Sunday, March 25, 2012

Cholera in Bangaldesh introduction, Ana Weil, Internal Medicine MGH 2

           The International Centre for Diarrheal Disease Research, Bangladesh (icddr, b) where I am working in cholera is a research center and hospital in Dhaka, unique because of the commitment of those who work there to savings lives through both clinical care and research. Known in Dhaka as the “cholera hospital” or “diarrhea hospital”, admission to the hospital requires diarrhea (except in HIV patients). During cholera season two times a year, up to a thousand patients per day can present at the hospital for treatment; during these times, tents for makeshift cholera wards are assembled in the parking lots. Cholera cots, or wooden cots lined with plastic sheeting with holes in the middle for stool collection and measurement of fluid losses, appear in every corner of the hospital.
            The staff at the icddr, b knows that if a patient arrives to the hospital breathing, death can be avoided. Even if a pulse is absent, an IV is placed and rehydration is initiated. The speed at which this treatment begins is incredible; I have seen large-bore IVs placed in an unconscious patient still in the doorway in the arms of a family member. The nurses and IV teams at the hospital know how important speed is; they are empowered to save lives and go to great extents to do so. They are the world’s experts in treating cholera. Medical staff from the icddr, b has traveled to every major cholera outbreak in the world in the last decade to train local staff. Because the amount of rehydration required in cholera is much more than used in other diarrheal diseases, inexperienced staff can inadvertently under resuscitate patients and death can result. Research studies have documented the decrease in case-fatality rate that occurs after an icddr, b team arrives at the site of a cholera outbreak.

            Oral rehydration solution was first used in Bangladesh during a cholera outbreak in the 1970s. This simple mixture of clean water, sugar and salt is one of the most important medical discoveries of the 21st century, and has saved millions of lives. For several decades, the icddr, b and other sites in Bangladesh have been leaders in research and clinical care of patients with diarrheal disease.

            More recently, the icddr, b has changed HIV care in Bangladesh. HIV is thought to be rare in Bangladesh, and the prevalence of disease is not known. The icddr, b is the only hospital in the country with an HIV ward with care specifically for HIV patients and their families. During my month in Dhaka I was able to join in on rounds during my time out of the lab, and also took part in teaching medical residents working in the HIV ward.
            For more than a decade the icddr, b and MGH have collaborated to study the immune responses to cholera with an aim to improve cholera vaccines. After cholera, patients are protected from severe disease for at least several years through immune mechanisms that are not well understood. We believe that anamnestic memory responses in the gut confer protection, and T cells may have a role in the creation or maintenance of this response. When a person is diagnosed with cholera at the icddr,b, a large field team in Dhaka enrolls patients and their household contacts in the immunology studies at the time of hospitalization for cholera. In the lab, we receive blood from the patient on day 2 of their hospitalization (usually also the day of discharge) after their stool culture grew Vibrio cholerae overnight. With fresh blood, PBMCs are extracted for B cell studies and whole blood is prepared for flow cytometry examination. During the next year, this same patient and their household contacts with have blood drawn several times, and field workers will visit their homes to ask them about any symptoms they have and send them back to the icddr, b for severe illness. My immunology work is focused on T cell responses to acute cholera infection, and utilizes unique techniques in preparation of whole blood for flow cytometry.
            During medical school I worked at the icddr,b for one year, and made lifelong friendships with my colleages in the lab at the iccdr,b. Together we stayed late in the lab, came in on weekends, and spent hours troubleshooting the flow cytometer. It was wonderful to return to the lab and continue this work, see old friends, and spend time in this colorful city. The relationship between the icddr, b and the community allow work in cholera immunology to enter a second decade, and I hope to continue to be part of this work because of both the importance of the science and the wonderful people I have had the privilege of working with.  

Cholera in Bangaldesh introduction, Ana Weil, Internal Medicine MGH

           I am a 2nd year medicine resident from MGH spending one month in Dhaka, Bangladesh to work in an immunology lab studying responses to cholera. I received a Center for Global Health Travel grant to pursue this work, and in these blogs will introduce the topic of cholera with a few details about the research I am doing and the institution where this research is conducted. 

            In Bangladesh, the most densely populated country in the world, the capitol city of Dhaka contains at least 15 million residents, many of whom live in urban slums. Dhaka is a colorful and chaotic city, and every day thousands of people come to Dhaka from the countryside of Bangladesh in search of a better life. Nearly all cholera patients come from the urban slums, particularly one called Mirpur. This slum contains around 3 million people living in shacks and makeshift residences, and the water supply is heavily manipulated by people tapping in water lines illegally. This manipulation leads to sewage lines mixing with the water supply. Most people do not boil or treat their water prior to using it, since fuel for a fire and water treatment supplies cost money. In Dhaka, diarrhea is a common and somewhat normalized fact of life for both visitors and the Bengali people, especially children. The usual causes are E coli spp as well as rotavirus, shigella, typhoid and other bacterial, fungal and viral causes, in addition to cholera.

            Cholera occurs in areas of the world where the 20th century innovations of clean water and latrine use are not yet realized. There are 3-5 million cases of cholera each year and most cases are in southeast Asia. Children are disproportionately affected. The organism that causes cholera, Vibrio cholerae, lives in the environment in the Ganges Delta, which is the largest river delta in the world. This flat, easily flooded plain includes much of Bengal in northeastern India, as well as Bangladesh. This area has supported large populations for thousands of years, and for centuries cholera has caused disease both year round and in epidemic spikes during the two rainy seasons each year. V. cholerae is spread by fecal-oral transmission and causes a range of disease from asymptomatic or subclinical infection to severe dehydrating diarrhea that can cause death within 6-12 hours if untreated. In this short time, patients can lose more than 10% of their body weight in fluid losses, and adults can loose 20 liters or more. The primary treatment is rehydration, and in most patients oral rehydration is sufficient. In cases accompanied by severe vomiting, or dehydration that progresses to depressed consciousness, intravenous rehydration is required. Antibiotic treatment decreases the severity of disease and shortens the duration of symptoms. In Dhaka, tens of thousands of cases of cholera occur each year.
            There are several vaccines for cholera, and these have improved significantly in the last several years. They provide partial protection for several years, but are not very effective in children. My work in immunology is focused on understanding the immune response to natural cholera infection, in an effort to understand what creates the longer-lasting immunity we see after natural infection versus the partial, shorter-lasting protection observed after vaccination.

Tuesday, March 20, 2012

Rehabilitation - from A to Z

Cheri Blauwet, MD
PGY-3, Physical Medicine and Rehabilitation
St. Marc, Haiti
Comprehensive Rehabilitation Program - Zanmi Lasante/Partners In Health

I am now one week into my rotation in Global Health/Physical Medicine and Rehabilitation with the Zanmi Lasante Rehabilitation Team and in partnership with my residency program at Spaulding Rehabilitation Hospital. In considering the lessons most poignantly learned over the past 7 days, the ability to care for spinal cord injury (SCI) patients through the continuum of their care remains a highlight of my experience thus far.

Last Saturday our colleague from the Emergency Department called to ask if we could come see a patient for lower extremity parasthesias/weakness after involvement in a motor vehicle accident. It had already been approximately 12 hours since the time of injury, however his exam was clearly consistent with spinal cord injury at approximately the L2/L3 level, to include a palpable step-off sign as well as the flaccidity and decreased reflexes associated with spinal shock. The next several hours involved no less than 50 calls to surgical facilities throughout Haiti in an attempt to obtain the appropriate neurosurgical management for his acute SCI. He was ultimately transported to Port au Prince and admitted to a facility with the capacity for CT imaging as well as surgical management. There, he was diagnosed with an L2 burst fracture and in most recent discussion, he remains on strict spinal precautions while awaiting surgical decompression/fusion until a neurosurgeon is available within the next few days.

Only a few days later, I had the opportunity to go on home visits to see spinal cord injury patients within the Artibonite region and to more fully understand the manner in which care can be provided in the community. Observing the work of the St. Boniface Hospital Rehabilitation Team (a organization whose mission is closely aligned with our own), I was exceptionally impressed with the commitment and resourcefulness that enabled individuals with SCI to live full, healthy lives in their own home environments as opposed to within institutions. To provide an example, we visited one woman with a C7 SCI (and therefore tetraplegia) who was discharged from the inpatient setting only 2 months ago. Immediately after her SCI, she had developed Stage IV decubitus ulcers prior to receiving appropriate care, and these were still in various stages of healing. The Team had contracted with a layperson in the community for purpose of dressing changes two times a day given the lack of hands-on nursing care in her rural community. A cadre of “community integration technicians” had visited her home and widened the doorway of her small, brick home in order to allow her wheelchair to enter. The Rehabilitation Team had brought a small but reasonable monthly supply of supplies not available in her community, such as urinary catheters, wound care supplies, and medications frequently useful to the SCI population such as Gabapentin for neuropathic pain. In this setting, she was doing quite well and appeared to be moving forward, both physically and emotionally, despite having a diagnosis that would likely have been considered end-stage only a few years ago prior to the implementation of community based rehabilitation.

                         On a home visit near Verrettes, Haiti (permission given to post)

                           An example of home modifications (door widened, sidewalk from 
                                        street created with small ramp into home)

This series of events brought home to me the possibilities inherent within the process of rehabilitation, from managing high acuity injuries to ultimately considering issues of community reintegration as a portion of our role as physiatrists. This true continuum of care is what heavily attracted me to this field, and it is what keeps me “hooked” at the end of the day. 

Saturday, March 17, 2012


Cheri Blauwet, MD
PGY-3, Physical Medicine and Rehabilitation
St. Marc, Haiti
Comprehensive Rehabilitation Program - Zanmi Lasante/Partners In Health

As a physician in the specialty of Physical Medicine and Rehabilitation, my primary focus is the promotion of function and quality of life for individuals with physical and cognitive disabilities such as stroke, brain injury, spinal cord injury, musculoskeletal injury, and pain that may result in disability. Of interest, I am also a wheelchair user due to having experienced a spinal cord injury when I was young. In this role and with an ongoing passion for global health work, I have no choice but to promote my own function and quality of life in order to maximize my ability to provide care, particularly in settings such as Haiti, where the built environment and natural landscape are predominantly inaccessible. This dichotomy is a familiar one to any medical resident. In this role and on a daily basis, we encounter trade offs between contributing to the well being of our patients while also preserving our own personal health and ability to thrive.

For me, this necessarily selfish quest actually began several months ago when the  Zanmi Lasante/Partners In Health (ZL/PIH) team in St. Marc and specifically my clinical mentor, Dr. Andree LeRoy, reached out to begin the conversation regarding a basic needs assessment.  Impressively, the team took the necessary steps to seek a contractor in St. Marc to build a ramp for the ZL/PIH house, and also purchased a shower chair that would be shipped to my house in Boston. I could then take it with me as a carry on when traveling to Haiti. In discussion, we felt that the hospital environment would certainly provide challenges, however because it had been retrofit with ramps after the Earthquake, would likely be at a level of accessibility to at least maintain a basic level of function. Now reaping the fruits of this labor, we are up and running. The ramp has been installed and in an almost endearing way is not quite up to code, however it is constructed beautifully and will soon be adjusted to a slope that is a bit more reasonable for a wheelchair user to use safely.

                     Dr. Andree LeRoy and Mede, ZL employee/friend check the ramp specs!

Of course, this is all put into perspective of our patients, for whom the day-to-day significance of living in this environment of barriers is invariably overwhelming. As a clinician in training and also a wheelchair user, it seems that working in a setting like Haiti affords the opportunity to even more sharply refine my skills in the clinical management of rehabilitation problems, but also in the tenets of empathy, cultural awareness, and true solidarity with my patients. As a member of the ZL/PIH Rehabilitation Team, I am thrilled to know that we will always consider health to be a human rights issue, and disability rights a pillar of our work.  With this, we understand that community inclusion, stigma reduction, and accessibility of the built environment are the foundation we stand upon when providing care to people with disabilities.  

Friday, March 16, 2012

Physicians Ultrasound in Rwanda Education Initiative (PURE)

Point-of-care ultrasound training for Rwandan physicians and its impact on patient management

January 6-22, 2012
Joshua Rempell, MD

In the majority of resource-limited settings diagnostic imaging is not available other than plain film radiography. Point-of-care ultrasound offers a relatively inexpensive, safe, and effective form of diagnostic technology in resource-limited settings such as Rwanda.  Ultrasound machines are becoming more portable, durable, and versatile.  Consequently, there has been increasing interest to introduce ultrasound programs in resource-limited settings throughout the world. Recent efforts are beginning to demonstrate the clinical effectiveness and sustainability of ultrasound programs introduced into resource poor settings.  Despite its potential, a recent literature review on use of portable ultrasound in resource-limited settings found only a small number of empirical studies on the effectiveness of ultrasound on health.

Rwanda has only 5 physicians per 100,000 people and less than 10 trained radiologists in the country.  The Physicians Ultrasound in Rwanda Education Initiative (PURE) is an organization that now includes over 70 Emergency Physicians and has come about through constant collaboration with the Rwandan Minister of Health and the provincial hospital administrators at 5 designated hospitals to take part in this pilot initiative.  The Minister of Health, Dr. Agnes Binagwaho, has designated one central hospital to serve as the center of expertise as well as the provincial hospitals that will take part in the initial pilot training period.

We hypothesize that implementation of POC ultrasound into 5 provincial hospitals in Rwanda is feasible and can improve patient outcomes.  We will implement a focused, locally relevant curriculum that we hope to share with the greater global health community.  Through our assessment, we hope to design both relevant content as well as a structured approach combining both didactic and hands-on instruction that can be applied to other resource limited settings where clinicians have constant and significant time constraints. 

We hope to study the changes in patient referrals before and after the introduction of our training program. Few prior studies of ultrasound services in remote settings have ever been performed, and many questions remain unanswered regarding best methods for teaching ultrasound in these settings, the most appropriate and useful ultrasound examinations to teach, and how the new ultrasound services will impact patient care and outcomes.

The knowledge gained from this ultrasound training program will inform the greater ultrasound and global health communities of the opportunity to make a significant impact through the use of POC ultrasound in such settings.  Through our efforts, we aim to further develop and validate a sustainable, replicable, and scalable model of point-of-care ultrasound in resource-constrained settings. 

While in Rwanda during January 2012, I was able to pilot the training curriculum we have developed through work based on a prior needs assessment as well as through work with our Rwandan physician collaborators.  I gave grand rounds to surgical as well as medical residents and attending physicians at the teaching hospital in Kigali followed by hands-on teaching in point of care ultrasound.

A brand new machine for the training
Training surgical residents at the primary teaching hospital in Kigali

During my time, I was also able to work toward the long term goals of PURE by meeting with the Dean of Medical Education, representative from the Rwandan Ministry of Health, as well as multiple medical directors at the district hospitals that have been designated as training sights.