Scaling up head trauma and critical care capacity in a resource-poor setting: Mbarara Hospital, Uganda (4 of 4)

Thursday, November 10, 2011

Today I was finally able to demonstrate the drill to Gerald and the residents. Since there had been no appropriate cases during the week, we bought some fresh goat heads from the market and performed burr holes and craniotomies on them. Fortunately, the electricity cooperated. The residents had a great time learning to put the drill together, practicing with the different attachments, and working on the goat heads. Among other things, we discovered that a goat�s frontal bone is very thick under its horns! We also discussed basic head trauma management, and the residents showed an excellent grasp of the relevant anatomy, physiology, and critical care despite having few opportunities to practice it. I reviewed the technique of exploratory burr holes, which I have never actually performed � because CT and angiography have been widely available for so long, few if any practicing neurosurgeons in the US have performed this technique. The residents helped me get a sense of what they try to do for head trauma patients in the ER. Since imaging is not available, they rely on the history and exam. Any loss of consciousness warrants 24-hour observation. They use the Glasgow Coma Scale, vital signs, and pupillary asymmetry to decide whether to give mannitol (intermittently available in the ER) or explore. However, even at MGH, by the time a patient exhibits the classic Cushing response or �blows� a pupil, it may be too late. Also, once a patient is admitted to the ward, such monitoring no longer occurs. It is common for patients to come in with a GCS of 13 or 14, then suddenly decompensate and die on the ward � presumably because of a rapidly expanding epidural or subdural hematoma that could have been addressed if an accurate imaging diagnosis had been available.

Through this discussion, I gained a much better understanding of the situation in Mbarara. This urban hospital is caring for head trauma patients every day, and the doctors have an excellent knowledge base � but they lack the resources to effectively triage and monitor patients. My sense is that the primary obstacle is inadequate monitoring on the ward - ongoing assessment of mental status, hemodynamics, chemistries, etc. � things that we might expect to occur in an ICU or stepdown unit. Thus, scaling up ICU care in Mbarara might go a long way toward improving head trauma outcomes. It will also be crucially important to have a CT scanner in order to diagnose intracranial hemorrhage in patients who have not already decompensated. But even without imaging, ongoing assessment of clinical exam will help capture more patients who require neurosurgical intervention.

Although I was only in Mbarara for a short time, I plan to return in the next few months � and to establish ongoing collaboration between my department and the surgeons there. Since they are used to a high-cost, high-complexity system, neurosurgeons in the US often take a fatalistic attitude toward global health, believing they cannot possibly contribute. I hope to help demonstrate the opposite � that neurosurgeons can and should help build up local resources to care for head trauma patients, reducing its worldwide burden of death and disability.

Anna R. Terry, MD, MPH
PGY-5, MGH Department of Neurosurgery

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Scaling up head trauma and critical care capacity in a resource-poor setting: Mbarara Hospital, Uganda (3 of 4)

Wednesday, November 8, 2011

 

We arrived on Tuesday morning only to find that the electricity had been out for several hours. The hospital has two ORs dedicated to obstetrics, and this area has its own generator. However, the two general surgery ORs do not have a generator, so all surgeries were being postponed. In the afternoon, I met Gerald Tumusiime, a general surgeon. We found him in the ER where he was in the process of admitting 6 surgical patients � about half the patients in the ER. Most of them were children, and most were ill enough for ICU admission had they been seen at MGH. The surgical problems included blunt abdominal trauma, appendiceal abscess, and a neck abscess in danger of causing airway obstruction. Gerald explained to us that there have been no potentially salvageable patients with severe head trauma this week.

Gerald has a work ethic that would embarrass the average American surgeon. He plans on getting all the surgeries done overnight, then a full day of teaching, patient care, and research � even though he gets no support for his research and only a small stipend for teaching.

On Wednesday morning, I met with Gerald, who amazingly had managed to operate on all the ER patients overnight, Paul Firth (MGH Anesthesiology), Mark Preston (MGH Urology/Oncology), and Dr. Lopez, a visiting Cuban general surgeon. We spent a couple of hours discussing both challenges and opportunities. Gerald has been compiling several sources of data to try to establish a baseline for tracking outcomes. There is an anesthesia case log tracking the surgical cases, indication, type of drugs used, and immediate outcome. This demonstrates the astonishing variety of surgical cases performed in Mbarara even in the absence of what we would consider adequate preop testing and imaging. Gerald has also been tracking all the ER and ward surgical cases with 14-day outcomes and mortalities, and has begun abstracting information on head trauma from this data. This is very difficult for him since there is no infrastructure to help with longer-term follow-up, and he has to do all the data entry in his limited spare time. So far, Gerald�s work has demonstrated that 35% of mortalities in surgical patients are due to head trauma � an astonishing fact. In addition, advanced presentations of metastatic cancers, particularly GI cancers, are very common, reflecting a lack of access to primary care and screening services.

The surgeons would like to have some administrative support to help with data collection. A longer-term need is laboratory, imaging, and pathology services to help them make an adequate and timely diagnosis, and thereby improve outcomes.

Considering neurotrauma, there is no CT scanner, invasive blood pressure monitoring, or protocol for expectant observation on the ward. So neurosurgery here is always exploratory, and is usually done as a last resort. Dr. Lopez explained the informal �Mbarara protocol� for head trauma, based on current guidelines and the unique resources of the hospital. It relies on neurologic exam, Glasgow Coma Scale, and vital signs to decide whether or not to explore. Unfortunately, by the time patients with rapidly expanding hematomas develop focal neurologic signs, they may not be salvageable even in a developed country with full OR/ICU resources, so this is discouraging. Many patients die shortly after surgery, and many die on the ward a few hours after being admitted. High spinal cord injury is almost invariably fatal because these patients need immediate ICU care and extensive long-term rehabilitation, which is not available here. However, this represents a huge opportunity for improvement. If we can direct some resources toward scaling up ICU care, we may be able to make a difference in the head trauma statistics.

In the afternoon, Mark and I met with Gerald again and lay the groundwork for future collaboration. Our goal is to establish a baseline for data collection and outcomes tracking. The more we talk to Gerald, the more we admire what he is able to accomplish with what we would consider very limited resources. We learned that part of what it means to be a doctor here is to be able to advocate for yourself and your patients to government officials and force them to live up to their responsibilities to provide those resources � a daunting task.

Anna R. Terry, MD, MPH
PGY-5, MGH Department of Neurosurgery

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Scaling up head trauma and critical care capacity in a resource-poor setting: Mbarara Hospital, Uganda (1 of 4)

Saturday, November 5, 2011

My main goal for the 10 days I will spend in Uganda is to help scale up head trauma capacity at Mbarara Regional Referral Hospital in Western Uganda. I have brought along a cranial drill and plan on training the general surgeons and residents in its use. In addition, I plan to look at how the hospital is managing head trauma, and help set up baseline data collection so we can track outcomes and measure the effects of interventions. Finally, I want to contribute to scaling up ICU care, since it is so crucial to caring for head trauma patients, and help establish future collaborations.

Other than a brief visit to Cape Town 8 years ago, this is my first trip to Africa. My first impression is that Uganda is a very young country. During the 5-hour drive from Kampala to Mbarara, I see a lot of kids, teenagers, and young people. Almost no one appears to be over 50. Kampala appears to be a hotbed of economic activity, with a proliferation of every imaginable type of small shop:  mobile phone kiosks, hair salons, bars, convenience stores, produce and meat stands, and furniture sellers. There are goats, chickens, and cows everywhere, often grazing alongside the road. People are carrying enormous loads of wood, water, produce, clothing, and even gas cans on their heads or shoulders, or on the backs of bodabodas (motorcycles) and bicycles. Many of the women also have a small child or two slung over their lower back or stomach. A lot of people are cooking food outdoors on wood or gas stoves.

Before coming here, I already knew that head trauma was a huge issue for developing countries. Here, I get firsthand glimpses of the road safety problem. The road to Mbarara is now officially �paved,� but it often changes to dirt or mud when going through populated areas, with potholes capable of popping off tires on cars or swallowing bodabodas. It is also narrow with almost no shoulder. Nevertheless, it has to be shared by cars and trucks, bodabodas, cyclists, pedestrians, and animals.

Anna R. Terry, MD, MPH
PGY-5, MGH Department of Neurosurgery

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Scaling up head trauma and critical care capacity in a resource-poor setting: Mbarara Hospital, Uganda (2 of 4)

Monday, November 7, 2011

In the morning, I toured the hospital with some of the visiting doctors. The hospital is addressing the medical needs of a large urban area (Mbarara has about 150,000 people) and of the surrounding rural areas, despite limited resources. It is basically a collection of low-rise buildings connected by pathways. The wards were built around 1950 and look as if they were meant to accommodate no more than 20 patients each, but at least 50-60 patients occupied each ward, many of them on the floor. There is an �ICU� that consists of 2 beds, with 1 working ventilator. A handwritten sign outside the OB ward listed supplies that were out of stock � sterile gloves, morphine, IV needles, and disinfectant. Care is supposedly free, but because of shortages of drugs and supplies, family members are often sent into town to purchase these items. Although there is activity everywhere � doctors, nurses, and students moving from place to place � there seems to be a lack of formal routine. Doctors are not checking on patients, and nurses are not taking vitals, nor do they appear to have blood pressure cuffs or stethoscopes for doing so.

Family members actually provide a lot of the care. Families cook for the patients and wash their clothes and linens, and often end up being the ones to notify the sisters (nurses) if there is a problem. When someone is in the hospital, families often travel hundreds of kilometers to care for them, losing valuable income.

I also learned that most of the surgeries performed at the hospital are emergent, not elective. However, most take place during the day (before 2pm), as staff are not always available to do procedures at night. In fact, much of the anesthesia is provided by �anesthetic officers,� who are technicians with variable training.

Finally, courtesy of Dr. Stephen Ttendo, an anesthesiologist who is our main contact in Mbarara, we get a tour of the new hospital building, which is under construction and should be finished by next summer. It will have more modern ORs, an 8-bed ICU, a CT and other imaging technology, and a chemistry lab. This expansion is greatly needed, and long overdue, since the hospital is already serving as a national referral center. I can already see that it is going to be a huge challenge to address the obvious needs related to head trauma. Without reliable ICU care, a way to monitor patients who are at high risk, or a social infrastructure to assist with aftercare for brain-injured patients, a surgeon can do only so much. I hope that the new facility can begin to address some of these challenges.

Anna R. Terry, MD, MPH
PGY-5, MGH Department of Neurosurgery

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Otolaryngology in Mbarara, Uganda

Otolaryngology in Mbarara, Uganda

(2 of 3)

It has been a busy week in Mbarara.  Much of the first day in town was spent with introductions, meeting clinical faculty at Mbarara Hospital and academic administrators at Mbarara University (MUST) who help coordinate post-graduate training and the relationship between MGH and MUST.  The short meetings made me not only feel welcome but also gave me a better idea of the structure of collaboration here.  It is nice to witness the outstanding relationship that has been established between MUST and MGH by dedicated individuals from both sides.

On the first day in clinic, starting around 8 AM, the line of patients had already stretched a good distance outside the one-room clinic that has handwritten letters "ENT" on the door.  Multiple patients are seen in different corners of the room at the same time by the resident, attending, and clinical officer.  There is a nurse who directs traffic, calling in new patients when a seat opens up, handing charts or referral notes to free clinicians, recording all patient visits in the master log, translating when necessary, and seeing to it treatment plans are completed.  Patients carry in their own medical records, records that consists of a soft notebook in which clinicians have documented past illnesses and treatment plans.  The majority of patients have no records.  

The clinic flow is steady and efficient.  On a small table in the center of the room sit an assortment of medical instruments that are constantly being reached for; sometimes the absence of something needed is quite noticeable to me but quickly improvised.  When the power goes out, the head-mirrors used to look in mouths, throats, and ears can no longer be used.  I'm glad I brought several battery-powered headlamps so that the exams can continue.  

Most of the patients present with problems I've seen before; hearing loss, cerumen impaction, ear pain, foreign bodies in the ears or nose, hoarseness, trouble swallowing, tonsillitis.  Several patients are seen with more complex, less common issues, like a new presentation of laryngeal tuberculosis and several advanced head and neck lesions/cancers not yet fully diagnosed.  When clinic ends, I'm am eager to find Internet access to do some reading.  I have no idea how I would treat a suspected enlarging nasal dermoid cyst in a 4-year-old seen that day (a cyst that has about a 30% chance of intracranial connection) without access to MRI or a CT-scan, tests that would normally be used to exclude or delineate this possible central nervous system connection prior to surgical removal.  I am told that there is a CT scanner in the capital city of Kampala, a 5-hour drive away, but no one I ask seems too sure of the cost or wait time for a scan.  I am certainly, and perhaps predictably, being challenged to think in different ways some of the time here.

When I look back at the past week, I feel very grateful to my Ugandan colleagues for allowing me the opportunity to work with them.  As a junior resident in otolaryngology, I find no shortage of learning opportunities in Mbarara.  I also see opportunities to build surgical capacity in several areas related to otolaryngology here and am beginning to brainstorm the creation a few small projects with the outstanding MUST resident.  I hope to touch on these projects the next time I write.  

Kyle Chambers, MD - PGY-2 Harvard Combined Program in Otolaryngology-Head & Neck Surgery

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Otolaryngology in Mbarara, Uganda

Otolaryngology in Mbarara (1 of 3)

As travel goes, the trip to Mbarara, Uganda, had a bit of everything. There was delay in Kigali due to an airplane crash on the Entebbe runway, failure of my hotel shuttle to pick me up (with several taxi drivers unexpectedly unwilling to take me), and the theft of some of my medical equipment out of my checked luggage somewhere in-transit. But there was also the stunning 5-hour drive from Entebbe to Mbarara and conversations with the driver about traditional medicine in Uganda, the role of foreign mzungu doctors, and the Ugandan soccer team that barely lost a birth to the Africa Cup by 1 point to rival Kenya. The drive also gave me a chance to take in the warm, visibly tropical environment of southern Unganda as we crossed the equator and catch a glimpse of Zebras as we passed close to Lake Mburo National Park.

I've arrived in Mbarara as an otolaryngology resident given the opportunity to spend 2 weeks learning about ENT Surgery in Uganda and also with hopes of exploring possible future research and educational collaborations with Mbarara Univerisity of Sciences and Technology (MUST) and the affiliated Mbarara Regional Referral Hospital. Mbarara is home to approximately 150,000 residents with 500,000 people in the surrounding area. Mbarara Hospital serves as a major referral hospital for all of southern Uganda with an even larger catchment of unknown numbers that at times includes patients from northern Rwanda, Tanzania, and the Congo. As a hospital, it offers two operative theaters, two-four ICU beds, multiple over-crowded adult wards (by most accounts), and roughly 6000-7000 pediatric admissions to the pediatric ward each year. There are currently plans in place to build/open a new hospital that will reportedly offer 8 ORs and greatly improve the capacity to accommodate the large inpatient volume, expected to be completed next year.

By the numbers, otolaryngology in Mbarara is easily considered a needed specialty. Mbarara Hospital has 1 staff otolaryngologist, who has been a different cuban otolaryngologist every 2 years for some time now. This makes the ratio of ENT surgeons to population in Mbarara is very similar to that of the national average in Uganda of 0.06 ENT surgeons per 100,000 people (based on a 2009 study), which is remarkably lower than the 1:100,000 ration in the UK and the approximately 3:100,000 ration in the US.
Over the past several years, however, MUST has been trying to alter this deficit in ENT surgeons by starting a residency program with the goal of training and retaining otolaryngologists to serve southern Uganda. There is currently one resident in her post-graduate year three of four years with hope of bringing in a second resident soon.

Having arrived in Mbarara, with this background in mind, I am very excited about the days ahead.

Kyle Chambers, MD - PGY-2
Harvard Combined Program in Otolaryngology-Head & Neck Surgery

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Ethiopia, the land of thirteen months of sunshine

Project: Surgical Capacity Assessment in Ethiopia
Partners: Harvard Humanitarian Initiative, MGH Department of Surgery, Harvard Program in Global Surgery and Social Change, Global Surgical Consortium


Ethiopia, the land of thirteen months of sunshine, is big.  Huge, in fact.  I spent this past October in  Ethiopia, crossing huge distances in planes, cars, and buses, visiting hospitals to administer a surgical capacity survey with the Harvard Humanitarian Initiative.

Visiting one of the hospitals in Debark with one of my co-researchers

After spending a couple days at the Ministry of Health and at Black Lion Hospital, working with the MoH Medical Director, Mr. Abebaw, and our local author, a pediatric surgeon named Dr. Miliard Derbew, we plotted out a rough idea of our country tour and then set about figuring out what combination of plane, bus, and car would get us where we needed to go.  It turns out that we needed to fly a LOT; I ended up taking eight domestic flights this month!  Fortunately, Ethiopian Airlines is quite good and, more importantly, inexpensive.

One of our many domestic flights required to reach hospitals around the country,
which is over one million square kilometers!

What we discovered through our travels is that hospitals in Ethiopia are distributed unevenly throughout the regions and city-states, with resultant disparities in physician:patient ratios in different areas.  Unfortunately, this limits the ability of many patients to access hospitals, particularly hospitals where surgery was available.  Though they frequently had access to primary care, the limited availability of surgical capacity translated into huge problems regarding obstetric care and trauma emergencies.  When patients are traveling by foot and camelback, the huge distances prove a problem.

Camelback is an acceptable alternative to an ambulance

While we also discovered infrastructure deficits, we were impressed by the creative workarounds that were developed.  Not only did we find the typical adaptations like electric generators and headlamps in areas without electricity, but we found air conditioners used to refrigerate medications, or living blood banks in areas without blood banking ability.  The ingenuity of the doctors and hospital administrators certainly was to be applauded.

Other than that, the country was a great pleasure to travel around.  We were able to experience a lot of wonderful things in Ethiopia, notably the wonderful coffee ceremonies.

Coffee ceremonies involve roasting green coffee beans, grinding them, and then cooking them over coals

Of course, no story would be complete without mentioning the incredible hospitality of the Ethiopian people we met, particularly the families, patients, and all the medical personnel we were able to meet with!

A gift from an Ethiopian family to keep warm; Ethiopia was surprisingly temperate!

Now that I'm back in Boston, I'll be taking some time to reflect on our experiences, but I will never forget this incredible month I spent in Ethiopia.

Tiffany E. Chao, MD, MPH
MGH Dept of Surgery PGY3

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A central TB diagnostic lab

I spent the past two days on a computer at the National Health Laboratory Service�s TB lab in Cape Town, finding codes and dates needed to link sputum samples to clinical data for a cohort I�m studying of MDR TB patients from a nearby farming region.  The South African government somehow has decided to keep this NHLS facility occupying prime downtown real estate � next door is historic Somerset hospital, and over lunch, I walked a couple of blocks to the high-end waterfront shopping mall � but inside, it�s a giant sample-processing factory.  Assembly lines of slides and stains and culture bottles, overflowing boxes of discarded samples making room for a new day�s sputa, a room of Bactec machines, new machines for rapid drug sensitivity testing, all kept running from early morning to 11pm, with two shifts of workers each day.  I made the mistake of trying to look up a sample by date, not realizing that a new one is logged about every two minutes.  And repetition makes the work efficient; this may seem silly, but I was amazed by how quickly the woman working next to me could stack up a tabletop array of glass slides that were lying side by side (15 or 20 per second, maybe? I�m not exaggerating - it was impressive.)

The high volume and necessarily rapid turnover mean it�s impossible to go back and find mycobacterial samples of interest after the fact.  But fortunately, our collaborators at Stellenbosch University have set up a system where all multidrug resistant samples automatically get sent to them for cataloguing, storage, and further typing and molecular analysis.  I�m eager to link their molecular data with the clinical data we�ve collected these past few weeks and see what we find.  Also curious to see whether we can show any effect from the recent implementation of rapid PCR diagnostics: Shorter times to reporting MDR TB? Shorter times to getting patients on appropriate treatment? Or, a longer shot but the real interesting question, less transmission in the community?


Emily Kendall, MGH, PGY-2 Internal Medicine

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MDR-TB in rural Western Cape, South Africa

I�m spending this month at Brewelskloof tuberculosis hospital in Worcester, a small town in South Africa�s Western Cape province.  It�s just a bit over an hour�s drive from Cape Town, but it�s a completely different world from that fairly cosmopolitan city.  It�s a farming town � lots of vineyards, some other fruit, a few livestock � and there�s not much else going on, although the setting is beautiful: grapes growing everywhere, ringed by mountains, spring wildflowers currently in bloom.  I�m gathering data on a cohort of patients with multidrug resistant tuberculosis (MDR TB), so I spend most of my time combing through paper hospital charts, doing my best to translate Afrikaans, and typing into a clunky Access database.  Not particularly exciting work, but the data is beginning to tell a few interesting stories. 

This population � at least the subset of people from these farming communities who get MDR-TB � is really disadvantaged.  Walking through expansive upscale shopping malls and trendy organic markets in the city (Cape Town, that is) on the weekends, it�s clear that there�s money in this country somewhere.  The hospital in Worcester is also immediately surrounded by lovely homes and estates.  The typical MDR-TB patient we read about, though, lives in a shack without water or electricity, has about a 6^th grade education, is trying to make ends meet through seasonal farm work, and binge drinks heavily on the weekends.  The tricky thing is that the same social factors that breed and spread MDR (poverty, crowding, and malnutrition that predispose to TB, and home and work instability and frequent intoxication that make it hard to take your TB drugs every day for six months) make it even hard to complete the two years of more-toxic treatment required to treat drug resistance.  

I�m also observing long delays before patients with MDR TB in their sputum got onto appropriate treatment.  Cultures take several weeks (and AFB smears, we�re told, tend to be reviewed hastily here and rarely come back positive), and then drug susceptibility testing take more time.  But besides waiting for lab results, there also must be other delay somewhere along the process of realizing a culture shows MDR, notifying the clinic, finding the patient, and getting them into treatment, because we are often seeing gaps of 3, 4, even 6 months between when a sputum is collected and when appropriate MDR treatment is started.  Plus, while waiting for the DST results, sometimes patients get a single drug added, or are started on treatment regimens with only 1 or 2 drugs that turn out to be active, which is exactly what you don�t want to see.  Starting first-line therapy after a positive smear or culture is automatic here, I�m told, even in patients with risk factors for drug resistance, but I�m curious to analyze whether these first-line regimens negatively impact either MDR outcomes or transmission of MDR within patient�s households and communities.

Finally, on a somewhat related note, all this reading of paper charts makes me appreciate electronic medical records.  But not everyone here views computers the same way.  We were talking today with South African collaborators about electronic records, about plans for expanding our electronic database to capture a broader slice of hospital�s data for research purposes, and even about the possibility of transitioning to a electronic medical record for clinical use.  The rural clinician in the group was puzzled about how this would work: the doctors would have to go back to their offices at the end of the day and type in everything they had done?  The idea of placing computers within the ward blew him away.  Another researcher mentioned that he�d been abroad and seen a clinical pharmacologist with an iPad, who was able to look up information about pharmacokinetics to show the team as they rounded; he�d been amazed.  But none of them really have a vision for what computers could add to their clinical or research work.  My American mentor/collaborator and I tried to convey the potential usefulness of an electronic record for prompting doctors to enter data that the hospital wants to collect, for keeping track of outcomes or adverse events in real time, or for retrospectively answering questions that no one has thought of yet, but I don�t think we got through.  I imagine that the push toward electronic charting isn�t so far away for a country like South Africa, but it will be a tough transition in isolated pockets like this one.  For one thing, they need to get internet; here in Worcester, I can�t connect long enough to find the CoE blog, so I�ll be posting this in a few days once I get to Cape Town for the weekend � where internet is still spotty, but slightly less so.  

Emily Kendall

PGY-2, Internal Medicine

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Hurry Up and... Teach?

Mark Siedner

August 31, 2011

Mbarara, Uganda

It was with a rolling boil of enthusiasm that I landed in Uganda three weeks ago. In the four years since I returned from my last prolonged international trip, my pager and chiefs afforded me only the briefest glimpses of foreign shores. On June 30^th, like for thousands of other residents and fellows, those days (and nights) of regimented educational servitude ended. Abruptly. As soon as my funders and wife allowed, I shoe-horned my life into two suitcases and arrived here in Mbarara with a polished study protocol, approved ethical reviews, and just enough grant funding to just maybe execute my project: a study of the acceptability and feasibility of using cell phones to communicate critical laboratory results to patients in resource limited settings.

Then, like so many of those first days of medical internship when we realize that no textbook can prepare us for unbridled sickness, I was overrun with humility. As the sheen on my proposal faded, the finality of ethics review waned, and the tensile strength of my budget unwound, I became increasingly befuddled and was oft sighted wandering the sand-blown alleys behind papaya stalls and chapatti wallahs mumbling things like, �Sub-contracts cannot be cost reimbursable,� �You forgot to charge indirects on your fringe,� and �Did you really you think you could pay for an IRB fee with a bill printed before 2005?� I would be remiss to bore you with the list of missteps, oversights, undersights, and unmet expectations I have experienced since my arrival. But I would also be shirking the chance to build invaluable empathy with my peers and possibly even prepare the incoming international study-minded residents and fellows by keeping quiet. So forgive me as I attempt to list a handful of the preparatory hiccups I choked on in the past few weeks:

a)    Grants afford me the chance to bid on a ticket. They do not get me on the plane and certainly don�t get me within a hemisphere of my destination. When working (and spending money) at a foreign site, the grant will first need to be agreed upon and signed by your home institution and funding organization. This requires finalization of budgets (likely before you are sure of your costs), IRB approval (for funds to be paid), and a whole lot of time spent hurling epithets on a system called InfoED (for you MGH folks) where all this information is entirely non-intuitively entered. I would say the whole thing is a bit like learning a new language, but that would only be true if that language was neither written, spoken, or heard by anyone aside from (I�m convinced) a pernicious little computer programmer who has made his or her life�s mission to avenge the rage at failing a quantum mechanics class in college on grantees and administrators like us. Once this process is completed, a sub-contract between your home institution and foreign site needs to be arranged. Given that the foreign site is likely in a resource poor setting and cannot pay up front and be reimbursed, a quarterly payment schedule will need to be arranged. Once these are completed (in my case, I am told to expect about two months, and am still in the beginning stages), a judicious waiting period to hire any needed research staff and procure materials should be expected. In short � congratulations on winning a grant. Now hurry up and do something else for a while.

b)   I would be in a more serene place now if I was more flexible with my initial budget projections (perhaps a motto for academic research?). As it stands, I have all the serenity of a hot rod without a muffler. My cost projections were a bit like those of a toddler just beginning to grasp the nebulous concept of worth. As I would then alternatively think a cheeseburger was worth either 16 cents or twelve million nickels, I�ve been caught budgeting translation fees as both 25 and 2,000 dollars on the same budget. As if not knowing that printing a piece of paper here cost a dollar but photocopying one runs you 4 cents was not enough, predicting the volatile exchange rate has forced me into fits of pseudo-seizures. A $600 wire transfer for IRB fees last month converted into local currency is worth exactly $502 today, the day the fees are to be paid. In hindsight, my advice to myself would be the following: Have patience, wait as long as possible to finalize your budgets (preferably once you are in country), and whatever you do, do not buy cell phones in the US or computers in Uganda.

c)    Administrators are like the brown sugar in chocolate chip cookies. At first I took them a bit for granted � bypassing their names in my email inbox for Groupons. But that day you�re asked to do it yourself, you�ll suddenly appreciate how there is no sweetness in life without them. There is no money, no approval, no study, no publication. There is only dry, tasteless dough. Buy them flowers and scotch. Get them out of jury duty. Babysit. Just make them happy. For Pete�s sake open their emails first! If I remember nothing else from this experience � I hope I remember this key ingredient to the research recipe.

So what have the last three weeks brought me aside from a new diagnosis of hypertension? Incredible opportunities. I�ve spent three weeks working in the HIV clinic, seeing over fifty patients and more with cyrptococcus, tuberculosis, and unidentifiable skin conditions that I did in my entire clinical fellowship year. I�ve had the incredible opportunity to teach medical students, yearning like sea sponges for every last bit of medical knowledge in this over-constrained education setting at rounds each week. I have organized a journal club and connected the faculty to a web-based monthly international HIV clinical conference. I am mentoring a small group of residents and staff on development of research projects, all locally grown. We are developing new protocols for infection control precautions and in the exploratory phases of designing a hospital antibiogram. This is of course, I remind myself daily, why I came here. Because the need is so great and though I am not the best person for any of these jobs, I am also all we�ve got! And I am so incredibly honored to have the privilege to work where the challenges are so great, but the interactions with patients, colleagues, and local mentors are so incredibly rewarding. I�ve gotten nothing I wanted to done. And so much more.

Mark Siedner MD MPH

Infectious Disease Fellow

MGH/BWH

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�Combating Chronic Diseases in India using Community Health Workers�, Blog 1

�Combating Chronic Diseases in India using Community Health Workers�

Bangalore, Karnataka, India

St. John's Research Institute 

Tanvir Hussain, MD, MSc

Blog 1: Project Background

On May 3, I returned to St. John�s Research Institute in Bangalore to continue working on the SPREAD Project.  The SPREAD project (Secondary Prevention of coronary Events After Discharge from hospital) is a randomized controlled trial in secondary prevention of acute coronary syndrome developed to serve the urban slums and rural village populations.  The design is an open trial comparing post-discharge interventions delivered by community health workers to standard care in 10 secondary and tertiary care hospitals. The objectives at the outset were to assess feasibility, estimate rates of adherence to pharmacotherapy, assess adherence to lifestyle modification, and obtain an estimate of the event rates in an Indian setting. 

SPREAD is an example of the response to changing disease burden globally.  As developing countries undergo epidemiologic transition and disease burden shifts from communicable disease towards chronic illnesses, current health delivery systems are being recognized as inadequate to manage CAD, DM, COPD, and cancer in low and middle income countries.  In 2009, the NIH provided funding to medical institutions in developing countries to implement innovative strategies in chronic disease care.  In India, where CVD is the leading cause of mortality in the urban and rural population, St. John's Institute of Bangalore is pioneering a community health worker (CHW) based secondary prevention model for CAD, the "SPREAD" project.

My role in the SPREAD project began during my six week global health elective funded by BWH Internal Medicine department during October through November 2010.  During this time, I enjoyed participating in the conceptualization of the intervention.  My role included working with experienced CHWs in producing a first draft of the CHW educational training materials.  I also produced a first draft of the patient encounter protocol for CHWs�that is, I developed a step-by-step tool CHWs could use during patient encounters to document and counsel patients during home visits, accessible to CHWs with primary school training. 

After I had left the project in the Fall of 2010, the team had taken several significant steps: identification of 14 potential study sites across India and a CHW at each site; translation of patient and CHW education materials into seven different languages (see pictures with Blog 1); training of the CHWs; evaluation of the CHWs; training of study sites for a non-�clinical� trial.  Conducting this process in several languages across fourteens sites was incredibly challenging.  And I was impressed by the team�s perseverance and accomplishments.  

Now that I had returned approximately eight months later, I was anxious to hear about the creative solutions created for the challenges faced by the team, the anecdotes and experiences bourn from the CHW trainings, the anticipations for the future, and more.  Part of my role on the project on this second visit would be to provide an assessment of the CHW training process to ensure the CHWs were adequately prepared to undertake the challenges of counseling and caring for post-MI patients from discharge to one year after their event, both at home and in the hospital.

In my next blog, I reflect on the unique challenges of employing a CHW model in chronic disease management, learnt from our project.

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Mobile West Bank Neurologist

I had the wonderful opportunity to spend a few weeks working with Physicians for Human Rights (PHR) in Israel, and to participate in a "mobile clinic" that brought a group of physicians, nurses, medical students, and other volunteers to both cities and small towns in the West Bank. I want to use this blog post to take you through a typical day:

The group left from Taybeh, a small town northeast of Ramallah, and it was typically made up of volunteers from Tel Aviv and Jerusalem, and a handful from the West Bank itself. We met in the coffeeshop of a gas station outside the town, where Al Jazeera was typically playing on the television:

After the group assembled, we would stand outside in a large circle, and our leader (in the light blue shirt) would tell us about the town we were going to, and then we would go around the circle and introduce ourselves. I was typically the only American in the group, with mostly Israelis and Palestinians, and then various observers from European countries.

We would then load up the vans with boxes of medications, and then we were off. Most of the town we visited were in "Area B" of the Palestinian Authority, which is to say they are under Palestinian civilian authority and Israeli military authority, although we did go to Area A (Palestinian civilian and military authority) as well, such as Jenin. We passed through checkpoints at various places along the way, many of which were entirely empty, to my surprise:

I was kind of surprised at how rapidly something changed across the border--even the cell phone provider!

If we were in Area A, we were escorted by one or two Palestinian Authority security vans:

We would then arrive at our site, and we would typically use a small school, or less frequently an actual clinic. The visit from PHR would have been announced in the mosque for a few days prior to our coming, so we would arrive to a large group of people waiting outside, and there was always a warm welcome.

Dozens of people from the town were there to greet us, including the leadership (often the mayor himself) and scores of volunteers. We would first gather in a large room and the mayor of the town would address the group.

 I would them be led to my "clinic room" where a sign in Arabic reading "Neurologist" was placed above the door. A neurologists' coming would also have been expressly announced in the mosque, and there were typically 20-30 people waiting to see me. Many of them were local, but many had actually traveled from other West Bank town, likely taking hours to get there. This was my clinic room (aka classroom) in Jenin:

The chaos then began. Typically a volunteer was tasked with maintaining the order of the patients, and he or she would take one in to see me one at a time.  I was provided excellent interpreters, typically Palestinian nurses or medical students, and they would speak to the patient in Arabic and then to me in either Hebrew or English, whichever was easier for them. I had at least one Israel medical student with me, and usually one of the European observers. Here is a picture taken by a Swiss observer of one of my patient encounters. I am talking to the patient, who is looking at the interpreter. The medical student in scrubs is keeping up with the documentation. Behind the patient is her brother, who was my next patient (families always came as a group--I would often see three or four people from the same family, one after the other), and then by the door was the list-keeper.

So I would see about 20 patients per day, and I was always the last one seeing patients, keeping the entire delegation from their late lunch. In terms of the cases that I saw, they spanned the entire spectrum of neurological complaints and diseases. There was plenty of migraine, neck pain and back pain with and without radiculopathy, carpal tunnel syndrome, and painful distal sensory neuropathy. Despite my insistence that I was an adult neurologist, I was asked to see children as well, typically developmentally delayed kids, just as an umpteenth opinion as to whether anything was possible to improve the child's neurological function. I was told that there is relatively more consanguinity in this population,  accounting for the large number of developmentally abnormal children, but I have no idea if that's true, and how prenatal and perinatal care have been taken into account. This child is nearly three. His twin died during labor, and his family was told that he had suffered a hypoxic injury. He is non-verbal, and cannot walk, and just in the photograph his hypotonia is obvious with his drooped posture and the fact that this mother is holding his head up.

I saw a few fascinating cases, including what I think was a first presentation of Wilson's disease, severe B12 deficiency (the lemon-yellow skin doesn't really show up on the photo, but it was profound, as was the exquisite dissociation between absence of dorsal column mediated sensation and intact spinothalamically mediated modalities.

I saw a young man (25 years old) with profound Parkinsonism, and from the history I could not begin to figure out what the underlying diagnosis was. The picture is shadowy, but his stooped posture (although no worse than mine) and masked facial expression can almost be appreciated. We went through the protracted process of getting him admitted to Israel for an inpatient workup.

 After all of the patients were seen, the PHR group and all of the volunteers had a meal together ("lunch" that not typically eaten until 4PM when the work was done), with some time for casual conversation, and then a short talk about the history of the town and the specific difficulties it is facing these days.

The mayor of Jayus, a town whose farmlands have been divided by the "wall" told us about the town, looking out over the wall itself.

We would them pack up and head back to Taybeh, and then I would get a ride back to Tel Aviv.

It was a phenomenal experience. Anyone who read this and would like to hear more about it, or be put in touch with the PHR people I worked with, email me anytime at elidiamond@post.harvard.edu.

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Beyond Biblical Days

Kuda Maloney, M.D/MPhil
Dermatology Resident
Trinidad and Tobago: A feasibility study on the utility of a standard set of Images as a screening tool for Hansen�s disease.

Two heavy barrels block the entrance to the street, communicating the wordless instruction to STAY OUT. But the man leaning against the fence recognizes the social worker, waves two youths over to move the barrels and we drive through. We are in a shanty town built along an old railway line in Southern Trinidad. The community is tight with low tolerance for outsiders, and the living space even tighter.
Despite this, the social worker has established a careful trust allowing the physical and social barriers into the community to be temporarily laid aside, as she visits our contacts. I marvel at her ability to impart vague detail, giving people the impression that they know what�s going on, enough so to allow us access, without imparting any information at all. � We are from the skin clinic� we smile.

We finally identify the house and climb the tenuous steps. She is lying spread across a mattress on the floor, the attraction of numerous flies. A nappied toddler crawls over her, patting her hopefully for attention. My heart stops for a second, fearing that she is dead, but returns to its usual cadence as I see her thin ribs rise and fall. She sleeps while we talk to her husband. We�ll have to wake her we explain, to look at her skin, as they were both listed as contacts for Hansen�s Disease. We explain what it is. � Haw, the one from the Bible?� He asks in awe and we affirm. Eventually we wake her and chat to her. She is spent beyond her 30 years. I�m glad that neither of them have skin lesions or sensory symptoms, glad to not have to add to their list of problems. The next family we screen, deep in a rural village, is a riot. The mother is indeed that biblical picture of the leper, with nose collapsed, drooping eyes, contractured joints, multiple amputations. She has managed to draw people to her, her house is bubbling with the activity and laughter of her children and her neighbors. Only her household contacts, her family, are on the list of people to be screened. It is sobering though when we find classic lesions for Hansen�s Disease in one of her friends who fortuitously dropped by that day. We suspect Hansen�s in one of her sons too, and refer them both for evaluation at the Hansen�s Disease Clinic. Our suspicions are later confirmed. We are again met with warmth at the next home we visit as well as a mixture of fascination and pride that a doctor would visit them at home. We also find a new case of Hansen�s Disease there. The numbers are telling...there is still work to be done.

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Thank you means no? Gia Dinh Hospital, Ho Chi Minh City, Vietnam

It's hard to live between culture, and I've found myself floundering a few times. Americans are so earnest, so honest, so straightforward at times, and I've grown to love this way of being. But I forget.

When my grandmother suffered a series of devastating strokes in Romania, we very sadly had to admit her to a nursing home, I'm sure with plenty of guilt of soul searching on the part of my parents. In addition in this country of transition we had to negotiate the usual channels of official and unofficial understandings. 

When my parents brought the gift for the director of the nursing home, she declined the gift so persistently they almost backed down. Then they remembered where they were, insisted, and the gift was accepted in the end. 

Observing this shifts in customs is familiar to anyone who has traveled across national borders, or even from one part of the US to another. 

In Vietnam I had to recalibrate my social compass. 

I don't fully understand how this works, and will need more experience, but the importance of "saving face," on a having a good outward interaction will often lead the Vietnamese to make promises and plans that will likely not pan out. They may have no intention of lying, and assume you have the experience to understand the situation. 

Several junior physicians had been cajoled into "inviting" me to various activities by my more senior host. They were clearly aware that I was foreign, and needed some guidance to settle in to the country. 

I was hesitant to accept the invitations, afraid of becoming indebted in some way I would not understand.  Not meaning to be rude, I accepted any persistent invitations, and sought out appropriate gifts. Once I replied to a text message asking what I would like to do with "thank you for thinking of me," and I'm thinking of these things.... There was no reply. The next week, in the hospital, I learned that "in Vietnam thank you means "no."" Or just thank you, of course.

Oh. OK. So I explained my own confusion, and we made plans, and carried a few out.

Since then there were a number of promises, plans, and many of them where carried out. Generally repeated confirmation and planning steps were a good sign of future activity. No reminders meant I could make other plans. 

One good friend is working for the CDC in Vietnam. Like many other Americans she was frustrated that agreed upon projects and goals were simply not pursued by their Vietnamese counterparts despite many promises and smiles. She was frustrated. I tried to work on her expectations a bit, understanding that "thank you" without any promises is a pretty clear no, while "yes" is very often maybe, and she'll have to take it easy and see when yes becomes real. 

She was only mildly relieved, but decided to reconsider her position.

Initial expressions of confusion or disbelief will not be very helpful. Anger is never helpful, and mutually embarrassing. Smiling always helps. East Europeans are not great smilers, and this may have been a problem even in Boston, but I'm learning, and Vietnam has been a good teacher. 

Just keep smiling. 

Dan-Victor Giurgiutiu

Partners Neurology

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Please bring food, water, and a caregiver Gia Dinh Hospital, Ho Chi Minh City, Vietnamskss

Since the decades of war ended in Vietnam seems to have always fostered large families (four or five siblings is common), until the recent introduction of a two child limit. The culture and even the language is built around a complex web of pronouns and deferential or authoritative addresses based on relative status drawn from age and kinship, then continuing out into relative social status outside the family.

While I can't cover how this shapes society, I'm particularly struck by the care provided in the hospital. The services that are offered in Boston, from orderlies taking care of bodily needs, to web of care from home visits to nursing homes takes in those who are no longer independent. In Vietnam this is rare, exceedingly rare, and often reserved for the well to do. Nursing homes are reserved for those abandoned by society, who have no one else to turn to.

Instead family steps in, with a rotation of caregivers across multiple generations allowing ailing family members to remain at home. When a hospitalization is required a family member is present throughout the day, and at times at night. Dutiful family members, often but not always a woman, sleep on reed mattresses below the fifty year old beds.

On hospitalization a large container of water, a supply of snacks and several forms of entertainment are arranged on the bedside table, and the patient is bathed and changed into the hospital's pajamas. From that point on feeding, bathing, changing is performed mainly by family. When there is money I understand that helpers can be hired. RNs administer medications, obtain tests, and orderlies help shuffle patients from crowded rooms and hallways to tests.

I wonder how this will change as the post war baby boom ages and the tasks of care shifts to the two children per couple. How will they be able to leave their jobs, or children to care for ailing parents or aunts or uncles? How could they possibly neglect their elder relatives to whom they owe so much? I wonder how the US system of care agencies and locations will be adapted in this country which places so much reverence on family support.

Dan-Victor Giurgiutiu

Partners Neurology

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Privacy and Personal Space, Gia Dinh Hospital, Ho Chi Minh City, Vietnam

Even in Boston I'm taken aback considering the experience of the sick, sharing rooms and experiences that are only making illness harder. The actively dying share rooms with the nearly well, and young, and I wonder if the thin curtain in the middle helps or hurts, if it would be better to just draw it back and share the spectacle of the illness.

In Vietnam this question has been in part answered for me.

When I'm told to see the patient in bed 42, I forget to ask a simple question: �Which one?�

Gia Dinh Hospital was build in the early 1950s, and has not been expanded since that time. A bed shortage forces patients to share beds, head to toe. This has been unfamiliar in the US since people stopped sleeping in the same bed in the 19th Century. However, I'm understanding more about the medical exam format note.

Most notes involved a general section, usually noted as NAD (no apparent distress), starting off the physical exam. 

However, the reason for this section dates back to when everyone worked in large open plan hospitals, where telling apart �a redheaded mustachioed man with a bandaged R arm� from the �redheaded mustachioed gentleman with glasses and a scar on the cheek,� would be your best bet to find the patient of interest among 30 other patients in a crowded ward with bed lined up against the wall.

So I've learned to ask for the bed and at least a few identifying features. At times this will include descriptions of a few family members who will volunteer extra information, and often spare the patient, no matter how well, the burden of telling the story, and will speak for them. 

We are surrounded by a gallery of spectators from the moment we walk in the ward, and they don't seem to want to disperse when we start the interview. Initially I asked if they were related to the patient. No, just passing the time. A family member may be down in the canteen, or having a smoke outside, but they'll be right back to help out.

So, two to a bed, every other patient and family member poking in, we start the interview. 

I'm surprised how much the bedmate, other patients, and other family members chime in when the patient has been interviewed many times before. They will describe if the patient was different yesterday, or what the last group of doctors has said. 

For a woman with likely bulbar ALS, her bedmate starts to share how the patient's husband has left her several months back, due to the illness. 

Once it comes time for the exam, and everyone crowds in to see as I push, pull, tap, prick, and walk with the patient, and much like the US, wonder what else I'll pull out my neurology bag.

Then, when we must speak with the family, and give the bad news, I'm left dancing, explaining that the damage is most likely in the brain and spinal cord, but shying away from the difficult discussion of prognosis. As you can see the subject of palliative care and end of life care is slowly being approached in Vietnam, and I am completely ignorant as to how to tell this woman that she will pass away soon. I promise to speak with the attending physician, to come back and check in. I take some small comfort in knowing she is not alone, that her children, and strangers sharing her bed and the hospital room will listen to her, and provide some of the comfort that we alway struggle to give as physicians.

Dan-Victor Giurgiutiu

Partners Neurology

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