Friday, July 13, 2018

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) 

Thursday, July 12, 2018

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.



Tuesday, July 10, 2018

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.



Monday, July 9, 2018

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. 

Friday, July 6, 2018

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. 

Thursday, July 5, 2018

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). 

Wednesday, July 4, 2018

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.






Tuesday, July 3, 2018

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. 

Monday, July 2, 2018

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)