German HCoV-EMC-local transmission

A 2nd case of the most recently identified HCoV, HCoV-EMC, reported on ProMED, in Germany. The Robert Koch Institute notes that There is still no evidence of continuous human-to-human transmission.

[VDU's first blog post!]

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Neurological Education and Practice in Uganda

Craig Williamson
MGH/BWH Neurology Resident


It is certainly with reluctance that I leave Uganda and return to the US.  Working here has been an educational and humbling experience that challenged me to think about how to manage common and uncommon neurological conditions without the resources available at MGH or the Brigham. On my final day, I prepared a talk for the post-graduates on the clinical evaluation and differential diagnosis of spinal cord disorders.  Just before the talk, I was called to the ED to examine a 22 year-old woman who has had one month of progressive lower extremity weakness, progressing to total inability to walk. She had been seen in the ED four days prior and had been sent out to get plain X-rays of her lumbosacral spine, which not surprisingly appeared normal.  On examination, she had flaccid weakness of the lower extremities with extremely brisk reflexes, sustained clonus in the ankles and upgoing toes - without any upper extremity symptoms her problems easily localize to the thoracic spinal cord. For all of my recently acquired knowledge about the many causes of myelopathy in tropical settings, it wasn't at all clear to me how to proceed with her evaluation and treatment. At MGH, she would be admitted, have an MRI of at least her thoracic spine, probably also of her cervical spine and brain, then would undergo a lumbar puncture that would be sent for a dizzying array of laboratory tests for infectious and inflammatory causes of myelopathy, in addition to other tests for various metabolic and nutritional causes. Depending on our determination of the etiology, she would most likely be treated with a course of high-dose steroids.  It was informative to talk through the case with the post-graduates and get their recommendations on how they would manage the patient without MRI and most laboratory tests.  Essentially, they would probably test her for HIV and then treat her for things they can treat - most likely TB. My own uncertainty with the case illustrates how difficult it is to come in to an unfamiliar setting for a short period of time and make constructive management recommendations.

Fortunately, another of my colleagues from the MGH/BWH neurology residency will be visiting Mbarara in just a few weeks and can build on some of the things I learned.  In addition to spending more time working with the very eager medical students, we can hopefully develop some clinical protocols to assist with management of common neurological issues.  In particular, there appears to be a tremendous need for improved prevention and management of traumatic brain injuries - one of the  most common reasons for ICU admissions - though it isn't at all clear how best to do this with less access to CT scanning and laboratory testing.  This is just one of many potential areas of academic inquiry that would be extremely rewarding to pursue.

Here, one of the medicine post-graduates waxes eloquently to the third-year students at the beside about the subtypes of Guillain-Barre syndrome and the side-effects of treatment with IVIG, which isn't available at MRRH.

An 8 bed ICU was recently opened in MRRH's new building. The use of motorcycles as the primary means of transportation in Mbarara - typically without helmets for the drivers or passengers - leads to an extremely high volume of TBI requiring neurosurgical intervention.

                   Some of the talented post-graduates waiting for me to begin my final talk.

Looking silly for the sake of education as I attempt to act out features of an MCA stroke.

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Neurological Practice and Education in Uganda

Craig Williamson

MGH/BWH Neurology Resident 

3/11/2013

The first week of my visit to Mbarara Regional Referral Hospital (MRRH)/ Mbarara University of Science and Technology (MUST) has been rich in learning, new experiences and new people.  It has also been quite rich in terms of neurological cases and teaching opportunities.  If meningitis is included, one-third of the admissions to the medical service are primarily neurological.

Many of the types of cases I have been seeing are our bread and butter admissions to the MGH and BWH Neurology Services:  hypertensive hemorrhages, ischemic strokes, guillain-barre syndrome and subdural hematomas. However, as anticipated, there is a much higher incidence of neuro-infectious diseases, particularly complications of AIDS - cryptococcal meningitis and tuberculous meningitis in particular. 

My visit comes at an exciting time, as MRRH just acquired a CT scanner a few months ago and residents are still learning how best to use this new technology.  There are no radiologists available, so I have found myself spending a lot of time helping with both CT scan interpretation, and deciding when scanning is clinically indicated.  I gave a formal teaching session to the medicine postgraduates on this topic, and have been doing informal consultations amongst the various ward teams. Patients and their families are expected to pay upfront for CT scans � a significant financial hardship for most � so it becomes important to decide when obtaining a scan will genuinely affect management.

The structure of the MRRH medical teams was well-described in the last blog post. There are a large number of medical students, and bedside medical student teaching is a core aspect of medical education. Given the large numbers of neurological cases, there has been ample opportunity for informal teaching about physical exam skills and clinical reasoning at the bedside. Sometimes after rounds, I will take the medical students and go over the clinical presentation and examination of a particular patient or discuss specific aspects of the neurological examination. For example, last week we examined a patient with guillain-barre together and discussed the differential diagnosis of acute bilateral weakness and paresthesias, and also did a session where the students practiced the cranial nerve examination on one another. 

Finally, while it has been gratifying to feel like my neurological training enables me to teach and contribute to clinical care, the medicine post-graduates have also been able to teach me a great deal. In the US, we generally don't think of tuberculous meningitis as a primary cause of stroke in young patients. However, here I have seen several cases of stroke due to TB or cryptococcal meningitis and the residents have been sharing their clinical pearls for deciding when to treat empirically for TB in HIV patients presenting with ischemic stroke. I have also had a chance to learn about differentiating cerebral malaria from other infectious causes of altered mental status, and the management of organophosphate pesticide poisoning, which is much more common here.

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Emergency Medicine in Colombia

GME Centers of Expertise Global Health Blog

David Beversluis MD MPH
Emergency Medicine PGY3
Characterizing Emergency Medicine in Colombia
(written 3/15/2013)

I'm now about 3 weeks into my 6 week elective here in Colombia and enjoying every minute.  And thrilled to get the news (even after I started) of support from the Centers of Expertise Travel Grant.  Thanks to all those working to provide this support to us residents committed to international work during residency!

I've split my elective time here in Colombia into two 3 week blocks.  First is a 3 week clinical experience working in several emergency departments in Bogota.  I'm just finishing this now and I'll write a bit more below about my impressions of working here below.  The second phase of my elective is to carry on the work of an ongoing survey of emergency medicine programs in several cities around the country.  This is work that was started by a few of my EM colleagues during a visit last year.  Much of this 'characterization' has already been done here in Bogota.  Our efforts during this trip focus on the other cities in the country that have active EM training programs.  I'll be flying north to Medellin tonight, and then next week to Cartagena to visit various hospitals, to lead some small group discussions with residents and to administer our surveys.   I'll also be meeting up with Dr. Christian Arbelaez one of the EM attendings at BWH, and the American College of Emergency Physicians (ACEP) Ambassador to Colombia.  His rich connections into the EM community here in Colombia are what is really making this project possible.  And I'm also very excited to be joined by Christina Wilson one of the HAEMR PGY2s for the next couple weeks in Cartagena.  So, more on that all in a future blog post...

During the last few weeks I've been spending my days at a couple of the emergency departments around Bogota.  Its been very interesting to see and observe the differences between our systems.  Emergency medicine in Colombia remains in a nascent phase, but is slowly expanding in influence and scale.  The first EM residency was started in Medellin in the mid-90s and there are now 5 programs total throughout the country.  This new specialty is still relatively unknown in Colombia however, with most urgent care provided by general practitioners with only 1 year of post-grad training.  Most Urgencias in the country are staffed exclusively by these doctors who consult surgery or internal medicine specialist for more difficult cases.  Several hospitals however are beginning to see the value of having EM trained staff and supervision, for patient care, throughput, cost-control and many other similar reasons.  The hospitals where I spent my time are all slowly making progress in also the transition and slowly advancing the field of EM here in Colombia.

During my first and second weeks I rotated at the Javeriana University San Ignacio Hospital in Bogota.  This is a large urban university hospital with access to plenty of internal resources but which is pushed to the limits by over-crowding issues.  The ED is designed for a quarter of the patients that it sees every day.  This leads to wait times for minor patients of up to 24 hours and to ED length of stay times of several days.  I spent time examining and speaking with patients who had been in the ED for 2-3 days sitting on rows of 8 or more chairs crammed into ED bays designed for one bed.  The amazing thing is how appreciative these patients remain despite this lack of space and staff to move them through the ED more quickly.  In the acute areas the flow and care is much better and patients are typically receiving top quality care from dedicated EM residents and physicians.  New patients are seen quickly and triaged to appropriate specialists as needed, for example I was impressed my first day there by a STEMI patient who quickly made it to the cath lab in under an hour.  Likewise, several septic and coding patients that I helped care for received great evidence based emergency care from the team.  Despite the overwhelming press of patients in the department these EM trained residents were successfully deploying and triaging their resources to address the most critically ill group.



For my final week of clinical work I switched to Mederi hospital.  This is another university based hospital in Bogota which takes residents from the San Rosario EM program.  The clinical care was similar with plenty of typical ED pathology including strokes, sepsis and coding patients.  Interestingly there was almost no trauma during my time in Bogota.  This is partly due to the hospitals and neighborhoods I was in, but also due to the overall development of Bogota.  Over the last 2 decades the city has become relatively safe.  So much so that the residents rotate for several months in Cali in the south to get a bit close to the FARC vs. military and urban poverty trauma which has mostly been resolved in the capital.  Despite the lack of trauma, I did get several procedures, which was one of the goals of my trip.  These hospitals are mostly still doing subclavian lines for central access which is something we've moved away from in Boston with our easy access to ultrasound; I got to put in plenty of these.  It was also great to intubate by direct laryngoscopy without the backup of our video assisted systems in Boston.

So, overall, my clinical experience was good from a procedures and clinical perspective, I'll definitely take some of these skills back to my work in Boston.  I can also feel my spanish slowly improving; I'll be using this ability in my work for the rest of my life.  Finally though, I'm glad to have this 3 weeks of experience and insight before I start the next phase of my work here.  Having seen Colombian emergency medicine from the inside will help me as I conduct interviews and site visits in Medellin and Cartagena and understand the emergency system as a whole.  I can't wait to see these places and keep up going with this fun work.

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Medical Education in Resource-Limited Settings - Rebecca Cook, MD, MSc

February 19, 2013

For most of my time in Uganda I've been based at Mbarara University of Science and Technology MUST / Mbarara Regional Referral Hospital (MRRH) on the internal medicine team.

Every morning we start the day with "post-take" which is review of new patient admissions, followed by work rounds on patients already on the medical ward. These rounds are attended by the medical house staff, a large crowd of medical students and an attending physician. The structure and cadence is very similar to that of the inpatient medicine rounds at MGH, but the disease pathology, the physical space and human resources are vastly different. On an open long hall with 30 beds and extra patients lying on mats on the floor, we go bed-to-bed; vigilant to not step on a patient or family member who is lying on the floor. Despite the rather low-tech set-up on the wards, our patients are often quite sick and I am amazed at the ability of the medical staff here to provide advanced care with limited resources, such as managing cardiogenic shock on a medical ward, titrating IV drips of pressors in drops/minute. Aside from a huge burden of advanced infectious diseases such as advanced HIV/AIDS and every opportunistic infection one can imagine, disseminated TB, severe malaria, we also have patients with the sequealae of non-communicable diseases: strokes, diabetes, and heart failure.

Interns and nursing student after morning �post-take�

One of my favorite aspects of daily life on the medical ward has been learning from and teaching medical students. Unlike at MGH where we may have 2-4 medical students on a team, here there are 10-15 and form a core part of the workforce in patient care. These third year students who are in their infancy of exposure in the hospital not only have the usual intense experience of learning how of integration into clinical medicine; they are also an integral part of the patient care due to the overall low number of nurses and physicians in the hospital. They are frequently the only ones to check vital signs; are responsible for placing IV catheters, drawing labs and filling out forms for investigations and updating the patient and family members outside of rounds.

Because nursing and allied health workers are scarce, the family, as in many resource-limited settings are integrally involved in patient care; her they involved in providing nutrition (including supplying and administering food through nasogastric tubes), administering oral medications, and much more. For those without loved ones, there is great tragedy and inequity in a system that relies so heavily on a patient�s family for basic care. At the same time, for patients who do have family, especially those with ongoing nursing needs at discharge, the family are often well positioned to continue care at home. It is ironic that because of the lack of trained health care workers; the families are more organically equipped to provide home health care.

I have been fortunate to have my visit here coincide with the Department of Internal Medicine's First "International Medical Update Conference." The three days of sessions have been high-yield learning from both local and international speakers on areas of clinical medicine that are not common in Massachusetts such as TB meningitis, as well as practical and innovative solutions on how to care for non-communicable diseases like diabetes and cancer in resource-limited settings. Beyond the individual clinical learning; the conference has been yet another reminder of what a privilege it is to work alongside and learn from the Ugandan internal medicine residents at MUST. Many of them presented their own research or areas of interest at the conference; I am so impressed with not only their intelligence but also their dedication. They not only maintain tremendous clinical responsibilities but also are committed to medical scholarship to real-life bedside-to-bench and back again

A few of the stellar internal medicine senior house officers

As my time in Uganda draws to a close, I'm really humbled by the opportunities I've had and excited to continue to keep of both the professional partnerships and personal friendships. I�m excited to work with Ugandan housestaff and co-residents at MGH who visit MUST on a handbook of clinical protocols that will help both visiting and local clinicians improve uniformity and quality of care for key medical conditions

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Medical Education in Uganda - Rebecca Cook, MD, MSc

February 7, 2013

This week we visited Bugoye which is a town nestled in the hills of Southwest Uganda. The MGH Global Primary Care Program is partnering with Mbarara University of Science and Technology and Bugoye Health Center to improve primary care in the area, particularly focusing on under five mortality. It has been a refreshing change from the dark and overcrowded wards of the regional hospital to learn about healthcare in action at a completely different level: in the community.

We have traveled with the village health teams home-to-home through some of the villages in the catchment area of the health center; learning the realities of the social determinants of health and how they are being addressed at the grassroots level. Village Health Team members are community members who are elected by their communities to be health advocates and a liaison with the health care system. They go home to home educating households on the most basic fundamentals of health; such as hygiene measures like a proper latrine, hand washing, and a drying rack for dishes.

The �tippy tap� a hands-free way to wash hands without running water

A women's group we visited in Bugoye has also received education in how to make indoor stoves out of mud that are more energy efficient and where smoke goes outside -- addressing two important aspects of health -- exposure to indoor smoke and environmental degradation through deforestation which affects rain patterns and soil erosion ultimately effecting the food supply. Interestingly, these women, of their own accord have made building the stove and other such "household improvements" a requirement for membership in the women's group � here they model ownership and support to make positive changes.

The Village Health Team at Bugoye is in the early stages of a new initiative: community case management of common childhood illnesses. A spin-off of the WHO Integrated Management of Childhood Illnesses IMCI village health workers have been trained in identification of danger signs in children, and appropriate basic management including treatment with basic antibiotics and anti-malarial and appropriate referrals. This week at a health outreach, we had the privilege of witnessing the unveiling of a drama they have written and perform in to help sensitize the community to this new initiative.

Village Health Team performing a drama to sensitize the community to new health initiatives

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