Monday, April 6, 2020

Clinical Elective in Dermatology in India, Part 2

Cristina Thomas, MD
Resident in the Harvard Combined Internal Medicine-Dermatology Residency Program

Dermatology Residents and Attendings at Amrita Institute of
Medical Sciences
I am wrapping up my time in Kerala, India and have been reflecting on the role of the dermatologist in India. With an interest in complex medical dermatology and tropical diseases, I am currently a PGY-5 in the combined internal medicine-dermatology residency program here at Harvard. While in India, I’ve noticed that almost all dermatologists practice at least some amount of internal medicine. Without a high prevalence of skin cancer, the majority of patients seen in the dermatology clinic are those with cutaneous manifestations of systemic disease. I can’t count the number of patients who have presented with extensive tinea corporis only to have the dermatologist check a HbA1c and diagnose the patient with diabetes which is a risk factor for tinea. The dermatologist often coordinates the multi-disciplinary care of leprosy patients who require neurology, podiatry, and PT/OT. The dermatologist manages cancer screening in a patient with paraneoplastic pemphigus. I could go on and on about the complexity of care that these physicians provide, and I’ve been so impressed with the compassion and expertise of these physicians.

Apart from the medicine, however, dermatologists also play a huge role in quality of life for these patients. Patients with dermatologic disease in India are often stigmatized against because of the visual nature of their condition. I saw a man with albinism who was fired from his job because of his skin condition, a young girl with vitiligo who was teased by her classmates, and a woman who was shunned by her family because she had lymphatic filariasis. The physicians I worked with not only treated these patients in order to improve their quality of life, but also sought to change the societal milieu which led to their discrimination. They took the time to educate the patients’ families and even organized educational activities in the community to reduce the stigma associated with dermatologic conditions like vitiligo, psoriasis, and leprosy. My interest in medicine as a field stemmed from a desire to improve quality of life in individuals and it has been refreshing to see this done each and every day at Amrita Hospital.

Clinical Elective in Dermatology in India, Part 1

Cristina Thomas, MD
Resident in the Harvard Combined Internal Medicine-Dermatology Residency Program

Hello from Kerala, India! I have now been working at Amrita Hospital in Kerala, India for the past two weeks and have learned so much over that time. I’ve been to India a number of times for global health work, but this elective has been very different from my prior work because I have had the opportunity to delve into clinical care rather than focus on research endeavors.

Amrita Institute of Medical Sciences
Amrita Hospital is a 1450-bed hospital that treats around 3000 outpatients daily. Within the dermatology department, a broad range of skin conditions are seen, ranging from common diseases that we see in the US like psoriasis to neglected tropical diseases like lymphatic filariasis. Despite the range of diseases seen, I have been struck by the department’s ability to practice cost-effective care. Although Amrita Hospital has the ability to perform many complex lab tests including dermatopathology (which is a key component of dermatology), the dermatologists at Amrita only order these tests if they are absolutely necessary. This is because, in general, patients are paying for their care out of pocket. This includes the physician visit, any lab testing, and any prescriptions. Without a reliance on ancillary testing, the dermatologists at Amrita have outstanding physical exam skills. They are able to distinguish between bullous pemphigoid and pemphigus vulgaris with the Asboe-Hansen sign, identify leprosy with palpation of a slightly thickened ulnar nerve, and diagnose oral lichen planus by picking up on fine white reticulations in the mouth of a patient with oral burning. Along with these excellent physical exam skills comes a true focus on the patient. The physicians spend time gathering a history to narrow their differential diagnosis and carefully examine each patient looking for any clues to point to a specific disease. This is in stark contrast to many of our patient encounters in the US where we have a short 15 minutes with the patient to develop our assessment and plan and thus, relay on testing to expedite the process. I have found it refreshing to reflect on my approach to clinical care through the lens of the health care infrastructure in India and am excited to continue this over the rest of my rotation.

Developing Systems of Care for Non-Communicable Diseases in Ethiopia

Zachary Hermes, M.D. 
Resident, Internal Medicine at the Brigham and Women’s Hospital, 

My time in Ethiopia has been a bit of a blur over the past 3 weeks traveling between busy cardiovascular clinics, crowded inpatient cardiology wards, and district hospital echocardiography clinics. Thankfully, I had a unique experience last Tuesday that allowed me to step back and take a birds’ eye view of the health care ecosystem in Ethiopia. I was invited to join a workshop hosted by the Federal Ministry of Health (FMOH) focused on Non-Communicable Diseases. The group had previously convened as the Ethiopian Non-Communicable Disease Interventions (NCDI) Commission, which was a cumulative effort by the FMOH, local academic institutions, individual experts, patient/professional associations with facilitation by the Global Lancet Commission on “Reframing Noncommunicable Diseases and Injuries (NCDIs) for the Poorest Billion.” This was an enlightening experience in that it provided macro-level, policy-focused view of health delivery in Ethiopia, and it complemented my on-the-ground perspective with holistic view of the entire ecosystem. Additionally, it was instructive to see the process and structure of a ministry-level governmental working group.

As we launched into the program, the discussion started with a snapshot of healthcare institutions and workforce. In terms of hospitals, there were approximately 25 tertiary hospitals, 80 general hospitals, and less than 200 primary hospitals which tend to be the center of care for almost all non-urban populations. Yet that 200, was far below the WHO recommendations which would translate to roughly 1000. Additionally, there was a little less than 1 healthcare worker per 1000 people which was similarly below the WHO goal level. The landscape for healthcare financing was also striking. Average healthcare expenditures/capita came out at roughly $33USD, but 70% of NCD services were  financed as out-of-pocket which also meant that health care was the number of cause of bankruptcy or financial distress for the population. This reaffirmed the importance of their objectives to identify essential NCD services, understand how to finance their provision with public dollars, and most importantly, how and where to actually deliver the care needed.

At Non-Communicable Diseases and Injuries (NCDI) Health
Sector Interventions Summit hosted by Ethiopia's Federal Ministry
of Health 
The next point of discussion was to review the previously determined package of essential health services in the context of the delivery platforms available to the health system. The key levels were tertiary care hospitals, general/primary hospitals (which were realistically the most accessible level of care for the majority of Ethiopians), health centers, community-based care through health workers, and population-based approaches. Our conversation focused on the interface between tertiary care hospitals and general hospitals, as this postulated to be a key leverage point to advance the decentralization of NCD care which was currently limited for the most part to Tertiary hospitals. What became clear to the group was that although an excellent and well-evidenced list of recommendations of what needs to be delivered, and ideally where it should be delivered, there wasn’t any data on how many of the selected interventions were actually being delivered at different levels, who was delivering those services, and why recommended packages were not being delivered. To see the hypothesis-generation and methodological refinement occur in real-time was amazing, and by the end of the workshop there was a proposed framework for assessing what is actually occurring at the primary hospital-level and tertiary-hospital level.

The group was gracious in welcoming me and were intentional about engaging me throughout the discussion. It was an honor to join the workshops, and I was thankful to spend the day learning from their perspective and experience.

Cardiovascular Care in Ethiopia

Zachary Hermes, M.D. 
Resident, Internal Medicine at the Brigham and Women’s Hospital, 

Ethiopia is located in Northeast Africa, and is one of the largest countries on the continent with a land mass three times larger than Germany and a population of nearly 100 million. Non-communicable diseases such as congenital heart disease, rheumatic heart disease, heart failure, and ischemic heart disease are of growing importance and consequence. Yet, access to cardiac services remains limited in Ethiopia. My time in Ethiopia was spent observing and diagnosing the growing burden of cardiovascular disease, exploring the ecosystem of cardiovascular services, and gaining insight into the challenges and opportunities to expanding cardiac care capacity.

Modern cardiovascular care was first made  available within Ethiopia in the mid-90’s. Most of this care has been at a relatively small scale and come in the form of visiting cardiac surgical and interventional cardiology teams. The first Ethiopian-led non-invasive and invasive cardiology (pacemaker insertion and percutaneous coronary interventions) care began to be offered in 2007. In the decade that followed the national Ministry of Health prioritized the establishment of modern cardiology units in their anchor, tertiary-level University Hospitals. With diligence and commitment a number of internists were trained abroad in non-invasivee and invasive cardiology, though their numbers are in the single-digits. Addis Ababa College of Health Sciences, which is affiliated with Black Lion Hospital, was one of the first to be outfitted with a modern catheterization laboratory in 2016 and they have subsequently launched an Ethiopian Cardiology Fellowship program in 2018. My elective work was spent with these endeavoring attending cardiologists and the third cohort of cardiology fellows. My days were split up between cardiovascular outpatient clinics, inpatient cardiology wards, and an occasional pacemaker implantation or balloon valvulotomy with rounds in the cardiac intensive care unit to follow. In the clinics, I saw over 100 patients in the clinics with roughly 40% of those with rheumatic heart disease spanning a spectrum of heart failure and another 30% with some variation of ischemic heart disease, hypertension, or diabetes. The morbidity caused by rheumatic heart disease was truly striking, with far too many teenage patients already with symptoms of heart failure and advanced structural disease that would necessitate valve replacement in other settings. Unfortunately for these patients, they were relegated to symptomatic management with diuretics. The waiting list for valve replacements hovers around 10,000 patients (!) with movement dependent on the aforementioned visiting groups. It was just in 2017 that the first open heart surgery was performed in Black Lion Hospital by an Ethiopian Surgeon supported by one of the foreign surgical teams. The momentum has been continued as their cardiology fellowship now has graduated their first cohort, a masters of cardiac nursing program is up and running, and a perfusionist training program is in place. Most excitingly, the Ethiopian and Netherlands governments had signed a joint deal with Phillips to break ground on a state of the art cardiac care facility on the Black Lion Campus. I had the pleasure of working with clinical lead of this project, Dr. Dejuma Yadeta, for a number of days and we visited the site. 
With Dr. Berhanu Nega, M.D., Associate Professor of Surgery
at Addis Ababa University School of Medicine, Head Cardiac
Service Team at Tikur Anbessa Hospital, in front of construction
site for state of the art Cardiac Hospital on Tikur Anbessa Hospital Campus

As the largest teaching hospital in Ethiopia, Black Lion Hospital and Addis Ababa University School of Medicine serves as a vibrant training center for undergraduate and postgraduate medical students and trainees. This was my base throughout my elective with interspersed time at number of smaller clinics and districts hospitals, which were envisioned to act as a referral network and means to decentralize care. Still, the hospital and its associated clinics act as the primary source of access for a significant proportion of both the urban and rural population. During my time I saw numerous patients who had traveled more than 300 kilometers for routine management, which highlighted the importance of decentralizing care for Non-Communicable Diseases (NCDs). Though the challenges are undoubtedly immense, I came away struck by the dedication, strategy, and thoughtfulness of my Ethiopian colleagues and sure that I will continue to support and collaborate them in any way I can as I move forward in my career.

Christian J Leuner, Abraha Hailu Weldegerima, Cardiology services in Ethiopia, European Heart Journal, Volume 39, Issue 29, 01 August 2018, Pages 2699–2700,

Attitudes about Death: Reflections on a Clinical Rotation in Lusaka, Zambia

Katie Holroyd, M.D. 
Partners MGH/BWH Neurology resident, 

From my experience thus far in American hospitals (acknowledging the limitation that I have trained exclusively at large, academic institutions in major east coast cities), there are two main types of deaths we see during training. The first is the unexpected, often catastrophic death from large strokes, traumas, cardiac arrhythmias, or other non-reversible conditions. These scenarios often involve prolonged codes, extensive resuscitation attempts, and utilization of a vast amount of resources in the emergency department or on a hospital floor. The second is the slow and deliberate transition to death, which can be referred to in many ways including comfort care, hospice, or palliative care.  This often occurs in older patients in whom additional diagnostics or treatments would cause more suffering than benefit, and takes place after extensive delicate discussions with family members (or at times the patient themselves). Regardless of the way that death occurs in the hospital, it is usually an intensely private experience, with patients moved to single rooms and all measures taken to support and respect family members during the transition.  

It has seemed to me, that death in the US is almost never viewed as inevitable until the very last moments, and that death without extreme investigations, treatments, and resuscitation is the exception not the rule.  In contrast, and with the disclaimer that I have very limited understanding and experience in Zambian culture after only one month, attitudes about death in Zambia seem to exist in an almost paradoxical fashion.

On one side, there are far fewer open medical discussions about the transition to death here. Countless patients who would be in an intensive care unit the United States lie in regular beds, and with one look any medical professional could identify that they will not make it out of the hospital alive, especially given the limited resuscitation resources here. However, these thoughts are not relayed directly to family. This comes in part because there is generally no acceptance of withdrawing care in Zambia.  As discussed in my previous post, families provide most of the direct care to patients in the hospital, and concepts such as stopping feeding (even if a patient is unable to swallow) or withdrawing medications do not exist. A palliative care service was briefly formed by some of the residents at UTH, but it was not accepted by patients, other physicians, or hospital administrators and was disbanded. Several of the residents here remain interested in performing projects to help better understand attitudes regarding palliative care, with the hope of re-instating this service in the future.

Contrarily, I have found death to be much more visceral, present, and commonplace here than in the United States. Far more of my patients here die, and die at much younger ages, than patients I see in the US. Often at least one patient I saw in the morning will have died by the afternoon. Sometimes this is expected in our sickest patients, but at other times, such as the 28 year old man who walked into the hospital with only a cranial nerve palsy one week earlier, it is very unexpected. These patients are passing away in shared rooms with 8-12 other patients, and thus there is no way to not be faced with death on a daily basis either for the physicians and nurses in the hospital, or the other patients and their families. In this sense, by force of necessity, death is directly witnessed much more frequently than in the US.

CT of the head showing an
old stroke as well as evidence
of neurocysticersosis infection
I have also found families ask far fewer questions surrounding a family member’s death—rarely questioning why, how, or making accusations of medical misconduct at any point. Whether this is based on language and cultural barriers with an American doctor, lack of medical literacy, or something else, I cannot say. However, it seems that many Zambians have been forced to experience death as a very real part of life, without extensive questioning or complaining. I can imagine this is due both to differences in life expectancy (61 in Zambia, compared to 78 in the US) and larger family size (average number of children in Zambia 5.5, compared to 1.9 in the US).

Importantly, I do not in any way mean to convey that families in Zambia are okay with a patient’s death. In fact, the grief rituals here involve wailing, screaming, and falling to the ground at the patient’s bedside, which last for many minutes and can be quite traumatizing to nearby patients.

I really have no other word to describe the fact that Zambians must experience a far greater proportion of preventable deaths from infection complications of chronic illnesses, and lack of resources, than unfair
. However, it has made me wonder if the American—or if not American, at least my personal—tendency to avoid, resist, deny, and disbelieve the inevitability of death, may at times do more harm than good.

Family Ties: Reflections on a Clinical Rotation in Lusaka, Zambia

Katie Holroyd, M.D. 
Partners MGH/BWH Neurology resident, 

Lets talk about family. I grew up an only child in the small town of Athens, Ohio. I have no siblings, and despite having five aunts and uncles, I also have no cousins. While I love my parents very much, this often made for extremely boring Thanksgiving dinners growing up, in which I was the only human under the age of 60 in the room. My mother, having cared for her mother who passed away from Alzheimer’s disease, has told me on numerous occasions that she does not want to ever be a burden to me, and to “put them in a home” at the first sign of ill health. While the latter statement is always tinged with humor, I believe her underlying sentiment is true: she never wants her old age or ill health to put limitations on my life as her only descendent.
Katie Holroyd and Anastasia Vishnevetsky stand outside
University Teaching Hospital in Lusaka, Zambia

Ok, so what does this have to do with Zambia? I traveled here for a one-month clinical rotation in Neurology at the University Teaching Hospital (UTH) in Lusaka, Zambia My initial underlying goals were two fold: to experience the practice of neurology in a lower resource setting, and to increase my exposure to neuro-infectious diseases with the goal of incorporating this into my fellowship following residency graduation.

The wards in Zambia consist of several bays, or open walled-off areas in one very large room. Each bay has from 8-12 beds next to each other, invariably always at or above capacity. Almost without exception, every patient is accompanied by a family member at all hours. While this makes for an extremely crowded work space, I have come to find that it is absolutely necessary in order for medical care to progress in the hospital. In the US, family visits are for exclusively that: visiting. Families are not expected to participate in basic care for the patient, provide supplies, or assist in obtaining diagnostic procedures. In Zambia, families must do all of these things, and perform almost all of the duties that nurses and nurses assistants do in the US.

At UTH, families must provide their own bedding for the hospital, and the outside of the hospital is covered in drying laundry on any sunny day.
They also provide all of the food for the patients, and bedside cabinets are filled with fruit and bowls of nshima (the local porridge eaten with each meal). In patients who require a nasogastric tube for feeding (which is quite a few of the neurology patients), families are even responsible for providing, preparing, and administering all food through the tube.  In order to provide this 24/7 care, families often roll out mats and sleep next to their family in the hospital, or even on the concrete pathways outside of the building.

Laundry hangs out to dry at the Hospital. Patients' Families must
supply and clean all of their own clothing and bedding. 
In addition, with the computer-less system here, families are often required to walk to the laboratory to request printed test results, travel to radiology to request disks of CT scans, or go to an outside pharmacy to purchase medical supplies such as the aforementioned nasogastric tubes. While some medications are free for families in the hospital, the hospital pharmacy has a much smaller selection of medications than are available at private pharmacies. Imagine my horror as a neurologist when I learned that the hospital was out of aspirin during my first week here! As a result, many of the medications we prescribe (from vitamins to blood pressure medications) are dependent on families to travel to an outside pharmacy and pay to purchase the medications and bring them back to be administered. Similarly, the hospital lab is often out of reagents for lab tests even as basic as electrolytes, and families who have means are asked to manually carry tubes of blood to a private lab to have tests performed.

Family members at the bedside are especially crucial for neurology patients who are often unable to talk or move on their own. Families are not only responsible for basic daily nursing care such as turning bedbound patients or helping patients up to use the bathroom, but they also provide much of the medical history during our interviews. In a culture where hospice and care withdrawal are not accepted or discussed, families also provide all care for patients at the end of their lives (see blog post #2 for more thoughts on this).

Finally, in a place where “long term care facilities” and “nursing homes” or “acute rehabs” really do not exist, families often take patients home who are completely dependent for all their needs. I have never once had a family question how they would care for their hemiplegic, mute, or even minimally conscious relatives at home. It is simply accepted and expected, and families often provide very good care for these relatives at home who return to clinic well fed and without bed sores. I now understand why many Zambians have upwards of 7 or 8 children—without them you have no care network.

This culture does not stop with a patient’s direct family. Rarely a patient visit goes by without the neighboring patient or their family (often only about 1 foot away separated at best with a thin curtain) chiming in on the history, helping with translation, or assisting in recounting lab or imaging tests results. While in the US this would be deemed a horrifying breach of privacy (ie HIPAA), this has resulted in many positive changes in patient care during my time here at UTH.

If patients do not have family, they are often stranded at the hospital for weeks or months relying on hospital staff to provide care that is much less thorough than would be provided by a loved one. If they do not have family to care for them at home, they are eventually discharged to one of very few “hospice” facilities that exist in Lusaka.

I hold deep respect and admiration for the families and patients that I have met in Zambia. Does this mean that I am going to take leave and care for my mother 24/7 if she should be hospitalized? I think the answer remains no, but I hope that I can bring some of the selflessness, support, and kindness that I have seen in Zambia back to the US.

Heart Failure and Cardiac Ultrasound Training in Rural Rwanda

Sheila Klassen, M.D. 
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.

Giving out completion certificates after heart failure and echo
training course. 
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. 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.
One of my trainees performing an echocardiogram in a rural
Rwandan hospital. 

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.

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. 

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

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

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, M.D. 
Resident, Harvard Affiliated Emergency Medicine Residency MGH/BWH, 

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.

Nyungwe Forest National Park
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.