Monday, September 28, 2015

Enhancing clinical care in rural Mexico part 2

Sunrise over Soledad
In my final weeks working in Chiapas, Mexico with Companeros en Salud (CES), I was stationed in two communities - Laguna del Cofre and Soledad. Laguna is one of the highest elevation mountain communities that CES serves, and it's also one of the biggest and most remote. Because of the large size of the community, clinic hours often started early and ran late. The Pasante did not turn patients away. As the other Pasantes I worked with, she was similarly skilled both in creative improvisation to provide appropriate medical care - we constructed an asthma inhaler spacer out of a plastic water bottle - but also in integrating herself as a trusted and valued member of the community.

It was here that I was also able to learn much more about the various stages of coffee processing from one of the local roasters, who provided a detailed explanation of coffee processing one morning before we began in clinic. Prior to my time in Chiapas, I'd pictured the coffee that we buy from the large franchise chains in the US as coming from large ranches in whatever country the coffee was being sourced from. It wasn't until living in Chiapas that I saw how all of these villagers were largely growing coffee to sell to large coffee retailers in the US. The villagers pool their coffee together in co-ops to try and negotiate for better deals. Though they drink coffee all the time, it's generally the worst quality coffee, because it's what can't be sold to the foreign markets that pay the highest price.

Stages of coffee bean processing

In my final week in Chiapas, I was working in the community of Soledad, a beautiful village built on mountainsides of striking red clay earth. Soledad was similarly one of the more remote communities that CES served. There, I stayed in the spare room of an incredibly friendly and generous family. The father of that family had recently left to try and cross over into the US. The percent of young men who planned to travel to the US for work was striking, though most were adamant that they wanted to return to Mexico to be reunited with their families. Husbands and wives would go weeks without being able to talk to each other - either because they didn't have the funds to communicate, or often the husband was moving from one job to the next in the US. After working and saving money, many planned to return to their home communities and use that money to increase their family's standing in the social hierarchy there - buy a better store, build a nicer house, or have a little more land to grow coffee.

Enhancing clinical care in rural Mexico part 1

Since working with Companeros en Salud (CES), the branch of Partners in Health that is located in the southern Mexican state of Chiapas, I've had the fortunate opportunity to live with and teach some outstanding Mexican medical students. In their final year of schooling,  all medical students in Mexico complete a "pasantia" -- a year of  service that largely translates into these medical students being posted at rural sites where they serve as the  primary point of clinical  care. To better support pasantes in some of the poorest communities, CES has partnered with the government to provide increased support for pasantes who serve areas of exceptionally increased risk. Currently, CES serves 10 clinic sites spaced throughout the Sierra Madre, providing increased logistical support and mentorship for the Pasantes (and in turn, improving clinical care) in these communities.

In my first week of work, I was stationed in the community of Plan de Libertad, which was really two communities  - "Plan Alto," the main community where we lived and worked, and "Plan Bajo," the smaller community that was a half hour hike down the winding dirt road, through the coffee ranches and solitary homes along the way. In our first week, the Pasante and  I saw a wide variety of cases - adults and children, chronic and acute complaints, surgical, medical, psychiatric, and social. It was striking how competent and capable the Pasante was in his duties, especially for his young age of 24. Functioning essentially as the town doctor, though still not yet having graduated from medical school or having taken his consolidating, final exams, he quickly and creatively dealt with any problem that would arise.  Someone came in with the distal phalange of their finger nearly chopped off from a machete accident - he sewed it all back on. There's no finger splint -- break a tongue depressor in half and make the edge smooth with the sandpaper he keeps in his kit.

The Pasantes are also viewed as outsiders in a way, in that they often come from more urban areas of Mexico - most frequently Mexico City. As with any doctor-patient relationship, it takes time for them to build trust with the local community members. In these small mountain villages of only a few hundred people, the intimate nature of the doctor-patient bond is even more amplified by the physical and social proximity of the Pasante with the other community members. In these communities, an unsatisfied patient likely lives only a few houses down the road or may be the owner of one of the few shops in the village.

The Pasante watching over the community at sunset.

Mbarara part 2

J. Reisel

The second project that I was able to continue work on while in Mbarara, Uganda was focused on Typhoid Intestinal Perforations or TIP.  This is a project that my Ugandan Co-PI and I developed over a year ago, but have yet to be able to give the attention it needed until I was able to come back to Uganda and work on it full time. 

Typhoid Fever is a life-threatening illness endemic to many low-and middle-income countries (LMICs) due to poor sanitation and water quality. If left untreated, it progresses to perforations of the intestines, commonly referred to as TIP. There are an estimated 12-20 million cases of Salmonella Typhi infections per year, however, due to a dearth of research on this topic, this is largely modeled data that does not account for the incidence of Typhoid perforations; however, in one study from Western Uganda, nearly half of all Typhoid cases progressed to TIP and the majority of patients affected were 19 years or younger. Little progress has been made in the prevention or treatment of this infectious disease.
The best treatment of TIP is prevention. Unfortunately, barriers to preventing and treating Typhoid infections are significant in the limited-resource setting. Without proper antibiotic treatment, a bacterial infection becomes a surgical emergency. However, surgical care is not straightforward in this population. Many patients in LMICs are mal-nourished and immune suppressed.  When compounded with delays to care, such patients are systemically ill and cannot tolerate an extended surgical procedure under anesthesia. Post-operative mortality rates reported for TIP have been as high as 50% and we see many of these complications in Mbarara. Currently there is no evidenced-based standard to approach such cases of TIP, and surgical providers rely on instinct to inform their clinical decisions. Borrowing from the pediatric and emergency surgery literature, my Ugandan collaborators and I thought a “Planned Second Look” (PSL) procedure might improve outcomes, however this has yet to be studied in TIP.
PSL procedures are well supported in the literature across all income levels and age groups in cases of trauma, necrotizing enterocolitis, and aggressive infection. In a PSL, the index operation is an abbreviated laparotomy, infection control, and wash out in an unstable patient so as to minimize exposure to stressful anesthetic agents that may cause hypothermia, hypotension, and acidosis. This is followed by post-operative stabilization of the patient before undergoing the definitive procedure, usually within 24-48 hours.  The PSL also allows providers to detect progression or regression of disease on the PSL, making decisions for definitive management more judicious. In the case of this proposed study for TIP, a PSL would be indicated only in patients deemed unable to withstand a protracted surgical procedure, as determined by the Mannheim Peritonitis Index (MPI).
My month in Mbarara allowed me to really focus on this project – and as a result, our research team was able to present the project to the Department of Surgery at MRRH – and they received it well.  Everyone who has worked in the operating theaters at MRRH has seen the terrible disease progression of TIP and recognizes the need to improve our outcomes in treating these patients.  Following the Department’s approval, we were then able to develop a study protocol and develop our IRB.  It was a busy but incredibly rewarding month in Mbarara!
From Right to Left: Francis Bajunirwe, Johanna Riesel, David Mutiibwa, Martin Situma, and Francis Bajunirwe:  The Typhoid Intestinal Study Team, after finalizing our study protocol at MRRH. 

Mbarara part I

J. Reisel

My time in Mbarara in March-April of 2015 was a really exciting one.  It is always great to be back in Mbarara and to reconnect with old friends and colleagues.  

During my month in Mbarara, I was able to continue work on 2 research projects that had been paused while working on research in Boston.  I will discuss the Typhoid project in the next blog entry.  

My other research project focussed on quality and safety in the surgery department at Mbarara Regional Referral Hospital (MRRH).  In Mbarara, similar to many resource constrained settings, medical records are maintained on paper charts.  There's no distinct filing system, and no standardized forms, so the admission notes and hospital records may vary from a succinct synopsis to a detailed account.  The records are papers held together by twine strung through ripped holes, and commonly pages (documenting days worth of treatment) are lost.  Similarly charts have a habit of "walking away" either with the patient who takes it with them in a pile of their belongings after discharges, or with a resident who needs to present the patient's case at conference.  

As a result, it becomes exceedingly difficult to assess what is actually taking place on the surgical service on a large scale.  While providers most certainly know that head injuries from road traffic accidents tend to do poorly, they may not know that children under the age of 5 do the worst and therefore need additional care and focus.  Or that in the dry season, cases of Typhoid perforations spike - and therefore suspicions for this disease should be raised when I patient presents with abdominal pain and fever.  

For this reason, I got involved with a quality assurance database built by faculty from MGH and MRRH.  This database provides a secure, electronic forum for documenting all surgical cases, their hospital course, and their outcomes at MRRH, making quality assurance not only easier but feasible.  We have learned a lot from this database - but one of the most salient lessons has been quite simply how to run such a database.  One of the most important elements of this has been transitioning from "free text entry" (for example:  "Admission Diagnosis: mild head injury") to standardized coded entries (e.g. ICD-10 codes) so that areas of interest can be easily queried and assessed.  

As a spin off of this project, I worked with a Harvard Medical Student and 3 Ugandan physicians to develop a project that would allow us to better understand what happens in the operating theaters so that we can better report what equipment is needed from the government in order to provide adequate surgical care.  During my month in Mbarara we were able to put our heads together and design a research project that will allow use to identify a condensed list of ICD-9 codes for procedures performed in the operating theater.  Recognizing that the same list of procedures performed in the US and elsewhere is not necessarily applicable in the resource-constrained setting (e.g.Laparoscopic gastric bypass surgery is not in high demand in Uganda), we wanted to create a condensed list that applies to directly to a setting like MRRH, but still uses a standardized and widely applicable set of codes such that cross country and continent data can be compared.  

It has been a wonderful process working through these ideas together and to develop a project that is important to everyone involved.  I am eager to see the end result

Peter Kayima, MRRH Surgical Resident and one of our partners in the condensed operative coding project, and I at the MGH Guest House in Mbarara, Uganda.   

Queen Elizabeth Central Hospital in Blantyre, Malawi

C. Chang

Queen Elizabeth Central Hospital (QECH) in Blantyre is the largest hospital in Malawi with 1,300 beds, and is the home to the University of Malawi College of Medicine, the country's only medical school. Following my 2 weeks at Muhimbili National Hospital in Dar Es Salaam, Tanzania, I spent 2 weeks in QECH's Accident and Emergency Trauma Centre, continuing my work on assessing the acceptability and feasibility of the medical emergency documentation tool as part of an effort led by the African Federation for Emergency Medicine.

While much of the effort in global health has focused on preventive health and the management of chronic illnesses, low- and middle-income countries are facing a growing burden of emergency conditions. Where EDs exist, they frequently see large volume of patients with high acuity and mortality rates. Many EDs in national referral centers, such as the one at QECH, serve as the main entrance to the hospital, serving sickest patients transferred from all over the country, often in private vehicles due to the lack of robust ambulance systems.

Spending time in clinical settings in LMICs often highlight the need for improved data collection so that already-limited resources can be allocated optimally. EKGs, which are indispensible to Western EDs, are rarely obtained in Malawi. They are arguably of limited utility in a place where one would be more likely to find electrolyte abnormalities on EKG than myocardial infarctions. Not surprisingly, the QECH ED's expensive EKG machine spends most of its time locked up in the department chair's office, and it's the rare clinician who knows how to interpret an EKG.  Even critically ill patients are rarely intubated due to the shortage of ventilators, oxygen tanks, medications, trained staff, electricity, or all of the above, and while considerable effort is spent on securing these resources, EDs frequently find themselves lacking one or more key pieces of the puzzle, rendering the whole endeavor futile.

Experiences such as these at Muhimbili National Hospital in Tanzania and QECH in Malawi brought home the potential for a robust, systematic data collection effort to improve our understanding of the role of EDs in LMICs and optimize their operations. I am excited about the potential for this project to improve patient care and resource allocation in low-resource EDs, and look forward to sharing the results in the near future!

Muhimbili National Hospital in Dar Es Salaam, Tanzania


Muhimbili National Hospital (MNH) in Dar Es Salaam is Tanzania's largest public hospital and the country's leading teaching and referral center with 1,500 beds.  The emergency department (ED) at MNH opened in 2010 and is home to one of few emergency medicine residencies in Africa, and sees nearly 40,000 patients annually. As part of an effort through the African Federation for Emergency Medicine (AFEM), I spent 2 weeks in March 2015 at MNH, holding focus groups with local administrators, physicians, and nurses to assess the feasibility and acceptability of AFEM's newly developed tool for documenting medical emergencies in low-resource emergency departments (EDs).

Poor clinical documentation and medical recordkeeping are key obstacles to improving emergency care in low-resource settings since they not only obscure patients' clinical course and leads to errors and poor outcomes, but also complicates systematic data collection and evaluation. In many parts of the world, clinical encounters are documented by hand on blank pieces of paper, classically in the "SOAP" format of Subjective, Objective, Assessment, and Plans. Frequently, given the high volume of critically ill patients seen throughout the day in many EDs, clinicians spend minimal time on documentation. As a result, charts are often difficult to interpret due to haphazard documentation or indecipherable handwriting. The goal of this project was to optimize a tool designed to simplify and standardize medical documentation in order to improve individual patient care and systematic data collection that ultimately boosts our understanding of the role of emergency care in low-resource settings.

The AFEM tool was modeled after a trauma documentation system that has been adopted as the chart for all trauma patients presenting to participating EDs across Africa. As a participating ED, MNH physicians had grown accustomed to the standardized trauma form, and had helpful insights into the use of standardized documentation in emergency settings and valuable suggestions for improving the newly designed form. Many expressed that while they were initially hesitant to adopt an entirely new way of documenting clinical encounters, they found that standardized forms not only saved time and mental energy during busy ED shifts, but also served as a "checklist" of must-do tasks.  With these comments and suggestions in mind, I next headed to Blantyre, Malawi to find out how a different group of clinicians in a different clinical setting would find the AFEM tool.

Wednesday, September 16, 2015

The "black box" of pulmonary epidemiology in Uganda part 2

March 1, 2015

Crystal North, MD
Clinical Research Fellow
Division of Pulmonary and Critical Care Medicine
Massachusetts General Hospital

I am delighted to report that I was selected to be a 2015 – 2016 Fogarty Global Health Fellow, and will be moving here (to Mbarara, Uganda) in August 2015!  This fellowship will directly support my work studying lung disease among people living with chronic HIV infection, and will hopefully be that key launching point to a successful research career that every junior investigator needs.

This last month has been a whirlwind of activity, meetings, writing and planning, with just enough relaxation in gorgeous Uganda to make it all manageable.  We’ve successfully submitted all necessary IRB documents, all study supplies haven been delivered and inventoried, training sessions for the research team on pulmonary function testing have begun, and work is well underway for the second project I’m involved with here in Uganda – the HopeNet Health Fair (which I’ll describe in a bit). The research team is excited to begin pulmonary function testing on study participants, and is so enthusiastically interested in why we’re choosing to add pulmonary function testing to the study.  I have deeply enjoyed getting to know them over the last 6 weeks, and I’m even proud to say I’ve picked up a few of the Runyankole greetings.  They keep trying to teach me more, but my knack for languages was never very good to begin with – I can barely remember any of the high school Spanish I once knew.  I’ve promised them that I’ll keep working on learning the language – mpora mpora (slowly).

The second project on which I have been working is planning of the HopeNet health fair.  To better understand the burden of chronic diseases in southwestern Uganda, we are planning for a community screening event to be held in June 2015.  Our health fair will screen for common yet under-diagnosed conditions – high blood pressure, chronic lung disease, heart disease and diabetes.  Given its emerging status as a chronic disease, we will be conducting HIV screening as well.  We hope to screen around 2,000 people over 5 days – which understandably is going to take quite a bit of planning.  I have quickly become well-versed in the language of contracts, payments and advertisement, and have developed a deep appreciation for international Skype meetings.  I know nothing about the stock market, but if it’s possible to own stock in Skype, I wish I did.  The skill set I’m developing as a part of this planning committee is priceless, and despite the multitude of emails and my necessary attachment to the internet at all times, I wouldn’t trade the experience for the world.  The opportunity to evaluate the pulmonary function of up to 2,000 Ugandans will provide such insight into pulmonary health in sub-Saharan Africa, and I’m quite thankful for the opportunity to be a part of this project. We are scheduled to have our health fair in June of 2015, barring any necessary readjustments, so cross your fingers for a successful and impactful HopeNet health fair!

The "black box" of pulmonary epidemiology in Uganda part 1

January 25, 2015

Crystal North, MD
Clinical Research Fellow
Division of Pulmonary and Critical Care Medicine
Massachusetts General Hospital

Stepping out of the airport in Entebbe and breathing in that first lungful of Ugandan fresh air never ceases to rejuvenate my jetlagged mind. My first trip here, I wasn’t sure quite what to expect. I had worked in other African countries, but it was my first time to Uganda.  18 months later, I’m returning with a specific purpose, and I can’t wait to get started.

Allow me to back up a few steps.  I’m a Pulmonary and Critical Care fellow from Massachusetts General Hospital, drawn to the study of lung health in sub-Saharan Africa because of the large “black box” that is pulmonary epidemiology in the developing world.  As a scientific community we’ve discovered that respiratory disease is the third leading cause of death and disability globally, and we know that air pollution from a lack of industrial regulations and biomass fuels is the leading threat to lung health internationally. What we don’t yet have a grasp on is what the epidemiology of lung disease in the developing world looks like – who gets lung disease, when do they get it, what other diseases might they have, how bad does the lung disease get, and do they die earlier than those who don’t have lung disease?  Since most developing countries lack enough (if any) pulmonologists or machines for pulmonary function testing, the opportunity to have a lasting impact on understanding lung health is significant.

I’ve come to Mbarara to begin work on two specific projects that will begin to shed light on some of these questions.  Each focuses on the epidemiology of pulmonary function in southwestern Uganda, and each has a slightly different approach.  First, in collaboration with an Infectious Diseases colleague from MGH, we will be studying the epidemiology of chronic lung disease in people living with chronic HIV in southwestern Uganda.  Chronic HIV infection is a risk factor for chronic lung disease in US and European cohorts, but whether this also holds true for those living in sub-Saharan African is unknown.  This study is set to begin enrollment in July 2015, so the primary purpose of this trip to Uganda is to finalize and submit all IRB documents to the Ugandan IRB and to deliver all equipment and supplies necessary to perform pulmonary function testing (two suitcases worth!).
I’m extremely lucky to be working with an established research team that has been enrolling study participants together for the last year, and am looking forward to meeting them this week and working together over the next 2 months and beyond.  My previous trip to Uganda was not research-focused, so I am eager to begin learning about the research infrastructure at the Mbarara University of Science and Technology (MUST), the processes for IRB submission and review, and generally how to go about beginning a study in another country.  I am fortunate to have excellent leadership in the junior and senior faculty who have gone before me, and I’m excited to begin this new chapter in my professional life.

Off to a little sleep (jetlag-willing) before the 5 hour drive to Mbarara in the morning!

Friday, September 11, 2015

Gallup. NM part 2


Contrary to popular belief, although “Native” Americans populated the Americas long before Europeans and other immigrants, Native American history is also one of immigration and migration throughout the North American and South American continents.

Over 1000 years ago, the Athabascans crossed the Bering Sea from the Eurasian landmass and settled parts of Western Canada and Alaska. Through cultural, linguistic, and genetic research, it was recently discovered that the Navajo are descended from the Athabascans and most likely branched off in the 1300-1400s when they migrated to the American Southwest. Other Athabascans diverged and became present-day Apaches.

Traditionally hunter-gatherers, the Navajo learned from neighboring Pueblo tribes how to farm and cultivate the land. Over time, they fended off threats from the Spanish but eventually were defeated by US forces including Colonel Christopher “Kit” Carson in the mid 1860s. This defeat culminated in the widespread deportation of Navajo people away from their homelands to Ft Sumner from 1864-1866 that came to be known as the “Long Walk” and the signing of treaties that led to the formation of Navajo Nation. It is purported that this was one of the first exposures of the Navajo people to tuberculosis. By 1912, 10% of Navajo had TB, and TB was responsible for 50% of all illness seen among the Navajo.

The Navajo word for TB is “jei di,” which literally means “disappearing heart.” There is a commonly held perception that TB can be caused by contact with wood that has been struck by lightning. Navajo Medicine asserts that TB or jei di can be cured by the shooting way ceremony to achieve harmony.

By 1953, almost a century after the “Long Walk", TB incidence was 100x higher among the Navajo than among the general US population. Around this time, a brave lady named Annie Wauneka led a public health campaign to educate her fellow Navajo about the dangers of TB and to correct misconceptions surrounding the disease. She taught Navajo medicine men about TB, pioneered a model of directly-observed therapy for TB, and encouraged Navajo to complete their TB treatment.

Today, tuberculosis still plagues the Dine at a rate many times that of the general US population. As you may know, tuberculosis is a curious disease in its ability to remain latent for many years before reactivating during times of sickness or immunosuppression. TB is called the “Second great imitator” due to its protein manifestations.

It is estimated that as many as 1/3 of all those who suffer from diabetes mellitus on the reservation have latent tuberculosis and are at risk for reactivation and transmission. As such, it is increasingly common for all those with DM to be screened for latent TB with a PPD or a serum quantiferon test.

Although TB rates and mortality have fallen drastically thanks to efforts by Annie Wauneka and others, TB is still a disturbingly common occurrence among the Navajo. While working with an infectious disease physician in Navajo Nation, I had the opportunity to meet and care for a kind lady on immunosuppressants for her rheumatoid arthritis who presented with severe hip pain. Although the thought was that she likely had a labral tear or her pain was a manifestation of her pre-existing RA, her joint was tapped and was positive for TB. She was treated with a 4 drug regimen, and before I left her pain had significantly improved.

For context for those reading, during my 6 year general medical training in the United States, although tuberculosis has been on the differential many times, I have never cared for a patient with newly diagnosed tuberculosis. I have read and seen patients with TB in India and southern Mexico but not once in the United States. By and large, it is a disease of poverty and affects the most vulnerable both from a medical and societal perspective.

In my next post, I hope to speak more about structural factors that affect health in Navajo Nation.

Post 3

“Next to the mountain. Literally right at the foot of the last mountain to your left.” That’s where she lived. Ms. G was a 60yo lady with diabetes, HIV, and a big heart. While here in Navajo Nation, I’ve had the opportunity to see amazing medicine in the clinic but also outside the clinic. In fact, when you think about it, most of what affects health doesn’t happen within the fours walls of a hospital or doctor’s office, but in a person’s home, among their family. As such, home visits can be a powerful lens for understanding how people live and how their environments contribute to their health in both positive and negative ways.

Yesterday, I was fortunate to travel with HIV community health workers to visit the homes of patients with HIV and make sure that they were being cared for and had their medications. For patient with HIV, adherence to anti-retroviral medications of 95% or greater is essential to rendering the HIV viral load undetectable. For many diseases, adherence of >70% is a victory, but for HIV high adherence means life or death. As such, ancillary support from social work, nursing, and family can be essential.

After traveling for 1.5 hrs and missing her home multiple times (there are many mountains on the reservation), we arrived at Ms. G’s humble abode - a 2 bedroom converted trailer home. Ms. G profusely apologized for missing her appointment and not answering the phone, but because of the rain and the unpaved roads on the reservation, she was afraid she would get stuck in the wet clay and so was unable to get to her appointment. Regarding the phone, she did not have a landline, and her daughter needed her only cell phone.

In speaking with the CHW, I found that this scenario was not uncommon. ~80% of the roads and driveways on the reservation are unpaved, and only 60% have access to landlines with fewer having access to internet and cell reception. More disturbingly, 9% of households do not have access to clean drinking water and sanitation.

The infrastructure that I take for granted in Boston is feeble at best on the reservation, further exacerbating the poverty and poor health that plague this community. Sadly, the Navajo Nation suffers from unemployment reaching over 50% by some estimates with yearly income 1/3 of the general US and rates of intimate partner violence as high as 39%. In this setting, health and healthcare often take a back seat to food, nutrition, housing, and other goods.

Ms. G was ever the gracious host, offering my companions and I a drink and making us feel welcome in her home. On the kitchen table, I was impressed to see a strict food diary with blood glucose levels and a medication dispenser organized by her daughter. Of course, this victory was hard won and over the past 2 years, Ms. G had been hospitalized for complications related to diabetes and come close to death many times. The CHW was able to re-schedule her appointment using a cellphone, schedule labs that had been missed due to the rain, and provide her with a more organized medication dispenser.

As a medical doctor, I am trained to interpret numbers, look for signs and symptoms, examine the body, and come up with a diagnostic and treatment plan. All too often, the most important elements of a patient’s daily life (i.e. rain, poor infrastructure, no cell phone, domestic violence, economics hardships) are left out of the plan to the detriment of the patient and society’s health. In these cases, we physicians re-double our efforts to treat patients in the ways we know how, but never are we trained to think about the big picture, to think about how access to clean water or to telephones can make an outsized impact on health. It is here that the CHW and the home visit really shine and add impact to a medical team.

In my next post, I’ll talk more in depth about innovative care delivery models in Navajo Nation.

Gallup, NM part 1


It is a Saturday morning in early May here in Gallup, NM, and as I sit down to write this post, I am staring at a flurry of snow outside my window and a blanket of white upon the town. In Boston, the snow often cloaks and transforms the city, but here in Gallup, the snow only shades the imperturbable land and sky. Indeed, what struck me most when I came here was the vastness of the land, of the sky, of the history. It is overwhelming and humbling at the same time.

Gallup is located squarely in the Navajo Nation, a tribal sovereign nation of close to 200,000 people who identify themselves as Navajo. It is bordered by other culturally and linguistically distinct tribes, the Zuni and the Hopi.

Much like the land, the people here are enduring and have weathered storms in the past - from rival tribes, to colonization by European powers, to subjugation at the hands of my country the United States, to more modern threats including pollution from coal and uranium mining and now substance abuse, HIV/AIDS, and diabetes.

Through it all, Dine, or "the people” in the Navajo language have persevered.

There have been bright spots in Navajo history, from the heroic role of code breakers in WWII to the establishment of the sovereign nation of Navajo to the retention and active use of Navajo language and traditions in everyday life.

The Indian Health Service and its hub in Gallup has pioneered a number of incredible innovations along the way to better service its constituents including the use of community health workers, the active treatment of HIV/AIDS, Hepatitis C, and Tuberculosis, and the implementation of telemedicine to enhance care.

Over the next few blog posts, I hope to explore Navajo history and culture and highlight my clinical experiences.

Stay tuned.

Tuesday, September 8, 2015

Introduction of Interventional Radiology in Rwanda part 2

Jeffrey Forris Beecham Chick, MD, MPH

Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115


Today we performed the first ever ultrasound-guided catheter drainage in Rwanda. The patient was a 2-year-old female with elevated amylase and lipase and a cystic mass arising adjacent to the pancreas thought to represent a pseudocyst or benign cyst from pancreatic injury. Although pancreatic pseudocysts are common in adults with alcoholism and pancreatitis, they are rare in young children and the entire radiology team was uncertain why the child developed such a cyst in the first place. These cystic masses are surgically resected in Rwanda, however, there was only one visiting pediatric surgeon in Rwanda and these procedures carry a high morbidity and mortality. We were hoping to drain the cyst completely by inserting a catheter rather than relegating the child to surgical intervention. It was time. Several pediatricians, nurses, and families watched as we prepared for the procedure. A pediatrician provided conscious sedation with ketamine as we were now doing routinely in Rwanda. After the child was sedated, we identified the cystic fluid collection using ultrasound and advanced a drainage catheter into it. As we advanced the catheter, an abundance of clear yellow fluid came spilling out in and around the catheter. We aspirated all the fluid we could obtain, over 800 mL, sutured the catheter in place, and used the ultrasound to confirm that the collection had resolved completely. We sent the fluid for amylase and lipase in an attempt to confirm that the cyst was indeed the proposed pseudocyst. Unfortunately, 2 days later, we learned that the laboratories in Rwanda are unable to analyze any fluid, other than blood, for amylase and lipase. Moreover, we discovered that the catheter had been inadvertently pulled back to the skin while the child was playing during the day and that it was no longer draining any fluid. Due to the concern that it would become infected we removed the catheter. While we had successfully placed and drained the majority of the collection, we had failed to drain it completely, and it seems as if the child will likely need a second catheter placed or undergo surgical intervention in the future. We plan to discuss our case with the surgical team.

A: Pre-procedural computed tomography image demonstrating a unilocular cystic mass adjacent to a normal appearing pancreas concerning for a pancreatic pseudocyst.

B: Pre-procedural ultrasound image confirming the large peripancreatic cystic mass.

C: Intra-procedural photograph showing continuous monitoring during ketamine anesthesia as well as creation of an incision prior to catheter placement.

D: Intra-procedural ultrasound image demonstrating the advancement of the catheter into the collection.

E: Computed tomography image obtained two days after the placement of the catheter demonstrating a residual peripancreatic collection with the catheter retracted to the skin surface and no longer functioning.

F: Repeat ultrasound image, prior to consideration of placing a second catheter, demonstrating the new septated appearance of the collection.

Introduction of Interventional Radiology in Rwanda

Jeffrey Forris Beecham Chick, MD, MPH
Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115

Today we performed the first ever computed tomography-guided biopsy in Rwanda. The patient was an 11-year-old female with large fat-containing abdominal mass which was concerning for a liposarcoma. Although the tumor was unlikely to be responsive to chemotherapy or surgical removal due to its advanced stage, the pediatric team requested the biopsy in an effort to have a definitive diagnosis prior to discharge home with palliation. Although the circumstances of this patient and case were certainly gloomy, there was a buzzing excitement throughout the radiology department as no one had performed or seen such a procedure in Rwanda. Our diagnostic radiology team arrived at 700AM. Anesthesia arrived at 830AM, although we requested the case start at 730AM, but a late start seems more of a cultural norm around here in Rwanda. Anesthesia provided procedural sedation with ketamine, which is different than we typically use in the United States, as our main population here in Rwanda is children unlike the adults we perform biopsies on at Brigham and Women’s Hospital. After the patient was anesthetized, my colleague, Nikunj Chauhan, and I donned our sterile attire, cleaned the patient’s skin, and placed the first “introducer” needle into the mass. A crowd of people, mainly doctors, nurses, and technologists watched as we worked, many taking cellular telephone photographs and videos. We took our first computed tomography scan and confirmed that the needle was indeed in the solid portion of the mass (which was necessary for confirming a diagnosis of liposarcoma). We then placed the biopsy device and took the first biopsy sample. There was intense anticipation as we waited to see what the sample looked like; it was white, indicating that we were likely in the tumor. The mass was much firmer than we anticipated, deforming the biopsy device, and pushing it out of the skin. Neither Nikunj nor I had experienced anything like this in the United States, but it raised the possibility that the tumor may be a desmoid, or fibrous tumor, rather than or originally proposed liposarcoma. Nevertheless, we continued on and took several additional samples of the mass. The large audience watched as we placed all of our samples in formalin. The procedure had gone well, without any complication, and we all felt as if we had done something beneficial for the patient as we placed her on the path to diagnosis. The disheartening part was that we’d have to wait 4-to-6 weeks to obtain the biopsy results

A: Pre-procedural computed tomography image demonstrating a predominately fat containing abdominal mass with several scattered islands of soft tissue concerning for liposarcoma.

B: Pre-procedural ultrasound image showing the ill defined infiltrating nature of the mass. Given an inability to adequately differentiate the soft tissue components under ultrasound, computed-tomography-guided biopsy was completed.

C: Intra-procedural photograph showing the setup and placement of the introducer needle in the first ever computed tomography-guided biopsy completed in Rwanda.

D: Intra-procedural computed tomography image demonstrating placement of the biopsy device within the soft tissue component.

E: Post-procedural computed tomography image demonstrating air within the soft tissue component confirming that the soft tissue component was indeed biopsied.

F: Photograph showing significant bending of the needles due to the hard nature of the mass raising the suspicion for a fibrous tumor such as a desmoid.

Wednesday, September 2, 2015

Rural Health Immersion in India Part 2

7/4/2015 Sishir Rao

I want to discuss the cardiac health and diabetic epidemic that is taking place in India. It is estimated that 60% of all heart disease burden worldwide occurs in the South Asian subcontinent. After experiences with family and friends suffering from cardiac disease, my brother Sevith Rao and I started a non-profit, the Indian Heart Association, also known as the IHA ( The logo is also attached. To date we have conducted screening camps in India, conducted social media and written educational outreach, and serve on an Indian governmental national cardiac committee.

In my experience with medical care in rural Tamil Nadu, there are anecdotally many cases daily of patients with cardiac risk factors including diabetes, hypertension, tobacco use, and hyperlipidemia. During this experience, I have also encountered patients as young as 40 with metabolic syndrome who present with acute coronary syndrome. Many of our patients both and women have poorly controlled Diabetes who present with diabetic feet or retinopathy. In fact, representatives from the Indian Medical Association have stated that South India including Tamil Nadu is the diabetic capital of the world! Below I am participating in the care of a patient with multiple cardiac risk factors.

During the last three week global health experience, I have continued my work with the IHA both through revamping of the website as well as writing content for both online and written formats. In the future, I hope to partner the Indian Heart Association with rural health organizations in India to increase cardiac health outreach to this population.

Rural Health Immersion in India

06/28/2015 Sishir Rao

My global health experience working in rural Kollidam hospital in Tamil Nadu, India has been a productive and enlightening one. The hospital is a rural hospital serving primarily an agrarian low-income population.

The hospital is staffed by one full-time physician as well as a small group comprised of technologists and nurses. Visiting specialists perform consultations and trainees rotate through the hospital as well. Dr. Venkatesh, my mentor is an ENT surgeon and is a skilled clinician. He performs procedures as varied as trauma surgeries such as burr hole placement for intracranial hemorrhage, intubation and tracheotomy, obstetric procedures such as c-section, appendectomies, a range of ENT surgeries, and burn surgeries.

During the last several days, I have been able to immerse myself in clinical medicine including performing preliminary patient care visits in both the outpatient and inpatient setting. I am currently a Radiology resident at MGH and will pursue a fellowship in IR. During this global health experience, I found myself putting my internal medicine internship training to good use! The hospital also has a portable x-ray unit, a portable ultrasound unit, and a c-arm for diagnostic and interventional fluoroscopic procedures. A nearby imaging center possesses CT and MRI facilities. I assisted in performing ultrasounds and interpretation of imaging with pictures below.

The hospital also has a small but well-equipped pharmacy that I enjoyed familiarizing myself with various drug formulations, some of which are different than U.S. medications.
Despite economic challenges, the private hospital has managed to serve patients regardless of their ability to pay through a combination of efficient, low-cost practices and willingness to sacrifice profit for the patient. The Tamil Nadu government has also launched a health insurance program for low income patients which has helped ease economic hardship for this patient population. I am interested in health economics and enjoyed the chance to interact with the insurance/billing manager.

In my next blog post, I will discuss the cardiac health epidemic in India that I am passionate about.

Rwanda part 2


Case 2

I couldn’t believe it. We haven’t even been here a week and we’ve already set up two procedures! I was really worried that we had brought all these supplies and by the time anyone found out about what we could do, it would be time to go.

However, yesterday morning a pediatric surgeon from the states had come into the reading room to review a possible surgical case. It was a 2-year-old girl presenting with a distended abdomen, vomiting, and weight loss for 2 months, along with intermittent fevers. Laboratory tests up until this point, including those for hepatitis and HIV have been unremarkable. The pediatric team had asked for a CT yesterday which demonstrated a large fluid collection that was intimately associated with the pancreas - concerning for a pancreatic pseudocyst.

Wait, but why would a 2-year-old have pancreatitis? Scorpion bite, I thought excitedly. Both Dr. Rosman, the radiologist we were working with, and the surgeon almost in unison, said ‘trauma.’ Apparently, as I was to find out over my time here, that next to infection, trauma is the etiology of almost everything else. Nonetheless, the patient’s mother apparently denied any trauma. I brought up the idea of catheter drainage, especially given that we had just had a conversation about horrendous post-operative care a couple days ago. The surgeon, almost immediately said, ‘it’s all yours.’

We found ourselves in the middle of the oncology ward, with twenty people observing, about to perform a catheter drainage on a 2-year-old. We had learned a few important lessons from our first procedure about improvising, using the towel that came with the surgical gown as a sterile drape, using a sterile glove as a ultrasound prove transducer cover, and removing flies from the sterile field. I had performed that first case, so it was my co-resident’s turn to perform this one and I was his assistant. We sedated with the help of an expatriate pediatric emergency attending (Dr. Rosman’s wife), prepped, draped, and without difficulty placed the catheter into the collection.

We then realized two things. For one that we didn’t have a syringe larger than 20cc to aspirate all the fluid, and two, we had completely forgotten to bring catheter drainage bags. As far as the syringe was concerned, there was no choice but to aspirate and dump into a bin. About fifteen minutes later, we had removed almost 1000mL of fluid and could aspirate no more. We confirmed with ultrasound that the collection had collapsed and turned our attention to the problem of a bag. Improvising again, we took a Foley catheter bag and inserted it into a 3cc syringe with the plunger removed. The syringe end of was then hooked up to the catheter and fluid freely flowed from the catheter into the bag. We then sent the aspirated fluid to the lab to evaluate for presence of amylase and lipase and congratulated ourselves on a job well done.

Then the real problems started. For one, we had not anticipated the nursing challenges. The nurses were unfamiliar with how to manage a catheter and many of them did not want to touch it. In addition, saline flushes were not available and we had not brought any, and so the catheter was not flushed. Also, while physicians routinely ordered the recording of ‘I&Os’, like vital signs they were rarely accurately documented and hence our catheter output measurements were approximates as some of the nurses did arbitrarily discard the fluid.

The next morning we rounded on our patient and found that she appeared very listless and had apparently a low-grade fever overnight. We asked that gram-stain and blood cultures be drawn and in consultation with the pediatric team added empiric antibiotic coverage. Confused about what may have happened, we conjectured that while we “sterilized” the skin with chlorhexidine, that patients in the developing world are often malnourished and their ability to mount a response to otherwise innocuous bacteria may be compromised.

On post procedure days two and three, she looked no better and catheter output had dropped off as far as we could tell. Now we were anxious about other possibilities. Did we perforate a viscous? Does she have a large hematoma? We asked for a repeat CT to look for any of these possibilities as well as how well the collection was drained. Unfortunately, we found that patient’s family was unable to afford the copay for a second CT scan and would have to consider selling a portion of the family’s farm in order to do so – a not uncommon situation apparently. Having encountered these types of situations before, Dr. Rosman and his wife had set up an emergency fund and the CT was paid through the fund. Ultimately, the fluid collection was found to be partially drained and the remaining collection was multiloculated with thick septations and so the catheter was removed. Much to our relief, the patient clinically improved a couple of days after catheter removal.

Despite the practical lessons learned during the course of this patient’s care, we also learned an important lesson about our limitations as providers, and that in the developed world we often take for granted the presence of our colleagues in other specialties. Unbeknownst to us, during our treatment course, the only pediatric surgeon in the country, the one who had referred us this patient, had completed his term here and left for the United States. And it turned out that another one would not be available for at least 6 months. While the patient ended up doing well during our time there, the partially drained collection could be an issue for her down the road as it could become secondarily infected or reaccumulate and now a surgeon may not be available for definitive treatment.

It is becoming crystal clear from the get-go that providing high-level care, in a country with limited human and physical resources is a challenge.

Rwanda part I

3/22/15 Nikunj Chauhan

Rwanda, here I come

“Sir, come here please. What’s in all those bags?” the customs officer remarked to me. Ohhhh I was so close to the exit, I thought. I have three oversized suitcases completely filled with catheters, needle, surgical gowns, gloves, lidocaine, syringes, and numerous other supplies and had been worried about this exact situation the whole flight over. I should be okay with it because I had talked my way out of things a few times before in India. But I wasn’t.

“Just some medical supplies,” I remarked.

“Open, please” he said. I did what I was told. “Oh wow. Do you have approval from Ministry of Health?”

“No, but I have this letter from CHUK,” I said. Luckily, four days ago I had thought about this issue and asked Dr. Rosman, the expatriate radiologist who we would be working with, to send me this letter; but I was really unsure that this would actually work.
“You need approval from the Ministry. I think we need to keep the bags and call Ministry in the morning. If they are okay, you come back and take bags.”

Well at least they aren’t taking me to some back room, I thought. But on the other hand, I will probably never see this supplies again if I go with this. I had to think quickly.

“Okay, fine, but I cannot come back. So just throw them out right now.”

“Huh?” he looked a bit confused.

“Yes just throw them out.”

“I come back.” He went over to his colleague in the office across from where I was standing and they chatted a way for several minutes and finally he comes back over.

“Okay you go now. But we keep this letter,” he said, waving Dr. Rosman’s letter around.

“Sounds good. Thank you.” I wiped my sweaty palms on my jeans and confidently (I hope) wheeled my cart filled with all of my suitcases out the door and into the ridiculously hot Rwandan night.

Sunday, July 5, 2015

Anesthesiology Lessons for Rwandan Residents: Troubleshooting Intraoperative Hypoxemia from the Lounge of a Luxury Hotel

How does a country with 13 anesthesiologist provide anesthesia care for a population of 12 million? In Rwanda, since 1997, anesthesia technicians have provided anesthesia in the operating theater after undergoing a 3-year training program, which they could enter from high school. Prior to the initiation of the first anesthesia residency class in Rwanda in 2006, the country had only 3 physician anesthesiologists who were trained in France and Belgium. The lack of any educational infrastructure prior to independence from Belgium in 1962, and the long-standing ethnic conflicts between the Tutsi’s and Hutu’s have hampered the development of medical care and education system. However, though in its ninth year of operation, the anesthesia residency program currently has only 9 out of its 24 positions filled. In sharp contrast to the rising popularity of anesthesiology as a career choice in the U.S. and Canada, few medical graduates in Rwanda choose anesthesiology due to a combination of high-stress, disproportionate patient morbidity and mortality, low salary and long hours, and excessive clinical and administrative burden.
With this dire shortage of physician anesthesiologists, the clinical role that these residents are expected to fill is utterly different from the role that I, as an anesthesiology resident in the U.S., am trained to fill. Rather than directly providing the anesthesia care, the Rwandan anesthesiologists will be mostly acting as consultants to the anesthesia techs. Currently, the techs could discuss complicated cases with the anesthesiologist on call, and can phone them when problems arise. Consequently, the residents infrequently take responsibility for a case from beginning to end. As well, with the responsibility to take overnight ICU calls, the residents are in the operating theater only about 2-3 days a week. This severely limits their intraoperative training and exposure to the infrequent but high acuity events that require rapid troubleshooting, diagnosis, and decision-making.
A key aspect to highlight is that with the shortage of physician anesthesiologists, in the absence of foreign anesthesiologists, the anesthesia residents would be learning anesthesia mainly from books and the anesthesia techs. This is an educational gap that the U.S. physicians working in Rwanda through the Human Resources of Health (HRH) collaborative have filled. The anesthesia techs perform a very admirable job of placing thousands of patients under general anesthesia and bringing them safely through surgery, especially for patients with advanced stages of disease and uncontrolled comorbidities that anesthesiologists in the developed world are mostly shielded from. However, without having been through college or medical school, they lack the fundamental understanding of physiology and disease processes that would alert physicians to perform more thoughtful preoperative investigation and optimization, and to manage the intraoperative and postoperative course. This became evident when I went with a U.S. attending anesthesiologist and the local resident he is paired with to the wards to evaluate patients with inexplicably high blood pressures, possible untreated heart failure, or pulmonary problems. Although the anesthesia techs had already performed a preoperatively evaluation of each patient the evening before, we felt strongly that further optimization and discussion with the primary team was necessary and postponed the cases. Thus, a critical aspect of the U.S. physicians’ interactions with the anesthesia residents is encouraging them to apply their medical education and years of practice as a general practitioner to think and act as a physician.
Under these circumstances, simulation is a critical component to the residents’ didactics to create opportunities for making managing complicated or emergency scenarios. However, the simulation center was recently shut down due to lack of funding for a managerial administrator. Also, as commonly happens to expensive equipment sent to developing countries lacking the technical support for maintenance, the SimMan requires repair and can function now only as a low-fidelity mannequin. Thus, instead of designing a classical intraoperative scenario, I designed cases where the residents were called on the phone to help an anesthesia tech manage an intraoperative event. Considering the role of anesthesiologists as consultants, not using the SimMan actually better approximates their future responsibility.
Another unanticipated challenge of simulating the case was relocating our class at a moment’s notice to the lounge of a hotel. We learned just when class was about to begin that no room was available at the college due to exams. This experience in teaching anesthesia in a low-resource country has challenged me to identify educational and knowledge gaps through careful observation, to tailor lessons to local practices, and to be flexible in adjusting to surprise circumstances. Thankfully, the two first-year residents I worked with were very obliging, and engaged fully in the scenario. Meanwhile, we were able to enjoy the perks of having class at a 5-star hotel – high-speed wifi, plush couches, and fine Rwandan coffee.

Friday, June 26, 2015

Teaching Anesthesiology to Rwandan Medical Students: Focus on ABC’s and Oxygen

Standing in front of the 10 medical students starting their 5-week anesthesia rotation, I realized that there is one primary objective I need to achieve: teaching resuscitation skills. This is their last clinical rotation; in 5 weeks, they will be disbursed as general practitioners to the district medical centers where they may be the one doctor available to both hold the scalpel and provide the anesthesia care for a C-section. “ABC’s and vitals” is the mantra I keep repeating to them. Ensure that the trauma patient who just comes into the emergency room has a patent Airway, is Breathing, and has Circulation, then check their vital signs to gage whether their heart or lungs may imminently collapse before tending to the specific injuries. These are the skills in recognizing respiratory or hemodynamic instability and the expertise in resuscitation that we cultivate in anesthesiology and are transferable to keeping a patient alive in any setting, not just the operating theater. Teaching medical students in Rwanda, I realize that these are the most important lessons to get across, not the more self-serving desire to show them “how cool anesthesiology is” and to entice them to follow my career choice.
The reality is, likely none of these students will choose anesthesiology as a specialty, at least not as their first, second, or even third choice. The popularity of anesthesiology as a career choice in Rwanda is similar to how it was like in the U.S. twenty years ago. High patient mortality leading to high stress, low pay, over-burdensome clinical duties due to lack of personnel, and limited respect are some of the top deterrents medical students listed on a survey I helped conduct this month on choice of specialty.

This perspective forms part of the context for designing lessons and case scenarios. The other key component is tailoring to their knowledge base. Speaking with anesthesiologists from the U.S. who have been teaching the medical students for almost a year, I learned that the medical students have received only very rudimentary lessons about the complex physiology of the respiratory system. Thus, we started our first lesson by explaining the fundamentals of why oxygen is crucial for survival and how oxygen enters the body. When a patient cannot take in sufficient oxygen (either due to anesthesia or medical condition), anesthesiologists step in as the “Oxygen-Providing Service.” This paring down to the core of what anesthesiologists provide removes the distractions arising from the technical aspects of anesthesiology, and focuses their attention on assessing a patient’s clinical status and intervening expeditiously.

Thus, the case scenario that I designed is set in the emergency room rather than the operating theater. It emphasizes vigilance, reassessment of a patient’s condition, stabilization of a patient’s cardiopulmonary status, refinement of their differential diagnoses, and anticipating next steps –skills that are important in any clinical setting. Faced with the challenge of managing an unstable patient, the students were very engaged, volunteered answers, and asked questions. In an education system where students were expected to simply absorb information and not encouraged to speak in class, this active involvement from the students was very encouraging.

The final class took place in the SimLab, where the students were able to put the theory and skills into practice by working as a team to resuscitate and ventilate the mannequins. Though most if not all of them will not become anesthesiologists, as practitioners in a country where there is 0.6 physician for every 10,000 people, they will likely encounter situations when they would be called upon to oxygenate and stabilize a patient. I hope they will remember the ABC’s from the Oxygen-Providing Service.