Tuesday, February 23, 2016

Last day at the lab!

Its Carnival Saturday, Im reviewing some new cases just out of curiosity as Im wrapping up things at the lab today since the week of Carnival is a virtual shut down of all operations in Trinidad.  Sherwin, our lab technologist whos been trying to perfect the labs Giemsa stain just stopped by for a chat about it.  Dr. Greaves couldnt see neutrophillic granules on bone marrow smears, but now I think I see a few (yay methanol fixation!).  We talked about writing an SOP so the conditions dont change then having the lab director, Dr. Greaves sign it and have it in a folder in the lab so that when another lab technologist comes on board we wont have to reinvent the wheel.  Productive morning so far.  Dr. Greaves is taking me out to lunch as a thank you for the last two weeks of work so Im using his office while he wraps up some grossing.

Slide session #2 at the hospital

Yesterday, I went to a hospital about 1.5 hours away from the lab and sat in 2.5 hours of traffic to get there, in rain with very little gas thus no air conditioner.  I was a soaked sweaty mess of a human walking into the Department of Pathology in San Fernando (a teaching hospital in Trinidad and Tobago), with surgeons, surgery residents, pathologists and pathology residents waiting.  I was 30 minutes late for a slide session that was scheduled at 10am and had to be back up to Dr. Greaves lab for another talk on molecular pathology by 1pm.  Of days Ive had so far in Trinidad yesterday was my most exhausting but perhaps my most rewarding.  It rains for 3 hours straight here at a time by the way, and then the sun comes out, the birds sing etc etc  But it rains and it rains hard, and it floods and people just stop on highways for no other reason than just to stop their cars.  Vent over.  My talk in San Fernando went well I think, I couldnt answer a few of the questions.  

Because I had to, the parking lot at the teaching hospital,
parking skills are a must..

The level of sophistication despite their resource restriction at the government hospital still amazes me.  Again, as I said in the first post, this has to be one of the most fulfilling experiences Ive had career-wise so far.

Im going to spend next week Monday and Tuesday in Trinidad playing CarnivalPlaying Carnival means putting on a costume and dancing in the streets.  Ill be with my sister, her friends and my best friend from high school.  I play in a band called Bliss (incredibly appropriate) on Monday and Tuesday.  But, before all that, Im going to (voluntarily) wake up at 3am, put on the oldest t-shirt and shorts I own and go get (again, voluntarily) smothered with mud to ring in the actual Carnival celebration.  That festival is called Jouvert (the opening). 

Steelpan (Trinidad's national instrument) rehearsals
for the big competition (Panorama).
The Carnival tradition began with French settlers in Trinidad, its akin to Mardi Gras in New Orleans.  Its a release of the flesh of sorts, a sinning time before the cleansing and penance of Ash Wednesday and Lent.  The history of it all is quite interesting in Trinidad.  Prior to 1880 or thereabouts, only the aristocrats (the bourgeois) could play Carnival on Monday and Tuesday.  In Trinidad at the time, it meant the whites.  Then came the Canboulay riots.  Freed slaves wanted to participate in the celebration of mas and werent allowed to do so.  In 1880, they burnt sugar canes (hence cannes brûlées' into Canboulay - Trinidad was once a French colony so French patois words still persist) and protested in the streets for their right to play.  And play they did.  Carnival became a unifying celebration of the races and classes, where there was dancing in the streets for two days, begun by Jouvert and ended by last lap on Tuesday.  It is an expression of the culture, the country and the people.  Your salary, your nationality, your skin color and your dance is inconsequential, as long as you have a good vibe, yuh in ting (Trinidadian for: youre all set).

I clearly paused the blog writing to play mas and am finishing this up back in the cold that is Boston.  I had quite the time dancing in the streets, working in the lab, teaching the residents and everything in between.  Im a little sad to have left.  In Trinidadian lingo, I have a little bit of a tabanca but in some ways Im also glad to be back to continue the collaboration, the inspiration and the good vibe.

Edible arrangement from the lab, a welcome back to the cold
from my new friends in Trinidad.

Pathology in Trinidad

Melanie Johncilla, MD
Fellow in BWH Pathology

I left Trinidad when I was 18 years old.  I’ve never worked in the country and since I left it’s always been a place I equate with vacation, beaches, sleeping in late and having home-cooked food.  Given my experience working with folks in other “lower resource” settings like Rwanda and Haiti, I began investigating Trinidad as one of those ‘settings’.  After a small needs based assessment, I decided to do a project that would bridge very evident knowledge and practice gaps in the country.

Showing Dr. Greaves and his house officer Kavita the
 telepathology system (the iphone is attached to the camera and 
I'm uploading it on to Ipath for outside consultation).

And here I am.  In a room in San Juan, Trinidad with blue walls and a rectangular window waiting for my turn with the one microscope (I gave it to ‘my house officer’ who is previewing some unknowns I brought from the Brigham for a teaching session later this week).  The microscope has no light filter, no 2 or 20x objective and - I’ve mentioned this already - there’s only one of them.  I need it to attach my one (donated) iphone so I can then project slide images onto my laptop and begin teaching.  It’s different from having my pick of the litter at the Brigham (objectives, filters, microscopes..) but oddly enough I love it.  I know I only have one microscope and I know that my old high school friends are leaving work early to go the bar or a carnival fete (it’s what Trinidadians call a party).  But I don’t think I’ve ever been this excited about a project before.  
The first attempt at immunohistochemistry I asked for:
Reynard and Sherwin, our lab assistants.

I could spend time on this blog regaling readers with tales of mistaken diagnoses, maltreatment based on diagnoses from the four (total!) pathologists here (the best of whom completed their training in the early 90’s and didn’t ‘believe’ in immunohistochemistry until a few years ago).  I could detail the story of  the one pathologist who diagnosed a 17cm mass in a decompensating 70 y/o man with the words “cells, staining for CD20, CD5 and CD3, clinical correlation is needed”.  But I, embarrassingly, expected that practice type.  What I did not expect is my colleague, Wesley Greaves, MD, FCAP who maintains the integrity, professionalism and knowledge base he built while at MD Anderson and Brown and then brought that essence to his practice in Trinidad.  Though severely restricted in terms of resources, his practice of pathology rivals that of the Brigham.  His staff is beyond motivated, beyond innovative and frankly, had they been based in the US with grants to apply for, courses to take, they would be among the best, if not the best.  Resource restriction is quite a thing.

The entire experience is not without its negatives (on my part).  As I sat in my one hour traffic filled commute, I momentarily lapsed into a  line of thinking probably fueled by the frustration of just getting to the lab.  Here I am, I thought, a fellow in Boston with arguably unlimited access to resources and connections and here I go, to a lab with three immunostains and one microscope, what am I doing here?  The gap is wide and after sitting here for four days and recovering from my commute, I feel my own privilege and my own entitlement and that’s also quite a thing.

The grossing station at the lab.
Other than this practice, if I could sum up Trinidad in one word, it would be hot.  Soca (calypso music with a faster beat) is playing on a laptop on our assistant’s desk as he comments on who will win the competitions that are coming up (Carnival is in two weeks and besides heavy dieting, Trinidadians turn into music critics and compare this year’s crop of costumes, ‘fetes’ and songs with the last years', somehow the last years' is always better).  Even though my accent is as strong as it’s ever been, my co-workers here still feel the need to educate me on things ‘Trini’.  I don’t know any of the new slang and tend to use the American term/pronunciation for a few things well rather than the more traditional British.  

I needed a few minutes to write this, but cases, patients and house officers await.  The practice of Pathology is different here.  It’s dynamic, engaging and developing.  And, four days in, I love it.

Wednesday, February 17, 2016

Challenges of Providing Neurological Care in Zambia, Part II

Challenges of Providing Neurological Care in Zambia, Part II  

In most Boston hospitals, medical emergencies come with a flurry of people in action:  A nurse or a resident placing a peripheral IV or a femoral line, monitors buzzing and beeping, pharmacists preparing medications as fast as they possibly can, and medications rapidly dripping through IV lines and into patients' veins.  At the University Teaching Hospital (“UTH”) in Lusaka, Zambia, the situation is very different. A patient in status epilepticus can go hours without receiving anti-epileptic drugs. Another patient with meningitis can go days without receiving a lumbar puncture (although, to be fair, there is significant taboo around lumbar punctures in Zambian society and Sub-Saharan Africa more broadly).  When we are reviewing mortalities during the daily morning report with residents and attending physicians, the clinical stories go something like this: “X-year old [gentleman/woman] with [heart failure/ stroke/ sepsis / disseminated TB/ fill in the blank] and no labs drawn [/ no medication given/ no imaging done] for X-days.” Physicians and nurses strive to give patients the best care and attention they possibly can, but making the “right” clinical decision for the patient does not always lead to a good outcome because of limitations in resources available. The pharmacy may be out of a medication, there may only be one dialysis spot available and 4 uremic patients to choose from, the CT scanner is down, or there simply may not be enough physician or nursing staffing bandwidth to attend to a patient’s needs. While there are many systemic causes for these problems in the Zambian health care system, the severe shortage of medical personnel has been especially very apparent to me during my time here.

With a population of 14.3 million, Zambia's patient community is enormous, yet the country has less than half the number of health-care workers required to adequately serve the population, including less than 2,000 doctors. As I mentioned in my previous post, there are three adult neurologists for the entire country. Without the development of new trainees, the neurological care in Zambia has been set up for failure. To combat this problem, Dr. Omar Siddiqi is hoping to establish the country’s first neurology residency and neurology fellowship program this coming fall.

One thing I have appreciated about my time at UTH has been taking part in different aspects of global health work. In addition to assisting with much-needed research and clinical care, I have also participated in expanding medical education and capacity building aimed at training effective practitioners. I have thoroughly enjoyed teaching medical students and junior residents, who have all been eager to learn and serve their patient population.

Some have argued that we can solve many medical problems in lower and middle-income countries (“LMICs”) like Zambia by simply purchasing the most modern technology and equipment for their hospitals. But, based on what I have witnessed at UTH so far, it’s clear to me that is not the only answer. The hospital staff must also be trained to properly use the equipment, and consistent and speedy technical support is needed to ensure the equipment is working at all times. For example, unlike some hospitals in LMICs, UTH has both a CT scanner and an MRI scanner. However, there is limited technical support, radiology support, and radiology technician support to properly and efficiently use these machines. When the CT scanner is not working, it can be down for weeks, because there is nobody locally able to fix the more complex problems that inevitably arise with the machine. Last week, a nurse walked into the MRI scanner with a metal oxygen tank, not having received MRI safety training. Furthermore, few radiologists at UTH have received formal training to read MRI studies.  Many of the MRI scans seem straightforward to me—but that is as a resident who reads MRIs on a daily basis.  Therefore, in addition to providing much-needed resources, like CT and MRI scanners, hospital staffs must also be trained properly so these additional resources can be used effectively.  I have seen the same sort of scenario unfold with regard to EEG machines. 

I am very grateful for having had the opportunity to come here this month, and to learn from Dr. Siddiqi and the physician staff at UTH. As I try to incorporate global health interests into my own career, I will surely also be incorporating the lessons I have learned here--particularly in terms of sustainability and providing adequate training.

Challenges of Providing Neurological Care in Zambia, Part I

Challenges of Providing Neurological Care in Zambia, Part I

It has been an eye-opening experience for me at the University Teaching Hospital (UTH) in Lusaka, Zambia, where I have been practicing as a neurologist this January, thanks to the MGH Center for Global Health Travel Grant. UTH is the largest hospital in Zambia with 1655 beds, a teaching hospital affiliated with the University of Zambia School of Medicine and a center for specialist referrals from across the entire country. I have been working with Dr. Omar Siddiqi from the Beth Israel Deaconess Medical Center. Dr. Siddiqi is one of three adult neurologists in the entire country (a population of 14.3 million people), and is working on enhancing TB meningitis diagnostics as well as building Zambia’s first neurology residency program. In Zambia, my workdays are strikingly similar to life as a medical resident in Boston: I see inpatient consultations, outpatients, and teach medical students.
But, there are many differences as well. For example, grieving is a very public process in Zambia. The hardest aspect of my job has been hearing the heart wrenching wailing and sobbing of patients’ family members reverberate throughout the hospital corridors, as they struggle to cope with the death of a loved one. Although painful to hear, I also remind myself of the silver lining in their grieving voices: many of the patients at UTH are surrounded by the heartwarming presence of their families and communities during their final days.  This is a strength that I have found often exists in resource-limited settings such as Zambia. Because of the high patient to nurse ratio that cannot accommodate the entire patient population at UTH, many patients have family members take turns as their primary caregiver in the hospital (“bedsiders”). These family members perform many tasks traditionally performed by nurses in the United States: from bathing to feeding to even taking serology tubes to the laboratory.  

Clinically, Zambia carries one of the largest HIV and TB burdens in the world, and the burden of CNS infectious diseases as a result of these infections is significant. Within the last two weeks, I have seen cases of cryptococcal meningitis, TB meningitis, Pott’s disease (TB in the spine), cerebellar atrophy from primary HIV infection (among many others). An equal caseload in the United States would take years to see and diagnose. I have been impressed by how fluent the residents and attending physicians at UTH are in the language of infectious diseases. I had to provide myself a crash course in neuro-infectious diseases just to keep up with the medical staff. These cases are certainly not the “bread and butter” of neurology that I have seen in Boston throughout most of my residency.
But, just as infectious diseases disproportionately impact low and middle-income countries (LMICs) like Zambia, so do non-communicable diseases (NCDs) such as stroke. In fact, nearly three-quarters of NCD deaths worldwide occur in LMICs. At UTH, I have also seen a significant number of NCD cases. While awareness of infectious diseases has increased in recent years, education about NCDs such as stroke is still low in Zambia. For example, a cab driver told me: “My friends and I are more worried about having a stroke than HIV, because we know there is treatment for HIV.” Stroke, he said, is considered to be more of an unknown disease. Furthermore, a patient asked me in clinic if there was a medicine I could prescribe to him to return strength to his muscles after a stroke. And, another patient’s daughter was brought to tears when I told her that the damage to her mother’s brain was permanent.  She was unaware of the irreversibility of damage from chronic diseases such as high blood pressure, high cholesterol, or stroke. These experiences demonstrate to me that educational and clinical efforts in global health must expand beyond infectious diseases and must include NCDs.

Despite these challenges, I have admired the Americans like Dr. Siddiqi who have brought their entire lives here to study infectious diseases and help strengthen the local medical infrastructure, just as much as I have admired the devoted Zambian doctors who work grueling hours with a significant patient work load.  I am also thankful for the travel grant and eager to continue learning for the remainder of my time here.