Wednesday, September 25, 2019

Conversation as a resource in Kigali

Lara Vogel, MD
Resident, Harvard Affiliated Emergency Medicine Residency MGH/BWH, 

Conversations surrounding code status and informed consent are a huge practicality of my job, and one I think I will always feel less prepared for than I should be. In the ER, I frequently give bad news, explain complex medical conditions, try to parse the high uncertainty of early diagnosis and ask for consent for treatment in only a few minutes. In another language, across a cultural barrier, with interpreters, there is of course additional layers of complexity. But even in my native language, these conversations are riddled with small misunderstandings and subtle nuance that make them difficult to leave feeling certain that we all share the same understanding of the patient’s condition and values and what I hope to treat and how.

In Kigali, I was a teacher—I could not speak to many of the patients without interpretation (Kinyarwanda was the strongly dominant language for this patient population), and I appropriately did not independently manage their care without residents and attendings involved in my decision making. However, even with interpreters I trusted and with time to talk to patients as my administrative duties were lessened, my chance for truly informed consent seemed slight given the vast distance of culture, language, and medical training between me and my patients.  As a result, I often left these conversations to the residents directly caring for patients, intervening only when I thought medical care was not being discussed at all. However, I was not prepared for the additional layer of consent conversations that had to be done by the physicians prior to the patients and their families. In a relatively resource-poor setting, there was often no conversation to be had with patients and their families. When we ran out of ventilators, when radiologists would not read a study, when the lab ran out of a certain test’s supplies, when patients could not afford central line or other equipment, we did everything else we could. I personally had not prepared for the brief but important preliminary discussion that had to be had among physicians regarding the resources available at any given time- resources were a fluid and changing thing but when they were gone, there was not always an alternative to discuss with a patient.

Clinical Rotation in an Emergency Department in Kigali

Lara Vogel, MD
Resident, Harvard Affiliated Emergency Medicine Residency MGH/BWH, 

In my work prior to medicine, I lived and worked in East Africa for multiple years, focusing primarily on education and the ways the HIV/AIDS epidemic impacted children in Kenya. Working on public health projects in rural Kenya through my twenties pushed me toward medicine, so now that residency was nearly finished for me, it was time for me to go back to the place where my interest in medicine started. Or at least get closer. Through attendings in the BWH ER Trish Henwood, Alice Bukhman and Regan Marsh, I was able to connect with the new Rwandan attendings running one of the first EM residencies in Sub-Saharan Africa. The Centre Hospitalier Universitaire de Kigali (CHUK) is about to graduate its second class of residents, and the ER is currently run entirely by its prior graduates. There are three of them. They work a lot.

I technically know that EM is a relatively new specialty in the US but seeing a new specialty establish itself is a fascinating process. This process at CHUK is relatively far along and I had the smallest glimpse, but watching these residents navigate their own hospital system, the ambulances, the insurance system (they often have to wait for proof of payment before they can treat), and the consultants’ understanding of patient care was an education in itself. Unsurprisingly, the medicine was the same between the two countries and the residents were exceptionally well trained—their comfort with trauma far exceeded my own, and their ability to make do with much less support from consultants, supplies, and patient’s understanding of disease was incredible—but ultimately, they had many more fights everyday to define the boundaries of their ER to themselves, to their patients and certainly to the hospital system. Their actions were always defined by the best interests of the patient, but when ICU patients spent weeks boarding in the ER, when the orthopedists could not operate or admit and yet would not stop accepting transfers, and when social services did not exist to support patients unable to care for themselves, the question of what was best for the patient became extremely complex and well beyond the scope of what I expect from an ER physician. Needless to say, they all managed it with grace and I was the one left confused.

Heart Failure and Cardiac Ultrasound Training in Rural Rwanda

Sheila Klassen, MD
Cardiovascular Disease and Global Health Equity Fellow at Harvard Medical School
(Formerly PGY8 Advanced Echocardiography Fellow at the Massachusetts General Hospital at the time of COE travel grant application)

Teaching basic echocardiography in rural Rwanda
Non-communicable diseases (NCDs) account for 44% of all deaths in Rwanda according to the WHO country profile fact sheet from 2018. Within that, cardiovascular disease and cardiovascular risk factors make up a large proportion of NCD mortality but there are only 6 cardiologists in the country, based in the capital city of Kigali. Within this context, I’ve spent the last 2 weeks teaching nurses, general practitioners, and internists from the rural district hospitals and smaller cities in the outer provinces of Rwanda about heart failure and demonstrating basic echocardiography skills which they can employ within their own settings. Their commitment to learning was palpable! Without having visited their home hospitals, I could tell from their level of interest and their questions that heart failure and cardiac disease was commonplace and that they struggled to know what to do with suspected cases of heart failure.

My students become teachers for each other!
My first week was comprised of a formal training session organized by the Ministry of Health in a central location in Rwinkwavu, located in the Eastern province of Rwanda. I taught on basic principles of ultrasound, basic echocardiographic views, normal cardiac anatomy and the most common cardiac pathologies affecting low resource settings such as Rwanda. After 3 days of training, it was amazing to see the transition from student to teacher – they were already starting to share cases and answer each others’ questions about echo findings and medication titration, particularly about strategies particular to the setting such as how to navigate stock at the local pharmacies for the heart failure drugs I was teaching about. I spent the second week in the NCD clinics of 2 district hospitals in the Northern province with nurses and local physicians. My role was to supervise, coach, and help them consolidate the knowledge they’ve gained and it was encouraging to see how capable they had become in a very short time. The next 2 weeks will be spent visiting the other 4 district hospital sites and doing the same.

The limitations at the district hospitals are difficult. There are many patients who don’t have access to life-saving diagnostics and treatments we take for granted. In the span of several days, I saw a 9-year-old with severe congenital mitral and tricuspid regurgitation in heart failure, a 16-year-old with dense hemiplegia from a stroke due to large left atrial thrombi from severe mitral stenosis, a 36-year-old with severe malnutrition and cor pulmonale. Even ECG machines are not readily available, nevermind cardiac cath and chest CT. But it was encouraging to see hypertensive heart disease now being adequately treated, severe cardiomyopathy on therapy, and my trainees counseling on low sodium diet. More to come in the next 2 weeks!