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

Andrew J.B. Pisansky, M.D., M.S.
Resident in Anesthesiology at Brigham and Women's Hospital
PGY-4

February 16, 2019

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

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

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

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

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

Andrew J.B. Pisansky, M.D., M.S.
Resident in Anesthesiology at Brigham and Women's Hospital
PGY-4

February 16, 2019

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

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

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

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

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

Reflections on paper charting

Jeffrey Gluckstein, M.D. 

Resident in neurology at BWH/MGH

PGY-3

February 15, 2019

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

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

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

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

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

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

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

Neurologic Care at a Referral Hospital in Zambia

Jeffrey Gluckstein, M.D. 

Resident in neurology at BWH/MGH

PGY-3

February 15, 2019

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

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

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

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

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

Improving Access to Emergency Care in Colombia

Jeffrey Chen, M.D.
Resident in Emergency Medicine at MGH/BWH
PGY 2

February 6, 2019

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

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

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

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

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

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

Rotating in the Emergency Department at Hospital Universitario San Ignacio

Jeffrey Chen, M.D.
Resident in Emergency Medicine at MGH/BWH
PGY 2

February 6, 2019

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

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

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

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

 A destroyed car donated to the simulation center allows trainees in emergency medicine and nursing to practice field extractions and resuscitations.

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

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

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

Medicine and Dermatology in Mirebalais, Haiti – Part 2

Emily Baumrin MD

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

February 16, 2019

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

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

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

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

Medicine and Dermatology in Mirebalais, Haiti - Part 1

Emily Baumrin MD

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

February 8^th, 2019

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

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

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

 

Teaching Palliative Care in Vietnam – Part 2

Alex T.Q. Nguyen, M.D.

Clinical Fellow, Harvard Interprofessional Palliative Care Fellowship

PGY4

Teaching Palliative Care in Vietnam – Part 2

During the second week in Vietnam, in the hot and humid weather, we commuted daily to the newly open City’s Children Hospital in Binh Chanh District of Ho Chi Minh City to provide clinical training for the pediatricians who participated in the palliative care course. They were divided into smaller groups of 8-12 trainees and were asked to provide palliative care assessment for pediatric patients ranging from the NICU, PICU, to Infectious Diseases ward. As part of these exercises, they were given different cases selected by the Palliative Care Consult Service. Of note, this is the only children hospital in Vietnam with a full-scope palliative care service that includes two physicians, a nurse, a psychologist, and a social worker.

Bedside teaching by Dr. Melody Cunningham in the NICU at City's
Children Hospital in Ho Chi Minh City

The most challenging cases involved patients with neurological injuries. Again, the conversation surrounding withdrawal of life-sustaining treatments were difficult. A number of the trainees had a difficult time differentiating between withdrawing life sustaining treatments with physician-assisted death. In addition, the concept of brain death is not viewed as actual death by Vietnamese laws, and it is not uncommon for brain dead patients to have cardiac arrest while on prolonged ventilatory support.

We also had very interesting and stimulating discussions about pain assessment in pediatric patients who lack the ability of verbal communication, especially neonates. Often, when a patient becomes unresponsive, pain assessment falls off the checklist in the ICU. We discussed the importance of understanding how certain diagnoses afflict pain or discomfort to a verbally capable patient, then how to translate that understanding of pain-inducing mechanisms to provide adequate pain control for a nonverbal patient.

At the end of the course, each group of trainees had the opportunity to present their cases to the rest of the class. It was their showcasing of what they have learned from the course and what lingering questions they hope the audience could help answer. One of the themes throughout this course was the cultivation of resiliency and self-care for the physicians who are the front line providers taking care of very sick patients. Burnout is not a unique phenomenon that only occurs in the U.S. In the under-resourced Vietnamese medical system, the number of patients a doctor sees each day can easily triple that in the U.S., and the support that Vietnamese doctors receive from their supervisors and colleagues are minimal to none, especially in the community setting. Teaching this palliative course in Vietnam makes me become more appreciative of the medical training environment that I’m currently part of in the U.S., albeit its downfalls. And helping to spread the knowledge of palliative care globally is extremely gratifying as the field is still young and the needs are exponential.

Teaching Palliative Care in Vietnam – Part 1

Alex T.Q. Nguyen, M.D.

Clinical Fellow, Harvard Interprofessional Palliative Care Fellowship

PGY4

Teaching Palliative Care in Vietnam – Part 1

During the first week in Vietnam, I assisted in teaching a palliative care course to Vietnamese physicians who are pursuing their specialist training. The two-week course took place at University of Pharmacy and Medicine in Ho Chi Minh City and the specialists came from various disciplines of internal medicine and pediatrics. The first week of the course consisted of mainly didactics with some small group discussions. The topics of these didactics ranged from pain management to communication skills to ethical principles for patients with serious illnesses not limited to just cancers. Some of the course’s participants spoke English. However, many of the trainees came from provincial or rural areas, therefore, the course was taught in Vietnamese. There were faculty who was fluent in both English and Vietnamese who helped teach the course and also translate for the faculty who came from the United States and South Africa. As a bilingual Vietnamese American, I had the chance to improve my medical Vietnamese, help with translating the conversations, and participate in the discussions with the Vietnamese physicians.

What I found was most difficult was the discussion involving withdrawal of life-sustaining treatments. What governs Vietnamese medical ethics are not necessarily the same as Western medical ethics. Almost universally in Vietnam, doctors do not recommend withdrawal of life support. This is viewed as giving up. Often, life support is withdrawn when the patient’s family can no longer afford paying for the care. Many of the patients with serious illnesses do not have the financial capability to pay for prolonged hospitalization. Unfortunately, a person’s wealth dictates the type of care they receive in the medical setting. Interestingly, even though doctors in Vietnam tend to practice paternalistic medicine, and very often the patients and their families expect that type of care delivery, if the patients or families demand continuation of life support despite poor prognosis, their doctors would almost never decline.

During the small group discussions, I also learned about the lack of access to opioid medications in Vietnam. With a simple medication like morphine, which we take for granted in the US, many doctors in Vietnam feel uncomfortable with prescribing because they have never been exposed to morphine in their training. Therefore, patients can only get access to morphine if they come to a major medical center. In addition to the difficulty of obtaining a morphine prescription, now they have to find a pharmacy that can fill the prescription. For patients who live far away in a rural area, it would be impossible to receive good palliative care.

All the faculty and participants of the palliative care course

Another interesting topic that was taught in the course was grief and bereavement. Similar to medical training in the US, Vietnamese medical schools do not teach about this topic adequately. Although, culturally speaking, it is much harder for Vietnamese physicians and patients to talk about emotions and psychological distress. Besides talking about the various stages of grief, we also discussed the relevance of religion, spirituality, and psychotherapy in helping patients’ families coping with death of their loved ones. At the end of the first week of the course, each participant wrote down on a piece of paper a memory or name of a deceased patient whom they have taken care of, these papers were collected and burned at a local temple as part of the memorial service.