There is no tomorrow...there is only today!

 Today I leave Bangladesh so quite literally there is no "I'll do it tomorrow"...but in a more philosophical meaning, we should never wait to do anything until the proverbial tomorrow, life is short. I've seen my own share of life to have adopted that motto at an early age and as such it led to pursuing my interest which grew into a passion for global health and more specifically giving back to Bangladesh. The image you see above is a product of not waiting until tomorrow, until I had a full time job or was "established", I wanted to go for this unique opportunity that formed in my head because I knew even if I was minimally successful it would give me an opportunity to make an impact. Many of us forget why we chose medicine in the hustle and bustle of every day but here I had a daily reminder. With the help of quite literally ALL OF YOU this was made possible, you've helped pave the way to hopefully a long future of contributions to the continuing medical education of physicians here in Bangladesh and in the process you have helped to inspire others to give back in any way they can, for any cause!

A few parting pictures and experiences...

For those who were with me about the fear of the machine being stolen, this room is the ICU medical officer's area and is located immediately outside of the ICU. The room has a padlock for which only those who work in the ICU have. It is within close proximity and easily accessible for the exact group of people the machine was meant for! 

This was my last 1:1 session with the main critical care physicians who identified themselves as interested and willing to lead the charge. You might be wondering why I am not in this picture..well it's because both of these physicians felt comfortable enough to show each other all the exams they had learned with little to no help from me! 

So you may be wondering the same thing I am, what comes next? How do we ensure that the machine is used and that the learning continues ? On a micro level we are devising a distance learning curriculum that will include videos of me reviewing all the basic exams that were taught as well as videos of us teaching newer and advanced concepts. There will hopefully be an exchange of interesting cases and testimonials of how the use of the machine is helpful to maintain the interest in its use. And as time passes we shall have to formulate a more macro level idea to make this work without any of us at the helm...a truly sustainable project in that case. 

Signing off from Bangladesh! As updates come in and progress happens I will certainly continue to document them as I have here--and again, thank you thank you thank you to ALL OF YOU! No person can achieve anything on their own--it happens as a result of a community, a village of people who are directly and indirectly a part of every step...I am a big fan of my particular village of friends and family as it is your support that pushed me forward especially on the days where I wasnt feeling well or thought for sure that THIS would be the mosquito bite that led to my demise! 

BIRDEM, BRAC and beyond

 

Sign translates:BIRDEM general hospital 

This hospital initially was created as the center for research and rehabilitation for Diabetes but has now grown to encompass every subspecialty. It is also the place that critical care in Bangladesh started and so it makes sense that we provide a workshop here as well. As the sole trainer today and yesterday I was fearful that it may not go as smoothly but without fail the participants showed me again why this is so fun. The group was smaller approximately 13 physicians but the energy and willingness to learn was as emphatic as any other group. They quickly picked up the concepts and lamented about the older machine they have in their ICU though not as functional as what we used today they still get a lot of use out of it. It's conversations like this that really make it clear how useful this quality machinery is, how much it's needed and how prohibitive the cost is. So, as planned, we have been making every attempt to find a way to make these machines more available to the hospitals here. Cue the meeting with a local group who deals in distributing high quality ultrasounds such as the one we have acquired--the discussion we had was to start a partnership wherein our training sessions are sponsored , a venture which will allow us to continue our efforts. 

So those of you who asked or wondered--how will ONE fundraised machine make a difference? We helped to introduce a new use for an old technology and by doing so in places where it is really needed we have generated interest and a buy-in. Obtaining a machine is one thing but helping others procure one and ensuring the education and training is quite another thing all together and I think in the long run will be the key to success.

To add to the excitement of the day I got a chance to sit down with someone I am a huge fan of, someone who has changed the face of humanitarianism, who has been successful in leading the charge against poverty, Sir Fazle Hasan Abed, the founder and chairman of BRAC. To me he is Abed uncle, a kind soul who is my fathers friend and might remember me as the clueless grade schooler then medical student who naively wanted to  do something to give back to the country with no real focus. He said to me today "ah so now you've come back with a teachable skill"..hearing the interest in his tone was the most priceless moment. While the meeting was brief we somehow covered the origins of oral saline, how cholera was defeated in Bangladesh and a discussion on the importance of empowering the women in each household in Bangladesh.  

When I was leaving he shook my hand and hugged me and said "thanks for coming to visit" and I was speechless--how do you thank the man who spends his life stamping out Poverty, who created the largest NGO in the world--for making time in his day to talk to one of his biggest fans. The only thing I could come up with is--let's continue what we are doing and strive to do more for the people of this country. 

 

The food is safe to eat here it's the ICDRR,B!

 

We start each session by referring to our participants as Dr. (insert name) but then as each session proceeds everyone starts to become "apa" (big sister) and "bhaiya" (big brother). It's an endearing term and it again shows the culture of hospitality and family that everyone exudes, today's session was no less. We had a didactic and hands on session at the world renowned International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B). As the title implies this was an institution originally created to study and treat the cholera epidemic, they were responsible for the creation and distribution of oral saline solution (Orsaline) which has been my best friend through all four bouts of gi illness here. As time passed and cholera was stamped out of Bangladesh the need for further research and development continued in the areas of respiratory infections such as TB, nutrition, sepsis etc and ICDDR,B has continued to rise to the occasion. Check out their website for more info, it's truly incredible what they are doing. They are well funded, organized and willing to collaborate with others if the common goal is reduce the overall morbidity and mortality of the population. (Website: icddrb.org) we are hopeful that in the future we can collaborate with them in the areas of respiratory research and the use of ultrasound, time will tell! Either way we will love the chance to continue knowledge sharing and didactic sessions in the future as the need arises. As a token of their appreciation they gave us these shirts! It was very sweet of them to do so!

Tomorrow is a national holiday! I will blog about my experience of visiting the famous Shahid Minar as we celebrate Eykushe February (21st of Feb) also known as International Mother Language Day! The history of which I'll fill you in on tomorrow along with some pictures. 

Our 15 minutes...hopefully a foot in the door for a lifetime

 

We came with a plan. A pilot training session that was organized by contacts who are from other departments of the hospital but who are close friends of my family (special thanks to Tablu uncle and Sheuli aunty). Their persistence and ability to help make tangible something that started as an idea on paper was nothing short of spectacular. Along with the persistence of my parents, and my father especially who tapped on the shoulder of anyone he thought would be interested in such an initiative. And then certainly I cannot leave out our trusted advisor and fathers best friend the colonel(Salam uncle) and his wife Rekha aunty who have watched over us ever so diligently. This team created reality from a dream and I am eternally thankful but they also did something else. They helped us lay roots for the rest of our journey, they drew the attention of the media (newspaper clips above) and of the honorable Secretary of the Minister of health so as to allow such a training program to become formalized. We are moving in the right direction and now must start to build a lasting relationship with those in country who are eager to further along our goal. Future endeavors include more basic as well as advanced ultrasound training, advanced airway management, code training and ACLS training if needed, ventilator management and curriculum building for upcoming critical care learners, the list could go on. 

An update on yet another success story--this image was acquired by one of our trainers-in-training who had a patient with unilateral lower extremity swelling and he diagnosed a blood clot. I get the feeling that teachers have now when the hard work they put into their students pays off. It's a reward that's not really describable. 

 

It is also the last day that Syeda will be with us and here she is being presented a plaque from our team of critical care doctors at Dhaka Medical College Hospital.  We have been deep in brainstorming our future activities and are eager to plan our next trip hopefully with many more skilled trainers coming with us (open invitation!!) .

 

But our goal is bigger than just furthering the education of those in the critical care department or emergency room, it is to hopefully show other second generation Bangladeshis that they too can find something they are passionate about as well and pursue it. You don't have to be in the medical field to give back, you just have to find the path that inspires you. 

Hospitality knows no bounds in this country

 

We were given these wonderful plaques today after our final session in Sylhet but what the participants and organizers may never realize is that the memories and feedback was the best memento we could take back with us. For instance we taught lung ultrasound yesterday and by today the participants were discussing a case where the patient's X-ray didn't clearly show a pleural effusion (fluid around the lungs) but the ultrasound did show fluid very clearly. Since the participants came from all over Sylhet there were a few who are from institutions without an ultrasound but possibly the hospital has the means to purchase a portable machine. The Buy-in for these participants was pretty immediate and they were already discussing which patients would benefit and how they could convince their administration to procure a machine. 

I can say quite confidently that what we did here made an impact in more than one way and I know I speak for both of us (me and my cotrainer Syeda) in saying that seeing the excitement and enthusiasm on the faces of the participants is incredibly rewarding, but hearing they could use what we taught them practically was priceless. 

**the two pictures in the background are my paternal grandfather (Dr. Shamsuddin Ahmed, deceased and my grandmother Mrs. Hosnara Ahmad) 

Sylhet you have won our hearts

 

Coming to sylhet has had quite a bit of personal significance. Here in this city is the home where I truly feel at home, in my own space. It's where my mother stayed after she and my dad were married and where my older sister stayed as well before they both joined my dad in the states. This city where so many times we have come and paid our respects at the grave of our grandfather, the inspiration for many of us to even enter the medical profession, the city where my grandmother reigned as principal in the Women's college she helped build. It is about time I have to opportunity to give back in the place where he gave his life and where she dedicated hers to higher education before coming to the US to help raise all of her grandkids. And so with a tug at the heartstrings all day we proceeded with a tremendous workshop with medical officers who attend in ICUs all over Sylhet. They picked up the concepts quite quickly and we really enjoyed their enthusiasm as well! 

 

(**credit to Dr. Paru Patrawalla of Beth Israel/Mt. Sinai for providing many of the pathological ultrasound images)

 

(**credit and special thanks to Drs. Vikramjit Mukherjee and Deepak Pradhan of NYU for providing some of the slides for these presentations which were later modified)

 

Training our trainers

 

We can't teach a two day course and expect everyone to know what they are doing! So we have identified a few intensivists, the few who are critical care trained and always in the ICU, as our designated trainers. They need to be proficient in the basics and hopefully over time with the gracious offer from tbt nuclear medicine and radiology department they can continue to practice their skills. I can already say after just a few extra hours with them each day (beyond the formal workshops) we are seeing a drastic improvement.

Even bigger news we are seeing a huge change in the pre and post tests meaning that what we are teaching them is sticking!! 

Our next stop is Sylhet! We fly out tomorrow. While Dhaka holds a special place in my heart Sylhet does as well, it is where we all fell in love with the "desh" meaning the the country and its land. 

 

Beautiful tea gardens everywhere and the added bonus of my fathers childhood home where we will stay. Lastly but most importantly it is the city where my paternal grandfather was killed by the Pakistani army--he was a surgeon who was working in Sylhet during the war in 1971 and although he heard that the opposing army was approaching he stayed because there were sick people who needed him. For anyone who wonders why I stay late at work sometimes or try to go the extra effort it is because of him, in a way that is how I try to preserve his memory and efforts. I am really looking forward to having the opportunity to train and work in the home city of my grandfather and grandmother, two people who have had a tremendous influence on me.

Friday our day of R&R

 After our first few days went so successfully we were lucky to have a Friday to relax. In Bangladesh many people have just one day off, and that day is Friday. The traffic is lighter because people are out enjoying time with their families and maybe even outside of the hustle and bustle of the city. I am lucky to have a huge family many of whom still reside in Dhaka and in Sylhet. I got to spend some time with them this Friday and like every other day I have had here it has been a learning experience. The picture shown above is called "amer bol" which is like the bud of a mango tree. You can see the tiny green buds which believe it or not will turn into full grown mangoes. Well here's the best part this tree is right outside the window of my aunts house it is so close in fact that one fully grown she can pluck a mango from right outside her window and enjoy the tasty fruit. This fruit is by far one of my favorite things to eat in this country!

Then I moved on to my uncles house where I played a beloved game to all Bangladeshis, Karom!!...we were lucky to have a board at home growing up..it is essentially like billiards but with chips as the billiard balls and a larger plastic disc which is the equivalent of the cue stick. While I lost to the two people flanking me who are brilliant at this game it was a very lively and exciting time...and nice not to talk about an ultrasound for the day. 

 

Luckily my stomach was starting to feel better(save for brief projectile emesis..because what's a weekend without that!) and I was able to enjoy some delicious food all day..which also involved some interesting discussions at the dinner table. 

 

The topic of why families are not allowed in the ICU came up as well as end of life decision making. I have learned a lot about our culture just from seeing many Bangladeshi patients in New York and how they and their families handle end of life situations. It's not a topic of conversation that is normal to have but it is crucial as it leads to family members understanding the wishes of their loved ones, this takes the burden off of anyone who is tasked with making any end of life decision if ever the time comes to do so. The silent thoughtfulness I noticed as we discussed this topic, given the personal nature for so many of us sitting there, all with our own experiences--was a sign that what I had stressed about the importance of such a conversation was registering. 

It was a phenomenal day this last Friday. And it reminds me why I love this country and will continue to come back to try and contribute to bettering the delivery of health care. 

Successfully concluded our first two day workshop!

 

This was a particularly fun day for me since focused echocardiography is my favorite of all the exams we are teaching! It is a technically challenging exam to learn and to teach but I must say it went beautifully! Everyone was engaged and helpful to each other in the learning process. After letting the participants show me what they retained I was incredibly delighted to see that everyone was able to do so! 

As the long term curriculum continues to form it is really great to see two or three members of the critical care department step forward and take a leadership role. It means that we have a fighting chance at continuing the concept of training the trainer. 

After a long two days these are the faces of two people who need a long nap!

 

About three thousand mosquito bites in but nothing beats this first day!

 

The day started super early half because my stomach is finally starting to realize it's in a foreign country and half from anticipation of our first session. With all of our stuff in tow (including an emergency stash of medications,oral saline to stay hydrated, 120 CDs with some instructional guides, two ultrasounds and our extra projector because it's always good to be prepared!) of course we checked the existing projector yesterday and we checked it again this morning and everything worked fine..and then at game time as it always happens the projector connection stopped working! Long story short crisis averted and everything went very nicely. It was a bit of a surprise to us to see that the session today was kicked off by an inaugural ceremony with the president of DMC along with multiple other medical directors. It was a very warm welcome for us and they even made mention that this is the first session like this of its kind, meaning from a topic perspective as well as the first type of session organized by the younger generation (though with a lot help) and all female at that and we received gorgeous flowers! The principal even went so far as to say how proud he was that we as American born Bangladeshis came back to do something like this. It was really incredible to see such hospitality, but why am I surprised? In this most hospitable country you cannot go anywhere without being offered  a delicious cup of tea and my favorite, toast biscuit (pronounced tozt beescoot). 

The feedback was wonderful. The physicians were engaged and excited and grateful. What we probably could have done better is to get the instructional material to people earlier but the list of participants came much later. It meant spending a great deal of time on some basic concepts but overall people picked up the concepts quite quickly. 

We are energized by this good start and look forward to what lies ahead! There are a few people in the critical care department who have stood out as interested in becoming trainers themselves and ensured that they would pursue continuing medical education (CME) seminars to retain what they learned.

The flowers we received today. 

 

T-1 day until the marathon teaching starts!

 

We are happy to welcome Dr. Syeda Hasan, also Bangladeshi and  an ER doc at Beth Israel! While we have never met in person before today her being here highlights the power of social media! Since we have so many people in common she noticed the facebook post when a dear friend shared it one day. She reached out and asked what the project was all about, and she said "you know I've been looking for something like this to do". It was one of the best things to hear someone say that about something you've poured so much time and effort into and I thought ok maybe next time she can come and be a part of this but she cleared a few weeks of her schedule and booked her trip to come to Bangladesh. 

So we embark tomorrow on our first training session with varying levels of anxiety and excitement. AFTER ICU rounds today at Dhaka Medical the two critical care anesthesiologists who are championing this project with us had at least four cases they wanted to immediately use the ultrasound for.

1. A boy with a suspected pneumothorax but an unclear CXR

2. A questionable diagnosis of heart failure

3. Possible fetal Demise and wanting to assess for movement or a heartbeat

4. A patient with fever of unknown origin and unclear diagnosis of the etiology  

After tomorrow hopefully all of those types of questions can be answered. 👍 

As for the rest of the month we are booked solid!!

2/8-2/9: Workshop at Dhaka Medical College Hospital

2/11-2/12: workshop at Dhaka Medical College and Hospital

2/14-2/15: workshop at Sylhet Medical College and Hospital

2/18-2/19: workshop at Bangabhandhu Sheikh Mujib Medical University 

2/20: one day session at the international center for diarrheal disease, Bangladesh (ICDDR,B)

2/22-2/23:  workshop at BIRDEM

2/25-2/26: workshop at Dhaka Medical College Hospital

These sessions in total will help train up to 100 physicians!!!!!!!!

Save the drama for your mamma, not my ultrasound!

 

You will all wonder how a machine this small can cost SO much. But that is the price we pay for now for good solid technology! I have finally exhaled for the first time in about three months as the stress of getting a machine to a foreign country had me holding my breath! But this machine you see before you is not the purchased machine--enter the drama of the last two weeks. As we recently learned there was a delay in processing the order as Sonosite is not profiting from selling this machine to us at more than 50% less its actual price this led to a few red flags at the headquarters in Bothell Wisconsin..where the machine was to be shipped from. So. Imagine the anxiety! Thankfully I still hear my mother's voice in my head to always be prepared, it's why I almost always have an umbrella with a slight chance of rain,  an extra layer of clothes when it's cold out, and a pen in my purse bc well you never know. So, with that in mind I had pre-requested a loaner machine in the off chance our purchased machine didn't make it on time.  Fast forward to today we have received the loaned machine and a second machine free of cost for our training sessions which we will return at the end of the month!

The good news is the ultrasound which all of YOU purchased is in the country and will be processed and in our hands in the next week.

Needless to say this whole experience on many levels has been a learning experience.

As for me--I am enjoying the ability to set some professional roots here for future projects. Though truth be told I have a long way to go to speak Bangla as well as I'd like, though fluent for the most part the mental translation that has to happen in order for a well structured sentence to come out of my mouth is quite exhausting. Luckily, the doctors here speak and understand English and we don't have to worry about translating complicated  medical terminology. 

On a bit of a funny and personal note, I have been running a great deal here to make up for the food I have been eating, all home cooked and incredible. Where I am staying is a quite safe area as it is enclosed and essentially under military guard as it is a development for army officers. As I go for my morning jog a normal activity for so many in the US, I am greeted with funny looks and people peeking behind me to see who I am so leisurely running away from...but truth be told, with the degree of "dhula" (dust) here I can understand why running outside is not so commonplace.  What I envision or rather really hope is that a few people start running along with me like in Rocky...I can just hear the music in my head now...for those of you who were possibly living under a rock during the 80's look up "eye of the tiger" and then imagine me running, for dramatic effect imagine me in a Sari, with a gaggle of Bangladeshis running behind me...and hilarity ensues. 

Tomorrow, the dry run!! We will haul the ultrasound to Dhaka Medical to practice our workshop!

Physical Therapists and Pharmacologists Wanted!

 

A little plug about my favorite international organization: 

BRAC one of the largest NGOs in the world based out of Bangladesh is a tremendous organization which has done so much to further the people of Bangladesh. One of their initiatives was to use recycled hand made paper to help prevent environmental degradation by targeting the corporate urban market in Bangladesh and to recycle their paper waste. This enterprise had a second function which was to support a small group of drop-out female students from BRAC's education program by providing them jobs at the production facility of this enterprise.  With this paper such creative products are being made like this tiny notebook which I then purchased at one of the plant nurseries that BRAC has in the city. 

Fast forward to today, as I scribble my thoughts and ideas on this beautiful recycled paper about what else we can do to better the delivery of care a few things stood out. First off I should mention that I rounded in another ICU with the father of critical care medicine here in Bangladesh, Dr. Mohammed Omar Faruk. The set up of this ICU was similar to Dhaka Medical--much like an emergency room bay with beds separated by a curtain. A few differences, there is one bedside dialysis machine available, an ultrasound at the bedside is available. Obtaining imaging is most certainly easier(I discovered as the team without hesitation appropriately ordered a repeat CT head on a patient) which is likely related to the patient population here being financially more stable. That said I noticed three things in particular. 

1. There were no families at the bedside

2. The number of "big gun" antibiotics being used far surpasses what most of our US patients are started on for similar diseases 

3. There are no chairs for able patients to sit in and very limited physical therapy 

Issue #1: why are there no families at the bedside? I shall need to investigate this further as the thought of not being able to spend time with a critically ill family member, conscious or not seems a bit difficult to fathom

Issue #2: as it happens multiple studies have shown that multi drug resistant organisms here in Bangladesh are quite prevalent, is this secondary to years of  an absence in antibiotic stewardship? Possibly. This will need to be a huge area of development and I call on my friends in the pharmacy world to help us come up with some solutions 

Issue #3: as more medical advances are made people are living longer. A stay in the hospital let alone the ICU can cause prolonged fatigue and weakness. A stay in the ICU which is often prolonged can lead to severe, measurable weakness, a state which has been deemed ICU-acquired weakness. Just getting out of bed to chair let alone extensive physical therapy can be useful  and yet the mechanism does not really exist here. The need is most certainly there and we need to put this on the future agenda!!!

Discrepancy in health care

I had an incredible meeting with an emergency medicine physician here who has joined our team. She is from Bangladesh, was trained outside of the country and came back here to work. She is like-minded in her pursuit of bettering the medical education and training here but unfortunately the field of emergency medicine, believe it or not Is still very very new here. Mostly patients are being triaged and theres a limit to how much treatment or resuscitation they are receiving. This is problematic because many disease processes require immediate attention and it's why ER physicians can do just about anything because they see such a variety of patients and they need to act right away. For example we know that the mortality of a patient with sepsis is improved if appropriate IV fluids and antibiotics are given in the first hour; And typically that first hour is when they are being evaluated by an emergency physician, and it is the ER doc who is providing those interventions first. 

Fast forward to my meeting today. I met up with this physician at one of the private hospitals where she works. A position she chose because it is one of few places that has an ER program.  The hospital itself is beautiful. As you pull in to the main driveway you are greeted by a sign advertising the availability of an on site PET scan (a type of CT scan often used when evaluating nodules or masses for their degree of metabolic activity which if high is most often concerning for malignancy though can be associated with other processes such as infections). As you walk in to the entrance of the building you see a sprawling lobby with a coffee kiosk. I thought I Star-Trek style teleported back to the US until the ever so familiar buzzing of a mosquito reminded me where I was. In my mind I pictured the entrance to Dhaka Medical (DMC) families and patients lining the halls because of a limitation of beds and space and again realized that the resources available at this private hospital will never reach the masses of people at DMC. And then my mind wandered to Bellevue in NYC where efforts are made to obtain the maximum amount of care  despite a patient's financial status. It occurs to me that no matter how flawed our health care system in the US it does allow for better access to care relative to how things work in so many other parts of the world. 

I can't save the world. I can't save health care and the limitation of resources in Bangladesh. But, here's what I can do: I can draw attention for those interested in doing the same kind of work and together we can spread medical training and education. And as we all know, education is the gift that keeps on giving. 

Inside DMC

 

Inside a private hospital