Last day at the lab!

It’s Carnival Saturday, I’m reviewing some new cases just out of curiosity as I’m wrapping up things at the lab today since the week of Carnival is a virtual shut down of all operations in Trinidad.  Sherwin, our lab technologist who’s been trying to perfect the lab’s Giemsa stain just stopped by for a chat about it.  Dr. Greaves couldn’t see neutrophillic granules on bone marrow smears, but now I think I see a few (yay methanol fixation!).  We talked about writing an SOP so the conditions don’t change then having the lab director, Dr. Greaves sign it and have it in a folder in the lab so that when another lab technologist comes on board we won’t have to reinvent the wheel.  Productive morning so far.  Dr. Greaves is taking me out to lunch as a thank you for the last two weeks of work so I’m using his office while he wraps up some grossing.

Slide session #2 at the hospital

Yesterday, I went to a hospital about 1.5 hours away from the lab and sat in 2.5 hours of traffic to get there, in rain with very little gas thus no air conditioner.  I was a soaked sweaty mess of a human walking into the Department of Pathology in San Fernando (a teaching hospital in Trinidad and Tobago), with surgeons, surgery residents, pathologists and pathology residents waiting.  I was 30 minutes late for a slide session that was scheduled at 10am and had to be back up to Dr. Greaves’ lab for another talk on molecular pathology by 1pm.  Of days I’ve had so far in Trinidad yesterday was my most exhausting but perhaps my most rewarding.  It rains for 3 hours straight here at a time by the way, and then the sun comes out, the birds sing etc etc…  But it rains and it rains hard, and it floods and people just stop on highways for no other reason than just to stop their cars.  Vent over.  My talk in San Fernando went well I think, I couldn’t answer a few of the questions.  

Because I had to, the parking lot at the teaching hospital,
parking skills are a must..

The level of sophistication despite their resource restriction at the government hospital still amazes me.  Again, as I said in the first post, this has to be one of the most fulfilling experiences I’ve had career-wise so far.

I’m going to spend next week Monday and Tuesday in Trinidad ‘playing Carnival’.  ‘Playing Carnival means putting on a costume and dancing in the streets.  I’ll be with my sister, her friends and my best friend from high school.  I ‘play’ in a band called Bliss (incredibly appropriate) on Monday and Tuesday.  But, before all that, I’m going to (voluntarily) wake up at 3am, put on the oldest t-shirt and shorts I own and go get (again, voluntarily) smothered with mud to ring in the actual Carnival celebration.  That festival is called J’ouvert (the opening). 

Steelpan (Trinidad's national instrument) rehearsals
for the big competition (Panorama).

The Carnival tradition began with French settlers in Trinidad, it’s akin to Mardi Gras in New Orleans.  It’s a release of the flesh of sorts, a sinning time before the cleansing and penance of Ash Wednesday and Lent.  The history of it all is quite interesting in Trinidad.  Prior to 1880 or thereabouts, only the aristocrats (the bourgeois) could ‘play’ Carnival on Monday and Tuesday.  In Trinidad at the time, it meant the whites.  Then came the Canboulay riots.  Freed slaves wanted to participate in the celebration of ‘mas’ and weren’t allowed to do so.  In 1880, they burnt sugar canes (hence ‘cannes brûlées' into ‘Canboulay’ - Trinidad was once a French colony so French patois words still persist) and protested in the streets for their right to play.  And play they did.  Carnival became a unifying celebration of the races and classes, where there was dancing in the streets for two days, begun by J’ouvert and ended by last lap on Tuesday.  It is an expression of the culture, the country and the people.  Your salary, your nationality, your skin color and your dance is inconsequential, as long as you have a good vibe, ‘yuh in ting’ (Trinidadian for: you’re all set).

I clearly paused the blog writing to ‘play mas’ and am finishing this up back in the cold that is Boston.  I had quite the time dancing in the streets, working in the lab, teaching the residents and everything in between.  I’m a little sad to have left.  In Trinidadian lingo, I have a little bit of a ‘tabanca’ but in some ways I’m also glad to be back to continue the collaboration, the inspiration and the good vibe.

Edible arrangement from the lab, a welcome back to the cold
from my new friends in Trinidad.

Pathology in Trinidad

Melanie Johncilla, MD
Fellow in BWH Pathology
PGY 5

I left Trinidad when I was 18 years old.  I’ve never worked in the country and since I left it’s always been a place I equate with vacation, beaches, sleeping in late and having home-cooked food.  Given my experience working with folks in other “lower resource” settings like Rwanda and Haiti, I began investigating Trinidad as one of those ‘settings’.  After a small needs based assessment, I decided to do a project that would bridge very evident knowledge and practice gaps in the country.

Showing Dr. Greaves and his house officer Kavita the
 telepathology system (the iphone is attached to the camera and 
I'm uploading it on to Ipath for outside consultation).

And here I am.  In a room in San Juan, Trinidad with blue walls and a rectangular window waiting for my turn with the one microscope (I gave it to ‘my house officer’ who is previewing some unknowns I brought from the Brigham for a teaching session later this week).  The microscope has no light filter, no 2 or 20x objective and - I’ve mentioned this already - there’s only one of them.  I need it to attach my one (donated) iphone so I can then project slide images onto my laptop and begin teaching.  It’s different from having my pick of the litter at the Brigham (objectives, filters, microscopes..) but oddly enough I love it.  I know I only have one microscope and I know that my old high school friends are leaving work early to go the bar or a carnival fete (it’s what Trinidadians call a party).  But I don’t think I’ve ever been this excited about a project before.  

The first attempt at immunohistochemistry I asked for:
Reynard and Sherwin, our lab assistants.

I could spend time on this blog regaling readers with tales of mistaken diagnoses, maltreatment based on diagnoses from the four (total!) pathologists here (the best of whom completed their training in the early 90’s and didn’t ‘believe’ in immunohistochemistry until a few years ago).  I could detail the story of  the one pathologist who diagnosed a 17cm mass in a decompensating 70 y/o man with the words “cells, staining for CD20, CD5 and CD3, clinical correlation is needed”.  But I, embarrassingly, expected that practice type.  What I did not expect is my colleague, Wesley Greaves, MD, FCAP who maintains the integrity, professionalism and knowledge base he built while at MD Anderson and Brown and then brought that essence to his practice in Trinidad.  Though severely restricted in terms of resources, his practice of pathology rivals that of the Brigham.  His staff is beyond motivated, beyond innovative and frankly, had they been based in the US with grants to apply for, courses to take, they would be among the best, if not the best.  Resource restriction is quite a thing.

The entire experience is not without its negatives (on my part).  As I sat in my one hour traffic filled commute, I momentarily lapsed into a  line of thinking probably fueled by the frustration of just getting to the lab.  Here I am, I thought, a fellow in Boston with arguably unlimited access to resources and connections and here I go, to a lab with three immunostains and one microscope, what am I doing here?  The gap is wide and after sitting here for four days and recovering from my commute, I feel my own privilege and my own entitlement and that’s also quite a thing.

The grossing station at the lab.

Other than this practice, if I could sum up Trinidad in one word, it would be hot.  Soca (calypso music with a faster beat) is playing on a laptop on our assistant’s desk as he comments on who will win the competitions that are coming up (Carnival is in two weeks and besides heavy dieting, Trinidadians turn into music critics and compare this year’s crop of costumes, ‘fetes’ and songs with the last years', somehow the last years' is always better).  Even though my accent is as strong as it’s ever been, my co-workers here still feel the need to educate me on things ‘Trini’.  I don’t know any of the new slang and tend to use the American term/pronunciation for a few things well rather than the more traditional British.  

I needed a few minutes to write this, but cases, patients and house officers await.  The practice of Pathology is different here.  It’s dynamic, engaging and developing.  And, four days in, I love it.

Challenges of Providing Neurological Care in Zambia, Part II

Challenges of Providing Neurological Care in Zambia, Part II  

In most Boston hospitals, medical emergencies come with a flurry of people in action:  A nurse or a resident placing a peripheral IV or a femoral line, monitors buzzing and beeping, pharmacists preparing medications as fast as they possibly can, and medications rapidly dripping through IV lines and into patients' veins.  At the University Teaching Hospital (“UTH”) in Lusaka, Zambia, the situation is very different. A patient in status epilepticus can go hours without receiving anti-epileptic drugs. Another patient with meningitis can go days without receiving a lumbar puncture (although, to be fair, there is significant taboo around lumbar punctures in Zambian society and Sub-Saharan Africa more broadly).  When we are reviewing mortalities during the daily morning report with residents and attending physicians, the clinical stories go something like this: “X-year old [gentleman/woman] with [heart failure/ stroke/ sepsis / disseminated TB/ fill in the blank] and no labs drawn [/ no medication given/ no imaging done] for X-days.” Physicians and nurses strive to give patients the best care and attention they possibly can, but making the “right” clinical decision for the patient does not always lead to a good outcome because of limitations in resources available. The pharmacy may be out of a medication, there may only be one dialysis spot available and 4 uremic patients to choose from, the CT scanner is down, or there simply may not be enough physician or nursing staffing bandwidth to attend to a patient’s needs. While there are many systemic causes for these problems in the Zambian health care system, the severe shortage of medical personnel has been especially very apparent to me during my time here.

With a population of 14.3 million, Zambia's patient community is enormous, yet the country has less than half the number of health-care workers required to adequately serve the population, including less than 2,000 doctors. As I mentioned in my previous post, there are three adult neurologists for the entire country. Without the development of new trainees, the neurological care in Zambia has been set up for failure. To combat this problem, Dr. Omar Siddiqi is hoping to establish the country’s first neurology residency and neurology fellowship program this coming fall.

One thing I have appreciated about my time at UTH has been taking part in different aspects of global health work. In addition to assisting with much-needed research and clinical care, I have also participated in expanding medical education and capacity building aimed at training effective practitioners. I have thoroughly enjoyed teaching medical students and junior residents, who have all been eager to learn and serve their patient population.

Some have argued that we can solve many medical problems in lower and middle-income countries (“LMICs”) like Zambia by simply purchasing the most modern technology and equipment for their hospitals. But, based on what I have witnessed at UTH so far, it’s clear to me that is not the only answer. The hospital staff must also be trained to properly use the equipment, and consistent and speedy technical support is needed to ensure the equipment is working at all times. For example, unlike some hospitals in LMICs, UTH has both a CT scanner and an MRI scanner. However, there is limited technical support, radiology support, and radiology technician support to properly and efficiently use these machines. When the CT scanner is not working, it can be down for weeks, because there is nobody locally able to fix the more complex problems that inevitably arise with the machine. Last week, a nurse walked into the MRI scanner with a metal oxygen tank, not having received MRI safety training. Furthermore, few radiologists at UTH have received formal training to read MRI studies.  Many of the MRI scans seem straightforward to me—but that is as a resident who reads MRIs on a daily basis.  Therefore, in addition to providing much-needed resources, like CT and MRI scanners, hospital staffs must also be trained properly so these additional resources can be used effectively.  I have seen the same sort of scenario unfold with regard to EEG machines. 

I am very grateful for having had the opportunity to come here this month, and to learn from Dr. Siddiqi and the physician staff at UTH. As I try to incorporate global health interests into my own career, I will surely also be incorporating the lessons I have learned here--particularly in terms of sustainability and providing adequate training.

Challenges of Providing Neurological Care in Zambia, Part I

Challenges of Providing Neurological Care in Zambia, Part I

It has been an eye-opening experience for me at the University Teaching Hospital (UTH) in Lusaka, Zambia, where I have been practicing as a neurologist this January, thanks to the MGH Center for Global Health Travel Grant. UTH is the largest hospital in Zambia with 1655 beds, a teaching hospital affiliated with the University of Zambia School of Medicine and a center for specialist referrals from across the entire country. I have been working with Dr. Omar Siddiqi from the Beth Israel Deaconess Medical Center. Dr. Siddiqi is one of three adult neurologists in the entire country (a population of 14.3 million people), and is working on enhancing TB meningitis diagnostics as well as building Zambia’s first neurology residency program. In Zambia, my workdays are strikingly similar to life as a medical resident in Boston: I see inpatient consultations, outpatients, and teach medical students.

But, there are many differences as well. For example, grieving is a very public process in Zambia. The hardest aspect of my job has been hearing the heart wrenching wailing and sobbing of patients’ family members reverberate throughout the hospital corridors, as they struggle to cope with the death of a loved one. Although painful to hear, I also remind myself of the silver lining in their grieving voices: many of the patients at UTH are surrounded by the heartwarming presence of their families and communities during their final days.  This is a strength that I have found often exists in resource-limited settings such as Zambia. Because of the high patient to nurse ratio that cannot accommodate the entire patient population at UTH, many patients have family members take turns as their primary caregiver in the hospital (“bedsiders”). These family members perform many tasks traditionally performed by nurses in the United States: from bathing to feeding to even taking serology tubes to the laboratory.  

Clinically, Zambia carries one of the largest HIV and TB burdens in the world, and the burden of CNS infectious diseases as a result of these infections is significant. Within the last two weeks, I have seen cases of cryptococcal meningitis, TB meningitis, Pott’s disease (TB in the spine), cerebellar atrophy from primary HIV infection (among many others). An equal caseload in the United States would take years to see and diagnose. I have been impressed by how fluent the residents and attending physicians at UTH are in the language of infectious diseases. I had to provide myself a crash course in neuro-infectious diseases just to keep up with the medical staff. These cases are certainly not the “bread and butter” of neurology that I have seen in Boston throughout most of my residency.

But, just as infectious diseases disproportionately impact low and middle-income countries (LMICs) like Zambia, so do non-communicable diseases (NCDs) such as stroke. In fact, nearly three-quarters of NCD deaths worldwide occur in LMICs. At UTH, I have also seen a significant number of NCD cases. While awareness of infectious diseases has increased in recent years, education about NCDs such as stroke is still low in Zambia. For example, a cab driver told me: “My friends and I are more worried about having a stroke than HIV, because we know there is treatment for HIV.” Stroke, he said, is considered to be more of an unknown disease. Furthermore, a patient asked me in clinic if there was a medicine I could prescribe to him to return strength to his muscles after a stroke. And, another patient’s daughter was brought to tears when I told her that the damage to her mother’s brain was permanent.  She was unaware of the irreversibility of damage from chronic diseases such as high blood pressure, high cholesterol, or stroke. These experiences demonstrate to me that educational and clinical efforts in global health must expand beyond infectious diseases and must include NCDs.

Despite these challenges, I have admired the Americans like Dr. Siddiqi who have brought their entire lives here to study infectious diseases and help strengthen the local medical infrastructure, just as much as I have admired the devoted Zambian doctors who work grueling hours with a significant patient work load.  I am also thankful for the travel grant and eager to continue learning for the remainder of my time here.



Enhancing clinical care in rural Mexico part 2

Sunrise over Soledad

In my final weeks working in Chiapas, Mexico with Companeros en Salud (CES), I was stationed in two communities - Laguna del Cofre and Soledad. Laguna is one of the highest elevation mountain communities that CES serves, and it's also one of the biggest and most remote. Because of the large size of the community, clinic hours often started early and ran late. The Pasante did not turn patients away. As the other Pasantes I worked with, she was similarly skilled both in creative improvisation to provide appropriate medical care - we constructed an asthma inhaler spacer out of a plastic water bottle - but also in integrating herself as a trusted and valued member of the community.

It was here that I was also able to learn much more about the various stages of coffee processing from one of the local roasters, who provided a detailed explanation of coffee processing one morning before we began in clinic. Prior to my time in Chiapas, I'd pictured the coffee that we buy from the large franchise chains in the US as coming from large ranches in whatever country the coffee was being sourced from. It wasn't until living in Chiapas that I saw how all of these villagers were largely growing coffee to sell to large coffee retailers in the US. The villagers pool their coffee together in co-ops to try and negotiate for better deals. Though they drink coffee all the time, it's generally the worst quality coffee, because it's what can't be sold to the foreign markets that pay the highest price.



Stages of coffee bean processing



In my final week in Chiapas, I was working in the community of Soledad, a beautiful village built on mountainsides of striking red clay earth. Soledad was similarly one of the more remote communities that CES served. There, I stayed in the spare room of an incredibly friendly and generous family. The father of that family had recently left to try and cross over into the US. The percent of young men who planned to travel to the US for work was striking, though most were adamant that they wanted to return to Mexico to be reunited with their families. Husbands and wives would go weeks without being able to talk to each other - either because they didn't have the funds to communicate, or often the husband was moving from one job to the next in the US. After working and saving money, many planned to return to their home communities and use that money to increase their family's standing in the social hierarchy there - buy a better store, build a nicer house, or have a little more land to grow coffee.



Enhancing clinical care in rural Mexico part 1

Since working with Companeros en Salud (CES), the branch of Partners in Health that is located in the southern Mexican state of Chiapas, I've had the fortunate opportunity to live with and teach some outstanding Mexican medical students. In their final year of schooling,  all medical students in Mexico complete a "pasantia" -- a year of  service that largely translates into these medical students being posted at rural sites where they serve as the  primary point of clinical  care. To better support pasantes in some of the poorest communities, CES has partnered with the government to provide increased support for pasantes who serve areas of exceptionally increased risk. Currently, CES serves 10 clinic sites spaced throughout the Sierra Madre, providing increased logistical support and mentorship for the Pasantes (and in turn, improving clinical care) in these communities.

In my first week of work, I was stationed in the community of Plan de Libertad, which was really two communities  - "Plan Alto," the main community where we lived and worked, and "Plan Bajo," the smaller community that was a half hour hike down the winding dirt road, through the coffee ranches and solitary homes along the way. In our first week, the Pasante and  I saw a wide variety of cases - adults and children, chronic and acute complaints, surgical, medical, psychiatric, and social. It was striking how competent and capable the Pasante was in his duties, especially for his young age of 24. Functioning essentially as the town doctor, though still not yet having graduated from medical school or having taken his consolidating, final exams, he quickly and creatively dealt with any problem that would arise.  Someone came in with the distal phalange of their finger nearly chopped off from a machete accident - he sewed it all back on. There's no finger splint -- break a tongue depressor in half and make the edge smooth with the sandpaper he keeps in his kit.

The Pasantes are also viewed as outsiders in a way, in that they often come from more urban areas of Mexico - most frequently Mexico City. As with any doctor-patient relationship, it takes time for them to build trust with the local community members. In these small mountain villages of only a few hundred people, the intimate nature of the doctor-patient bond is even more amplified by the physical and social proximity of the Pasante with the other community members. In these communities, an unsatisfied patient likely lives only a few houses down the road or may be the owner of one of the few shops in the village.



The Pasante watching over the community at sunset.



Mbarara part 2

J. Reisel

The second project that I was able to continue work on while in Mbarara, Uganda was focused on Typhoid Intestinal Perforations or TIP.  This is a project that my Ugandan Co-PI and I developed over a year ago, but have yet to be able to give the attention it needed until I was able to come back to Uganda and work on it full time. 

Typhoid Fever is a life-threatening illness endemic to many low-and middle-income countries (LMICs) due to poor sanitation and water quality. If left untreated, it progresses to perforations of the intestines, commonly referred to as TIP. There are an estimated 12-20 million cases of Salmonella Typhi infections per year, however, due to a dearth of research on this topic, this is largely modeled data that does not account for the incidence of Typhoid perforations; however, in one study from Western Uganda, nearly half of all Typhoid cases progressed to TIP and the majority of patients affected were 19 years or younger. Little progress has been made in the prevention or treatment of this infectious disease.

The best treatment of TIP is prevention. Unfortunately, barriers to preventing and treating Typhoid infections are significant in the limited-resource setting. Without proper antibiotic treatment, a bacterial infection becomes a surgical emergency. However, surgical care is not straightforward in this population. Many patients in LMICs are mal-nourished and immune suppressed.  When compounded with delays to care, such patients are systemically ill and cannot tolerate an extended surgical procedure under anesthesia. Post-operative mortality rates reported for TIP have been as high as 50% and we see many of these complications in Mbarara. Currently there is no evidenced-based standard to approach such cases of TIP, and surgical providers rely on instinct to inform their clinical decisions. Borrowing from the pediatric and emergency surgery literature, my Ugandan collaborators and I thought a “Planned Second Look” (PSL) procedure might improve outcomes, however this has yet to be studied in TIP.

PSL procedures are well supported in the literature across all income levels and age groups in cases of trauma, necrotizing enterocolitis, and aggressive infection. In a PSL, the index operation is an abbreviated laparotomy, infection control, and wash out in an unstable patient so as to minimize exposure to stressful anesthetic agents that may cause hypothermia, hypotension, and acidosis. This is followed by post-operative stabilization of the patient before undergoing the definitive procedure, usually within 24-48 hours.  The PSL also allows providers to detect progression or regression of disease on the PSL, making decisions for definitive management more judicious. In the case of this proposed study for TIP, a PSL would be indicated only in patients deemed unable to withstand a protracted surgical procedure, as determined by the Mannheim Peritonitis Index (MPI).

My month in Mbarara allowed me to really focus on this project – and as a result, our research team was able to present the project to the Department of Surgery at MRRH – and they received it well.  Everyone who has worked in the operating theaters at MRRH has seen the terrible disease progression of TIP and recognizes the need to improve our outcomes in treating these patients.  Following the Department’s approval, we were then able to develop a study protocol and develop our IRB.  It was a busy but incredibly rewarding month in Mbarara!

From Right to Left: Francis Bajunirwe, Johanna Riesel, David Mutiibwa, Martin Situma, and Francis Bajunirwe:  The Typhoid Intestinal Study Team, after finalizing our study protocol at MRRH. 

Mbarara part I

J. Reisel

My time in Mbarara in March-April of 2015 was a really exciting one.  It is always great to be back in Mbarara and to reconnect with old friends and colleagues.  

During my month in Mbarara, I was able to continue work on 2 research projects that had been paused while working on research in Boston.  I will discuss the Typhoid project in the next blog entry.  

My other research project focussed on quality and safety in the surgery department at Mbarara Regional Referral Hospital (MRRH).  In Mbarara, similar to many resource constrained settings, medical records are maintained on paper charts.  There's no distinct filing system, and no standardized forms, so the admission notes and hospital records may vary from a succinct synopsis to a detailed account.  The records are papers held together by twine strung through ripped holes, and commonly pages (documenting days worth of treatment) are lost.  Similarly charts have a habit of "walking away" either with the patient who takes it with them in a pile of their belongings after discharges, or with a resident who needs to present the patient's case at conference.  

As a result, it becomes exceedingly difficult to assess what is actually taking place on the surgical service on a large scale.  While providers most certainly know that head injuries from road traffic accidents tend to do poorly, they may not know that children under the age of 5 do the worst and therefore need additional care and focus.  Or that in the dry season, cases of Typhoid perforations spike - and therefore suspicions for this disease should be raised when I patient presents with abdominal pain and fever.  

For this reason, I got involved with a quality assurance database built by faculty from MGH and MRRH.  This database provides a secure, electronic forum for documenting all surgical cases, their hospital course, and their outcomes at MRRH, making quality assurance not only easier but feasible.  We have learned a lot from this database - but one of the most salient lessons has been quite simply how to run such a database.  One of the most important elements of this has been transitioning from "free text entry" (for example:  "Admission Diagnosis: mild head injury") to standardized coded entries (e.g. ICD-10 codes) so that areas of interest can be easily queried and assessed.  



As a spin off of this project, I worked with a Harvard Medical Student and 3 Ugandan physicians to develop a project that would allow us to better understand what happens in the operating theaters so that we can better report what equipment is needed from the government in order to provide adequate surgical care.  During my month in Mbarara we were able to put our heads together and design a research project that will allow use to identify a condensed list of ICD-9 codes for procedures performed in the operating theater.  Recognizing that the same list of procedures performed in the US and elsewhere is not necessarily applicable in the resource-constrained setting (e.g.Laparoscopic gastric bypass surgery is not in high demand in Uganda), we wanted to create a condensed list that applies to directly to a setting like MRRH, but still uses a standardized and widely applicable set of codes such that cross country and continent data can be compared.  

It has been a wonderful process working through these ideas together and to develop a project that is important to everyone involved.  I am eager to see the end result





Peter Kayima, MRRH Surgical Resident and one of our partners in the condensed operative coding project, and I at the MGH Guest House in Mbarara, Uganda.   



Queen Elizabeth Central Hospital in Blantyre, Malawi

C. Chang

Queen Elizabeth Central Hospital (QECH) in Blantyre is the largest hospital in Malawi with 1,300 beds, and is the home to the University of Malawi College of Medicine, the country's only medical school. Following my 2 weeks at Muhimbili National Hospital in Dar Es Salaam, Tanzania, I spent 2 weeks in QECH's Accident and Emergency Trauma Centre, continuing my work on assessing the acceptability and feasibility of the medical emergency documentation tool as part of an effort led by the African Federation for Emergency Medicine.

While much of the effort in global health has focused on preventive health and the management of chronic illnesses, low- and middle-income countries are facing a growing burden of emergency conditions. Where EDs exist, they frequently see large volume of patients with high acuity and mortality rates. Many EDs in national referral centers, such as the one at QECH, serve as the main entrance to the hospital, serving sickest patients transferred from all over the country, often in private vehicles due to the lack of robust ambulance systems.

Spending time in clinical settings in LMICs often highlight the need for improved data collection so that already-limited resources can be allocated optimally. EKGs, which are indispensible to Western EDs, are rarely obtained in Malawi. They are arguably of limited utility in a place where one would be more likely to find electrolyte abnormalities on EKG than myocardial infarctions. Not surprisingly, the QECH ED's expensive EKG machine spends most of its time locked up in the department chair's office, and it's the rare clinician who knows how to interpret an EKG.  Even critically ill patients are rarely intubated due to the shortage of ventilators, oxygen tanks, medications, trained staff, electricity, or all of the above, and while considerable effort is spent on securing these resources, EDs frequently find themselves lacking one or more key pieces of the puzzle, rendering the whole endeavor futile.

Experiences such as these at Muhimbili National Hospital in Tanzania and QECH in Malawi brought home the potential for a robust, systematic data collection effort to improve our understanding of the role of EDs in LMICs and optimize their operations. I am excited about the potential for this project to improve patient care and resource allocation in low-resource EDs, and look forward to sharing the results in the near future!

Muhimbili National Hospital in Dar Es Salaam, Tanzania

C.Chang

Muhimbili National Hospital (MNH) in Dar Es Salaam is Tanzania's largest public hospital and the country's leading teaching and referral center with 1,500 beds.  The emergency department (ED) at MNH opened in 2010 and is home to one of few emergency medicine residencies in Africa, and sees nearly 40,000 patients annually. As part of an effort through the African Federation for Emergency Medicine (AFEM), I spent 2 weeks in March 2015 at MNH, holding focus groups with local administrators, physicians, and nurses to assess the feasibility and acceptability of AFEM's newly developed tool for documenting medical emergencies in low-resource emergency departments (EDs).

Poor clinical documentation and medical recordkeeping are key obstacles to improving emergency care in low-resource settings since they not only obscure patients' clinical course and leads to errors and poor outcomes, but also complicates systematic data collection and evaluation. In many parts of the world, clinical encounters are documented by hand on blank pieces of paper, classically in the "SOAP" format of Subjective, Objective, Assessment, and Plans. Frequently, given the high volume of critically ill patients seen throughout the day in many EDs, clinicians spend minimal time on documentation. As a result, charts are often difficult to interpret due to haphazard documentation or indecipherable handwriting. The goal of this project was to optimize a tool designed to simplify and standardize medical documentation in order to improve individual patient care and systematic data collection that ultimately boosts our understanding of the role of emergency care in low-resource settings.

The AFEM tool was modeled after a trauma documentation system that has been adopted as the chart for all trauma patients presenting to participating EDs across Africa. As a participating ED, MNH physicians had grown accustomed to the standardized trauma form, and had helpful insights into the use of standardized documentation in emergency settings and valuable suggestions for improving the newly designed form. Many expressed that while they were initially hesitant to adopt an entirely new way of documenting clinical encounters, they found that standardized forms not only saved time and mental energy during busy ED shifts, but also served as a "checklist" of must-do tasks.  With these comments and suggestions in mind, I next headed to Blantyre, Malawi to find out how a different group of clinicians in a different clinical setting would find the AFEM tool.