tag:blogger.com,1999:blog-54225211126146043232024-03-17T23:03:28.019-04:00Mass General Brigham's Center of Expertise in Global and Community HealthMass General Brigham's Centers of Expertise (COEs) are innovative cross-specialty educational opportunities that allows trainees to explore areas of medicine and health care delivery relevant to all specialties such as medical education, quality & safety, global & community health, and health care policy & management. This blog is authored by trainees who have received research grants that include travel from the COEs and the impact of this grant.Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.comBlogger329125tag:blogger.com,1999:blog-5422521112614604323.post-65464750680487675682020-04-06T12:37:00.002-04:002020-04-06T12:51:43.038-04:00Clinical Elective in Dermatology in India, Part 2<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormalCxSpFirst" style="line-height: normal;">
<span style="font-family: inherit;">Cristina Thomas, MD</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal;">
<span style="font-family: inherit;">
Resident in the Harvard Combined Internal Medicine-Dermatology Residency
Program<o:p></o:p></span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal;">
<span style="font-family: inherit;">PGY-5<o:p></o:p></span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal;">
<o:p><span style="font-family: inherit;">02/25/2020</span></o:p></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal;">
<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; text-align: center;"><tbody>
<tr><td style="text-align: center;"><img border="0" data-original-height="640" data-original-width="1040" height="196" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6RL8nfxoyAbsR06pufgbNMw65AxlAvG-9ZOtCYUlalhf-GN5Wujw1W28SctXD_WJxnQqFRc6X0PfQDzl2rG_nAXZEHiroc-Xz5TKwIvRyimzc8HRVk-x5nHBP_4FYX4B6-_5EmpVRfFk/s320/Thomas_2a.jpg" style="margin-left: auto; margin-right: auto;" width="320" /></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Dermatology Residents and Attendings at Amrita Institute of<br />
Medical Sciences</td></tr>
</tbody></table>
<div class="MsoNormalCxSpMiddle" style="line-height: normal;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6RL8nfxoyAbsR06pufgbNMw65AxlAvG-9ZOtCYUlalhf-GN5Wujw1W28SctXD_WJxnQqFRc6X0PfQDzl2rG_nAXZEHiroc-Xz5TKwIvRyimzc8HRVk-x5nHBP_4FYX4B6-_5EmpVRfFk/s1600/Thomas_2a.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span style="font-family: inherit;"></span></a><span style="font-family: inherit;">I am wrapping up my
time in Kerala, India and have been reflecting on the role of the dermatologist
in India. With an interest in complex medical dermatology and tropical
diseases, I am currently a PGY-5 in the combined internal medicine-dermatology
residency program here at Harvard. While in India, I’ve noticed that almost all
dermatologists practice at least some amount of internal medicine. Without a
high prevalence of skin cancer, the majority of patients seen in the
dermatology clinic are those with cutaneous manifestations of systemic disease.
I can’t count the number of patients who have presented with extensive tinea
corporis only to have the dermatologist check a HbA1c and diagnose the patient
with diabetes which is a risk factor for tinea. The dermatologist often
coordinates the multi-disciplinary care of leprosy patients who require
neurology, podiatry, and PT/OT. The dermatologist manages cancer screening in a
patient with paraneoplastic pemphigus. I could go on and on about the
complexity of care that these physicians provide, and I’ve been so impressed
with the compassion and expertise of these physicians. <o:p></o:p></span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal;">
<br /></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal;">
<span style="font-family: inherit;">Apart from the
medicine, however, dermatologists also play a huge role in quality of life for
these patients. Patients with dermatologic disease in India are often
stigmatized against because of the visual nature of their condition. I saw a
man with albinism who was fired from his job because of his skin condition, a
young girl with vitiligo who was teased by her classmates, and a woman who was
shunned by her family because she had lymphatic filariasis. The physicians I
worked with not only treated these patients in order to improve their quality
of life, but also sought to change the societal milieu which led to their
discrimination. They took the time to educate the patients’ families and even
organized educational activities in the community to reduce the stigma
associated with dermatologic conditions like vitiligo, psoriasis, and leprosy.
My interest in medicine as a field stemmed from a desire to improve quality of
life in individuals and it has been refreshing to see this done each and every
day at Amrita Hospital.<o:p></o:p></span></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com70tag:blogger.com,1999:blog-5422521112614604323.post-34310731461075120172020-04-06T12:34:00.001-04:002020-04-08T09:01:17.802-04:00Clinical Elective in Dermatology in India, Part 1<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormalCxSpFirst" style="line-height: normal;">
<span style="font-family: inherit;">Cristina Thomas, MD</span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal;">
<span style="font-family: inherit;">
Resident in the Harvard Combined Internal Medicine-Dermatology Residency
Program<o:p></o:p></span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal;">
<span style="font-family: inherit;">PGY-5<o:p></o:p></span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal;">
<o:p><span style="font-family: inherit;">02/25/2020 </span></o:p></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal;">
<o:p><span style="font-family: inherit;"><br /></span></o:p></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal;">
<span style="font-family: inherit;">Hello from Kerala,
India! I have now been working at Amrita Hospital in Kerala, India for the past
two weeks and have learned so much over that time. I’ve been to India a number
of times for global health work, but this elective has been very different from
my prior work because I have had the opportunity to delve into clinical care
rather than focus on research endeavors. <o:p></o:p></span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal;">
<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; text-align: center;"><tbody>
<tr><td style="text-align: center;"><img border="0" data-original-height="1600" data-original-width="1362" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEic4mV7kzO5vL7HaQHdbySWKAN0mEqZqheMANkey-Y8lhHo_UJaBOsrEErwwgAACxBFp6trgTSYFr9LgPiQ_zBcO5I4LlJmU-tNIK_UicpDPOj9GDVLwORub5hRn-iufnWuWuQRgd9s9qw/s320/Thomas_1a.jpg" style="margin-left: auto; margin-right: auto;" width="272" /></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Amrita Institute of Medical Sciences</td></tr>
</tbody></table>
<div class="MsoNormalCxSpMiddle" style="line-height: normal;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEic4mV7kzO5vL7HaQHdbySWKAN0mEqZqheMANkey-Y8lhHo_UJaBOsrEErwwgAACxBFp6trgTSYFr9LgPiQ_zBcO5I4LlJmU-tNIK_UicpDPOj9GDVLwORub5hRn-iufnWuWuQRgd9s9qw/s1600/Thomas_1a.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><span style="font-family: inherit;"></span></a><span style="font-family: inherit;">Amrita Hospital is a
1450-bed hospital that treats around 3000 outpatients daily. Within the
dermatology department, a broad range of skin conditions are seen, ranging from
common diseases that we see in the US like psoriasis to neglected tropical
diseases like lymphatic filariasis. Despite the range of diseases seen, I have
been struck by the department’s ability to practice cost-effective care. Although
Amrita Hospital has the ability to perform many complex lab tests including
dermatopathology (which is a key component of dermatology), the dermatologists
at Amrita only order these tests if they are absolutely necessary. This is
because, in general, patients are paying for their care out of pocket. This
includes the physician visit, any lab testing, and any prescriptions. Without a
reliance on ancillary testing, the dermatologists at Amrita have outstanding
physical exam skills. They are able to distinguish between bullous pemphigoid
and pemphigus vulgaris with the Asboe-Hansen sign, identify leprosy with
palpation of a slightly thickened ulnar nerve, and diagnose oral lichen planus
by picking up on fine white reticulations in the mouth of a patient with oral
burning. Along with these excellent physical exam skills comes a true focus on
the patient. The physicians spend time gathering a history to narrow their
differential diagnosis and carefully examine each patient looking for any clues
to point to a specific disease. This is in stark contrast to many of our
patient encounters in the US where we have a short 15 minutes with the patient
to develop our assessment and plan and thus, relay on testing to expedite the
process. I have found it refreshing to reflect on my approach to clinical care
through the lens of the health care infrastructure in India and am excited to
continue this over the rest of my rotation.<o:p></o:p></span></div>
<div class="MsoNormalCxSpMiddle" style="line-height: normal;">
<br /></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com62tag:blogger.com,1999:blog-5422521112614604323.post-28203878156889608602020-04-06T12:18:00.000-04:002020-04-08T09:00:11.039-04:00Developing Systems of Care for Non-Communicable Diseases in Ethiopia<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
<span style="font-family: inherit;">Zachary Hermes, M.D. </span></div>
<div class="MsoNormal">
<span style="font-family: inherit;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">Resident, Internal Medicine at the Brigham and Women’s
Hospital, </span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">PGY3<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">02/08/2020</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: inherit;">My time in Ethiopia has been a bit of a blur over the past 3
weeks traveling between busy cardiovascular clinics, crowded inpatient
cardiology wards, and district hospital echocardiography clinics. Thankfully, I
had a unique experience last Tuesday that allowed me to step back and take a
birds’ eye view of the health care ecosystem in Ethiopia. I was invited to join
a workshop hosted by the Federal Ministry of Health (FMOH) focused on
Non-Communicable Diseases. The group had previously convened as the Ethiopian
Non-Communicable Disease Interventions (NCDI) Commission, which was a
cumulative effort by the FMOH, local academic institutions, individual experts,
patient/professional associations with facilitation by the Global Lancet
Commission on “Reframing Noncommunicable Diseases and Injuries (NCDIs) for the
Poorest Billion.” This was an enlightening experience in that it provided
macro-level, policy-focused view of health delivery in Ethiopia, and it
complemented my on-the-ground perspective with holistic view of the entire
ecosystem. Additionally, it was instructive to see the process and structure of
a ministry-level governmental working group.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: inherit;">As we launched into the program, the discussion started with
a snapshot of healthcare institutions and workforce. In terms of hospitals,
there were approximately 25 tertiary hospitals, 80 general hospitals, and less
than 200 primary hospitals which tend to be the center of care for almost all
non-urban populations. Yet that 200, was far below the WHO recommendations which
would translate to roughly 1000. Additionally, there was a little less than 1
healthcare worker per 1000 people which was similarly below the WHO goal level.
The landscape for healthcare financing was also striking. Average healthcare
expenditures/capita came out at roughly $33USD, but 70% of NCD services
were<span style="mso-spacerun: yes;"> </span>financed as out-of-pocket which
also meant that health care was the number of cause of bankruptcy or financial
distress for the population. This reaffirmed the importance of their objectives
to identify essential NCD services, understand how to finance their provision
with public dollars, and most importantly, how and where to actually deliver
the care needed.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-family: inherit;"><br /></span>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghlAoDFdhq5WLmP38NUNcjpLHehn_VKQfmxHvX7-8E8qBhJYwcxQw5kaU0yzsMiTlxsECFRFSoeKd_dRNumoz1-qczVA7GdKuQzfHCGfBq8JehGr-AzrFum_s9gRCFhuRBz5vrMwsB-8c/s1600/Hermes_2a.jpeg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><span style="font-family: inherit;"></span></a></div>
<div style="text-align: left;">
</div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghlAoDFdhq5WLmP38NUNcjpLHehn_VKQfmxHvX7-8E8qBhJYwcxQw5kaU0yzsMiTlxsECFRFSoeKd_dRNumoz1-qczVA7GdKuQzfHCGfBq8JehGr-AzrFum_s9gRCFhuRBz5vrMwsB-8c/s1600/Hermes_2a.jpeg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1200" data-original-width="1600" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghlAoDFdhq5WLmP38NUNcjpLHehn_VKQfmxHvX7-8E8qBhJYwcxQw5kaU0yzsMiTlxsECFRFSoeKd_dRNumoz1-qczVA7GdKuQzfHCGfBq8JehGr-AzrFum_s9gRCFhuRBz5vrMwsB-8c/s320/Hermes_2a.jpeg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">At Non-Communicable Diseases and Injuries (NCDI) Health<br />
Sector Interventions Summit hosted by Ethiopia's Federal Ministry<br />
of Health </td></tr>
</tbody></table>
<span style="font-family: inherit;">The next point of discussion was to review the previously
determined package of essential health services in the context of the delivery
platforms available to the health system. The key levels were tertiary care
hospitals, general/primary hospitals (which were realistically the most
accessible level of care for the majority of Ethiopians), health centers,
community-based care through health workers, and population-based approaches.
Our conversation focused on the interface between tertiary care hospitals and
general hospitals, as this postulated to be a key leverage point to advance the
decentralization of NCD care which was currently limited for the most part to
Tertiary hospitals. What became clear to the group was that although an
excellent and well-evidenced list of recommendations of what needs to be
delivered, and ideally where it should be delivered, there wasn’t any data on
how many of the selected interventions were actually being delivered at
different levels, who was delivering those services, and why recommended
packages were not being delivered. To see the hypothesis-generation and
methodological refinement occur in real-time was amazing, and by the end of the
workshop there was a proposed framework for assessing what is actually
occurring at the primary hospital-level and tertiary-hospital level. </span><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: inherit;">The group was gracious in welcoming me and were intentional
about engaging me throughout the discussion. It was an honor to join the
workshops, and I was thankful to spend the day learning from their perspective
and experience.</span></div>
</div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com61tag:blogger.com,1999:blog-5422521112614604323.post-17067099788196142122020-04-06T12:11:00.004-04:002020-04-08T08:59:51.647-04:00Cardiovascular Care in Ethiopia<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
Zachary Hermes, M.D. </div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
Resident, Internal Medicine at the Brigham and Women’s
Hospital, </div>
<div class="MsoNormal">
PGY3<o:p></o:p></div>
<div class="MsoNormal">
0208/2020</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Ethiopia is located in Northeast Africa, and is one of the
largest countries on the continent with a land mass three times larger than
Germany and a population of nearly 100 million. Non-communicable diseases such
as congenital heart disease, rheumatic heart disease, heart failure, and
ischemic heart disease are of growing importance and consequence. Yet, access
to cardiac services remains limited in Ethiopia. My time in Ethiopia was spent
observing and diagnosing the growing burden of cardiovascular disease,
exploring the ecosystem of cardiovascular services, and gaining insight into
the challenges and opportunities to expanding cardiac care capacity.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Modern cardiovascular care was first made<span style="mso-spacerun: yes;"> </span>available within Ethiopia in the mid-90’s.
Most of this care has been at a relatively small scale and come in the form of
visiting cardiac surgical and interventional cardiology teams. The first
Ethiopian-led non-invasive and invasive cardiology (pacemaker insertion and
percutaneous coronary interventions) care began to be offered in 2007. In the
decade that followed the national Ministry of Health prioritized the
establishment of modern cardiology units in their anchor, tertiary-level
University Hospitals. With diligence and commitment a number of internists were
trained abroad in non-invasivee and invasive cardiology, though their numbers
are in the single-digits. Addis Ababa College of Health Sciences, which is
affiliated with Black Lion Hospital, was one of the first to be outfitted with
a modern catheterization laboratory in 2016 and they have subsequently launched
an Ethiopian Cardiology Fellowship program in 2018. My elective work was spent
with these endeavoring attending cardiologists and the third cohort of
cardiology fellows. My days were split up between cardiovascular outpatient
clinics, inpatient cardiology wards, and an occasional pacemaker implantation
or balloon valvulotomy with rounds in the cardiac intensive care unit to
follow. In the clinics, I saw over 100 patients in the clinics with roughly 40%
of those with rheumatic heart disease spanning a spectrum of heart failure and
another 30% with some variation of ischemic heart disease, hypertension, or
diabetes. The morbidity caused by rheumatic heart disease was truly striking,
with far too many teenage patients already with symptoms of heart failure and
advanced structural disease that would necessitate valve replacement in other
settings. Unfortunately for these patients, they were relegated to symptomatic
management with diuretics. The waiting list for valve replacements hovers
around 10,000 patients (!) with movement dependent on the aforementioned
visiting groups. It was just in 2017 that the first open heart surgery was
performed in Black Lion Hospital by an Ethiopian Surgeon supported by one of
the foreign surgical teams. The momentum has been continued as their cardiology
fellowship now has graduated their first cohort, a masters of cardiac nursing
program is up and running, and a perfusionist training program is in place.
Most excitingly, the Ethiopian and Netherlands governments had signed a joint
deal with Phillips to break ground on a state of the art cardiac care facility
on the Black Lion Campus. I had the pleasure of working with clinical lead of
this project, Dr. Dejuma Yadeta, for a number of days and we visited the site. </div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8Dwi0v3afMsj3fknFdr2ZplsR9hm2nt-upR8S-J10nMQqpDgJMhfKTVhUcaqd3eqCGgTQ543_tn51ncvES7kEQRUhsMpwqfLG8BvJhsQ23SsqC01ncAtoQhUnChCYLDVw9p5RNxODd0s/s1600/Hermes_1a.jpeg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="480" data-original-width="640" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8Dwi0v3afMsj3fknFdr2ZplsR9hm2nt-upR8S-J10nMQqpDgJMhfKTVhUcaqd3eqCGgTQ543_tn51ncvES7kEQRUhsMpwqfLG8BvJhsQ23SsqC01ncAtoQhUnChCYLDVw9p5RNxODd0s/s320/Hermes_1a.jpeg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">With Dr. Berhanu Nega, M.D., Associate Professor of Surgery<br />
at Addis Ababa University School of Medicine, Head Cardiac<br />
Service Team at Tikur Anbessa Hospital, in front of construction<br />
site for state of the art Cardiac Hospital on Tikur Anbessa Hospital Campus</td></tr>
</tbody></table>
<o:p></o:p><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
As the largest teaching hospital in Ethiopia, Black Lion
Hospital and Addis Ababa University School of Medicine serves as a vibrant
training center for undergraduate and postgraduate medical students and
trainees. This was my base throughout my elective with interspersed time at
number of smaller clinics and districts hospitals, which were envisioned to act
as a referral network and means to decentralize care. Still, the hospital and
its associated clinics act as the primary source of access for a significant
proportion of both the urban and rural population. During my time I saw
numerous patients who had traveled more than 300 kilometers for routine
management, which highlighted the importance of decentralizing care for
Non-Communicable Diseases (NCDs). Though the challenges are undoubtedly
immense, I came away struck by the dedication, strategy, and thoughtfulness of
my Ethiopian colleagues and sure that I will continue to support and
collaborate them in any way I can as I move forward in my career. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b>Reference<o:p></o:p></b></div>
<div class="MsoNormal">
Christian J Leuner, Abraha Hailu Weldegerima, Cardiology
services in Ethiopia, <i>European Heart Journal</i>, Volume 39, Issue 29,
01 August 2018, Pages 2699–2700, <a href="https://doi.org/10.1093/eurheartj/ehy373">https://doi.org/10.1093/eurheartj/ehy373</a><o:p></o:p></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com45tag:blogger.com,1999:blog-5422521112614604323.post-70600116855748560152020-04-06T11:58:00.000-04:002020-04-08T10:08:04.080-04:00Attitudes about Death: Reflections on a Clinical Rotation in Lusaka, Zambia<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
Katie Holroyd, M.D. </div>
<div class="MsoNormal">
Partners MGH/BWH Neurology resident, </div>
<div class="MsoNormal">
PGY3</div>
<div class="MsoNormal">
12/09/2019</div>
<div class="MsoNormal">
<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
From my experience thus far in American hospitals
(acknowledging the limitation that I have trained exclusively at large,
academic institutions in major east coast cities), there are two main types of
deaths we see during training. The first is the unexpected, often catastrophic death
from large strokes, traumas, cardiac arrhythmias, or other non-reversible
conditions. These scenarios often involve prolonged codes, extensive
resuscitation attempts, and utilization of a vast amount of resources in the
emergency department or on a hospital floor. The second is the slow and
deliberate transition to death, which can be referred to in many ways including
comfort care, hospice, or palliative care.<span style="mso-spacerun: yes;">
</span>This often occurs in older patients in whom additional diagnostics or
treatments would cause more suffering than benefit, and takes place after
extensive delicate discussions with family members (or at times the patient
themselves). Regardless of the way that death occurs in the hospital, it is
usually an intensely private experience, with patients moved to single rooms and
all measures taken to support and respect family members during the transition.
<span style="mso-spacerun: yes;"> </span><o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
It has seemed to me, that death in the US is almost never
viewed as inevitable until the very last moments, and that death without
extreme investigations, treatments, and resuscitation is the exception not the
rule.<span style="mso-spacerun: yes;"> </span>In contrast, and with the
disclaimer that I have very limited understanding and experience in Zambian
culture after only one month, attitudes about death in Zambia seem to exist in
an almost paradoxical fashion.<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
On one side, there are far fewer open medical discussions
about the transition to death here. Countless patients who would be in an
intensive care unit the United States lie in regular beds, and with one look
any medical professional could identify that they will not make it out of the
hospital alive, especially given the limited resuscitation resources here.
However, these thoughts are not relayed directly to family. This comes in part
because there is generally no acceptance of withdrawing care in Zambia.<span style="mso-spacerun: yes;"> </span>As discussed in my previous post, families
provide most of the direct care to patients in the hospital, and concepts such
as stopping feeding (even if a patient is unable to swallow) or withdrawing
medications do not exist. A palliative care service was briefly formed by some
of the residents at UTH, but it was not accepted by patients, other physicians,
or hospital administrators and was disbanded. Several of the residents here
remain interested in performing projects to help better understand attitudes
regarding palliative care, with the hope of re-instating this service in the
future. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Contrarily, I have found death to be much more visceral, present,
and commonplace here than in the United States. Far more of my patients here die,
and die at much younger ages, than patients I see in the US. Often at least one
patient I saw in the morning will have died by the afternoon. Sometimes this is
expected in our sickest patients, but at other times, such as the 28 year old
man who walked into the hospital with only a cranial nerve palsy one week
earlier, it is very unexpected. These patients are passing away in shared rooms
with 8-12 other patients, and thus there is no way to not be faced with death
on a daily basis either for the physicians and nurses in the hospital, or the
other patients and their families. In this sense, by force of necessity, death
is directly witnessed much more frequently than in the US. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYXXy4PfbzhyGtQ0nrlXeiEKVo1dM2SKkpYhShyd0Ksno4ck-bVwttzFo_KOa4wFrFCn07Pay6ushwhgp5bVtCFAveNaT0c0rs7qzBZybS-ecwwGa5Exf4d6QKn6relu3gJsnwK-KB4j0/s1600/Holroyd_2a.PNG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1600" data-original-width="740" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiYXXy4PfbzhyGtQ0nrlXeiEKVo1dM2SKkpYhShyd0Ksno4ck-bVwttzFo_KOa4wFrFCn07Pay6ushwhgp5bVtCFAveNaT0c0rs7qzBZybS-ecwwGa5Exf4d6QKn6relu3gJsnwK-KB4j0/s320/Holroyd_2a.PNG" width="147" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">CT of the head showing an<br />
old stroke as well as evidence<br />
of neurocysticersosis infection</td></tr>
</tbody></table>
<div class="MsoNormal">
I have also found families ask far fewer questions
surrounding a family member’s death—rarely questioning why, how, or making
accusations of medical misconduct at any point. Whether this is based on
language and cultural barriers with an American doctor, lack of medical
literacy, or something else, I cannot say. However, it seems that many Zambians
have been forced to experience death as a very real part of life, without extensive
questioning or complaining. I can imagine this is due both to differences in
life expectancy (61 in Zambia, compared to 78 in the US) and larger family size
(average number of children in Zambia 5.5, compared to 1.9 in the US).<o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Importantly, I do not in any way mean to convey that
families in Zambia are okay with a patient’s death. In fact, the grief rituals
here involve wailing, screaming, and falling to the ground at the patient’s bedside,
which last for many minutes and can be quite traumatizing to nearby patients. <o:p></o:p></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
I really have no other word to describe the fact that
Zambians must experience a far greater proportion of preventable deaths from
infection complications of chronic illnesses, and lack of resources, than unfair
</div>
. However, it has made me wonder
if the American—or if not American, at least my personal—tendency to avoid,
resist, deny, and disbelieve the inevitability of death, may at times do more
harm than good.</div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com43tag:blogger.com,1999:blog-5422521112614604323.post-25257739365283755522020-04-06T11:54:00.000-04:002020-04-08T10:07:56.995-04:00Family Ties: Reflections on a Clinical Rotation in Lusaka, Zambia<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em; text-align: left;">
</div>
<br />
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
Katie Holroyd, M.D. </div>
<div class="MsoNormal">
Partners MGH/BWH Neurology resident, </div>
<div class="MsoNormal">
PGY3<o:p></o:p></div>
<div class="MsoNormal">
12/09/2019</div>
<div class="MsoNormal">
<span style="font-family: inherit;"><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: inherit;">Lets talk about family. I grew up an only child in the small
town of Athens, Ohio. I have no siblings, and despite having five aunts and
uncles, I also have no cousins. While I love my parents very much, this often
made for extremely boring Thanksgiving dinners growing up, in which I was the
only human under the age of 60 in the room. My mother, having cared for her
mother who passed away from Alzheimer’s disease, has told me on numerous
occasions that she does not want to ever be a burden to me, and to “put them in
a home” at the first sign of ill health. While the latter statement is always tinged
with humor, I believe her underlying sentiment is true: she never wants her old
age or ill health to put limitations on my life as her only descendent. <o:p></o:p></span></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigNkjvl5_-Y8Wjp_ak40OG6kiQV_8LZdgttCG-TN8y9TrA22QXe_QaMSaSIQwMvCy3UdEl9WbJ9BEh4aqF1C_kb75pBbZlpHjqRIeizGWwLQ_PK6j0aSLAp_sitdrWvJK_vjoMDTTcMDI/s1600/Holroyd_1a.JPG" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1440" data-original-width="1440" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEigNkjvl5_-Y8Wjp_ak40OG6kiQV_8LZdgttCG-TN8y9TrA22QXe_QaMSaSIQwMvCy3UdEl9WbJ9BEh4aqF1C_kb75pBbZlpHjqRIeizGWwLQ_PK6j0aSLAp_sitdrWvJK_vjoMDTTcMDI/s320/Holroyd_1a.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Katie Holroyd and Anastasia Vishnevetsky stand outside<br />
University Teaching Hospital in Lusaka, Zambia</td></tr>
</tbody></table>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: inherit;">Ok, so what does this have to do with Zambia? I traveled
here for a one-month clinical rotation in Neurology at the University Teaching
Hospital (UTH) in Lusaka, Zambia My initial underlying goals were two fold: to experience the practice
of neurology in a lower resource setting, and to increase my exposure to
neuro-infectious diseases with the goal of incorporating this into my
fellowship following residency graduation. <o:p></o:p></span></div>
<b style="mso-bidi-font-weight: normal;"><span style="font-family: inherit;">.</span></b><br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: inherit;">The wards in Zambia consist of several bays, or open walled-off
areas in one very large room. Each bay has from 8-12 beds next to each other,
invariably always at or above capacity. Almost without exception, every patient
is accompanied by a family member at all hours. While this makes for an
extremely crowded work space, I have come to find that it is absolutely
necessary in order for medical care to progress in the hospital. In the US,
family visits are for exclusively that: visiting. Families are not expected to
participate in basic care for the patient, provide supplies, or assist in obtaining
diagnostic procedures. In Zambia, families must do <i style="mso-bidi-font-style: normal;">all</i> of these things, and perform almost all of the duties that
nurses and nurses assistants do in the US. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: inherit;">At UTH, families must provide their own bedding for the
hospital, and the outside of the hospital is covered in drying laundry on any
sunny day.<b style="mso-bidi-font-weight: normal;"></b></span></div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: inherit;"><b style="mso-bidi-font-weight: normal;"></b></span></div>
<span style="font-family: inherit;">They also
provide all of the food for the patients, and bedside cabinets are filled with
fruit and bowls of nshima (the local porridge eaten with each meal). In
patients who require a nasogastric tube for feeding (which is quite a few of
the neurology patients), families are even responsible for providing,
preparing, and administering all food through the tube.<span style="mso-spacerun: yes;"> </span>In order to provide this 24/7 care, families
often roll out mats and sleep next to their family in the hospital, or even on
the concrete pathways outside of the building. <o:p></o:p></span><br />
<div style="text-align: right;">
</div>
<div class="MsoNormal">
<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizVg-vjpuojBDn4LwEErxehauJtvuYgtiPJ3C0oYbm0lVOc873WiePw4Uh8pAhlvaWTsSHhNKZBgdb9LNFnR14dGmisp07Xp37toL241AGh-rUaIvP1nKloB3o6Unxp-G91zkz9seRZm0/s1600/Holroyd_1b.jpeg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1200" data-original-width="1600" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEizVg-vjpuojBDn4LwEErxehauJtvuYgtiPJ3C0oYbm0lVOc873WiePw4Uh8pAhlvaWTsSHhNKZBgdb9LNFnR14dGmisp07Xp37toL241AGh-rUaIvP1nKloB3o6Unxp-G91zkz9seRZm0/s320/Holroyd_1b.jpeg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Laundry hangs out to dry at the Hospital. Patients' Families must<br />
supply and clean all of their own clothing and bedding. </td></tr>
</tbody></table>
<div class="MsoNormal">
<span style="font-family: inherit;">In addition, with the computer-less system here, families
are often required to walk to the laboratory to request printed test results,
travel to radiology to request disks of CT scans, or go to an outside pharmacy
to purchase medical supplies such as the aforementioned nasogastric tubes. While
some medications are free for families in the hospital, the hospital pharmacy
has a much smaller selection of medications than are available at private
pharmacies. Imagine my horror as a neurologist when I learned that the hospital
was out of aspirin during my first week here! As a result, many of the
medications we prescribe (from vitamins to blood pressure medications) are
dependent on families to travel to an outside pharmacy and pay to purchase the
medications and bring them back to be administered. Similarly, the hospital lab
is often out of reagents for lab tests even as basic as electrolytes, and
families who have means are asked to manually carry tubes of blood to a private
lab to have tests performed. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: inherit;">Family members at the bedside are especially crucial for
neurology patients who are often unable to talk or move on their own. Families
are not only responsible for basic daily nursing care such as turning bedbound
patients or helping patients up to use the bathroom, but they also provide much
of the medical history during our interviews. In a culture where hospice and
care withdrawal are not accepted or discussed, families also provide all care
for patients at the end of their lives (see blog post #2 for more thoughts on
this).<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: inherit;">Finally, in a place where “long term care facilities” and
“nursing homes” or “acute rehabs” really do not exist, families often take
patients home who are completely dependent for all their needs. I have never
once had a family question how they would care for their hemiplegic, mute, or
even minimally conscious relatives at home. It is simply accepted and expected,
and families often provide very good care for these relatives at home who
return to clinic well fed and without bed sores. I now understand why many
Zambians have upwards of 7 or 8 children—without them you have no care network.
<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: inherit;">This culture does not stop with a patient’s direct family.
Rarely a patient visit goes by without the neighboring patient or their family (often
only about 1 foot away separated at best with a thin curtain) chiming in on the
history, helping with translation, or assisting in recounting lab or imaging
tests results. While in the US this would be deemed a horrifying breach of
privacy (ie HIPAA), this has resulted in many positive changes in patient care
during my time here at UTH. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: inherit;">If patients do not have family, they are often stranded at
the hospital for weeks or months relying on hospital staff to provide care that
is much less thorough than would be provided by a loved one. If they do not
have family to care for them at home, they are eventually discharged to one of
very few “hospice” facilities that exist in Lusaka. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: inherit;">I hold deep respect and admiration for the families and
patients that I have met in Zambia. Does this mean that I am going to take
leave and care for my mother 24/7 if she should be hospitalized? I think the
answer remains no, but I hope that I can bring some of the selflessness, support,
and kindness that I have seen in Zambia back to the US. <o:p></o:p></span></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com37tag:blogger.com,1999:blog-5422521112614604323.post-71898834584480055252020-04-06T11:25:00.002-04:002020-04-08T10:07:12.698-04:00Heart Failure and Cardiac Ultrasound Training in Rural Rwanda<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
<span style="font-family: inherit;">Sheila Klassen, M.D. </span></div>
<div class="MsoNormal">
<span style="mso-ansi-language: EN-US;"><span style="font-family: inherit;">Cardiovascular Disease
and Global Health Equity Fellow at Harvard Medical School<o:p></o:p></span></span></div>
<div class="MsoNormal">
<span style="mso-ansi-language: EN-US;"><span style="font-family: inherit;">PGY 5</span></span></div>
<div class="MsoNormal">
<span style="mso-ansi-language: EN-US;"><span style="font-family: inherit;">10/10/2019</span></span></div>
<br />
<br />
<div class="MsoNormal">
<span style="font-family: inherit;">As my month in rural
Rwanda draws to a close, I’ve had some opportunity to reflect on the successes
and the challenges of healthcare provision in this country. I was able to spend
4 weeks doing simplified heart failure and echocardiography training across 7
hospitals in the country. It meant a lot of time traveling and many hours on
the road, but it also gave me an appreciation of health care delivery in
Rwanda.</span></div>
<div class="MsoNormal">
<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjp_ZXF_j2yvxD7fVkWF9JlaROdfALNjqMlY73OdHxvpf4wSW_ytUqQnviGmK_gYRL3WNxmqXO9fMUY1X61wX9HTs5oSF5zfgBYBYtQuXy0TtlEK34vho7oC1z_HxK6lLTMEsJodz9QAzQ/s1600/Image+3+for+COE+blog+post.png" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><span style="font-family: inherit;"><img border="0" data-original-height="1186" data-original-width="1600" height="237" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjp_ZXF_j2yvxD7fVkWF9JlaROdfALNjqMlY73OdHxvpf4wSW_ytUqQnviGmK_gYRL3WNxmqXO9fMUY1X61wX9HTs5oSF5zfgBYBYtQuXy0TtlEK34vho7oC1z_HxK6lLTMEsJodz9QAzQ/s320/Image+3+for+COE+blog+post.png" width="320" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: inherit; font-size: small;">Giving out completion certificates after heart failure and echo<br />training course. </span></td></tr>
</tbody></table>
<div class="MsoNormal">
<span style="mso-ansi-language: EN-US;"><span style="font-family: inherit;">There is a large
emphasis on community in Rwanda which is encouraged by the government. There is
a community event called Umuganda every last Saturday of the month where
citizens are required to meet with their local communities and either perform
manual labour tasks to better their communities such as filling in potholes or
helping an older neighbor patch their leaking roof. Other Umuganda activities
include having community meetings on security or other local issues. Years ago,
the government distributed approximately 3 million cows to rural the rural
population as a way of both decreasing malnutrition and creating industry. This
has resulted in lower priced milk for Rwandans and in addition has created a
sustainable export to neighboring countries. Community members who own cows
that eventually calve are required to give away these calves to those do not
own cows at no cost. Communities often gather at church on weekends, and the
local water pumps are always overrun with children who meet daily to fill their
jugs (running water in homes is not yet available). This community engagement
could be a strength in health care delivery as community members look after
each other. There is potential for shared medical appointments where members of
the same community who have similar medical problems (diabetes, high blood
pressure) have medical appointments with healthcare providers together so that
they can both support each other and alleviate the burden on the few healthcare
providers that are in country.<o:p></o:p></span></span></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi30dt7d9JOAqarsr36SfwvnsqXzRlPSpL06jKjtV6b01KQlAxHFMwWigLDhyphenhyphenS3R0ydWrrqDbnwlJF7q3lrzFDpOkbjDUkXNdB7QyRxKShnS_49cZx7wYFxF1L04tT45K9kEwAyJ2g9jMc/s1600/Image+4+for+COE+blog+post.png" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><span style="font-family: inherit;"><img border="0" data-original-height="1217" data-original-width="1600" height="243" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi30dt7d9JOAqarsr36SfwvnsqXzRlPSpL06jKjtV6b01KQlAxHFMwWigLDhyphenhyphenS3R0ydWrrqDbnwlJF7q3lrzFDpOkbjDUkXNdB7QyRxKShnS_49cZx7wYFxF1L04tT45K9kEwAyJ2g9jMc/s320/Image+4+for+COE+blog+post.png" width="320" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: inherit; font-size: small;">One of my trainees performing an echocardiogram in a rural<br />Rwandan hospital. </span></td></tr>
</tbody></table>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-ansi-language: EN-US;"><span style="font-family: inherit;">Spending time in rural
hospitals, it was gratifying to see my trainees very capably performing cardiac
ultrasound and managing heart failure patients appropriately. They still
required support and voiced a need for ongoing mentorship but this was a big
leap from where they started, which was next-to-no skill in managing heart
failure and cardiac disease.<o:p></o:p></span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="mso-ansi-language: EN-US;"><span style="font-family: inherit;">Challenges are still
many. Limited resources, limited training opportunities, limited expertise, and
lack of infrastructure due to lack of resources still pose barriers to adequate
health provision in the country. Providers are accustomed to providing care
without resources which can make them complacent. There is a very high volume
of patients because of the level of poverty of the population and high
frequency of the socioeconomic determinants of poor health. At the same time,
there is provider scarcity. Procurement of supplies, transportation of medical
equipment, and biomedical support is all limited. Despite these challenges,
Rwanda has pulled itself from its status as a broken state and poorest country
in the world after the 1994 genocide to a growing health system with stable
infrastructure. There is a way forward. Capacity building and training as well
as continued resource support, possibly involving public private partnerships
can continue to benefit the country and improve the health of its population.
I’m glad I was able to use this travel grant to both share my cardiac knowledge
with Rwandan healthcare providers and be part of Rwanda’s rebuilding as a
country. </span></span></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com44tag:blogger.com,1999:blog-5422521112614604323.post-30077822567022985282020-03-30T13:49:00.000-04:002020-03-30T13:49:21.145-04:00Clinical Use of Ultrasound at a High Altitude Clinic in Nepal<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: inherit;"><br /></span>
<br />
<div class="MsoNormal">
<span style="font-family: inherit;">Bryan Jarrett, M.D. </span></div>
<div class="MsoNormal">
<span style="font-family: inherit;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">Wilderness Medicine Fellow, </span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">Massachusetts General Hospital
Department of Emergency Medicine<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">PGY4</span><br />
<span style="font-family: inherit;">06/29/2019</span></div>
<div class="MsoNormal">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal">
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMDu6yneZa-nez0HafgFTSBIeIYf9plQ9zLExp-1nRatJoFNVmZDZLDRouTeeRWNNLX_qqmaxYRKSQ5mY2exsG3kg590tychbDx5GhA5I6JtfNGlmckkTJ8DKf8wQ4dt5_r5ggKW3JAdM/s1600/Blog2P1%25281%2529.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1200" data-original-width="1600" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMDu6yneZa-nez0HafgFTSBIeIYf9plQ9zLExp-1nRatJoFNVmZDZLDRouTeeRWNNLX_qqmaxYRKSQ5mY2exsG3kg590tychbDx5GhA5I6JtfNGlmckkTJ8DKf8wQ4dt5_r5ggKW3JAdM/s320/Blog2P1%25281%2529.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Performing a right upper quadrant ultrasound to evaluate for<br />
biliary pathology </td></tr>
</tbody></table>
<span style="font-family: inherit;">Bedside ultrasound in the emergency department has become a
standard supplement to traditional imaging such as x-rays and CT. It is now
becoming a primary imaging modality when these more traditional methods are
unavailable, especially as we realize the breadth of pathologies ultrasound can
diagnose. I recently returned from three months working at a clinic in a remote
region of Nepal run by the Himalayan Rescue Association. Pheriche is a small
town which sits at approximately 14,000 ft altitude on the trek into the Khumbu
valley to Everest Base Camp, and sees approximately 600 to 800 patients each
Spring and Fall season. The closest small hospital is in Kunde, a town north of
Namche approximately one or two day’s walk away, and has x-ray and ultrasound
capabilities. The closest CT scanner is in Kathmandu, a few hours by helicopter
or 4 days of hiking and a plane flight away.</span></div>
<div class="MsoNormal">
<span style="font-family: inherit;"><o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">I had the privilege of bringing along a Sonosite M Turbo
ultrasound provided by their global health division as well as the new
ultra-portable Butterfly IQ handheld ultrasound. Through the use of these
ultrasounds, I was able to greatly improve clinical care and diagnostic
certainty in this remote clinic without access to other imaging modalities. <o:p></o:p></span></div>
<div class="MsoNormal">
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgAoZ-UmZUuWfwQYEfx7iEtfSZqAXNTT_40jUmK7f89QNp32qT7CJ3e_wnV2JoHB9s_P_3Tsit_DAf_qKkK_EJ6Mah2SD9HA8n1MrPrdmGokXBnmdve_4tUyGQ90CT-jgFhB1-JIbLPXL8/s1600/Blog2P2%25281%2529.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgAoZ-UmZUuWfwQYEfx7iEtfSZqAXNTT_40jUmK7f89QNp32qT7CJ3e_wnV2JoHB9s_P_3Tsit_DAf_qKkK_EJ6Mah2SD9HA8n1MrPrdmGokXBnmdve_4tUyGQ90CT-jgFhB1-JIbLPXL8/s320/Blog2P2%25281%2529.jpg" width="240" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Lung ultrasound is a very sensitive modality<br />
to detect interstitial pulmonary, such as that<br />
seen in high altitude pulmonary edema (HAPE)</td></tr>
</tbody></table>
<span style="font-family: inherit;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">Over the course of the spring 2019 season I performed 83
clinical ultrasounds on 75 patients, which represented 14.4% of our total
number of patients. Thirteen of these ultrasounds changed management, 2
improved procedures, and 48 improved diagnostic certainty by providing a useful
positive or negative result. The most common ultrasounds performed were
pulmonary or lung studies, as more than 30 percent of our patients had
respiratory tract infections. Other common modalities included cardiac
echocardiograms, obstetric, musculoskeletal, and abdominal ultrasound. As an
advocate for training in and access to this incredibly useful diagnostic tool,
it was amazing to observe its benefits in a remote environment where it really
shines. <o:p></o:p></span></div>
<span style="font-family: inherit;"><br /></span>
<br />
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxplyGMwj-mrmJVXNXvICMlPZUTsiIv8pxCIoj_Voc_iOjwVuZMEmKqJaj-aKHOvMCGD49_NDjSbefKNSXGDMmy33YpaHy9nVkKGU-n3rvB6vceru9DwdCjL5-TTzHx1uG3ZFOlwpqRiY/s1600/Blog2P3%25281%2529.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjxplyGMwj-mrmJVXNXvICMlPZUTsiIv8pxCIoj_Voc_iOjwVuZMEmKqJaj-aKHOvMCGD49_NDjSbefKNSXGDMmy33YpaHy9nVkKGU-n3rvB6vceru9DwdCjL5-TTzHx1uG3ZFOlwpqRiY/s320/Blog2P3%25281%2529.jpg" width="240" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Patient with peritonsillar abscess receiving nebulized<br />
lidocaine before drainage guided by ultrasound imaging<br />
before and afterwards. </td></tr>
</tbody></table>
<span style="font-family: inherit;">One interesting case in which ultrasound proved useful was in
a young man who came in with unilateral throat pain. He had what clinically appeared
to be a peritonsillar abscess which usually requires either needle aspiration
or incision and drainage. The major risk of this procedure is damage to the
carotid artery which lies behind the tonsils, sometimes perilously close within
a centimeter or two. Thanks to the small linear probe covered in a sterile
glove, we were able to visualize the abscess as well as the carotid, and assure
that our drainage would stay well away from this critical vessel. Granted, an
experience ear, nose, and throat surgeon would usually do this without
ultrasound guidance, but they would also have the close back-up of a nearby
operating room if anything were to go wrong, a contingency we did not have.
Ultrasound in this case made this procedure much safer for the patient and much
more comfortable for the providers, and we were able to confirm afterwards with
repeat imaging that we had removed as much as possible from the abscess. He
felt significantly better after draining 17 cc of purulent material and happily
continued towards Everest Base Camp the following day.</span><br />
<div class="MsoNormal">
<span style="font-family: inherit;"><o:p></o:p></span></div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<br />
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com36tag:blogger.com,1999:blog-5422521112614604323.post-23191714867424863572020-03-30T13:47:00.001-04:002020-03-30T13:47:44.512-04:00High Altitude Medicine - Caring for locals and trekkers at 14,000 feet in Pheriche, Nepal<div dir="ltr" style="text-align: left;" trbidi="on">
<span style="font-family: inherit;"><br /></span>
<br />
<div class="MsoNormal">
<span style="font-family: inherit;">Bryan Jarrett, M.D. </span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">Wilderness Medicine Fellow, </span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">Massachusetts General Hospital
Department of Emergency Medicine<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">PGY4</span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">06/29/2019</span></div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<span style="font-family: inherit;"><br /></span>
<br />
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJrPJAcx06C051NDnKGuZG3-rxctRFIXNGTy-rVpAqq9VqpzQW9W6aIUH6TdqRIiIrhtfufD1ayL3AM2dpocetkfT5cOUL9fzj_ZnxMUe9bd8FSO8fCMCfv8oA2Bc9f42M0VIL232MQNI/s1600/Blog1P1%25281%2529.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><span style="font-family: inherit;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJrPJAcx06C051NDnKGuZG3-rxctRFIXNGTy-rVpAqq9VqpzQW9W6aIUH6TdqRIiIrhtfufD1ayL3AM2dpocetkfT5cOUL9fzj_ZnxMUe9bd8FSO8fCMCfv8oA2Bc9f42M0VIL232MQNI/s320/Blog1P1%25281%2529.jpg" width="240" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: inherit; font-size: x-small;">The Himalayan Rescue Association Clinic in</span><br />
<span style="font-family: inherit; font-size: x-small;">Pheriche with Anna Dablam in the background</span></td></tr>
</tbody></table>
<span style="font-family: inherit;">Three months above 14,000ft at a high altitude clinic 10 km away
from Everest Base camp taking care of trekkers and the local Nepali population,
armed only with my stethoscope, an ultrasound, and my clinical training… sign
me up. My name is Bryan Jarrett, and I am a Wilderness Medicine Fellow at
Massachusetts General Hospital. Our specialty focuses on providing care in
resource-limited and remote environments, and this certainly qualified.</span><br />
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">The Himalayan Rescue Association has been providing care in
the Khumbu region since the 1970s. Their first and longest operating clinic is
in the town of Pheriche, a stop on the trek to Everest Base camp and multiple
other locations, done by approximately 25-30,000 international visitors each
season (the trekking seasons are in the Fall and Spring). In order to support
these trekkers, a large number of Nepali lodge workers and porters migrate
seasonally to these high altitude communities during these times. By the end of
almost two and a half months of clinical work, our team of three physicians and
a Nepali medic named Thaneshwar had taken care of almost 700 patients and
evacuated 27 people by helicopter for severe illnesses.</span><br />
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">The majority of our patients were Nepali (70%), and the most
common diagnoses we saw were upper respiratory tract infections (33.6%),
followed closely by acute mountain sickness (8.6%), gastroenteritis (8.3%), and
musculoskeletal complaints (6.2%),</span><br />
<div class="MsoNormal">
<span style="font-family: inherit;"><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7eiPvrjeFEmnPx4CEp0QiHZHYKHax1o6RgwAiLs-g8TSIhWXiYQ7i7YeOrf-4CUO9peEi9JOkSPsjYnQ9ikODgMe7zPnEH4tMwMDe2COU1sGaU7coRMLQtjw-YeSf5_fbd6W-CoZQlls/s1600/Blog1P2%25281%2529.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1200" data-original-width="1600" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7eiPvrjeFEmnPx4CEp0QiHZHYKHax1o6RgwAiLs-g8TSIhWXiYQ7i7YeOrf-4CUO9peEi9JOkSPsjYnQ9ikODgMe7zPnEH4tMwMDe2COU1sGaU7coRMLQtjw-YeSf5_fbd6W-CoZQlls/s320/Blog1P2%25281%2529.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Helicopter evacuation of a critical patient after a large snowstorm </td></tr>
</tbody></table>
making this experience just as much international
primary care as it was high altitude medicine. Our interesting cases were a
good mix of typical emergency medicine cases presenting in this austere
environment as well as a large number of the two severe forms of altitude
illness, high altitude pulmonary edema (HAPE) and high altitude cerebral edema
(HACE). <o:p></o:p></span></div>
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">High altitude pulmonary edema is the more common of these
two, resulting in interstitial fluid in the lungs causing shortness of breath
at rest, and in its most severe form, significant hypoxia and possibly death.
We had 22 cases of HAPE, of which the majority were Nepali, and we evacuated 13
of these by helicopter down to Lukla approximately 5000 ft below Pheriche, or
usually all the way down to Kathmandu. A normal oxygen saturation at 14,000 ft
is approximately 80-90%, but most of our patients with HAPE presented with
saturations in the 50’s with significant shortness of breath. The mainstay of
our treatment was supplemental oxygen via oxygen concentrators which we ran off
of power supplied from solar panels, and most patients improved on oxygen and
nifedipine, a medicine to decrease the blood pressure in the lungs. Thankfully,
all patients we saw were able to either ride a horse or helicopter down to lower
altitudes for a safe recovery.</span><br />
<span style="font-family: inherit;"><br /></span>
<span style="font-family: inherit;">Fewer patients presented with high altitude cerebral edema,
a condition in which the brain swells at high altitude causing confusion and
difficulty walking. All but one of these six patients were evacuated by
helicopter after treatment with oxygen and dexamethasone, a steroid shown to be
helpful in improving this swelling. Many of these patients came in being
carried by friends, horses, or porters; confused, and unable to walk on their
own.</span><br />
<div class="MsoNormal">
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; text-align: left;"><tbody>
<tr><td style="text-align: left;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiErIQgY_82m7VAI9EWZ_gvbbUfXW-wtZSuR0oAdUb2Jz0BLFTgZ0reUXGrOyFUxfQhrnw8vUKakEA2n7Es_UZFMXRr6LDvr-TubXG5XYWYl1tbuFpW-dkqwemTDgjd01VcosljZAdovgU/s1600/Blog1P3%25281%2529.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><span style="font-family: inherit;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiErIQgY_82m7VAI9EWZ_gvbbUfXW-wtZSuR0oAdUb2Jz0BLFTgZ0reUXGrOyFUxfQhrnw8vUKakEA2n7Es_UZFMXRr6LDvr-TubXG5XYWYl1tbuFpW-dkqwemTDgjd01VcosljZAdovgU/s320/Blog1P3%25281%2529.jpg" width="240" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><div style="text-align: center;">
<span style="font-family: inherit; font-size: x-small;"> A patient with HAPE, with a normal saturation </span></div>
<span style="font-family: inherit; font-size: x-small;"></span><br />
<div style="text-align: center;">
<span style="font-family: inherit; font-size: x-small;"><span style="font-family: inherit;">on supplemental oxygen, with ultrasound images </span></span></div>
<span style="font-family: inherit; font-size: x-small;">
</span>
<div style="text-align: center;">
<span style="font-family: inherit; font-size: x-small;"><span style="font-family: inherit;">of B-Lines representing the Interstitial edema in </span></span></div>
<span style="font-family: inherit; font-size: x-small;">
<div style="text-align: center;">
<span style="font-family: inherit;">his lungs</span></div>
</span></td></tr>
</tbody></table>
<span style="font-family: inherit;"></span><br />
<span style="font-family: inherit;"></span><span style="font-family: inherit;">There are very few places where one can treat young,
otherwise healthy patients with acute, potentially deadly conditions and watch
them improve over 12 to 24 hours with treatment. This was a truly special
aspect of this experience. While providing care for these unique pathologies
only found with this prevalence in a few locations around the globe was
invaluable, the true joy was providing medical care to the local population.
This was less glamorous, and provided less excitement, but ultimately greater
satisfaction. We were able to repair significant lacerations, give antibiotics
to respiratory and skin infections, and treat basic aches and pains. I will
never forget the beautiful mountains, the young patients who are still alive
because we were there to provide them with much-needed care, and the friends I
made in the process.</span></div>
<div class="MsoNormal">
<o:p></o:p></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com34tag:blogger.com,1999:blog-5422521112614604323.post-74082797121630354912019-11-19T09:38:00.000-05:002020-04-06T11:17:54.156-04:00Clinical Rotation in an Emergency Department in Kigali<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
<span style="font-family: inherit;">Lara Vogel, M.D. </span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">Resident, Harvard Affiliated Emergency Medicine Residency
MGH/BWH, </span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">PGY4<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">08/28/2019</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: inherit;">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. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijafg_x17JpDZ0as1nuVMjd6uHJLC5wYrkx2uyI91wpSuFaq1g-U1xUq82j6HK1T88_0DANWgP1FEe8XBWuEVOGaW8bm2XIQXx0g0P2vUWcLzPLx37WcWPQpXsr2Bj3th-ZXxYpu3F6Z0/s1600/002.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><span style="font-family: inherit;"><img border="0" data-original-height="320" data-original-width="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijafg_x17JpDZ0as1nuVMjd6uHJLC5wYrkx2uyI91wpSuFaq1g-U1xUq82j6HK1T88_0DANWgP1FEe8XBWuEVOGaW8bm2XIQXx0g0P2vUWcLzPLx37WcWPQpXsr2Bj3th-ZXxYpu3F6Z0/s1600/002.jpg" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: inherit; font-size: small;">Nyungwe Forest National Park</span></td></tr>
</tbody></table>
<div class="MsoNormal">
<span style="font-family: inherit;">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.</span><o:p></o:p></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com47tag:blogger.com,1999:blog-5422521112614604323.post-74327685493429085792019-09-25T08:22:00.004-04:002020-04-06T11:17:47.902-04:00Conversation as a resource in Kigali<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
<span style="font-family: inherit;">Lara Vogel, M.D. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">Resident, Harvard Affiliated Emergency Medicine Residency
MGH/BWH,<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">PGY 4</span></div>
<div class="MsoNormal">
<span style="font-family: inherit;">08/28/2019</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: inherit;">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. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgbR2kjgrPQoi2rWi9aTp_nCUlO5fQCd_zYZKxe78xyN7pwB_S9QgWOH5DpFg2VtD10VwUILg6YkAaVUQA_LyJf98LId1AhbH4qTPOWHtn1eRLF1mNBUoHqeMaoR3r5b8vL-I9cJY-dQVg/s1600/001.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><span style="font-family: inherit;"><img border="0" data-original-height="240" data-original-width="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgbR2kjgrPQoi2rWi9aTp_nCUlO5fQCd_zYZKxe78xyN7pwB_S9QgWOH5DpFg2VtD10VwUILg6YkAaVUQA_LyJf98LId1AhbH4qTPOWHtn1eRLF1mNBUoHqeMaoR3r5b8vL-I9cJY-dQVg/s1600/001.jpg" /></span></a><span style="font-family: inherit;">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.<span style="mso-spacerun: yes;"> </span>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.<o:p></o:p></span></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com1389tag:blogger.com,1999:blog-5422521112614604323.post-61012451130327158842019-06-24T12:59:00.001-04:002019-06-24T12:59:35.514-04:00Stories of Flight: Trauma and mental health among forcibly displaced and conflict-affected refugee populations in Uganda<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
<span lang="EN">Hazar H. Khidir, M.D. </span></div>
<div class="MsoNormal">
<span lang="EN">Resident in PHS Emergency Medicine Residency</span></div>
<div class="MsoNormal">
<span lang="EN">PGY 2</span></div>
<div class="MsoNormal">
<span lang="EN"><br /></span></div>
<div class="MsoNormal">
<span lang="EN">June 18, 2019</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN">“There are so many princes here” Doddy, a
community health worker in Nakivale, relayed to me. We stood under a corrugated
tin-roofed gazebo on the premises of Nakivale Health Centre Number III in
Uganda. He points to a man standing across the dusty courtyard between the
health centers wards. This man, a refugee who had lived in Nakivale for many
years, was once the son of a powerful chief in the Congo. He had a privileged
life by international standards with material wealth,<span style="mso-spacerun: yes;"> </span>a high-quality private school education,
trips to the United States as a child. Everything changed when his father died
and a rival Congolese community group seized power. He lost all his material
possessions and was forced to leave, fearing that conflict with the new
community group would result in loss of his life, too. Though he has half
siblings in the United States, he could not ask for their help. With no other
social supports, his migration took him to Nakivale. After many years alone in
the refugee camp, he turned to substance use for comfort. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQxeq0-DpSafFT_Od6BHDjgC-ETRTCZW3rZHWBcs1vcZ6HjoNC87FN7fZlYfVEKa83CerDWIuE35CK2Z84TdmYFxSUGzCqmrnVhxhQUjPLx23G2AVG5IDIMBU2hBPofL2xs_wyU745pTY/s1600/khidir+2a.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="240" data-original-width="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQxeq0-DpSafFT_Od6BHDjgC-ETRTCZW3rZHWBcs1vcZ6HjoNC87FN7fZlYfVEKa83CerDWIuE35CK2Z84TdmYFxSUGzCqmrnVhxhQUjPLx23G2AVG5IDIMBU2hBPofL2xs_wyU745pTY/s1600/khidir+2a.JPG" /></a><i><span lang="EN">I had just met Doddy a few minutes before.
He came to the health center with a kind-appearing couple that he brought for a
medical check-up</span></i><span lang="EN">. They recently made it to Nakivale in
the past year from the Democratic Republic of Congo. The couple were happily
married and had eight children. They migrated to Nakivale to escape political
violence. The husband had been kidnapped by a local rebel militia group and was
taken to the group’s secluded base in the bush. He was forced into servitude
and underwent disturbing physical and sexual violence. He managed to reunite
with his family and they all fled the DRC together. He came to the clinic
requesting HIV testing. He abstained from intimacy since reuniting with his
wife due to fears that he had contracted HIV during his assault. He recounted
each traumatic incident with complete composure and no betrayal of his emotion,
speaking to the health worker calmly and politely. Next to him, his wife wept
silently for him.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<i><span lang="EN">Doddy left for a home visit within the
settlement.</span></i><span lang="EN"> Soon after, a smiling, tall, dark-skinned
Ethiopian walked up to greet me. He informed me that he worked as an Amharic
translator at the health center. When I asked how he had come to Nakivale, he
explained that he was born in Ethiopia and belonged to the Anuak Tribe. As an
ethnic minority within Ethiopia, his tribe had endured persecution time and
again through the booms and busts of civilizations in the region, serving as
slaves during the Abyssinian Empire to freedom but second class citizenry under
a brief period of British rule to de facto servitude after the Ethiopian
government regained authority of the region. In the 1970s, when he was
relatively young, both his parents were killed during a forcible eviction of
his tribe from their land in the Gambella region of Ethiopia. He was able to
flee to South Sudan with a few of his siblings. He lived in a refugee camp in
South Sudan until four years ago when violence erupted between the South
Sudanese government and anti-governmental rebels. During an escalation in the
conflict, rebels opened fire at the refugee camp, killing a few refugees. He
made a one month and ten day journey crossing the northern Ugandan border and
traversing hundreds of miles to the southwestern region of the country to reach
Nakivale settlement. He made the journey with one of his brothers. One of his
children and few of his siblings stayed in South Sudan. Somewhere along the
journey, through an experience that I was too reluctant to inquire about, he
was separated from his daughter. He has been unable to contact or gather any
information about her since he fled South Sudan.<o:p></o:p></span></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com24tag:blogger.com,1999:blog-5422521112614604323.post-48358510530636481432019-06-24T12:58:00.001-04:002019-06-24T12:58:02.893-04:00Trauma and mental health among forcibly displaced and conflict-affected refugee populations in Uganda<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<br />
<div class="MsoNormal">
<span lang="EN">Hazar H. Khidir, M.D. </span></div>
<div class="MsoNormal">
<span lang="EN">Resident in PHS Emergency Medicine Residency </span></div>
<div class="MsoNormal">
<span lang="EN">PGY 2</span></div>
<div class="MsoNormal">
<span lang="EN"><br /></span></div>
<div class="MsoNormal">
June 18, 2019</div>
<div class="MsoNormal">
<span lang="EN"><br /></span></div>
<div class="MsoNormal">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtuBpHfI_gtn0_SeevJz2nBshcnqb7J-MOJympvSJLFo8q0kwXL6_PhF4DyQnynTPWx8-5CwCSR1ltPepH2RikguH5Z4lzaQbVibSxSg-jMnVt4cA6LTp0uVFNg9jYskJ8H8do3zBQbj8/s1600/khidir+1a.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="320" data-original-width="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgtuBpHfI_gtn0_SeevJz2nBshcnqb7J-MOJympvSJLFo8q0kwXL6_PhF4DyQnynTPWx8-5CwCSR1ltPepH2RikguH5Z4lzaQbVibSxSg-jMnVt4cA6LTp0uVFNg9jYskJ8H8do3zBQbj8/s1600/khidir+1a.JPG" /></a><span lang="EN">What makes one want to leave their home? For
refugees, it is the feeling of needing to flee from violence, poverty, and/or
persecution. This impetus<span style="mso-spacerun: yes;"> </span>is what
fundamentally distinguishes refugees from other migrants.<span style="mso-spacerun: yes;"> </span>Refugees flee whereas migrants immigrate.
Thus, the pre-migration, perimigration, and post-migration experiences of
refugees are uniquely marked by higher incidents of trauma. I understood this
from by background research on incidents of trauma and prevalence of mental
health illnesses (depression, anxiety, post-traumatic stress disorder) among
refugee populations globally. My aim in traveling to Nakivale in person was to
try to understand the forces of flight, migration experience, and the mental
health outcomes of refugees on a more individual, human level.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN">Nakivale Refugee Settlement was opened in 1958
and officially established as a settlement in 1960. Officially, based on UNHCR
(the UN Refugee Agency) figures, Nakivale hosts > 100,000 refugees from
Burundi, the Democratic Republic of Congo, Eritrea, Ethiopia, Rwanda, Somalia,
Sudan, and South Sudan. During the Burundi crisis in 2015, the population of
the settlement greatly increased and has since remained this high.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN">The settlement span across 185 km. It is at
times both sparsely populated with small clusters of modest homes scattered
across a large area of land and densely populated, informal shopping markets.
The markets are impressive in scope, with hundreds of stalls. Stalls sell food,
offer salon services, and locally manufactured goods such as metal gates,
wooden bed frames, and cultural garb.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgj5ixHsZDbj9vtx_UZ3TjzoSMSFFRTR79GdndXh31M54M8oEfDtNeZbk1PexbzPxRmS7keyC_11i-b2pUaQA2Y3SsWUE4xq-ILtcah-R6RzXcykpwGtwlnmU7zEyrTZj6dGULr8swl-40/s1600/khidir+1b.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="240" data-original-width="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgj5ixHsZDbj9vtx_UZ3TjzoSMSFFRTR79GdndXh31M54M8oEfDtNeZbk1PexbzPxRmS7keyC_11i-b2pUaQA2Y3SsWUE4xq-ILtcah-R6RzXcykpwGtwlnmU7zEyrTZj6dGULr8swl-40/s1600/khidir+1b.JPG" /></a><span lang="EN">There are several individual communities
within the settlement that are largely separated based on country of origin
(i.e. Burundi Camp, Somali camp, Ethiopian camp, “New congo”). There are one or
two camps that host an integrated community of refugees. Religion appears to be
a factor that has resulted in self-segregation of the Somali refugee community
from refugees of other nationalities.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN">There is also noticeable variation in
socioeconomic status. There are those who have established successful shops and
are relatively thriving and those who can’t afford enough food and are
dependent on World Food Program distributions. All residents of Nakivale
Settlement receive care from three clinics. These clinics off very basic
medical testing but no imaging (including chest x-rays) or other diagnostics.
The nearest referral center for the clinics is Mbarara’s University Hospital,
the second largest referral hospital in Uganda. <o:p></o:p></span></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com27tag:blogger.com,1999:blog-5422521112614604323.post-50885428349657361022019-06-07T13:48:00.000-04:002019-06-07T13:48:07.570-04:00Clinical Elective in Trauma Emergency Department at Groote Schuur Hospital, Cape Town, South Africa Part 2<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
<span style="font-family: Helvetica, sans-serif;">Kelsy
Greenwald, MD</span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "Helvetica",sans-serif; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Resident, <o:p></o:p></span><span style="font-family: Helvetica, sans-serif;">Harvard Affiliated Emergency Medicine Residency</span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "Helvetica",sans-serif; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><o:p>PGY 2</o:p></span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "Helvetica",sans-serif; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><o:p><br /></o:p></span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "Helvetica",sans-serif; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><o:p>May 30, 2019</o:p></span></div>
<div class="MsoNormal">
<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhESh75JPWmo_wHmN74s22ZkHE6Ch_0fCjaulGwRO1hfXt5Km5vrYJTrPzISN2kHVTe_c9Gkh58rhR8ux6sxtBQMF5LDppL5lgwgmDrUtW0TGGpCcBv9EsW3kkYK2vwDRPtlKwE8lF5JvQ/s1600/greenwald+2a.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="185" data-original-width="244" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhESh75JPWmo_wHmN74s22ZkHE6Ch_0fCjaulGwRO1hfXt5Km5vrYJTrPzISN2kHVTe_c9Gkh58rhR8ux6sxtBQMF5LDppL5lgwgmDrUtW0TGGpCcBv9EsW3kkYK2vwDRPtlKwE8lF5JvQ/s1600/greenwald+2a.jpg" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Bruising from a sjambok</td></tr>
</tbody></table>
<div class="MsoNormal">
<span style="color: black; font-family: "Helvetica",sans-serif; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The
busiest times at Groote Schuur Hospital are weekend nights. On one such
weekend night, we heard a bell go off, which would be a sign to everyone in the
trauma section that a patient was being brought to the resuscitation unit. When
we arrive, the EMS providers tell us this patient was involved in a community
assault. This is a form of vigilantism. Distrustful of the local police force,
a community mob will attack a person who was involved in a robbery or other
crime. Instead of calling the police, the mob (often 20 or more people,
including children) will take it upon themselves to punish the offender, often
beating him with bricks, sticks, and sjambok (whips) until his family members call
an ambulance or the police. Here you can see bruising marks from the sjambok. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "Helvetica",sans-serif; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "Helvetica",sans-serif; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: left; margin-right: 1em; text-align: left;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjhJEAgGDR0lV5L2D-UvqaEGQYybrJiLPqdwx7u5h3KryEDRiplSuCfYP5B5SGHhrwbQqzZlhllLsKvadPvLWw56LEnlWSuE7NX55jP_btB-Uz64rzUpJNtMI16B8HRk6aEMo_fR0dZIPs/s1600/greenwald+2b.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="191" data-original-width="234" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjhJEAgGDR0lV5L2D-UvqaEGQYybrJiLPqdwx7u5h3KryEDRiplSuCfYP5B5SGHhrwbQqzZlhllLsKvadPvLWw56LEnlWSuE7NX55jP_btB-Uz64rzUpJNtMI16B8HRk6aEMo_fR0dZIPs/s1600/greenwald+2b.jpg" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">The Lodox</td></tr>
</tbody></table>
<div class="MsoNormal">
<span style="color: black; font-family: "Helvetica",sans-serif; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">The
patient had multiple lacerations around his scalp, multiple skull fractures
around his occiput, bilateral hemopneumothorax, right humerus and femur
fractures, but luckily no intra-abdominal injuries. He was placed on a
special stretcher that is used to take a full body x-ray with the special x-ray
machine that is located right in the resuscitation room, the Lodox.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "Helvetica",sans-serif; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><br /></span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "Helvetica",sans-serif; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">After
receiving bilateral chest tubes, intubated, and given blood, he was stable
enough to rush to the CT scanner (3 hallways away). Rather than a mobile
ventilator, a doctor bags the patient the whole way, with
epinephrine/adrenaline and fentanyl in their pocket. Only after first
receiving a brain CT, showing a non-fatal head bleed, did the radiologist
consent to further scans of the c-spine, chest and abdomen. The patient
eventually went to the operating room with orthopedics. This was one of eight
resuscitation patients of the night. <o:p></o:p></span></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com20tag:blogger.com,1999:blog-5422521112614604323.post-61099240175183007262019-06-07T13:45:00.000-04:002019-06-07T13:48:24.504-04:00Clinical Elective in Trauma Emergency Department at Groote Schuur Hospital, Cape Town, South Africa. <div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
<span style="font-family: "helvetica" , sans-serif;">Kelsy
Greenwald, MD</span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "helvetica" , sans-serif; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Resident, Harvard Affiliated Emergency Medicine Residency<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="color: black; font-family: "helvetica" , sans-serif; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><o:p>PGY 2 </o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjfquXmZTxcKiW399ikQUcvvJqwSr5HPTmQoiPBcDSmhJ92_p2iFckDP1PPp8Rw7LhzpMu9vhv35HOdo4Xmu0zf0IimQRLNA3sbVfmSO8PgIaBZm6Hd6ELc_Kbk3t1g6TZj0o0ow68Ssik/s1600/greenwald+1a.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="295" data-original-width="396" height="238" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjfquXmZTxcKiW399ikQUcvvJqwSr5HPTmQoiPBcDSmhJ92_p2iFckDP1PPp8Rw7LhzpMu9vhv35HOdo4Xmu0zf0IimQRLNA3sbVfmSO8PgIaBZm6Hd6ELc_Kbk3t1g6TZj0o0ow68Ssik/s320/greenwald+1a.jpg" width="320" /></a><span style="color: black; font-family: "helvetica" , sans-serif; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Groote
Schuur Hospital - a hospital situated in gorgeous Cape Town, overlooking one of
the modern seven wonders of the nature. And yet, a violent area, with a
homicide rate of 62 per 100,000, and in the poorest sub-district of Khayelitsha
the rate is 120 per 100,000 people. For comparison, Detroit’s homicide
rate is 40 per 100,000. <br />
<br />
Groote Schuur Hospital is a government funded public hospital, where most
patients pay little to nothing for their care. It is a tertiary hospital and is
well respected for its trauma care. Many visiting physicians come from
around the world to train at GSH. The trauma center alone sees 1300 patients
each month, with 50 beds in total and 10 high care beds. The trauma center sees
both blunt and penetrating trauma, intentional gunshot and stab wounds and
unintentional motor vehicle accidents. The number of gunshot wounds is high,
averaging 70-80 per month. Groote Schuur Hospital is the referral site
for many of the surrounding hospitals as it is one of two hospitals in all of
Cape Town with 24 hour access to CT scanner (though it is still at least a 5
min walk/run from the resuscitation area). <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvqSfSZf4QMhqPrN0SstrOrc89ZPFO87sJjmfzW_EVVk1T5lBPgvs_Dr_w18sRkHvghr4MEyyk6kOr478BNSqIA6_tr6fAJuFrpBropu-cLW788k5YsVRl_kzIQXT2Bjj4hOaJQbhOzr8/s1600/greenwald+1b.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="306" data-original-width="408" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvqSfSZf4QMhqPrN0SstrOrc89ZPFO87sJjmfzW_EVVk1T5lBPgvs_Dr_w18sRkHvghr4MEyyk6kOr478BNSqIA6_tr6fAJuFrpBropu-cLW788k5YsVRl_kzIQXT2Bjj4hOaJQbhOzr8/s320/greenwald+1b.jpg" width="320" /></a></div>
<div class="MsoNormal">
<span style="color: black; font-family: "helvetica" , sans-serif; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">Shifts in
its trauma unit are run from 8am-6pm, and a night shift from 6pm-8am. Each
shift usually has 2-3 registrars, or residents, and 2 interns. Attendings round
with the residents at each shift change, but otherwise the registrars run the
trauma center. Most registrars work roughly 50-60 hours per week. The trauma
center is split into three sections: green (the most stable patients, left in
chairs), yellow (those that require a stretcher), and resuscitation (those that
require monitoring – codes, unstable vitals, penetrating trauma to the chest or
abdomen, or those with Glasgow Coma Scales less than 14). <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="color: black; font-family: "helvetica" , sans-serif; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";">I spent
my time doing 4 15-hour overnight shifts each week, from Thursday to Sunday,
the times the most trauma occurred. I was able to learn from these incredible
registrars who would see more trauma in one month than the residents in my home
hospital would see all year. From crash chest tubes, to open skull fractures,
hemorrhaging bleeds from stab wounds to the neck, and multiple chest and
abdomen gunshot wounds, the registrars calmly and efficiently manage it all. I
was incredibly impressed with the capabilities, knowledge, and courage of the
South African residents.</span><o:p></o:p></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com28tag:blogger.com,1999:blog-5422521112614604323.post-82525574279114666832019-06-07T13:42:00.000-04:002019-06-07T13:42:36.764-04:00Capacity Building in Rwanda<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
<span style="color: #212121; font-family: "Segoe UI", sans-serif; font-size: 11.5pt;">Jessica Crothers, MD</span></div>
<div class="MsoNormal">
<span style="color: #212121; font-family: "Segoe UI",sans-serif; font-size: 11.5pt; mso-fareast-font-family: "Times New Roman";">Fellow, Medical
Microbiology, Brigham and Women’s Hospital<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="color: #212121; font-family: "Segoe UI",sans-serif; font-size: 11.5pt; mso-fareast-font-family: "Times New Roman";">PGY7<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<o:p>May 30, 2019</o:p></div>
<div class="MsoNormal">
<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhg6Rl_Zq31NqGF34TD3dtbq8u3XDUE7zdTMS8RWsXM2CG63gUIu0z53QwV7ufBZhECNy06e9oYWXIY57vMvrstH-z0raQy22st5aAzQcClGKaF-opCN2uety-gAV4_QzwHExp2v_FGDGk/s1600/crothers+3a.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="609" data-original-width="456" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhg6Rl_Zq31NqGF34TD3dtbq8u3XDUE7zdTMS8RWsXM2CG63gUIu0z53QwV7ufBZhECNy06e9oYWXIY57vMvrstH-z0raQy22st5aAzQcClGKaF-opCN2uety-gAV4_QzwHExp2v_FGDGk/s320/crothers+3a.jpg" width="239" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Working in the Lab in Kigali, Rwanda</td></tr>
</tbody></table>
<div class="MsoNormal">
I went into medicine with all sorts of ideas about what my
career would look like, not many of them very usual. Global health,
anthropology, art therapy, women’s advocacy, integrative care, and innumerable
other things that seemed to pop up by the month. I’ve always been like that,
interested in most things that come my way.<span style="mso-spacerun: yes;">
</span>But then I started the long road of medical training and I began to meet
the neigh-sayers. Your career can’t look like that because of reimbursement.
That sounds nice, but you don’t get that much time with patients. Academic
careers won’t allow you to take that much time for international work. I began
to feel trapped by the confines of real-life medical practice, but I always
found ways to keep my secret career dreams alive.<span style="mso-spacerun: yes;"> </span>My path rambled, as they all do, and I
eventually found my way into a fellowship at BWH where I was introduced to the
COE. I began going to dinners, symposiums and even applied for a travel grant.
Through the Center I have met physicians with careers that look even more
diverse and interesting than the dreams I had been quietly keeping alive. And,
more importantly, I began to see how to make my dreams become reality.<span style="mso-spacerun: yes;"> </span>The COE serves a powerful role as connector,
facilitator and dream builder. I am incredibly grateful for the opportunities
it’s afforded me, and the people it’s brought into my world. The career I once
dreamed of is finally taking shape. <o:p></o:p></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com25tag:blogger.com,1999:blog-5422521112614604323.post-65280410524209713552019-05-23T08:05:00.000-04:002019-05-23T08:05:05.559-04:00Building mental health capacity in rural communities<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="Body">
<span style="font-family: Arial, sans-serif;">Katherine Schiavoni,
MD, MPP</span></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">Resident in Medicine
and Pediatrics<o:p></o:p></span></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">PGY-4<o:p></o:p></span></div>
<div class="Body">
<br /></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;"><o:p>May 11, 2019. </o:p></span></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;"><o:p><br /></o:p></span></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">I am nearing the end
of my one-month rotation with Compañeros en Salud / Partners in Health in Chiapas,
Mexico. As mentioned in my last post, I am working a resident mentor in several
rural community clinics in the Sierra Madre region of Chiapas state.<o:p></o:p></span></div>
<div class="Body">
<br /></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">During my month in
Chiapas, I have had the opportunity to learn more about the mental health program
developed here by Compañeros en Salud (CES). Mental illness, particularly
depression, is increasingly recognized as an equal concern in poorer areas as
it is in well-resourced settings. The World Health Organization estimates that
depression will be the leading cause of disability worldwide by 2030. CES trains
its social service year physicians (pasantes) to deliver mental health care in
the rural primary care setting. The pasantes receive training by the mental
health team, including a psychiatrist and psychologist, to deliver brief
structured interventions in the clinic using motivational interviewing and
cognitive behavioral therapy techniques. They also receive training in
pharmacotherapy and are able to initiate medications when needed.<o:p></o:p></span></div>
<div class="Body">
<br /></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">This month, I witnessed
several beautifully conducted visits for depression. In one consult, a woman in
her mid-30s presented for headaches and pain in her neck and arms. The pasante,
Alex, asked thorough questions about her physical symptoms and listened to the
ways in which the pain impacted her. After about 10 minutes, he gently asked,
"and how is your mood? Is there anything difficult going on in your life
right now?". She began to cry and discuss how her husband's alcohol use is
impacting her children, and how she feels guilty about what they have
experienced and hopeless about the future. Alex provided psychoeducation about
depression, and about the effects that trauma can have on children's behavior.
They engaged in brief motivational interviewing about problem solving
strategies and agreed to meet again, including with her children, next week. He
also prescribed an NSAID for the headaches. Upon leaving, the patient looked
visibly relieved.<o:p></o:p></span></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGGahZqjZN9JwlfVxA1OJVr_JlolWASfD0Zg9V__7kAhY9BRYAWa_Nn_aeHnZVYcGm5-c0yhS9-aCC43jOLPyoBzIvvu55EjDspmWQQXCKPEAl8xrulA2zMSnXV1fEUSVgp19XJ3qxRqw/s1600/schiavoni+2a.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="960" data-original-width="1280" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjGGahZqjZN9JwlfVxA1OJVr_JlolWASfD0Zg9V__7kAhY9BRYAWa_Nn_aeHnZVYcGm5-c0yhS9-aCC43jOLPyoBzIvvu55EjDspmWQQXCKPEAl8xrulA2zMSnXV1fEUSVgp19XJ3qxRqw/s320/schiavoni+2a.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Letrero Community</td></tr>
</tbody></table>
<div class="Body">
<br /></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">In collaboration
with the mental health team, pasantes also treat patients with schizophrenia.
Before CES began working in Chiapas, many patients with psychosis were confined
to small rooms, or chained in their homes because families had no other
options. The clinicians on the mental health team can now visit these patients
in their homes and pasantes can provide oral and injectable antipsychotics. In
one of our consults, woman in her late 20s with schizophrenia presented with
her mother for a follow up visit. The patient wore dark sunglasses and spoke at
length about her concern that there was a microchip implanted in her brain.
Despite her delusions, she has been functioning at home and able to sell foods
with her mother as part of their business. Her mother displayed a high level of
understanding about the nature of her daughter's disease. The patient was
moderately controlled on risperidone, and we made plans to coordinate with the
mental health team’s psychiatrist for further titration of her medication. Many
challenges remain, but the quality of life for patients with psychosis is
generally improving.<o:p></o:p></span></div>
<div class="Body">
<br /></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">Compañeros en Salud
is now in the process of training mental health community health workers,
called acompañantes, similar to their existing programs in chronic disease and
maternal health. The acompañantes will receive a training course in recognizing
mental health conditions, providing psychoeducation and talk therapy. They will
also follow patients longitudinally who are being treated with pharmacotherapy
by other members of the team. A large part of their role will be to help reduce
stigma and increase education about mental illness in the community. <o:p></o:p></span></div>
<div class="Body">
<br /></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">The process of
building mental health capacity is ongoing, but there have been tremendous
gains already. It has been a privilege to see the amazing work happening and to
be part of the care of patients at the community clinics.<o:p></o:p></span></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com21tag:blogger.com,1999:blog-5422521112614604323.post-91887224215890402212019-05-23T08:03:00.003-04:002019-05-23T08:03:42.423-04:00Doctor as teacher in rural Mexico<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="Body">
<span style="font-family: Arial, sans-serif;">Katherine Schiavoni,
MD, MPP</span></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">Resident in Medicine
and Pediatrics<o:p></o:p></span></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">PGY-4<o:p></o:p></span></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;"><o:p><br /></o:p></span></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;"><o:p>May 2, 2019</o:p></span></div>
<div class="Body">
<br /></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">¡Saludos! I am about
half-way through a one-month rotation with Compañeros en Salud / Partners in
Health in the rural Sierra Madre region of Chiapas, Mexico. I am fortunate to
return to Chiapas after rotating with Compañeros en Salud (CES) as a resident
mentor last year. During my rotation this year, I am visiting 3 different clinics
in the communities of Reforma, Capitán, and Letrero.<o:p></o:p></span></div>
<div class="Body">
<br /></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">I am in my final
year of medicine and pediatrics residency, and next year will be staying in
Boston to practice primary care at a community health center and do a
fellowship in population health. I am interested in social determinants of
health and caring for adults and children across the life span, particularly in
Latino communities. My away rotations in Chiapas have been a tremendous
opportunity to learn about the people and culture of this region, understand
the health care system in rural Mexico, and develop skills in delivering care
in a low resource setting. At its core, rotating with CES also provides great
learning in broad spectrum primary care.<o:p></o:p></span></div>
<div class="Body">
<br /></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">Compañeros en Salud (CES)
works collaboratively with the Mexican Ministry of Health to support 10 rural
clinics in the Sierra Madre region of Chiapas. The clinics are staffed by a
social service year physician (pasante), nurses, and community health workers
(acompañantes). The primary role of a resident is to see patients with the
pasante and to provide mentorship and teaching. CES provides additional
teaching, supervision, and clinic supplies/medications beyond what would
typically be offered in the social service year. The organization also offers
an ever-growing network of mental health, maternal health, and chronic disease
services for patients, as well as access to secondary and tertiary care through
its referral program.<o:p></o:p></span></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5EuKmy1jpWU1qpgnIOf46H4zYED2EhtqkZW-XmB5IPPPwfMSBiWn4C8hOAfB8Qqh2FCXrcJUt1GnGY_4M70kZiRZLjGhpjz1VLeVMoSaQEaIKtVl4QvtyyYBgSeL5FRHG84TsZAfhWtk/s1600/schiavoni+1a.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="960" data-original-width="1280" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5EuKmy1jpWU1qpgnIOf46H4zYED2EhtqkZW-XmB5IPPPwfMSBiWn4C8hOAfB8Qqh2FCXrcJUt1GnGY_4M70kZiRZLjGhpjz1VLeVMoSaQEaIKtVl4QvtyyYBgSeL5FRHG84TsZAfhWtk/s320/schiavoni+1a.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Sunset on the square in Reforma community </td></tr>
</tbody></table>
<div class="Body">
<br /></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">I have been
particularly impressed by the ability of pasantes to serve as teachers to their
patients and clinic communities. During our clinic consultations, we spend a
significant amount of time talking with the patient about our assessment of
their condition and proposed treatment plan. There is significant emphasis on
explaining a diagnosis in understandable terms, and relating treatments to familiar
touch points, such as taking vitamins. The pharmacy is also located in the
clinic space, and therefore pasantes can teach patients about their medications
with the actual pills they will take. Particularly for patients who cannot
read, it is very helpful to show them the pills, explain the purpose of each,
and how to take it. The visual learning seems to improve understanding and
adherence. Patients also bring back the physical boxes of medication for follow
up visits and medication reconciliation.<o:p></o:p></span></div>
<div class="Body">
<br /></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">The pasantes also
lead group visits (consultas compartidas) for chronic conditions, including
diabetes. I was able to participate in several diabetes group visits with the
pasante Irving at the Reforma clinic. One of the groups had been meeting
monthly for a year. During the groups, Irving taught about 1 topic per session
such as healthy diet, medical complications of diabetes, or myths about
medications. The patients also supported each other with suggestions about
dietary changes they had made, or reframing misconceptions. For example, it is
often believed that using Insulin will cause blindness and therefore patients
are reluctant to use it. Two of the patients in this group had been on insulin
for several months and are now doing well, which has changed the perception of
other group members and made them more amenable to using insulin if needed. It
was inspiring to watch the mutual respect and encouragement in the group.<o:p></o:p></span></div>
<div class="Body">
<br /></div>
<div class="Body">
<span style="font-family: "Arial",sans-serif;">Doctors in CES have
developed a direct role in teaching patients about chronic disease management
in a way that is appropriate to the cultural context and health literacy. I
look forward to using more of these techniques in my own clinic in Boston!<o:p></o:p></span></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com18tag:blogger.com,1999:blog-5422521112614604323.post-85182961105524349312019-05-23T08:01:00.003-04:002019-05-23T08:01:42.341-04:00Capacity Building in Rwanda. <div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
<span style="color: #212121; font-size: 11.5pt;"><span style="font-family: inherit;">Jessica Crothers, MD</span></span></div>
<div class="MsoNormal">
<span style="color: #212121; font-size: 11.5pt;"><span style="font-family: inherit;">Fellow, Medical
Microbiology, Brigham and Women’s Hospital<o:p></o:p></span></span></div>
<div class="MsoNormal">
<span style="color: #212121; font-size: 11.5pt;"><span style="font-family: inherit;">PGY7<o:p></o:p></span></span></div>
<div class="MsoNormal">
<span style="color: #212121; font-size: 11.5pt;"><span style="font-family: inherit;"><br /></span></span></div>
<div class="MsoNormal">
<span style="color: #212121; font-size: 11.5pt;"><span style="font-family: inherit;">May 22, 2019. </span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgiPhA1EWZTCx1T0i1bxU6Ug-SPpXOUIoBXjlG59jIZKA_k_10LNJ3_Sn78vVusXFAF7a2ZePKvLSw-KDoVAtjmSx-0kqNwxM_5EorpD2N11aIDw0HVgh9eelAed1d0x384zU94kKHcj6o/s1600/crothers+3a.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><span style="font-family: inherit;"><img border="0" data-original-height="608" data-original-width="455" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgiPhA1EWZTCx1T0i1bxU6Ug-SPpXOUIoBXjlG59jIZKA_k_10LNJ3_Sn78vVusXFAF7a2ZePKvLSw-KDoVAtjmSx-0kqNwxM_5EorpD2N11aIDw0HVgh9eelAed1d0x384zU94kKHcj6o/s320/crothers+3a.jpg" width="239" /></span></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: inherit;">Working in the lab in Kigali, Rwanda</span></td></tr>
</tbody></table>
<div class="MsoNormal">
<span style="font-family: inherit;">I went into medicine with all sorts of ideas about what my
career would look like, not many of them very usual. Global health,
anthropology, art therapy, women’s advocacy, integrative care, and innumerable
other things that seemed to pop up by the month. I’ve always been like that,
interested in most things that come my way.<span style="mso-spacerun: yes;">
</span>But then I started the long road of medical training and I began to meet
the neigh-sayers. Your career can’t look like that because of reimbursement.
That sounds nice, but you don’t get that much time with patients. Academic
careers won’t allow you to take that much time for international work. I began
to feel trapped by the confines of real-life medical practice, but I always
found ways to keep my secret career dreams alive.<span style="mso-spacerun: yes;"> </span>My path rambled, as they all do, and I
eventually found my way into a fellowship at BWH where I was introduced to the
COE. I began going to dinners, symposiums and even applied for a travel grant.
Through the Center I have met physicians with careers that look even more
diverse and interesting than the dreams I had been quietly keeping alive. And,
more importantly, I began to see how to make my dreams become reality.<span style="mso-spacerun: yes;"> </span>The COE serves a powerful role as connector,
facilitator and dream builder. I am incredibly grateful for the opportunities
it’s afforded me, and the people it’s brought into my world. The career I once
dreamed of is finally taking shape.</span></div>
</div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com20tag:blogger.com,1999:blog-5422521112614604323.post-68011885454445344612019-05-16T09:10:00.000-04:002019-05-16T14:48:22.837-04:00Global Health Symposium <div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
<span style="font-family: "arial" , "helvetica" , sans-serif;">Catherine A. Colaianni, M.D. </span></div>
<div class="MsoNormal">
<span style="font-family: "arial" , "helvetica" , sans-serif;">Resident in Otolaryngology </span></div>
<div class="MsoNormal">
<span style="font-family: "arial" , "helvetica" , sans-serif;">PGY 4</span></div>
<div class="MsoNormal">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "arial" , "helvetica" , sans-serif;">May 14, 2019</span></div>
<div class="MsoNormal">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "arial" , "helvetica" , sans-serif;">As an
otolaryngology resident with an interest in global surgery and ethics, I am always
on the lookout for thoughtful programming related to these topics. To that end,
I was thrilled to hear about and apply for admission to the Global Health
Symposium this October, sponsored by the Partners Center of Expertise in Global
and Humanitarian Health. I came with an intention to learn more not only about
the practicalities of designing a career serving abroad, but also to identify
specific mentors who have had success pursuing careers and research in this
arena. Therefore, in particular, the panel discussion held during the symposium
was especially useful for me. The panels were broken out by specialty, and so I
joined a group of surgeons and anesthesiologists to discuss how they had found –
or, put more accurately, designed – their career paths in global and
humanitarian health. The outcome of this discussion has changed the way that
I’m thinking about my next academic and career steps. I’m in the midst of
applying for fellowship in head and neck surgical oncology, and as a result of
the panel discussion during the Symposium, I am specifically targeting institutions
that have a history of global and humanitarian health work, as well as
longstanding teaching relationships with institutions abroad. I feel that this
will best position me to be able to contribute in meaningful ways, and to continue
to identify surgical mentors whose interests align with my own. </span></div>
<div class="MsoNormal">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh70wNRybRjjWm-UhCCLdDBa8ArXLfieEY99EZqtuVtLe2DYJ5Ho-ghzdwFCki6Ju3RHbMRkllLsCVWpcIJWKmP1Z5Bcj12L56ky4s7YR2uWqYOI0NDD4lMeLeQ2n0G2G4ypGahgqrzqn0/s1600/colaianni+1a.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><img border="0" data-original-height="1600" data-original-width="1280" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh70wNRybRjjWm-UhCCLdDBa8ArXLfieEY99EZqtuVtLe2DYJ5Ho-ghzdwFCki6Ju3RHbMRkllLsCVWpcIJWKmP1Z5Bcj12L56ky4s7YR2uWqYOI0NDD4lMeLeQ2n0G2G4ypGahgqrzqn0/s320/colaianni+1a.JPG" width="256" /></span></a><span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: "arial" , "helvetica" , sans-serif;">The symposium
was also helpful in alerting me to the existence of travel grants for which
residents are eligible. After learning about it from one of the panelists, I applied
for and received the American Academy of Otolaryngology-Head and Neck Surgery
Humanitarian Travel Award to partially fund a ten-day surgical mission trip to
Conakry, Guinea with the Mercy Ships organization. Having this funding
significantly lessened the trip’s personal financial impact that I had been
preparing for, and as a result, I am now looking into returning in the next
year or two to build on my experience. Having access to organized experiences such
as the Global Health Symposium during residency training is crucial – it has
helped me think about being creative when pursuing academic funding, making
connections early, and identifying career mentors who share my enthusiasm for
global surgery. <o:p></o:p></span></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com18tag:blogger.com,1999:blog-5422521112614604323.post-11042899041929916492019-05-16T09:02:00.000-04:002019-05-16T09:02:23.376-04:00International Clinical Elective in Palliative Care in Kampala Uganda - Part 2<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal" style="line-height: 12.65pt; mso-line-height-rule: exactly;">
<span lang="EN" style="font-family: "Arial",sans-serif; mso-ansi-language: EN; mso-fareast-font-family: Arial;">Kayla Wolofsky, M.B.B.S. </span></div>
<div class="MsoNormal" style="line-height: 12.65pt; mso-line-height-rule: exactly;">
<span style="font-family: Arial, sans-serif;">Fellow in Hospice & Palliative Care at MGH </span></div>
<div class="MsoNormal" style="line-height: 12.65pt; mso-line-height-rule: exactly;">
<span style="font-family: Arial, sans-serif;">PGY 4</span></div>
<div class="MsoNormal" style="line-height: 12.65pt; mso-line-height-rule: exactly;">
<o:p></o:p></div>
<div class="MsoNormal" style="line-height: 12.65pt; mso-line-height-rule: exactly;">
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<span style="font-family: Arial, sans-serif;">May 10, 2019. </span><span style="font-family: Arial, sans-serif;"> </span></div>
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<span lang="EN" style="font-family: "Arial",sans-serif; mso-ansi-language: EN; mso-fareast-font-family: Arial;">Everyday at Massachusetts General Hospital we see people
who are suffering and terminally ill. I was recently asked to reflect what made
providing palliative care in Uganda different and at times more morally
distressing. This question is best answered by reflecting on my last two weeks
in Uganda. </span><o:p></o:p></div>
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<span lang="EN" style="font-family: "Arial",sans-serif; mso-ansi-language: EN; mso-fareast-font-family: Arial;">During the second half of my elective I had the privilege
of visiting patients in their home and providing palliative care. I worked with
Hospice Africa Uganda (HAU) visiting patients in their homes in Kampala and the
surrounding area. I later spent time in Naggalama, a small town in the central
region of Uganda, working with nurses and nursing assistants at the St. Francis
Naggalama Hospital visiting patients in their villages. It was such a privilege
to be invited into the homes of these patients and their families.</span><o:p></o:p></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAVTPn37NiQ2FwBz8gVjGZnOcbC9y0ZH5jBbUdAWLVo5sZgeBGGZNs_FapogQ702jfnE1SyRIzctXXcOjkAglLaNXXpezQY1swvoQw3nQlQJvoXc9nOjPi4sI5NZ_XhJry0F75rvaQnVs/s1600/wolofsky+2a.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="640" data-original-width="640" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhAVTPn37NiQ2FwBz8gVjGZnOcbC9y0ZH5jBbUdAWLVo5sZgeBGGZNs_FapogQ702jfnE1SyRIzctXXcOjkAglLaNXXpezQY1swvoQw3nQlQJvoXc9nOjPi4sI5NZ_XhJry0F75rvaQnVs/s200/wolofsky+2a.jpg" width="200" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Daily transport carrying our medications and <br />supplies for the day </td></tr>
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<span lang="EN" style="font-family: "Arial",sans-serif; mso-ansi-language: EN; mso-fareast-font-family: Arial;">At HAU our day would begin with prayer where “hymns were
sung, drums were drummed” and daily announcements were made before we tended to
some of the poorest of the poor with life limiting illnesses. The team would
then meet and discuss the patients we planned to see that day. We would all
then pile into a white van, alongside the much needed medications and supplies
and begin our long commute in Kampala traffic to bring clinical care to
patients in their homes. </span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMxeIdgFsRXTmB1EFKiDReR4c58n5DNw3Strv0ZnMgtpVTihW-EjKxiLeN5NO_1mMb5MKP2dSqVUNDsqxtGHh-Kgw4WUtcHcwdSzNAvKeot4-KiIM1iGGzZXYd7CQkX-VryEXO8aFcXPc/s1600/wolofsky+2b.JPG" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="640" data-original-width="480" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMxeIdgFsRXTmB1EFKiDReR4c58n5DNw3Strv0ZnMgtpVTihW-EjKxiLeN5NO_1mMb5MKP2dSqVUNDsqxtGHh-Kgw4WUtcHcwdSzNAvKeot4-KiIM1iGGzZXYd7CQkX-VryEXO8aFcXPc/s200/wolofsky+2b.JPG" width="150" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Beautiful drive between home <br />visits through the Countryside</td></tr>
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<span lang="EN" style="font-family: "Arial",sans-serif; mso-ansi-language: EN; mso-fareast-font-family: Arial;">In Naggalama this meant driving
along long stretches of beautiful back roads in the Ugandan countryside.</span><o:p></o:p></div>
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<span lang="EN" style="font-family: "Arial",sans-serif; mso-ansi-language: EN; mso-fareast-font-family: Arial;">During my visits we encountered complex ranges of
psychosocial problems, diseases, cancers, and very poor living conditions. Many
of the homes were made from homemade brick or mud covered with roofs made from
thatched-grass or iron. Most homes had<span style="mso-spacerun: yes;">
</span>plastic mats that covered the mud made floor or homemade rugs to protect
the hand cut wood floors. Walls were lined with beautiful fabrics and the one
large room that existed was separated by a curtain to make additional rooms.<span style="mso-spacerun: yes;"> </span>The homes were frequently decorated with
family heirlooms, biblical posters, and some even had a TV or radio.
Unfortunately, some homes were often only large enough to provide shelter and
home visits were had outside in the field on the ground or on wooden
benches.<span style="mso-spacerun: yes;"> </span></span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVt_WHGwXuIPEg1JumKRYEkCTgtVGo0UxfW6vajYuea89GZ1mKzvf35l4_WNJu1Mbk0WKbQQouq_HKyTe82pu3GU16mktGbzOlyZUacyR9h4_L0yWZyPM0VB5Tdi-kDiQv1R_t37TuYG0/s1600/wolofsky+2c.JPG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="480" data-original-width="640" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVt_WHGwXuIPEg1JumKRYEkCTgtVGo0UxfW6vajYuea89GZ1mKzvf35l4_WNJu1Mbk0WKbQQouq_HKyTe82pu3GU16mktGbzOlyZUacyR9h4_L0yWZyPM0VB5Tdi-kDiQv1R_t37TuYG0/s200/wolofsky+2c.JPG" width="200" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Home with with the team from <br />St. Francis Naggalama Hospital </td></tr>
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<span lang="EN" style="font-family: "Arial",sans-serif; mso-ansi-language: EN; mso-fareast-font-family: Arial;">There was no running water in many of these homes, and
the nearest water well for many was at least half a mile away. Many of the
patients we saw were so critically unwell they were unable to get water or food
and <span style="mso-spacerun: yes;"> </span>were very dehydrated and
malnourished on our arrival. <o:p></o:p></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgCKUDsgux-aGzNAGaNOOVlNPRbd7GU87fx6a8vi9D0vzUKzFzuNlDKLWkqNK44dd8uVKVCaG3gIaMDrzuCTJTLaqYOW0qXxcWsHF5Apkl0gK07WgQ07CQgrDsTcuWTqVbsT_QHIbxQMdg/s1600/wolofsky+2d.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="480" data-original-width="640" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgCKUDsgux-aGzNAGaNOOVlNPRbd7GU87fx6a8vi9D0vzUKzFzuNlDKLWkqNK44dd8uVKVCaG3gIaMDrzuCTJTLaqYOW0qXxcWsHF5Apkl0gK07WgQ07CQgrDsTcuWTqVbsT_QHIbxQMdg/s200/wolofsky+2d.JPG" width="200" /></a><span lang="EN" style="font-family: "Arial",sans-serif; mso-ansi-language: EN; mso-fareast-font-family: Arial;">What made this
elective challenging, was being aware that if there was better access to health
care and medications we could minimize their suffering. Despite the team's best
efforts they were limited by lack of medications or resources. However, despite
this very difficult path, where access to even the most basic medical care and
treatments are a luxury,<span style="mso-spacerun: yes;"> </span>patients, their
families and communities continued to demonstrate their resourcefulness and
continued to have a unwavering positive attitude. My past month in Uganda was
such an amazing and unforgettable experience. I am grateful for the staff,
volunteers and those that made this experience possible and to the patients who
shared their story.</span><o:p></o:p></div>
</div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com18tag:blogger.com,1999:blog-5422521112614604323.post-81932435034061702002019-05-09T10:44:00.000-04:002019-05-09T10:44:09.430-04:00Diagnosis of Mycobacterial Infections in Rwanda<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="color: #212121; font-family: "Segoe UI", sans-serif; font-size: 11.5pt;">Jessica Crothers, MD</span></div>
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<span style="color: #212121; font-family: "Segoe UI",sans-serif; font-size: 11.5pt; mso-fareast-font-family: "Times New Roman";">Fellow, Medical
Microbiology, Brigham and Women’s Hospital<o:p></o:p></span></div>
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<span style="color: #212121; font-family: "Segoe UI",sans-serif; font-size: 11.5pt; mso-fareast-font-family: "Times New Roman";">PGY 7<o:p></o:p></span></div>
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<span style="color: #212121; font-family: "Segoe UI",sans-serif; font-size: 11.5pt; mso-fareast-font-family: "Times New Roman";"><o:p>May 8, 2019</o:p></span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhUeH6rkUE1Pf-FK6kmazG-fN08Yb8mADWMPc-BdoUinoY_QbHzqVtWo9DM1hBnJSF1y6BPGCibsnxJnPYqc6qp7n5LMhat7b40qspuXw_1QZfhzEmqN7INgUhZBE-1XF2t0cdbmo3ltBo/s1600/crothers+2a.jpg" imageanchor="1" style="clear: left; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="451" data-original-width="575" height="250" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhUeH6rkUE1Pf-FK6kmazG-fN08Yb8mADWMPc-BdoUinoY_QbHzqVtWo9DM1hBnJSF1y6BPGCibsnxJnPYqc6qp7n5LMhat7b40qspuXw_1QZfhzEmqN7INgUhZBE-1XF2t0cdbmo3ltBo/s320/crothers+2a.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Entrance to Butaro Hospital in northern Rwanda</td></tr>
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<span style="color: #212121; font-family: "Segoe UI",sans-serif; font-size: 11.5pt; mso-fareast-font-family: "Times New Roman";">Tuberculosis is the
leading cause of death from a single infectious agent worldwide. The WHO
estimates that 10 million people developed active tuberculosis in 2017 and that
1.5 million of them died. Compounding these staggering statistics, <i style="mso-bidi-font-style: normal;">Mycobacterium tuberculosis</i> (MTB), the
causative organism of tuberculosis, can be one of the most challenging
diagnoses in clinical medicine. Notoriously difficult to culture, MTB often
takes 4-6 weeks to grow in laboratory conditions and false negatives are
common. Histologic visualization of the organism is similarly challenging,
requiring special stains, time and experience as infections are often
impressively pauci-bacillary and difficult to establish. Additional diagnostic
strategies have been implemented to enhance timely diagnosis and therapeutic
intervention, particularly in resource-limited settings in which patient
follow-up can be difficult. These include AFB smear review and molecular (PCR)
testing directly from patient specimens (GeneXpert, Cephied).<span style="mso-spacerun: yes;"> </span>The multimodal and time-consuming approach
needed for accurate diagnosis, often pushes physicians in high prevalence
regions towards presumptive diagnosis and treatment as an important tact for
both patient care and epidemiologic containment. <o:p></o:p></span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_sf3m_tWsN3TG2K1L6qGla3eDi-HH9eF5qg2ApK-8BJEjODv5Muw5pUsk6Tm-5DLnSvtwl2vXjsDwr2oMlLzfWgwT2xaT3NlC8s29U8WMOPjiMQNBpxSohAXx24izN3qGMH0SPs1SbtA/s1600/crothers+2b.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="433" data-original-width="575" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh_sf3m_tWsN3TG2K1L6qGla3eDi-HH9eF5qg2ApK-8BJEjODv5Muw5pUsk6Tm-5DLnSvtwl2vXjsDwr2oMlLzfWgwT2xaT3NlC8s29U8WMOPjiMQNBpxSohAXx24izN3qGMH0SPs1SbtA/s320/crothers+2b.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Land of one thousand hills, Rwanda is lush and agrarian</td></tr>
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<span style="color: #212121; font-family: "Segoe UI",sans-serif; font-size: 11.5pt; mso-fareast-font-family: "Times New Roman";">Rwanda suffers high
rates of tuberculosis, particularly in the context of HIV-infection. Diagnosis often
includes clinical assessment, PCR testing with GeneXpert, histologic evaluation
and less frequently culture, which is only available at the national reference
laboratory. Not uncommonly, surgical pathology specimens are consistent with a
tuberculosis infection, revealing granulomatous or suppurative inflammation,
but are unexpected and thus no culture/PCR or AFB smear was performed. In
illustration of this, a young woman presented to CHUK with primary infertility.
An exploratory laparotomy was performed and she was found to have bilateral
hydrosalpinx. Histology revealed diffuse granulomatous inflammation and while
MTB was suspected, it could not be confirmed. She was initiated on 9+ months of
antituberculousis therapy, no small task. In truth, she could have MTB. But she
also may not. Her disease could be due to gonorrhea, chlamydia or immunologic
dysfunction. But without the appropriate diagnostic tests, she must be treated
statistically: granulomas in a high-burden region = tuberculosis. <o:p></o:p></span></div>
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<span style="color: #212121; font-family: "Segoe UI",sans-serif; font-size: 11.5pt; mso-fareast-font-family: "Times New Roman";">As countries like
Rwanda continue to build their medical infrastructure and capacity, scenarios
like this can be focused. Without too much technical burden, special chemical
stains (AFB/Kinyoun/Ziehl-Neelsen) can be performed on surgical specimens to enhance
diagnostic precision. Visualization of acid-fast bacilli in the context of
granulomatous inflammation is much more likely to represent true tuberculosis infection
and warrant intensive therapy. To that end, we plan to help develop a protocol
and procedure for AFB staining of paraffin-embedded histologic tissue sections
in the CHUK laboratory while here in Rwanda. I brought supplies in my luggage
(which luckily didn’t result in tie-dyed clothing!) and we began staining. It
was challenging, not straightforward and of course, took ten times longer than
expected. Working in new environments with language and cultural barriers can
often be frustrating, and I felt it today, but these experiences also offer the
promise of a special kind of success. When you overcome small differences, find
common ground, and work towards a common goal, the collective success you feel
is so much greater than if it had been easy.<span style="mso-spacerun: yes;">
</span>The first day, it took us 2 hours to even start staining, just finding
the proper glass wear and reagents was challenging.<span style="mso-spacerun: yes;"> </span>But, by the end of the week, a new tool was
added to the local armamentarium.<o:p></o:p></span></div>
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<span style="color: #212121; font-family: "Segoe UI",sans-serif; font-size: 11.5pt; mso-fareast-font-family: "Times New Roman";">Of course, the disease
encountered in this particular young woman could be MTB, it could be gonorrhea,
but it could also represent a different type of mycobacterial infection; like <i style="mso-bidi-font-style: normal;">M. abcessus</i> or <i style="mso-bidi-font-style: normal;">M. chelonea</i>. Such diagnoses, however, require identification by
culture or genetic sequencing. We discussed and taught about the molecular and
culture differences that can be encountered in these infections, but test
implementation may be a task for another day!<o:p></o:p></span></div>
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</div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com14tag:blogger.com,1999:blog-5422521112614604323.post-45389595138247478482019-05-09T10:40:00.000-04:002019-05-09T10:40:56.208-04:00Capacity Building in Rwanda<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="color: #212121;"><span style="font-family: Arial, Helvetica, sans-serif;">Jessica Crothers, MD</span></span></div>
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<span style="color: #212121;"><span style="font-family: Arial, Helvetica, sans-serif;">Fellow, Medical
Microbiology, Brigham and Women’s Hospital<o:p></o:p></span></span></div>
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<span style="color: #212121;"><span style="font-family: Arial, Helvetica, sans-serif;">PGY 7<o:p></o:p></span></span></div>
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<span style="color: #212121;"><o:p><span style="font-family: Arial, Helvetica, sans-serif;">May 8, 2019</span></o:p></span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh06fJcBpqtudD6J67pu0L7mvKYyIp6utmOcV-34kZf-vYH_LhtU0eaNZyHFPzdSDtkLmLFynbv3QBar8U3EBt_5AZowBqidQiDGO1_pu8yPuVBuAa5lXDVT7GJvQhacDMBV9Bby5808Ns/s1600/crothers+1a.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="432" data-original-width="575" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh06fJcBpqtudD6J67pu0L7mvKYyIp6utmOcV-34kZf-vYH_LhtU0eaNZyHFPzdSDtkLmLFynbv3QBar8U3EBt_5AZowBqidQiDGO1_pu8yPuVBuAa5lXDVT7GJvQhacDMBV9Bby5808Ns/s320/crothers+1a.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Reviewing cases at the multiheaded microscope at CHUK in Kigali, Rwanda</td></tr>
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<span style="color: #212121;"><span style="font-family: Arial, Helvetica, sans-serif;">The plane doors open
and I step down the portable staircase onto the tarmac.<span style="mso-spacerun: yes;"> </span>The warm, humid air surrounds me. It feels
vaguely familiar, like a strange homecoming. I have never been to Rwanda, but
after 11 years of medical school, residency, and fellowship, I have once again donned
my red backpack and reentered the world. More than a decade ago, I wore this
same backpack across Asia, South America and Europe. I had wanted to step away
from the comforts, contacts, and safeties of home and see if the world would
catch me; it did. As many fellow travelers can attest to, the world has a
strange way of offering you just what you need if you are open to receiving it.
It’s not always what you think you want, or the easiest road, but the universe,
and the people in it, tend to provide to those with the faith to leap. I had
leapt and was rewarded. New friends, new ways of seeing, new experiences,
beautiful places, scary places, stories to tell. But, I had wanted to “help”,
to participate, to add to the experience of humanity, and I quickly realized
that desire was not enough. I needed something – a skill, knowledge, resources
- in order to be useful. And so I ultimately returned home and began the long,
arduous path of medical training. Now, 11 years later I return. <o:p></o:p></span></span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZ1PkH_lJfp1snBVUEbZ_QlTuwuBDBOe9XY8lXIsegwfugL4k96_Y-xqG6M9VH3szMxcvsWowhwhc2hA3ttsf3mABiwl0jOcl7z5vfimZtqaE-pYVGQkep5aeUs6TUFAuwuP7PUHo0h3A/s1600/crothers+1b.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="432" data-original-width="575" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZ1PkH_lJfp1snBVUEbZ_QlTuwuBDBOe9XY8lXIsegwfugL4k96_Y-xqG6M9VH3szMxcvsWowhwhc2hA3ttsf3mABiwl0jOcl7z5vfimZtqaE-pYVGQkep5aeUs6TUFAuwuP7PUHo0h3A/s320/crothers+1b.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Histology slides processed at CHUK laboratory </td></tr>
</tbody></table>
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<span style="color: #212121;"><span style="font-family: Arial, Helvetica, sans-serif;">Armed with new
knowledge, experience and an ever-increasing folder of power point
presentations, I come to Rwanda to help train their next generation of
pathologists. I come with my mentor, who began coming to Rwanda a decade ago (about
the same time I left the road, he began to forge the one that I now join). At
that time, the country was home to only two pathologists, both foreign-born.
Many diagnoses went un-made, specimens un-grossed, slides un-reviewed. The push
was for “tele-medicine” and international consultation, but the decision and
motivation existed to increase local capacity and a local pathology residency
training program was born. Now, 17 Rwandese pathologists practice in Rwanda! The
residency program has more than a dozen trainees. They eagerly bring us
interesting cases, hoping to confirm difficult diagnoses and proudly sharing
exciting ones. They show us new developments: a new cryostat, grossing
facility, histology capabilities. The day has come: Rwandese are providing high
quality medical care for Rwandese. <o:p></o:p></span></span></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHERRjWwelROszLRBGrCh8moz_2PTQk2fTkLlc-nT4i4MJzViGF7eQgHYmKdrmFP6H3Adx0M0emdSTRChpnLlkY6Y98_EqVHGAJ9tSBjYgMopPJiljmPMUpwtjS_XbieuFW1sC_PIRb6Y/s1600/crothers+1c.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="432" data-original-width="575" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHERRjWwelROszLRBGrCh8moz_2PTQk2fTkLlc-nT4i4MJzViGF7eQgHYmKdrmFP6H3Adx0M0emdSTRChpnLlkY6Y98_EqVHGAJ9tSBjYgMopPJiljmPMUpwtjS_XbieuFW1sC_PIRb6Y/s320/crothers+1c.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">New grossing bench at CHUK!</td></tr>
</tbody></table>
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<span style="color: #212121;"><span style="font-family: Arial, Helvetica, sans-serif;">Rwandan has suffered
more than most and its story is complicated, but the present reality is
inspiring. Ravaged by a holocaust only 25 years ago, the country has made
incredible progress in rebuilding and rebonding. The residents we teach are children
of this holocaust, having lived through it as toddlers and small children. Each
has their own story, but all are survivors. At first it seems abstract, but as
I get to know each them, it becomes real, personal, and strangely inspiring.
After so many years of slow, careful, difficult building, we are all in a place
to finally create the future we believe in.</span></span></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com17tag:blogger.com,1999:blog-5422521112614604323.post-80093803749423095682019-05-03T07:48:00.000-04:002019-05-03T07:48:11.287-04:00International Clinical Elective in Palliative Care in Kampala, Uganda Part 1<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="Normal1">
Kayla Wolofsky, MBBS</div>
<div class="Normal1">
<span lang="EN">Fellow, Palliative Care at Massachusetts General Hospital <o:p></o:p></span></div>
<div class="Normal1">
<span lang="EN">PGY 4</span></div>
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</div>
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<span lang="EN">Inequality of access to palliative care is one
of the greatest disparities in global health care. In Uganda, the provision of
palliative care services started in 1993 with the establishment of Hospice
Africa Uganda by Dr. Anne Merriman, who I had the honour of meeting on my
second day in Kampala.<o:p></o:p></span></div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijHnGPa5W4KRxzUSMz7U4B-0DJhrgEiwuylyuewfvkFoydAw4a_oSXlkImdLICfSOxEAnRAs7UiPMHJ0ZFH01lA19-TykQj3b1AiOHn9Rabjv1ayFu7ZKsj72FnbLXv4E2nE5jRXqlQJY/s1600/wolofsky+1a.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="640" data-original-width="640" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijHnGPa5W4KRxzUSMz7U4B-0DJhrgEiwuylyuewfvkFoydAw4a_oSXlkImdLICfSOxEAnRAs7UiPMHJ0ZFH01lA19-TykQj3b1AiOHn9Rabjv1ayFu7ZKsj72FnbLXv4E2nE5jRXqlQJY/s320/wolofsky+1a.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">A signed copy of Dr. Anne Merriman's novel "Audacity to Love: The Story of Hospice Africa: Bringing Hope and Peace for the Dying." </td></tr>
</tbody></table>
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<span lang="EN">Hospice Africa Uganda is licensed by the
National Drug Authority to import morphine powder and reconstitute it into
liquid form. This is done by Ugandan health workers who are trained to mix the
powder with water to create oral morphine ( which is then poured into recycled,
clean plastic bottles).<span style="mso-spacerun: yes;"> </span>There are two
different strengths of oral morphine available, 5mg/5ml and 50mg/5ml. <table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMeHNQvVA6wnLOG5vAeqg1XxaEZx4O52yPOWM81h8DmYJHfBRaIg5NvdVhBrW0_hVPSzlTl9KsY_2LknEfqXO7eGk5B7pXuLN6cS5vKUViNDhYK2bJnT8HurQ6S4Y-Rb4JxT0Ey0q7uPo/s1600/wolofsky+1b.JPG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="640" data-original-width="480" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgMeHNQvVA6wnLOG5vAeqg1XxaEZx4O52yPOWM81h8DmYJHfBRaIg5NvdVhBrW0_hVPSzlTl9KsY_2LknEfqXO7eGk5B7pXuLN6cS5vKUViNDhYK2bJnT8HurQ6S4Y-Rb4JxT0Ey0q7uPo/s320/wolofsky+1b.JPG" width="240" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Liquid oral morphine in two different strengths. <br />
Green: 5mg/5ml and Red 50mg/5ml.</td></tr>
</tbody></table>
</span>The International
Narcotics Control Board determines how much opioid each country can receive per
year. These estimates are based on a country's own prediction of its pain
treatment needs for the projected year using data consumed in the previous
year. Thus a country that consumed low amounts of opioids the previous year are
allocated a low of opioids the following year.</div>
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<span lang="EN">I came to Kampala to learn about symptom
management in a resource limited environment. I spent the first two weeks of my
elective on the palliative care consult service at Mulago Hospital <o:p></o:p></span></div>
<div class="Normal1">
<br /></div>
<div class="Normal1">
<span lang="EN">Coming to Uganda, I anticipated medications to
manage patient symptoms would only be medications on the essential medication
drug list. For pain management this would include: Tramadol, Codeine,
Pethidine, and Morphine (oral and IV). I knew pain management would be
challenging at times, but had hopes that with access to morphine, a medication
we take for granted in North America, pain could be better controlled with the
assistance of the palliative care team. However, despite being on the essential
medication list, there have been very limited amounts of oral morphine
available in the hospital and there is almost no IV/SC morphine. <o:p></o:p></span></div>
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<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg11yiVpiaKoejz_Iio05jyoknDxVZG47nrSmSRFbRJZl_jkl52ci_tMuLItKtxugIdEqDtmPOoQ_BZj_L0FcHvYZ95xDAZxCp02JUr74dYznVL7ugjun-AxaMLft4OmhnyNjWL7Ka_40M/s1600/wolofsky+1c.JPG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="480" data-original-width="640" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg11yiVpiaKoejz_Iio05jyoknDxVZG47nrSmSRFbRJZl_jkl52ci_tMuLItKtxugIdEqDtmPOoQ_BZj_L0FcHvYZ95xDAZxCp02JUr74dYznVL7ugjun-AxaMLft4OmhnyNjWL7Ka_40M/s320/wolofsky+1c.JPG" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Mulago National Specialised Hospital</td></tr>
</tbody></table>
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<span lang="EN">Physicians will write a prescription for
morphine and caregivers will have to go to the hospital pharmacy and fill the
prescription. There have been times where the hospital has been out of stock
and the caregiver will have to search for pharmacies that may carry morphine.
Even if the patients are fortunate enough to be able to afford the materials
necessary for <span style="mso-spacerun: yes;"> </span>IV or subcutaneous
morphine it is very unlikely they will be able to find a pharmacy that stocks
this form of morphine. It has been very challenging to see patients in extreme
pain and not be able to make them more comfortable. <o:p></o:p></span></div>
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<br /></div>
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<span lang="EN">In addition to lack of access to morphine many
patients I have managed fear morphine and despite being prescribed may not fill
the prescription. This is known as “opioidphobia”. Patients are aware of the
opioid addiction crisis in the Western world and fear becoming addicted. They
are aso very fearful of the side effects such as constipation. In addition to
the patients fear of opioids, physicians and pharmacists are very cautious and
also uncomfortable prescribing and distributing higher doses of morphine.
Pharmacists despite having a written prescription for morphine by a physician
will sometimes not administer what has been prescribed as they fear the dose is
unsafe and patients do not get what they were prescribed.<o:p></o:p></span></div>
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<br /></div>
<div class="Normal1">
<span lang="EN">It is clear that there are two significant
barriers to access to morphine.<span style="mso-spacerun: yes;"> </span>The international
drug control system and the propaganda that promotes two myths about opioids:
that they are always dangerous and instantly addictive.<o:p></o:p></span></div>
<div class="Normal1">
<br /></div>
<div class="Normal1">
<span lang="EN">Coming to Kampala, I knew there would be
challenges with symptom management and access to non-essential medications,
what I did not anticipate was the lack of access to medications on the
essential medication list and the resistance to prescribing morphine. While
enthusiasm for pain education and clinical training in developing countries has
grown, restrictions by governments and health administrations have represented
a significant barrier to practice changes.</span></div>
<br /></div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com20tag:blogger.com,1999:blog-5422521112614604323.post-27141056114287809672019-04-30T09:31:00.000-04:002019-04-30T09:31:14.808-04:00Emergency and Critical Care Capacity in Kono, Sierra Leone Part 2<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
Paul Sonenthal, MD<o:p></o:p></div>
<div class="MsoNormal">
Fellow, Pulmonary and Critical Care Medicine at Brigham and
Women’s Hospital<o:p></o:p></div>
<div class="MsoNormal">
PGY-6<o:p></o:p></div>
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<br /></div>
<div class="MsoNormal">
April 24, 2019</div>
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<br /></div>
<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCWv9fRCbn8W23KBYBvai0-MP5H60PTSJR5mv7gzG7MRjIHAhG31CF0P7u9F0_CX3AxINm9WEtg4w7m2HuKzi00XEXIUGoexFpPiRS9V2X9VnRjtNvQnYPJsh1z3oLu45c2he6wj6cEvI/s1600/sonenthal+2a.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1080" data-original-width="607" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCWv9fRCbn8W23KBYBvai0-MP5H60PTSJR5mv7gzG7MRjIHAhG31CF0P7u9F0_CX3AxINm9WEtg4w7m2HuKzi00XEXIUGoexFpPiRS9V2X9VnRjtNvQnYPJsh1z3oLu45c2he6wj6cEvI/s320/sonenthal+2a.jpg" width="179" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Delivering
a training session at <br />Koidu Government Hospital</td></tr>
</tbody></table>
<div class="MsoNormal">
<span style="font-family: "Arial",sans-serif; font-size: 11.0pt;">My
schedule in Kono District began each day at around 8:30am, when I would arrive
at Koidu Government Hospital (KGH) for the morning report. This is the meeting
where all of the significant overnight events in the hospital are reviewed by a
team of doctors, nurses, and clinical officers. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-family: "Arial",sans-serif; font-size: 11.0pt;">Following
the morning report, I would make myself available to the clinicians working
throughout the hospital to discuss particularly challenging patient cases that
fell within my specialty of Pulmonary and Critical Care Medicine. Additionally,
I held meetings with key stakeholders from different parts of the hospital and
health system to informally discuss my research project and solicit their
feedback. <o:p></o:p></span></div>
<div class="MsoNormal">
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<div class="MsoNormal">
<span style="font-family: "Arial",sans-serif; font-size: 11.0pt;">Each
afternoon, I traveled to a nearby clinic and conducted a 90 minute training
session for nurses and clinical officers on pre-selected topics, including managing
patients with shock, and initial assessment of critically ill patients.
Immediately following these sessions, I would then travel back to KGH to
conduct a second 90 minute training session for another group of nurses,
clinical officers, and physicians. <o:p></o:p></span></div>
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<span style="font-family: "Arial",sans-serif; font-size: 11.0pt;">Overall,
I thoroughly enjoyed my time in Kono District—I learned a tremendous amount and
received valuable feedback that will help with my research. Also, I am
incredibly grateful for the hospitality and support of everyone I met during
this trip. I very much look forward to getting an opportunity to return to
Sierra Leone in the near future.</span></div>
</div>
Partners Center of Expertise in Global and Humanitarian Healthhttp://www.blogger.com/profile/03424368934048146473noreply@blogger.com31