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.