Monday, March 30, 2020

Clinical Use of Ultrasound at a High Altitude Clinic in Nepal



Bryan Jarrett, M.D. 
Wilderness Medicine Fellow, 
Massachusetts General Hospital Department of Emergency Medicine
PGY4
06/29/2019

Performing a right upper quadrant ultrasound to evaluate for
biliary pathology 
Bedside ultrasound in the emergency department has become a standard supplement to traditional imaging such as x-rays and CT. It is now becoming a primary imaging modality when these more traditional methods are unavailable, especially as we realize the breadth of pathologies ultrasound can diagnose. I recently returned from three months working at a clinic in a remote region of Nepal run by the Himalayan Rescue Association. Pheriche is a small town which sits at approximately 14,000 ft altitude on the trek into the Khumbu valley to Everest Base Camp, and sees approximately 600 to 800 patients each Spring and Fall season. The closest small hospital is in Kunde, a town north of Namche approximately one or two day’s walk away, and has x-ray and ultrasound capabilities. The closest CT scanner is in Kathmandu, a few hours by helicopter or 4 days of hiking and a plane flight away.

I had the privilege of bringing along a Sonosite M Turbo ultrasound provided by their global health division as well as the new ultra-portable Butterfly IQ handheld ultrasound. Through the use of these ultrasounds, I was able to greatly improve clinical care and diagnostic certainty in this remote clinic without access to other imaging modalities.
Lung ultrasound is a very sensitive modality
to detect interstitial pulmonary, such as that
seen in high altitude pulmonary edema (HAPE)

Over the course of the spring 2019 season I performed 83 clinical ultrasounds on 75 patients, which represented 14.4% of our total number of patients. Thirteen of these ultrasounds changed management, 2 improved procedures, and 48 improved diagnostic certainty by providing a useful positive or negative result. The most common ultrasounds performed were pulmonary or lung studies, as more than 30 percent of our patients had respiratory tract infections. Other common modalities included cardiac echocardiograms, obstetric, musculoskeletal, and abdominal ultrasound. As an advocate for training in and access to this incredibly useful diagnostic tool, it was amazing to observe its benefits in a remote environment where it really shines.


Patient with peritonsillar abscess receiving nebulized
lidocaine before drainage guided by ultrasound imaging
before and afterwards. 
One interesting case in which ultrasound proved useful was in a young man who came in with unilateral throat pain. He had what clinically appeared to be a peritonsillar abscess which usually requires either needle aspiration or incision and drainage. The major risk of this procedure is damage to the carotid artery which lies behind the tonsils, sometimes perilously close within a centimeter or two. Thanks to the small linear probe covered in a sterile glove, we were able to visualize the abscess as well as the carotid, and assure that our drainage would stay well away from this critical vessel. Granted, an experience ear, nose, and throat surgeon would usually do this without ultrasound guidance, but they would also have the close back-up of a nearby operating room if anything were to go wrong, a contingency we did not have. Ultrasound in this case made this procedure much safer for the patient and much more comfortable for the providers, and we were able to confirm afterwards with repeat imaging that we had removed as much as possible from the abscess. He felt significantly better after draining 17 cc of purulent material and happily continued towards Everest Base Camp the following day.


High Altitude Medicine - Caring for locals and trekkers at 14,000 feet in Pheriche, Nepal



Bryan Jarrett, M.D. 
Wilderness Medicine Fellow, 
Massachusetts General Hospital Department of Emergency Medicine
PGY4
06/29/2019


The Himalayan Rescue Association Clinic in
Pheriche with Anna Dablam in the background
Three months above 14,000ft at a high altitude clinic 10 km away from Everest Base camp taking care of trekkers and the local Nepali population, armed only with my stethoscope, an ultrasound, and my clinical training… sign me up. My name is Bryan Jarrett, and I am a Wilderness Medicine Fellow at Massachusetts General Hospital. Our specialty focuses on providing care in resource-limited and remote environments, and this certainly qualified.

The Himalayan Rescue Association has been providing care in the Khumbu region since the 1970s. Their first and longest operating clinic is in the town of Pheriche, a stop on the trek to Everest Base camp and multiple other locations, done by approximately 25-30,000 international visitors each season (the trekking seasons are in the Fall and Spring). In order to support these trekkers, a large number of Nepali lodge workers and porters migrate seasonally to these high altitude communities during these times. By the end of almost two and a half months of clinical work, our team of three physicians and a Nepali medic named Thaneshwar had taken care of almost 700 patients and evacuated 27 people by helicopter for severe illnesses.

The majority of our patients were Nepali (70%), and the most common diagnoses we saw were upper respiratory tract infections (33.6%), followed closely by acute mountain sickness (8.6%), gastroenteritis (8.3%), and musculoskeletal complaints (6.2%),
Helicopter evacuation of a critical patient after a large snowstorm 
making this experience just as much international primary care as it was high altitude medicine. Our interesting cases were a good mix of typical emergency medicine cases presenting in this austere environment as well as a large number of the two severe forms of altitude illness, high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE).

High altitude pulmonary edema is the more common of these two, resulting in interstitial fluid in the lungs causing shortness of breath at rest, and in its most severe form, significant hypoxia and possibly death. We had 22 cases of HAPE, of which the majority were Nepali, and we evacuated 13 of these by helicopter down to Lukla approximately 5000 ft below Pheriche, or usually all the way down to Kathmandu. A normal oxygen saturation at 14,000 ft is approximately 80-90%, but most of our patients with HAPE presented with saturations in the 50’s with significant shortness of breath. The mainstay of our treatment was supplemental oxygen via oxygen concentrators which we ran off of power supplied from solar panels, and most patients improved on oxygen and nifedipine, a medicine to decrease the blood pressure in the lungs. Thankfully, all patients we saw were able to either ride a horse or helicopter down to lower altitudes for a safe recovery.

Fewer patients presented with high altitude cerebral edema, a condition in which the brain swells at high altitude causing confusion and difficulty walking. All but one of these six patients were evacuated by helicopter after treatment with oxygen and dexamethasone, a steroid shown to be helpful in improving this swelling. Many of these patients came in being carried by friends, horses, or porters; confused, and unable to walk on their own.
 A patient with HAPE, with a normal saturation 

on supplemental oxygen, with ultrasound images 
of B-Lines representing the Interstitial edema in 
his lungs

There are very few places where one can treat young, otherwise healthy patients with acute, potentially deadly conditions and watch them improve over 12 to 24 hours with treatment. This was a truly special aspect of this experience. While providing care for these unique pathologies only found with this prevalence in a few locations around the globe was invaluable, the true joy was providing medical care to the local population. This was less glamorous, and provided less excitement, but ultimately greater satisfaction. We were able to repair significant lacerations, give antibiotics to respiratory and skin infections, and treat basic aches and pains. I will never forget the beautiful mountains, the young patients who are still alive because we were there to provide them with much-needed care, and the friends I made in the process.

Tuesday, November 19, 2019

Clinical Rotation in an Emergency Department in Kigali


Lara Vogel

Resident, Harvard Affiliated Emergency Medicine Residency MGH/BWH, PGY4


In my work prior to medicine, I lived and worked in East Africa for multiple years, focusing primarily on education and the ways the HIV/AIDS epidemic impacted children in Kenya. Working on public health projects in rural Kenya through my twenties pushed me toward medicine, so now that residency was nearly finished for me, it was time for me to go back to the place where my interest in medicine started. Or at least get closer. Through attending’s in the BWH ER Trish Henwood, Alice Bukhman and Regan Marsh, I was able to connect with the new Rwandan attending’s running one of the first EM residencies in Sub-Saharan Africa. The Centre Hospitalier Universitaire de Kigali (CHUK) is about to graduate its second class of residents, and the ER is currently run entirely by its prior graduates. There are three of them. They work a lot.
I technically know that EM is a relatively new specialty in the US but seeing a new specialty establish itself is a fascinating process. This process at CHUK is relatively far along and I had the smallest glimpse, but watching these residents navigate their own hospital system, the ambulances, the insurance system
Nyungwe Forest National Park
(they often have to wait for proof of payment before they can treat), and the consultants’ understanding of patient care was an education in itself. Unsurprisingly, the medicine was the same between the two countries and the residents were exceptionally well trained—their comfort with trauma far exceeded my own, and their ability to make do with much less support from consultants, supplies, and patient’s understanding of disease was incredible—but ultimately, they had many more fights everyday to define the boundaries of their ER to themselves, to their patients and certainly to the hospital system. Their actions were always defined by the best interests of the patient, but when ICU patients spent weeks boarding in the ER, when the orthopedists could not operate or admit and yet would not stop accepting transfers, and when social services did not exist to support patients unable to care for themselves, the question of what was best for the patient became extremely complex and well beyond the scope of what I expect from an ER physician. Needless to say, they all managed it with grace and I was the one left confused.


Friday, November 8, 2019

Heart Failure and Cardiac Ultrasound Training in Rural Rwanda


Sheila Klassen
Cardiovascular Disease and Global Health Equity Fellow at Harvard Medical School



As my month in rural Rwanda draws to a close, I’ve had some opportunity to reflect on the successes and the challenges of healthcare provision in this country. I was able to spend 4 weeks doing simplified heart failure and echocardiography training across 7 hospitals in the country. It meant a lot of time traveling and many hours on the road, but it also gave me an appreciation of health care delivery in Rwanda.


There is a large emphasis on community in Rwanda which is encouraged by the government. There is a community event called Umuganda every last Saturday of the month where citizens are required to meet with their local communities and either perform manual labour tasks to better their communities such as filling in potholes or helping an older neighbor patch their leaking roof. Other Umuganda activities include having community meetings on security or other local issues.
Giving out completion certificates
after heart failure and echo training course
Years ago, the government distributed approximately 3 million cows to rural the rural population as a way of both decreasing malnutrition and creating industry. This has resulted in lower priced milk for Rwandans and in addition has created a sustainable export to neighboring countries. Community members who own cows that eventually calve are required to give away these calves to those do not own cows at no cost. Communities often gather at church on weekends, and the local water pumps are always overrun with children who meet daily to fill their jugs (running water in homes is not yet available). This community engagement could be a strength in health care delivery as community members look after each other. There is potential for shared medical appointments where members of the same community who have similar medical problems (diabetes, high blood pressure) have medical appointments with healthcare providers together so that they can both support each other and alleviate the burden on the few healthcare providers that are in country.

Spending time in rural hospitals, it was gratifying to see my trainees very capably performing cardiac ultrasound and managing heart failure patients appropriately. They still required support and voiced a need for ongoing mentorship but this was a big leap from where they started, which was next-to-no skill in managing heart failure and cardiac disease.

One of my trainees performing an echocardiogram
in a rural Rwandan hospital


Challenges are still many. Limited resources, limited training opportunities, limited expertise, and lack of infrastructure due to lack of resources still pose barriers to adequate health provision in the country. Providers are accustomed to providing care without resources which can make them complacent. There is a very high volume of patients because of the level of poverty of the population and high frequency of the socioeconomic determinants of poor health. At the same time, there is provider scarcity. Procurement of supplies, transportation of medical equipment, and biomedical support is all limited. Despite these challenges, Rwanda has pulled itself from its status as a broken state and poorest country in the world after the 1994 genocide to a growing health system with stable infrastructure. There is a way forward. Capacity building and training as well as continued resource support, possibly involving public private partnerships can continue to benefit the country and improve the health of its population. I’m glad I was able to use this travel grant to both share my cardiac knowledge with Rwandan healthcare providers and be part of Rwanda’s rebuilding as a country.














Wednesday, September 25, 2019

Conversation as a resource in Kigali


Lara Vogel, MD
Resident, Harvard Affiliated Emergency Medicine Residency MGH/BWH, 
PGY4

Conversations surrounding code status and informed consent are a huge practicality of my job, and one I think I will always feel less prepared for than I should be. In the ER, I frequently give bad news, explain complex medical conditions, try to parse the high uncertainty of early diagnosis and ask for consent for treatment in only a few minutes. In another language, across a cultural barrier, with interpreters, there is of course additional layers of complexity. But even in my native language, these conversations are riddled with small misunderstandings and subtle nuance that make them difficult to leave feeling certain that we all share the same understanding of the patient’s condition and values and what I hope to treat and how.

In Kigali, I was a teacher—I could not speak to many of the patients without interpretation (Kinyarwanda was the strongly dominant language for this patient population), and I appropriately did not independently manage their care without residents and attendings involved in my decision making. However, even with interpreters I trusted and with time to talk to patients as my administrative duties were lessened, my chance for truly informed consent seemed slight given the vast distance of culture, language, and medical training between me and my patients.  As a result, I often left these conversations to the residents directly caring for patients, intervening only when I thought medical care was not being discussed at all. However, I was not prepared for the additional layer of consent conversations that had to be done by the physicians prior to the patients and their families. In a relatively resource-poor setting, there was often no conversation to be had with patients and their families. When we ran out of ventilators, when radiologists would not read a study, when the lab ran out of a certain test’s supplies, when patients could not afford central line or other equipment, we did everything else we could. I personally had not prepared for the brief but important preliminary discussion that had to be had among physicians regarding the resources available at any given time- resources were a fluid and changing thing but when they were gone, there was not always an alternative to discuss with a patient.

Clinical Rotation in an Emergency Department in Kigali


Lara Vogel, MD
Resident, Harvard Affiliated Emergency Medicine Residency MGH/BWH, 
PGY4



In my work prior to medicine, I lived and worked in East Africa for multiple years, focusing primarily on education and the ways the HIV/AIDS epidemic impacted children in Kenya. Working on public health projects in rural Kenya through my twenties pushed me toward medicine, so now that residency was nearly finished for me, it was time for me to go back to the place where my interest in medicine started. Or at least get closer. Through attendings in the BWH ER Trish Henwood, Alice Bukhman and Regan Marsh, I was able to connect with the new Rwandan attendings running one of the first EM residencies in Sub-Saharan Africa. The Centre Hospitalier Universitaire de Kigali (CHUK) is about to graduate its second class of residents, and the ER is currently run entirely by its prior graduates. There are three of them. They work a lot.

I technically know that EM is a relatively new specialty in the US but seeing a new specialty establish itself is a fascinating process. This process at CHUK is relatively far along and I had the smallest glimpse, but watching these residents navigate their own hospital system, the ambulances, the insurance system (they often have to wait for proof of payment before they can treat), and the consultants’ understanding of patient care was an education in itself. Unsurprisingly, the medicine was the same between the two countries and the residents were exceptionally well trained—their comfort with trauma far exceeded my own, and their ability to make do with much less support from consultants, supplies, and patient’s understanding of disease was incredible—but ultimately, they had many more fights everyday to define the boundaries of their ER to themselves, to their patients and certainly to the hospital system. Their actions were always defined by the best interests of the patient, but when ICU patients spent weeks boarding in the ER, when the orthopedists could not operate or admit and yet would not stop accepting transfers, and when social services did not exist to support patients unable to care for themselves, the question of what was best for the patient became extremely complex and well beyond the scope of what I expect from an ER physician. Needless to say, they all managed it with grace and I was the one left confused.

Heart Failure and Cardiac Ultrasound Training in Rural Rwanda


Sheila Klassen, MD
Cardiovascular Disease and Global Health Equity Fellow at Harvard Medical School
(Formerly PGY8 Advanced Echocardiography Fellow at the Massachusetts General Hospital at the time of COE travel grant application)



Teaching basic echocardiography in rural Rwanda
Non-communicable diseases (NCDs) account for 44% of all deaths in Rwanda according to the WHO country profile fact sheet from 2018. Within that, cardiovascular disease and cardiovascular risk factors make up a large proportion of NCD mortality but there are only 6 cardiologists in the country, based in the capital city of Kigali. Within this context, I’ve spent the last 2 weeks teaching nurses, general practitioners, and internists from the rural district hospitals and smaller cities in the outer provinces of Rwanda about heart failure and demonstrating basic echocardiography skills which they can employ within their own settings. Their commitment to learning was palpable! Without having visited their home hospitals, I could tell from their level of interest and their questions that heart failure and cardiac disease was commonplace and that they struggled to know what to do with suspected cases of heart failure.

My students become teachers for each other!
My first week was comprised of a formal training session organized by the Ministry of Health in a central location in Rwinkwavu, located in the Eastern province of Rwanda. I taught on basic principles of ultrasound, basic echocardiographic views, normal cardiac anatomy and the most common cardiac pathologies affecting low resource settings such as Rwanda. After 3 days of training, it was amazing to see the transition from student to teacher – they were already starting to share cases and answer each others’ questions about echo findings and medication titration, particularly about strategies particular to the setting such as how to navigate stock at the local pharmacies for the heart failure drugs I was teaching about. I spent the second week in the NCD clinics of 2 district hospitals in the Northern province with nurses and local physicians. My role was to supervise, coach, and help them consolidate the knowledge they’ve gained and it was encouraging to see how capable they had become in a very short time. The next 2 weeks will be spent visiting the other 4 district hospital sites and doing the same.

The limitations at the district hospitals are difficult. There are many patients who don’t have access to life-saving diagnostics and treatments we take for granted. In the span of several days, I saw a 9-year-old with severe congenital mitral and tricuspid regurgitation in heart failure, a 16-year-old with dense hemiplegia from a stroke due to large left atrial thrombi from severe mitral stenosis, a 36-year-old with severe malnutrition and cor pulmonale. Even ECG machines are not readily available, nevermind cardiac cath and chest CT. But it was encouraging to see hypertensive heart disease now being adequately treated, severe cardiomyopathy on therapy, and my trainees counseling on low sodium diet. More to come in the next 2 weeks!

Monday, June 24, 2019

Stories of Flight: Trauma and mental health among forcibly displaced and conflict-affected refugee populations in Uganda


Hazar H. Khidir, M.D. 
Resident in PHS Emergency Medicine Residency
PGY 2

June 18, 2019

“There are so many princes here” Doddy, a community health worker in Nakivale, relayed to me. We stood under a corrugated tin-roofed gazebo on the premises of Nakivale Health Centre Number III in Uganda. He points to a man standing across the dusty courtyard between the health centers wards. This man, a refugee who had lived in Nakivale for many years, was once the son of a powerful chief in the Congo. He had a privileged life by international standards with material wealth,  a high-quality private school education, trips to the United States as a child. Everything changed when his father died and a rival Congolese community group seized power. He lost all his material possessions and was forced to leave, fearing that conflict with the new community group would result in loss of his life, too. Though he has half siblings in the United States, he could not ask for their help. With no other social supports, his migration took him to Nakivale. After many years alone in the refugee camp, he turned to substance use for comfort.

I had just met Doddy a few minutes before. He came to the health center with a kind-appearing couple that he brought for a medical check-up. They recently made it to Nakivale in the past year from the Democratic Republic of Congo. The couple were happily married and had eight children. They migrated to Nakivale to escape political violence. The husband had been kidnapped by a local rebel militia group and was taken to the group’s secluded base in the bush. He was forced into servitude and underwent disturbing physical and sexual violence. He managed to reunite with his family and they all fled the DRC together. He came to the clinic requesting HIV testing. He abstained from intimacy since reuniting with his wife due to fears that he had contracted HIV during his assault. He recounted each traumatic incident with complete composure and no betrayal of his emotion, speaking to the health worker calmly and politely. Next to him, his wife wept silently for him.

Doddy left for a home visit within the settlement. Soon after, a smiling, tall, dark-skinned Ethiopian walked up to greet me. He informed me that he worked as an Amharic translator at the health center. When I asked how he had come to Nakivale, he explained that he was born in Ethiopia and belonged to the Anuak Tribe. As an ethnic minority within Ethiopia, his tribe had endured persecution time and again through the booms and busts of civilizations in the region, serving as slaves during the Abyssinian Empire to freedom but second class citizenry under a brief period of British rule to de facto servitude after the Ethiopian government regained authority of the region. In the 1970s, when he was relatively young, both his parents were killed during a forcible eviction of his tribe from their land in the Gambella region of Ethiopia. He was able to flee to South Sudan with a few of his siblings. He lived in a refugee camp in South Sudan until four years ago when violence erupted between the South Sudanese government and anti-governmental rebels. During an escalation in the conflict, rebels opened fire at the refugee camp, killing a few refugees. He made a one month and ten day journey crossing the northern Ugandan border and traversing hundreds of miles to the southwestern region of the country to reach Nakivale settlement. He made the journey with one of his brothers. One of his children and few of his siblings stayed in South Sudan. Somewhere along the journey, through an experience that I was too reluctant to inquire about, he was separated from his daughter. He has been unable to contact or gather any information about her since he fled South Sudan.

Trauma and mental health among forcibly displaced and conflict-affected refugee populations in Uganda



Hazar H. Khidir, M.D. 
Resident in PHS Emergency Medicine Residency 
PGY 2

June 18, 2019

What makes one want to leave their home? For refugees, it is the feeling of needing to flee from violence, poverty, and/or persecution. This impetus  is what fundamentally distinguishes refugees from other migrants.  Refugees flee whereas migrants immigrate. Thus, the pre-migration, perimigration, and post-migration experiences of refugees are uniquely marked by higher incidents of trauma. I understood this from by background research on incidents of trauma and prevalence of mental health illnesses (depression, anxiety, post-traumatic stress disorder) among refugee populations globally. My aim in traveling to Nakivale in person was to try to understand the forces of flight, migration experience, and the mental health outcomes of refugees on a more individual, human level. 

Nakivale Refugee Settlement was opened in 1958 and officially established as a settlement in 1960. Officially, based on UNHCR (the UN Refugee Agency) figures, Nakivale hosts > 100,000 refugees from Burundi, the Democratic Republic of Congo, Eritrea, Ethiopia, Rwanda, Somalia, Sudan, and South Sudan. During the Burundi crisis in 2015, the population of the settlement greatly increased and has since remained this high.

The settlement span across 185 km. It is at times both sparsely populated with small clusters of modest homes scattered across a large area of land and densely populated, informal shopping markets. The markets are impressive in scope, with hundreds of stalls. Stalls sell food, offer salon services, and locally manufactured goods such as metal gates, wooden bed frames, and cultural garb.

There are several individual communities within the settlement that are largely separated based on country of origin (i.e. Burundi Camp, Somali camp, Ethiopian camp, “New congo”). There are one or two camps that host an integrated community of refugees. Religion appears to be a factor that has resulted in self-segregation of the Somali refugee community from refugees of other nationalities.

There is also noticeable variation in socioeconomic status. There are those who have established successful shops and are relatively thriving and those who can’t afford enough food and are dependent on World Food Program distributions. All residents of Nakivale Settlement receive care from three clinics. These clinics off very basic medical testing but no imaging (including chest x-rays) or other diagnostics. The nearest referral center for the clinics is Mbarara’s University Hospital, the second largest referral hospital in Uganda.

Friday, June 7, 2019

Clinical Elective in Trauma Emergency Department at Groote Schuur Hospital, Cape Town, South Africa Part 2


Kelsy Greenwald, MD
Resident, Harvard Affiliated Emergency Medicine Residency
PGY 2

May 30, 2019

Bruising from a sjambok
The busiest times at Groote Schuur Hospital are weekend nights. On one such weekend night, we heard a bell go off, which would be a sign to everyone in the trauma section that a patient was being brought to the resuscitation unit. When we arrive, the EMS providers tell us this patient was involved in a community assault. This is a form of vigilantism. Distrustful of the local police force, a community mob will attack a person who was involved in a robbery or other crime. Instead of calling the police, the mob (often 20 or more people, including children) will take it upon themselves to punish the offender, often beating him with bricks, sticks, and sjambok (whips) until his family members call an ambulance or the police. Here you can see bruising marks from the sjambok.


The Lodox
The patient had multiple lacerations around his scalp, multiple skull fractures around his occiput, bilateral hemopneumothorax, right humerus and femur fractures, but luckily no intra-abdominal injuries. He was placed on a special stretcher that is used to take a full body x-ray with the special x-ray machine that is located right in the resuscitation room, the Lodox.

After receiving bilateral chest tubes, intubated, and given blood, he was stable enough to rush to the CT scanner (3 hallways away). Rather than a mobile ventilator, a doctor bags the patient the whole way, with epinephrine/adrenaline and fentanyl in their pocket. Only after first receiving a brain CT, showing a non-fatal head bleed, did the radiologist consent to further scans of the c-spine, chest and abdomen. The patient eventually went to the operating room with orthopedics. This was one of eight resuscitation patients of the night.