Stories From The Field

Ms. M is a 45-year-old female with HIV who presented to Siriraj Hospital with altered mental status and fever. As we watched her writhing in bed in four-point restraints, it was clear to the hematology consults team that she was not herself. By this time, she carried a presumptive diagnosis of thrombotic thrombocytopenic purpura based on her clinical picture, thrombocytopenia, and schistocytes on her blood smear. It should have been simple enough to start treating her with daily plasmapheresis. However, we had not bargained for the disruption created by the 6-day long national holiday that was Songkran - Thai New Year - that was beginning the following day. Plasmapheresis is not available over the weekends or on national holidays at Siriraj Hospital. Our recommendation to the team was to support Ms. M. with daily plasma infusions until such a time as plasmapheresis became available. It was clearly suboptimal therapy and we knew her risk of mortality was significantly increased. Nevertheless, such was this woman's luck: her chance at cure held hostage by a national holiday.

It would be easy to paint a dismal landscape from the above situation and label Siriraj Hospital as the bad guy; however, it represents the blessing and the curse of providing health care for a majority of the population in a setting of limited resources. The fact is that resources are always limited - some countries seem to feel the squeeze more painfully than others. But, it is the way we choose to allocate those resources that clearly sets one health system apart from the other. Siriraj has every advance of modern medicine you can imagine: state of the art imaging centers, MRI, multi-slice CT-scanners, you name it! Siriraj is a well-recognized name in Thai medicine. The >2000-bed hospital provides care to millions of Thais a year, rich and poor alike. However, where CT imaging is available on an as needed basis over the holiday weekend, plasmapheresis is not. It happens to be an artificial dividing line of what Siriraj Hospital has determined it can and cannot pay for. For us in the United States, we may not have as much of an apparent challenge with needing to allocate scarce resources; however, with the millions of our population lacking access to care, we are not very different from the folks at Siriraj Hospital. We have simply made a different choice.

The scenario painted above and many similar ones have been eye-opening and life changing. Many times, I have been forced to become introspective, asking myself whether, given the same resources and unique patient populations, I would make different choices. I find myself appreciating many things in Western medicine that I have taken for granted and thinking critically about similar challenges we share but are yet to solve. When I walked off the plane and into Thailand, I knew I would be a different physician heading back to the States. But I was not really prepared for how much my perspectives would change. Given another opportunity, I would do it again.

Toyosi Fatunase is an Internal Medicine Resident at Duke. She rotated at Siriraj Hospital in Bangkok for 2 months.

In my weeks at Karapitya Hospital in Galle, Sri Lanka, what I remember most is my first patient who died. A twenty nine year old with nephrotic syndrome who developed worsening renal failure, metabolic acidosis and died while waiting for dialysis. His death was not unexpected. It is perhaps an odd thing that I keep running the events through my head. After all, I am a physician, I have had patients die before- this is not my first trip to the rodeo. In fact this isn't even the first time I have worked in a developing country. I spent two years as a Peace Corps volunteer in West Africa before medical school. People died in my village every week. People would come to my house and ask for help for their loved ones and while I could pay for the taxi fare to the hospital, I was otherwise useless in the face of their need. I always dreamed of being able to go back after finishing my training and actually be able to do something. To diagnose. To treat. To be of some use. I looked at Karapitya Hospital as a dry run to see what it would be like to work in a developing country. To see if the intervening years of medical school and residency had made a difference.

At first it was startlingly similar to my inpatient rotations at Duke, despite the differences in the physical environment. Morning spent watching medical students frantically running around trying to have all the information on their overnight admissions ready for rounds. Pre-rounding with the registrars and house officers, the equivalent of junior residents and interns respectively, and then rounds with the consultant aka the attending. Rounds were fast, we had to get through anywhere from 30 -70 patients. And work-ups limited. Patients were often discharged in a few days with follow up in the hospital clinics. The goal was to make sure we would have beds available for the next casualty or admitting day. Because even if there were no physical beds, patients would still be admitted to the hospital. I thrust myself into the routine without much difficulty. And most days went by without incident although it was difficult to become accustomed to the omission of tests and studies that I would have ordered if back in North Carolina.

Then one morning I came in to find my patient with nephrotic syndrome on 50% facemask in acute respiratory distress. He had been diagnosed with membranoproliferative glomerulonephritis as a teenager, but had been lost to follow up. He had shown up in the hospital clinic two weeks prior with severe anasarca, shortness of breath and metabolic acidosis. His family had been working on obtaining a kidney transplant for the past several months, but had been unable to find a donor. In Sri Lanka, there are no cadaveric organ transplants. In order to have a transplant there must be a living related donor. He had been dialyzed twice after being admitted due to his metabolic acidosis on the only dialysis machine in the hospital. He again needed dialysis, but the machine was already committed to two other patients. There were no other machines in the southern part of Sri Lanka. There was no where we could send him. We gave him morphine to help with his shortness of breath and continued with rounds. Over the next half an hour we could hear him struggling for air. There are no private rooms. The patients all lay together in an open air ward. There was no escape from the sounds. After rounds were complete, one of the house officers called me over to the bed and we waited while he took his last few agonal breaths. The family stood at the foot of the bed and watched as we checked for a heart beat. The patients in the beds next to him watched as we pronounced his time of death. A registrar turned to me and said, "It costs 2500 rupees ($25) for dialysis. For lack of 2500 rupees he died." There was nothing I could say in response. I had nothing to offer to make up for the lack of a dialysis slot. All my training still could not save this one life.

Throughout my time in Sri Lanka I have been grateful for the camaraderie, patience and expertise of the wonderful and dedicated clinicians with whom I have worked. However, my true debt lies with the patients who graciously allowed me to practice my profession and who smiled even when there was nothing I could offer. As for my twenty nine year old with nephrotic syndrome, I am grateful for the chance to have known him. And for the reminder that my training comes with a responsibility to not only work to make my patients better, but to work to correct the differences that lie between the developing and the developed world. I hope to return to Sri Lanka in the future intent on achieving both goals.

Divya Bappanad is an Internal Medicine Resident at Duke. She worked at Karapitiya Hospital in Sri Lanka during her global health elective.

I've been in full swing at Adelaide for at least 5 weeks now. I've split my time between research and the palliative care service, and tomorrow I am starting on the medicine service.

The most valuable aspect thus far has been that I have gained a much greater appreciation for another health care system. Australians both publicly and privately fund health care. Everyone has access through the public system, but those who earn a certain income have tax incentives to obtain private insurance. General internists act as specialists, caring for more complex patients with general practictioners doing all of the preventative management. In addition, the palliative care physicians use their hospice unit as an acute care unit. The palliative care physicians admit people to manage their symptoms, with the expectation that they will be discharged home with better functional status.

At a time when we as Americans are initiating changes to our health system, it has been good to learn about and experience care delivery here. For me, this rotation has served as a real-time immersion in comparative health systems. Though there may be starker contrasts between the United States and resource poor nations, anyone interested in health policy in the United States would benefit from coming to Australia. Australia tackles similar problems, including health inequities between minority and majority populations, battles between state and federal control of health policy, and the balance between tertiary and primary care.

Brooke Cunningham, an Internal Medicine Resident at Duke, trained at Flinders Medical Center in Adelaide during her senior year.

The faded curtains hanging between patient beds in the sweltering non-AC open air ward, patients spilling out onto the hallway floors, electricity going out in the midst of procedures, labs returning in the mornings with sometimes unreliable numbers, one dialysis machine and one cardiologist for the whole southern region of the country...

In the first week - actually, make that in the first hour - of being on the Karapitiya Hospital general medicine wards, I knew we were going to have a very different environment to practice inpatient medicine in than on the eighth floor of Duke Hospital. With so many stark contrasts between the two hospitals, which became readily apparent on a daily basis, what struck me most about my whole experience in Galle, Sri Lanka, though, was what we and the Sri Lankan residents ultimately had in common. We struggled with ICU beds all being taken and having to manage patients with pressors on the floor, with miscommunications between the interns and surgical consult residents, with attendings demanding workups for esoteric diseases, with nurses who had missed a set of vitals, with junior residents unwilling to discharge patients days after their acute problem had been managed. We shared a social life of talking about our patients, medicine, and the hospital, wishing for more hours in the day to spend with our families and friends. Of course, the resource limitations we faced on the wards were a continual reminder of how much more challenging it was to work at Karapitiya. We saw patients die because there weren't enough ventilators to get them through a COPD flare, from toxic ingestions because the supply of antidote was out.

Then one day, Thursday April 16, I came face-to-face with a much deeper difference between our experience and that of the Sri Lankan residents. We were having tea with a few other senior residents at the Canteen after rounds, when the 2004 tsunami came up in conversation. Two of the residents had been the interns on call December 26, 2004, and they began to tell the vivid story of bodies after bodies being brought to the hospital. They only had four ventilators at the time, and even though they knew there was no way to stabilize the hundreds of remaining patients with respiratory distress from aspiration, they desperately did chest compressions on men and women and bag-masked children for hours, finally realizing the futility. And then they were left with a 600-bed, 3-story morgue, with cadavers extending way beyond the hospital grounds. In the days that followed, they talked about not only the physical death that pervaded the town, but the hopelessness and resignation that was overwhelming. When international aid agencies came to provide medical help, they said there was such an influx of acetaminophen that in the following weeks, there most frequent admission was for acetaminophen overdose.

Even now in 2009, the number of admissions I saw at Karapitiya for attempted suicide in three months was more than I'd seen my entire three years at Duke. The background of the civil war between the government and Liberation Tigers of Tamil Eelam (LTTE), we discovered, was also part of this, as so many young men had died in battle, and mothers and wives were left to pick up the pieces. One of the Sri Lankan men working at the guesthouse we lived at told us about his brother dying in the war, and even the mention of the city Jaffna often stirred a distracted blank stare.

These stories gave me an appreciation for the unique context Karapitiya Hospital operates in and a great respect for the residents who work there. I developed both personal and professional ties that I hope will bring me back to the country in the future.

Neela Goswami is currently an Infectious Disease Fellow at Duke. She completed a 3 month global health rotation at Karapitiya Hospital in Galle, Sri Lanka, from February-May, 2009.

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.