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.
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.
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