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)