Tuesday, February 26, 2019

Smartphone-Based EEG as a Screening Tool for Status Epilepticus in Patients with Altered Mental Status in a Zambian Hospital Part 2

Morgan Prust, M.D. 
Resident in PHS Neurology 

February 15, 2019

Working in Zambia, or in any setting where the medical need vastly exceeds the healthcare system’s capacities, one is witness to a heartbreaking amount of morbidity and death that would be preventable in any hospital in the developed world. In-hospital DVTs are very common, owing to prolonged hospital stays and a lack of DVT prophylaxis. Because routine labs are not checked on a daily (or even weekly) basis for inpatients, electrolyte abnormalities are widespread, and lead to renal failure and fatal cardiac arrhythmias. In neurology patients, however, aspiration pneumonia poses a particular challenge.

At BWH and MGH, all stroke patients are mandated to undergo a swallow safety evaluation, and patients fail this, they are evaluated by an SLP specialist, and, if needed, given modified diets, placed on aspiration precautions, and in advanced cases, fed exclusively through an NG tube. None of the infrastructure exists for this level of care in Zambia, and at UTH, aspiration pneumonia is tragically high in neurology patients in general, and stroke patients in particular. This arises from a number of contributing factors beyond the traditional organic risk factors like altered mental status and oropharyngeal dysphagia.

Patient's head of bed propped up by clothing
and personal possessions
First of all it takes tremendous effort simply to elevate the head of the bed here, as the beds have no mechanism for inclining the mattress. One's best bet is to find a box, when available, to place under the mattress. When no box is to be found, the belongings of the patient or their family can be used, though this is sub-optimal for self-evident reasons, and there's no standardization of this practice to make it happen as a matter of course. There's also a cultural emphasis on food as being central to the healing process, and families will feed their loved ones regardless of how obtunded or dysphagic they are. NG tubes are available but have to be purchased by families, and X-rays, hard enough to come by for patients with pneumonia and respiratory failure, aren't used to confirm placement. There simply isn't enough nurse care to allow for supervised feeding, and all of the feeding is administered by family members who are generally unable to recognize clinical signs of aspiration. There is no institutionalized practice of swallow screening and no SLP specialists. So, taken together, the risk of in-hospital aspiration is very high.

My project for this trip has been to catalog the feeding practices for stroke patients (while doing my best to optimize adherence to standard aspiration precautions), and follow them throughout their hospital stay to determine who develops aspiration and who doesn’t, with the hope of identifying key modifiable risk factors that could be targeted. My hope is that these data can be used to justify the implementation of standardized and concrete aspiration preventive measures, and be used as a baseline to judge the efficacy of those measures. The simpler and cheaper an intervention is, the easier it is to adopt, implement and scale. It is amazing to think of one day being able to give tPA for acute strokes at UTH, but for now, so many more complications and deaths can be prevented by addressing much lower hanging fruit like preventing aspiration pneumonia.  

Smartphone-Based EEG as a Screening Tool for Status Epilepticus in Patients with Altered Mental Status in a Zambian Hospital Part 1

Morgan Prust, M.D.
Resident in PHS Neurology
PGY -5

I arrived in Lusaka, Zambia in early October 2018. This was my second trip to Zambia in residency, my first having been last year, when I spent a month working as a general neurology consultant at the University Teaching Hospital (UTH) in Zambia’s capital city. That experience helped catalyze my interest in global health, and I felt so fortunate to be able to go back. I returned this year to help take care of patients, collect data for a stroke-related research project, and help out with the early stages of Zambia’s first ever neurology residency, which officially got underway a week or so before I arrived. As was the case when I was in Zambia last year, it’s been an incredible experience, marked with the highs and lows of practicing medicine in a low-resource setting that has an astronomical burden of neurologic disease.

Zambia is a landlocked country in southern Africa, sandwiched between Angola, Congo, Tanzania, Malawi, Mozambique, Zimbabwe, Botswana and Namibia. It is a former British colony which gained independence in 1964, and has had a peaceful and relatively stable existence, although its economy is precariously tied to the country’s copper trade and its fluctuating fortunes. It has a population of about 17 million, and Zambia, like many of its neighbors, was hit particularly hard by the HIV epidemic. While HIV treatment and prevention have significantly improved overall life expectancies over the past 20 years, the rate of adult HIV infection in Zambia is still about 13%, and is the population’s greatest driver of mortality. HIV is associated with a broad spectrum of neurologic diseases that comprises a subspeciality of neurology in itself. TB meningitis and complications of CNS opportunistic infections are exceedingly common (it is more common for patients to present with multiple concurrent CNS OIs than a single one). Epilepsy is very common, owing to the high rate of brain lesions from CNS OIs and other neuro-infectious diseases, and poor access to specialized care/AEDs for patients with primary seizure disorders. Beyond the realm of HIV-associated disorders, stroke is the eighth leading cause of mortality, and speaks to a high prevalence of untreated hypertension and diabetes.

For Zambia’s 17 million people, there are four adult neurologists (and now three Zambian neurology residents). They all practice at UTH in Lusaka (with the exception of a pediatric neurologist who practices in a smaller city called Ndola in the country’s Copper Belt region). The launch of the residency program will hopefully allow the specialty to grow in a country that sorely needs more neurologists. There is also a steady flow of expat neurologists and neurology residents like me who come to work for a month or two a time, owing to the presence of the American neurologists who work and live there full time. I work primarily with neurologists Omar Siddiqi and Deanna Saylor as my attending mentors. Omar is based at BIDMC, but primary lives and works in Lusaka and has been supervising visiting neurology residents for many years. Deanna, who arrived in Lusaka earlier this year to head the new residency program, is a neuroimmunologist/neuro-ID specialist from Johns Hopkins.

My typical day involves getting to the hospital around 7:30am. I round on all the neurology patients in the ICU, which has about 15 beds and seven ventilators. Common reasons for neurology admissions to the ICU include cerebral hemorrhages requiring extraventricular drains, status epilepticus requiring sedative doses of AEDs, and neuro-infectious emergencies. After rounding in the ICU, I pass through all the inpatient wards and the emergency ward to see any new stroke patients and to follow up on all known stroke patients for a research project I’m doing on aspiration pneumonia and stroke (see next post). In the afternoons, I typically continue seeing patients, either stroke patients or other non-vascular neurology consults, and staff cases with Deanna and the other neurology residents.
Exterior and interior of the UTH intensive care unit
 CT is the predominant imaging modality, owing to its relative ease of access, and to the fact that the hospital’s MRI has been down since this past spring (patients with private funds can go to one of the local private hospital’s for an MRI, though the image quality is generally poor). it’s very difficult to get any vascular imaging other than carotid ultrasound, which significantly limits the ability to diagnose the cause of an acute stroke. We have an electrophysiology lab here, which has EEG (including a portable EEG workstation that can be wheeled to patient’s bedsides) and EMG. Lumbar puncture is very often indicated but are not infrequently refused by patients or their families due to a widespread misperception that LPs cause death. This stems from the story of a former politician with an advanced neurologic illness who died coincidentally shortly after undergoing an LP. When we do get LPs, the results have to be interpreted with caution, as the accuracy of the laboratory’s CSF assays is inconsistent (for example, the RBC count will often be quoted as 0 despite a tap with gross blood).

Here are some images from some of the patient's I've been taking care of:

Multifocal left parietal tuberculoma in a patient with poorly controlled HIV

Multifocal lesions in 42F with CD4<10 o:p="">

Overall, it’s been an incredibly gratifying experience to be here once again. I feel so grateful for the opportunity to use the skills I’ve learned in residency in a place where the need is so great. There are days when the volume of tragedy weighs heavily, but the joys of working with amazing colleagues and universally lovely and grateful patients, and getting treat complex and fascinating neurologic illnesses make it so worthwhile.

Pilot study of flutter valve device among COPD patients in India- Part 2

Ashish Rai, M.D.
Chief Resident, North Shore Medical Center
PGY- 4

February 15, 2019

During my visit I was surprised to discover the existing infrastructure and support in a tier-two city with a middle to low income in a developing nation. CRF has an established and functioning spirometry lab, available pulmonary consultants, internist, microbiologist with an equipped microbiology lab and all the required technical and administrative support.  At present the institution maintains a registry of over 2000 patients with COPD from across the city and adjacent rural areas who frequently visit CRF, for their outpatient pulmonary follow up which is provided free of cost and receive subsidized medications and equipment to manage their underlying pulmonary disease.

More than half of the patient population registered at the institution are currently enrolled in a clinical or biomedical research, which are conducted and supervised by the institution with support from the local and national government and interested pharmaceutical companies.

The patients at CRF appeared to be unaware of the harmful effects of smoking and the use of biomass for cooking, and only saw a physician when they were sick and needed to visit the emergency room. 

In majority of the cases the barrier to medical treatment seemed to be not just a lack of medical resource, but also a lack of awareness towards primary and secondary prevention.

An outpatient center dedicated towards pulmonary disease with a goal for primary and secondary prevention, in a country with a population having lower purchasing power and high medical cost appears to be proving the much-needed solution to its patient population.

I also discovered that the population of COPD patients in India and in particularly in rural areas is unique as an estimated 60% of the COPD patient population registered at Chest Research Foundation, had biomass exposure as an etiology, while in the developed countries cigarette smoking is the primary cause, and the world’s leading cause for COPD is biomass exposure and not smoking.

A center like CRF, which has a large registry of 
patients with COPD and asthma and the resources to conduct clinical and biomedical research while providing outpatient care is an excellent example of public-private joint venture which looks to be the solution to the ever-growing health care need in a developing country.
(Research team members at CRF, Pune, India. Left to right: Sandhya (research coordinator), Dr. Vijay (attending internal medicine physician), Dr. Ashish Rai, Dr. Sudeep Salvi (attending pulmonary physician and Chief of CRF) and Dr. Govinda Narke (attending preventive and social medicine physician)

Pilot study of flutter valve device (Acapella) among COPD patients in India- Part 1

Ashish Rai, M.D.
Chief Resident, North Shore Medical Center

February 15, 2019

Chronic obstructive pulmonary disease (COPD) accounts for 5% of global deaths with 80% of these deaths occurring in low to middle income countries as per the recent WHO global burden of disease report. Flutter valve devices could be a low resource tool that could decrease the mortality and morbidity associated with this disease.

Explaining the use of acapella device.
With this background I travelled to Chest Research Foundation (CRF), Pune, India to undertake a pilot study looking into the efficacy of flutter valve devices among individuals with severe COPD living with low to middle income. CRF is an autonomous institution that provides outpatient care to patients suffering from pulmonary disease, with specialization in treating asthma and COPD. The institution was set up in 2002 by group of pulmonologists and internists practicing in Pune, India with aids from the Indian government and pharmaceuticals companies with a goal to bridge the gap between the health care provider and patients and to provide a platform for researchers interested in Asthma and COPD.

Giving informed consent.
Prior to my arrival, physicians at CRF, Dr. Govinda Narke (attending preventive and social medicine) and Dr. Sudeep Salvi (attending pulmonologist and chief of CRF) had arranged for a list of potential patients with severe COPD based on the inclusion and exclusion criteria of the study and received the respective institutional ethics committee approvals.

On the day of my arrival at CRF we started with the process of recruitment which included donating, explaining the potential benefits and risk and demonstrating the use of the Acapella device signing of informed consent and filling out lifestyle indices in the local language with help of Dr. Govinda Narke.

Measuring pulmonary function.
Every day we were able to recruit two to four people depending on the availability and by the time of my departure we were able to recruit 20 patients with a plan to recruit 10 more in this week. Prior to the departure patients were requested to demonstrate the use of Acapella and ask any queries they may have related to its use. 
and pulmonary function tests.

Everyone with their device.
Most patients that were recruited were from the rural areas which were on average 30-40 miles away from institution and were driven with the help of transport arranged from the institution and were provided with a meal and lost wages by CRF.

After explaining to the participant about the potential for decrease in the frequency of COPD exacerbation and hence avoiding hospital admissions, patients appeared to be more accepting for the use of the device and agreed to use it as per the directions. They have been advised to revisit CRF in 15 days for a repeat measurement of pulmonary function test and documenting lifestyle indices, which will be performed by the team at CRF.

Our hypothesis from this project is that outpatient use of a flutter valve device improves pulmonary function and quality of life among severe COPD patients and can be used as an adjunct to pulmonary rehabilitation especially in low to middle income countries.

Thursday, February 21, 2019

Cardiac Surgery for Rheumatic Heart Disease in Kigali, Rwanda – Part 2

Andrew J.B. Pisansky, M.D., M.S.
Resident in Anesthesiology at Brigham and Women's Hospital

February 16, 2019

With the eight days of operating behind us and our part of the work completed, it is easier to reflect on the work we did and see beyond the operations and to the patients and their families. In total, we provided cardiac anesthesia for 17 operations (16 primary valve surgeries and 1 reoperation for persistent bleeding).  The days were long and our need to be continually vigilant to prevent medical errors or harm from coming to the patients persisted until the end of our trip. However, we were successful in our cases and there was not a single anesthetic complication resulting in patient harm.

The best part of the trip, however, was seeing the resilience of our patients. Despite many of our patients being adolescents, they were incredibly stoic and brave both before and after their surgery.  We would visit them each day in the ICU and the step-down unit.  They made remarkable and rapid progress and we would often arrive to find them already up and out of bed, singing and dancing despite being only 2 days postoperative from their surgery.  It was incredible.

However, there was more than enough time to see the systems challenges that continue to face King Faisal Hospital and Team Heart as we work toward the goal of King Faisal cardiac surgery teams being able to treat patients during the months when our teams are not present.  This capacity-building component of Team Heart has been part of the project’s mission since its inception.  Self sufficiency in cardiac surgery is a possibility, but plenty of work remains to be done.  At present, there is a Rwandan surgeon who has completed his training in cardiac surgery and recently joined the staff at King Faisal.  He will continue to operate with Team Heart surgeons as part of his continual training.  However, the other supporting services will require continued development: anesthesiology, cardiac perfusionists, scrub nurses, and intensivists still need to be trained.  This is a lesson for future development projects, in that all health care is made up of a system and each part of the system must function well in order to drive positive outcomes.

My time in Kigali with Team Heart was amazing.  The clinical experience and the patient population were truly unique and will add to my clinical skillset and appreciation for how medicine can be done in environments with which we are unfamiliar.  Team Heart will be back next year.  Although I will not be with them, I was glad to have contributed to the mission for one trip and will take the lessons learned with me.

Cardiac Surgery for Rheumatic Heart Disease in Kigali, Rwanda – Part 1

Andrew J.B. Pisansky, M.D., M.S.
Resident in Anesthesiology at Brigham and Women's Hospital

February 16, 2019

For over 12 years, Team Heart has been bringing teams from the US to Kigali, Rwanda in order to provide cardiac surgery to patients with rheumatic heart disease, typically due to sequelae of untreated strep throat.  Prior to our arrival as part of the operative team, there had been months of planning by the coordinators back in Boston, Denver, and Vermont.  Additionally, for several weeks before we arrived, the cardiologists from Team Heart had staffed many hours of clinics during which the operative candidates were screened for surgery.  Unlike in the US, underweight patients were more of a concern than overweight, and our cut-off for patient size was 30 kg (more than a few of our actual patients were no more than one or two kilograms above the cut off weight). 

On our first day at King Faisal Hospital in Kigali, we set up our operating room and attended the patient selection finalization meeting.  The operating room started out looking relatively empty, but we soon filled it with the familiar sights and sounds of anesthetic machinery and medications, the cardiopulmonary bypass machine, and surgical equipment.  At the patient selection meeting, our entire team for the week (about 60 individuals of all specialties from the operating room to the step-down unit) met for a conference to discuss the final list of patients for our trip.  We would operate for 8 days and do 16 cases in total. 

The first few days required an adjustment to our usual work flow.  There was no electronic medical record.  All lab values traveled in the chart with the patient.  All records of the anesthetic were documented on carbon copy paper forms. The pumps that delivered our usual cardiac medications were from the US, but different from what we typically used.  The motto of the American Society of Anesthesiologists is one word, “Vigilance.”  It quickly became clear that we would be caring for some of the most advanced cardiac pathology I had ever seen (certainly far worse than we typically see in Boston) while also operating in an unfamiliar environment.  Although our systems in the US make redundancy in safety commonplace, it was clear that vigilance would play more of a part in our work than was typically the case.

We worked through progressively more difficult cases during the week.  Our first case, severe mitral regurgitation for a mechanical mitral valve.  But soon we progressed to combined valvular lesions: severe mitral regurgitation with moderate mitral stenosis and severe aortic insufficiency, or severe tricuspid regurgitation, severe mitral regurgitation, moderate aortic insufficiency, severe pulmonary hypertension and right ventricular dysfunction for mitral and aortic valve replacement as well as tricuspid valve repair.  These are typically the tales of textbooks and lecture halls, but we were managing this advanced pathology in patients as young as 16 years old, many of them with weights in the mid 30-kg range and a blood volume less than half of what we typically encounter in US patients. 

However, by halfway through the week, the team had found a rhythm.  Everyone worked in relative harmony.  Each day brought about 2 more successful operations.  4 days down, 4 to go.

Reflections on paper charting

Jeffrey Gluckstein, M.D. 
Resident in neurology at BWH/MGH

February 15, 2019

I’ve only worked in the era of electronic medical records. I’ve heard older physicians complain about the transition to computerized record systems and agree with their frustrations with the lack of interoperability and the emphasis on billing. That said, I always suspected that the complaints stemmed primarily from the difficulties of using a new system and couldn’t image using a medical record that wasn’t (somewhat) searchable and accessible anywhere.

Working with paper records has turned me into an evangelist for electronic systems. While the paper record system in Zambia isn’t optimized, working on paper introduced me to some unavoidable problems with paper charts.

Perhaps most importantly, paper charts can only be in one place at one time. Usually, that place is the bedside or a nursing station. Sometimes it’s a patient’s home. Occasionally, it’s somewhere unknown. While having to search for a patient’s chart or walk to the bedside to figure out what other teams are thinking may seem like a mere annoyance, it actually changes how much one can do. I spent about 30 minutes a day looking for charts or rewriting lost notes. For patients whose old charts were completely lost (that includes scans, medication records, and notes), we’d have to rely solely on patient and family history. Unfortunately, those histories are often very different from what actually happened to a patient.

Secondly, the stereotype about doctors’ handwriting is true. While many physicians write absolutely beautiful notes, illegible writing made some doctors’ evaluations completely unusable (including my own, initially). While this is solvable in principle with good penmanship, typing or dictation solves it in practice by converting all characters into the same, legible print. 

Finally, manipulating data in paper charts is incredibly slow. While I could painstakingly turn through a 100-page chart to see how a patient’s lab values responded to changes in medication over time, in practice it’s nearly impossible. Pages can be out of order, lab values can go missing, there’s no way to search for when medications were changed, and I often can’t read the notes I need. This leads to a more “impressionistic” evaluation of trends over time.

Older physicians in the US complain that electronic medical records encourage people to cut and paste from old notes. That’s completely true. It leads to the bloated and occasionally inaccurate but easily billable notes written by most residents in the US. I thought that paper notes might solve that problem, but people still copy past notes. Sure, the notes aren’t as long, which makes it easier to focus on the important parts. Unfortunately, they are just as easily filled with incorrect diagnoses from the past (sometimes due to incorrect transcriptions of unclear handwriting).

Of course, there are some virtues to paper notes. Having the chart at the patient’s bedside gives me more time with the family, so they can think of more questions and I can add to my examination if I think of additional testing while writing my note. My slow handwriting forces me to be succinct with my notes (though I’d probably get faster with time). And, in a country with limited infrastructure, occasionally unreliable power, and limited funds, paper charts are cheap and easy. Maintaining the workstations required to run an electronic medical record seems out of reach in a place where the lab regularly runs out of reagents for common tests. I wouldn’t change the system here, but I’m much more appreciative of the clunky, bloated electronic record system I use in Boston.

Neurologic Care at a Referral Hospital in Zambia

Jeffrey Gluckstein, M.D. 
Resident in neurology at BWH/MGH

February 15, 2019

I’m currently working on the neurology service in a referral center in Zambia. There are three Zambian adult neurology residents and only one attending supervising the inpatient clinical services at any given time. With nearly 1700 patients in the hospital, the neurologists are stretched thin between the wards, ICU, clinics, and consults.

I chose to spend four weeks in Zambia because I wanted learn to provide neurological care in a resource-limited tropical setting. So far, my PGY-3 neurology colleague from Rush and I have focused on recently-admitted inpatients. My typical day involves entering a room with 48 male patients and literally walking from bed-to-bed to determine whether patients have neurologic problems. I write notes and give my thoughts to the families, interns, and nurses. I repeat the process in the female ward, eat a late lunch, and check in on consults and old patients scattered around the hospital in the afternoon. We typically spend about 9 hours in the hospital before coming home for a quiet night.

In my first week I saw 44 new patients and discussed many more with my colleagues. 11 were ischemic strokes, 7 were intracerebral hemorrhages, 7 were seizures, and 4 were CNS TB (either meningitis or tuberculomas). To keep things interesting, we also saw likely metronidazole toxicity in a patient with undetected AKI and 2.5 weeks of antibiotic therapy, severe hydrocephalus in previously undiagnosed neurocysticercosis, and a case of clinically diagnosed Morvan syndrome now responsive to IVIg. The average patient age was 48. While infectious diseases bring the majority of my young patients to the hospital, a surprising number have intracerebral hemorrhages and ischemic strokes without a clear underlying cause (through the resource limitations make the hunt for a definitive diagnosis difficult).

All charting is done on paper - and I mean all of it. Old notes from previous admissions or clinic visits sit in a stack at the bedside. Test results have to be manually retrieved by nursing from the laboratory and stapled to the chart. Discs of cross-sectional imaging are added to the chart with a paper copy of the radiology evaluation added 1-2 days after the scan is done (for patients wealthy and stable enough to obtain imaging at an outside facility, as the hospital’s 2 CT scanners and 1 MRI are both broken at the moment). Orders are entered in notes and the medication administration record, but often aren’t acted upon until the busy nurses have the chance to review them, deliver a paper prescription to the pharmacy, and bring back a medication. 

Despite the resource limitations and my lack of familiarity with neuroepidemiology in Zambia, I feel that an American neurology resident can be useful here. The hospital is absolutely deluged with neurological illness, so there are many patients who would wait a long time to be seen by a neurologist without me looking at their chart, asking for their chief complaint, or simply spotting a neglect or gaze palsy from across the room. Neurophobia is probably more prevalent among interns than in the United States, so identifying deficits on exam, explaining a diagnosis to a patient, or slightly modifying care plans can greatly advance management. Of course, I’m learning an incredible amount from the trainees and practicing neurologists here. CNS tuberculosis or cysticercosis are rare cases in Boston, but they’re becoming my bread and butter. Perhaps more importantly, I’m learning to trust by history and exam more completely, as diagnostic testing can take days and patients often need urgent treatment based on clinical diagnoses. I hope to become even more helpful as I become more familiar with local epidemiology, the available medications, and our limited diagnostic tests.

Improving Access to Emergency Care in Colombia

Jeffrey Chen, M.D.
Resident in Emergency Medicine at MGH/BWH

February 6, 2019

Emergency medicine was first recognized as a specialty in Colombia in 2005. Since then, there have been 7 EM residencies founded throughout the country. Many of these EM-trained providers stay in urban hospitals. However, in Colombia and many other Latin American countries, there is a huge gap between care in densely-populated cities and rural areas.

Rather than the system here in the US, where medical students typically start residency straight after medical school, in Colombia, graduates freshly out of medical school perform a year of Servicio Social Obligatorio (SSO) where they are placed in rural sites. These hospitals are often less well-staffed and have far fewer resources than are available in urban hospitals.

One of my goals in going to Colombia was to help evaluate the knowledge and level of comfort of last-year medical students with the management of emergency conditions – just before they are sent off to practice on their own or with relatively less supervision in these rural areas with more vulnerable patient populations. This is for the preparation of the rollout of the Basic Emergency Care Course developed by the World Health Organization, which teaches knowledge and skills like airway management, resuscitation of shock, trauma evaluation and care, and other fundamental life-saving skills.

Working with emergency medicine residents and medical students to improve our survey regarding comfort and knowledge with emergency medical conditions.

Another project I’m helping out with here is with the Harvard Humanitarian Initiative. In 2016, Colombia ended a decades-long conflict between the government, paramilitary, and guerrilla groups. In my time here already, I’ve met many healthcare professionals who had stories about how this conflict affected their medical and nursing education as well as their ability to provide good care. Stories of different armed groups coming to hospitals were not uncommon, as well as changes both positive and negative made to the curricula as a result of these conflicts. These were especially common in rural areas, and many of the doctors I’ve met have surmounted incredible challenges in the past.

Being involved in these academic projects has been inspirational. To meet so many people here in Colombia working to improve the healthcare system and access to emergency care is incredible. I look forward to watching this evolution.

Rotating in the Emergency Department at Hospital Universitario San Ignacio

Jeffrey Chen, M.D.
Resident in Emergency Medicine at MGH/BWH

February 6, 2019

In my time here in Colombia, I’ve had a few main goals. Firstly, I’ve spent time in the emergency department at Hospital Universitario San Ignacio, the primary teaching hospital of Pontificia Universidad Javeriana in Bogotá. Every year, this department sees about as many, if not more patients than the MGH ED, totaling about 120,000-140,000 patients per year. Just like the MGH ED, it’s a busy place divided similarly into a resuscitation area, an evaluation area, a clinical decision unit, an observation unit, and a pediatrics department.

Outside the Hospital Universitario San Ignacio, hospital leaders set up a candlelight vigil, with each candle representing the healing of a patient in the hospital.

Of course, with the emergency medicine curriculum being so standardized, there are far more similarities than differences in the way the department functions. A patient with a displaced leg fracture, for example, will be evaluated first by an emergency physician who will perform a neurovascular exam and provide initial pain control before calling an orthopedist to help reduce the fracture. A young patient coming in cardiorespiratory arrest from asthma will have half the staff in the resuscitation area descend upon them to obtain vascular access, perform CPR, run the code, etc.

Moreover, there is an academic conference day each Friday filled with lectures on topics ranging from chemotherapy toxicities to priapism to medication overdoses. There is a simulation center to practice procedures such as central line insertion as well as trauma resuscitations. This center even has a model of a destroyed car to practice extractions from the scene as well as out of hospital resuscitations.

 A destroyed car donated to the simulation center allows trainees in emergency medicine and nursing to practice field extractions and resuscitations.
I’ve also been keen to observe some of the differences in practice. Patients in this ED spend a lot more time boarding there than here, as much as we have a problem. For example, I saw many patients with myocardial infarctions (heart attacks) go from the ED to the catheterization lab, get a procedure/stent placed, and then come back to the ED to board more. Some of these patients were then discharged directly from the ED, though some were able to go up to the CCU. As a result, the ED docs here know an incredible amount of the literature about MI aftercare, long-term medications after stent placement, etc.

Another thing I’ve been impressed by is the fact that subclavian central access is first-line here. This is due to the reduced rates of infections and DVTs in these lines, though we tend to avoid these in our EDs to the higher rates of pneumothorax. The doctors in the ED at Javeriana however put these in with ease and with confidence.

Overall, it’s been an amazing honor to work and observe here alongside the amazing emergency physicians here in Bogota. It sheds light into the amazing work that has gone into building emergency care systems here to care for patients in their greatest times of need.

Wednesday, February 20, 2019

Medicine and Dermatology in Mirebalais, Haiti – Part 2

Emily Baumrin MD
Resident in combined internal medicine and dermatology at Brigham and Women’s Hospital and Harvard University, PGY4

February 16, 2019

This week marks the end of my second week in Mirebalais, Haiti serving both a clinical and educational role as a senior internal medicine and dermatology resident. This week was focused on education in which I gave a series of case-based seminars on topics in complex medical dermatology and dermatologic manifestations of systemic disease. The internal medicine residents have a set curriculum with lectures in each medical specialty including pulmonary, cardiac, renal, endocrine etc. These lectures are given by a combination of Haitian specialists from Port-Au-Prince and from ex-pat specialists who visit Mirebalais on a rotating basis. While they have two Haitian dermatologists, the dermatologists are focused on providing clinical care given the limited time they spend in Mirebalais. This lecture series was the first dermatology focused didactic curriculum given to the residents.

The seminars were extremely rewarding but provided unique challenges compared to similar lectures that I have given to internal medicine residents in Boston. Dermatology uses a large lexicon of very technical terminology. Medical education in Haiti is taught in French, care is provided in Creole, and most students and residents speak English. Navigating dermatology terminology between the three languages was difficult and led to confusion at times. After the first lecture, I found that modifying the cases to focus on descriptive language and clinical reasoning, using photos to reinforce principles was more effective. There was a wide range of familiarity with the subject matter and I found that facilitating the more knowledgeable residents to teach the other residents and students in language and terminology familiar to their educational process was the best strategy. I will take these teaching principles back with me for medical education in Boston since I think it increased learner participation, engagement, and application of reasoning to a wide spectrum of dermatologic processes.

At the end of the week, the residents told me they were excited to use the physical exam of the skin to help diagnose internal disease and asked me to share dermatology textbooks for further self-directed education. Skin for the win!

Case based lecture to Haitian medical students and residents at Hospital University Mirebalais.

Tuesday, February 19, 2019

Medicine and Dermatology in Mirebalais, Haiti - Part 1

Emily Baumrin MD
Resident in combined internal medicine and dermatology at Brigham and Women’s Hospital and Harvard University, PGY4

February 8th, 2019

I am spending 3 weeks at Lopital Inivesite Mibale (Hospital University of Mirebalais) in Mirebalais, Haiti. Hospital University of Mirebalais is a 205,000 square foot 300-bed hospital which serves Mirebalais and 2 nearby communities. However, it attracts patients from a larger catchment area including the central plateau and Port-Au-Prince due its specialty services as well as low cost to the patient. Hospital University of Mirebalais is a teaching hospital to Haitian medical students, nursing students, and residents.

My time at Hospital University of Mirebalais is an educational and clinical exchange with the dermatology and internal medicine departments. During my first week, I spent 2 days of the week with the hospital dermatologists. There are 2 Haitian dermatologists who provide clinical care at the hospital, each dermatologist is present 1 day per week spending the rest of their time at clinical sites in other cities. We saw patients in clinic together. The disease burden is quite different from Boston with the predominant presentations infectious in nature including dermatophyte and candida infections, scabies, and secondary infection of atopic dermatitis. The formulary is certainly more limited here with only 1-2 options for topical corticosteroids, oral and topical antifungal agents. There are no systemic treatments available for atopic dermatitis or psoriasis. However, I was surprised to find the number of effective topical treatments that they use here that we do not use at all in Boston. I have learned alternative therapeutic regimens for a number of common dermatologic conditions.

I spent the other days with the internal medicine residents and attendings. Their day is structured much like ours starting with a morning report where new admissions are discussed with the entire department, followed by rounding, a noon didactic conference, and time to work and admit patients in the afternoons. I have been struck by the burden of cardiac disease that they see particularly post-partum cardiomyopathy and right sided heart failure from chronic lung disease and TB. The residents here are excellent ultrasonographers and have taught me many skills to take home. We have had a number of dermatologic cases including drug induced bullous pemphigoid and acute lupus. I will teach a series of case based lectures to the internal medicine residents next week on medical dermatology. Stay tuned!