Poverty strikes no matter how beautiful the country

A beautiful shoreline greeted me this morning. We arrived safely back in Freetown late last night after a 7 hour bus ride across the country. We passed gorgeous country side and witnessed a magnificent sunset:

But, not far from our thoughts was the chaos we had left behind in Bo. Though many of us have been physically challenged by the surroundings, from GI upset to Asthma exacerbations, these were small challenges that we were prepared for and will never stop us from continuing our work. How easy it is for me to reach for my inhaler or antibiotics when needed—a fact I appreciate more than ever after spending a week here. We are lucky and privileged to have the embarrassment of riches in our own country, should it not then be our responsibility to give back whatever we can?

Leaving these missions always induces a mix of complex emotions. I selfishly feel glad I will sleep in my own bed and eat, free of stress over whether or not this meal is the one to send me to the bathroom for days. Simultaneously I feel awful that I have a choice. We will all think back to the harrowing sights that stay with us and motivate us to do more, because the inflictions on the human condition do not rest. Meanwhile in Yemen a famine rages, and we wonder how can we give more, how can we contribute. The day I opened my eyes to the devastation that our fellow human beings undergo, and I mean really open my eyes and SEE it in person, was the day I vowed to never take my comfortable life for granted—that those of us who are lucky to be the “haves” should logically be the ones to to help the “have-nots”. 

Let us not forget what we have seen, what we are capable of and how much there is to do. 

On this mission we had a team of surgeons both Ob/gyn and general surgeons who were able to provide life saving surgeries as well as help teach and train the local surgeons. Some of the challenges they faced were the lack of operating room lighting. Can you even imagine!? That an error from surgery may be due to lack of light. How quickly I change a light bulb in my own home when it dies. There are no retractors to help maintain a large field of exposure—one of the keys to surgery is being able to see as much as you can in your field so you know what blood vessels and organs are nearby. Both of these things are easy enough to arrange and MedGlobal is working on how to potentially provide these.


On the medical side our docs have seen and treated diseases from typhoid to malaria to diabetes and high blood pressure. We were able to provide free medications and donate a very large supply of medications upon our departure. Challenges faced were numerous—misunderstandings and stigma behind certain diseases, the instinct to turn to herbal remedies for life-threatening diseases with a cure. Our team did a wonderful job treating and counseling patients, each of them working with a local community health worker. 

On the educational side we provided training for over thirty health care providers, from doctors to nurses to community health workers. The challenges we faced revolved around tailoring our training to the paucity of resources. This meant getting creative and brainstorming ways to improvise with what IS available.  We were able to provide a brief ultrasound training to those with access to ultrasound and focused heavily on the recognition of sick patients and intervening early. We trained local physicians so that they could then re-administer this course thereby creating a path to sustainability. The most exciting part for me is the ability to stay in touch through social media and communication apps such as WhatsApp. Already I have received requests to share educational materials and training videos! 

As I sit here and reflect on this trip I can’t help but think about where I’ll go next and how I’ll take the lessons I have learned here with me. I am hopeful that we were able to start something here in Sierra Leone that will have a lasting impact as MedGlobal continues to come back. I am hopeful that in training one person to manage acutely ill patients that we have saved the lives of those they encounter. I am hopeful that I will return soon and continue the work as there is still so much left to do.

Signing off from Sierra Leone. Up next, Dhaka, Cox’s Bazaar and Khatmandu in February. 

“People go to the hospital not expecting to make it out alive”

The health care system here is riddled with problems. I don’t think I have ever encountered such a limited setting and so much poverty. We each came with a role, some to perform surgeries, some to see patients in primary care, and some, like myself, who came to train local physicians. We each felt the frustrations of working in such an impoverished country where the supplies we bring are coveted like diamonds. To be clear this country does not lack the human resource nor the ingenuity and sheer intelligence it is the physical and financial resources that are missing. We cannot swoop in with just money or physicians for such a short time without a plan. The plan is we come, we work, we scout and collect data so that we can make this a successful site in future visits. The first visit is always a bit rocky and we have had our share of hiccups but each hiccup was a lesson learned. 

While so many cases were devastating, such as the children dying of treatable diseases like malaria with complications such as cerebral malaria, or a patient with meningitis who didn’t survive the night or the case of a woman with cervical cancer who has no options for chemo or radiation—our docs saw some incredibly painful cases. Yet there were some incredible saves like the young patient with appendicitis who had her appendix taken out by one of our surgeons or the diagnoses of acute HIV before significant complications. Then there was the unbelievable gratitude and appreciation from the local physicians and community health officers who sat through four days of lectures and practical skill building sessions, hanging on to every word and asking for more—there were successes and there were learning opportunities but never any failures.

In the end we realized that the poverty here is at a level that feels insurmountable, presenting challenges in the delivery of our care and educational interventions, however that has just made us all want to work harder to figure out how to come back and do more, create more impact and hopefully help the Sierra Leoneans slowly chip away at health care inequities. 

Pictured here: the crowd of patients waiting to be seen. 

Though there are so few resources their intelligence and ingenuity abounds

Today we launched the first day of the BASIC course in Developing Health systems, with health care providers from all across Sierra Leone. The group was close to 50 people who have come from up to 6 hours away in the name of education and improving the delivery of health care. This group includes physicians and nurses and community health workers (CHW). The CHWs are folks who have finished their primary and secondary schooling and then have attended three years of training. They may see patients in the clinic or in-hospital and trust me when I tell you, they can diagnose malaria and several other disease processes endemic to this area than any physician plucked out of the US and placed here. We are not only teaching them but we are learning from them. Today I learned that while Malaria is a huge problem here it is of course treatable but often times those inflicted will not seek medical attention out of potential distrust for medical services, instead they may seek out herbal remedies and then when they potentially do seek medical attention they are then presenting with evidence of herbal toxicity AND malaria! 

In our session today we talked a lot about how to recognize sick patients and being able to prioritize who needs attention first. We received all sorts of relevant questions regarding how to manage patients within the limitations of each hospital. The frustrating part is to see the sheer intelligence and motivation to do good but the limitations often feel so insurmountable. 

Regardless of the fact that so many of the health care providers seen here work in settings without an ICU, the truth is the same level of sick patients exist regardless and this leads to a significant degree of ingenuity. One of the skills we will review is the insertion of a chest tube into the pleural cavity to drain fluid from around the lung. These are tubes with holes on the end that goes into the pleural cavity, and they usually come in a kit and are attached to a drain that collects whatever comes out. These kits are most definitely not available here but urinary catheters are available—and they similarly have holes on the end. These urinary catheters are easily available and are used in lieu of expensive chest tube kits, the drains are make-shift as well and the solution is a successful one when needed. 

While many issues are not possible to overcome with just ingenuity the importance then shifts to discussing when a patient is too sick to keep where they are, and discussing where they should be referred for a higher level of care, but this comes with high expenses and several transportation limitations. 

By the end of the day we had reviewed several key concepts regarding how to manage sick patients. The local trainers that we have helped prepare were running the simulations and skill stations with ease, proving to us that they are more than ready to run this course in their respective cities and hospitals, which means this course could have exponential impact in a short period of time!

From the US to Freetown to Bo—two days of travel and we have arrived

Departed Philadelphia at 630 pm on 11/2, reached Paris in 6 hours where I met several of our 25-person group. Immediately greeted by friendly faces, as if I knew them all from a prior life. 

Sharing stories from prior trips, sharing our apprehensions and glowing about our supportive families and/or significant others left behind led to a quick bond. We each reminded each other to take our anti malaria prophylaxis and shared war stories from the slew of vaccines we took prior to our departure.

Finally we arrived in Freetown, Sierra Leone close to a 24 hour travel day later...with a ferry ride from the airport to the hotel as the only thing left between us and our beds. The hospitality in this country is immediate, a crew of Sierra Leoneans ready and waiting to receive us, smiling and grateful. We were taken to the ferry dock and greeted by this bridge—dark on the other side, slightly rickety—a metaphor for this trip...it’s the first mission to Sierra Leone for Med global and of course there’s always an aspect of the unknown no matter how much planning, and let me be clear there was A LOT of planning on the side of our fearless leaders here! 

We arrived at our hotel, a beautiful little place by the ocean called Sierra Palms, scurried to dinner and then put to bed to prepare for the next morning. The next morning our Sierra Leonean liaison Josephine (without whom this trip would not be possible), introduced to a rep from the Health Ministry and the two of them discussed cultural sensitivity. The topic is so crucial, there are so many gestures that we find common and “normal” may seem offensive—the simple act of a female shaking a male’s hand. Although some of this came from the Ebola era and encouraging folks to practice strict hand hygiene, the fact remains that what we may find a polite gesture may come off the wrong way. Furthermore keeping in mind that Ebola left a huge scar on the people of this country—families wiped out, nearly 30% of physicians wiped out, communities crippled, people are still healing, PTSD is not uncommon secondary to the atrocities this country has seen in the last 20 years. 

After the morning session we set off for Bo town, a near 6 hour drive through lush country side, rich with greenery a stark contrast to the poverty within it. We passed some towns that appeared completely abandoned and I wondered if this was an area that was effected by Ebola—what a clear nightmare to the region, a country so beautiful it feels so cruel to have undergone such devastation. 

Though these trips have mixed sentiments, often feelings of hopelessness and frustration, can we really do enough? The saving grace is the company, my fellow bus buddies, like-minded folks with similar energy and passion. The ride was long but full of inspiring stories and ideas for how to make the world a better place—and quickly I’m reminded, of course we can’t ever really do ENOUGH, there’s always more, but we are all in this together, along with so many others across the globe, from all walks of life. 

We are all brimming with excitement for what the week brings, and looking forward to sharing it with you all. 

Bo town in Sierra Leone, the next stop!

Looking forward to the next installment of sustainable global health education as a team of us from Med Global embark on the first mission to Sierra Leone!

My role in this trip is to help train local physicians in the management of acutely ill patients using a template  called BASIC developed by a wonderful group in Hong Kong. We are using the version for developing health systems which is being tweaked based on available resources. The key is to build capacity not build physical resources that over time can’t be maintained.

Taking off from Philadelphia tomorrow so stay tuned with more to come!

Reflecting Back and looking forward: another success for sustainable medical education

My last day at Black Lion Hospital in Addis Ababa was bittersweet. It has been an exhilarating two weeks with the exhaustion and jet lag now an afterthought. Practicing medicine in various countries comes with consequences—GI upsets, political strife depending on the location, local infectious diseases—but seeing the fruits of your labor is well worth whatever inconvenience there may be. Come prepared for what may be in store and none of those consequences are very burdensome because at the end of it is the best freaking prize of all: a lasting impact (or so I hope). 

We started the day just like any other. There was one new admission in the ICU. A young man who came to the hospital after being started on medications for Tuberculosis (TB). He was recently diagnosed with HIV and at that time was also found to have TB as well as potentially two other infections which only attack patients with such compromised immune systems. The TB medications have the potential to cause injury to the liver, this is a common adverse event and is very manageable. This patient was admitted to the hospital because he was confused and delirious, something that seems to have been worsening for days. He was found to have some degree of liver injury though minimal, and significant kidney injury as evidenced by alterations in his blood tests as well as the fact that he was making close to no urine. His blood pressure was low as well. The initial team to treat him prior to his transfer to the ICU treated his confusion as if it were a consequence of his liver injury (we see this degree of confusion with liver injury much worse than what this patient had). Upon transfer into the ICU the patient’s treatment regimen continued. So I asked the team today to explain how such minimal liver injury could cause his confusion, and why did we hang on to the bias of the prior treating physician. Immediately light bulbs went off—this patient has a severely compromised immune system and could have an infection in his central nervous system, or maybe he has a new bacterial infection causing sepsis. While we should certainly take into consideration the diagnostics of the prior treating physician as the team now caring for this patient we must look at him with fresh eyes!

And so we proceeded to discuss his case. Why was his blood pressure low, was he on the right antibiotics, did we give him enough fluid, why aren’t his kidneys working? As each question came up the fellow urged the team to use the ultrasound for guidance. With the help of the ultrasound the team gathered two critical pieces of information. 1. The urinary catheter was not correctly sitting in the bladder and thereby blocking the flow of urine 2. The patient did not receive enough fluids to treat his underlying infected state 

Both of these issues are easily fixable. By the afternoon there was a marked improvement in the patient’s clinical status. The key to this story is that while throughout the week the team has been using the ultrasound I have been heavily guiding them and giving them tips to help get better images of the heart or lungs, while today the ultrasound exam was successfully completed without one word of guidance. What an amazing parting gift—to see that the extra hours of practice in obtaining images and interpreting them has changed the way they are practicing. 

I left feeling fulfilled—I set out with a goal and this team far exceeded my expectations and will likely continue to do so as we will remain in touch—sharing knowledge and difficult cases so we can all learn from each other over time. All made possible by the glory of the internet :-)

I look forward to hearing about how the program grows and builds itself as the intelligence and capabilities are present and am hopeful I will have the chance to return in the near future. 

(One of the critical care fellows performing bedside ultrasound on his own) 

Our Severe Malaria Patient Has Recovered! Some psychologic trauma remains from her ICU stay.

For days now I have referred to a young woman who came in with Severe Malaria and Severe Sepsis complicated by kidney failure. She is the patient who taught me about being prepared during an intubation for the failure of oxygen delivery. She is the patient whose physical exam findings didn't quite fit one diagnosis and the use of the ultrasound to look at her heart and lungs provided our team with a tremendous amount of information that has been helpful. Every day she has been improving, two days ago she was extubated, meaning she was taken off the mechanical ventilator given improvement in her respiratory failure. Her kidneys have started working again. She has a clear mental status. While rounding on her yesterday the team mentioned that she occasionally becomes tachypneic (meaning her respiratory rate increases) and they were worried that she would need to be intubated again. We examined her, looking for any indication of why her breathing was rapid. Of note, here at Black Lion Hospital gowns are not readily available for the patients. In the US we go through patient gowns sometimes multiple times throughout the day without hesitation. Here, patient gowns are limited. This means they are often covered by a sheet or sometimes not at all if linens are scarce. The ICU here and in most resource limited hospitals has an open floor plan. There are no curtains between patients let alone large private rooms like we have in the states. Imagine as a women especially, not having a cover over your chest--as multiple physicians, males included come in and out of the area you are staying in. It can be traumatic enough to be in an ICU with foreign noises and smells and people constantly probing you to check your temperature, to check your blood pressure etc. It occurred to me that this young woman was breathing rapidly from anxiety--her eyes were wide, she would shake occasionally as well and it seemed she was terrified, and OF COURSE SHE IS! Anyone would be terrified given what she has gone through, who knows what she does and does not remember of her stay here! What I learned is that Ethiopia has over 80 dialects!! Amharic is the most common language but many people that come to Black Lion do not speak Amharic and there is a language barrier--so I cannot even verbally help her to relax. In the interim I asked the team to make sure she is covered at all times, that she can see the sunlight and that family is at her bedside to help comfort her. In the midst of all the medical complications she had we lost sight of such an important fact that the patient we treated, and treated successfully is a PERSON and psychologic effects of an ICU stay are very common and have long term effects.

I am excited about her recovery and hope that she continues to do well. The team worked tirelessly to play the roles of physical therapist, respiratory therapist and physician as they often have to given the limitation of staff in those fields. They used every resource available to their advantage, from the new ultrasound skills they learned to their advanced physical exam findings.  They advocated for the patient and they are now recognizing more readily signs of pain, agitation, anxiety. The excitement for me is to see the application of the conceptual teaching that has occurred through out the last two weeks. I look forward hearing about their continued progress over time.

Modifying Evidence Based Medicine to Fit into the Resource-Limited Setting

In the ICU there is an entity called Acute Respiratory Distress Syndrome (ARDS) which has been the source of years of research and consternation. It is a process that occurs usually following an infection or trauma causing significantly low oxygen levels which often do not improve with just intubation and mechanical ventilation but require special settings on the ventilator to limit injury to the lung as we allow time to pass giving the lung a chance to heal. That's the short story of ARDS. Over time many different mods of mechanical ventilation have been tried, many medical therapies and one particularly interesting therapy called Proning. This is the act of turning the patient from laying on their back to on their stomach. This allows areas of the lung that are not receiving oxygen to receive oxygen. ARDS is defined by criteria that require obtaining an arterial blood gas and the act of proning the patient requires multiple staff and the ability to closely monitor the patient thereafter. This background is important as a new patient was admitted in the last day with a recent diagnosis of pneumonia and now has developed ARDS. A few challenges-we do not have a working machine to check a blood value called an arterial blood gas that would give us the level of oxygen in her blood stream. The oxygen saturation which displays on the monitor should correlate to some extent but this is not nearly as accurate. Furthermore, as evidenced from the last two cases the steady flow of oxygen is a problem. When a patient is proned they should be left this way for 16 hours and then turned on their back for 8 hours and this is continued for variable duration. This whole process, making particular changes on the ventilator and turning the patient on to their abdomen requires the patient to be DEEPLY sedated so that their respiratory muscles do absolutely no work and the machine does the most of it. Here comes another challenge--the availability of medications to be given so frequently. (in the US these medications are given on a continuous basis) OK so. where do we go from here then?

Being in a resource limited setting we had to come to a few large conclusions--we have to use the oxygen saturation (which is measured by an infrared probe placed on the finger which then projects a number on the monitor and this is supposed to correlate with the level of oxygen in the blood stream stated simply, but again is not nearly as accurate as the blood value),  we may be limited with staffing so this act of proning must be done with full staff available. We need to find out how frequently she requires a dose of pain/sedation medication so we can schedule this accordingly. It took some time and some coordination but, for one of the first times in this ICU a patient with ARDS was placed in the prone position with almost immediate improvement. Will the patient do well in the long run? That is yet to be determined. But the lesson here is two fold-one, many of the papers published in our field that provide guidelines and recommendations for management are not applicable everywhere, almost always their implementation is limited in resource poor settings and we must remember to modify our approach in such settings. HOWEVER--given the right effort and coordination those modifications may provide a way to bring evidenced based medicine to the resource limited setting and maybe, just maybe provide one small step in improving outcomes.

 (All pictures taken w/ permission, no identifying features are shown) The first image highlights just how many people were necessary to turn the patient. This requires making sure all of the IV lines are in place, that the breathing tube is held in place and the the urinary catheter is in place while the patient is turned. The second image shows the patient successfully proned.

Oxygen Supply Strikes Again---The Ultrasound To The Rescue

As many of you may have noticed with the endless facebook posts of Elephants, I had the weekend off and was able to spend every minute of it doing some incredible things. I took a brief two hour flight to Nairobi, obtained my Visa at the airport, was certain to have evidence of my yellow fever vaccine as Ethiopia is high risk and this is needed for entry. I then enjoyed the heck out of an abridged safari through Amboseli National Reserve (about three hours outside of Nairobi depending on how traffic behaves) with some incredible views of Mount Kilimanjaro as well as a variety of wildlife, including my favorite, ELEPHANTS! Our Safari Jeep got stuck in some mud and we had to be towed out by park rangers..but I enjoyed the adventure, Hakuna Matata! But as most weekends do it ended with being back at work Monday morning with so many stories to share. 

We had a fantastic morning with a few new patients that came over the weekend with some interesting yet sad stories to tell. Rounds are the act of seeing patients with the team of doctors managing them. This includes the residents(physicians training in Internal Medicine), the fellows (who are training to be Pulmonary/Critical Care physicians)and then me. Each resident carries a patient and that patient is presented on rounds every morning.  The presentation is when the resident details the patient's history, physical, laboratory values and imaging as well as formulates a plan to address the pertinent problems with a goal of advancing the patient one more step towards recovery if possible. Each presentation today had an added portion to it---the Ultrasound Exam! What a feeling of pride I had today hearing the residents discuss their Ultrasound findings, an extra step they took with the guidance of the fellows, to use their newly acquired skills to help manage their patients. This has led to the diagnosis of a blood clot in a large vein in the leg of one patient, has helped identify why a patient's oxygen level is low and then was acutely helpful in a scenario in which the lack of certainty with oxygen delivery was again highlighted! 

After morning rounds some of the fellows very kindly took me for a traditional Ethiopian lunch. The 

dish you see below is a very classic one, injera (the wrap like carb that is the base) topped with several variations of chick-pea based items and some vegetables. You use the excess injera on the outer portion of this dish as your "spoon" using it to sop up the various deliciousness seen below. I can tell you this gesture means so much for them to treat me and their generosity and kindness is so appreciated. We ended our meal with a fragrant cup of coffee and returned back to the hospital.

As we were returning from lunch one of the fellows received a distress call from the residents who are the bedside of a patient who just this morning I had shown one of the first year fellows how to place an ultrasound-guided Intravenous line, one that goes into a central vein (the internal jugular vein in the neck), called a central venous catheter. One of the complications of this catheter placement is that you are potentially close enough to the lung to cause a nick in the lung and collapse of the lung which we call a pneumothorax. Upon arrival to the bedside the patient's oxygen levels (called the saturation) were low and she was hypoxic to 50% (normal saturation is 98%), the fellow quickly looked with the ultrasound for a sign that helps us rule OUT a pneumothorax, she breathes a sigh of relief as this was her first successful placement of such a catheter and to have a procedure related complication would have been very upsetting for everyone. So now we start trouble shooting. Earlier in the day we had noticed that the patient has a lot of fluid in her lungs so we treated this with a medication called a diuretic to help her urinate so she can rid her body of excess fluid. Meanwhile we checked to see if she had a lot of mucous in the breathing tube--nope she did not. We thought about blood clots in the lung as well. 

We used something called a Bag-Mask-Valve or Ambu-Bag, which is when we remove the patient from the ventilator and use this device you see here (which is attached to a different oxygen tank) and in using this manually her oxygen saturation increased very quickly. We attached her back to the ventilator and again her oxygenation saturation dropped rapidly. 

The machine was reading 21% oxygen (room air is made up of about 21% oxygen), however we had set the machine to give her 100% inspired oxygen. What in the heck?! This is when it struck me. THE OXYGEN! there must be a leak somewhere. We checked the tubing there were no holes, we immediately called for someone to help us change the tanks, continuously using the Ambu-bag to maintain her saturation level. 

Once the new tank was connected the machine read 99% showing us that now the intended level of oxygen for her to receive was indeed what the machine was sensing and her oxygen saturation remained at an adequate level.  

Another day of being kept on my toes, another day of realizing how incredibly gratifying it is to see that our daily practice with the use of the ultrasound is now becoming part of their repertoire, and it is MAKING A DIFFERENCE. Being a teacher comes in all shapes and sizes in all professions--it's part of taking a skill and knowledge that you spent your life learning and sharing it with others for the greater good. 

Incorporating end of life care and hospice-a national challenge

We have been rounding on a young man with a devastating outcome of a type of Guillan Barre Syndrome. He hasn’t recovered any of his strength and is dependent on a ventilator. The neighboring patient similarly came in acutely ill but has not recovered and is chronically malnourished, with muscle wasting and a grimace that seems permanently on her face despite how much we try to control her pain. Both patients have bed sores which developed while in the hospital, likely due to lack of staffing to turn patients as frequently as they should be turned . I know that I don’t have any real chance to offer them a road to recovery and so every day I urge the students and residents to pay close attention to all non verbal cues of pain and anxiety. In the US this is done expertly by the nurses who follow a protocol which is meant to ensure proper control of pain and anxiety as being in an ICU, on a ventilator is very traumatic. Studies show that those that survive an ICU stay have significant psychological trauma from the under treatment of pain and anxiety leading to severe PTSD. In many cases when we have patients we cannot fix, maybe a patient with overwhelming sepsis with a background of a devastating cancer or end stage liver disease with no chance of transplant, or so many other disease processes where no meaningful recovery can be achieved we discuss the potential for comfort guided care and Hospice. The services provided are so incredible for the patient and the family and it is again something I used to take for granted. Here, these two patients I mentioned would benefit from Palliative care and Hospice however there is no mechanism for this and no structure of inpatient hospice or outpatient hospice. In fact, the case of the first patient with Guillian Barre, he has close family who want to take him home, meaning they understand that this means removing him from the ventilator. The desperation is clear, they feel it too, there is no meaningful outcome for him so why keep doing what we are doing, in a setting (the ICU in a hospital) which causes so much anxiety and pain. Instead of being able to discharge him to hospice his family had to sign the equivalent of an “AMA” form (Against Medical Advice) to take him home which is an 800 km travel distance. We made it clear he may not survive the transport but that it is best he is with family. Ideally in a scenario in the US where we discontinue the use of the mechanical ventilator we discuss the process of what will happen and have pain medications (which can also be used to treat breathlessness) ready to keep the patient as comfortable as possible with the minimal amount of medication. Unfortunately given that this patient is technically leaving AMA we are unable to provide him with any of these medications. This was a difficult thing for me to come to terms with as I have actively been a part of the process of discontinuing life support in settings where comfort-guided care is chosen as the mode of treatment, those who heavily rely on life support may pass quickly—as this patient likely will. If not prepared this can be traumatic for the patient and the family as the patient appears to be and likely is in great distress. Our job as the clinician is to allow the natural process of death to happen, not to hasten it but to allow as much peace as possible.  I can only hope however he passes that it is as peaceful as possible and that he feels the presence of his family and the breeze of the cool Ethiopian air as he attempts to make it to his home.

When I asked what the obstacles were to pursuing hospice and palliative care the response was seemingly frustrating to the Physician who clearly has been campaigning for such a system. He said that this has to go through Parliament and that process not only will take time but he did  not feel optimistic that it could happen. So what is the trickle down effect of this? Well in cost-effective terms—over utilization of resources. In human terms—prolongation of suffering. That said we are trying our best to provide the most comfort to the patients who we know can’t recover, being even more thoughtful about interventions we provide in thinning about the true benefit they provide. The collective hope of all of us here in the ICU at Black Lion Hospital is that in time such services will be available. 

And just like that, I'll never take electricity nor the steady flow of oxygen for granted. Here's why.

No matter how many times I work in a resource-limited setting I am always absolutely blown away by the ingenuity of the medical staff I work with. They take being prepared to a whole new level. My brain works in a certain way(and if you're in critical care, chances are you may think in the same manner)--it goes like this: identify the scenario, identify all possible options to manage the scenario, proceed down the best path, anticipate EVERYTHING that can go wrong, assume it will, take solace in being prepared when it does go wrong, be relieved if it does not. It means your brain is going a mile a minute but externally you remain in control, block out the noise and map out your next move seconds before you execute it. So why all the back story on how the brain of an Intensivist works? Let me tell you. 

What you need to know before you read on: Intubation means placing a breathing tube in someone's mouth which goes into their trachea and allows a ventilator to breathe for the patient. In the best of scenarios this can be difficult, in the worst of scenarios this has the potential to be terrifying. Hemoptysis is when a person coughs up blood. Coughing up blood makes it challenging to see the vocal cords when you are trying to intubate someone as the vocal cords are one of the landmarks to identify so you know where to put the tube. The word hypoxic refers to a patient having low oxygen levels. OK, read on. 

Rounding in the afternoon on our patients. We had our eye on the young lady with questionable severe malaria versus severe sepsis (widespread life threatening infection ). She looked more sleepy. Her respiratory rate was 40-50 breaths a minute. She needed to be intubated, and asap. The process of intubation should always be controlled, have all of your supplies ready, have back up supplies ready because again, anticipate things can go wrong. Problem 1: limited back up supplies for intubation. OK, I knew we had enough of what we needed. We proceeded. Everyone was assigned their role. We made sure we could give enough oxygen to the patient with a mask. One of the supplies we keep ready is a catheter for suctioning, this catheter should be able to suction sputum or blood whatever is in the way to clear the view to see the vocal cords. In the US the oxygen is provided by a connection in the wall that is connected to a larger more central supply of oxygen. I don't ever think about the tank behind the wall or that the supply may run out. Here, the supply of oxygen is via a large tank. The patient received a significant dose of medications to make her sleepy. I open her mouth and blood is in the way. The suction stops working. The power goes out. The oxygen supply runs out, but the team is prepared with another, because THEY KNOW, they know this is a possibility. The tube goes in successfully. Initial sigh of relief followed by the deafening sound of the monitor, the beeping which in my head is translated into a voice yelling "THE PATIENT IS HYPOXIC".  Of course this can't go smoothly. There is a clot, sitting at the base of the tube, probably dislodged as the tube entered into her airway, blocking the flow of oxygen. We suction and suction, using a syringe now to manually suction--a large clot emerges and finally the beeping slows and stops and the patient is oxygenating. My own pulse slows. And the room audibly exhales. 

so what's the lesson? When you think you're prepared, When you think you have imagined every scenario, think again. Each possible scenario must be tailored to the physical environment you are in. Know what you have, know what you don't. Remember your limitations. Remember that you do not do this alone, and the day you think that you will fail. It's a team effort. This team rocked the worst case scenario. I'm proud to get this opportunity to learn from my colleagues here. They continue to teach me how to REALLY be prepared, they continue to teach me to think outside of the box. These medical trips are never unidirectional--they're fully bidirectional, the education goes both ways!

The oxygen tanks that were ready and waiting to be moved (requiring multiple people to do so). 

Same ultrasound course different Country

It’s the same ultrasound course we delivered in Bangladesh in February 2017 and 2018, the same ultrasound course we delivered for the Penn Critical Care division in the spring of 2018. Now in a different country with a different brand of machine the same course is delivered and with the same wonderful response and outcome!

This morning I was groggy from lack of a good nights rest, not because of the jet lag but because of the monsoon like rainfall and hail that rapped on my window for hours. But sleep deprivation is a close friend and that didn’t bother me as the views from my window of the amazing force of nature was well worth it. I climbed my 8 flights for the day not requiring a break and feeling victorious.  The first discussion today was of a case of a man who was referred from another hospital. He had been seen by a primary care physician at an unknown location for joint pains and was given a steroid called dexamethasone which likely improved his pain because he continued to take this medication for TWO YEARS. Dexamethasone is a potent steroid and like many oral steroids comes with several consequences when taken at high doses and over a long period of time. It can cause a consistent increase in blood sugar and lead to diabetes, excessive steroid use leads to elevated levels of cortisol which has several adverse effects including severe electrolyte abnormalities, hypertension, abdominal obesity and a whole slew of other issues (this is called Cushings syndrome). This patient had both consequences--Cushing's and steroid induced diabetes. The steroids + the diabetes put this man at risk for opportunistic infections as his immune system was likely compromised. He presented with an oral lesion which was black in appearance (necrotic) and basically created an ulcer in his hard palate. This was worrisome for something called Mucormycosis which is an advanced fungal infection. Two problems occurred then, the anti fungal medication needed to treat this was not available, and remained unavailable for TWO WEEKS. The patient waxed and waned and then suddenly had trouble breathing one day with his respiratory rate alarmingly high and his oxygenation low but with a clear chest xray. The first concern was Pulmonary Embolus versus a more rare but possible etiology which could be worsening of the fungal infection causing invasion into the blood vessels in the lung which could mimic a pulmonary embolus. Either way--it does not look good for this patient and the bigger question is how did he obtain steroids for such a long period of time! No one could answer that and thought it strange that he could obtain this medication without a prescription.

We rounded quickly through the ICU and then started the ultrasound course. At first the room was quiet for the first of the 7 lectures I deliver in this course.  The best lesson I learned was from delivering this lecture in Bangladesh the first time and realizing my tendency is to speak quickly, paired with my american accent, it's quite difficult to understand for anyone not from the US. I spoke slowly and deliberately as I now do with this course--careful not to use regional lingo. As the second lecture started the room seemed to warm up, hands shooting up to ask questions and engage and I breathed a sigh of relief. It's starting to come together--as the morning went on more hands went up to ask relevant and intelligent questions.  3.5 hours of lectures later we took a welcome break for lunch. My colleagues here took me out to a SUPERB traditional Ethiopian meal where I savored the injera and local sauces and spices and lentils. Then back to the hospital for the practical portion of the ultrasound course--the hands-on session is where everyone comes alive! The fellows got their hands dirty, quickly picking up the concepts I delivered in the morning. We scanned patients with real pathology, finding things that would take DAYS due to the inability to obtain an Xray immediately. The buy-in to use ultrasound is always immediate in these scenarios. And by the end of the day I felt that feeling all over again--that I am leaving behind tools that can prove useful in patient management.

The plan is to continue practicing every afternoon, the group is energized and have patients lined up to evaluate with the ultrasound. I suspect we will have some experts by the end of two weeks!

I've said it before and I will say it again. Nothing beats the feeling that teachers get to feel on a daily basis when they see their students grasp a concept. It's why Academic medicine always feels like the right decision, but most importantly it's why I pursue this concept of sustainable medical education in resource-limited settings. It's a gift that keeps on giving.

Empirical Medicine at its best

I climbed the 8 flights today--catching the cool breeze of the rainy season through the open windows in the stairwell. The hospital seemed exceptionally more crowded today than yesterday, or perhaps the haziness of jetlag has let up. My first task today was to give a lecture on treating pain, agitation and delirium in the ICU. I got a brief look yesterday on how this is done, and usually with intermittent dosing of pain regimens while in the US our teams are accustomed to starting continuous infusions. Cost is a real issue here and all decisions are made with that in mind. My lecture went well but many of the limitations I discussed were based on availability of certain types of medications.

Following the 8a-9a lecture were rounds in the ICU. I led rounds today which was such an interesting experience. The ventilators are different the make-up of the teams is widely variable. The residents from yesterday are not the ones who presented today. The presentations are full and complete and often data is a few days behind and empiric decisions are being made--and often correctly as the practice of medicine is so artful here. To give an example, one particular patient who was improving the day prior started to have increased tracheal secretions (sputum production), he was not tolerating being weaned from the ventilator and had exam findings consistent with a new pneumonia. The CXR would take some time to obtain and the wbc count was from two days prior. However, our clinical gestalt was the deciding factor between just monitoring and starting antibiotics, we went with the latter.

The next patient was a 45 yo female who was admitted with a hemorrhagic stroke. The likely cause was uncontrolled hypertension or high blood pressure. One of the most important primary care campaigns in Ethiopia and arguably the world is the importance of recognizing hypertension. It is called the silent killer and with good reason. This woman did not even know she had high blood pressure until her stroke. Her stroke was quite large and she was treated with an osmotic agent to reduce swelling in her brain. Her mental status was a little better today and her blood pressure is now controlled. She is being fed via a feeding tube through her nose and neurosurgery has declined any surgical intervention. In a patient like this, with such a severe stroke she may have been kept in the ICU for a day or two longer but the truth is there are no further ICU interventions and she will be transferred to the general ward.

With the knowledge of a bed opening in the ICU we took 6 flights down to the ER to evaluate the potential candidates for ICU admission. Often if there is no room in the ICU we are at least able to provide our consultant services. We made a similar trek to the Emergency Room yesterday. It is on the 2nd floor and PACKED. There are just hoards of people everywhere and a feeling of helplessness as a medical professional is more than overwhelming. We entered the critical unit of the Emergency Room, similar to the "resuscitation bay" in most US Emergency Rooms. We attended to a woman just yesterday with likely a clot on her mechanical mitral valve in acute heart failure who I thought may still be there but she had unfortunately died and her place was taken by an equally sick patient. Today's patient was a young woman from a malaria endemic part of Ethiopia. She came in with fevers, mental status changes, a high heart rate and high respiratory rate and a borderline low blood pressure. Her kidneys were acutely injured and she was barely making any urine. She was in great distress, breathing over 40 breaths a minute, using all available muscles to breathe--an act most of us perform without any effort. Her blood smear was positive for Plasmodium Falciparium--the major cause of severe malaria.  The patient had many features, such as evidence of shock, impaired consciousness and renal impairment but she was missing other features such as severe anemia and the parasite load on the blood smear was not available. A key piece of her history is that she just recently was admitted for cleft palate surgery--this presentation happened only a few days after her surgery. Now sepsis was on the differential diagnosis. She was only being treated for malaria and we suggested antibacterial coverage as well and asked that she promptly be moved to the ICU. The unfortunate issue was that there were physically no more ventilators and she would likely require intubation and a respirator, almost certainly. I was not shocked by the limitation of available ventilators because this is not uncommon in a resource limited center. Just earlier today a patient on the ventilator was requiring bag-mask-valve ventilation while the oxygen tanks were being exchanged--a problem we do not ever see in a resource rich setting.

Every patient and all decisions made towards treating a patient, even down to the medications ordered has to come with a great deal of thought. The patient's families are responsible for obtaining and purchasing the medications needed if the hospital cannot provide it. This requires understanding the cost with each type of medication and the burden it places on the patient and their family. In truth we should be more mindful of this in the US but most hospital culture does not allow for that--at least not as readily as it probably should. 

A reminder of the power of highly developed physical exam skills

It’s rare these days that I hear such a wonderfully complete presentation with a physical exam that Degowin and Bates (authors of two of our most beloved physical exam guides) would even be proud of. In the US everything can be imaged quickly, from obtaining a chest X-ray to look at the lungs to an echocardiogram to look at the heart. Here, each exam finding is reported, the presence or absence of something may be crucial to the diagnostic management. A resident was scrutinized for reporting a murmur incorrectly, the implications of which change the patients clinical presentation quite dramatically.  

The day started on the 8th floor, where the pulmonary office is located. I made the mistake of taking the elevator which almost didn’t close and worse yet had well over the maximum amount of people..this is a lesson I should have learned in Bangladesh. It turns out most of the medical staff take the stairs no matter how far—a habit I am happy to take on.  We rounded through the ICU, located on the 4th floor, along with the surgical ICU and pediatric ICU. The number of beds allocated for the medical icu are 4-6 at most. To give you a reference, the main Medical ICU at UPenn can accommodate 24 patients and there’s a second medical ICU that accommodates 8. Both of those ICUs are always full. However here, given the limitation of resources the criteria for admission is strict—only patients who are salvageable. This seems brutal but to be honest it is the unfortunate reality. For instance—we saw a young patient who received a recent diagnosis of leukemia, she received a round of chemotherapy and this was complicated by a severe infection which is now why she is in the ICU. The unfortunate thing is that her disease while treatable has a poor prognosis and now with this infection and to complicate the matter she is on a ventilator, she almost certainly will not recover to the extent that she could be treated for her underlying cancer. Her admission to the ICU was controversial. Meanwhile another woman has been admitted for 4 months with overall poor prognosis and no sign of any recovery. She was admitted after a cardiac arrest and likely was not resuscitated in time. The attending physician said to me, “in your country this is a patient who would benefit from hospice but we don’t really have a mechanism for that here”. If you followed my posts from Bangladesh you’ll remember that this was also missing in the repertoire of the critical care physicians. But this is not a criticism, this is an acknowledgement that often times the culture is what it is and to introduce something like hospice and palliative care it would potentially mean an upheaval of cultural norms. 

My first day was quite incredible. I am humbled by the expertise around me and how much can be done with such limited resources. I am again reminded that a limitation of resources never means a limitation on quality care—the patients here at Black Lion Hospital are receiving wonderful care and I look forward to getting to know the medical staff over the next two weeks. 

(View from the stair well as I took a quick breather at flight 6 of 8) 

A brand new adventure on the horizon!

Leaving Philadelphia, the 90 degree heat is making it easy to enter into the beautifully air conditioned 30th street station. One of my favorite statues bids me farewell as I am about to embark to Newark Airport followed by what my ticket says will be a grueling 17 hour flight.

 What lies on the other side ? The East African Training Initiative. 

Launched by Dr. Neil Schluger from Columbia and Dr. Charles Sherman from Brown in 2013 with the following purpose :

• To address the dire need for pulmonary and critical care specialists in the country
• To ensure the fellowship training program is self-sustainable by EATI-trained physicians by the year 2020
• To provide expertise and consultation to the Ethiopian Ministry of Health

I am incredibly excited to join a long list of physicians who have had the opportunity to be a part of this teaching mission! Looking forward to sharing the entire experience with all of you as promised! 

Thanks to the internet this project survives!

My last day of providing ultrasound training to the critical care team of Dhaka Medical college Hospital has come and gone. It was a light day, reviewing some new topics in advanced cardiac ultrasound, a primer into what’s coming down the pipeline. The session today was small, mostly to focus on my “champions”, defined as the group I have been training more closely so that they too can provide the same teaching sessions to their trainees. The final step was to pass on modified versions of the lectures as well as discuss how we can measure the success or failure of the “trickle down effect” or the “train the trainer” method. I am incredibly hopeful as the first batch of trainees has already been receiving some hands on training! In all honesty I believe that the end date of this project, meaning the time when I can fully hand it over, may be sooner than expected. This is thrilling as I am already thinking and planning about the next few educational sessions for the future. 

Above are my trainers, practicing some more advanced echo with our willing volunteer! 

But what is the key to success here? The use of social media and web-based teaching has been immensely helpful. But, even in this day and age, the age of technology, it can sometimes be difficult to stay in touch. On top of that there is an 11 hour time difference between the east coast and Dhaka. Regardless, we have been able to bridge time and distance to keep this project going, sharing ideas and scholarly activity and more importantly educational tools. I learn from them as much as they learn from me and this trip has been incredibly eye-opening!

What is coming down the road you may ask?

The use of non-invasive ventilation is a gap that we have identified and admittedly it seems that it is because of the lack of awareness of its uses and that it is not part of the hospital culture so-to-speak. The goal will be to involve the existing emergency department services so that patients who are identified early as potential candidates for non-invasive ventilation can be triagedappropriately if they show improvement. A resource-limited ICU May be very different from a resource-rich ICU in many ways but one way that it is not is in the constantly full census. Proper utilization of resources is crucial here as is sustainable interventions. Excited to see what the future will bring, a teaser is that we are planning a large ultrasound training session for Dhaka City critical care physicians in the next year with hopes to being a few US trainers along with me! Stay tuned and thanks for following along !

Just because my trip is ending doesn’t mean the problems go away

There was a time that the people of Bangladesh fought to make Bangla their national language. In fact, students died for it. Imagine that, the power of the spoken and the written word that you would risk your life for it? It was nearly 20 years later the country would gain its independence and since that time it has struggled to move forward in the areas of education, health care and equal rights. But, hope is here too, and with the combination of hope, grit and resourcefulness this country is making strides. It makes me wonder about my time spent here and how much there is left to do. It makes me think about the Rohingya and how they have no land or written language to even fight for, nomads for so long they’ve not known where they belong. I watched the news today in horror of what is happening in Syria. So many people in this world are suffering and I know we cannot save them all but in places like Bangladesh and Syria and so many other countries where poor people are in peril, I do personally believe that the International community has a responsibility to help.

Human beings cannot live in these conditions forever. It cannot be that the world waits for Bangladesh to take control as they themselves are trying to manage the overwhelming poverty that already exists. The world cannot wait for Myanmar to repatriate because let’s be honest they will not return. And in watching CNN this morning—it seems many agree. 

So where does the responsibility fall? I am not quite sure but the discussion on the news was that this could be a good task for the UN, creating a protected area of land wherein a whole separate economy and infrastructure can be built. The solution is still a long ways away and in the meantime the clinics I have visited and worked with are running out of medications and supplies as the number of Rohingya patients grow. 

The OBAT helpers clinic, pictured above has had a “record breaking” number of patients every day. The clinic is deep in one of the camps, where volunteers are hiking back and forth daily to help. Their daily number of patients is increasing faster than supplies can be refreshed. This is one of the sites donations will be sent once the GOFUNDME campaign is closed. 

As my trip comes to an end I wonder how I can continue to give back while back in the states: fundraising efforts, staying in contact to help with any educational needs, and spreading the word!

Back to Dhaka...but the Rohingyas are still on my mind

The toll of witnessing human suffering is high. I spent a week hearing about the atrocities and seeing the state of the Rohingya in Cox’s bazaar. Just that one week has made it difficult to continue my daily life without thinking about them and wondering what will happen. I think a lot about it especially at night when I get the chance to sleep in a safe and secure home, knowing that food is not scarce. They have spent months, no years witnessing and experiencing human suffering. What must each moment of each day be like for them?

It was hard to leave Cox’s Bazaar knowing there is so much to be done there. It’s been harder still to answer the question of “so, how was it?”  The response, “it was great,” just seems insensitive, saying “it was eye opening” is an understatement. I am left with the comment that it is dissatisfying to those who ask, that my feelings on being there for a week are an incredibly complex. I am glad to have joined such a wonderful group, MedGlobal is a great organization and I think there is a lot of potential to do good work with them. I am saddened and heart broken by what I saw but energized by the willingness of local and international organizations to protect these people. And lastly I am motivated to find out how I can continue to contribute.

I returned to Dhaka with the chance to unwind for two days with family before launching back into the ultrasound teaching sessions which started up today. The group was a motivated one as usual and it struck me again how important the gift of teaching is and how these sessions have the chance to be sustainable in the next few years. Because of my constantly wandering mind, I thought in that instant how this could be applied in a crisis such as that of the Rohingya in Cox’s Bazaar. At current there are a number of organizations that are using the community health worker model as a way to both empower the local community as well as spread valuable education in the areas of health and wellness (or anything for that matter).  The specific example I thought of was in regards to respiratory health. Many of the patients we attended to likely had asthma or COPD, yet inhaler use is difficult to teach and often inhalers are mid-used. Even with spacers, a device that helps with inhaler use and effectiveness, patients still have a very hard time, and that is common in America too. Shown here is a disposable spacer made basically from a paper cup. 

If there was a way to more reliably follow up with these patients and review inhaler technique as well as review their symptoms it is conceivable that these disease processes could be better controlled. Well, the community health workers may be a great group to teach respiratory health, but this is only one example of a multitude of educational campaigns—discussing birth control, control of chronic disease processes such as diabetes or hypertension, hand hygiene etc. I am looking forward to how the NGO community further optimizes the potential of community health workers as I think the possibilities are endless !

How many more times can a heart break?

These are the faces(taken with permission) of the Rohingya. They have traveled from another land, from Myanmar where they were without citizenship of any kind, without the written word. Those who were lucky and I mean very lucky, may have gone to school and even up through college. But they were never made to feel a part of the land they lived on for over a century. Their spirits and their bodies beaten they left their country for another, and this country now they still do not have citizenship. What will happen to them? Will they find peace in their new Homeland or will the poor country of Bangladesh who’s own people are also suffering be able to take on this responsibility? Likely not, and it is maybe up to the international community to pull the weight but it’s a complex situation. 

We see patients daily, asking them to hydrate and then it occurs to us all, is this even possible? These wells exist all over the camps but they are not nearly deep enough, the WHO reported in November that 62% of available water available to households is contaminated with high levels of E.Coli. It is no wonder they do not feel safe in drinking the water, it is no wonder almost every patient we see is dehydrated.



They wait in lines to receive bags of food which was originally being distributed per head of household rather than the number of members in the house (if you can call it that). Only recently has the rule changed...it’s not uncommon for families to have 6-7 children!  Proper  vitamins and nutrients are often missing in their diet leading to diseases that have long since been eradicated in other countries due to dietary supplementation in the foods we eat. It is no wonder that malnutrition runs rampant! 




The rainy season is a known entity here, often with cyclones occurring as well. Many of these camps are situated on dirt hills, in clear danger of mudslides. Beyond that the rainy season will be a nidus for infection as water borne illness like typhoid, shigella will arise. There are many talks happening on how to fix this—relocation versus cyclone-proofing homes. There are close to 1 million refugees in Bangladesh right now...i hope this large scale attempt to prevent damages from flood rains will be successful. 




But what about the host country..how do they feel? There are banners that suggest hostility, I can understand the perspective I suppose. Bangladesh itself is a resource-poor country who’s own people are suffering disease and the effects of floods. In many ways the host community has been incredibly hospitable—but they must also think of their own demise. The homes we pass along the route to the camps are not necessarily any better than those in the camps. I am sure that the daily movement of large vans filled with international workers can be disruptive. But, this is an international crisis—I am aware it is not the only one currently happening in the world but it is a matter of real urgency. Talks of repatriation are ongoing but will the Rohingya be guaranteed safety ? Will they be allowed citizenship and therefore the right to an education and freedom ? 

I’ll end with this. Nothing has been more powerful than the stories that were so graciously shared. Today my patient said that while he was crossing over a river en route to Bangladesh two of his sons were shot dead right in front of his eyes. He worries about being sent back to Myanmar without the guarantee of safety and even then..would it truly be safe. His back pains and leg pains are from a former life of labor. He sits at home mostly now, thinking of the loss he’s suffered and what his future looks like. His facial expression speaks volumes mostly filled with struggle and strife and the will to go on surviving despite a very unknown future.

“No, I want to show my face”

“I want to show my face” she said when I asked to take her picture and said that we could cover her face to protect her identity but she adamantly declined, with such conviction! She represents the patients I treated today who told me their stories. Two women stuck out to me today. The woman above and another who came to the clinic with headaches, full body pain, decreased appetite and trouble sleeping. I delved further asking about dietary habits, about whether the feeling was worse when standing whether they were having blurry vision and reviewing their blood pressure diligently. Then I asked about how long they’ve been in Bangladesh and what the journey was like, did everyone make it? The first patient looked at me with her eyes filling up, “I once had 7 children and a brother and sister-in-law”... “three of my children and my brother and sister in law were killed in front of me and now we are only a family of 6”. They were killed before they could cross the border from Myanmar to Bangladesh, and the men that killed her family were in army uniform—presumably Myanmar army as further news breaks of the atrocities that have been ongoing. She went on to tell me that when she thinks about this she can’t sleep she can’t eat and her body has intractable pain. We talked for a bit and she seemed lighter, just talking about it. The immediate next patient has exactly the same symptoms and her story was somewhat different but still full of loss. She walked for days on end to come to Bangladesh and one day her son went missing, she has no idea where he went or whether he is still alive and the thought of that recreates her symptoms. 

While there are some efforts to help with psychological trauma it is likely not enough and certainly difficult to plug people in to these services. 

I won’t spend any other time talking about anything else because the image of this woman is the image of every man woman and child here. Resilience, Strength and wanting,  no NEEDING to be heard and have a voice. I hear you. We hear you. And we will do what we can, you are not alone. 

Amazed by the resilience of the Rohingya

Another day another incredible eye opening experience and lesson in resilience. The day started with two very sick patients in the emergency bay, one who was a year old baby boy who had a high fever and seizure overnight and the other a 65 year old female with significant shortness of breath and low oxygen levels.  The baby boy got an IV immediately and we started fluids slowly—the beauty of having a multidisciplinary team is being able to rely on colleagues for help—like the rate of fluids in a baby for instance! The adult patient seemed a bit more complex—thankfully the combination of physical exam and ultrasound was useful in figuring out what was wrong. My initial instinct was to give her fluids but once I checked her heart rate I knew right away this wasn’t so straight forward. Her heart beat irregularly and the pulse oximeter which also gives the pulse kept going from 80 to 150 confirming my suspicion that she probably has atrial fibrillation. Thankfully an EKG is available and that definitively confirmed my suspicion. Upon further examination she had evidence of pulmonary edema (water in her lungs). In the mean time the baby in the next bed was getting IV antibiotics but was still sleepy and breathing quite fast, we placed some oxygen on him and gave it some time. Circling back to my adult in distress we had given something to slow her heart rate down which did the trick and a small dose of a water pill to help her lungs. Over the next several hours our team worked diligently to monitor and treat these patients and both went home doing much better. We had all the tools we needed and it turns out it wasn’t much—we didn’t need to order a CT scan or any heavy duty testing but just remembering the basics of empiric medicine we could treat both patients to the best of our ability. 

Next the patient with the kidney infection from yesterday had returned for follow up, she was able to walk in to the clinic today without assistance she hadn’t had any fevers in the last 12 hours and her heart rate had improved dramatically. This was a huge win. While the physicians here are mostly international the ancillary staff are local and they are learning new things each day as we are also learning from them. The sustainability lies in the training of the local staff and in just a few days I have seen so much progress. 

Even just the basics of hand washing, just by a simple educational intervention now everyone has habitually been washing their hands when coming in and out of the clinic.  Education and training—the real tools to sustainability!

During a quick 10 minute break, mostly to grab a sip of water, I traded stories with my MedGlobal colleague. She said her last patient had mentioned that his vision has gone bad since he came to Bangladesh. He thought that happened because he witnessed his son being shot down in front of his eyes and afterward he cried so much his vision went bad. Meanwhile one of the female patients I saw today mentioned that her husband was in a Myanmar jail cell not sure if he was alive or dead but he was beat up and arrested on the 5 day trek over. Luckily her and her three children survived the migration and as did her brothers who are helping to take care of her now. I feel helpless hearing these stories, the cruelty that they have been subjected to. 

Their fate remains unknown but their resilience is quite clear. 

The last patient I had was a 12 year old girl. She came in stoic, mentioning that she cut her chin while pumping water from the well, she lost grip of the well handle and it slammed into her chin cutting open a 2 cm gash almost down to the bone. She didn’t cry one bit. We irrigated the wound with saline and antiseptic solution until it was as pristine as possible. The importance of this cannot be overstated as leaving any infected tissue and then suturing the wound would surely lead to infection. We then administered some lidocaine superficially and deep to numb the area prior to suturing. Again she did not cry. If this were me I probably would have at least winced if not teared up. To her this pain was likely nothing, she has been through worse and she survived. It is clear by the experience in her eyes that nothing that comes her way now is as bad as it was before. And maybe there is the silver lining, the hope that life that will be better here in Bangladesh. 

(Finished product above...I prayed for steady hands and ease of apposition so she would not have a bad scar)

And lastly..as the day came to and end I heard an inspirational story from one of the coordinators from OBAT helpers. (FYI the coordinators at MedGlobal and OBAT are nothing short of miracle workers and without them we would be rendered useless). She told me of a story of one of the Rohingya volunteers who was born in Bangladesh, his parents came in the first wave of refugees in 1994. He has been saving since 2014 to build a school and has been going to school himself as well. Just recently he has saved enough money to build this school with the help of his friends and they plan to teach Rohingya children here. Again—the resilience, the ability to re-start a life and have the motivation to help others—that is the best of humanity in the worst of circumstances. 

Transferring a patient from the clinic, not so simple

Today was exceptionally warm. Having access to clean water I chugged two bottles of water prior to leaving my air conditioned hotel room. I sat with my colleagues in an air conditioned van, with our designated driver weaving skillfully through traffic. We passed beautiful scenery on the way to the camps, as usual.   Not for one minute of that 70 minute commute do I stop thinking about the daily amenities we have that are beyond a luxury for the Rohingya—it makes me uncomfortable and more apt to minimizing my life. It’s to the extent that often we don’t even like to drink or eat in front of them in the clinic. 

Unlike other days I was stationed in the “emergency bay” of the clinic. This was basically where sicker patients were triaged and where the other clinic docs would send their sicker cases. At my disposal were the following : tools to start an IV, a good supply of IV fluids and a handful of IV medications, an oxygen compressor, a few oxygen tanks and nebulizers. It’s not a bad supply of tools to help treat some of the sick patients, but if we can’t turn a patient around in a few hours we have to refer them and that process is difficult given where the clinic is situated. 

The first few hours were pretty straight forward and then I received a patient with low blood pressure and a horrible cough that started a few days ago. The emergency bay was starting to get busy as it doubles as the lab where we can do a few things—a malaria smear, a hemoglobin, and a urinalysis. As my nurse and medical assistant were busy I had to do something that some of us are not entirely used to anymore—fending for ourselves! I placed an IV in her right arm and spiked a bag of saline, I hung it on the pole that this patient shared with the woman in the next bed. Her oxygen saturation was low and she required oxygen..and all of a sudden I worried that the electricity source would give out for the oxygen compressor—but luckily the generator held. Her heart rate was a staggering 150 beats per minute and she has a slight fever. She was also wheezing so I administered a nebulizer, but, I was unable to provide her oxygen while giving the nebulizer so every few minutes I would interrupt the nebulizer to give her oxygen. After two hours of this and continuous fluids her blood pressure had improved as did her heart rate but her oxygenation was not ideal. We were left with no choice but to transfer her. As I was wrapping her case up the nurse and medical assistant with me were stabilizing a patient with a severe asthma attack who also required transfer.

I wondered how both elderly, currently critically ill patients would be transferred to the closest hospital. And then someone brought this forward:

Each woman was put into this and carried down the mountainside. 

The trek is about 30 minutes. Now remember, we don’t have real portable oxygen tanks, and access to water on the way may be difficult as clean water is still not a guarantee despite wells that were built for the Rohingya. I hope I get a chance to know how both of these women fared.

The day eeked forward at a staggering slow pace today as if the heat of the sun was willing the clock to stop or slow down.  As we got to the end of the day a 21 year old female was brought to the emergency bay for a urinalysis, she was pregnant and writhing in pain. She had a fever of 104 degrees and was holding on to her right flank. Her urine was positive for an infection and given her flank pain we were all convinced her urine infection had spread to the kidney. We were able to quickly give her some IV fluids and one dose of IV antibiotics and after some time she seemed much better though still with a fever of 103. Luckily, she lives quite close to the clinic and can come back every day for the next few days for fluids and her daily dose of IV antibiotics until she shows improvement. It was not a situation I would have opted for had we been in a fully functional hospital but she demonstrated she could walk with assistance and that was enough for us to stroke up this compromise. 

Each day poses a new challenge that forces us to be both creative and realistic about our capabilities and what we can offer but more so accepting what we cannot offer. As we continue to gather data so that we understand the needs of the population we can then tailor the supplies and medications accordingly.

 

Who is the patient the mother or the baby..oh both!

We are a mixed bag of physicians here, an Electophysiologist (cardiologist who specializes in abnormal heart rhythms), family Medicine practitioners, hospitalists, intensivists, some of us see children on a regular basis and others (like me) do not. However today we are all pediatricians, we all dug deep into the forgotten vault of baby knowledge. Today I remembered Weight-based formulas and standard rashes that I tucked away in a file in my brain titled “Save for the apocalypse”. Ahh yes THAT is tinea corporis..oh right that is what an infected ear looks like..the list goes on of forgotten disease entities being unlocked from what seems like another life. There’s a line I always say—which most people think is a joke—that children and pregnant women scare me. The response is usually “you’re an ICU doctor nothing scares you”, oh how untrue that is. But thankfully, and not surprisingly given the amount of support staff and thanks to the handy MSF clinical guidelines App, everything went fantastic today.

Less patients than the previous day meant the ability to really spend some time chatting. Learning of the trials and tribulations of arriving to this country, those who are lucky made it with the entire family intact. Not uncommonly are the patients I saw who did not make it to Bangladesh with their full families intact, or hearing about those who arrived as the sole survivor of their family. 

Some of the interesting observations today: The 70 year old woman who had not had a BM in over a week, who was urinating frequently and constantly thirsty, we checked her blood sugar and it was 564.  She had ketones in her urine (in the US that may provide cause to consider diabetic ketoacidosis (DKA)however here starvation alone can do that). She probably does have DKA with that sugar and those symptoms..we gave her some iv fluids and oral medications for diabetes knowing full well this would likely be much less effective than subcutaneous insulin. But, imagine how that would work..would she come to the clinic every day, walking an hour there and an hour back, to receive her medication? No hut has a refrigerator, there’s no way to properly store this medication at home. And in fact she is unable to ambulate and was carried home in a basket tied to a pole held at either end by two young men. 

Then there was the gentleman with the frequent urination and occasional blood in his urine. While certainly his age lends to a diagnosis of an enlarged prostrate I was worried about a kidney stone or even worse cancer in the bladder. While performing a CT scan is impossible I could at least perform an ultrasound of his abdomen, looking for a bladder mass or any obvious masses on the kidney. 

Indeed his prostate was enlarged, however I did not see any other abnormalities. While that doesn’t guarantee anything it is at least some added information. I was able to perform another ultrasound exam on a woman who was short of breath and had a little bit of fluid in her legs and could definitively diagnose her with heart failure. In another patient who had a severe fall I was able to rule out any bleeding in the abdomen saving her a long trek to a hospital that could provide further imaging.  I brought this handheld ultrasound with me and it has been a tremendously useful tool and I hope that over time funds will be available to provide similar tools here.