Tuesday, February 24, 2015

NEURONS IN UNIFORMS: Neurology at the Indian Armed Forces Medical Institution,New Delhi,India

January 24,2015

Week 2 and Beyond

Salient Aspects of Outpatient Department

India has a "bilingual medical system “patient interviews in Hindi and case presentations in English. Unless absolutely needed the CT scans and MRI were not done emergently and this made my brain exercise a lot in localizing lesions based on clinical presentation alone Neurocysticercosis and tuberculous brain abscess were relatively common in far flunked remote areas with limited access to medical care and these people would then come to us with some classic textbook radiology findings. I also saw many seizure patients and all the drugs commonly used in US were freely available at least in this center. If these patients insisted on following up with local Army hospitals (and not the special 8 Neurology Centers) we had to be more judicious in our medication choice for these patients. This was because there was limited variety of antiepileptic medications available at peripheral smaller medical centers.

Didactics and Conferences
Monday Journal Club comprised of discussing about CHANCE and SAMPRISS trials. Tuesday Chief rounds was an interesting case of Peripheral lower extremity tingling which completely resolved in 4 days and what was left was some ankle weakness and minimal limb girdle weakness. Interestingly the nerve conduction studies, Electromyography, Brain and Spine MRI were all normal. CSF analysis was unremarkable as well. Onwards plan was to repeat EMG. A muscle biopsy was to follow suite. Wednesay Neuroradiology conference was again exciting with a case of ring enhancing lesion on MRI Brain. It was really nice of Neuroradiology folks to spend some extra time with me teaching me about some tips and tricks of reading “films”. There was also a joint Neurology and Medicine case conference on approach to Altered Mental status. A round table discussion about a bed bound patient and its prognosis made us all plunge into article review about prognosis of Coma which then was discussed in resident report of the week. I discussed about an article in Journal of Neurology, Neurosurgery and Psychiatry on Medical Coma Prognosis.

Inpatient and Neuroscience ICU cases.
Vascular Neurology cases (stroke, subarachnoid hemorrhage, intracerebral hemorrhage) were the mainstay in the ICU. There was also a case of Guillain-Barre syndrome. We had some great attending inputs on how lack of long term rehab units or acute level rehab facilities tend to cause prolonged stay of some patients in ICU and floors. An interesting case of refractory seizures with normal MRI and not so helpful interictal (inbetween seizure event) EEG was puzzling everyone.24 hour Video EEG was available but not so commonly used and the patient was referred to All India Institute of Medical Sciences for further care.

Visiting All India Institute of Medical Sciences(A.I.I.M.S)
Army Institution did not have an Epilepsy Monitoring unit and not a very aggressive Neuro Intervention team. They referred complex Epilepsy cases to A.I.I.M.S.So, towards the end of my elective my preceptor helped me connect with this hospital and the Neurology faculty there. It is the best public sector Indian hospital with all sub specialties and a huge patient workload. The Epilepsy monitoring unit was pretty similar to what I had seen at Brigham and Women hospital .I spent the morning rounds on these patients with Epilepsy fellow and attending. There was an interesting case of Frontal Lobe seizures which required sharp eyes to decipher the location of seizure onset on EEG. There was another interesting case of what looked like Non epileptic spells and I was part of a long family meeting and patient counseling on this issue.Similar settings like our Neuropsychiatry team at Brigham talking to patients with similar presentations and etiologies.

The Neuroradiology conference was wonderful and I felt “homely” seeing Centricity Software (used at Brigham) being used to see the Neurology Images at A.I.I.M.S..
Epilepsy Surgery case conference were a treat to attend. The residents told me that the reason they went on so well was that the head of Epilepsy division was married to the Head of Epilepsy surgery division. One can understand the popularity of this institution and the huge patient workload by the fact that the wait time for Epilepsy monitoring admissions was close to 1 year.

The Epilepsy clinics were held each day and were blessed with some of the finest cases from the country. Structural lesions causing seizures (prior stroke or hemorrhage, sequlae of brain infections, tumors) as well as childhood syndromes comprised the majority and for many the cause was yet to be determined. My aim in clinic was to learn and understand the selection of anti-epileptic medications based on age, gender, co-morbidities, seizure type and most importantly (believe it or not) cost and availability at patients home city or village.

The rich and poor paradox in India in Healthcare Sector
On my last day, I decided to spend a few hours at the other extreme of Medical care; A super specialty ultra modern western model of corporate hospital called Medanta-The Medicity(A hub of what is popularly called as Medical Tourism).  It had a completely different patient population. Very well to do families from other Asian countries and also Africa were the major clients/patients here in addition to affluent Indians. My aim of visiting this place was to see how choice of anti-epiletic medication or the approach towards Neurology Intervention procedures/surgeries changes when patients are from super well to do families. 

Neurons in Uniforms: Armed Forces Medical Instituion in New Delhi,India

January 10, 2015

Week 1 Day 1: The Beginning
Finally, after an 18 hour flight and a new year eve somewhere in the skies over the Arabian sea,i joined the Neurology team at Army  hospital. Day 1 was exciting, challenging, demanding and surprising all at the same time.

Monday was a busy outpatient clinic day. No appointments are needed and patients can just show up on Monday, Wednesday or Friday mornings. Together with 3 other residents, I was supposed to see a long queue of patients waiting outside the room. It took me almost 30 minutes to interview, examine and make notes of my first case; what looked like a case of mononeuropathy multiplex. With a list of 40-50 patients (old and new) and limited time(close to 3-4 hours to see all of them) the residents would usually write very small notes and do a quick focused and limited exam. The patient population comprised of Armed forces personal (serving and retired) and their family members. With only 8 defense forces Neurology centers all across the country, the outpatient department gets interesting referrals from hundreds of smaller base hospitals. The clinics were followed by Journal Club on Oral Medications for Multiple Sclerosis. I also shared my experience about the Partners MS Center Clinics and our most current practices.India, although a largely warm country does has its share of high altitudes in Himalayas and Multiple Sclerosis cases are found in this belt. The rest of the day comprised of inpatient bed side rounds which are usually lightning fast on Outpatient Clinic days.

Day 2 and beyond
Day 2 began with a case presentation of distal myopathy. I had presented a similar case of Titin mutation anterior tibial compartment myopathy at Brigham neuropathology conference in 11/2014 and I felt really excited to see a similar case on the other side of the globe. The highlight of Day 2 was my first exposure to their bed side rounds. There is just one team that rounds ED Neurology, ICU Neurology, inpatient consults on other services as well as Neurology inpatient. A typical daily census is 5-6 new floor admits, 3-4 new consults and 1-2 ICU admit daily on Neurology service. In absence of acute rehabs and virtually no step down units, the inpatient stay is usually longer than what it is in US. Also there are lots of outside hospital transfers from smaller district level centers. It took almost 5 hours to round on approx 50 patients. The residents (including) me were asked management pertinent questions and given an assignment during rounds which was discussed the next day. An interesting case i saw was Tubercular Transverse Myelitis which helped me revise Spinal Cord anatomy and syndromes in fine detail.

Day 3 was again the outpatient day. Now i was well versed with the system. Soon i realized that Migraine, Sciatica, Carpal Tunnel Syndrome, Diabetic and Vitamin B12 peripheral neuropathy are the flag bearers of Neurology outpatient cases all over the world. I saw plenty of follow-up intracerebral hemorrhage cases and it is exciting to see CT scans and MRI on “films” rather than computers. Didactics comprised of a presentation on Visual Evoked potential and Brain Stem Auditory evoked potential by a senior resident.

By day 4, I began to appreciate a very strict hierarchical system in the Armed Force Medical wing."Sir" and "Madam" were supposed to be used strictly for anyone senior to you and most of the times also for your colleagues. Among the new admissions overnight the most interesting was a cardioembolic stroke in the left middle cerebral artery territory who presented with right face, arm and leg weakness. He was given IV thrombolytic (tPA) and NIH stroke scale improved from 10 to 5. I realized that intra arterial therapy (tPA) or even mechanical clot retrieval was not well developed in this center and in spite of presenting within 2 hours of presentation a CT angiogram was not pursued emergently.  I gave a brief talk and discussed how intra-arterial treatment was pursued in our system.

Day 5 was again the outpatient clinics. I was more inclined to develop expertise in reading MRI and CT films so requested the Clinic manager(who doubles up as EEG tech in afternoon) to direct all patients who have films in their hands towards my room. It was great discussing all these cases with my attending who shared some very useful tips about these reads.

On Day 6, I decided to ditch my car and took the local Metro train to make it to a Neuroradiology conference. The cases comprised of space occupying lesions, intractable epilepsy and some spinal cord pathologies. It was a completely different cup of tea to look at films and appreciate subtle deficits. I missed our PACS, CAS and Centricity (Computer software based Radiology image viewers) so badly.

Overall, my intial days helped me understand a system which has immense patient load and limited radiology support but lots of clinical marvels to learn Neurology.

Monday, February 9, 2015

Process Mapping in Ghana

Emily Aaronson
Emergency Medicine

After a week of orienting to the Emergency Department, I started in on my project in earnest this week. The objective of identifying opportunities to improve the process, and thus create more capacity, was met with enthusiasm almost uniformly. I was able to complete several process mapping sessions this week – with the accounts staff, medical officers and front line nurses, all of whom seemed excited to engage in the project and interested in the methodology.

Our findings are very encouraging – that there are many areas of the process that – once mapped out and through structured discussion - are redundant, prone to error or un necessary. Each group also offered many creative ideas for how the processes could be improved and solutions for some of the barriers they identified.

I will now work to translate the walls of post-its into Lucid Chart (great process mapping software) and then circle back with each of the groups and see if there area any other areas we are missing. I am working with the clinical coordinator to help vet my findings, and put a report together with some suggestions based on the staff’s ideas, on how to improve the workflow.

Ultimately the hope is that by identifying the areas of the process that can be streamlined, reducing the waste and redundancies, we are able to move patients through the department more quickly, and thus increase the capacity of the (always crowded!) ER and the capacity of the staff to care for their patients.

Process Mapping in Ghana

Emily Aaronson
Emergency Medicine

Having been here a week, my work is well underway and am sadly realizing a lifetime of dedication to this emergency department couldn't accomplish what I was hoping to do in a few weeks. Ghana itself is amazing – although some things, like the incessant honking from the Ghanaian trotros (shared ride cabs), 80 degree nights (and 95 degree days), and constant call of ‘obruni’ (the Ghanian slang for white lady), are familiar from other travels, there are many things that make west Africa like no place I have ever been. To begin with, I was met by a thick red dust coating the city, which in combination with the stifling heat, felt remarkably unfamiliar. The Harmattan – a dusty trade wind that brings with it the Saharra dessert, coating West Africa between November and March, is apparently at it’s worst in 20 years. This has left everything (including my glasses by the time I got to the hospital) coated in a thick layer of red dust. This, mixed with the somewhat more familiar stench of burning garbage and open latrines, was the first assertion Beantown was far behind.

So although the climate is somewhat unwelcoming, the people couldn't be more friendly. Ghana – an English speaking country roughly the size of Oregon with the population of Canada – is largely lauded as being among the most friendly nations on the continent. Indeed, everyone I have encountered since I arrived have appeared uniformly excited to see me – to show off the city, tour me around the hospital, introduce me to the food or teach me the language (twi is one of many local languages that flows freely in and out of most English sentences).  Having traveled a fair bit in the last decade, I will say that I have been nowhere that I have felt less threatened and more secure than in Ghana.
The hospital however is a less hospitable place. The staff are wonderful and the administrators welcoming, but the state of healthcare here is certainly unfamiliar. The hospital I am working at, Korle Bu, sits surrounded by some of the poorest communities in Accra and has a strong commitment to serving all comers. Despite this principled mission, the infrastructure, equipment, supplies and staffing doesn't exist to support it. I am working primarily in the Emergency Department – on a project aimed at increasing capacity by identifying areas of inefficacy – but recognize the problem is larger than my weeks here will impact.The physician I am working with is truly an inspiration though – a native New Yorker who starting coming here 7 years ago, trained in Emergency Medicine and still supported by NYU and Bellevue Hospital. She has been living here full time for almost 4 years and through incredible relationship building, political navigation and patient care, created the first department of Emergency Medicine at Korle Bu. The department, which she is now the clinical coordinator of, is vital to help resuscitate the hoards of patients that arrive critically ill secondary to a system with almost no preventative medicine, little access to primary acute care, and a mostly fee for service model that leaves people without the medications or diagnostic tests that they need. The acuity of the patients I have seen over the last week arriving in the Emergency Department, is truly unfathomable.

In partnership with the hospital, and incredible local collaborators and colleagues, they have created this department now teeming with over 50 stretchers in various states of disrepair, which admits to an over 2000 bed hospital (MGH has 950  as a point of comparison). The issues remain though: no oxygen masks the day I arrived, a defibrillator that has been broken for over a year, a marked shortage of certain medications and intermittent access to the limited diagnostic tests they have.  With that all said, the commitment is here – the dedication to the patients and belief that through focused work the system will advance – as it already has in recent years.  So that at least, is inspiring.So after a week of observing in ER, meeting the staff, administrators and beginning to understand the cultural communication nuances that will hopefully help me be successful I look forward to digging into the work next week.