See One, Do One, Teach One in Mirebalais, Haiti

Oren Johnson, MD 

Resident in Diagnostic Radiology at Brigham and Women’s Hospital 

PGY 5

See One, Do One, Teach One in Mirebalais, Haiti

My days have been busy. The clinical teams are not used to having radiologists on site, and have been keen to involve us in their clinical work.  At morning report, we were asked by the medicine team to ultrasound one of their patients for lower extremity deep venous thrombosis (DVT).  The patient had presented with sudden onset leg pain and swelling. She had been started on anticoagulation, but the team wanted to make sure she had a DVT. The patient lived hours away and logistically checking her INR would be nearly impossible.

Hopital Universitaire de Mirebalais Resident Learn to Perform DVT Ultrasound

I met the residents in the Women’s Ward around 5pm. When I got there, they had the ultrasound machine setup for me, or at least, that’s what I thought when I saw the machine near the patient. I picked up the ultrasound probe to start and scan the patient’s leg, when I was quickly stopped. The resident asked if he could scan. He wanted to show me his understanding of DVT ultrasound and asked me to correct him as he proceeded. This proved to be a great lesson for me on many fronts.

First, there was no point in me just doing the ultrasound without building his capacity to perform/interpret them on his own. Second, it allowed me to gauge the resident’s baseline knowledge and tailor my teaching. Third, I had no idea how to turn their machine on. The resident proceeded to scan and make a finding in the patient’s posterior calf.  He knew it wasn’t a DVT, but also knew it wasn’t normal. The patient had a ruptured Baker’s cyst, explaining her pain/swelling, and allowing them to stop anticoagulation. It was a fun finding to make, and it had immediate impact. I gave feedback on the resident’s technique, showed him how I would have scanned, and figured we could call it a day.

I was wrong. The resident then asked me if we could scan the other 3 patients on that side of the ward.  He wanted to reinforce what he learned. I was impressed with the initiative and was happy to oblige. All 3 patients were normal, but the resident improved each time on his ability to obtain the images he needed.

The next day after Morning Report, the resident asked if I would check another patient for DVT. He was pretty sure he diagnosed a popliteal DVT.  I double-checked him, and sure enough he had diagnosed a DVT. He called the other residents on the ward over and proudly showed them his finding.  I couldn’t have been happier.

Hopital Universitaire de Mirebalais Resident Performs DVT Ultrasound

 

Morning Report in Mirebalais, Haiti

Oren Johnson, MD 

Resident in Diagnostic Radiology at Brigham and Women’s Hospital

PGY 5

Morning Report in Mirebalais, Haiti 

“Education then, beyond all other devices of human origin, is the great equalizer of the conditions of men, the balance-wheel of the social machinery.” -Horace Mann

I went to Mirebalais, Haiti to work at Hôpital Universitaire de Mirebalais (HUM), primarily to teach the Internal Medicine and Emergency Medicine residents basic image interpretation. The hospital has imaging capabilities, but no radiologists on-site to interpret the studies in real time. The clinical teams are often the primary read/interpretation while they wait for a remote radiology interpretation to be completed.  Our plan was to teach as much as possible, consult on cases, and really understand the clinical landscape at HUM.

I interpret studies for HUM, while in Boston, but honestly had no context or understanding of what then happens with that information or under what clinical constraints my colleagues had in country. The Internal Medicine and Emergency Medicine programs welcomed and invited us to the Internal Medicine morning report and Emergency Medicine morning rounds.  I knew this would be my greatest opportunity to understand how medicine was practiced at HUM.

 Internal Medicine Morning Report Hopital Universitaire de Mirebalais, Haiti

Today was our first Morning Report. I sat in the resident library, more of conference/computer room, at a table that was surrounded by 30 people (residents, medical students, and attendings). My program director and I sat in anticipation of how the morning report would be run and what our role would be. I hadn’t been to a medicine morning report since my intern year, 4 years ago. The room was quiet, except for the drone of spinning fans, and the occasional goat or cow you could hear in the fields adjacent to the hospital.

Then, rather abruptly, one of the residents started to address the group with a certain degree of forced confidence in Haitian creole.  I don’t speak a word of Haitian creole, but the tone of her voice, universal signs of concealed nervousness, and the stack of patient charts that lie before her, made it clear. She was the Admitting Resident overnight, and she was tasked with presenting the newly admitted patients and their overnight management. There was a welcomed familiarity with this construct and dynamic.

This country and hospital were foreign, but I strangely felt at home in the midst of these patient discussions. The resident presented the first case, a patient with HIV that had stopped their anti-retroviral medications, and was quickly interrupted and corrected when she said the patient was “non-compliant”.  The chief of medicine opened a discussion about the difference between adherence and compliance. A topic I remember distinctly discussing as an intern at my own morning report.

Outside of Hopital Universitaire de Mirebalais, Haiti

The resident continued with the case, often getting no more than three words out before more questions were asked. What are the stages of chronic kidney disease? Do you really think this is right heart failure?  Can you interpret this EKG?  At each juncture, residents sitting at the table would pull up various articles on their devices, quoting the most recent literature. I was amazed by the intellectual curiosity, engagement, and command of this knowledge. Residents at different levels were contributing to the discussion, providing insight from articles they had recently read or were accessing at that very moment. I saw how powerful access and knowledge can be.

These discussions were spirited, and I was fortunate to have one of the residents translating the details of the conversation. I felt the attendings were challenging the residents, and the residents were rising to the occasion. It was inspiring that this level of discourse was taking place, and it was only the first patient admission being presented.

I was brought back to reality when after the first patient presentation, there was a final question posed by the chief of medicine. “So now how are you going to manage the patient...here?”  Each patient presentation boiled down to this question. These amazing residents had the entire body of medical literature at their fingertips. They knew or learning how to optimally manage their patients based on the latest evidence, and they couldn’t fully implement what they were learning. No access to a cath lab, limited access to hemodialysis, a limited formulary and lab, and patients with no financial resources to adhere to prescribed treatment, the challenges are many. It was disheartening at first to see this process.

Upon reflection, I realized how much more I was impressed by the residents and attendings. They faced the limitations of their environment head on with unwavering dedication to learn and practice medicine to the best of their ability. I would come to learn and appreciate this first-hand in my daily radiology teaching sessions.

Baseline Hospital Assessments in Rwanda

Kristin Ojomo MD

Arthur Tracy Cabot Research Fellow / Henry Ellis Warren Fellow

Center for Surgery and Public Health

Brigham and Women’s Hospital

PGY3

Baseline Hospital Assessments in Rwanda

 

My time in Rwanda is also dedicated to working with the Ministry of Health to form a National Surgical Plan. An estimated 58.7% of Rwandans currently do not have access to timely, safe, and affordable surgical and anaesthesia care. Whereas surgery has traditionally been a neglected part of health care worldwide, recent research and evidence demonstrate that surgery must become a priority in strengthening health systems. During the 2015 World Health Assembly, Rwanda took an active role in drafting Resolution 68.15 to prioritize emergency and essential surgical care and anaesthesia as a part of universal heal In 2013, The Lancet initiated a process to convene experts in surgery and anaesthesia, researchers, economists, and policymakers to address the state of surgery worldwide and to provide concrete recommendations for its improvement. The Lancet Commission on Global Surgery culminated in the release of the seminal report, Global Surgery 2030.  This report included startling findings: 5 billion people do not have access to safe, affordable, and timely surgical and anaesthesia care. 143 million additional procedures are needed worldwide to meet the gap between available and necessary procedures.  At least a quarter of patients who do receive surgery are financially impoverished as a result. Economic losses from burden of surgical illness amounted to almost 2% of the GDP of low and middle-income economies. The work of the Commission showed that investing in surgery and anaesthesia is a critical component of sound economic growth. Additionally, the Commission recommended a pathway for countries to be able to scale-up surgical access and services in a coordinated and effective manner.  This pathway, called the National Surgical Plan framework, presents concrete recommendations in the five essential domains of an effective and resilient surgical system: (1) infrastructure (2) workforce (3) service delivery (4) information management and (5) financing.

The Republic of Rwanda is a low-income country in sub-Saharan Africa. It has the highest population density in East Africa (total 11.5 million), with most people living in rural areas.  In 2015, the average life expectancy in Rwanda was 66.7 years, and maternal mortality was 210 per 100,000 live births (DHS 2015). The Rwandan government spends 7.5% of its GDP on health expenditures (World Bank 2014). As of 2014, there are 478 health centers, 35 district hospitals, 4 provincial hospitals, and 8 national referral hospitals (Annual Health Statistics Booklet 2014). Out of the 35 district hospitals, only a small minority are currently able to provide emergency and essential surgical services, as described by Disease Control Priorities, Third Edition (DCP3).

Working with the Rwanda Surgical Society, and the Program for Global Surgery and Social Change (Boston Children’s Hospital) we have started the process of drafting a national surgical plan. The first step in this process is baseline hospital assessments to be able to define the current landscape of surgical care. Along with 10 residents from the University of Kigali, I helped carry out hospital assessments of all 42 district hospitals. We are currently undergoing the analysis and will present our findings to the Ministry of Health to further guide the priorities of the National Surgical Plan.  This week, I will be traveling back to Rwanda to continue this process by holding a NSP workshop where all the major stakeholders for the country will get together to start discussing different aspects of the NSOAP including workforce, infrastructure, service delivery, information and management, and financing. Our plan is to complete a draft of the plan by the end of May.

Residents visiting a district hospital to carry out a surgical hospital assessment.

MHealth at a District Hospital in Rural Rwanda

Kristin Ojomo MD

Arthur Tracy Cabot Research Fellow / Henry Ellis Warren Fellow

Center for Surgery and Public Health

Brigham and Women’s Hospital

PGY3

MHealth at a District Hospital in Rural Rwanda

Surgical site infections (SSI) are a significant cause of morbidity and mortality worldwide, and particularly in low- and middle-income countries, where geographic and infrastructural barriers often delay or prevent post-operative patients from returning to care. In these settings, rates of SSI can reach 30%. In Rwanda, the current standard of care does not include follow-up of post-operative surgical patients. There, a network of community health workers (CHWs) are employed to provide care and follow-up for pregnant and post-partum women as well as children under five years of age. However, the limited education and existing work load of these workers preclude them from supporting the follow-up of other specialized conditions, such as post-operative patients.

Funded by a R21, and under the direction of Dr. Robert Riviello MD, and Bethany Hedt-Gauthier PhD (co-PIs)  I recently traveled to Rwanda as the study coordinator for a randomized control trial evaluating the utilization of CHWs in the surgical realm. The first aim of the study is to optimize a screening protocol to identify SSI in patients receiving surgery at Kirehe District Hospital (KDH) post operatively. This initial phase involves screening 450 patients first by a general practitioner and then by a surgical CHW (sCHW) using a six-question protocol (on a table using a mobile application). The second aim is to evaluate the impact of the SSI screening protocol, delivered by sCHWs on the rate of return to care for patients with SSI 10 days post-operation. Two CHW-mHealth interventions will be evaluated. In the first, a sCHW will visit post-operative study participants in their homes to administer the screening protocol prompted by the mobile phone. In the second, a sCHW will call the patient and administer the same screening protocol over the phone. In this phase of the research, 400 patients will be assigned to each of these delivery arms, and the rates of appropriate return to care will be compared to that of 400 patients in a control arm receiving the standard of care (i.e. no additional follow-up).

During this first trip, my goal was to help organize and start Phase 1 of the study.  Along with 2 data collectors and a study coordinator, we traveled to Kirehe Hospital, located approximately 3 hours from Kigali.  Kirehe is a District Hospital with 120 beds, 2 operating rooms, 1 Ob-gynecologists, and 12 general practitioners. The hospital performs almost exclusively c-sections (close to 1200/year).  We were warmly welcomed by the hospital staff who were excited about the potential for this clinical research to improve surgical care.  We were able hire a CHW who we trained for 2 weeks prior to the initiation of our study. Our first day of enrollment was March 20^th and we had a very successful day enrolling over 9 patients. To date, we have now enrolled close to 90 patients and our CHW has already started to correctly diagnose surgical site infections.  We plan to continue this phase until the end of August, prior to initiation of randomization. 

Study Staff: Theo (study coordinator), Kristin (study coordinator), Bahati (data collector), Leni (data analyst), Edison (data collector)