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.