Monday, December 23, 2013

Anesthesia Teaching in Kigali - Life as a local medical student on rotation


I walked into an operating room two hours after inducing the patient with a resident. The patient was covered from head to toe in a green sheet and no one was in the room. My first thought was, “oh no, what happened, how did this patient die?” This was not an unreasonable question given the number of codes that occur in the ORs. But then I heard the steady chirping of the pulse ox and realized that my patient was still alive and seems to doing well under the sheets despite being alone and unmonitored in the room. I went to find the surgery resident to see what the situation was. His response was “we were hungry and it was lunch time so we covered him up and went for food.” This patient was having a craniotomy for a meningioma removal so his brain was exposed where the skull defect was. I don’t remember what my response was because of being so shell shocked. It turned out, after prying information out of the resident, that one of their surgical instruments were not sterilized yet despite the request being made a few days ago so they decided to break scrub until the equipment could be used 2 hours later. A typical example of the going-ons at CHUK operating rooms.

The past two days have been much more satisfying. I gave the medical students a lecture in anaphylaxis yesterday and have really taken on the role of being the medical student instructor in the OR. Having never had the opportunity to teach in the past, I have found it to be a very satisfying and rewarding job. These students are extremely easy to teach. They seem so starved for information and were so enthusiastic about any information that is taught to them. There is currently no real medical student curriculum and no one to teach them or guide them. I remember how terrible it was when I was a medical student feeling neglected during my rotations. It felt like no one really care about what you were doing. This is 500x worst. The reality here is that no one does care about them. They make their own schedules, they show up to the OR and to the ICU when they feel like it and leave when they feel like it. There is no accountability. At first I was shocked by their seemingly lack of motivation but then seeing what their rotation is like, I wouldn’t waste my time at the hospital either if I wasn’t learning anything standing around.

It wasn’t until now that I realized why there was such an emphasis on the painful 10 page H+P and presentations in med school. It pounded in the organizational skills that we needed to have in order to systematically think about problems, formulate plans and perform tasks. We had a set curriculum during our non-clinical years that provided us with our basic science framework and all the rotations that we had had a set curriculum that allowed to learn about the basics of each specialty. It seems though that no one has really provided them with a strong foundation in which to build their medical knowledge on. Things like intracranial pressure is not understood by the students, the idea of ventilation vs. oxygenation is foreign to them. It was with this in mind that along with my attendings, I decided to write a medical student curriculum. The challenging part was to decide how to do this in a way that would be sustainable. We decided to write four modules on topics that I felt like are the most vital for each medical student to know: airway management, fluid and blood management, pain management, basic life support and communication. Each module consisted of a transcript with a PowerPoint, simulator sessions, and discussion points that precisely provided all the information that is needed. The hope is that any anesthesiologist can pick up this transcript and be able to run this module without any difficulty. By providing this framework, we hope that it will create an easy transition to the local physicians who plan continue to this curriculum when both I and my attending are gone.

 Me with our residents and med students after our OB postpartum hemorrhage simulator case. The patient survived.

 My med students. Celebrating after surviving one of our anesthesia modules!

 
 This was a part of our airway management module with an airway simulator session at the sim center at the hospital.


 
 

Anesthesia in Kigali, Rwanda - What is the BIG Difference?


At CHUK, I had the opportunity to work with HRH faculty that have been in the country for a period of time. In speaking to them, their thoughts are that the current medical system doesn’t lack professionals with medical knowledge but the issue is that the system itself and the cultural background that it runs on is ineffective. There is no effective OR scheduling systems. Elective cases bump emergency cases. There’s no system in place to book emergent cases. Anesthetized patients are often left alone during the procedures. Most of the cases are performed by anesthesia technicians who are trained at a local technical college without any education by a physicians. The local attendings are not often involved in the OR cases despite being the ones responsible and definitely never do their own cases. The residents similarly are extra staff. They are extra hands that are not essential to the running of the OR. Their rooms are completely set up by the technicians who have sole control over the anesthesia supplies. The ICU consists of 5 beds who are constantly full. “ICU boarders” in the PACU are essentially homeless patient with no primary team and no one following them in the PACU and often end up in what is called a “slow code.” It’s a system of survival of the fittest. I had asked if this was a product of a lack of man power and resources or a systems issues and his answer was that it was that it was the system.

The PACU and pre-op area was one of the first areas where my first thought was “this was  medicine a third world setting.” Basic principles of anesthesia in CHUK(Central Hospital University in Kigali) I’m told are to make sure that I have any equipment I need available. Many of the things are not in the room so definitely do a pre-op check and do not rely on anyone else. Second, do not trust anyone else’s’ preop. Patients are often seen the night before by a technician but their exams are not often reliable. Patients are not often pre-oped until they are in the OR, lying on the OR table. Communication is big issue in all aspects of care: hand offs, discussion with surgeons, PACU signouts, designation of roles and etc.

A summary of what I know so far:

Operating Rooms at CHUK:

Main OR: 6 ORs

OB: 2 ORs

About 6 surgeries are performed each day in OB. This is the only place where I've seen daily exploratory laparotomies for peritonitis from botched C-sections from the districts. I didn't even realize that could happen from C/S. A total of around 70 operations performed each week in all the operating rooms.

There is not an effective scheduling system for the rooms. Elective cases bump urgent and emergent cases frequently. There is a hand written schedule on a white board but cases often get moved around. Patients do not have identifying wrist bands or other identifiers and therefore confirmation of the right patient and right surgery is completely dependent on the nurse.

-          There is no morphine. Pain control consists of fentanyl, IV tramadol and IV Tylenol. I thought this was crazy but apparently patients don’t complain of pain much postop. Rwanda is a palliative care nightmare. There is no palliation even if you want it.

-          Patients have to pay for their surgery and buy the drugs they need for their surgeries and take it with them on the day of surgery in order for the procedure to occur.

-          Limiting factors for the OR

o   Supplies for the OR

o   Electricity

o   Water – although with water outages, the surgeons just have buckets of waters that they use to scrub

o   Staffing

o   Anesthesia machine – all of them are broken to some extent. There are only limited numbers of ventilators so if one is used by a patient in the PACU then one OR can’t run.

o   Patients who require ventilators postop who are spontaneous breathing are attached via a endotracheal tube elbow that is then connected to a wall O2 source when a ventilator not available. There is also a shortage of monitors so generally you keep your fingers crossed and hope that the patients continue to spontaneously breathe and assume that their vitals are normal…until you get called for a code.

o   Only 2 main OR anesthesia machines have capnography

o   There is now a code cart in one of the rooms after the recent failed accreditation visit. But there are not any defibrillators around.

-          Surgical safety checklist is being implemented by the HRH staff

-          ICU only has 5 bed and is constantly full. Patients cannot be discharged from the hospital until they pay their bills. For the patients that cannot afford to pay for their bill, they stay in the hospital in definitely. As a consequence, patients from the OR who needs an ICU bed are brought out to the PACU where they are monitored and suffer what is called a “slow code” until they pass away.

-          PACU, where over 10-15 patients are consistently and is managed by 2 nurses. Only some patients have constant vital sign monitoring. Ventilated patients who requires the ICU are not consistently managed and there is no physician who takes responsibility for these patients and many of them end up dying.

-          Patient are usually pre-oped the night before by anesthesia techs who do not relay the information to the day team. Patients are usually first seen by the anesthesia team when they are rolled into the OR and have been moved to the OR table. This is where the short preop assessment is made and the IV is started.

-          Anesthesia residents and anesthesia techs routinely leave the room leaving the anesthetized patient completely unattended.

-          Each OR is manned by either 2 anesthesia techs or 1 tech with a resident.

-          The tech is responsible for setting up the room, getting the airway equipment, drawing the drugs. The airway equipment is often not in the room during induction and are stored in a locked locker that only the techs have access to.

-          The techs are usually not supervised by anyone as the consultants who are supposed to be responsible are generally not around. The techs are the ones that usually train the residents initially and therefore they usually pick up their bad habits.

o   Machines often are not checked

o   Not all monitors may be on before induction

o   Suction is not on(only long soft tipped catheters are used)

o   Airway equipment often not checked, laryngoscopes not checked and not in the room, oral airway not available

o   No working ambu-bag

o   Not all drugs available

o   No real personalized anesthesia plan is developed for each patient, airway exam, preop assessments often are not performed

-          “infected” patients are operated on as the last case in the room in order to prevent contamination of subsequent patients no matter how urgent/emergent the case is – the HRH people are trying to stop this practice. For example, I have seen many instances where an elective C/S or D+C is performed before a peritonitis ex. lap. There is definitely a difference in the sense of urgency.

Overall I think the most important thing that I have experienced is that the physicians and residents often do have medical knowledge and have access to book and information. What needs improvement is systems based problems such as overall organizational skills, thinking over anesthetic plans, the implications of anesthetics and its actions on patients and etc.

Anesthesia Teaching in Kigali, Rwanda


This is my first trip to Africa. Rwanda has only been this textbook entry that I read about in class during to the horrible genocide 20 years ago. It’s hard to believe that I am actually here. I have been waiting and planning for the trip for the past year and yet I felt completely emotionally unprepared now that I am actually here. It’s finally starting to feel real now that I am actually here. First impressions as the plane was making its descent was “where are all the lights.” I was craning my neck with my face plastered against the plane window, searching for evidence of the city where I was going to spend the next month of my life but yet could only make out occasional flickers of light in the distance. I double checked the monitors and saw that we had 11 miles to go, 10, 8… Where were the lights? Slowly more lights appeared on the horizon, reinforcing the fact that I was likely approaching the right place.

My first day of work  at Central University Hospital of Kigali(CHUK) started on Monday, also known as their nonclinical academic day. I got eased into the schedule but sitting through a morning of lectures much like what we do at BWH. The hospital actually reminds me quite like the Hawaii hospitals. Low one story structures that almost look like small bunkers that are surrounded by greenways separating each unit. The operating rooms were surprisingly much bigger, more spacious and nicely warm instead of the frigid conditions that most of our operating rooms operate under. Being from Asia, it was easy for me to ignore the mold on the walls. The Glostavent is an amazing ventilator that I encountered for the first time. It operates in conditions where both electricity and/or oxygen supply is inconsistent. The most glaring difference in the ORs is the lack of a scavenging systems on the ventilators. For the non-anesthesiologists, this is the system that takes the wasted/exhaled gases from the patient and removes it to a scavenging waste system. Without it, the halothane that the patient was exhaling was being dumped into the OR and then being breathed in by us. I had no idea why I felt so exhausted every night after work until I found out that I was essentially being anesthetized on a daily basis.
 
 I saw this on the bulletin board in the OR.

 Our OR schedule, but don't worry, no one really follows the daily room schedule.

 The Pre-op holding area. This is not a place where you want to be when you are sick. There is generally staff taking care of patients here and patients are not often seen by any medical staff until they are lying on the OR bed.

 Our operating room.

 The Amazing Glostavent.

 Our sterile facemasks being hung outside to dry.
 

The saying “change has to come from within” definitely applies here and to the motto of the Human Resources for Health(HRH) physicians and to the foreign staff working here. Their goals are not to join the workforce but to provide guidance to the physicians already there. If they ever establish themselves as working staff, the thought is that the local staff would disappear and simply let them do all the work. One of the mistakes that was repeatedly emphasized to me is the enthusiasm of foreign staff to change the way things are done or practiced. This can happen with tremendous effort on the part of the initiator however things quickly fall apartment once the foreign presence leaves. Change can only be sustainable if a local staff takes responsibility for the project and carries it forward in the system and their peers. However not many local physicians seem to have the motivation to do this. This was not something that I had really considered before when I developed my interest in global health but makes so much sense now that I got to see it in person.

During my first week, it was easy to get lost and often found myself wondering how I could really contribute to training the students and residents here. It wasn’t until a few days into my time at CHUK that I started noticing how neglected the medical students were on their rotation that I decided to make them my students for the month. Rwanda is desperate for anesthesiologists. The country has about 12 MD anesthesiologists while most of the anesthetics are provided by anesthesia techs. The one of the goals of the anesthesia team for Human Resources for Health is to recruit residents. There is no current first year residents. I believe that recruitment should start with medical students. Also after graduation, medical students are required to have an intern year and then practice independently for 2 years as a general practitioner before being eligible to apply for residents. I had a month to prepare these medical students with all the basic knowledge of airway assessment, fluid and blood management and pain management that they needed to take care of patients in the district hospitals when they are the sole practitioner 2 years from now. It was a daunting task!

Thursday, December 12, 2013

EMERGENCY NEEDS ASSESSMENT IN WESTERN KENYA

Hello again from Western Kenya. As I conclude my trip, I wanted to update everyone on the status of the project. It's been a wild 6 weeks, full of travel. We were able to visit 27 facilities in total - learning a great deal from all of the wonderful medical providers who gave their time to help in this project.



Not surprisingly, we've discovered there is definite room for improvement for emergency care in Western Kenya. Finding out how we can focus our efforts best will be the greatest challenge. We have found that even basic supplies like X-ray and ECG machines are lacking, the providers (especially specialists) are frequently overworked and spread-thin, referring patient's to a higher level of care poses many challenges and can be dangerous, and many providers are requesting more trainings to be able to take care of their patients better.




I was able to pass the torch to another fellow resident who will continue collecting data. When complete, we will analyze our data and work with local medical officials to raise the standards of emergency care in the region. Fortunately, we've already started a pilot training program to train some providers on emergency anesthesia.

Dave Young, MD

Sunday, December 8, 2013

Zuni IHS Community Experiences

Despite the small size of the population and the Zuni Health Center, I believe they are doing very progressive work through community outreach, population health and the group practice of medicine.  I have shared just short tidbits of some of the amazing opportunities I had the privilege of being part of during my short time in Zuni.

Zuni, New Mexico – A Special Place

I had heard a lot of good things, but really didn’t know what to expect upon arriving to work at the Zuni Comprehensive Community Health Center  – a 2 ½ hour drive from Albuquerque on the Zuni Indian Reservation in Western New Mexico, near the Arizona border.  I was welcomed with open arms to a beautiful community that is visually stunning, culturally unique and home to proud and amazing people.  The health center and its healthcare professionals were inspirational practitioners of healing.  They had found their calling working in Zuni and it came through in their approach to medicine and living life.  I could not have been made to feel more welcome to be part of a community and a practice of medicine.

Zuni Comprehensive Community Health Center serves approximately 10,000 Zunis and 4,000 Navajo who live on surrounding Navajo Nation reservations lands. The majority of Zunis are bilingual, with Zuni being their first language. Many Navajo over 45 years may not speak English. There are Zuni and Navajo employees who can assist with translation.  Silver-smithing is the main source of cash income and Zunis are renowned for their intricate jewelry work and fetish carving. Employment for others is through government or tribal organizations, the school system or our facility. The median Zuni family income (1999 data) is  approximately $21,000/year and approximately 50% of the population falls below the poverty level. Traditional ceremonies are the center of nearly all social activities and Zunis follow a calendar of night dances and rain dances which take place in the plaza at the center of the old village. Zuni society is divided into six fraternal kiva religious organizations, 10 medicine societies, and 12 matrilineal clans. Traditional medicine is also an important part of Zuni culture and many Zunis incorporate visits to medicine men, bone pressors, or traditional midwives along with seeking care at our facility.  


Dowa Yalanne (DY) A Sacred Mesa, a shelter to the Zuni People during their resistance to the Spanish (my wife and son)





Monday, November 18, 2013

EMERGENCY NEEDS ASSESSMENT IN WESTERN KENYA

After the first few weeks performing a needs assessment in and around Kisumu, Kenya, I'm getting the handle on the survey. I've managed to adopt a bit of an accent in order for the practitioners to understand me. And if I speak slowly enough, a true challenge for me, the language barrier is minimal. All the providers have been very helpful. At first, most seem a little skeptical and resistant to sit down with me for a full hour of interviewing. Eventually, they are able to find some time for our team and have a good conversation about their emergency care capabilities. Unfortunately, sometimes the conversation can run over sometimes, but that usually means we were laughing to much trying to get to know each other.


Dave Young, MD

Sunday, November 17, 2013


Antenatal Ultrasound Training in Resource-Limited Regions of Western Kenya

 

Maternal mortality continues to be a significant public health problem throughout the developing world.  Sub-Saharan Africa accounts for approximately 50% of all maternal deaths globally.  World Health Organization data suggests that the majority of these deaths could be prevented if emergency obstetric care were available at every birth. However, since almost half of all births in developing countries take place at home without a skilled birth attendant, life-saving obstetrical interventions are often delayed.  This results in unnecessary maternal and fetal morbidity and mortality.

 

A new generation of affordable, hand-held ultrasound machines has opened the possibility for antenatal ultrasound screening programs in resource-limited settings, such as rural Kenya.  However, given the general paucity of radiologists in Kenya, the training of non-radiologist clinicians in point-of-care ultrasound is essential.  I had the pleasure of working with the Division of Global Health and Human Rights and Kisumu Medical Education Trust, our in country partner, to train midwives in point-of-care maternal ultrasound in Western Kenya.

 

Working with an ultrasound-trained Emergency Room physician from California and three Kenyan midwives with subspecialty training in ultrasound, we provided one week of refresher training in antenatal ultrasound to 16 nurse midwives from all over Western Kenya.  The midwives participating in the refresher course had received initial antenatal ultrasound training through our program nearly 1 year prior.  In the mean time they had integrated limited antenatal ultrasound services into their rural obstetrical practices.

 

 

It was great to reunite with the midwives whom I had worked with before and to meet and hear the stories of those midwives whom I was meeting for the first time.  These dedicated health care providers shared powerful stories of how ultrasound had impacted their patients in positive ways.  By identifying high-risk conditions early (i.e., placenta previa, twin gestation, and abnormal presentation), providers could arrange hospital delivery for these patients.  In the absence of these ultrasound-based diagnoses, these patients may have delivered at home, potentially resulting in untreated complications of delivery.

 

 

Overall, I feel blessed to have had the opportunity to participate in the amazing ultrasound work happening in Western Kenya.  Recently, the Kenyan Ministry of Health decided to provide free hospital-based labor and delivery care to any woman in Kenya who desired it – effectively eliminating another barrier to safe perinatal care for Kenyan women.  I look forward to continuing my participation in this important mission and thank the Partners Center of Expertise in Global and Humanitarian Health for helping to make it possible.

 

H. Benjamin Harvey, MD, JD

Resident

Department of Radiology

Massachusetts General Hospital

Wednesday, November 13, 2013

OB/GYN MGH/MRRH Collaboration

I’m now almost at the end of my first trip to Mbarara Regional Referral Hospital. It’s been quite the whirlwind and time always flies so fast.  As I’ve gotten to know this hospital and in particular the obstetrics and gynecology department I have realized there is a trail of hospital equipment that tells the tale of visitors past and perhaps present.


On the antenatal ward for example I came across two digital fetal doppler machines. These are handheld, very portable and useful in finding and listening to fetal heart tones in utero. They are essentially a digital replacement of the pinard (fetal stethescope).






Digital Fetal Doppler

As handy as the digital dopplers are, their portability and attractiveness were their downfall when it came to their use on the antenatal ward. Concerned about their inherent, “walkability”, the donors/department created small metal cages, with no openings and attached to the metal IV to host the handheld devices. Unfortunately this has meant that the devices cannot be cleaned, or the batteries changed, so now the devices simply sit there, tugged along whenever the IV pole is in use, but unable to perform their ascribed function. Fixing this issue seems a simple undertaking, but perhaps it is a measure of their lack of desirability by local clinicians that the dopplers continue to sit there, literally gathering dust, and the pinard continues to be the preferred mode of auscultation. Indeed although it may seem like the digital device is an improvement, this very scenario prompts me to question if there is any evidence that demonstrates one is better than the other and if such evidence is relevant in the local setting.


This picture of forlorn and non functioning equipment is seen again and again all over the hospital. Most often, it is not a simple matter to fix the equipment – the expertise or the parts needed are simply not available. In the medicine department for example, there are several donated light boxes with a similar fate. Each is made up of a box, with a white screen and a light bulb to illuminate – technology that is seemingly simple and therefore easily transferrable from one setting to another. Unfortunately these boxes are manufactured with specialized light bulbs with unique sockets and shapes that are unavailable locally, rendering the light boxes unusable once they burn out. Another example is seen in the operating rooms where I noticed several electrocautery machines sitting quietly in corners. They are handy when available, but clearly not essential, and without any local expertise trained in fixing them and almost no hope of company technicians coming out to fix them,  more than likely they will go on sitting in the corner -too expensive to discard, and yet not essential enough to find a solution to.


This is not to say that such equipment is unnecessary or fated to be relegated to an iron cage. I also saw several examples of machines both donated and bought integrated successfully into clinical care.  Nonetheless, the trail of quietly forgotten equipment should remind us to be careful in what we wish for or even in some cases introduce as visitors. It’s very easy to think that x instrument or y machine would make such a difference and let’s do what we can to get it here. It might even work for 6 months or perhaps 1 or 2 years, and perhaps that is worth it, but often it appears that they don’t even make it that far and clinicians revert to their known and perhaps more reliable methods.


Perhaps a more exciting and more sustainable approach is that taken by new institutions like CAMtech. Its stated goal is to to improve and accelerate high-quality, affordable medical technology development for low- and middle-income countries (LMICs)”. CAMtech’s very first innovation lab is currently growing roots in Mbarara, Uganda.  I had the opportunity to see it in action when I went in search of their first engineer. 


Patrick Ssonko at CAMTech
I was lucky enough to meet Patrick Ssonko.  He recently graduated from engineering school and just this past summer was hired as the engineer in house at CAMTech.

Patrick's monitor in development
 I was very impressed and encouraged by his enthusiasm, creativity and zeal. During my visit, he demonstrated his self developed heart rate and temperature monitor and even let me test it out. The instrument is in its early phases but the potential is huge. He plans to build in a component that can relay the values to a separate screen and more importantly have the ability to send text message alerts to clinicians.


The potential for this kind of enterprise to positively impact clinical care in MRRH is huge. First of all if engineers like Patrick are connected to and collaborate with physicians and nurses working on the ground in Mbarara , devices created are much more likely to be directly applicable to the clinical setting within which they work. Home grown devices also likely mean cheaper components and more importantly that the replacement components and the local expertise on how to replace them are available.  

Adeline Boatin, MD MPH
OB/GYN Global Health Fellow


Sunday, November 10, 2013

Western Kenya - Maternal Ultrasound Screening Programs


This morning I landed in Kisumu, Kenya on a beautiful summer day. Kisumu is the third largest city in the country, located in Western Kenya on Lake Victoria. I traveled via tuk tuk (rickshaw) to the MGH guest house. The road was a little bumpy, as the major road to the airport was under construction. Sometimes the course of growth and development has bumps in the road, but the outcome is undoubtedly worth it.

 


After adjusting to the time difference, I woke up this morning ready for our first day in the field. Our research team embarked for Kaimosi to perform obstetric ultrasound screening. Kaimosi is a small town/village located 40 kilometers NNE of Kisumu. The drive through the Kenyan countryside was beautiful. The natural beauty helped distract me from the narrow, often unpaved roads that seemed quite treacherous at times.

 


Upon arrival, we met the hospital administrator who was very gracious. I had the opportunity to tour the hospital grounds and facilities. The resources were quite modest in terms of physical equipment and human resource availability. Additionally, one of the major challenges that the hospital faced was related to energy. The energy grid in the region was somewhat unpredictable. I learned that it was not uncommon for the hospital to go without power for 2 to 3 days at a time.

It was also clear that inpatient care within the hospital was a family endeavor.  Patient families were often present and assisting in caring for their loved ones. Family members would bring food, wash linens and clothes and attend to various needs that are customarily provided as part of inpatient care in the U.S.

As a radiology resident, I was specifically interested in the imaging equipment. While walking through the courtyard, I saw a radiographic film hanging on a clothesline. The film was still wet; the true origin of the term “wet read.”  In addition to plain film radiography, the hospital had a fluoroscopy unit which was used for barium studies.

Utilizing the portable ultrasound machine we brought, we were able to provide obstetric ultrasound screening examinations. The portability and durability of the ultrasound machine as an imaging tool in resource limited areas became quite evident.
 


 
 
 

Thursday, November 7, 2013

MGH/MRRH OB/GYN Collaboration: Mbarara Uganda (Sep-Oct 2013)

I can’t say that I was shocked when I got to Mbarara Regional Referral Hospital.  I had been there before, so to speak,  only in a different country on the opposite side of the continent. I knew the stark and dramatic differences. I was however taken aback yet again. It was hard not to compare what I trained in and knew well with what I faced in Mbarara. At MGH we have 11 delivery rooms, each private, with large beds equipped with movable and removable parts. These accommodate 3000 deliveries a year. At MRRH they have 2 delivery beds. Simple steel frames with a thin black pad. 

Delivery bed on the Labour Ward at MRRH

These 2 beds take the hospital through over 8000 deliveries a year.  This most basic difference in physical resources is only just the beginning. In almost every aspect of patient care and management the residents and obstetricians at MRRH make do with so much less – almost zero nursing support, limited supply of drugs and equipment, limited antenatal records, often no dating of pregnancies, no electronic fetal monitoring, limited availability of neonatal resuscitation, limited or no oxygen. This list goes on and on.


Despite the limitations of medical care and lack of – almost everything physical, I have been most impressed by the abundance of fortitude and patience displayed by the women seeking obstetric care at MRRH. After a cesarean section, women simply get on with the necessities of life with very little support. To begin with, they get an astonishingly limited amount of pain medication. At MGH women routinely receive IV toradal, shortly followed by regular doses of oxycodone or dilaudid, which they not only have throughout their hospital stay, but also go home with. Here at MRRH, it is a dose or two of pethidine (demerol) immediately post op, and then rectal diclofenac as needed. That’s it, and no complaints - they just deal with it.  They go to the bathroom themselves, empty their foleys themselves, , provide for their own meals, own sheets, and own supplies as needed.  They get only the basics from the hospital – a “Mama Kit” which includes: a bar of soap, 2 plastic sheets (on which they have their vaginal exams and on which they deliver), a roll of cotton wool (which become their pads), 2 packs of gauze, 2 razor blades, and a health card for their child. 

Mama Kit Provided to Patients on Admission
On top of that, their recovery is far from comfortable.  In a postnatal ward built to accommodate 30 women, there are often as many as 60. When the beds run out, which they always do, women, post vaginal delivery or some even post-cesarean get a mat pad and make a space on the floor – either squeezed in between two beds or at the foot of the beds. This happens every day. In the time I have been here I have never seen any woman complain, argue or express the slightest irritation at being placed on the floor. If they are asked to move to allow a doctor or nurse to get to a patient or a piece of equipment, again no frustration or complaints they simply pick up their mats, their personal belongings and their babies and move.

Postnatal Ward at MRRH

Without a doubt these women display extra-ordinary fortitude in coping with their physical pain and in managing without many of the comforts and support that women in Boston taken for granted. Perhaps even more remarkable is the resilience shown by a significant portion of these women  recovering from a neonatal loss, or delivery of a stillborn child. At this hospital the stillbirth rate has ranged from over 2-6% of deliveries. That is as many as 58 stillbirths per month, with over half of those often occurring intrapartum. Women who have suffered these losses also simply go on, also squeezed into the postpartum ward, perhaps next to, or in between women who are fortunate enough to have their babies well and crying at their sides. Their expressions and demeanor often reveal little and it is so easy to walk past them, or even examine and assess them without recognizing or acknowledging their loss.


 On rounds one day I attempted to ask a woman where her baby was. I was with a resident from India and we both could not communicate well. The woman lying next to her listened to our fumbled attempts, and took pity on us.  She could speak English –“the baby is in the Toto ward” (pediatric ward), she said quite simply, “they’ve taken it for testing”.  We thanked her and continued with our assessment of that patient. About 5 minutes later we got to the woman who had helped us. She also had no baby. We asked and she said – her baby didn’t make it. It was born alive and died shortly afterwards. From our conversation 5 minutes earlier I would never have known. For this woman, I had the opportunity to acknowledge her loss, and express some amount of empathy – though from where I stood I clearly had no concept of how she really felt. I wondered how many other women I had walked past or assessed without any recognition or acknowledgement of their loss. Knowing the stillbirth and neonatal rates, that I had done so was a certainty. 

Adeline Boatin
OB/GYN Global Health Fellow

Wednesday, November 6, 2013

Durban, South Africa

Determining HIV-associated cryptococcal disease with clinic-based, point-of-care screening in Durban, South Africa.

In August, I traveled to Durban, South Africa to collect pilot data for a study of diagnostics and to set up a new study related to cryptococcal infections, a common cause of HIV-related mortality.

The global burden of cryptococcal meningitis (CM) is estimated at 958,000 cases and 625,000 deaths per year, making CM a leading cause of AIDS-related mortality. The vast majority of CM occurs among HIV-infected people with advanced immunosuppression or within 3 months of antiretroviral therapy (ART) initiation. In sub-Saharan Africa, an estimated 7-19% of HIV-infected adults have asymptomatic cryptococcal antigenemia (CrAg) at the time of HIV diagnosis, and circulating CrAg predicts onset of CM and mortality. These antigens appear weeks before the onset of neurological symptoms, and among those with circulating antigens oral anti-fungal therapy (fluconazole) reduces the risk of CM and death. Thus, early detection of CrAg and prophylactic anti-fungal therapy might improve health outcomes, but few laboratories in resource-limited settings (RLS) have had the ability to expeditiously test for CrAg in serum.

In the first study, I worked with Ms. Julia Kleene (pictured below), a medical student at Stony Brook School of Medicine, to conduct testing of stored urine samples from a previous cohort (photos below).  In one long, exhausting day we managed to test approximately 800 urine samples using a rapid test for cryptococcal antigens.  This study was the first assessment of cryptoccocal antigen prevalence in the KwaZulu-Natal Province.  We tested participants with a wide range of CD4 counts.  We found about 10% prevalence of cryptococcosis among newly-diagnosed HIV-infected adults, and the results did not differ among people with higher CD4 counts, which is contrary to most other studies.  The results formed the basis for pilot data related to a K23 grant application and are currently being prepared for publication.

In the second study, I used the time to set up a new longitudinal study to determine the impact of clinic-based screening for cryptococcal infections at the time of HIV diagnosis.  During my visit, we were able to hire a local research assistant and a local research nurse.  We spent time at our clinical site arranging the flow of the participants through the stages of the study, preparing documents, and meeting with various research partners.  The study then started enrollment on September 12, and to date we have already enrolled over 200 participants.

The location of this study is the iThembalabantu Clinic in Umlazi, a township of Durban with over 1.2 million people and a very high burden of HIV and TB. The clinic offers HIV testing, counseling, and treatment, and has a pharmacy to dispense ART (first and second line regimens) and therapy for opportunistic infections. The clinic is staffed by 2 full-time physicians, 10 nurses, 4 HIV counselors, and a cadre of community health workers. Each day, clinic counselors test 30-40 adults for HIV, of whom an average of 36% are HIV-infected, and clinicians provide comprehensive care for >100 HIV-infected people.   The results of these studies will help inform future studies of point-of-care CrAg screening in South Africa, as well as other resource-limited settings, to help prevent AIDS-related mortality.

The travel funds provided an essential opportunity for me to travel to Durban to collect pilot data for my K23 application, and at the same time to lay the groundwork to initiate a new prospective clinical study. I have very grateful to Partners for the Global Health Center of Expertise travel grant to help support my clinical research projects.  I would definitely recommend this funding opportunity to other clinical fellows.


Sunday, November 3, 2013

Cape Town, South Africa – Jessica Magidson, Postdoctoral Fellow, Chester M. Pierce, MD Division of Global Psychiatry, MGH


After leaving Harare, the second part of my trip is in Cape Town South Africa. Here I am focusing on clinical research, primarily to build relationships with faculty in the psychiatry department at University of Cape Town (UCT) who are also involved in the capacity building initiatives in Zimbabwe and the clinical research we were working on while in Harare—to train health care workers in empirically supported behavioral interventions for improving antiretroviral therapy (ART) adherence and depression. In addition to discussing with UCT faculty the ongoing progress on the work in Zimbabwe, I am also discussing ideas for future clinical and research collaborations with their team to pursue during my postdoctoral fellowship. While in Cape Town, I am also spending time at Stellenbosch University and Tygerberg Hospital in the departments of psychiatry, infectious disease, and the department of medicine to become familiar with ongoing research projects and initiatives across these departments.  

One of the projects that my team in Behavioral Medicine at MGH has been planning with faculty in psychiatry at UCT is a randomized clinical trial (RCT) to examine the effectiveness of cognitive behavioral therapy (CBT) for improving depression and ART adherence in the South African setting. In this study, CBT will be implemented by nurses working in HIV clinics in the local townships, for instance in Khayelitsha. Khayelitsha is an impoverished settlement just east of Cape Town where an estimated 500,000 people reside. Recent estimates of the HIV prevalence in this area are approximately 20%. Further, rates of depression are also very high in these areas—among individuals with HIV, it has been estimated that rates of depression reach up to about 40%. There is a huge need for treatments for depression that can be integrated into HIV care in this context.
Khayelitsha



 
A manual for improving HIV medication adherence in HIV clinics in Khayelitsha that was developed by UCT faculty and our behavioral medicine director, Dr. Safren, which incorporates modifications for this setting.
There has been some preliminary work conducted by our team and the UCT faculty to adapt existing adherence interventions such as Life-Steps and CBT for depression for this setting. The resulting intervention culturally tailored for this setting, called “Ziphamandla”, translates as ‘to be empowered’ in Xhosa. Xhosa, by the way, is one of the 11 official languages spoken in South Africa, and one of the most common spoken in the local townships such as Khayelitsha. Interestingly Xhosa has the unique feature of “click” consonants – the word Xhosa, pronounced “Kosa” also begins with a click. 

The CBT Ziphamandla intervention has been implemented thus far by two Xhosa-speaking nurses, one of whom was a psychiatric nurse, the other without previous mental health training. 14 individuals have been recruited from two of the busiest clinics in Khayelitsha, the Ubuntu and Michael Mapongwana ART clinics. The Ubuntu ART clinic was the first clinic in South Africa to offer ART and has approximately 7,000 HIV-positive patients registered in their database, the majority of whom are currently on ART. Initial results evaluating Ziphamandla seem very promising for improving depression, ART adherence, and overall functioning. The lead psychologist conducting this work, Dr. Lena Andersen, and I spent a lot of time during the visit discussing plans to disseminating the findings to the scientific community. The future RCT to compare this intervention with a control comparison condition in a larger sample will be an important future direction of this work and was an important priority for discussion throughout meetings with UCT faculty.

While in Cape Town I have also spent time at Stellenbosch University and Tygerberg Hospital to meet with faculty across different departments, including the Children’s Infectious Diseases Clinical Research Unit (KID-CRU), the psychiatry department, and the department of medicine.

During meetings at KID-CRU, although my clinical and research interests to date have largely focused on adults, we had interesting discussions regarding maternal psychosocial factors that may influence adherence and outcomes among infants and children living with HIV, as well as an emerging concern – psychosocial struggles among adolescents who are now living into adolescence and young adulthood following ART initiation from birth. 
KID-CRU, an impressive clinical research unit with its own pharmacy and laboratory, the site of numerous ongoing clinical trials focusing on improving HIV and TB outcomes among infants and children


This theme again came up while visiting the psychiatry department, where we discussed more in depth the types of psychosocial struggles among HIV-infected adolescents who have been taking ART since birth, and more specifically how factors such as substance use and impulsivity may affect adherence. It was also interesting to learn more about the structure of the psychiatry department at Stellenbosch and the different psychiatric clinical settings in the area (although I unfortunately could not visit the actual department...)





Finally, the meetings in the department of medicine were also very productive. We discussed the importance of integrating behavioral HIV research with other chronic conditions, importantly TB in this setting. We also discussed the lack of psychiatric epidemiological research to date on substance abuse among HIV-infected individuals in South Africa and ways in which initial quantitative research could lend itself to future intervention developmental efforts in an area. It is this area—the intersection of substance use, depression, and HIV self-care behaviors in both the South African and Zimbabwean context—that I hope to continue to pursue both clinically and in research.


I am extremely thankful for the opportunity to meet with faculty at UCT, Stellenbosch, and Tygerberg Hospital during this visit, for the hospitality of our gracious hosts in Zimbabwe, the support of Dr. Conall O’Cleirigh throughout the trip, as well as the mentorship in my global psychiatry fellowship from Drs. Steve Safren, Dave Henderson, and Greg Fricchione. I am very appreciative of the support from the COE travel award to enable these opportunities, particularly to be able to visit Zimbabwe for the first time. This was a fantastic experience for both clinical and research training, and I am already looking forward to the next visit to continue developing this line of clinical research and building  relationships with these clinical research teams in both Harare and Cape Town.
Early morning hike in the clouds up Table Mountain! Beautiful view of Cape Town.