Tuesday, March 26, 2013

Neurological Education and Practice in Uganda

Craig Williamson
MGH/BWH Neurology Resident

It is certainly with reluctance that I leave Uganda and return to the US.  Working here has been an educational and humbling experience that challenged me to think about how to manage common and uncommon neurological conditions without the resources available at MGH or the Brigham. On my final day, I prepared a talk for the post-graduates on the clinical evaluation and differential diagnosis of spinal cord disorders.  Just before the talk, I was called to the ED to examine a 22 year-old woman who has had one month of progressive lower extremity weakness, progressing to total inability to walk. She had been seen in the ED four days prior and had been sent out to get plain X-rays of her lumbosacral spine, which not surprisingly appeared normal.  On examination, she had flaccid weakness of the lower extremities with extremely brisk reflexes, sustained clonus in the ankles and upgoing toes - without any upper extremity symptoms her problems easily localize to the thoracic spinal cord. For all of my recently acquired knowledge about the many causes of myelopathy in tropical settings, it wasn't at all clear to me how to proceed with her evaluation and treatment. At MGH, she would be admitted, have an MRI of at least her thoracic spine, probably also of her cervical spine and brain, then would undergo a lumbar puncture that would be sent for a dizzying array of laboratory tests for infectious and inflammatory causes of myelopathy, in addition to other tests for various metabolic and nutritional causes. Depending on our determination of the etiology, she would most likely be treated with a course of high-dose steroids.  It was informative to talk through the case with the post-graduates and get their recommendations on how they would manage the patient without MRI and most laboratory tests.  Essentially, they would probably test her for HIV and then treat her for things they can treat - most likely TB. My own uncertainty with the case illustrates how difficult it is to come in to an unfamiliar setting for a short period of time and make constructive management recommendations.

Fortunately, another of my colleagues from the MGH/BWH neurology residency will be visiting Mbarara in just a few weeks and can build on some of the things I learned.  In addition to spending more time working with the very eager medical students, we can hopefully develop some clinical protocols to assist with management of common neurological issues.  In particular, there appears to be a tremendous need for improved prevention and management of traumatic brain injuries - one of the  most common reasons for ICU admissions - though it isn't at all clear how best to do this with less access to CT scanning and laboratory testing.  This is just one of many potential areas of academic inquiry that would be extremely rewarding to pursue.

Here, one of the medicine post-graduates waxes eloquently to the third-year students at the beside about the subtypes of Guillain-Barre syndrome and the side-effects of treatment with IVIG, which isn't available at MRRH.

An 8 bed ICU was recently opened in MRRH's new building. The use of motorcycles as the primary means of transportation in Mbarara - typically without helmets for the drivers or passengers - leads to an extremely high volume of TBI requiring neurosurgical intervention.

                   Some of the talented post-graduates waiting for me to begin my final talk.

Looking silly for the sake of education as I attempt to act out features of an MCA stroke.

Sunday, March 24, 2013

Neurological Practice and Education in Uganda

Craig Williamson
MGH/BWH Neurology Resident 

The first week of my visit to Mbarara Regional Referral Hospital (MRRH)/ Mbarara University of Science and Technology (MUST) has been rich in learning, new experiences and new people.  It has also been quite rich in terms of neurological cases and teaching opportunities.  If meningitis is included, one-third of the admissions to the medical service are primarily neurological.

Many of the types of cases I have been seeing are our bread and butter admissions to the MGH and BWH Neurology Services:  hypertensive hemorrhages, ischemic strokes, guillain-barre syndrome and subdural hematomas. However, as anticipated, there is a much higher incidence of neuro-infectious diseases, particularly complications of AIDS - cryptococcal meningitis and tuberculous meningitis in particular. 

My visit comes at an exciting time, as MRRH just acquired a CT scanner a few months ago and residents are still learning how best to use this new technology.  There are no radiologists available, so I have found myself spending a lot of time helping with both CT scan interpretation, and deciding when scanning is clinically indicated.  I gave a formal teaching session to the medicine postgraduates on this topic, and have been doing informal consultations amongst the various ward teams. Patients and their families are expected to pay upfront for CT scans – a significant financial hardship for most – so it becomes important to decide when obtaining a scan will genuinely affect management.

The structure of the MRRH medical teams was well-described in the last blog post. There are a large number of medical students, and bedside medical student teaching is a core aspect of medical education. Given the large numbers of neurological cases, there has been ample opportunity for informal teaching about physical exam skills and clinical reasoning at the bedside. Sometimes after rounds, I will take the medical students and go over the clinical presentation and examination of a particular patient or discuss specific aspects of the neurological examination. For example, last week we examined a patient with guillain-barre together and discussed the differential diagnosis of acute bilateral weakness and paresthesias, and also did a session where the students practiced the cranial nerve examination on one another. 

Finally, while it has been gratifying to feel like my neurological training enables me to teach and contribute to clinical care, the medicine post-graduates have also been able to teach me a great deal. In the US, we generally don't think of tuberculous meningitis as a primary cause of stroke in young patients. However, here I have seen several cases of stroke due to TB or cryptococcal meningitis and the residents have been sharing their clinical pearls for deciding when to treat empirically for TB in HIV patients presenting with ischemic stroke. I have also had a chance to learn about differentiating cerebral malaria from other infectious causes of altered mental status, and the management of organophosphate pesticide poisoning, which is much more common here.

Thursday, March 21, 2013

Emergency Medicine in Colombia

GME Centers of Expertise Global Health Blog

David Beversluis MD MPH
Emergency Medicine PGY3
Characterizing Emergency Medicine in Colombia
(written 3/15/2013)

I'm now about 3 weeks into my 6 week elective here in Colombia and enjoying every minute.  And thrilled to get the news (even after I started) of support from the Centers of Expertise Travel Grant.  Thanks to all those working to provide this support to us residents committed to international work during residency!

I've split my elective time here in Colombia into two 3 week blocks.  First is a 3 week clinical experience working in several emergency departments in Bogota.  I'm just finishing this now and I'll write a bit more below about my impressions of working here below.  The second phase of my elective is to carry on the work of an ongoing survey of emergency medicine programs in several cities around the country.  This is work that was started by a few of my EM colleagues during a visit last year.  Much of this 'characterization' has already been done here in Bogota.  Our efforts during this trip focus on the other cities in the country that have active EM training programs.  I'll be flying north to Medellin tonight, and then next week to Cartagena to visit various hospitals, to lead some small group discussions with residents and to administer our surveys.   I'll also be meeting up with Dr. Christian Arbelaez one of the EM attendings at BWH, and the American College of Emergency Physicians (ACEP) Ambassador to Colombia.  His rich connections into the EM community here in Colombia are what is really making this project possible.  And I'm also very excited to be joined by Christina Wilson one of the HAEMR PGY2s for the next couple weeks in Cartagena.  So, more on that all in a future blog post...

During the last few weeks I've been spending my days at a couple of the emergency departments around Bogota.  Its been very interesting to see and observe the differences between our systems.  Emergency medicine in Colombia remains in a nascent phase, but is slowly expanding in influence and scale.  The first EM residency was started in Medellin in the mid-90s and there are now 5 programs total throughout the country.  This new specialty is still relatively unknown in Colombia however, with most urgent care provided by general practitioners with only 1 year of post-grad training.  Most Urgencias in the country are staffed exclusively by these doctors who consult surgery or internal medicine specialist for more difficult cases.  Several hospitals however are beginning to see the value of having EM trained staff and supervision, for patient care, throughput, cost-control and many other similar reasons.  The hospitals where I spent my time are all slowly making progress in also the transition and slowly advancing the field of EM here in Colombia.

During my first and second weeks I rotated at the Javeriana University San Ignacio Hospital in Bogota.  This is a large urban university hospital with access to plenty of internal resources but which is pushed to the limits by over-crowding issues.  The ED is designed for a quarter of the patients that it sees every day.  This leads to wait times for minor patients of up to 24 hours and to ED length of stay times of several days.  I spent time examining and speaking with patients who had been in the ED for 2-3 days sitting on rows of 8 or more chairs crammed into ED bays designed for one bed.  The amazing thing is how appreciative these patients remain despite this lack of space and staff to move them through the ED more quickly.  In the acute areas the flow and care is much better and patients are typically receiving top quality care from dedicated EM residents and physicians.  New patients are seen quickly and triaged to appropriate specialists as needed, for example I was impressed my first day there by a STEMI patient who quickly made it to the cath lab in under an hour.  Likewise, several septic and coding patients that I helped care for received great evidence based emergency care from the team.  Despite the overwhelming press of patients in the department these EM trained residents were successfully deploying and triaging their resources to address the most critically ill group.

For my final week of clinical work I switched to Mederi hospital.  This is another university based hospital in Bogota which takes residents from the San Rosario EM program.  The clinical care was similar with plenty of typical ED pathology including strokes, sepsis and coding patients.  Interestingly there was almost no trauma during my time in Bogota.  This is partly due to the hospitals and neighborhoods I was in, but also due to the overall development of Bogota.  Over the last 2 decades the city has become relatively safe.  So much so that the residents rotate for several months in Cali in the south to get a bit close to the FARC vs. military and urban poverty trauma which has mostly been resolved in the capital.  Despite the lack of trauma, I did get several procedures, which was one of the goals of my trip.  These hospitals are mostly still doing subclavian lines for central access which is something we've moved away from in Boston with our easy access to ultrasound; I got to put in plenty of these.  It was also great to intubate by direct laryngoscopy without the backup of our video assisted systems in Boston.

So, overall, my clinical experience was good from a procedures and clinical perspective, I'll definitely take some of these skills back to my work in Boston.  I can also feel my spanish slowly improving; I'll be using this ability in my work for the rest of my life.  Finally though, I'm glad to have this 3 weeks of experience and insight before I start the next phase of my work here.  Having seen Colombian emergency medicine from the inside will help me as I conduct interviews and site visits in Medellin and Cartagena and understand the emergency system as a whole.  I can't wait to see these places and keep up going with this fun work.