Bangladesh, Part #2

It's been a full week at LAMB - I'm staying busy either doing ultrasounds, rounding on antepartum and postpartum patients, and working on the labor & delivery unit!  I had two 24 hr call shifts this week with lots of interesting patients.
I've also been introduced to the difficult concept that female infants are considered a liability.  A few families have been disappointed this week because they delivered females, and one family refused a C-section for a very distressed infant because they knew it was going to be a girl from an ultrasound they obtained elsewhere.  Here, we don't tell anyone gender on ultrasound because of this phenomenon.
It's also interesting to be the second or third hospital that people come to for care.  Last week I admitted a term severe preeclamptic (BP 190/110 with headache and significant edema) who had been treated at a clinic for high blood pressure...3 days before.  The clinic had actually given her a shot of magnesium and sent her home.  Incredibly, the baby was still OK.
On my most recent call night, a woman came in with severe abdominal pain and a very small amount of vaginal bleeding after 2 months of amenorrhea.  She gave the odd history that she had 2 prior D&Cs, both done in outside clinics.  She was awake for the first D&C and no product came out - the doctor simply told her that the baby must have already passed despite having no bleeding.  After 2 more weeks of pain, she had a second D&C at the same clinic.  And now she came to us with exquisite abdominal tenderness.  I was surprised by the ultrasound to see products of conception and a fetus (without heartbeat), but also saw fluid and irregular masses everywhere.  I called Dr. B who agreed this was a very strange ultrasound. We discussed the possibility of uterine perforation vs ectopic.  After overnight antibiotics, we took her to surgery yesterday and found an abdomen full of blood clots, swollen adnexa & tubes, and a huge ectopic pregnancy in her right ovary - it was actually difficult to find the tiny uterus in the midst of the mess in her pelvis.  Learning point...if you  can't get the products out on D&C, the fetus is probably somewhere else!
I have been so impressed with the quality of medicine that is done here at LAMB with relatively few resources. The guidelines that the hospital follows and teaches the residents are evidence-based and up to date, the facilities are very clean, and everyone is constantly looking for ways to learn and improve.  It's definitely a model of missions hospital that others could learn a lot from.  I've felt so welcomed and have been working with the best people - both the Bangladeshi staff and missionaries.
Feel free to email if anyone has questions :-) I'm looking forward to sharing more when I get back!

Hello from LAMB Hospital, Bangladesh!  It's hard to believe that I arrived here a whole week ago - it's going quickly!

First a brief overview of LAMB - it's an impressive hospital and community health system, and the hospital compound where I'm living and working is also home to an elementary school, nursing school, and midwife training program.  In communities around the hospital, LAMB has 28 clinics, including 18 safe delivery units.  The community activities include not only health related activities, but also community development and disaster preparedness.

LAMB now has more than 1000 staff – mostly Bangladeshi, but with approximately 25 foreign staff to bring additional expertise and training capacity.

I'm working in the obstetric/gynecology unit along with Bangladeshi senior doctors and residents and one Swiss physician, Dr. Ambauen, who has worked here for a number of years and heads the department.  I arrived Sunday evening and my introduction to the hospital started Monday morning with a retained placenta - 5 hours after delivering the baby at home, the patient had sustained huge postpartum hemorrhage and was in hypovolemic shock.  By noon, I found myself in the operating room again doing a C-section, and assisted a molar pregnancy D&C that afternoon.  So it was a solid start to the month here!  I was put on the call schedule as a senior doctor, which made me a bit nervous on my 3rd day in a country where they talk about "normal ecclampsia" (when mothers seize but recover without complications).  Fortunately I had a back-up in case of emergency and honestly, things went smoothly on my first call day Wednesday.  The midwives handle all low-risk cases - I'm still getting used to not knowing about all the deliveries!  Junior doctors have a range of experience from 1 month to over 2 years.  I've been working with the youngest junior doctors on suturing the fascia in the OR and doing basic growth ultrasounds.  The experienced junior doctors can handle most things themselves, but call about decision making or any complicated cases.  Many women here deliver in SDUs (safe delivery units) that are midwife-staffed.  I visited one of these this morning and was impressed with the services offered there.  If there are problems, the women are sent here to the hospital.

Friday was particularly interesting- we hosted "Fistula Camp" and operated on 7 complicated fistula cases in a single 13 hour day.  A well-known fistula surgeon flew in for the day from Dhaka and I got a crash course in assisting fistula cases.  It's mind-blowing to think of 2 million women worldwide suffering from constant leaking and the stigma that goes with fistulas, and with poor access to labor care, more women are developing these daily. It was a great learning experience to assist on these repairs, and meeting these women was a reminder of how critical it is to have access to proper intrapartum care.

And just like that, I have reached my last day at LDL. This week, I have gotten to see a few repeat patients and it has been fun to have some continuity in my short time here. Both were newly diagnosed CHF patients that are undergoing diuresis and it has been so satisfying to see how much better they are doing with just a week or 2 of treatment. As I reflect on my time, I remain so impressed by the work that I see the long term missionaries doing here. I would have a day where I frequently got interrupted and would be annoyed, then I would go interrupt my preceptor, who would be interrupted about 4 more times during my interruption and just take it in stride. More and more patients are accessing the hospital from outside of the local area because they don't trust the care elsewhere, or the cost is too high. These providers continue to prioritize their local patients, but they remain patient focused when they turn people away or when they make exceptions for outside patients. At their hearts, they want to serve their community the best they can. I am impressed by the skills of the different providers. It has been especially inspiring to watch the teamwork that occurs when more acute issues come up. I have seen firsthand how everyone comes to code blues and rapid responses, all troubleshooting together. I have been a part of 2 complicated deliveries where people rallied to create both neonatal and maternal teams. Yesterday, a patient around 35 weeks went to section. She had been admitted for several days of monitoring because she initially presented with maternal fever and fetal tachycardia in the 200s that converted with maternal dioxin. She was induced after her NSTs showed late decelerations with contractions and her temperature again began to rise after discontinuing antibiotics. When she developed persistent fetal tachycardia with minimal variability, she went to section. I was there to help with the baby's initial resuscitation along with 1 family medicine and 1 ER doctor. With the baby stable, I went to finally share lab results with a clinic patient that had been waiting for a couple of hours. While there, I heard calls for the pediatrician and figured something had happened. As I wrapped up with my patient, I was approached by one of the nurses to help with another clinic patient whose provider was in the same cesarean delivery. I was able to pop my head in and discuss the patient with him, then begin to work on her counseling and medications before she headed back up the mountains. When her appointment was completed, we went back to see the baby. I watched the pediatrician guide the family medicine doctor on his umbilical line placement. I heard the ER doctor confirm the appropriate dosage for the medication. I watched the nurse run to the pharmacy to evaluate which IV antiarrhythmics we had in stock. The tech came in to perform the chest x-ray to check line placement. The baby had initially received adenosine, but the heart rate remained in the 250s. The 2 family medicine doctors, pediatrician, and ER doctor discussed what medications we should try next and at what doses. It was decided to repeat adenosine because the umbilical line was initially too distal. The dose was also increased. The baby converted immediately. The decisions and treatments happened as a team and were wonderfully successful. I am not sure if international medical mission work is something that I envision for my life fulltime, but it has given me an opportunity to see how important it is for the long term missionaries to have providers that can come to help lighten the load when a long term member leaves on furlough. It has been a pleasure to be a temporary team member here.

Today was a sad day in LDL. I was planning on sharing about this pair of patients, but I was hoping it would be a better outcome. A patient, K, that had been staying in the discounted housing near LDL for the last few weeks delivered on Tuesday night. She has sickle cell disease and was having multiple sickle cell crises throughout pregnancy. Then she had the misfortune to developed severe preeclampsia and possible HELLP syndrome at 30 weeks gestation. LDL has never had a baby under 30 weeks survive, and few below 3 pounds survive. K was counseled on her risk and her risk to her baby. I placed her cytotec on Tuesday night and we started her on magnesium. There are only 2 nurses and 1 CNA at LDL overnight covering the entirety of Med Surg, Labor and Delivery, and the ER. We discussed that for safety reasons, one nurse would have to be committed to Labor and Delivery. If they were overwhelmed, they would have to call in a second nurse or call me in. She did well overnight and made it to the following day with little cervical change. K was also severely anemic and had a rare antibody that was being explored that made any transfusion highly risky for reaction. The decision was made to perform a cesarean delivery for K. I watched the providers at LDL work together to coordinate the delivery of blood for K from the Red Cross across the country, a process that required the blood to be flown and then driven about 1.5 hours. LDL also doesn't have surfactant, but they were able to get it from the town 1.5 hours away because they were anticipating this delivery. As soon as everything was available, we proceeded with the cesarean delivery. The team included 3 operating providers, one provider administering anesthesia, one scrub nurse, one nurse primarily for the baby, and 4 providers committed to the baby's resuscitation. I watched the ingenuity of the baby's providers as they prepared a bubble CPAP using a canister of water, tongue depressors, and a Y connector for oxygen. It was one of the fastest sections I've seen and it included a tubal libation per the patient's request. She is 25 and this was her first pregnancy, but she decided that a repeat pregnancy would be too high risk, despite knowing this baby had a probable less than 50% chance of survival. Her suction canister had no more than 100 cc of blood in it. The baby had an initial Apgar of 0 and was briefly intubated, but was able to be transitioned to CPAP. He was placed in a Ziploc bag for temperature regulation. He had an umbilical line and NG tube placed. He received his surfactant. He weighed just over 2 pounds. The team was hopeful but cognizant of their last early premature infant that died at 48 hours of life. LDL doesn't have the luxury to ship babies to a different hospital because they are not a level III NICU and cannot take babies under a certain gestational age. So they get creative and work as a team to do everything they can to give baby J the past chance he can get. He was undergoing phototherapy on Thursday. He was stable on CPAP and maintaining his temperature with the warmer alone. He was strong with an opinion. He made it past 48 hours. But this morning, the nurses called a code blue. When I walked in the room (the first provider to arrive and probably the one with the least amount of NICU experience), his oxygen saturation was in the 40s despite bag masking him. He had likely become apneic and there wasn't a quick enough or adequate enough response despite one-to-one nursing. We struggled to get his oxygen above 70% and it was often below 50%. Blood prevented adequate visualization for intubation. His heart rate started to slow. A tech was called in for a chest x-ray. They attempted needle decompression for possible pneumothorax. He got fluids and epinephrine. They had caffeine ready. But he wouldn't breathe on his own and we could barely maintain his saturations even with good chest rise. He was finally intubated but with no improvement. So we took out his tubes and his family came in to hold him as he died. Would he have died in the states? I don't know. I watched heroic efforts and creative thinking. I watched a team commit to this patient. It was beautiful and tragic. I hoped to talk about how well he was doing with his limited resources. I still think incredible work happened for him. But would he have died in the states?

It has been a busy week for me. I started to see my own clinic patients on Tuesday, call on Thursday, and call this weekend. This may sound silly, but I feel like I am appreciating in a very different way how underserved LDL's patients are. Let me start by saying that this global health experience is significantly different than others that I have had in the past. My first was in undergrad with Global Medical Brigades. We flew into Tegucigalpa, Honduras and would bus a couple of hours to different areas to essentially provide pop-up clinics for a single day. Those patients were underserved in different ways. They did not have access to established healthcare providers. There was a lot that we could not do in a single day clinic and we often had to bemoan our limited resources because we didn't come with specialty care. This was also a single week trip, where I served as a medical interpreter. And not even a very good one at that point in my Spanish skills. My next experience was in medical school. I went with an ENT brigade to Catacombs, Honduras to an established hospital primarily staffed by Honduran medical providers. This was again a weeklong trip. The patients we saw had been screened and selected to be seen by the brigade. And in contrast to my other trip, the providers with whom I worked were actually frustrated at times that the patients they saw weren't needy enough. I don't mean this critically, they were the specialist group and they ultimately wanted to provide their specialized services to the most appropriate patients-i.e. removing a cholesteatoma, not treating allergic rhinitis. These patients were also underserved, but I was part of the group that they had been awaiting and there weren't many pre-screened patients that we couldn't treat. My medical skills had advanced a bit, so I still served as a (more capable) medical interpreter but also participated in procedures with the excitement of an inexperienced 3rd year medical student. LDL is the first place that I have gone where I have enough medical experience to be medically useful. It is also the first place where I have filled the same role as a long term provider, though this is temporary. LDL is a mission hospital that has fulltime American staff. They have 2 surgeons, one that focuses more on orthopedics and another that focuses more on general. They have general docs and OB providers. They have a trauma/ER doc. They provide clinic hours 5 days a week and take walk-in patients as much as possible. They have a 24/7 ER. They can admit patients. They have their own running lists of patients to see visiting specialists, likely urology or ENT. There's a lot that can be done. But there are still limits. I think of my patients at Sunrise as underserved. This is true, but it is in such a different way. My patients may have trouble scheduling an appointment with their PCP. We may get frustrated that they cannot get specialty care quickly or economically. They may over or underutilize the ER. But generally speaking, their access is pretty good. There are many people that I have seen in clinic that do not have problems very different from my own patients-arthritis, GERD, rashes, neuropathy, etc. But these patients travel multiple hours to be seen, and that's not always cheap. Clinic is often wrapping up in the late afternoon because these patients are anxious to get out in time for the last bus, which is between 2 and 3. My patients have broken limbs and accidents. But they can go to an ER and be treated immediately. At LDL, they try not to call in their staff on weekends or in the middle of the night unless it is absolutely necessary. This week particularly has been frustrating because the fluoro has not been working well, so the surgeon is not even sure when he can treat certain cases. We have one patient admitted with a broken femur who is getting PO tramadol while he awaits a surgical date because this was more economical for him than trying to get his surgery at a different hospital, where the price is literally about 20 times more expensive. And some patients simply show up too late from their injury to be adequately treated. I am so impressed by the work that these long term providers have done to provide the best quality care possible. They are thoughtful about their care and reserving resources, so they try their best to make care more inexpensive and more accessible to their "local" patients (within a couple of hours of the hospital). I know that this is a constant tension for them-trying to provide high quality care with a limited number of resources. This is simply something that I just do not have to think about when it comes to 98% of patients, at least not in such a distinct way. Even though I feel like I have a global patient population with treating many patients that are refugees, I am not struggling with the unique resource limitations that come with practicing internationally.

Consider this post from Monday, 4/16/18 given some posting troubles: I  have completed my first official day at Loma de Luz. I spent it with a family nurse practitioner that has been here for a year. She had me see patients and work with the EMR, and it was fun to do things as a team. That is an emerging theme here-the long term missionaries really rely on each other. I had my typical struggle with getting accustomed to the accent and speed of the patients' speech. Today I was most struck by the tension between limited resources and relatively easy, unchecked access to medications and testing. My most recent rotation was in Sterling, where the doctor with whom I worked was diligent about making sure that the appropriate health maintenance and documentation had been completed for billing purposes. Conversely, in Loma de Luz (LDL), we are working to be thoughtful about the testing and imaging we order for patients-to consider cost/time for them, cost/time for the hospital, and to consider whether or not a test would change our management-stark contrast to the diabetic/hypertensive patients that were getting lipid panels every 3 months in Sterling. At the same time, it was frustrating to see patients that came in with ultrasound results that the providers could not assume to be reliable. We also had patients that were taking medications that would require a prescription in the states. These are medications that should be monitored and medications that might not even be appropriate for them in some cases. So patients struggle to access medical care, but pharmacies and companies are happy to take their money for medications and ultrasounds that they may not even need. Also, patients travel several hours to be seen and usually expect... something. I struggled with prescribing a patient cough syrup for a likely viral URI-it is not something I would even typically do in the states because of the extra cost with minimal benefit to the patient. But here was this patient, who had traveled several hours, for a follow-up on knee pain. She had great results from bilateral joint injections less than 2 months ago and was still doing well. She was understandably frustrated that she came back as instructed 4-6 weeks later to be seen by a different provider (her last one was in the states visiting family) only be told that she was doing well and to come back again when things changed. So she mentioned her cough and wanted something for it.  The NP with whom I was working said that patients often think the meds at LDL work better and their satisfaction is often much higher if they get something. Was this relatively harmless placebo worth this patient's extra money on top of her the cost of her consult? That I struggle to answer. The NP also talked about how patients will get ultrasounds that show gallstones, fibroids, or ovarian cysts even if they do not have symptoms. They often have to explain to patients why surgery is unnecessary and could be harmful in many cases-VOMIT (victim of medical imaging technology) right here in Honduras even without multiple CTs in a lifetime. On a different note, one of the providers here told us about a patient that he had just seen that was diagnosed with heart failure. She was taking amlodipine and had developed lower extremity edema. At a different facility, she was diagnosed with heart failure due to these symptoms and started on Lasix without any further testing. Her chest x-ray and EKG at LDL were normal. He stopped her Lasix and switched her amlodipine, then scheduled her for follow-up. He said that this is not an uncommon occurrence-they often have to correct other providers' diagnoses. So here I struggle with responsible, appropriate medical care for patients-not so different from home but in a different way. I have tremendous respect for the providers that struggle with this daily in their effort to provide the best, sustainable medical care to their patients. More in a couple of days about my first call shift!

Last Week Already??

As the rotation is winding down, I mostly find myself saying "where did the time go??" I've hit a few more speed bumps along the way, including my hostel owner forgetting that I reserved my room until April 6th, so tomorrow I get to move. Also, ironically enough, I passed out yesterday while discussing syncope in the ICU. So the gringa who already sticks out like a sore thumb just made herself that much more conspicuous. But hey, I got to experience going to the ER as a patient for the first time ever while in Ecuador. (I'm fine, fyi)

So now that I'm pretty much packed up to move tomorrow before work, I can continue my reflection on this rotation. One useful thing I've noted during this rotation is the commitment to medical education across the board. The family medicine and internal medicine faculty continuously question the residents (myself included) and students and the residents question the students. Each morning, the family medicine faculty review admissions with the residents and students. Every day there's a case review led by one of the internal medicine faculty members. Expectations are definitely high in this environment, which certainly contributes to the excellent reputation of the hospital.

As I've mentioned before, this hospital has patients who are better insured and have more resources than the majority of patients I see at Sunrise. Reflecting on resource allocation and reconciling what I experience here just has not yet been applicable. However, I've had the experience of assisting a patient who was unfamiliar with the health care system and Spanish was not his first language. While working with a family medicine physician in clinic, we saw a patient who had recently moved to Ecuador. He did not speak Spanish, but the physician and I were able to communicate with him in his native language. After his appointment was finished, he mentioned that he had difficulty finding the clinic within the hospital. So I showed him to the lab, imaging, and endoscopy lab. Today, I helped him understand the colonoscopy prep instructions. Seeing the health care system through his eyes reminded me of why I chose to work at a clinic like Sunrise where I can help patients navigate the complex health care system and confirms that that's the sort of environment I want to continue working in.