The Butterfly Ultrasound in Global Health

The black appearing object on the far left is a vein which is not compressible and therefore indicates there is presence of a clot. 

The most fun I had on this trip was being able to introduce the Butterfly Ultrasound to the trainees. For those of you who have been following along on my Global Health journey you may have picked up on the recent excitement over a handheld ultrasound probe that plugs in to your phone. This tech is so incredible for so many reasons--it has an incredible price point of $2000 USD versus the larger machines which can be up to $20-40K!! The image quality is great and the portability makes it easy to take to the most rural of places! I have now used this device in Rural Bangladesh at the Rohingya Refugee camps, in Nepal, in Ethiopia and will go on to use this in a project with Bridge to Health in Kenya and Uganda! In the image above we diagnosed a blood clot in the leg of a patient with cervical cancer. In the images below there was a patient who was found to have a lung abscess and I wanted to show the trainees what this may look like on ultrasound. ( All photos taken with permission ) We spent the rest of the day asking several patients if they would allow us to perform simple ultrasound to identify normal and abnormal pathology. While the training session itself was limited to the week that I was present we really focused on some basic concepts and luckily the physician who is mainly in charge of the Medical ICU at Ayder is well trained in ultrasound and so with a local expert there is even more of an incentive for trainees to practice and continue to identify important pathology that may aide in early intervention and better patient outcomes. 

examining a patient's lung with the butterfly ultrasound

a lung abscess on lung ultrasound-what you cannot see is the presence of an outer capsule of this fluid filled structure and lung tissue surrounding it

Early Recognition is life-saving

Today’s lesson is in “early recognition”. I have probably said this over a million times in my short career thus far but I truly think that early recognition and early action are the pieces missing in resource-limited settings. In resource limited areas it is difficult to decide when that early intervention should occur. Frankly, ICU medicine as we know it in the US is a very resource intensive and costly intervention--it has to be redefined in resource-limited countries. I feel very strongly about the power of education and that is not just at the level of health care providers but community level education.  I am referring to going out in the community and talking about the signs/symptoms that should bring people into the hospital, it is far too often that we see the end result of a disease process, when it is too late to act. It is even more important that this early recognition occurs especially when a patient is IN hospital. While on rounds this morning we discussed the new admission, she is a patient who came in with nausea and vomiting, with a history of prior abdominal surgeries. A tube was placed in to her stomach to help decompress her stomach, an X-ray was pretty convincing for bowel obstruction. Over the next 12 hours she started having abdominal pain and there was a concern that her obstruction was worsening so she was taken to the operating room. There she notably had a perforated intestine and had low blood pressures during the procedure. She was taken to the Post op area and for three days continued to have low blood pressures. By the time she came to the medical ICU we were seeing blood pressures of 66/30 (as seen in the picture). I will tell you--when we see this in a medical ICU in a resource-rich country the nurses are already grabbing the pressor medication to help support the blood pressure so that vital organs can be perfused. In many resource limited settings such as this one there may be only one medication available, usually it's Dopamine which is a medication we do not reach for anymore. If the patient requires an additional medication to support his/her blood pressure the patient's family will need to go purchase this medication from the pharmacy and then return with it. Time is crucial in this setting--the longer the patient's blood pressure remains this low the more injury there is to the kidneys, to the brain, to the heart, to all of the vital organs. Unfortunately this patient's family could not afford the appropriate medications and this patient despite everything we COULD do within our capabilities, did not survive. Because of the limitations of the hospital system, of space, the availability of a ventilator--this patient was not able to receive timely interventions. 

This is the devastating reality of what medicine looks like in these parts of the world. 

A triumph for our trainees but a tragedy for the patient

The patient gave permission for all photos to be taken and published here

It is difficult sometimes in medicine to temper the interest and maybe even excitement over seeing something abnormal, and reminding ourselves that there is a patient attached to that rare or interesting finding. In teaching at the bedside it is important to remind our trainees that we must respect the true teacher in the room--the patient. Today’s focus is a patient who I am so sad about. He is a 21 year old male who came to Ayder with shortness of breath, he was found to have a significant amount of fluid around his heart and luckily when he came the CT scanner was working so he was able to obtain a scan which showed a large mass sitting inside of his chest. The location of this mass was worrisome for several things including lymphoma. He was evaluated for several different types of infections, fungal and TB especially. Tuberculosis (TB) can really present as anything. After all that was completed he was started on steroids under the presumed diagnosis of Lymphoma. Biopsies were taken, the fluid was drained, he remains on a ventilator because the mass is so big that it is compressing his trachea. Given that he has no indication for sedation, he is getting only intermittent doses of thiopental as needed(a medication we really do not use in the US but is cheap and available here)—this is such a stark contrast to our patients back home who generally end up requiring some level of sedation even continuous infusions to keep them calm and comfortable on the ventilator—I imagine its because we have a lower threshold to start these medications and of course they are more readily available. Back to the patient—he was biopsied and we await the results however given the concern for progression it was decided that he empirically be started on chemotherapy. We shall see how he does—I hope for the best for him, he has his entire life ahead of him, he is awake and interactive and even jokes around with us. Human beings and their capacity for resilience is truly something to behold. The depths of pain people can go through and still remain positive is awe-inspiring to me.

Cow Horn Injury--wait what's that?!

A depiction by Sir Charles Bell of a soldier with Tetanus (from 1890)

There was a time that being in a new environment, not knowing where anything was, or not having any cell service nor maybe even wifi, was terrifying and anxiety provoking. This career in global health has helped me to release that fear somewhat; don’t get me wrong it is still intimidating and always a humbling experience but that initial fear of the unknown has started to melt away or rather transform into excitement and anticipation of what these new experiences will bring, for instance, my first experience with Generalized Tetanus. 

On my first day at Ayder University Hospital in Mek’elle I rounded in the ICU and saw my first case of generalized tetanus. The patient had a testicular injury via cow horn—meaning he was essentially head-butted by a cow. I listened on rounds as this was presented and quietly asked the student next to me what “cow horn” was…she looked at me puzzled, and answered, “You know, like a cow, ‘moo’”. Between the laughter and embarrassment I remembered the rural scene on the drive into the city and had to remind myself “you are no longer in Philadelphia”.  After that moment passed my next question was whether or not the tetanus vaccine was widely available, while the answer is yes, it seems that actual compliance in obtaining it is the difficult part especially in rural parts of Ethiopia. Men are more inclined to get tetanus than women because of the fact that most women of age have had children and it is a part of the antenatal care received. Tetanus can cause painful spasms from such minimal stimulation, the patient requires the mechanical ventilator and frequent doses of sedation. If he is to recover it could take up to 4 weeks of time! 

My Return to Ethiopia (delayed posts)

This year I was asked to bring some critical care lectures and ultrasound training to Mek’elle, Ethiopia. If you recall, last year I had the pleasure of working at Black Lion Hospital in Addis Ababa, the capital of Ethiopia. It was a wonderful experience that was provided by the East African Training Initiative—a group that initiated out of Columbia University and over the years has partnered with several other academic institutions, to bring a Pulmonary Fellowship to Black Lion Hospital. Now years after its inception the program has trained and dispersed several well-trained Pulmonologists who are now all over the country. Mek’elle is a beautiful city about an hour plane ride away from Addis. I was greeted by greenery and beautiful rolling hills as we descended on to Mek’elle. The drive to the hotel displayed the rural areas outside of Mek’elle and within 20 minutes we arrived in the city center. After 24 hours of travel I am exhausted but excited to see what Ayder University Hospital has to teach me!

I will never cross any border line without thinking of today

The crisis in Venezuela has left its citizens without proper healthcare, with gross inflation leading to virtually worthless currency and lack of consistency in the education system as well as violence and economic instability. This crisis is not new--it has been ongoing for years but tensions have been rising recently which have led to a mass exodus out of Venezuela. Neighboring Colombia has been bearing the brunt of this migration, doing its best to accept everyone they can. At the legal border crossings (one of which is seen above) there are several conditions for which migrants can enter : they must have proper documentation, they must have a pre existing medical appointment or a temporary work permit or children who are now in school in Colombia may be accompanied by their parents. The vast majority of those crossing are doing so at unsafe and unsanctioned sites on the border which is what you see in the picture below.

This process is dangerous and yet thousands cross daily, women with small children and I mean even neonates !! They are carrying as much as they can and they are braving the gang activitiy which exists primarily to benefit from those crossing (charging a tarriff). Colombian police are stationed everywhere doing what they can to prevent extortion of those crossing but it is an overwhelming sight to behold. Many are crossing through Colombia with plans to WALK to neighboring countries because they cannot afford to pay for a bus ticket. Along the way are humanitarian aid in the form of shelter, food, vaccines/healthcare (which are NOT available in Venezuela thereby increasing the prevalence of preventable diseases ie Measles). The first refuge spot after the border is approx 20 plus miles away. We crossed many "caminantes", the walkers, making their way to Ecuador or Peru or Chile, a trek that could take over a month. 

Along the way we happened across a group of women and children. Three mothers to be exact, one pregnant of 5 months and holding her 2 year old son, another carrying a newborn and another minding the other very small children. We had to stop and help further them along to the next refuge down the road, the sky was turning dark and it was about to start pouring rain. We dropped them at a shelter where at least another hundred migrants were taking shelter for the night. In the morning they would all set out , again on foot, to the next shelter along the route to their destination country. (Consent obtained for the photo below)

Back in Cucuta we had a very productive trip, visiting the main public hospital that attends to the majority of the Venezuelan migrants as well as the vulnerable Colombian population as well. However due to the complexity of the health care system it's quite difficult to obtain follow up care let alone the service of sub Specialist Consultants. There is a large majority of Venezuelan women who go through an entire pregnancy without any pre natal care! Our mission was to assess the need for capacity building--it is clear that the emergency department at this hospital is overwhelmed, "collapsed" as they say here in Colombia. We identified all the right persons to help us implement a course in ultrasound which could potentially cut down the time needed to evaluate patients and help the turn over rate in the ER. We are also of course going to have volunteers here on the ground providing direct medical care in the highest areas of need, general medicine, pediatrics, and maternal care. BUT, all of that fell to the background after really witnessing what is happening at the border. 

I will leave you with this. At one point, while visiting the border crossing we heard rifles in the distance. We dove for cover, people were running and the police ran into the area of gunfire. Within minutes it had ceased and we soon learned we were far enough away to have remained safe. The altercation was initiated between to groups of traffickers fighting over territory. What struck me was how "normal" this seemed for all involved. Even those I witnessed crossing at the unsanctioned site--their faces were hardened, they didn't exhibit the same look of shock that I had on my face. I cannot believe we live in a world where this situation feels normal or usual for anyone. 

My heart hurts for Venezuela but I truly am uplifted by the motivation of Colombia to help its neighbors. The effort on the ground is tremendous and I look forward to any opportunity to contribute to this humanitarian crisis.

Bienvenido a Cucuta!

What a beautiful country this is. Cucuta, Colombia is surrounded by beautiful mountains. The people are wonderful and welcoming and yet it is clear that a crisis abounds.  Sharing the border with Venezuela, Colombia has been the entry site for over 200,000 Venezuelan migrants and potentially more as people are entering the country through illegal and frankly, unsafe entry sites. Imagine the desperation in Venezuela if women are carrying their children miles upon miles, crossing at unsafe borders and continuing to walk as far as Peru or Chile--a trek that could take MONTHS on foot. This crisis is not a new one-it has been ongoing for several years and has lately been reaching a critical mass as tensions continue to rise in Venezuela. Across the border on the Colombian side there are upwards of 40 NGOs doing what they can to support the excellent Colombian physicians and nurses who are just overwhelmed as the sheer number of patients continues to rise. Some of the most commonly seen medical issues are related to pregnancy, including maternal deaths, malnourished mothers and babies as well as sequelae of chronic medical disease such as hypertension and diabetes. Then of course, there is the issue that vaccinations are not possible in Venezuela and so Measles is on the rise--at point of entry one of the very first things offered are vaccinations. However, just as in any mass migration there is the concern of the host community as well. Just like any country, Colombia has its share of less fortunate people--unable to receive proper care because they themselves cannot afford to do so. So, as we saw in Bangladesh, how can a country which is itself struggling in some respects to financially care for their own, be expected to do so for such a large population of migrants? And even with that financial stress--the overall sentiment of those we have met today in the public health sector is overwhelmingly optimistic and positive. It is a tremendous thing to see. The main lessons I learned today are that just as in Bangladesh or Ethiopia or some of the other countries I have worked in, it is important to seek the guidance of regulatory agencies such as the Health Secretary. Every country has protocols and policies in place which should not be circumvented as our success is contingent on a solid partnership. Luckily our staff here on the ground are absolutely wonderful and well plugged in and connected to all the right people to allow for productive discussions on how we can play a role.

Far Left: Yesmith Garay (our brilliant coordinator in Cucuta), Middle: The Health Secretary of Cucuta

Volunteering in the Rohingya Refugee Camps: An Unexpected Loss

I'm not even sure I wanted to write about this. It took me a day to collect my thoughts. But, I think It's important. Before I talk about the loss that occurred in clinic yesterday let me give you a little bit of background of where I am right now and what I'm doing. I'm currently in Cox's Bazaar, Bangladesh, a town that is essentially adjacent to the border of Myanmar. An area where close to 1 million refugees from the Rakhine State in Myanmar migrated to under violent conditions. Many lost children, limbs, significant others, along the way. The devastating fact is that the persecution of the Rohingya is not new, it has been ongoing since the 1940s and has sparked a few large migrations to Bangladesh and other surrounding countires but the most recent one incited in August 2017 when the Myanmar army enacted a series of violent attacks on the Rohingya.  The area of land that the largest camps reside on are hilly and suffered the wrath of the rainy season with several homes relocated. Ironically enough, Cox's Bazaar is a beach resort town--a mere 23 Km away reside the camps of thousands and thousands of refugees, living in bamboo huts. The roads that lead to the camps are flanked by these beautiful green rice paddies--the color of Bangladesh.

Yet the closer we get to the Kutopalong camp, one of the largest of the Rohingya camps, we start to see sparse green fields, several tin roofed homes that belong to the host community. In fact, several volunteers in the past as they get closer to the camps, mistake the homes of the host community for those of the Rohingya. The truth is, nearly a million refugees were taken into Bangladesh while the country still has its own poor people who need help--it's very understandable why there exists so many tensions in the area. 

We pull into the camp area, bamboo huts greet us. It is here in the Kutupalong Camp #4 that our clinic resides, a place where we can see mostly outpatient issues and there is a small 4 bed acute care area where we can stabilize patients. Compared to my visit here last year, there is now vegetation which is a site for sore eyes. I see homes growing squash along their roofs and chickens running around--a sign of some sustainability though with a backdrop of homes that are strewn together. There is a steep stairwell that leads into the clinic--climbing it is sometimes a challenge with the dry dusty air and the heat--it's quite metaphoric to the feat of getting through a day's clinic. 

My first day here was fantastic. I had a phenomenal knowledge-sharing session with the community health volunteers who are Rohingya, to review such things as how to use an inhaler as we so much asthma and COPD here in the clinic as well as review diarrheal disease and the importance of using oral rehydration salts. 

(all photos have been taken w/ permission)

My second day started out EXTREMELY busy. One of my first patients was a young woman, 18 years of age. She presented with left breast pain and clearly had a severe infection. She had a very high fever, she was shivering and her blood pressure was quite low, she looked "toxic"-a term we use when someone appears very ill. She was accompanied by her sister and her mother who were helping watch her 3 month old baby, a healthy baby girl. We started to resuscitate the patient--starting an IV and giving saline. We used a blood pressure cuff to maximize the rate at which we were giving her fluids. 

We were able to give her antibiotics through her IV within an hour of her being in the clinic.  Her baby was interactive and well throughout most of the morning, being brought in periodically to see her mother. The mother remained quite ill and we were discussing referring her to a higher level facility for continuous IV antibiotics and fluids as we have the ability to stabilize but then if someone does not turn around quickly we need to refer them out. The patient herself was declining referral as she just wanted to go home--during that discussion the baby was brought in as it seemed like something was wrong. I looked at this beautiful child--who at first glance appeared to be sleeping, initially the baby was given to the mother to feed but very quickly we realized something was very wrong, within seconds we started CPR, an ambu-bag was retrieved and oxygen and respirations were administered. emergency medications were administered. I felt like I was having an out of body experience--as I continued chest compressions all I could think about was--where do we go from here if we can revive this baby? There is ONE medical ICU bed in all the camps--and there are limited neonatal ICUs and none are close by. After 20 minutes of CPR the child remained pulseless. We called the time of death. The deafening screams of the family were overwhelming for all of us. As I stepped aside for a minute to collect myself, one of the translators who is also Rohingya said to me, " the messenger of death passes freely among us". He said this with such ease--again emphasizing that his community has been through SO much that it is not beyond reason to have seen death several times. 

I am telling you this story for one very big reason--to try and help everyone understand just what kind of dire situation these people are in. I cannot explain why that baby died, it's a complete mystery to all of us involved. I can tell you that even had the baby survived this cardiac arrest it is quite unlikely she would have survived much longer given how limited the resources are across the region. The field hospitals here are for emergent, salvageable cases. I maintain hope because if the Rohingya can maintain their hope then I certainly must.  

Needless to say, the baby's mother and remainder of her family went home. I remained concerned about her all night, worrying she herself would not survive because of how sick she was. We sent a community health volunteer to her home this  morning to follow-up--to request that she seek medical attention, but of course we did not expect her to come back to our clinic given the trauma of what happened there. She was sent home yesterday with oral antibiotics as a back up--and had continued to take them, she was doing OK and actually requested that she come back to our clinic to see our physicians--she trusted us as she felt that the only reason she was still alive was because of the care we were able to provide. I cannot imagine what she must be going through. We all needed time to process just what happened--but I can say, the team at the MedGlobal Clinic in Kutupalong were phenomenal, everyone responded immediately, the room was as calm as it could be--I couldn't be prouder of the team involved. We tried our best, we tried everything within the resources that we had...

And this morning--we all had to wake up and come back to work again, trying our best to put what happened behind us and to learn as much as we could from it. 

Signing off for today. 

A break from the medical world to see an orphanage and our last two Ultrasound training sessions in Dhaka

Sometimes I have tunnel vision around the task at hand, it's the only way to keep focus especially when it's so easy to be distracted by so much of the dysfunction and pain and suffering around us. However, it's important to take a moment, take a step back and shift the focus to get some perspective. I have as of late mostly focused on what I know, Critical Care and especially the use of bedside ultrasound in patient management. The more I see the more I realize that there really is SO much more to do--and these aren't distractions from my task at hand but opportunities to help others. I find that the more I use social media and blog and connect with people the more opportunities I get to connect those with experiences that give them a chance to give back as well. Sometimes just being the go-between is an important role to play and I happily take on that role for any of you who want to participate in any of the activities I post about.

That is a long segue into my recent trip to the orphanage that was opened by the organization Distressed Children and Infants, International (DCI). Their mission is quite simple but impactful--protect the rights of children, advance their opportunities via access to education and safe housing. They are primarily run by individual donors and it's incredible to see what they have achieved. Click Here to see their website.  I dragged along my colleague Alex who has been working alongside me throughout this trip, he happily tagged along and it was really a remarkable trip for us, but also really tugged at our heart strings learning about how some of the orphaned girls came to live here at the Sunchild Home. Some of the girls here were abandoned at birth because they were conceived in the setting of a rape, some were given up after their mothers may have re-married and their new husband may have declined looking after the child from a previous marriage, heartbreaking stories to hear. The orphanage has the capacity for up to 50 girls and they can stay there up until the age of 25. They all have access to education, and are driven to school every day via a minibus. Computer classes and job counseling are available to provide skills that can be used for gainful employment after finishing secondary school and college. First inaugurated in 1996 DCI now is starting to see the older children from their sponsorship program and orphanage reach the age where they are going on to university and beyond. One of the women has been admitted to Nursing School even!

These sweet faces greeted us as we entered the orphanage. So happy to see visitors! They talked to us about school and the various playground sports they excel at. There was a cultural program at their school and they all have been practicing singing and dancing classical Bengali Folk songs that even I remember from my own childhood--they performed several of these acts for us, proud to show off the product of their hard work.

After getting to meet all the kids we sat down to lunch with them. The food that we ate was the same food available to them on a daily basis--it was absolutely DELICIOUS. Extra helpings of rice and chicken and vegetables were available for everyone, there was absolutely no shortage.

After about a week of seeing sick adult patients in several different ICUs around Dhaka and going through exhausting training sessions it was incredible to be reminded of why we do this kind of work, because the youth of this world deserve a better tomorrow.

A very beautifully choreographed dance performed by the kids to the tune
of a classical Bengali Folk Song. 

I urge you all to check out their website, learn about what they are doing, and if you feel like it is something you want to be a part of--donate, donate once, or donate a recurrent amount in the form of sponsoring a child (for $15/month). I myself am sponsoring a child who lives in a village with her mother but without the support of this organization wouldn't have otherwise been able to go to school. I get a report card and pictures and I love hearing about how she is doing and I'm hopeful that maybe this will be an opportunity for her to have a life that she could have never imagined before.

After a great day with the kids at DCI--teaching us probably the biggest life lesson, that happiness is not reliant on the material, we moved on to our last two training sessions at BSMMU. This was a great end to our time here in Dhaka as we really got a chance to use several different ultrasound machines--we taught all of our exams on the home institution's ultrasound machine as well as showed the quality of two other devices, the Sonosite ultrasound that we brought with us and we again introduced to the butterfly ultrasound to a whole new group. The picture quality on that handheld device is unparalleled when compared to the alternative machines here. Hopeful we can get this tech out to those interested very soon!!

 

I am using the butterfly device and my trainee is using their ultrasound machine
to compare the quality. The butterfly has a better price point and plugs into the iphone
making all imaging capabilities available at your fingertips!

The program in Dhaka has been wonderful, Alex and I were welcomed with open arms. It was incredible to see how easy it was for him, an English speaker primarily, to deliver all of the lectures and training sessions, all of which were received very well. All of our courses are in English making it very easy for us to bring more US trainers in the future--something I very much hope to do by next year!!

Next up:

Leaving Dhaka for Cox's Bazaar to return to the Rohingya Camps via Medglobal, while I can only give a week of my time, I'm going to be rolling out a teaching session with the Rohingya Community Health Volunteers to help recognize asthma exacerbations as well as how to recognize different levels of dehydration and what can be treated in the home or what needs to be seen by a physician. 

The Cholera Hospital, a shampoo bottle used to treat pneumonia, and our latest Ultrasound Course!

It's been a busy 48 hours but as usual--filled with new sights and sounds and learners. One of our latest stops was the International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B). A hospital which I've talked about in previous visits, it is also known as the "Cholera Hospital" because of its pivotal role in helping to manage the cholera epidemic in Bangladesh. Established in the 1960s its most notable achievement was the key role in developing, testing and implementing oral rehydration solution. This is a simple packet of sugar and salts (costs 5 taka, 80 taka = 1 USD) which is mixed with clean drinking water to provide an oral method of rehydration for those with mild to moderate diarrhea. Because of the growing need for a facility to also treat such patients a hospital facility was build adjacent to the clinical research facility which now has an outpatient department, a general ward for long and short stays, and a neonatal, pediatric and adult ICU, all treatment is FREE OF CHARGE. We visited this facility for a few reasons--1. it is a phenomenal example of a well funded facility which can provide life-saving treatment as well as life-saving clinical research 2. to meet Dr. Jobayer Chisti who I've had the pleasure or working with before who has been doing some exciting new work in the area of management of severe pneumonia in children.

As far as the Cholera Hospital aspect of the hospital--there is a real rhythm to how patients are treated with diarrheal illness, less so Cholera now, but diarrheal disease in general is still a very big problem here. The hospital has beds with strategically placed holes in the bed, the wards are cleaned and sprayed down at regular increments throughout the day, bags of saline hang on each bed, ready to be spiked as soon as a patient is placed in the bed. 

From top left clockwise: Entrance to ICDDRB, Cholera Cot with IV saline, display of local foods that can be used to create nutritious meals, a video of a popular cartoon character which plays in the outpatient waiting area describing how to make oral saline.  

Regarding the second reason we had visited the ICDDR,B--to meet up with Dr. Chisti, a wonderful physician and brilliant scientist who is so very kind hearted as he took time out of a very busy schedule to sit down and talk about how we can collaborate in the future as one of his upcoming projects will involve the use of the ultrasound! I was also curious to see the "bubble CPAP" that he has recently received international recognition for!

The bubble cpap is an already existing low-tech intervention which has been used for neonates mostly. It has split tubing, one that delivers oxygen to the child through nasal prongs, the other is a tube that goes from the nasal prongs to a bottle with water, as the patient exhales, bubbles are created in the bottle and a certain amount of pressure is applied to keep open the air sacs in the lungs thereby improving oxygenation. He extrapolated the use of this from neonates to the pediatric population and has preliminarily shown the number of deaths from severe pneumonia decrease. Granted, he is still in the phase of research and development of this low-tech device which can be used in a setting such as this, its implications are vast. 

We were incredibly impressed by the work they continue to do at the ICDDR and I am hopeful that I can collaborate with Dr. Chisti in the future along with those who are experts in pediatric ultrasound (not my forte so I'll be calling on those of you out there who are!)

The following day we delivered an abbreviated version of the ultrasound course to a group of 20 physicians at BIRDEM hospital--a hospital which specializes in patients with complications from diabetes. As are many of the hospitals here, it is filled to the brim with sick patients. With a country the size of Wisconsin with 164 million people (8 million of whom live in Dhaka) it is no wonder that there is a need for SEVERAL hospitals and they are ALL full! For each course that we teach we do our best to remember that the local machine used may be different. Teaching on the machine available is also a very important aspect (something that requires figuring out the machine on the fly...something I feel has gotten easier the more I do this)--but also showing the importance of having quality images is equally as crucial. While the concepts may be exhausting and challenging to teach all of those issues are moot when the trainees are able to acquire beautiful images. Seen below one of our trainees, after several hours of instruction throughout the day and near the end of our hands on session, is acquiring a beautiful image of a typically challenging view of the heart.

Signing off for today--next up:

a visit to an orphanage in Dhaka which has several education and health care initiatives
our last two sessions at our third and final site in Dhaka

The evolution of our train the trainer course: how a personal experience changed the way I perceived global health

Every morning of every session I wake up wondering, “are we providing a real benefit?” I always hope the answer is yes but only time and commitment will tell. The general ultrasound teaching sessions are comprehensive and packed in a short period of time, covering lung ultrasound to help diagnose a collapsed lung, pneumonia or heart failure, cardiac ultrasound to help differentiate types of shock, deep vein ultrasound to help diagnose clots and the abdominal exam to help identify blood in the abdomen after trauma. The mastery of these skills takes time and practice and we recognize that a one or two-day course is not sufficient, so how do we sustain the medical education delivered here today? 

I’ll tell you a story to answer that question. There was a great man by the name of Mr. Zahin Ahmed. He was the heart and soul of an NGO called Friends in Village Development Bangladesh (FIVDB), he also was a very close family member. 

In 2009 I came to Bangladesh as a medical student and I visited his office in Sylhet and he took me out to a village to show me what he was working on. I don’t think I truly understood the impact that visit would have until now; he took me to a village and had me sit in on a community meeting and see the various programming in adult literacy and other such capacity building endeavors. He helped me to see that by providing a structured basis for education you could literally change lives as his interventions helped the poorest of the poor build skills to allow them to then provide for their family, and allowed communities to practice safe birthing techniques which was and still is, revolutionary. 

Fast forward, nearly ten years later, that experience still resonates with me, maybe even more so now than ever. As I started to develop my passion for Global medicine I wanted very much to create a manner in which we could make a lasting impact; that led me to medical education, a career in academics and pursuing medical training as my pathway into Global Health. So, that is the long winded explanation of how we have arrived to the “train the trainer” course!

For two days we are conducting a small group session with JUST hands-on training, scanning as many patients as we can. While everyone received hands-on training during the course this more intimate teaching environment allows for fine tuning as well as teaching how to troubleshoot and how to teach others. The purpose of this course is to build the capacity of these pre-identifies leaders in ultrasound so they can then take the responsibility to teach others long after we have left. Through the wonderful World Wide Web we then have several ways to share cases and imaging to allow expert feed back in as close to “real-time” as possible. 

While I have tried this in an informal way in the past, this year I wanted to proceed more formally,  hopeful that the inauguration of this course will lead to more widespread use of the ultrasound and a sustainable impact. 

The more you do...The MORE you do...it's a good problem to have

Apologies for the delay!! It’s been a whirlwind of a few days and it’s been difficult to get some time to fill you all in-by all means though that’s a good thing on this end.

So the transit from Philadelphia to Dhaka was seamless, as seamless as a 30 hour travel period can be! Given the short time and packed agenda the plan was to fly to Sylhet on the same day of my arrival. A 30 minute flight but after a draining 1.5 days of travel that's practically a drop in the hat. 

 

Sylhet as many of you may remember, is rich in history for the Ahmed family. It’s where my Father and his siblings grew up, it is where my Grandfather, Dr. Shamsuddin Ahmed, a renowned surgeon, was killed during the Liberation War when he stayed back at his hospital to help both Bangladeshi and Pakistani soldiers who were injured. It is where my late grandmother, Mrs. Hosnara Ahmad was the first principal of Sylhet Women’s College and advocated for women’s education and advancement and continues to be a legacy as a foundation in her name sponsors schooling for 11 girls yearly, it is where my uncle Mr. Zahin Ahmed created the Friends in Village Development of Bangladesh, an NGO that has done so much for the villages surrounding Sylhet from providing a pathway for women to acquire marketable skills to community education initiatives which have lowered the maternal-fetal mortality rate. I landed in Sylhet late on Feb 3^rd and the following day was off to the races—

The first stop was Noor Jahan Hospital in Sylhet where I had a phenomenal discussion with several members of the Critical Care department; we were brainstorming about the several initiatives that are both necessary and feasible in the near future. This includes a training program for nurses in the ICU which hopefully will also act as a way to recruit nurses to work in the ICU ( interestingly a highly sought after unit to work in the US but not nearly so here in Bangladesh for reasons I am still trying to understand). We also discussed a way to bring antibiotic stewardship to Bangladesh, and perhaps trying in a small microcosm in Sylhet before attempting to apply such a program throughout the country. There were many more topics discussed but the root of the discussion was that sustainable medical education is the key to every improvement!

The next stop in Sylhet was the Kidney Foundation Hospital that was opened recently and has been a passion project for several members of my family. It is an incredible space--it brings low cost care to those in SIGNIFICANT need. Renal Failure as a consequence of Diabetes and Hypertension is very much a national problem without adequate resources to accommodate the continuing growing problem. With mostly charitable donations this center was built in Sylhet to provide care to those in need--seen here is the entrance to the outpatient Dialysis center. On my visit there I encountered several patients who were receiving dialysis, smiles on their faces--the clinic has its own lab as well as quarters for physicians so they can consult with patients at regular intervals. 

After such a long day I returned home and quickly re-learned the importance of adequate hydration.  Long flights can dry you out, only making jetlag worse, then add the dry air this time of year and heat all combined leading to a bit of orthostasis and a frantic need to catch up on my required fluid intake. (enter my trusty old friend, Oral Rehydration Salts, known as OrSaline here--think pedialyte but better) . The following day heralded the return to Dhaka and subsequently the start of a fruitful two days. The added bonus of this trip is that I am joined by a colleague from The University of Pennsylvania, Dr. Alex Bonnel, who is currently a fellow in Ultrasound (after completing his Internal Medicine Residency). He has an avid interest in global health and medical education in resource limited settings and is an amazing addition to the trip. 

For those who are just joining the journey let me give you a bit of background of what we are doing here--As a trainee in Pulmonary and Critical Care at NYU/Bellevue I acquired the skills necessary to use and train others in point-of-care ultrasound. This term refers to a new way of using old technology (i.e. the ultrasound)-in which the healthcare provider now has the ability to use this machine, acquire images, interpret the images and integrate the findings into clinical decision-making. This is revolutionary for a few reasons--it allows additional data points in medical-decision making at a rapid pace and has significant implications for resource-limited settings where reliable imaging such as Chest Xrays let alone CT scans are not available. Fast forward to my 3rd and final year of fellowship where I created a GoFundMe account to raise money to purchase an ultrasound for the Dhaka Medical College Hospital ICU with the intent to deliver it along with hands-on training which was initiated in February 2017. That ultrasound remains in great shape--seen below, and is used on a daily basis. Furthermore, those that were trained in the first two years are now training others!

Now back for the third iteration of this course, we were welcomed graciously as always at Dhaka Medical College Hospital (DMCH), banner and all! The best part about the continuity that exists with returning to the same location is that those I've spent significant time with training to be champions of US here at DMCH have done their part in exposing all of their trainees to ultrasound. It is an integral part of their training and as such all of the participants in this course quickly picked up the concepts as they have been learning about this technology over the last year.

The additionally exciting aspect of this trip was the ability to share some of the exciting new technology that is emerging, for instance the Butterfly Ultrasound Probe (seen here we are demonstrating its use on our own trainers) which plugs into your iphone and has a simple App which can be used--and has a terrific price point versus the 20-30K machines that are far too expensive to acquire here.

 

 

The first two days of the course were long but fruitful as by the end of the day we were identifying pathology in patients! A case of a man who was admitted overnight to the ICU with respiratory distress and fever. He was able to obtain a chest xray which did show a pneumonia but it wasn't nearly so clear that he had an effusion (fluid around the lungs) given the limitations of the portable chest xray. The next morning when we evaluated him with the ultrasound the trainees were able to identify signs consistent with pneumonia and very clearly pointed out the effusion around the lungs. The buy-in for this technology literally happens immediately which makes this whole process SO worthwhile!! 

With two long days of training behind us we were glad to have a free day--normally the weekend here is Friday/Saturday, or more typically just Friday given that many folks work 6 days a week. 

Tomorrow we are excited to start the first official "Train the Trainer" course which will include 6 physicians who have gone through this training course and have been identified as potential leaders in ultrasound for their institution. Signing off for now--hopeful tomorrow heralds the start of a new phase of this training which will help sustain this project with less involvement from external sources.  

Wheels Up to Bangladesh in 24 hours—a month of hard work ahead but couldn’t be more excited

It's been an incredible year since February 2018, there was Addis Ababa in June and Sierra Leone in November--two incredible medical education and clinical practice experiences that were only made possible by the success of the project in Bangladesh. For the young folks following along, the best advice I can give in pursuing a career in Global Health is 1. don't let it be a hobby 2. NETWORK! use your existing network, reach out to anyone and everyone with similar interests and MAKE IT HAPPEN! 

As I progress in my career I have learned valuable lessons through successes and failures alike. If anyone wants to reach out to collaborate, or to just chat about any of the experiences I've blogged about, please do reach out:

Nahreen.H.Ahmed@gmail.com

That's not an empty offer, I'm always looking for new and exciting ideas to pursue.

So..back to Bangladesh--wheels up tomorrow evening and it is a JAM PACKED calendar. Here's what we have to look forward to:

1. First stop Sylhet, Bangladesh, exploring how to bring a new ICU curriculum to a local hospital there

2. Dhaka, Bangladesh (2 weeks)--we will once again delve into Critical Care Ultrasound training of local physicians from hospitals all across Dhaka with additional days to train those who will be champions of ultrasound in their own institutions and go on to train their residents.

The ultrasound that ALL OF YOU helped crowdfund continues to be IMMENSELY helpful and I look forward to sharing more about that with you while in Dhaka

3. Cox's Bazaar, Bangladesh (1 week) Back to the Rohingya Refugee Camps via MedGlobal
This is REALLY exciting, we are working on rolling out a small training seminar for Rohingya Community Health Volunteers in the area of asthma inhaler use and diarrheal disease

4. Khatmandu, Nepal (4 days) - Rolling out a Hemodynamics Lecture for local docs in the area of critical care, emergency medicine and anesthesia
A brand new site, brand new network!

Can't wait for you all to come along with me as this new adventure unfolds.