Clinical Rotation in an Emergency Department in Kigali

Lara Vogel, M.D. 

Resident, Harvard Affiliated Emergency Medicine Residency MGH/BWH, 

PGY4

08/28/2019

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.

Nyungwe Forest National Park

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.

Conversation as a resource in Kigali

Lara Vogel, M.D. 

Resident, Harvard Affiliated Emergency Medicine Residency MGH/BWH,

PGY 4

08/28/2019

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

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

Stories of Flight: Trauma and mental health among forcibly displaced and conflict-affected refugee populations in Uganda

Hazar H. Khidir, M.D. 

Resident in PHS Emergency Medicine Residency

PGY 2

June 18, 2019

“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,  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.

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. 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.

Doddy left for a home visit within the settlement. 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.

Trauma and mental health among forcibly displaced and conflict-affected refugee populations in Uganda

Hazar H. Khidir, M.D. 

Resident in PHS Emergency Medicine Residency 

PGY 2

June 18, 2019

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  is what fundamentally distinguishes refugees from other migrants.  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. 

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.

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.

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.

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.

Clinical Elective in Trauma Emergency Department at Groote Schuur Hospital, Cape Town, South Africa Part 2

Kelsy Greenwald, MD

Resident, Harvard Affiliated Emergency Medicine Residency

PGY 2

May 30, 2019

Bruising from a sjambok

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.

The Lodox

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.

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.

Clinical Elective in Trauma Emergency Department at Groote Schuur Hospital, Cape Town, South Africa.

Kelsy Greenwald, MD

Resident, Harvard Affiliated Emergency Medicine Residency

PGY 2 

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.

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). 

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).

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.

Capacity Building in Rwanda

Jessica Crothers, MD

Fellow, Medical Microbiology, Brigham and Women’s Hospital

PGY7

May 30, 2019

Working in the Lab in Kigali, Rwanda

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.  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.  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.  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.

Building mental health capacity in rural communities

Katherine Schiavoni, MD, MPP

Resident in Medicine and Pediatrics

PGY-4

May 11, 2019. 

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.

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.

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.

Letrero Community

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.

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.

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.

Doctor as teacher in rural Mexico

Katherine Schiavoni, MD, MPP

Resident in Medicine and Pediatrics

PGY-4

May 2, 2019

¡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.

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.

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.

Sunset on the square in Reforma community 

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.

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.

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!

Capacity Building in Rwanda.

Jessica Crothers, MD

Fellow, Medical Microbiology, Brigham and Women’s Hospital

PGY7

May 22, 2019. 

Working in the lab in Kigali, Rwanda

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.  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.  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.  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.

Global Health Symposium

Catherine A. Colaianni, M.D. 

Resident in Otolaryngology 

PGY 4

May 14, 2019

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. 

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.

International Clinical Elective in Palliative Care in Kampala Uganda - Part 2

Kayla Wolofsky, M.B.B.S. 

Fellow in Hospice & Palliative Care at MGH 

PGY 4

May 10, 2019.  

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.

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.

Daily transport carrying our  medications and
supplies for the day 

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. 

Beautiful drive between home
visits through the Countryside

In Naggalama this meant driving along long stretches of beautiful back roads in the Ugandan countryside.

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  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.  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.  

Home with with the team from
St. Francis Naggalama Hospital 

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  were very dehydrated and malnourished on our arrival.

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,  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.

Diagnosis of Mycobacterial Infections in Rwanda

Jessica Crothers, MD

Fellow, Medical Microbiology, Brigham and Women’s Hospital

PGY 7

May 8, 2019

Entrance to Butaro Hospital in northern Rwanda

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, Mycobacterium tuberculosis (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).  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.

Land of one thousand hills, Rwanda is lush and agrarian

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.

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.  The first day, it took us 2 hours to even start staining, just finding the proper glass wear and reagents was challenging.  But, by the end of the week, a new tool was added to the local armamentarium.

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 M. abcessus or M. chelonea. 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!

Capacity Building in Rwanda

Jessica Crothers, MD

Fellow, Medical Microbiology, Brigham and Women’s Hospital

PGY 7

May 8, 2019

Reviewing cases at the multiheaded microscope at CHUK in Kigali, Rwanda

The plane doors open and I step down the portable staircase onto the tarmac.  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.

Histology slides processed at CHUK laboratory 

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.

New grossing bench at CHUK!

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.

International Clinical Elective in Palliative Care in Kampala, Uganda Part 1

Kayla Wolofsky, MBBS

Fellow, Palliative Care at Massachusetts General Hospital 

PGY 4

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.

A signed copy of Dr. Anne Merriman's novel "Audacity to Love: The Story of Hospice Africa: Bringing Hope and Peace for the Dying." 

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).  There are two different strengths of oral morphine available, 5mg/5ml and 50mg/5ml. 

Liquid oral morphine in two different strengths.
Green: 5mg/5ml and Red 50mg/5ml.

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.

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 

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.

Mulago National Specialised Hospital

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  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.

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.

It is clear that there are two significant barriers to access to morphine.  The international drug control system and the propaganda that promotes two myths about opioids: that they are always dangerous and instantly addictive.

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.

Emergency and Critical Care Capacity in Kono, Sierra Leone Part 2

Paul Sonenthal, MD

Fellow, Pulmonary and Critical Care Medicine at Brigham and Women’s Hospital

PGY-6

April 24, 2019

Delivering a training session at
Koidu Government Hospital

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.

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.

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.

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.

Emergency and Critical Care Capacity in Kono, Sierra Leone

Paul Sonenthal, MD

Fellow, Pulmonary and Critical Care Medicine at Brigham and Women’s Hospital

PGY-6

April 24, 2019

Located in West Africa, Sierra Leone has suffered some of the worst health outcomes in the world. After the Ebola outbreak in 2014-2016, the health system in Sierra Leone was crippled with substantial challenges in human resources for health, due to loss of staff to Ebola and disruption of education and training programs. Efforts to rebuild the health system are underway, with continued need for improved quality of care in health facilities, particularly in public hospitals.

Most acutely sick patients in Sierra Leone are managed at district hospitals. Currently, 22 hospitals function as secondary district facilities and referral centers, managing critically ill patients (i.e. severely sick patients, with life-threatening conditions such as shock and respiratory failure) sent from the primary level. The management of these patients is critically deficient due to lack of skills among the health care workers.

View from the entrance at Wellbody Clinic

In the 2016 Annual Health System Performance Report, the Sierra Leone Ministry of Health and Sanitation (MOHS) emphasized that lack of human resources is “a major contributor to the poor health outcomes seen in Sierra Leone,” and identified “ongoing in-service training and support for all cadres of [health care workers]” as a key priority.

Kono District, in eastern Sierra Leone, has a population of 506,000 and is served by Koidu Government Hospital (KGH)—a secondary hospital with 170 beds and the only referral center in the district. At the epicenter of a brutal civil war and then Ebola, Kono district suffers from a particularly striking lack of skilled health workers, a high burden of disease and health outcomes that are routinely worse than the rest of the country.

During my fellowship in Pulmonary and Critical Care Medicine, I have collaborated with Partners In Health (PIH), to support taking initial steps towards addressing the gaps in critical care capacity at PIH-supported sites. I am currently working with a team of critical care and emergency physicians at Brigham and Women’s hospital to develop a mixed-methods survey to assess critical care capacity as well as a series of training workshops for front-line health workers on topics in Emergency and Critical Care Medicine.

With the support of the Partners Center of Expertise in Global and Humanitarian Health, I traveled to Kono District on March 23^rd, with a plan to meet with local stakeholders and solicit input on the survey instrument we are developing, as well as to provide clinical training and support at KGH and a satellite facility, Wellbody Clinic.

Reflections on Access to Care in Rural Mexico

Anna Ruman

Resident in Pediatrics at Massachusetts General Hospital

PGY2

April 10, 2019

Hello again! I’ve just returned from my one month rotation in Chiapas, Mexico with Compañeros en Salud. I’d like to briefly describe my time in Soledad, the second community in which I worked as a resident mentor to the local pasante, as well as my overall reflections on the elective.

Mountains and red soil, Soledad from above

Soledad is another small community in the predominantly coffee growing region of the Sierra Madre. It’s a little bit bigger and slightly better resourced that Matazano, which made for a slightly different teaching experience for me. Seleni, the pasante working in Soledad for the year, certainly saw more patients per day, which resulted in some later nights for us. With our limited teaching time, we chose to focus my educational workshops on asthma, bronchiolitis, and malnutrition as I had in Matazano. However, a few cases and projects proved more interesting than others. I saw my second case of varicella ever (the first I saw in Matazano), and we were able to look up both photographs and clinical guidelines since the Soledad clinic has the advantage of Internet on site. With the middle school right next door, we spent a quiet afternoon setting up a very popular condom dispenser in front of the clinic. Sadly, our most time intensive project involved an elderly man with schizophrenia who had elected to forego his depot antipsychotic injection that month. Without his medication, he became progressively more aggressive, frightening both his family and neighbors. Apparently in the past, he had required injections by force, and we were left with the conundrum of whether to ply him with food and money or to again inject by force. We visited him daily with snacks, hoping that that day might be the day that he would take his medication, but we were unsuccessful after three consecutive visits. I do not know the ultimate conclusion of this situation, but I was so impressed with Seleni’s empathy and utilization of Compañeros en Salud’s mental health team as a resource throughout this difficult case. After a week in Soledad, I returned to Jaltenango for the conclusion of my elective.

Companeros en Salud Clinic, Soledad

With respect to my overall experience, it was certainly both challenging and meaningful. Although I have worked in low-resource international settings prior (including a year living and working in Mexico after college), this opportunity represents my first actual clinical immersion abroad as a supervising physician. I’m still not sure exactly what type of pediatrician I want to be after residency (am currently deciding between primary care vs. a more acute care subspecialty), and I’m not sure that this elective helped me figure that out. However, it reminded me that global and community health will continue to be the focus of my career going forward, regardless of the level of acuity at which I plan to practice. In addition, I found many of the systems issues really engaging, i.e. how to maintain an emergency backpack in each clinic, fully stocked, with procedures about how often and when to revise it, how to ensure the contained medications and materials don’t expire, and how to balance what to include in the emergency kit based on most common complaints, typical resources/transport time (6-8 hours via car on a dirt road to the nearest pediatric hospital), and just overall resource limitation. (More to follow on this project! Will be continuing to work on this). Or the lack of access to microbiology cultures in the region, meaning that obtaining a urine culture on a simple UTI is challenging and requires extensive travel on the part of a patient, and GBS screening during pregnancy is absolutely out of the question. Lastly, it also reminds me how much I love to teach.  I’m already using some of the techniques that I practiced in Matazano back on the pedi wards at MGH. For me, education will certainly comprise a significant chunk of my career focus going forward.

One final reflection: I’m also really fascinated by the intersection between education and typical development for children in low resource settings. Compañeros en Salud is currently launching an infant development/stimulation program for typically developing infants in its target communities. I love the idea, and I wonder what’s next. What does it mean that most children from these rural communities attend school fewer hours per week than recommended? How does that impact their development and, from a bigger picture perspective, their ultimate educational and economic opportunities? For the well child, how can we optimize their opportunity for success? How do we take the next step? Again, the bigger questions of the role of healthcare vs. medicine vs. public health – those of interdisciplinary development - we probably won’t be able to answer today, but I hope that someday I will be able to help answer these and many more for some of the most vulnerable families and children, both domestically and abroad.

Thank you for reading and to the Centers of Expertise in Global and Community Health as well as the Massachusetts Medical Society for their grant support of this project.