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.