Stories From The Field

I was not exactly sure what to expect prior to my arrival in Beijing. I had heard numerous things about the rotation while still in the US and was unaware of what my role would be exactly. Given the language barrier, I expected that I would have a resident by my side as an interpreter and that I would be shadowing the team. I was also told that I would be to prepare several lectures that I would present to residents. Although this brief "orientation" was fairly accurate, it in no way captures the true feeling of this experience.

I am still trying to figure out my exact role in the hospital. The housestaff and attendings are extremely welcoming and allow me to select the topics I am most interested in. Since I have been on GI and Cardiology teams, they have offered to let me be present for numerous EGD's, colonoscopy's, pacemaker insertions, and cardiac cath's. I pre-round with the team, take part in attending rounds, and sit in on lectures and conferences where I am often asked my opinion about the case by some of the program leadership. However, the language barrier has remained a challenge throughout most of the experience as technical medical terms and names for medication often are difficult to translate.

My interactions with the housestaff and attendings however have been the highlight of my experience. The more time I spend here, the more I realize that to truly benefit from this unique experience, I need to maximize my time interacting with my new colleagues. While giving formal lectures soon after my arrival, I realized very quickly that the residents love to speak English. With this in mind, I rarely do purely lecture type presentations and rather try to make the presentations interactive with the use of the blackboard. I have offered the residents who are particularly interested in practicing their English skills the chance to present full H&P's to me as new patients were admitted to the hospital or on particularly interesting cases. They love this opportunity and on average, I hear at least 1-2 cases each day. At the conclusion of each presentation, I usually repeat the entire case for them and write down key English medical terms on the board. We then generate a differential diagnosis and talk about differences in standard treatment between my institution and theirs. It is these informal teaching sessions which have been the highlight for me.

I feel as if my teaching skills are truly being tested to the limit as I try to overcome the language barrier. It is becoming easier with each day that passes, and I find that this has been one of the greatest teaching experiences I have ever had. I am hopeful that I will be able to continue to build on these skills and incorporate them in my duties as a senior resident on my return to Duke as well as eventually as a fellow and attending.

Hope all is well in Durham! Talk to you soon,

Andrew
Andrew Rassi is a Senior Resident in the Department of Medicine. He is currently completing a three month global health rotation at Beijing Hospital and hoping to get tickets to an Olympic event.

I lost a patient today. She was not my first, and unfortunately, she will not be my last. But today was different.

Tuesday

She arrived yesterday on a typical Rwandan stretcher (see picture). This required eight people, who worked in shifts, to carry her up the mountain to Shyira Hospital at 6,000 feet above sea level. She was clearly in respiratory distress, so we bypassed the clinic and admitted her directly to our 35-bed internal medicine ward. As she paused to catch her breath between words, she described one year of a progressive dry cough and pain in her right breast.

I began to examine her, and she looked at me with a mix of fear and hope in her eyes as she pointed to her right breast. After I lifted up her shirt, I understood her fear. Her breast was a large, rock-like, solid mass! As I continued to listen to her extremely coarse breath sounds, I felt my own heart sink.

How could she have waited a whole year with this?!? Why do people wait so long before coming to us for treatment? In the U.S., she would have been knocking at her doctor's door months before, but in rural Rwanda, traditional healers are often still first line. She probably went to a healer, who told her that she had been poisoned. He would then give her something that might make her vomit. If she vomited, she had clearly been poisoned. If she did not vomit, she might then consider going to the hospital. These healers have nothing like a Hippocratic Oath, so patients always have to wonder whether or not their healer has been paid by somebody to give them something dangerous. This may be one of many reasons that Western medicine is growing in the region.

Despite that growth, I was still standing and looking at this patient that I now knew was HIV positive and had an oxygen saturation of 81%. While I had been pondering questions about how my patient ended up in such a dire situation, new and more dreadful questions hit me... What does she have? How can I possibly find out? What can I do for her?

Diagnosis

She most likely had a breast cancer or breast tuberculosis, although other causes could not be ruled out. To diagnose cancer or tuberculosis would require the ability to analyze tissue, which is not yet available at Shyira. We ordered sputum smears for tuberculosis, but she had a dry cough, and we are not able to induce sputums in Shyira. We were also out of the reagent used in the testing of the sputum.

Maybe imaging would be helpful? To get a chest x-ray requires a one-hour drive down the rockiest road that I have ever seen. Most patients vomit in the car either on the way there or back. The patients are usually dropped off there in the morning and picked up at night. To get a CT scan or pathology analysis would require a 3-hour drive each way to Kigali, the capital city. As if this was not complicated enough, the entire country was out of x-ray film. And of course, any such transportation is not possible with a woman in respiratory distress and an oxygen saturation of 81%.

Treatment

She was hypoxic at 81% on room air and had very coarse breath sounds and wheezing. At the very least, she needed oxygen. While we had oxygen available, we did not have electricity to run the oxygen machine. She needed some relief from her respiratory distress, but we did not have any nebulizers or inhalers.

Her breast mass was most likely cancer or tuberculosis. If it was cancer, it was likely inoperable, and we could not definitively say without imaging. Either way, surgery and limited chemotherapy would not be available except three hours away in Kigali. Radiation therapy does not exist in Rwanda. If it was tuberculosis, we could treat her, but we doubted whether the treatment could work fast enough to reverse the course of her very progressive illness.

We gave her antibiotics, anti-tuberculosis medication, and steroids and then hoped for the best.

Friday

I did not see her yesterday. I was at a meeting with the mayor and other government officials as we tried to organize plans to provide more consistent hydroelectric power to the area. The Rwandan government, Belgian government, American donors/investors, and Rwandan investors have all combined efforts and funds to help provide life-saving electricity to the area.

But as I look at my patient today, I know that these plans will not save her. She is breathing at a rate of 36 breaths per minute. She cannot talk as she gasps for air. We are making arrangements to provide her with palliative oxygen as we transfer her to a private room. At the end of rounds, I ask the nurses if she has been transferred to a private room. They reply, "Oui, mais elle est morte." Yes, but she is dead.

I pray for her and her family and then head to lunch.

Michael Bestawros is a Senior Resident in the Department of Medicine. He is currently completing a three month global health rotation at Shyira Hospital in Ruhengeri, Rwanda. This fall he will pursue a master's in public health at UNC.

I have been in Shiprock for four weeks now, and so far have found it to be one of my most rewarding experiences in residency.

Many of the patients are living without running water or electricity, which is amazing in a country as rich as the United States. Just last week I saw a gentleman with obstructive sleep apnea who has had a CPAP machine for years, but has been unable to use it because he does not have any electricity. You also see a lot of the same diseases that you see at Duke, but in different proportions - there is tons of diabetes, rheumatoid arthritis, gall bladder disease, ear disease, but very little lung cancer.

On the other hand, the hospital itself has lots of resources, although somewhat limited in comparison to teaching institutions such as Duke. There are MRIs, but only on Tuesdays. There are TTEs, but only about 12 a month. There is an ICU, but it only has 4 beds. As a result, you have to work closely with the neighboring hospitals, and it has been very illuminating to be the "Outside Hospital." I have already transferred a patient with likely renal cell carcinoma and paraneoplastic syndrome to a neighboring hospital because we have no oncologists here. Another patient needed a biliary drain changed, and so I sent him to a neighboring hospital with an interventional radiologist; he went there for the procedure and then came back the same day.

The physicians here come from a wide range of backgrounds, and are very collegial and interested in teaching. Almost all of them live on the "hospital compound," and so are next door neighbors. They regularly get together for various events; just last week we all met up in the evening to watch a slide show presented by a physician who had recently been in India. You also work closely with the surgical service and the family medicine service, and it has been fun to be a consultant on a variety of cases.

Emily Schroeder is a Senior Resident in the Department of Medicine. She is currently completing a three month global health rotation at the Northern Navajo Medical Center in Shiprock, New Mexico.

Greetings from Shiprock. We are having a wonderful time out here. One of the main reasons I wanted to work in the Indian Health Service was to experience this unique publicly-funded healthcare system. The Indian Health Service provides free medical care, including free prescription coverage, and free hospital care, to all of the Navajo Indians on the reservation. No copays, no deductibles, etc. I do not get the sense that the patients realize how different this is than health care for other Americans. From what I have seen thus far, the care provided to these patients is excellent, despite the fact that per capita health care expenditures are less than half of that for the total US population. The health care system here is based in organized and systematic primary care. Specialists are few and far between, and generally play a true "consultant" role – often over the phone rather than in person. It has been a very valuable experience for me, as someone interested in going into academic primary care, to work in a system in which primary care physicians play the central role in the care of patients, both inpatient and outpatient.

It has also been fascinating to learn about the culture and history of the Navajo - something I knew little about before coming here. Yesterday I traveled two hours west into the Arizona town of Kayenta, also on the Navajo reservation. We were there to screen former uranium miners for lung disease, and to help those with lung disease attempt to obtain compensation from the federal government. The US government recruited the Navajo to work in uranium mines in this area in the 1950s and 60s. Although the miners were exposed to radon exposures well in excess of that known to be hazardous, they were not informed of this risk, and the mines were not ventilated to improve safety. Beginning in 1990, by act of congress, former uranium miners with lung disease could apply for compensation from the government. A branch of the Indian Health Service runs clinics to screen patients that would like to be evaluated to see whether they qualify for compensation. In addition to working in a uranium mine for more than two years, one of the patients we met yesterday had also worked as a code talker during World War II, another interesting piece of US history. He told us about how he was recruited and worked in the South Pacific, only to be "captured" by an American soldier who mistook him for Japanese, and freed only when he was recognized by his own unit. Incidentally, there is a museum about the code talkers in Kayenta, located inside of the Burger King. Fast food is unfortunately at the center of life here.

Hope all is well in Durham, Erin

Erin Van Scoyoc is a Senior Resident in the Department of Medicine. She is currently completing a three month global health rotation at the Northern Navajo Medical Center in Shiprock, New Mexico.

My time here has been spent almost exclusively on the wards and it has been intellectually stimulating, challenging and satisfying.  It has also been frustrating, sad, and just as frequently, diagnostically unsatisfying.  Since I was here 3 years ago I have some metric against which to measure my current experience.  I certainly know more and have experience managing teams.  When someone asks about sickle cell disease I can do a 5 minute impromptu teaching session without a problem.  Nonetheless, I have had to radically change the way in which I think about and manage patients since diagnostic capability is so limited, many therapies are empiric, and the scope of disease is very different.

I am primarily responsible for taking care of many patient populations that I do not routinely manage.  AIDS, Tb, malaria, and malnutrition are probably the most common of these and have fairly extensive WHO management guidelines which help.  And then there are the more exotic problems, like the 3 year old with an 8 month history of abdominal swelling who had a spleen that crossed the midline and extended to her pubic symphisis.  Her only other pertinent was moderate malnutrition and a liver down about 4cm.  We had at our diagnostic disposal some basic lab work (CBC, peripheral smear, AST/ALT, HIV serology), CXR, abd U/S, and echo.  Other than malaria seen on peripheral smear, anemia and thrombocytopenia, and the organomegaly, the labs were normal.  A bone marrow was performed by one of the residents and was dry (though I suspect this was due more to the poor suction generated by the ancient glass syringe than a truly dry marrow).  Our differential included malignancy such as leukemia or lymphoma but the indolent nature of her presentation without any other significant findings (e.g. no blasts on smear, no adenopathy, no masses on U/S) made it less likely.  An indolent lymphoma could do this but without any palpable nodes and the inability of the family to afford a CT there was not much more diagnostically we could do.  Hyperreactive Malarial Splenomegaly Syndrome was also possible though 3 is a very young age of presentation.  Then there are some of the less common disorders such as Gauchers which we have no ability to diagnose much less treat.  The patient was in the hospital for nearly a month and was treated with several courses of antibiotics (for what I was never sure) and quinine for the malaria, with no change in her condition. And so we were left to treat Malarial Splenomegaly Syndrome empirically with weekly chloroquine and have the patient follow up monthly to see if there is any improvement.

As a resident you can really make a difference here.  You are certainly not taking anyone's job.  There are only 5 attendings, 5 residents, and a variable number of interns (1-4) covering wards with a normal census of ~80 and several busy clinics.  The clinics, which are run by the attendings, are usually given staffing priority meaning the wards are often covered by an intern who may only have a week or two of pediatric experience or, even worse, an AMO student (roughly the equivalent of a PA but with far, far less training).  So to have a resident on the wards every day helping with management is a terrific help.  What was nice for me (since even as a resident I often craved someone senior to bounce a few ideas off of) is that Satish Gopal, a med-peds doc here with the Baylor Pediatric AIDS Corp, would come down most afternoons to see if there were any difficult patients I wanted to discuss.  So there was a nice balance of autonomy with some attending level teaching and discussion.

My wife and I are now scheming about ways for us to come back over for a more extended period of time.  We will see what happens!  Hope all is well back in Durham.  See you in a few weeks.

Kevin Watt is a Senior Resident in the Department of Pediatrics. He is currently completing a two month global health rotation at Kilimanjaro Christian Medical Center accompanied by his wife and son.

Global health is a term that has several different meanings and implications. To many, it signifies providing health care in underserved areas faced with a scarcity of resources. However, the term also incorporates many present and future socioeconomic implications, as I have witnessed first hand. At Bangkok's Siriraj Hospital, a 2600-bed tertiary care center, physicians have available to them many of the technologies that are commonplace in the developed world. However, there are daily reminders that despite the technological advances, the demand far outweighs the supply.

I have seen several cases over the last 6 weeks that have personified global healthcare and resource allocation. However, one case in particular demonstrates not only the immediate consequences but also the long-term/lifelong effects.

A 20-yr old Thais man presented to his local village physician with acute ankle pain. As the patient performs many laborious tasks working, it was unclear as to the traumatic nature of the injury. Initial evaluation did not demonstrate any significant abnormalities and given the lack of an available Xray, radiographs were deferred and the young man was instructed to RICE his injury. Over the next 2 days, the ankle became more swollen, red and painful, and the patient presented again to his local medical clinic. There were several other patients to be seen before him and he did not feel the need to wait, thus, he went to the local pharmacy, purchased different NSAIDs and returned home. The next morning, the patient woke up with fevers and right-eye blindness. He was taken to the ED by his family. Evaluation at that time revealed signs of possible endophthalmitis and oligoarthritis. He was started on appropriate therapy and transferred to Siriraj Hospital where further investigation would reveal septic arthritis, bilateral endophthalmitis, meningitis, and blood cultures eventually grew S. agalactiae. After receiving appropriate therapy, the majority of symptoms improved with the exception of the blindness.

As a young Thais man, he provides approximately one-third of his family's income and thus bears significant responsibility. Now, his visual impairment drastically affects his ability to work and provide for his family. Due to limited resources and staffing at his local healthcare facility, there was a delay in diagnosis and thus appropriate management. This delay not only resulted in immediate increases in health care cost, but also the opportunity cost for what this man would have done with unimpaired vision.

I have no doubt that I will continue to learn firsthand the implications of providing health care in such underserved areas, and these life lessons will undoubtedly change the way I practice medicine. Thanks for this opportunity!

Sharif Halim is a Senior Resident in the Department of Medicine. He is currently completing a three month global health rotation at Siriraj Hospital in Thailand