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.

Do not take your life for granted others have less and yet are still smiling

I woke up nervous today, not sure what I was going to see. I work in a medical intensive care unit in the U.S., it’s a clean unit with innumerable staff and monitors beeping with every breath. Surrounded by death and dying and often blood and gore, I thought, well I should be prepared somewhat for the worst of the worst of the human condition. I’m not sure anything in this world short of going through it myself could have prepared me for seeing what I saw today. The pictures don’t do it justice. My words will never be enough.

The irony of this, we are staying at a nice hotel in Cox’s Bazaar. The road to the camps we are working in has absolutely stunning views of the beach front of Bangladesh, a view I have never seen in the number of times of been here. The trees and the rice paddies lining the entirely-too-narrow two-lane roads have inspired songs and poetry and it’s understandable why. Within 45 minutes we reach the entrance to the camp, marked by a dirt road that was built by the government to access the area. As we drive down the dirt path I see a few huts and homes of Bangladeshis who live close to the camps and I wonder how their lives have changed. I wonder what they think about the daily influx of vans of foreigners here to help the Rohingya. I wonder if there’s ever a thought of, “what about us?” It’s not as if the living conditions in some of the areas we passed along the way are that much better. That thought quickly fades to black as we approach the clearing where this particular camp site can be seen in its entirety. My heart sank to my toes. I don’t think it has recovered since.

                              

The road to the camp vs Entering the camp 

The clinic I was assigned to today was named the OBAT helpers clinic. The OBAT Hepers started as a family initiative to provide aid, support, education and economic empowerment to the displaced populations residing in camps in Bangladesh. While initially the intent of the organization at its inception was to aid stranded Pakistanis, Biharis or Urdu-speaking people,  they of course leapt to the aide of the Rohingya when the crisis escalated this summer. I brought with me an EKG machine that was donated by Dr. Tonbira Zaman and the Cooley Dickinson Hospital in NorthHampton Massachusetts, a machine that I lugged with me from the U.S. I’m used to carrying the weight of this machine so as I got out of the van I went to grab the machine and our coordinator said, “nope, we will hire someone for that, you can’t carry that where we are going”. Initially offended she didn’t trust my ability (just kidding, I wasn’t really), she pointed to where we were going. A building with two flags flapping in the dusty wind, sitting atop the highest point in this particular camp with steps carved into the hills. She was right, I’d have to focus mainly on climbing the stairs. 

We were a group of four physicians today. Making our way to the clinic atop the hill we passed hut after hut. Bamboo frames tied together with tarps as the rooftop. Immediately I had the heart-stopping thought: what will happen when the rainy season comes? My brain could barely compute what was in front of me let alone the possibility for further demise in a few months. As I contemplated this I heard the sweet voices of a few kids following along with us. They were saying, in one breath, “Hi how are you, fine, thank you, you’re welcome”.  They were smiling.

We reached the clinic, and after a quick run-down of how things work I sat down in my cubicle to see patients. With me I had a translator, a young girl who also is Rohingya by lineage, her parents were Rohingya but came in the first wave decades ago, she is about 18 years old. She was born in Bangladesh and she was thrilled to hear that I could speak Bangla and so she stayed with me all day. She told me that she still lives in a camp but it is in better condition than this, but that is where she has lived all of her life. She attended school in Bangladesh as well. Her commute to this clinic is an hour walk each way which she does not mind doing. From 930-5 pm I myself saw maybe 70-80 patients, and the others averaged the same. Some of the cases were chronic pain, likely related to the days worth of walking it took to come to Bangladesh. Other cases were respiratory disease, cough and cold symptoms, asthma, allergies.  I had one case of likely pancreatic cancer—what a cruelty, to have made it to asylum only to realize that your life will be cut short regardless.  Each patient came with a medical book where their vitals were written down by the medical assistant who triaged them, I would then write down a brief history and exam and a diagnosis and treatment plan. Basic medications are available but only by crowdfunding and donors. The clinic funds are running low however and it is clear this will start to be a problem soon. This is a scary fact since up to 200 patients are seen in this clinic daily, DAILY! A field hospital is also being built by the OBAT group and then comes the daunting task of how to staff it. As the day’s light started to dwindle we were told to quickly wrap things up. There was a worried tone about those that were ushering us out of the clinic. We were in a race against the clock as it turns out, as it is illegal for us to remain in the camp after sundown, in fact people have been arrested! The reason is that the safety of the Rohingya is crucial, they are a vulnerable population and protecting them from things such as human trafficking or other such atrocities is incredibly important!

The power of saline

It is not lost on me or anyone for that matter, that every time I come to Bangladesh my gut bacteria take some time to adjust, and inevitably I have at least one horrific day of GI upset. I bring this up every time because I am still in awe of the wonder of fluid resuscitation in the form of these oral saline powder packs. They contain sodium chloride, potassium and glucose, and when the inopportune moment strikes it certainly comes in handy. 

I first learned about orsaline when I came to Bangladesh as a medical student almost 9 years ago and became ill. It brought me back to life as it did many who were suffering from Cholera in Bangladesh years ago. In fact I have now twice visited the International center for diarrheal disease research (ICDDR) in the last few visits and it never ceases to amaze me how much they’ve accomplished with so many illnesses. In fact it was at the ICDDR that as a medical student I learned how to assess a sick patient with no other tools but my own hands—checking a pulse, checking skin turgor and beneath the eyes and the mouth for evidence of hypovolemia, tools I still use today despite years of advanced training and skilled use of machinery (even the ultrasound!) 

When resources are scarce in comparison to the sheer number of people it is then that ingenuity surfaces, that is indeed in abundance here in Bangladesh and it is this ingenuity that will allow this country to persevere despite so many obstacles. 

A day late but some new insight in the process!

The first day of training a new batch of learners was an interesting experience. The learning curve was steep at this session, learners picked up on the lingo and were immediately comfortable with the ultrasound probes. It was such a seamless session that two days worth of work fit into one! The hands-on session was equally as seamless showing me that the trainers we left behind are doing a fantastic job with introducing the basics to their trainees. 

So..now that I know this method of training the trainer can work here the obvious next thought is what to focus on next,once this project is on cruise control (estimated 3 years). Well that came to me in a very interactive way to say the least. It started with my urge to check out the Dhaka Art Summit after work...which by the way is an incredible exhibit of creativity, collaboration and progress. This exhibit which features international artists and displays the talent of international curators is in a beautiful building with beautiful outdoor space. Well lately I have been noticing that the fog and gloomy skies just has not been clearing and in fact it feels “heavy” outside. As many of you may or may not know recent information indicates that Dhaka is the most polluted city in the world. Well I felt that for myself when checking out the outdoor space at the art summit. I felt it in the form of post nasal drip, shortness of breath and a cough. As soon as I got home I immediately used my inhaler and took some antihistamines and because dehydration somehow is a result of just about everything I also rehydrated with some oral saline (for those of you following before this trip you’ll remember that oral saline is just about my favorite thing). It occurred to me that respiratory health must be a huge issue here and maybe there’s a need for primarily respiratory health centers that are small efficient and possibly mobile. (Wheels turning..) anyhow it’s an idea that’s a work in progress.

Only 8 mosquito bites in...

Maybe the mosquitoes know I’m here to stay..they’ve given up feasting on me? Fingers crossed! 

Forging ahead we spent a few hours on some more advanced ultrasound techniques as well as the use of ultrasound in bedside procedures in patients where access may be difficult. Below two of my three champions of ultrasound in Dhaka are doing a bedside focused echocardiogram with little to no added guidance from me.

We went on to discuss what other ways we could work together to improve care. During our discussion the power went out, a common problem that may occur. Usually there are generators however sometimes the ventilatorr may fail if there is no back up battery. Maintenance of machines can be problematic and just having a systematic way to assess quality improvement and assurance is something that the team is working on. As far as improving the critical care education they are using the lectures that I provided them and building their own as well. These lectures are power point presentations that over the course of three years my co-fellows from NYU and I had created and they so generously shared! Beyond that acquiring such machinery as a bronchoscope for the ICU and working dialysis machines are ongoing challenges.

Tomorrow we start another round of training sessions! Hopefully we can be as successful as last year!

In other news: Bangladesh has recently jumped to the top of the charts with air pollution...having mild asthma of my own it is very clear that air quality is a problem as I can feel it any time I am outside for any period of time. I can only imagine the effect that repeated exposure is having on those that live here and are outside every day! 

The positive of today, Day 3 and just barely some GI discomfort! Maybe my gut flora are adjusting faster this year !