Function

Cheri Blauwet, MD

PGY-3, Physical Medicine and Rehabilitation
St. Marc, Haiti
Comprehensive Rehabilitation Program - Zanmi Lasante/Partners In Health

As a physician in the specialty of Physical Medicine and Rehabilitation, my primary focus is the promotion of function and quality of life for individuals with physical and cognitive disabilities such as stroke, brain injury, spinal cord injury, musculoskeletal injury, and pain that may result in disability. Of interest, I am also a wheelchair user due to having experienced a spinal cord injury when I was young. In this role and with an ongoing passion for global health work, I have no choice but to promote my own function and quality of life in order to maximize my ability to provide care, particularly in settings such as Haiti, where the built environment and natural landscape are predominantly inaccessible. This dichotomy is a familiar one to any medical resident. In this role and on a daily basis, we encounter trade offs between contributing to the well being of our patients while also preserving our own personal health and ability to thrive.

For me, this necessarily selfish quest actually began several months ago when the  Zanmi Lasante/Partners In Health (ZL/PIH) team in St. Marc and specifically my clinical mentor, Dr. Andree LeRoy, reached out to begin the conversation regarding a basic needs assessment.  Impressively, the team took the necessary steps to seek a contractor in St. Marc to build a ramp for the ZL/PIH house, and also purchased a shower chair that would be shipped to my house in Boston. I could then take it with me as a carry on when traveling to Haiti. In discussion, we felt that the hospital environment would certainly provide challenges, however because it had been retrofit with ramps after the Earthquake, would likely be at a level of accessibility to at least maintain a basic level of function. Now reaping the fruits of this labor, we are up and running. The ramp has been installed and in an almost endearing way is not quite up to code, however it is constructed beautifully and will soon be adjusted to a slope that is a bit more reasonable for a wheelchair user to use safely.

                     Dr. Andree LeRoy and Mede, ZL employee/friend check the ramp specs!

Of course, this is all put into perspective of our patients, for whom the day-to-day significance of living in this environment of barriers is invariably overwhelming. As a clinician in training and also a wheelchair user, it seems that working in a setting like Haiti affords the opportunity to even more sharply refine my skills in the clinical management of rehabilitation problems, but also in the tenets of empathy, cultural awareness, and true solidarity with my patients. As a member of the ZL/PIH Rehabilitation Team, I am thrilled to know that we will always consider health to be a human rights issue, and disability rights a pillar of our work.  With this, we understand that community inclusion, stigma reduction, and accessibility of the built environment are the foundation we stand upon when providing care to people with disabilities.  

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Physicians Ultrasound in Rwanda Education Initiative (PURE)

Point-of-care ultrasound training for Rwandan physicians and its impact on patient management

Rwanda
January 6-22, 2012
Joshua Rempell, MD

In the majority of resource-limited settings diagnostic imaging is not available other than plain film radiography. Point-of-care ultrasound offers a relatively inexpensive, safe, and effective form of diagnostic technology in resource-limited settings such as Rwanda.  Ultrasound machines are becoming more portable, durable, and versatile.  Consequently, there has been increasing interest to introduce ultrasound programs in resource-limited settings throughout the world. Recent efforts are beginning to demonstrate the clinical effectiveness and sustainability of ultrasound programs introduced into resource poor settings.  Despite its potential, a recent literature review on use of portable ultrasound in resource-limited settings found only a small number of empirical studies on the effectiveness of ultrasound on health.

Rwanda has only 5 physicians per 100,000 people and less than 10 trained radiologists in the country.  The Physicians Ultrasound in Rwanda Education Initiative (PURE) is an organization that now includes over 70 Emergency Physicians and has come about through constant collaboration with the Rwandan Minister of Health and the provincial hospital administrators at 5 designated hospitals to take part in this pilot initiative.  The Minister of Health, Dr. Agnes Binagwaho, has designated one central hospital to serve as the center of expertise as well as the provincial hospitals that will take part in the initial pilot training period.

We hypothesize that implementation of POC ultrasound into 5 provincial hospitals in Rwanda is feasible and can improve patient outcomes.  We will implement a focused, locally relevant curriculum that we hope to share with the greater global health community.  Through our assessment, we hope to design both relevant content as well as a structured approach combining both didactic and hands-on instruction that can be applied to other resource limited settings where clinicians have constant and significant time constraints. 

We hope to study the changes in patient referrals before and after the introduction of our training program. Few prior studies of ultrasound services in remote settings have ever been performed, and many questions remain unanswered regarding best methods for teaching ultrasound in these settings, the most appropriate and useful ultrasound examinations to teach, and how the new ultrasound services will impact patient care and outcomes.

The knowledge gained from this ultrasound training program will inform the greater ultrasound and global health communities of the opportunity to make a significant impact through the use of POC ultrasound in such settings.  Through our efforts, we aim to further develop and validate a sustainable, replicable, and scalable model of point-of-care ultrasound in resource-constrained settings. 

While in Rwanda during January 2012, I was able to pilot the training curriculum we have developed through work based on a prior needs assessment as well as through work with our Rwandan physician collaborators.  I gave grand rounds to surgical as well as medical residents and attending physicians at the teaching hospital in Kigali followed by hands-on teaching in point of care ultrasound.

A brand new machine for the training

Training surgical residents at the primary teaching hospital in Kigali

During my time, I was also able to work toward the long term goals of PURE by meeting with the Dean of Medical Education, representative from the Rwandan Ministry of Health, as well as multiple medical directors at the district hospitals that have been designated as training sights. 

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