Tuesday, August 2, 2016

Orthopedic Trauma Surgery in Haiti

William Slikker
Orthopedic Fellow at BWH

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

      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

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

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

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 -20oC 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.