Saturday, May 31, 2014

Mental Health Inequality in Chiapas, Mexico

This is the room where a man has been incarcerated for five years, without ever leaving.  I don't call him a patient because I didn't meet him personally, but his story churns my stomach.  He is somewhere around 60 years old, and developed schizophrenia when he was 18.  He was odd but functional for many years, but in later years grew increasingly aggressive and threatening both to his family and to people in the community.  He had one psychiatric hospitalization, where they used injection medications that aren't available in the community.  Once he was discharged back home, he refused to take oral medications.  After he attacked his family, they decided he needed to be locked up, for the safety of everyone.  It took eight men to restrain him and secure him in the above room and he hadn't left this room in five years.  

Note the rope that is tied to the metal door... That is to keep it locked.  There is a hole where they pass him food and he uses the floor to go to the bathroom.  No shower, no grooming in five years.  As we walked near the house, it smelled of filth.  He yelled for his mother repeatedly and said that he wanted us to go away, whoever we were.  I don't know if he meant us or voices he was hearing, although we're the most likely culprits.

We were there to try and convince the family to let CompaƱeros en Salud try and get an injectable antipsychotic in the community that lasts for a month, in the hopes that it will make him calm enough to be able to come out of his locked room.  The proposal was that we get the police and lots of back up, open the door, sedate him, clean him and bathe him, give him the medication and return him to the room after it has been cleaned.  The hope is that he may be able to be calmed enough that he won't have to stay a prisoner for the rest of his life. 

His family was hesitant; they'd had lots of doctors try to fix him, and all of them had demanded large sums of money.  They also didn't want to be hurt.  Another big concern...  We would need to destroy the metal door, which had been solderd shut and they didn't have money for a new door.  But the seed has been planted, and hopefully they will make it happen.

The situation makes me feel physically ill. There is nothing humane about what is being done to him, which I say even as I understand why his family is doing it.  There simply are not places for people like this man to go in the long term in rural Mexico.   With only one psychiatric hospital, there are long wait times for a place in the hospital, and there are no discharge locations where patients who need interim care can go. While his family was trying to mitigate the harm he could cause, I can't imagine a more terrifying situation for a paranoid patient than to be locked in solitary confinement, essentially forever.  People of sound mind go crazy under those circumstances, let alone people with his degree of illness.  

I say this with deep respect for each of the individual players, who are doing their best in a terrible situation.  And yet the horrific inequality of how impotent we were in the face of this awfulness shows how large the problem looms.  And it is a hard measure of how well they are able to take care of the mentally ill, some of society's most vulnerable.

-Sarah Kimball, PGY-3
Internal Medicine, Brigham and Women's Hospital

Thursday, May 29, 2014

First Aid Response Training in Mbarara, Uganda

The incredible need for such a course was immediately apparent to me on my first day in the Accidents and Emergency (A&E) Ward, MRRH’s equivalent of an Emergency Department. It was clear that the majority of patients were being evaluated for traumatic injuries, most from recent encounters with a boda-boda.  Half of them had their heads wrapped in gauze to either cover their head wound or to secure the post-surgical drain from their recent hematoma evacuation. Upon walking in, you were hit with a wave of a distinct scent of old, crusted blood mixed with the smell of purulent drainage and the natural odor of the human species, when one is unable to take a shower for days, all combined in a hot, humid air that is caught in a building that is located on the equator with no air conditioner. It was a difficult scene to process, at first, especially when a 13 year-old boy comes in with his peritoneum exposed and a deep abrasion to his scalp after being hit by a boda-boda. His eyes filled with fear and confusion as he holds tightly to his mother’s arm and lets out cries of suffering. Unfortunately, you become slightly desensitized after a few days because such a sight is not uncommon. 

I had arrived in Mbarara with nothing but a small set of slides and the knowledge I had obtained from reading about similar courses done around the world in the last 10 years.  Yet, one step into the A&E Ward gave me the motivation required to make any apprehension I had, about my ability to execute such a course, completely disappear. I realized that even though a one-day first aid course for only 40 drivers would be a drop in the ocean, it would still be the first step towards improving prehospital care in a city where that concept was barely being introduced. I had the responsibility of creating the first aid course from the ground up in 14 days.  Along with the mentorship from Dr. Hilarie Cranmer, Director of Disaster Response at MGH Center for Global Health, Dr. Miriam Aschkenasy, Deputy Director of Disasater Response at MGH Center for Global Health, Dr. Anna Baylor, Program Director for MUST Research Collaboration, and Dr. Jon Mousally, EM Faculty at MGH who is working on a similar project in Bangladesh, Sarah Graham, who is the Program Manager for the MUST Research Collaboration, was my main collaborator on the ground.

The first stage of planning was focused on the logistics of the course. We wanted to formulate a small course which did not over-extend our resources and risk the quality of the course. Additionally, we were executing a project that we had never done before to a community that was new to the concept. Our target population were the drives and staff of the MUST Research Collaboration. This was a good group to start with because they were familiar with MGH and had a stable handle on the English language. Preference was given to collaboration drivers. Within the first six hours of opening up the course, all available positions were filled. The demand was so great that we were forced to turn down requests to take the course. Furthermore, after the course, participants were asking when the next course would be available. The primary emphasis of the course was for it to be hands-on with minimal lecture time. Given resource and time constraints as well as the local cultural customs, we elected to make the course four hours long with a 20-minute break in between. In order to ensure participants had adequate one-on-one instruction, the course was implanted over two days in two four-hour sessions with 20 positions for each course. After having the basic logistical skeleton for the course, our attention shifted to finalizing the curriculum, response cards, and first aid kits. 
The curriculum was focused on subjects that had proven to be universally valuable in low-resource settings. It centered on scene safety, universal precautions, airway, recovery position, wound dressing, tourniquets, splints, and cervical spine precautions. Using current literature, I used the small set of slides I had prepared prior to arriving to Mbarara and expanded them to create a four-hour course.  We then created a response card based on the pictures used for the course. Our end-goal was to make this course self-sustaining, so the involvement of Ugandan physicians was critical from the conception of the course. We recruited four Ugandan physicians: three interns and one Mmed, the equivalent of a resident. On average, there was a one to four or five ratio of instructors to participants. The curriculum was taught using materials from a first aid kit that was made from locally-sourced supplies. We spent three days searched for the best supplies available and negotiated for the best price. The only out-sourced portion of the kit was the bag in which the supplies were packaged; it was donated by Global Disaster Response at MGH Center for Global Health. Supplies included: gauze bandages packages – 3 units, gauze Pads – 12 units, elastic Bandage – 3 units, medical tape – 2 units, medical gloves – 10 pairs, scissors – 1 unit, hand sanitizer – 2 units, 1ft wooden dowels – 4 units, crowbar – 1 units, water bottle – 1 unit. The participants were taught using only these materials and resources that would be available to them in case of an accident (e.g., a towel, shirt, sheet). Each kit also included a first aid response card that illustrated each skill taught in the course in addition to the list of supplies and location where they were obtained. Each driver received a first aid kit, a portable water bottle (also donated by Global Disaster Response at MGH Center for Global Health), and a certificate. The participants were made responsible for restocking their kits as supplies were used. A six-question test was completed at the end of the course to evaluate the participants’ knowledge retention. This test showed that scores were lower in the session in which collaboration drivers made up 80% of the participants. In Uganda, drivers tend to have lower education levels than other professionals. The lower test scores of this session could be attributed to lower education levels, language barrier, and less exposure to the medical field.
Although I had originally proposed to execute a 3-week first response training course for about 200 participants and a disaster drill, I was only able to take a small first step towards this grand goal. As you know, international emergency medicine is a very dynamic world. When dealing with communities of low resources, especially abroad, it is difficult to execute a project without the full understanding of the local culture, community, and infrastructure, which is what I was able to accomplish during my 4 weeks in Mbarara. The course laid the foundation for a better product because of community engagement and capacity building of Ugandan physicians. Additionally, my trip also focused on meetings with key stakeholder in the city and medical community of Mbrarara. Dr. Cranmer, Dr. Baylor, and I met with the Vice-Chancellor of MUST, the Dean of the MUST Medical School, the Chief of Police, the Chief of Fire, the heading of nursing for both the hospital and the university, and the Department Chiefs of MRRH. These meetings were integral to the development of disaster preparedness in Mbarara. The intent is to organize and establish a self-sustained, Ugandan-led pre-hospital training course that will culminate in a city-wide disaster preparedness and response plan, including mass-casualty exercises and drills. As the Vice-Chancellor of the Mbarara University of Science and Technology put it, “Our hope is to make Mbarara the model for country and hopefully East Africa.”
In order to start working towards our long term goal, in November 2014, we will conduct a risk and needs assessment focused on formulating a basic first response training course tailored to the specific needs of the Mbarara community. The assessment will address the capabilities of the local Ugandan taxi drivers, fire, police, University and Hospital staff, and healthcare workers. It will quantify the types of injuries they come across and qualify the skills they feel they are able to offer.  The modes of transportation injured patrons utilize to go to the hospital will be measured and reviewed.  By the end of this long-term project, we seek to create capacity in pre-hospital care and emergency health care delivery. Hopefully, in a couple of years, a 13 yr-old boy with an exposed peritoneum will come in at least partially stabilized and with proper wound dressings.

Sunday, May 18, 2014

Thoughts on two weeks of rural primary care in Mexico

Update: I go to Jaltenango today enroute to Refoma, the second community that I am working in.  From what I understand, it is both more rural and yet closer to Jaltenango.  It is apparently also a community of many Jehovah's Witnesses.  

My last night in Laguna was marked by an after-dark walk to the pantheon/cemetary to try and get phone reception in order to talk to the main office about a case.  All the lights are gone, which is unsurprising after the three days of gloomy cold rain.  It also means that I haven't showered in two days because it is too cold to envision an icy bucket bath.

I've learned a tremendous amount about how I have (mostly subconsciously) learned to practice medicine by being here.  Today, we had a female patient who has a history of gallstones and who clinically seems to have progressed to pancreatitis.  As usual, the question arises of whether she is safe to stay here in the community until Monday, when her family can take her to the local hospital with surgical capabilities.  And the answer as to whether she is safe, as with so many things here, is that I haven't a clue.  I know how to risk-stratify pancreatitis in a hospital, where I can get labs and imaging.  I can fearlessly quote mortality statistics.  Here, I'm fairly certain of our diagnosis, but without the laboratory confirmation that I've learned to rely on, I feel paralyzed with doubt on how to treat people.  My pasante is so much more fearless, having gotten used to trusting her instinct without needing multiple (or any) forms of confirmation of her clinical instinct.  Somewhere in the middle is probably best for patients.

How can I tell how likely it is that our patient's chest pain is angina without ever getting an EKG, or lipids?  What is the pretest probability in a rural Mexican farmer who has never smoked but who probably inhaled tons of smoke in an indoor kitchen?  How do I treat him without access to a stress test?  How applicable is the Framingham Risk Score (or pick your favorite) to him?

I've learned that, in the absence of the screening tests that the majority of my patients get, I tend to suspect cancer at every turn.  I blame this in part on three years at BWH, with all our Dana Farber patients.  But in every abdominal pain in an older man, I see colon cancer and I fret about every woman with pelvic pain having cervical cancer.  I hadn't realized how much comfort I personally take in having an easily accessible screening panel.

In addition, so much of my practice at home is based on not missing anything.  We will get chest x-rays and labs for the lowest probability events.  So often, we use the language of 'ruling something out.'  Here, as testing is so hard to come by, you have to be pretty darn sure that you need something before you make someone travel.  

In my last day, we had two children who clinically looked like they had hepatitis A (one of whom's mom actually said, "his urine looks like coca-cola and his eyes are yellow."). How many kids in the past two weeks with diarrhea and abdominal pain actually had hepatitis?  Are we sitting on an outbreak?  Do you need the serological confirmation?  All these questions are new ground for me.

On an unrelated note, here's my pasante, myself, our neighbor's daughter and one of a thousand local dogs.

-Sarah Kimball, MD

Health related graffiti in Jaltenango, Mexico

I'm a total sucker for health-related graffiti.  There seems to be an HIV educational campaign in Jaltenango, which makes for some amusing artwork.

"HIV/AIDS.  Bring me, look for me, use me!"

"HIV/AIDS can only be aquired by means of sex and blood.  And a mother can transmit the virus to her child during pregnancy, delivery and breast feeding."

And my personal favorite:
"If you want to have sex, you should protect yourself with a condom."

-Sarah Kimball, MD

Primary Care in Chiapas, Mexico

Some of these posts are backdated, due to poor internet access in Chiapas.  But in short, thanks to funding from the Partners Center of Excellence, I'll be spending the next month in rural primary care clinics in Chiapas, Mexico with CompaƱeros en Salud, the Mexican arm of Partners in Health.  While I work on my Spanish (starting from a place of fumbling with many years out of practice), I'm hoping to get a sense of how primary care is practiced in a place where routine health exams are not the norm, and where people come without good access to the health care system.

My role here is as a medical consultant to the Mexican pas antes who are stationed here for a year.  They do six years of schooling, including a year of hospital training.  As a payback to their community (because medical school is paid for by the government), all pasantes do a year of community service.  My first post is in Laguna de Cofre, high up in the mountains of Chiapas, and about two hours from Jaltenango.  We have a small house next to the clinic where my pasante and her nurse live along with anyone else who comes along and needs a place to crash, like me.

On our first day, we left Jaltenango at 7am and headed straight for clinic, as the line was already getting long by the time we arrived at 9:30  From what I understood from my broken, aching Spanish, today's clinic included (in semi-medical speak)
Pts 1-4: pregnant mother and there kids, there for HIV testing.  Kids negative, mother positive.  Presumably from father, who travels back and forth to Tiajuana for work, as HIV rates are quite low here. 
Pt 5: well pregnancy check
Pt 6:  woman with pain in multiple parts of body, likely from stress.  IUD placed. 
Pt 7: woman with RA, who was getting dexamethasone injections and developed Cushings Syndrome and diabetes.  Now off steroids, but in lots of pain.  No clear other medication options available.
Pt 8: 60 yo man with exertional chest pain. No EKG or stress test easily available.  No clear idea of protest probabilities without lipid testing. Opted for nitrate trial diagnostically.  
Pt 9: 70 y.o. man with hypertension and vision changes.  As a side note, he was as tall standing as I am sitting.  
Pt 10: 70 y.o M with hemorrhoids and hearing issues.  Clearly no colonoscopy, but they have hydrocortisone suppositories with lidocaine in them.  Brilliant!
Pt 11: hypertension and sore throat
Pt 12:  well pregnancy check.  23 year old with three other children
Pt 13: sick kid (eeek! I don't know what to do with kids!) with diarrhea.  Fortunately, the wonderful
Pasante that I am working with knows kids may better.
Pt 14: teenaged boy with facial dermatitis
Pt 15: urosepsis in a 70 y.o. man with a permanent supracatheter.  Looked bad.  IV fluids, abx, monitored, no labs.  Will see tonight and tomorrow (he lives across the street) to make sure he doesn't need to be shipped to a local hospital (which he almost certainly does, but it is such an issue here to make happen)
Pt 16: told by a naturalist doc that he had bladder inflammation that he healed.  Wanted to talk to someone else, which is good because the story didn't make sense.
Pt 17: young girl with diarrhea
Pt 18: very depressed 15 y.o. girl who walked 2 hours to get to clinic.  Her problem is, in short, that she is a female in a a village in Chiapas without the ability to get out.  Not something sertaline will help, but that was what we had,
Pt 19: 19 y.o. lady with constipation
Pt 20: 15 y.o who was pregnant.  Wanted an abortion, but it is illegal in this state.  More about that later, which I find baffling and angering.

Off to this spot, which is my bed for the next ten days.

And our kitchen, which is barely functional but doesn't really need to be.

-Sarah Kimball, MD

Sunday, May 11, 2014

First Aid Response Training in Mbrarara, Uganda.

Arriving in Rwanda

After a 3 yr hiatus, I am getting back on the road (or plane if you will). Last time I was abroad, I was so anxious to one day be able to go back into the world with a little knowledge under my belt. My year abroad taught me so much, but it was frustrating for me to not have the medical experience to be able to give back. I was a little medical student following the Senegalese/ Laotian resident around. I am now returning as an MD. A little baby MD with training wheels still on, but a Doctor nonetheless.  I am very excited but also nervous to get back on my travel horse. Although I have traveled a great deal, it is still scary to jump on a plane to a unknown land and culture. Here we go once again!

 May 2, 2014

 I started of my adventure with a 21 hour journey from Boston to Uganda (Boston -> Amsterdam -> Rwanda- > Uganda), which was followed by another 13 hours on the ground until I reach my final destination of Mbarara, Uganda. I arrived into Kampala, the Ugandan capital, at 10pm. It was a surreal experience to be setting foot in Africa again. My first hour here, from the airport to the hotel, was one giant flashback. It made me truly miss Senegal. I have kept Senegal very close to my heart since I left. It will forever be my first time in Africa and first time I went out into the world completely on my own. Uganda had big shoes to fill. As I walked out of the airport, all I could see and hear were the Senegalese taxi drivers yelling to get your attention in French and Wolof. I remembered those butterflies in my stomach, the sweat in my palms, and the feeling of my heart racing that I felt when I first landed in Dakar 3 years ago. I was so scared back then. All I kept thinking was to keep walking forward and seem as calm as possible, when all I really wanted to do was crawl in to a little ball and be teleported back home with my Momma. This time it was different. I knew what to expect, and my appearance of calm was not a facade but reality. It made me a little sad.  You only get to have your first kiss once, and you only get to be a 24yr old girl during her first time in Africa once too. As I looked up and saw the million stars in the sky, I smiled and thought to myself, “ Hi
Africa, I’m back!” Uganda is very beautiful. Senegal is in the middle of the Sahara, so it was nothing but desert and Boaboa trees. Uganda is dead center on the equator. It is about 80 degrees year round, so it is very green, a little humid, and filled with valleys.  All the nervous feelings I had as I prepared for my trip disappeared on my way to the hotel. It was like riding a bicycle. I immediately adjusted to the stores on the side of the road, the aluminum roofs, and old concrete or brick. The familiar smell of 1970s cars mixed with fresh air and old world was all around me. I was thinking of how wonderful it was to be able to come back to such a beautiful part of the world, when we arrived to the hotel gates with a security guard holding a machine gun the size of a small child. It was reality reminding me of where I was in the world.   

May 6, 2014
It has barely been 2 days, and I already feel like I have been here a week. Right away it is very obvious that this trip is unlike any trip I have taken. I have always gone abroad to study or work on a project.  Yet, my trips have always been focused on me learning. Even when I have gone abroad to complete a project, no one was depending on my results for anything. The expectation was that I get out as much as I could out of the trip and my experience in order to further my knowledge that specific field or topic. This trip is different because I have very real responsibilities. There are both Ugandans and Americans that are depending on my work and the results I obtain. It feels like the first trip of the rest of my life and career. I feel like my previous trips were done in preparation for this trip and the work I will do from now on. It is both daunting and very exciting.

May 7, 2014
A&E = Emergency Department

Working in the A&E ( accidents and emergencies), which is the Ugandan version of the emergency department is going to be such an incredible learning experience. I have been working hard these last 2 years as a resident to learn as much as I could and gain as much experience as possible as a clinician. It has been a very steep learning curve. Going from an oblivious little intern to now an up-coming PGY-3, the difference in my skills as a doctor are incredible.  On my first day of residency, it took me an  hour and a half to see and complete the evaluation of my first patient. I still remember his face, the room he was in, and his chief complaint. I was so scared to prescribed Tylenol because I knew that if I put in the order, the nurse would actually give it. It wasn’t like medical school, where everything is practice and things have to be approved by your senior resident or attending. Although I had plenty plenty of support and help if I needed it, my orders for medications and interventions would actually be given. Anyway, so I went from getting butterflies from prescribing Tylenol  to being able to confidently treat septic patients,  
Procedure Room
strokes, doing intubation, placing central lines, and ordering medications that could rapidly and drastically alter someone’s physiology as well as having the ability of being responsible of as many as 15-20 patients at the same time on my overnight shifts. I still have a lot to learn, but the difference is mind-boggling. 

Type and Crossing
 Well, I came from that back to step one again. Being here in the Uganda A&E, I don’t know where any of the medications are, how the system works, the extent of the capabilities of the department, or how to simply write a note. My first day, it took me 2 hours to complete the evaluation and admission of 1 patient. Obviously, some of that had to do with how the system works, but the intern had to talk me through how to write a note and work up a patient. I felt like a day 1 intern all over again. I was learning more from the Ugandan doctors and interns than they were learning from me. Me, the American doctor being trained with “advanced” techniques and was here to teach them a few things! Because they do not have the tools and technology we have available to us in the west, they rely mostly on their skills as clinicians and physical exam. It is an art that is quickly fading in the west due to our growing reliance on technology.  
Blood Bank
I needed it, my orders for medications and interventions would actually be given. Anyway, so I went from getting 

It reminded me that I have to always be paying attention. There is no difference between me and the 13yo boy I say in the A&E the other day, who was hit by a boda boda. He came in with a head injury, cuts, and a very large open wound that involved the entire left side of his abdomen. He was lucky because it didn’t involve the part of the body that keep your organs and intestines inside. He was sutured up and discharged home later in the day.

May 8, 2014
I wake up at 630am-7am every morning and have not been able to go to sleep until about 11pm every night, not much difference than my days back in the US. Well, I little different. I don’t think I will have to take-on strings of days/weeks of getting 5-6hrs of sleep per night.

I have already had two amazing experiences. On Tuesday, I tagged along with a field team who deliveries HIV medications to rural communities. We drove out about 1 hour from Mbrarara into the tiny huts and houses that are in the middle of banana plant fields and miles from anything remotely modern. It was awesome!! I was honored to be the guest into their homes and sit in the one chair or bench of their home. The houses are usually made of clay, using old palm tree leaves as the structure backbone of the clay walls. The roof is usually made tin or dry palm leaves weaved together.

View of Mbarara Regional Referral Hospital
Today, I accompanied one of the internal medicine residents who is also here to a rural clinic that was 4 hours away from Mbarara. In order to get there, you have to drive through Queen Elizabeth National park, which is the main game reserve here in Uganda. There we were, making a very ordinary drive out to the clinic while seeing elephants, water buffalo, water bucks, and exotic birds on the way. No big deal. Just another part of our day! I couldn’t help but laugh and smile about the life I am lucky enough to live. 

The clinic experience was eye-opening. These patients are so far away from any major city, that this clinic is all they have for medical assistance.  There is no doctor. There is a chief medical officer, who was trained for 3 years after high school and is responsible for every patient, and a team of nurses. The clinic has a catchment area of about 40, 000 people, so it is no small task. He is able to work with limited medications to treat diseases that would require entire medical teams in the west. It was very humbling.

May 11, 2014
This first week was all about getting to know my environment, the people, the culture. I spent months trying to plan out my project, but it is so different to actually arrive and to start doing it. The beginning stages of organizing the first aid course have started. I have a specific plan of action. The program coordinator, Sarah, has been here for about 2 years so she knows the system very well. I had the curriculum and overall concept of the course planned out in my mind, but she is helping me adjust it to the setting in which I am working. Next week will be very busy. We are implementing the course in 8 days. It is not a lot of time to implement a course that I have never executed before in a setting that I am just getting familiar with. Yet, I know that we will get it done. We are going to start off small. We are planning to have only 40 participants this time around. My hope is that this course will grow and develop to become a city-wide event. 

Central Market

Chickens for sale at market.

Roadside Rest Stop

Elephant on my way to rural clinic.

Lake Bunyonyi
Ugandan kids

Tuesday, May 6, 2014

Healthcare for All at Hospital San Carlos, Altamirano, Chiapas, Mexico

With the incredible nuns of Hospital San Carlos.
The evening prior to my departure from Altamirano, the Hospital San Carlos nuns invited me to join them for dinner in their community.  As I mentioned in my prior entry, they are a truly incredible group of women.  Each has unique and important responsibilities in the daily functions of the hospital.  Among them include: Sor Rosario, determined hospital director and fearless leader; Sor Edith, wise clinical supervisor and xray technician; Sor Genoveva, director of nursing and nursing education; Sor Paz, pharmacist; Sor Consuelo, near to my heart, head pediatric nurse; Sor Rosaura, head medicine nurse; and Sor Anita, the most senior of the group, tireless nurse anesthetist.  Though each came to Catholic sisterhood through distinct paths, they all share a deeply religious and loving dedication to the poor and marginalized.  A story they shared that evening highlights the irreplaceable role that they and the Hospital play in providing care to so many families throughout Chiapas amidst a sea of barriers:
During a weekend when I had taken a respite to visit the Mayan ruins in Palenque, a gravely ill five year old girl was carried through the doors of the hospital by her parents in the middle of the night.  She was in severe respiratory distress, with a fever, and a concerning murmur, likely decompensating from pneumonia superimposed on a previously undiagnosed congenital heart disease.  Francisco, one of the several new physicians spending his year of social service at the Hospital, immediately called Carlos, an outstanding family medicine physician from Spain who has served as the hospital pediatrician for several years. The patient was rapidly stabilized and survived the 3-4 hour long journey to the pediatric subspecialty hospital in Tuxtla Gutierrez, where she was intubated and placed on a ventilator. Francisco formed a special bond with the family, who, like him, spoke the indigenous language of Tzotzil.  Later the following week, he received a phone call from the parents, informing him that their daughter had died after several days of medical care. They had been profoundly impacted and upset by a question that a Tuxtla provider had asked them, “Why did you take so long to bring your daughter to the hospital?”  Perhaps a sign of a provider having trouble coping with the injustice of losing a young life, or perhaps willful ignorance with regards to daily injustices, including poverty and discrimination, faced by the indigenous communities of Chiapas.
Hospital San Carlos serves as a safe, accessible, and culturally sensitive and acceptable provider of inpatient, outpatient, medical, surgical, pediatric, and OB/GYN care for indigenous as well as autonomous communities throughout much of the state of Chiapas.  Of course, resources are limited.  Plain films and basic labs (which do not include cultures) are available during the day as well as at night in the case of emergencies. Bedside ultrasound skills are acquired by some of the physicians over time.  Outpatient subspecialty referrals can be challenging, whether due to lack of patient resources or long wait lists.  Inpatient transfers, such as for neonates who may need CPAP or intubation, are at times refused by the referral hospital due to lack of beds. 

One segment of the infant and toddler's unit.
Caring for patients in both the inpatient and outpatient pediatric units was truly an excellent clinical experience.  In addition to a handful of newborns, we typically had somewhere between 3 and 7 inpatient pediatric patients.  Admission diagnosis were reflective of two the top five killers of children under five globally, acute respiratory tract infection and acute diarrheal illness.  Probably about a third of infants and toddlers were admitted with bronchiolitis, pneumonia, and a surprisingly high proportion of bronchodilator-responsive bronchospasm, perhaps secondary to indoor air pollution from firewood use.  Another third were admitted with dehydration in the setting of viral gastroenteritis, dysentery, and parasitosis.  These diagnoses certainly have parallels with those that most commonly lead to admission to MGHfC; however, the superimposed stunting and/or wasting among most of the patients clearly demonstrated how chronic and acute malnutrition might contribute to 50% of under-five mortality around the world. 

I learned a number of infectious disease-related clinical pearls during my month: one should assume that all children with severe acute malnutrition have a severe bacterial infection whether or not they have signs or symptoms such as fever; iron repletion for anemia should be deferred until treatment of bacterial infections (e.g. infectious enteritis, see: BMJ 2002;325:1142) has been completed, as there is a theoretical risk of worsened infection; congenital tuberculosis exists (see: N Engl J Med 1994; 330:1051-1054); and the management of fever without a source in well-appearing newborns/infants in the absence of culture data can rely significantly on clinical suspicion. 

Abnormal L5
The remaining one third of admissions encompassed an interesting mix of subspecialty issues. These included: a 12 year old boy with anasarca, ascities, pericardial effusion, and pleural effusions secondary to nephrotic syndrome; a 3 year old girl with >50% partial and full thickness second degree scald burns, one week out from injury, who was transferred AMA from government hospital; a 7 month old boy with tachypnea since birth and failure to thrive, without murmur, but certainly with a yet undetermined congenital heart defect, admitted with worsened respiratory distress; a 3 month old girl with severe stunting, presenting with vomiting since birth, found to have hemoglobin of 4 and guaiac positive stools; an 18 year old boy admitted after intentional ingestion of Gramaxone (aka Paraquat), an almost universally fatal herbicide without effective treatment nor antidote; and a full term, newborn boy with perinatal asphyxia, low apgars, who developed clinical seizures on day two of life, requiring phenobarbital.  I also encountered a good deal of developmental delay, including a 2 year old boy who presented to clinical with a URI and who apparently could not walk, stand, nor really sit appropriately.  He had bilateral ankle clonus, lower extremity spasticity, bilateral Babinski, and these apparent findings on physical exam and plain film:

Violaceous mass over lower lumbar spine.

Hospital de Especialidades Pediatricas - Tuxtla, Gutierrez
I was frequently left with the desire to teleconsult my MGHfC attendings and fellows and, in fact, did speak with one of our wonderful cardiologists, Dr. Manuella Lahoud-Rahme regarding one of our CHD patients.  Wait times for consultations with subspecialists at Hospital de Especialidades Pediatricas are often prolonged, and the prospect of enduring the costs and opportunity costs of travel make the trip all the way to Tuxtla Gutierrez prohibitively expensive for many families.  Performing an echocardiogram while Dr. Lahoud-Rahme watches via Skype, is just one example of the potential for telemedicine to advance access to subspecialty pediatric care at Hospital San Carlos.

Helping Babies Breathe - Workshop 1
In addition to the clinical and community-oriented aspects to my trip, I spent some time working in the realm of formal medical education and quality improvement.  I gave a chalk-talk on a variety of neonatal health issues for the physicians during one of the biweekly morning conferences.  This was perhaps more of a learning experience for me, as my audience helped me grasp the many adaptations necessary to take care of newborns in a low resource setting. Continuing with the theme of neonatal health, Dr. Jennifer Kasper and I prepared an abbreviated Helping Babies Breathe© training for nurses, nursing students, and auxiliary staff at Hospital San Carlos, in collaboration with Sor Genoveva. 
Nursing students at their capping ceremony.
There were 42 participants who attended one of two, two-hour sessions that focused on the Golden Minute of life and practicing scenarios with NeoNatalie newborn mannequins. About 3 weeks later, I was able to schedule a follow-up refresher session, and while this landed at the tail end of vacation week for the nursing students, 31 learners participated in the workshop, including 10 new participants.  While I had intended to perform OSCEs to evaluate effectiveness of the first workshop measuring retention of knowledge and skills, this was ultimately not feasible in light of time and resource constraints.  Subjectively, the students expressed that they very much appreciated the opportunity to reinforce and practice their skills.  I could see that many were more prepared to revive their mock newborn patients, and to do so within the first minute of life.  The second session also gave me the opportunity to fine-tuning practices that I had observed in the delivery room during my month, for example: not delaying bag mask ventilation to attach oxygen to the self-inflating ambu bag and acting upon an emergency plan (i.e. calling Carlos) at the first sign of trouble, whether fetal distress or difficulty with ventilation. 

Carlos (pediatrician in-charge) and I.
Lastly, I worked with one of the hospital administrators and Carlos to create a self-evaluation tool for the pediatrics unit that could be used to highlight and select priority issues for quality improvement.  Drawing from hospital standards from the WHO, the Mexican General Health Council, and other resources, the tool asks doctors and nurses to respond to questions relating to seven themes using Likert scales: professional communication, medications and errors, rights of the hospitalized child, involvement and education of families, evaluation and treatment of pain, hygiene and prevention of infection, personnel and equipment, and trainees and continuing medical education.

I truly hope that I will have an opportunity to return to Chiapas and to Hospital San Carlos.  My upcoming fellowship program in pediatric emergency medicine is affiliated with two hospitals, UCSF and Highland, who send attendings and residents to San Carlos.  Now that I’ve had a chance to reflect on my trip, it’s time to get busy thinking of next steps.  Next steps in strengthening the Hospital’s referral capabilities, perhaps via telemedicine … next steps in ongoing capacity-building in skills such as neonatal resuscitation and pediatric ultrasound.  I’m so grateful to all my new, amazing colleagues in Chiapas, the sisters of Hospital San Carlos, Dr. Jennifer Kasper, Dr. Juan Manuel Canales, and Doctors for Global Health, who together made this experience as enriching as it was.  Many thanks as well to MGHfC Pediatric Residency Program and the Partners Center of Expertise in Global and Humanitarian Health without which this incredible experience would not have been possible.

Ashkon Shaahinfar, MD, MPH
MassGeneral Hospital for Children
Pediatrics, PGY3