Monday, May 16, 2016

Counting Drops- International ICU Rotation in Kigali, Rwanda

Erin Blackstock, MD
Resident in Internal Medicine, MGH

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

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
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 CompaƱeros 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 CompaƱeros 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.  

Wednesday, May 4, 2016

Pathology in Rwanda: Waiting for Installation

 Isaac H. Solomon, MD, PhD
 Fellow in Infectious Disease and Molecular Microbiology at Brigham and Women's Hospital

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

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.