Friday, February 10, 2017

Teaching and Learning in Botswana

Jonathan Cunningham
Resident in Internal Medicine at Brigham and Women's Hospital

One of the most rewarding parts of my 4 weeks at Scottish Livingstone Hospital in Molepolole, Botswana was learning from and teaching the local medical team. My application for a limited medical license says I came for “capacity building,” but I had so much to learn as well. 

The skill set of the local team was dramatically different from my own. At first I felt useless. Many patients had medical issues I had never encountered in the United States. Extra-pulmonary tuberculosis and opportunistic infections such as cryptococcal meningitis and Kaposi’s sarcoma in AIDS patients are among the most common diagnoses. I was also unaccustomed to practicing with so little objective patient data. At Scottish Livingstone, labs come back the next day and must be drawn by the physician. Physical exam is more important. At home I often examine patients after imaging has made the diagnosis. In Botswana, CT scan is a scarce resource that requires transfer to the national tertiary care hospital. It was a privilege to learn from the skills of my local colleagues. 

"The multi-disciplinary team on the male medical ward”
I eventually found that I had something to contribute as well. In Botswana, medical school graduates receive only one year of post-graduate training before becoming independent doctors; only 3 months are devoted to internal medicine (the rest is pediatrics, surgery, and OB/GYN). On issues like asthma and congestive heart failure, which are prevalent in Boston, I was able to share the standard of care we provide in Boston. I led a teaching session on cardiac tamponade, an under-recognized issue in Botswana. We were also able to present difficult cases to specialists in Boston over the phone to bring their expertise to Botswana.

The two-way street of teaching between our Harvard team and local doctors fostered camaraderie and was great fun. I hope that I was able to build a small bit of capacity by sharing my excitement about internal medicine. Just as important, my time at Scottish Livingstone will change my practice in Boston by helping me to rely less on advanced testing. I’m grateful for the chance to work with these dedicated doctors in a very different setting.

The Challenges of Acute Care in Botswana

Jonathan Cunningham
Resident in Internal Medicine at Brigham and Women's Hospital

My first patient at Scottish Livingstone Hospital in Botswana was 60-year old woman with a new diagnosis of diabetes and ketoacidosis. She had actually been admitted three days earlier over the New Years holiday, but no physician had seen her since the Emergency Room. At Brigham & Women’s Hospital where I am a resident, the care of patients with diabetic ketoacidosis is standardized. Patients with the degree of acidosis this patient had (pH of 7.1) are admitted to the ICU, where they receive IV fluids and blood tests every 4-6 hours to facilitate the potassium supplementation. This patient had received little fluid and no blood testing. When we checked her potassium that morning it was extremely low; thankfully she appeared well. The local medical interns with whom I was rounding taught me that the standard of care at Scottish Livingstone was to start oral potassium and check lab tests every other day. We implemented this plan, and the patient did well heading into my first weekend, when we do not go to the hospital. 

When I returned on Monday, I learned that she had passed away suddenly from respiratory failure. My attending felt that acute muscle paralysis from low potassium was most likely the cause. I was devastated. I felt (as I still do) that I could have prevented this outcome by organizing more aggressive potassium checks over the weekend, or coming in to do them myself. But the local members of our team felt differently. They reminded me that there are only two physicians at the hospital over the weekend who must draw all laboratory testing as well perform urgent procedures such as Cesarean sections. Checking labs daily on well-appearing patients, they said, prevents other patients from receiving necessary care.
"Learning to draw blood is an important part of working at Scottish Livingstone"

I believe the truth lies somewhere between my feelings and those of my local colleagues. Both poor medical care—our failure to recognize that she required more careful monitoring—and limited resources contributed to this outcome. To raise the quality of care in Botswana, it will be necessary both to fight for more resources (such as a phlebotomy service or more staffing on weekends) as well as to train local physicians to allocate them more efficiently. I would be na├»ve to think I contributed to these goals in my short time in Botswana. However, this patient and others helped me gain an appreciation for the challenges faced by physicians in resource-limited settings. 

Tuesday, October 25, 2016

The Palestinian Medical Referral Process: A Study of Process in Process

Erica L Nelson
Resident in Emergency Medicine at Massachusetts General Hospital and Brigham and Women’s Hospital

October 16th, 2016

Anecdotes over tiny cups of Arabic coffee: the 17 year-old, traumatic head bleed patient that waited
five days for transfer for neurosurgical evaluation to a hospital located not even a 2-hour drive away. He died. The 39 year-old woman who spent 14 months at Hadassah Hospital after receiving a life-saving bone marrow transplant. She lived. The critically-ill patient that was driven to the border in a Palestinian-permit ambulance, then moved to a wheelchair to cross the border, then transferred to an Israeli-permitted ambulance for the completion of the journey. A back-to-back transfer that took an extra hour with oxygen lines and epinephrine still running. The cacophony of successes and frustrations, tragedies and man-made miracles, politics and goodwill create nothing less than a Pollock-painting when I try to disentangle the Palestinian referral process. As a physician, an empiricist, I try to step back and consider before the judgement.

First, an examination of ‘self’: How do we transfer patients in the United States from a clinic to a hospital? One hospital to the next? An institution outside of our medical record system? Is it a simple phone call, a hurried and harried hospital summary, printed labs and consultation notes, the coveted but oft-corrupted CD of imaging? Where do the referrals land?

In our Emergency Departments, there’s all too often sighs regarding incomplete documentation, a confusing narrative, the questionable reason for transfer. Time-willing, there are phone calls and faxing, curriers and clarifications. But how often do we start over, clicking through inordinate EPIC tabs to order the reportedly-normal labs ‘just to have them in our system’? Our process is not above reproach.

And with that in mind, let’s think about a cross-factional, cross-border medical referral process:

There are 4,682,467 people in the Palestinian territories, 1.4 million refugees and tens of thousands of patients that need higher levels of care. A two-year-old with acute leukocytic leukemia, that 17-year-old who sustained a traumatic sub-arachnoid, breast cancer patients, congenital heart cases, hemodialysis patients, oncology, coronary disease, orthopedics, pediatrics –thousands upon thousands of patients that need to be transferred. The infrastructural and literal violence, the administrative fragmentation and resource shortages that have created such a situation is a critical part of the conversation, but, frankly, not what I am here to address. I am here to study the complexities, realities and challenges of getting patients to the care they need.

When first conducting feasibility interviews in January, physicians (both Israeli and Palestinian) commented that there was hardly ‘a process’, but multiple variations derived from a non-standardized, ambiguous, unmonitored, untrackable system that required 1) referrals, 2) sponsorship and 3) Israeli travel permits. A whole host of complications were offered up –transfers are untimely, procedures delayed, medical information lost, sponsorship and reimbursements remain problematic. So, over the last 9 months, my research team developed a survey to understand both referring and referral-accepting MD experiences, and started building relationships with officials to obtain both Palestinian and Israeli, disaggregated referral data.

These last two weeks in Israel and Palestine have been several, tortoise-paced steps towards unfurling this project and ultimately understanding an inherently complicated process in a stochastic environment complete with multiple factions and border-crossings, two Ministries of Health, three governments, varied donors, hospital structures and perspectives. Each moment of analysis and judgement demands self-reflection and contextualization. This study of a process is very much still in process.

Wednesday, October 12, 2016

The Palestinian Medical Referral Process: A Study of Process in Process

Erica L Nelson
Resident in Emergency Medicine at Massachusetts General Hospital and Brigham and Women’s Hospital

October 9th, 2016

Sandwiched in between Rosh Hashanah and Yom Kippur, volleying between Jerusalem, Hebron, Ramallah, Nablus, nine different hospitals, multiple check points, cups of mint tea and strong coffee, Arabic, English, Hebrew, check-point, vibrant market, dingy office, immaculate NICU and disquieting ED, I find myself in a (needless to say), politically tricky situation. In a context wherein the origin of a mashed chickpea dip is contentious, I somehow have the audacity to attempt to examine the Palestinian/Israeli medical referral process. Even writing a blog post about it, trying to to craft each word to be perceived as politically neutral, is giving me tremendous anxiety.

Perhaps a year ago, when this project to study and potentially improve the Palestinian medical referral process started to take on solid form, I knew how wrought it would be. A feasibility assessment in January uncovered numerous interpretations of the non-standardized, untracked process that brought a Palestinian patient to East Jerusalem or Israel. A several month-long struggle with Western-trained empiricists trying to lend statistical validity to a study that inevitably could be nothing more than convenience sampling stalled international IRB processes. Imperative, quantitative data lay in distant hands, on paper, in spreadsheets, awaiting data-sharing negotiations before the woeful process of cleansing and justification even began. And politics colored every word and movement, document, grant application, border crossing and hospital visit. Nothing about this is easy.

And that, nestled beside simple human compassion and lofty Hippocratic imperatives, is why it is so compelling. The delivery of healthcare or, in this case, the delivery of patients to healthcare, is complex, context-bound, political and socio-economic. Systems that efficiently and effectively deliver healthcare, whether it be a Public Health Department or an Emergency Department, a ‘medical mission’ or a longitudinal development initiative must continuously examine the environment that surrounds their patients and their institutions. Any initiative, study, treatment plan or discharge that ignores context, will at very least lack generalizability and at worst, fail.

This reality, as an intellectual concept, is easy to understand. But the cognitive and logistical burdens it creates, the resources and time required to complete a comprehensive needs assessment and contextual analysis (of a system in crisis or a patient in crisis) often feels insurmountable. More than the tangible Likert-survey distribution and database creation, the logistical regressions and geoanalytics, this experience has been about tenacity, continuous re-calibration and humility. Whether it be in a Ministry of Health meeting or in Acute Bay 1 at Massachusetts General Hospital, these are the attributes that I must take a moment (to breathe) and summon.

Tuesday, August 2, 2016

Orthopedic Trauma Surgery in Haiti

William Slikker
Orthopedic Fellow at BWH

Resources in Haiti are limited and this includes the supply of surgical instrumentation. During our trip we encountered many obstacles but the most difficult to overcome was the lack of appropriate surgical instrumentation and devices that we would typically use in the U.S. For instance, there was no intra-operative fluoroscopy, which we would have normally used for a majority of the procedures we completed on the trip. It took careful planning and a dose of ingenuity to overcome the lack of instrumentation. Adapting to a foreign operating room was difficult, but the local orthopedic surgeons had much to teach us in regards to tackling surgical cases using their set of instrumentation. With the help of the Haitian orthopedic surgeons, we were able to accomplish our goal of providing safe and impactful clinical care. But by collaborating with the Haitian surgeons in this way, we also built a partnership which we hope will continue long into the future.

            This trip served to open my eyes to the complexity of international outreach and the nuances of effectively collaborating with local surgeons and staff. It taught me many things about how to successfully provide clinical care in an international setting. It also demonstrated how the short term efforts of providing direct clinical care are not as important as building bridges for education and communication in a long term grassroots effort to bolster the local medical system in which we are only temporary visitors. Although we accomplished many successful surgeries, our efforts at partnering with the local orthopedic attendings and residents will hopefully build a connection that is even more impactful in the long term.