The Palestinian Medical Referral Process: A Study of Process in Process

Erica L Nelson

Resident in Emergency Medicine at Massachusetts General Hospital and Brigham and Women’s Hospital

PGY-4

October 16^th, 2016

Anecdotes over tiny cups of Arabic coffee: the 17 year-old, traumatic head bleed patient that waited

five days for transfer for neurosurgical evaluation to a hospital located not even a 2-hour drive away. He died. The 39 year-old woman who spent 14 months at Hadassah Hospital after receiving a life-saving bone marrow transplant. She lived. The critically-ill patient that was driven to the border in a Palestinian-permit ambulance, then moved to a wheelchair to cross the border, then transferred to an Israeli-permitted ambulance for the completion of the journey. A back-to-back transfer that took an extra hour with oxygen lines and epinephrine still running. The cacophony of successes and frustrations, tragedies and man-made miracles, politics and goodwill create nothing less than a Pollock-painting when I try to disentangle the Palestinian referral process. As a physician, an empiricist, I try to step back and consider before the judgement.

First, an examination of ‘self’: How do we transfer patients in the United States from a clinic to a hospital? One hospital to the next? An institution outside of our medical record system? Is it a simple phone call, a hurried and harried hospital summary, printed labs and consultation notes, the coveted but oft-corrupted CD of imaging? Where do the referrals land?

In our Emergency Departments, there’s all too often sighs regarding incomplete documentation, a confusing narrative, the questionable reason for transfer. Time-willing, there are phone calls and faxing, curriers and clarifications. But how often do we start over, clicking through inordinate EPIC tabs to order the reportedly-normal labs ‘just to have them in our system’? Our process is not above reproach.

And with that in mind, let’s think about a cross-factional, cross-border medical referral process:

There are 4,682,467 people in the Palestinian territories, 1.4 million refugees and tens of thousands of patients that need higher levels of care. A two-year-old with acute leukocytic leukemia, that 17-year-old who sustained a traumatic sub-arachnoid, breast cancer patients, congenital heart cases, hemodialysis patients, oncology, coronary disease, orthopedics, pediatrics –thousands upon thousands of patients that need to be transferred. The infrastructural and literal violence, the administrative fragmentation and resource shortages that have created such a situation is a critical part of the conversation, but, frankly, not what I am here to address. I am here to study the complexities, realities and challenges of getting patients to the care they need.

When first conducting feasibility interviews in January, physicians (both Israeli and Palestinian) commented that there was hardly ‘a process’, but multiple variations derived from a non-standardized, ambiguous, unmonitored, untrackable system that required 1) referrals, 2) sponsorship and 3) Israeli travel permits. A whole host of complications were offered up –transfers are untimely, procedures delayed, medical information lost, sponsorship and reimbursements remain problematic. So, over the last 9 months, my research team developed a survey to understand both referring and referral-accepting MD experiences, and started building relationships with officials to obtain both Palestinian and Israeli, disaggregated referral data.

These last two weeks in Israel and Palestine have been several, tortoise-paced steps towards unfurling this project and ultimately understanding an inherently complicated process in a stochastic environment complete with multiple factions and border-crossings, two Ministries of Health, three governments, varied donors, hospital structures and perspectives. Each moment of analysis and judgement demands self-reflection and contextualization. This study of a process is very much still in process.

The Palestinian Medical Referral Process: A Study of Process in Process

Erica L Nelson

Resident in Emergency Medicine at Massachusetts General Hospital and Brigham and Women’s Hospital

PGY-4

October 9^th, 2016

Sandwiched in between Rosh Hashanah and Yom Kippur, volleying between Jerusalem, Hebron, Ramallah, Nablus, nine different hospitals, multiple check points, cups of mint tea and strong coffee, Arabic, English, Hebrew, check-point, vibrant market, dingy office, immaculate NICU and disquieting ED, I find myself in a (needless to say), politically tricky situation. In a context wherein the origin of a mashed chickpea dip is contentious, I somehow have the audacity to attempt to examine the Palestinian/Israeli medical referral process. Even writing a blog post about it, trying to to craft each word to be perceived as politically neutral, is giving me tremendous anxiety.

Perhaps a year ago, when this project to study and potentially improve the Palestinian medical referral process started to take on solid form, I knew how wrought it would be. A feasibility assessment in January uncovered numerous interpretations of the non-standardized, untracked process that brought a Palestinian patient to East Jerusalem or Israel. A several month-long struggle with Western-trained empiricists trying to lend statistical validity to a study that inevitably could be nothing more than convenience sampling stalled international IRB processes. Imperative, quantitative data lay in distant hands, on paper, in spreadsheets, awaiting data-sharing negotiations before the woeful process of cleansing and justification even began. And politics colored every word and movement, document, grant application, border crossing and hospital visit. Nothing about this is easy.

And that, nestled beside simple human compassion and lofty Hippocratic imperatives, is why it is so compelling. The delivery of healthcare or, in this case, the delivery of patients to healthcare, is complex, context-bound, political and socio-economic. Systems that efficiently and effectively deliver healthcare, whether it be a Public Health Department or an Emergency Department, a ‘medical mission’ or a longitudinal development initiative must continuously examine the environment that surrounds their patients and their institutions. Any initiative, study, treatment plan or discharge that ignores context, will at very least lack generalizability and at worst, fail.

This reality, as an intellectual concept, is easy to understand. But the cognitive and logistical burdens it creates, the resources and time required to complete a comprehensive needs assessment and contextual analysis (of a system in crisis or a patient in crisis) often feels insurmountable. More than the tangible Likert-survey distribution and database creation, the logistical regressions and geoanalytics, this experience has been about tenacity, continuous re-calibration and humility. Whether it be in a Ministry of Health meeting or in Acute Bay 1 at Massachusetts General Hospital, these are the attributes that I must take a moment (to breathe) and summon.

Orthopedic Trauma Surgery in Haiti

William Slikker

Orthopedic Fellow at BWH

PGY-6

Resources in Haiti are limited and this includes the supply of surgical instrumentation. During our trip we encountered many obstacles but the most difficult to overcome was the lack of appropriate surgical instrumentation and devices that we would typically use in the U.S. For instance, there was no intra-operative fluoroscopy, which we would have normally used for a majority of the procedures we completed on the trip. It took careful planning and a dose of ingenuity to overcome the lack of instrumentation. Adapting to a foreign operating room was difficult, but the local orthopedic surgeons had much to teach us in regards to tackling surgical cases using their set of instrumentation. With the help of the Haitian orthopedic surgeons, we were able to accomplish our goal of providing safe and impactful clinical care. But by collaborating with the Haitian surgeons in this way, we also built a partnership which we hope will continue long into the future.

            This trip served to open my eyes to the complexity of international outreach and the nuances of effectively collaborating with local surgeons and staff. It taught me many things about how to successfully provide clinical care in an international setting. It also demonstrated how the short term efforts of providing direct clinical care are not as important as building bridges for education and communication in a long term grassroots effort to bolster the local medical system in which we are only temporary visitors. Although we accomplished many successful surgeries, our efforts at partnering with the local orthopedic attendings and residents will hopefully build a connection that is even more impactful in the long term.

Academic Emergency Medicine in Rural Haiti: Epilogue

Nahzinine Shakeri, MD

Resident in Emergency Medicine, Brigham and Women’s Hospital and Massachusetts General Hospital

PGY-4

      As I look back on the four weeks I spent as a visiting professor of Emergency Medicine at Hôpital Universitaire de Mirebalais (HUM) in Mirebalais, Haiti, I realize how much I gained from the experience.

As an emergency physician, I was challenged. Over the course of the month, I cared for more critically ill children than I had seen in all of residency, helped manage a mass casualty event when a tap-tap crashed, encountered patients with unfamiliar and tremendously advanced disease processes, and made indescribably difficult decisions. I learned to approach even familiar clinical situations in a new way: diagnosing bacterial meningitis clinically and starting antibiotic treatment without the confirmatory cerebrospinal fluid testing I was used to obtaining, for example, or even using a urine dipstick to check cerebrospinal fluid at the bedside for signs of infection, an evidence-based trick I learned from the brilliant and resourceful HUM residents. 

As a leader, I grew tremendously. I had spent the last year in Boston supervising junior residents at MGH and the Brigham, but always with an attending at my side. This was different. Backup was always available by phone if I needed it, but in most cases I was the most senior emergency physician in the department, acting independently and making clinical decisions on my own. While very much out of my comfort zone initially, I grew to be more comfortable in my role. I learned that I love being an attending, and I was more prepared to make this transition than I had imagined.

As a medical educator, I was inspired. During my short time at HUM, I watched the residents grow, watched them apply new skills I had taught them such as gallbladder ultrasound and chest tube placement. On one residency conference day, I collaborated with another visiting professor to create a pseudo-high fidelity simulation experience with the resources we had available to us and watched the residents approach it with excitement and focus, eager to excel and practice their skills. It was a poignant and profound realization for me that the HUM emergency medicine residents, the soon-to-be first residency trained emergency physicians in their country, are the future of emergency medicine in Haiti. They are the future bedside teachers and residency program directors and curriculum designers who will be teaching Haiti’s next generation of emergency physicians how to ultrasound gallbladders and place chest tubes and run simulations. Education, it seemed to me, was a truly sustainable intervention which would have lasting and exponentially-reaching effects, here in Haiti and everywhere.

As a citizen of the earth, I was stirred by the degree of disparity I encountered, my resolve strengthened to use my career to help alleviate suffering in underserved areas at home and abroad.

I look forward to returning to Mirebalais.

“and with that, my last shift is over and i'm off. goodbye Mirebalais. this morning i'm thinking about the amazing emergency medicine residents at HUM, the soon-to-be first emergency physicians in their country, the future of EM in haiti. and i'm thinking about the patients i cared for, a part of their tragedy and grief becoming my own. and all the amazing, dedicated, inspirational people i met here.

goodbye.. for now.”

-journal entry, 4/30

Orthopedic Trauma Surgery in Haiti

William Slikker

Orthopedic Fellow at BWH

PGY-6

My international outreach experience in Marabelias, Haiti was quite eye opening. After 8 hours of air and land travel to our hospital site, we immediately went to work seeing patients in the clinic and assisting in urgent operations that were taking place in the OR.  Similar to the U.S., it was not uncommon to encounter several severe femur and tibial fractures from motor vehicle accidents on a daily basis that needed urgent treatment. However, we did encounter more unusual injuries as well, including a machete injury cutting off half of the elbow, enormous masses of the extremities with no previous treatment, and chronic shoulder and hip dislocations which would have otherwise been corrected acutely in the U.S.

During our time in Haiti, our team accomplished more than 25 major orthopedic surgeries and evaluated upwards of 40 patients. However, we realized that although we were effective in completing surgeries, there was no way that a short term trip would have long lasting effects. Therefore, our efforts during the trip were focused on education of the local orthopedic residents and collaboration with the Haitian attending orthopedic surgeons. By fostering friendship and partnership during the trip, we hope to establish a line of communication, which will continue via phone, email, and video after our departure. In addition, we provided both clinical orthopedic books and live surgical videos to begin a library collection for the local residents. 

We are currently beta testing a live, streaming surgical video device, which would provide free, real-time interaction and consultation from Boston to the hospital in Marabelias.

Academic Emergency Medicine in Rural Haiti: Prologue

Nahzinine Shakeri, MD

Resident in Emergency Medicine, Brigham and Women’s Hospital and Massachusetts General Hospital

PGY-4

From my vantage point in the back seat of the old Land Rover, bouncing and jolting this way and that down the uneven dirt roads of Port au Prince on the way to Mirebalais, Haiti, things looked bleak. I’d just arrived from Boston, and it didn’t take long to recognize poverty more grim than I’d ever seen it, road traffic conditions primed for trauma, and a paucity of basic fundamentals necessary for the population to stave off disease – clean water, food, sanitation, durable housing.

 Haiti is the poorest country in the Americas and, despite the relatively high burden of disease facing its people, has severely limited healthcare infrastructure and limited access to medical care for most.

I’d traveled to Haiti to learn more about how these seemingly insurmountable problems were being addressed and to see if, in the span of four weeks, I could apply my skills as an emergency physician and aspiring medical educator to contribute in some tiny way.

Outside the window, the terrain became much more rural, more mountainous. Embedded among the rolling green hills and mountains of Haiti’s Central Plateau and the community of Mirebalais was a beautiful white and iron structure - Hôpital Universitaire de Mirebalais (HUM). HUM is a 300-bed tertiary, public teaching hospital which opened its doors in 2013 and is funded by Partners in Health, grants and the Haitian government. The hospital is the first of its kind in Haiti, providing cutting edge care to the community without the traditional fee-for-service payment model. Residency training programs in a number of medical specialties at HUM draw medical school graduates from all over the country, including Haiti’s first emergency medicine residency which was founded in 2014 and which will graduate the country’s very first class of residency-trained emergency physicians in 2017.

Over the next four weeks, I would be living in Mirebalais and working as a visiting professor of emergency medicine at HUM. This would provide me with the opportunity to teach the emergency medicine residents both at the bedside and in the classroom, to care for patients, to learn about what it takes to build, develop and sustain an emergency medicine residency in this setting, and more than I understood at the time, to think about medical education in a new way.

Rollercoaster Rides in Program Development and Implementation in Chiapas, Mexico

Rose Molina, MD

Global Women’s Health Fellow, The Connors Center for Women’s Health and Gender Biology, Brigham and Women’s Hospital

I returned to Chiapas, Mexico in June 2016 to continue my Global Women’s Health Fellowship research project. Working closely alongside the maternal health team at Compañeros En Salud (CES), I have advanced our project around adapting and implementing the WHO Safe Childbirth Checklist (SCC) for a new cadre of obstetric nurses in a basic community hospital. During this most recent trip, our maternal health team focused on curriculum development, grant writing, and adapting and piloting the SCC in our context in Chiapas. Additionally, we have been working with a group of students in creating the checklist into a mobile platform in anticipation of the obstetric nurses’ arrival in August 2016.

This visit has highlighted the ups and downs and turns of embarking on a maternal health project in close collaboration with the Ministry of Health in a new type of health facility (secondary level hospital as opposed to primary care clinics, which is where CES currently works). In order to achieve sustained engagement with the public sector, political setbacks are par for the course. However, it is important to remain optimistic in resolving problems in order to move work forward together. Only when the government is involved can a project be truly adopted and sustained as part of a larger health agenda that can be scaled up to a regional or state level.

Andrea Reyes (CES Maternal Health Coordinator) and Carolina Menchu (Professional Midwife) caring for a pregnant woman in Chiapas, Mexico

I am grateful for the opportunity to have continuous involvement with this project over the course of my two-year Global Women’s Health Fellowship. It has been a wonderful opportunity to see the nuts and bolts of program development and implementation in a new clinical area and with a new collaboration with the Mexican Ministry of Health. Furthermore, I have grown with the maternal health team and have learned valuable lessons in communication and relationship-building, which are the foundation of any meaningful long-term engagement. Lastly, I am excited to bring on a new research volunteer to lead our on-the-ground research efforts in measuring the impact of our project. It has been a roller-coaster ride of all emotions—fear, thrill, uncertainty, and excitement—but a foundational experience in building my career in global health implementation science.

The Interminable ICU Stay – CHUK, Kigali, Rwanda

Erin Blackstock, MD  
Resident in Internal Medicine, MGH
PGY3

During previous rotations, I had been told that medicine patients are often not admitted to the ICU because of their poor prognoses.  While medicine patients may in fact have poor prognoses, I do not think this is the reason they are infrequently admitted to the ICU.  During my rotation, consistently 5-6 beds of the 7 bed unit were taken by neurosurgery patients, the majority after severe TBI.  As one bed opened, the bed would immediately be filled with another TBI.  Some attendings suggested that this occurred because the neurosurgeon advocates strongly for his patients.  He did, but so did other surgeons and internists.  Rather, I think this distribution stems from a severe bottleneck.  Severe TBI or other neurological ailments resulting in coma typically require weeks to months of ventilator support as we await potential recovery.  LTACs do not exist.  If no one leaves, no one enters.  The absence of a bed, however, does not necessarily stop an intubation in the ED.  Waiting for days (with or without a ventilator)in an overworked, understaffed, chaotic  ED is not the place where a patient intubated because they “can’t”  breath thrives, but a patient who “won’t” breath may do just fine.  Days later a bed opens and the comatose patient who survived days in the ED moves in. 

How can we start to remedy this bottleneck issue? Callously one could recommend not intubating these patients with terrible GCSs since the prognosis is truly poor.   Unfortunately it is difficult to determine the prognosis immediately on arrival.  Alternatively, increasing training and comfort with goals of care discussions may allow providers to help families consider withdrawing care.  During my three week rotation, no goals of care discussions were held.  Withdrawing care is not seen as an option.  Not only for the use of resources but also for the quality of life of these patients, these discussions are fundamental to ICU care.  How can we as visitors, outsiders, begin to engage in these discussions with providers and potentially with families and patients?

Relationship between Cognitive Impairment and Acute Mountain Sickness, Nepal Experience

Isabel M. Algaze Gonzalez, MD

Program: Fellow in Wilderness Medicine at MGH

PGY: 5

Nepali baby with gastroenteritis the most common infection in Nepal

My first case of High Altitude Cerebral Edema (HACE) was a mild one and I hesitated to make the diagnosis. I was expecting someone completely disoriented, incoherent and ill looking.  It was a middle aged man that was complaining of "my feet are not going where they are supposed to"  He was coherent, oriented times 4, looked good in general, however had a headache and marked ataxia. The nepali interpreter and aid post manager, who had vast experience assisting doctors before me, saw me performing all sorts of neurological exams and when I was about to go through the mini mental, he put his hand on my shoulder and told me "yes this is HACE". The patient was appropriately treated and, also to my surprise, there was great improvement after 6 hrs into treatment.

  

Everest climber with HAPE. Checking for B lines.

At the end of the season we saw 500 patients 65% Nepali and the rest were foreign trekkers and climbers. We saw about 15 High Altitude Pulmonary edema (HAPE) cases, 9 HACE and 5 combined HAPE and HACE. Acute Mountain Sickness (AMS) was one of the predominant diagnosis along with gastroenteritis, Khumbu cough (type of bronchitis) and pneumonia.
There was a surprising amount of Nepali suffering from AMS. Foreigners developed altitude related illness mostly from coming up too fast. In contrast Nepali patients developed symptoms mostly because of carrying heavy loads, poor hydration or lack of altitude     experience. 

          Gastroenteritis seemed inevitable given general hygiene practices, boiling water was not enough. If the gastro didn't get you the dryness, cold and dust in the air could trigger the dreaded Khumbu cough, where patient's cough, and cough and cough until your chest hurt.
Pneumonia was quite predominant in locals because heating was based on sitting next to a burning fire stove every day. 

Kata from our porter and guide to Everest Base Camp. Here with the Indonesian Dr. Chandra Sembiring and friends

As for my study, the researchers arrived and trekked to their respective altitudes. We recruited our target number of subjects. We noticed many changes in cognition amongst ascending trekkers. Data is very exciting and we aim to publish sometime this year.
I had the great opportunity to absorb cultures very different from mine. l got to see and treat illnesses that I would have not encountered under other circumstances. I learned to survive under extreme conditions. I gained knowledge about climbers, trekkers and their medical needs. I learned about cognitive impairment. This was an incredibly amazing, challenging, beautiful journey and I'm very grateful to have this opportunity and hope that my findings benefit and advance the care of the increasing number of people that engage in wilderness experiences.

On top of Kala Pattar. Behind me Mt. Everest

Relationship between Cognitive Impairment and Acute Mountain Sickness, Nepal Experience

Isabel M. Algaze Gonzalez, MD

Program: Fellow in Wilderness Medicine at MGH

PGY: 5

 On top of Namche Bazaar.

As a born raised Puerto Rican, my comfort lies in the tropical setting, rainforest green and caribbean blue were part of my landscape before moving to Boston a year ago. I have seldom seen snow before and had only experienced cold weather once or twice in my lifetime. As part of Harvard's Wilderness Medicine fellowship program is my duty to venture and polish my wilderness physician skills in a remote location. So, I jumped at the opportunity to practice medicine with the Himalayan Rescue Association Pheriche Aid post, precisely because I  had never experienced cold or altitude personally and more importantly as a physician.

The first challenge was to prepare. Understanding that our stay in a third world country, in a remote area, would be three months long, with temperatures as low as -20^oC was intimidating but fascinating; adventure looks promising. I don’t own any cold weather gear or clothes, but the good thing is that I’m working under Harvard's Wilderness gurus who were very prompt to offer advice and reassurance. I kept reading about the diseases that I will encounter and frankly I may never see if it wasn’t for this volunteer opportunity. Since I would be staying for so long we decided that it will be very valuable to the community to engage in altitude research. We came up with a research that will evaluate the relationship between Acute Mountain Sickness and Mild Cognitive Impairment in trekkers ascending through the Khunde region in Nepal. A subject that has been poorly understood and studied given the difficulties to complete research in a remote location and harsh environment. The trekkers were tested in three different altitudes to finally compare the changes of cognitive behavior in altitude.

Friends for life. Indonesia and Puerto Rico.

Upon arrival to Kathmandu the cultural differences where absolute. The atmosphere is very hectic, loud and dusty. The mix of Hindu and Buddhist religions is very evident, from their building structures to their traditional clothing. I was eager to start the ascent from Lukla to Pheriche and apply all the reading that I’ve done. But before we got to trekked, we were given lectures on Nepali health problems and Nepali language. We got to meet and explore Katmandu with a very international group of doctors. The Pheriche group consisted of a Swiss Doctor with helicopter rescue background, whose partner is a mountain guide, an Indonesian Doctor with a Disaster medicine background and myself. The Manang group consisted of another USA Wilderness Fellow, and Irish Doctor who works in Australia and a Canadian from Montreal. We prepared the medications and were briefed on our responsibilities at the post.

The Trekking day has arrived and we are up at 4am given that the flight to Lukla is very dependent on the weather. We check all our excess food, medications bags, the aid post’s chimney and board the tiny airplane to arrive tightly in between two mountains at an air strip that was built at an angle to compensate for its short length at 9,383 ft. We already felt like we survived.

Porters carry all of our supplies. We each have a back pack with immediate necessities. There are no roads, the paths are rocky, steep and dusty terrain. The first day of trekking we hike from Lukla to Monjo. I thought I was in shape, but just going up 2 steps was enough to make me gasp for air. How do the porters carry more than twice their weight though this terrain? For me, they are proof of the amazing adaptability of the human species. Any movement caused significant fatigue and I thought to myself what have I gotten myself into? While catching my breath, I got the first glance of the beautiful imposing scenery of the Himalayas. I’m convinced that this is what heaven is supposed to look like.

 Research time. Giving and scoring the test.

There are many “Tea houses” along the way. The rooms have 2 twin beds and a light. Charging stations and sometimes internet are available for a fee in the public dining hall where every guest comes to share stories, the warmth of the stove, tea and food. Water is scarce, warm showers are expensive and very hard to find. People make due with baby wipes.

We stay 2 nights for acclimatization in Namche Bazaar, the biggest town in the mountains. We all had mild headaches that resolved with food and hydration. We hiked 4 hrs to the nearest “hospital” in Kunde to ask for tips and to see what services they offer there, cases we could refer there instead of a evacuating a patient by helicopter back to Kathmandu. We had our first shower and our last chance to use internet. The fifth day of hiking we ascend to Tengboche. Where we were able to see Lobuche peak,  also Ama Dablam and Everest along the way.  The sixth day of hiking was a particular cold and windy hike through the ridge of one of the many mountains in the Khunde region. We finally arrived to the Himalayan Rescue association Pheriche Aid post at 14,340 ft. My pulse was in the hundreds and my oxygenation in the eighties resting. Tachycardic and hypoxic by “normal” standards, were now a new “normal” at this altitude. We settle into our rooms and rest to organize and hopefully open the clinic in two days. We have no fuel for the night, little water and no heating. It will be a cold long night.

We wake up early and start to clean the Aid post that has been unused since last season. The clinic has solar power but the day has been cold and very foggy, not enough sun to fill the battery. We hope that no-one needs the oxygen concentrator today. We accommodate the medications and we have our first Nepali patient. We make a schedule and practice the Altitude talk that we are going to give every day at 3 pm.  

Trekkers receiving a Lecture on Altitude Sickness. Everyday at 3pm

On the other hand it has been years since I seat down as a family to eat, talk and play card games. I honestly felt a little uneasy and guilty that I was not living my hectic life. I guess I have nine more weeks to also “acclimatize” to another way of life. We start to introduce ourselves to the community and we have six more Nepali patients. The locals are very happy to have us here since is the only aid post 2 days at any direction. Foreigners are yet to come as climbing season is around the corner.

Counting Drops- International ICU Rotation in Kigali, Rwanda

Erin Blackstock, MD

Resident in Internal Medicine, MGH

PGY 3

Practicing in Rwanda’s CHUK Intensive Care Unit has unmasked my dependency on pharmacy, respiratory therapy, and critical care nursing; the frequently overlooked, yet invaluable members of our ICU team.  Early in the away rotation, I noticed a bottle of propofol infusing without a pump.  I asked the resident, “How do we know the infusion rate?”  He replied, “15-20 drops/min is estimated to be 1 cc/min.”  With this new knowledge I then set to work calculating the infusion rate for our patient, bringing back the math skills I had used in grade school – making sure I kept the units straight.  

At MGH I would have just entered an order with prepopulated recommended dosing ranges, then pharmacy, nursing, and our pump’s computer systems would have ensured the patient received the correct and at a minimum a safe dose of the medication.   

A few patients later on rounds, we found ourselves trying to troubleshoot a problem on the ventilator.  As a budding pulmonologist, I thought my ventilator skill set to be advanced for a third year resident.  While I may be able to suggest changes for patients with challenging physiology, I quickly realized that I typically rely on our superb respiratory therapists to monitor and correct many problems with the vent. 

I was struck that in our context, our resource-rich environment, we can find our skill set limited by the tremendous support available to us.  While partnering with these additional team members undoubtedly benefits patient care, if we do not intentionally seek out these additional skills, they will be sorely missed in more limited settings.  As I return to Boston, I have been inspired to seek out additional training from our respiratory therapists, pharmacists, and critical care nurses so that next time I find myself in a developing country’s ICU I will feel more equipped to care for those patients.

Undocumented Immigrants

Matthew Gartland, MD

Resident in Medicine and Pediatrics at Massachusetts General Hospital

PGY-3

There are many stories of migration in Chiapas, Mexico. The state sits on the southern border with Guatemala and is a major crossing for nearly all undocumented Central American immigrants to the US, including those riding ‘La Bestia,’ a cargo train crossing the border estimated to carry a half a million migrants each year.

"Health is a human right. The care we offer is completely free we do not
 discriminate  based on country, community, type of insurance, or gender."

The region itself is also the starting point for many immigrants to the United States. Chiapas is the poorest state in Mexico with an estimated poverty rate of 76.2% in 2014. Despite being the most southern state in the country, it supplied the highest proportion of migrants to the US of any state in Mexico as recently as 2008. During my time in Chiapas I encountered many personal stories of families with relatives living in the US, as well as people whom had returned to the Chiapas after spending years working in the US.

One of my motivations for traveling to Mexico was the opportunity to view the issue of immigration to the US from another perspective. This is particularly important to me as I see many undocumented Central American immigrants in my clinic at MGH Revere, some of who passed through Chiapas on their journey.

During my time in Mexico I also came to understand the struggle of undocumented immigrants living in Chiapas. This group of migrants represents one of the more marginalized populations in the region having fled poverty and violence in Guatemala only to arrive in a new community with few social and economic resources.

 

For example, In the clinic in Salvador Urbina we met a Guatemalan woman who was 36 weeks pregnant and seeking prenatal care for the first time. She had tried to enroll in Seguro Popular, a public insurance program in Mexico for the poor. She was told she was not eligible because she lacked immigration documents. As a result, she had delayed presenting for care and was planning on a home birth with a local birth attendant.

Another Guatemalan patient we saw spoke only Mam, an indigenous Mayan language shared by almost a half a million people spanning the border. He was coming to the clinic for chronic shortness of breath and we suspected COPD. The likely cause of his chronic dyspnea was not tobacco smoke, but indoor air pollution from a wood-burning stove. We spent 10 minutes teaching the man to use two types of inhalers, but this was struggle given the language barrier and his low health literacy.

 We used a color/pictorial guide to convey the complicated schedule of medicines. We also used an empty water bottle to rig up a “spacer” to help improve delivery of the inhaled medicine.

In many ways these stories of the challenges of delivering healthcare were not unique to immigrants, but are more broadly challenges of poverty. Still, undocumented immigrants are among the most vulnerable patients owing to language, ethnicity, and poor literacy as well as lack social support structures, discrimination, and disenfranchisement. These challenges represent an opportunity for additional research, advocacy, and tailored programs.

Relationships in Primary Care

Matthew Gartland, MD

Resident in Medicine and Pediatrics at Massachusetts General Hospital

PGY-3

 

In the days before I left for Chiapas, Mexico, I spoke several times to one of my primary care patients. I called him at home one night and he answered the phone out of breath, speaking in short quiet sentences, and gasping to catch his breath during long pauses. He had been experiencing progressive shortness of breath and anxiety over the past 2 weeks, but had not called the office or come to the clinic because he was afraid to go to the hospital. He had lived alone since his wife died and I had tried unsuccessfully over the past several months to arrange elder services to make visits to his home. After convincing him to go to the emergency room that night I visited his room and we talked about a range of topics – his family, the care he wanted at the end of his life, and my upcoming trip to Mexico.

This patient represents many of the best and most challenging elements of primary care in residency. He and I have developed a strong relationship that extends beyond the exam room at the clinic. This has helped me to guide him in what will likely be the last months of his life. On the other hand, I have struggled to address his diabetes and anxiety, chronic diseases that deeply impact his quality of life. It has been even harder to change social issues such as his isolation and loneliness.

In Chiapas I had the privilege to work with Compañeros en Salud (Partners in Health sister organization in Mexico) in two communities, Salvador Urbina and Soledad, in the mountains of southern Mexico. There I witnessed the delivery of primary care by young, passionate Mexican physicians, or pasantes. We saw many patients who reminded me of my experiences with primary care in Boston. I was able to share lessons learned in my few years of training, but beyond that I saw novel approaches to address the challenges of delivering equitable and comprehensive primary care to the poor of Chiapas.

Soledad is a town of about 1200 people spanning a large valley almost a mile above sea level. There I worked with with Monse, a pasante who had been living in Soledad for a little more than 3 months.

Almost every night we walked the hills making home visits. One evening we saw a pregnant woman and convinced her to deliver in a regional hospital rather than at home. Another we paid a house call to a patient recovering after a hysterectomy. On my last night in town we climbed to the house of a child with epilepsy having increased seizures.

One visit stands out in my memory. A 16 year-old girl suffering from panic attacks and anxiety came to the clinic after school. The pasante had created an environment in her clinic to welcome patients struggling with mental health issues. The young girl unburdened herself over the course of a 30-minute visit. We discussed her symptoms and educated her about anxiety. We put together a therapeutic plan — regular visits to the clinic, relaxation techniques and avoidance of triggers, a trial of a medication, and even tutoring sessions with Monse on Saturdays to reduce the stress of school and provide another safe space for her to share her feelings. After seeking the patient’s permission, Monse and I then went to her home later that day to discuss the visit with the girl’s parents. We sat in their kitchen drinking tea and advised them on how to guide their daughter through a tough adolescence.

To me this represented the essence of being a community doctor. Monse is part of a group of 10 amazing pasantes supported by the resources of the Mexican government and Compañeros en Salud. They are stationed in small rural communities where they tackle the growing burden of non-communicable chronic diseases like diabetes, hypertension, and hyperlipidemia. The organization is also introducing novel approaches to heavily stigmatized disorders such as depression and anxiety using community health workers, support groups, and physician home visits to reach the poorest and most vulnerable members of these communities.

The work is not without significant challenges, many reminiscent of my own experiences in Boston. Patients miss appointments, get confused about how to take medications, and struggle to make changes in their unhealthy lifestyles. But the organization has created a strong infrastructure and tapped into the energy and dedication of young physicians and the passion of local staff and community health workers to address these challenges.  

Pathology in Rwanda: Waiting for Installation

 Isaac H. Solomon, MD, PhD

 Fellow in Infectious Disease and Molecular Microbiology at Brigham and Women's Hospital

 PGY-3

In two weeks you can learn a lot about a place.  It's enough time to learn the basic layout of a city (Kigali), where to find cheap bottled water and delicious food, and to visit a genocide memorial.  Two weeks is enough time to learn a few key words in Kinyarwanda such as "murakoze" (thank you) and "mzungu" (someone with white skin; literally translated as someone who roams around aimlessly), and to make some new friends.  Oh right, it's also enough time to teach a little pathology. 

During my two-week visit to Rwanda, I spent a majority of my time interacting with the dozen or so pathology residents who left their various locations around the country to assemble at the University Central Hospital of Kigali (CHUK).  Through a combination of lectures, slides, and writing assignments, we covered a variety of topics including implementation of standardized synoptic reports, histopathological features of infections, and scientific writing.  We also made some progress in reducing the backlog of cases, which were accumulating due to the combination of a broken tissue processor, requiring samples to be sent to another lab prior to the preparation of slides, and limited pathologists available for interpretation.

A reoccurring theme during our review of cases was the limitations of hematoxylin and eosin staining, which is easily overcome at BWH.  In many cases, "special stains" or immunohistochemical stains could have definitively proven a diagnosis or provided additional clinically actionable information.  Either type of ancillary study could be performed in a matter of hours by the available personnel with the equipment on site.  Instead, these tests required sending of material to another lab due to lack of reagents, taking days to weeks to receive the final results.  In the case of a tumor diagnosis this is less than ideal; in the case of an acute infection it is often futile. 

When you first walk into the building housing the pathology lab, you notice a crate taking up a large portion of the hallway with a label that reads "New machine (cryostat) waiting for installation."   In the adjacent room, a shiny metal workbench awaiting ventilation duct hookups is labeled "Grossing station to be installed." I was at first excited that CHUK had received this upgraded equipment, until being informed that the machines had been sitting there for years with no imminent plans for installation.  Struggling to figure out why equipment goes unused, unfixed, or underutilized and why relatively inexpensive reagents cannot be obtained, I was forced to conclude that not everything can be learned in two weeks, but at least it’s a start.

Pathology in Rwanda: Synopsis of Synoptics

Isaac H. Solomon, MD, PhD

 Fellow in Infectious Disease and Molecular Microbiology at Brigham and Women's Hospital

 PGY-3

Health and healthcare have changed tremendously in Rwanda over the last several decades, resulting in significant increases in life expectancy.  As the population ages, cancer is becoming an increasing problem.  In order to avoid over- or under-treating patients who present with a potential malignancy, a tissue-based diagnosis must be made by a pathologist.  Until 2012, only a few pathologists were available to serve the entire country of over 11 million people, and residency training required traveling to neighboring Tanzania or Kenya.  However, the first cohort of pathology residents in Rwanda will complete their training in the summer of 2017, considerably bolstering the ranks.

While training enough pathologists to do the work is a critical first step, additional improvements in patient care can be accomplished through improving communication between clinicians and pathologists, which is true in all settings around the globe.  Since the way in which pathologists communicate the most is through their written reports, inclusion of the most relevant information in a concise format is essential.  To this end, synoptic reports, reporting templates designed to present all the relevant findings of a case in a systematic fashion using standardized terminology, have been created by various pathology organizations.  Data from these reports can then be easily compiled and analyzed by epidemiologists and researchers to conduct population level studies.  Therefore, the primary goal of my project in Rwanda was to introduce synoptics to the current pathology trainees, starting with breast cancer and cervical cancer, in order to facilitate broader implementation. 

The residents as a group were very interested in the concept of synoptic reporting. I prepared a few lectures explaining all of the components in depth, and together we worked through several hypothetical examples of how to write the reports. We then reviewed several previously reported cases from BWH and Rwanda at the microscope.  During these activities, it became evident that some changes in grossing practices on behalf of the residents would be necessary to fully complete the reports, such as inking and additional sampling.  The residents, in turn, raised minor areas of concern regarding the additional level of detail required, significant increase in report length, and difficulty in assigning many of the histological features to "present” or “absent" options without equivocation.  By then end of the visit, it became evident that immediate adoption of synoptic reports in a drop-down menu format was unlikely to occur.  However, the residents were very enthusiastic about using the templates as a guide when preparing their reports in a narrative format to ensure completeness.  While there is still much work to be done, this was an excellent next step.

The Tangled Pair: Implementation Science and Service Delivery in Chiapas, Mexico

Rose Molina, MD

Fellow in Global Women’s Health, The Connors Center for Women’s Health and Gender Biology, Brigham and Women's Hospital

PGY 5

Rose Molina (Global Women's Health Fellow) and
Carolina Menchu (Professional Midwife) in
Laguna del Cofre, Chiapas

As part of my Global Women’s Health Fellowship, I have collaborated with Partners In  Health/Compañeros En Salud (CES) in Chiapas, Mexico in implementing and evaluating the impact of a rural maternity center in providing peripartum care for women with low-risk pregnancies. I traveled to Chiapas for 2 weeks in March as part of this ongoing collaboration over the course of my two-year fellowship. As I reflect on this project, I have realized that there are several challenges in the relationship between service delivery and implementation science. However, overcoming these challenges is essential for both teams to achieve their ultimate goal in improving health outcomes and being able to demonstrate impact in our context in Chiapas.

Implementation science has been defined as “the study of methods…to understand the behavior of healthcare professionals and other stakeholders as a key variable in the sustainable uptake, adoption, and implementation of evidence-based interventions” with the intent “to investigate and address major bottlenecks (e.g. social, behavioral, economic, management) that impede effective implementation, test new approaches to improve health programming, as well as determine a causal relationship between the intervention and its impact.” Along with adaptive trial designs, implementation science has become a buzzword in global health research. It occupies a space on the continuum of monitoring and evaluation (M+E) for internal organizational needs and rigorous research for knowledge generation. Purpose, funders, and resources determine its location on this continuum.

OB ultrasound course in Jaltenango, Chiapas

Global health work encompasses many levels of direct patient care, program analysis, and policy change. One of the central goals in global health work is to demonstrate the impact of interventions and scale up the successful ones in a sustainable way. This is where implementation science is needed. Decision-makers and funders need high-quality data to decide what programs to fund for scale-up. Questions that need to be addressed are 1) What types of data are needed to influence health policy makers and funders to improve health systems? 2) How should meaningful impact be defined for a given intervention? The purpose of implementation science research is to measure the impact of how a program or intervention is designed and carried out. This requires close collaboration between the research team and the team designing and implementing the program, as each informs the other. Good implementation science is iterative, reflecting and evolving with program development. One example of how we applied a research lens to program development was the process of integrating respectful maternity care into existing best practices and developing systems to evaluate these new indicators in our rural maternity center.

Despite the need for implementation science research, little or no infrastructure exists for this purpose in many resource-limited settings. Limited mentorship from personnel experienced with this type of research is another challenge. Furthermore, where limited funding exists, resource allocation may place research priorities further toward monitoring and evaluation on the continuum, which may have implications for generalizability and potential for scale-up.

Maternity center in Revolucio'n, Chiapas

While I was in Chiapas for this recent trip, I had the opportunity to participate in both the service delivery and research teams. With regard to clinical teaching and supervision, an OB/GYN resident and I led a basic obstetric ultrasound course for the general physicians in CES. We performed approximately 35-40 ultrasounds on pregnant women in 4 communities, and we saw the physicians’ skills improve in a short period of time. With regard to research, I helped develop M+E indicators and research protocols that evolve with the changing scope of the project. As I continue to work on this project in Chiapas, my goal is to ground my research in ongoing clinical activities, which can then provide continuous iteration in how the research can best adapt to the clinical reality of the maternity center. This experience continues to shape how I understand implementation science research within an organization dedicated to providing excellence in primary care in a challenging, marginalized environment. Lessons learned from this experience have been invaluable in further developing my career in global health research.