round diabetes education, patient treatment and monitoring in that isolated region of the Central Pacific … where the need is great.

Over the last ten years, Pacific Islands Medical Aid (PIMA) under the leadership of it’s president, Carlton Smith, has sponsored several trips to Kiritimati (Christmas Island) by diabetes and obesity specialists, where type 2 diabetes has reached epidemic proportions…. More than 30 per cent of the adult population suffer with this destructive disease.

In the summer of 2018, the Christmas Island doctors and the visiting diabetes team agreed that the island community would be well served by establishing a program that allows for diabetes education and monitoring year-round by local diabetes community workers.

We discussed our plans with Dr. Lydia Lam of the University of Southern California Keck School of Medicine, who has volunteered on Kiritimati several times and who has coordinated many visits there by medical specialists.

Dr. Lam approached philanthropist Mr. Atul Dhablania, a supporter of international medical aid projects through the USC Institute on Inequalities in Global Health, who has generously donated $10,000 a year for three years to the PIMA Diabetes Team to establish the diabetes program.

Last resort: Without appropriate care and medication, often the last resort is amputation, done quite often in the islands. Our hope is to help reduce the enormous burden of this destructive disease.

Last resort: Without appropriate care and medication, often the last resort is amputation, done quite often in the islands. Our hope is to help reduce the enormous burden of this destructive disease.

In discussions with local doctors on Kiritimati, it was agreed that two local diabetes community workers (DCWs) be hired full time. Local ob/gyn Dr. Baranika Toroman, has selected two candidates each of whom have excellent rapport with their local communities, basic nursing experience and good language and computer skills.

Their work conditions and salary will be similar to those of nurse aides on the island and they will work under the supervision of the island’s senior nurse and the local physician and diabetes team doctor, Dr. John Tekanene, under the Kiribati Ministry of Health medical officer in charge, Dr. Teraira Bangao. Salaries will be paid by PIMA through the Kiribati Ministry of Health.

Amputations and death due to foot infections and ulcerations are currently a devastating problem on the islands, and yet in most cases are preventable.

So our first goal is to establish a foot care program.

Late this month, our DCWs will be trained by Dr. Julie Chatigny, DPM, who is scheduled to arrive on the island Jan. 23. She will first teach them to conduct basic foot examinations and to maintain high-quality medical records.

Problems identified will be discussed with local medical staff so they can implement an appropriate plan of care. Weekly reports will be sent to Dr. Chatigny and her podiatric surgery colleagues in the U.S. The PIMA team will monitor the findings and identify areas needing improvement such as educational materials, specialized equipment and medications.

Islanders Suffer: Islanders in the central Pacific nation of Kiribati suffer greatly, where more than 30 per cent of the adult population has Type 2 diabetes. Our initial goal is to establish a foot care program and to establish a foundation of sustainable diabetes prevention and care in the Line Islands of Kiribati.

Islanders Suffer: Islanders in the central Pacific nation of Kiribati suffer greatly, where more than 30 per cent of the adult population has Type 2 diabetes. Our initial goal is to establish a foot care program and to establish a foundation of sustainable diabetes prevention and care in the Line Islands of Kiribati.

Once the foot examination program is running smoothly in the next few months, the DCWs will begin giving diabetes related educational sessions across the island, coordinated with each village’s different Village Welfare Committees, and held in schools, churches, maneabas (local meeting houses), and in some workplaces.

In mid 2019, we plan to train the DCWs to assist in our work in the schools, where the focus will be on identifying the causes of the diabetes epidemic and finding ways to address this, under the direction of Dr. Michael Goran, PhD, who is the program director for Diabetes and Obesity at Children’s Hospital in Los Angeles and professor of pediatrics at the Keck School of Medicine of USC. His team includes Dr. Jasmine Plows, PhD; Ms. Claudia Rios, MS, RD; and Ms. Skylar Steinberg, BS.

Our overall goal with the PIMA Diabetes Program is to establish a foundation for sustainable diabetes prevention and care on Kiritimati (Christmas Island) in Kiribati and help reduce the enormous burden of this destructive disease

We thank all those who have helped establish this program and look forward to sharing our progress with you.

(Dr. Elizabeth Beale, MD, is the PIMA Diabetes Team program leader and Diabetologist with the University of Southern California Keck School of Medicine in Los Angeles. Dr. Julie Chatigny, DPM, is a podiatric physician and surgeon and president and owner of Central Coast Foot and Ankle Specialists in Templeton, California).

Volunteer OB/GYN Helps on Tarawa; Observations Aim to Help Outcomes

One of our most highly regarded ob/gyns has returned home to Mount Sinai Hospital in New York after spending two weeks on far-away Tarawa in the Republic of Kiribati, helping the obstetrics department at the main government hospital there.

“It was a great experience and one that I hope to do again and again,” according to Dr. Maria Teaiwa-Rutherford, MD, assistant professor at the department of obstetrics and gynecology, Icahn School of Medicine Mount Sinai Hospital.

“I was there for two weeks and spent time with the obstetrics team consisting of two physicians, including one physician from Cuba who spoke no English or I-Kiribati, two registrars and four interns,” she said. Her observations, in her own words:

P.S. We at Pacific Islands Medical Aid were blessed to have found Dr. Maria. She has relatives who live on Tarawa in Kiribati. Hope she can return again and again.

By Maria Teaiwa-Rutherford, M.D.

Since they had midwives doing deliveries, they mostly needed my help with gynecology. We did rounds every morning on the in-patients, saw patients in the emergency room and gynecology clinics.

At the end of the day, I would sit with the interns on the labor floor and go over triage patients with them, taught them how to use the ultrasound (they rely on the ultrasound tech but I have always liked to do my own.) I think they enjoyed seeing that.

I taught the interns and residents some simple office procedures like endometrial biopsies. I think the hands-on teaching was much appreciated.

The power went out during a c-section surgery and I asked the people to shine their smartphone flashlights into the field.

The power went out during a c-section surgery and I asked the people to shine their smartphone flashlights into the field.

The attendings take calls every night for a week and all the C-Sections happen overnight so they are often tired and take breaks or nap which is totally reasonable. They gave me one day on the OR and I think it was a nice break for them.

The power went out during a C-Section and I asked people to shine their smartphone flashlights into the field.

I was shocked at the number of anemic patients admitted for blood transfusions. A typical admission was abnormal uterine bleeding with a hemoglobin of 6 requiring a blood transfusion. I saw probably 10 patients like this in two weeks. The blood bank cannot keep up with those demands and after the first unit of blood, the patient is told to go find blood donors.

Needed is education about diet and getting enough iron and vitamin C. The staple of rice and fish is not helping anyone’s iron stores!

I was also surprised at the volume of deliveries. The Tarawa Hospital does 150-200 deliveries a month and has a 15 percent C-Section rate.

Overall it was an incredible trip. I definitely plan to return.

Blind Islanders Can See Again; Team Performs 48 Surgeries

Helping the blind to see again.Few things are as rewarding as watching the joy on a cataract patient’s face when the bandages first come off and he or she can see again after being blind for years.

The expression of wonder and happiness makes all the effort worthwhile.

For the fourth time in six years, our great eye surgery team, led by Oregon ophthalmologists Dr. Paul Jorizzo and Dr. Paul Imperia, have returned home after completing 48 eye surgeries, this time on patients from Christmas Island (Kiritimati), Teraina and Tabuaeran in the Line Islands of Kiribati.

“Most were cataracts and the outcomes were universally excellent,” Dr. Jorizzo said, “with many patients seeing for the first time in several years.”

He said the excitement of people being able to return to their normal lives was contagious, “leaving us moved and feeling fortunate that we were able to participate in the experience.”

This year’s eye surgery expedition required a lot of pre-planning and organization, according to Carlton Smith, president of Pacific Islands Medical Aid, Inc. (PIMA) He said an advance team, led by long-time PIMA volunteer, general surgeon Dr. Larry Falk and ophthalmologist Dr. Jack Mason, traveled to Christmas Island (Kiritimati) and the neighboring islands of Tabuaeran and Teraina to examine and assess eye patients and prepare a list of patients for surgery back on Christmas Island.

Happy patients lined up, recovering. So excited to see again.Then, patients were brought by boat and plane to Christmas Island for surgery at the small hospital there, Carlton said, under the direction of the medical officer in charge for the Kiribati Ministry of Health, Dr. Teraira Bangao.

Surgery supplies and loaned equipment was provided by Seeing Eye Expeditions (SEE International) in Santa Barbara, California, “a wonderful organization that we have worked with over the years,” Carlton said.

In addition to Dr. Paul Jorizzo, Dr. Paul Imperia, Dr. Larry Falk and Dr.Jack Mason, the surgery team consisted of ophthalmologist Dr. John Welling, nurse Laura Imperia and nurse Jessica Jones, from Medical Eye Center in Medford, Oregon.

“We were blessed to have such a great team help the good people of Kiribati,” Smith said, “and we look forward to being able to continue this worthwhile effort.”

If a picture is worth a thousand words, we have attached a volume’s worth in our newsletter this edition. As you look at the faces, just imagine the feelings of the patients at the moment they are able to see again.

Here is Dr. Paul Jorizzo’s story, in his own words:

By Dr. Paul Jorizzo, MD

Our eye team returned to Christmas Island for the fourth time. Patients at Christmas (Kiritimati), Fanning (Tabuaeran) and Washington (Teraina) had been screened by Dr. Larry Falk and Dr. Jack Mason, who, in addition to addressing their medical needs, found 50 patients in need of surgery.

Happy patient can see again after cataract surgery.  Happy patient can see again after cataract surgery.  Happy patient can see again after cataract surgery.  Happy patient can see again after cataract surgery.

A substantial coordinated effort to get patients and supplies to Christmas Island was greatly aided by Dr. Falk, Carlton Smith at PIMA, Surgical Eye Expeditions (SEE) International and the motor sailing vessel Kwai.

High quality surgical microscopes and supplies arrived along with the patients from the outlying islands prior to our arrival.

Under the guiding eye of Dr. Teraira, Dr. Paul Imperia and Dr. Jack Mason efficiently performed pre-operative examinations and measurements. Dr. Larry Falk was miraculous in finding ways to make all of our equipment work.

From blind to sight, in one day!

Meanwhile, the operating room team of Dr. John Welling, Laura Imperia RN and Jessica Jones, RM, joined me in setting up the operating room to accommodate two patients simultaneously.

With surprising efficiency, we were operating the next morning. Thanks to excellent screening, the majority of patients were profoundly blind… many blind bilaterally.

With the help of the Kiribati nursing staff, we completed 48 surgeries in one week. Most were cataracts and the outcomes were universally excellent, many patients seeing for the first time in several years.

The excitement of people being able to return to their normal lives was contagious, leaving us moved and fortunate that we were able to participate in the experience.

Paul and I had visited Christmas Island on several occasions prior to our surgical trips and hoped to find a way to give back to the warm people that we had visited. We are so appreciative of Carlton Smith and Pacific Islands Medical Aid, and the wonderful team at SEE International for helping us fulfill our quest.

We look forward to our next trip.

Iakobwa Now Learns to Walk; Shriners Brings About Miracle

Iakobwa Kabong could only walk on his knees and shuffle around on pieces of cardboard back on Christmas Island in Kiribati before he was admitted to Shriners Hospital for Children in Honolulu. And he didn’t have use of his hands. He would push himself forward on his knuckles and use the cardboard like a sled along the rough ground.

Iakobwa in wheelchair at airport heading home after more than a year at Shriners Hospital for Children in Honolulu.

Iakobwa in wheelchair at airport heading home after more than a year at Shriners Hospital for Children in Honolulu.

After a little more than a year at Shriners Hospital and multiple surgeries, Iakobwa (pronounced ya-ko-bah) can now stand and has use of his hands. With exercises and the use of a walker, he should soon be walking on his own, say the doctors at Shriners.

Iakobwa, now 18, was brought to Shriners under a program initiated with Shriners and Pacific Islands Medical Aid several years ago. Shriners takes care of all medical needs and we at Pacific Islands Medical Aid provide financial help for food, lodging, local transportation and translation services.

“We are eternally grateful to Shriners Hospital, it’s leader Dr. Craig Ono, MD and all the physicians, nurses and support staff involved in Iakobwa’s miracle,” said Carlton Smith, president of Pacific Islands Medical Aid (PIMA). “And thanks to our many good hearted donors who helped make this happen.”

Iakobwa needed a dozen surgeries to help correct his malformed legs and hands, Smith said, and he was able to spend more than a year at the hospital in Honolulu with his mother during that time.

Intrepid PIMA volunteer Kaitibo Timon in Honolulu, who was born in Kiribati, helped with translations and local transportation during the entire time, Smith said.

After hundreds and hundreds of hours of therapy, Iakobwa was sent on his way back to Christmas Island with a walker, wheelchair and electric scooter… all thanks to Shriners Hospital for Children!

Shriners nurse and social worker Cindy Shimabukuro said Iakobwa first arrived at Shriners Hospital in Honolulu on April 25, 2017 with a diagnosis of arthrogryposis. “He has undergone many procedures and surgical interventions since his arrival and the young man who came to us unable to stand and would walk on his knees, is now able to stand and walk short distances with a walker.

Throughout his stay, she said, Iakobwa has demonstrated strength and dedication to work toward his goal of walking. She also credits Iakobwa’s mother who was his ‘biggest cheerleader.’

“They were wonderful members of our Shriners Family Center always supporting others. We already miss this family’s positive attitude and strength,” she said.

PIMA Heart Team Sees 177; Nine Require Cardiac Surgery

Our intrepid heart team has returned home after seeing 177 patients in a week’s time on isolated Christmas Island in the central Pacific, where they identified nine needing life-saving surgery.

Nine heart patients heading for surgery. Plans are underway now to bring the nine patients to Baylor Scott White Heart Hospital in Plano, Texas for surgery, says team leader cardiothoracic surgeon Dr. David Moore, M.D.

Team members on the island were divided into small units for their one-week stay and were able to perform 176 heart echoes on adult patients and 975 rheumatic heart disease-screening echoes for children at local schools on the island.

In addition, team members offered educational talks to teachers and students about rheumatic heart disease, its causes and cures… where many islanders suffer as a result of undiagnosed and untreated rheumatic fever in children that results in heart disease later in life.

Counseling Patient: Volunteer cardiothoracic surgeon Dr. David Moore, M.D., counsels patient on Christmas Island after tests show the patient needs heart surgery to correct the effects of his rheumatic heart disease. In just one week, the PIMA Heart Team saw 177 patients with 176 echos and 9 patients identified for surgery back in the U.S.

Counseling Patient: Volunteer cardiothoracic surgeon Dr. David Moore, M.D., counsels patient on Christmas Island after tests show the patient needs heart surgery to correct the effects of his rheumatic heart disease. In just one week, the PIMA Heart Team saw 177 patients with 176 echos and 9 patients identified for surgery back in the U.S.

“We are really proud of our professional team members who volunteered time and expertise in helping the good people of Kiribati, where the need it great,” said Carlton Smith, president of Pacific Islands Medical Aid.

The physician and medical officer in charge for the Kiribati Ministry of Health on Christmas Island, Dr. Teraira Bangao, says ‘the team worked very hard when they were here… they did a great job… starting out each day at 8:30 a.m. and working straight through to 6 p.m.”

“We are so thankful to the team members and everyone at Pacific Islands Medical Aid and look forward to their next visit,” he said.

In this humanitarian outreach, Dr. Moore and his team of heart surgeons at Cardiac Specialists in Plano, Texas and Baylor Scott White Heart Hospital in Plano will provide surgeries and hospitalization for the patients, while Pacific Islands Medical Aid provides all housing, meals and local transportation in the Dallas area for the patients and their chaperones, and the Kiribati Ministry of Health provides round trip airfare.

Please help support this life-saving program with your donation. Here is Dr. Moore’s report.

By Dr. David Moore, M.D.

Rheumatic heart disease remains a major global health concern primarily affecting young adults in the developing world.

This is particularly true in many of the islands of the central and western Pacific.

Our team from Baylor Scott White Heart Hospital in Plano, Texas recently returned to Kiritimati (Christmas Island) in the Republic of Kiribati with the support and coordination of Pacific Islands Medical Aid.

 

Team members included Dr. David Moore, CV surgery; Dr. Steve Mottl, cardiology; Michael Rampoldi, echo cardiographer, Candice Rampoldi, echo assistant and echo data collection; Amy Moore, trip coordinator and data management; Sherry Swanson, Baylor Heart Hospital social services; and Tom Roma, school education program.

Little Ones Included: All islanders, young and old, showing signs of possible heart disease were checked out by our volunteer heart team on their most recent visit to Christmas Island in Kiribati, where nine were identified for life-saving heart surgery back in the U.S.

Little Ones Included: All islanders, young and old, showing signs of possible heart disease were checked out by our volunteer heart team on their most recent visit to Christmas Island in Kiribati, where nine were identified for life-saving heart surgery back in the U.S.

In the course of our week on the island, we functioned as two teams; one evaluating patients in the clinic at Ronton Hospital and the other focusing on education regarding prevention of rheumatic heart disease (RHD) as well as echo screening in the primary schools.

Echo screening of asymptomatic children allows for early detection of RHD with the identification of subtle abnormalities in the heart valves. Children with these findings can then be started on prophylactic penicillin injections preventing subsequent episodes of Strep Throat and thus avoiding further immune response and valve damage.

A total of 950 children were screened by our team over a period of four days. At the same time, children, teachers and some parents received education on the prevention of RHD, emphasizing hand washing, appropriate coverage for cough, and the need to see a physician or nurse for treatment of sore throats.

At the clinic, our team evaluated and obtained an echo on 175 patients. Two children with congenital heart disease were identified, three adults with probable coronary artery disease and eight patients with rheumatic heart disease were diagnosed.  The adult patients will be brought to Baylor Scott White Heart Hospital in Plano, Texas for additional testing and surgery. The children with congenital heart disease will be referred to an appropriate facility for surgical correction.

Our team appreciates the opportunity to continue this good work made possible by Baylor Scott White Health Care System, the Republic of Kiribati Ministry of Health and Pacific Islands Medical Aid.

We are grateful to the people of Kiritimati (Christmas Island) for their warm hospitality and support.