Monday, March 23, 2015

Update #1 from Internal Medicine Resident Elizabeth Gulleen during international rotation in Damak, Nepal

Namaste from Nepal!  Today marks the one-week anniversary since I disembarked in Damak, Nepal rather tired and disheveled after 48 hours and 3 plane rides.  Since my arrival, I have been overwhelmed by the hospitality and kindness of my hosts.  The people here have gone out of their way to welcome me, from providing endless cups of tea to hosting dinner parties and even acting as weekend tour guides.  Consequently, I am looking forward to an excellent and educational time over the next seven weeks.

My clinical experiences this week have alternated between spending time at Life Line Hospital and working with the local IOM.  Life Line Hospital is the clinical site where I will be primarily based throughout my stay.  The facility has an active outpatient department and a 100 bed hospital divided into medical, surgical, pediatric, and obstetric wards.  The hospital has good diagnostic capabilities including a basic lab, ultrasound and x-ray departments, and even a CT scanner.  It will soon expand to house a 9-bed ICU as well as a NICU.   Next week, I will begin rounding with the medicine physicians here.  I did have the opportunity to attend the annual board meeting of the shareholders, which gave me a chance to introduce the University of Minnesota as well as our global health program.  The shareholders and physicians here are eager to continue collaborating with UMN and hope to develop a long-term partnership with our program.

While I did get a brief taste of Life Line Hospital, most of my time has been spent at the IOM, which is located about 1 block from the hospital.  It has been interesting and informative to experience refugee health from this side of the globe.   Unfortunately, given my limited time with the IOM, I am only able to spend about ½ of a day seeing each portion of the healthcare process.  The first day was spent touring the facility and observing the vaccination program, the second day I observed TB screening facilities (including x-ray and the microbiology lab), and the third day was spent with the IOM physicians observing new medical and pre-departure exams.  I plan to complete this week by learning about the TB treatment program, understanding mental health in the refugee camps, and hopefully visiting the camp itself.

Actually, the resettlement of the Bhutanese refugees here in Nepal is drawing to a close.  Only two of the original seven camps still exist and only about 10,000 refugees need to be relocated.  Consequently, many of those who remain in the camps are older and have more complex health conditions that precluded them from earlier travel.  I had not previously appreciated the coordination it takes to stabilize these patients prior to travel.  During the initial health screening, all medical conditions are evaluated and any necessary work-up or treatment is initiated.  This can include subspecialty consultations, work-ups of malignancies, surgeries, and hospital admissions.  Once the patients are medically stabilized, they are deemed safe for travel.   When the time for departure is scheduled, the patients undergo a final health check with a physician and are sent to a central processing site in Kathmandu 10 days before leaving Nepal for further monitoring.  About once per week, a flight is coordinated for the patients with complex medical conditions such as COPD, CHF, active psychosis or other mental health issues.  Physicians are chosen to fly with the patients to ensure medical stability until arrival.  Depending on the medical condition, subspecialists may be chosen to be among the physicians traveling (for example, a recent flight contained a patient with a complex cardiac history, so a cardiologist was one of the physicians included).

The physicians here are very worried about what happens with the patients’ healthcare after arrival in the US.  Since the IOM physicians serve as primary care doctors from the time of initial health screening through departure, they are very concerned about appropriate follow-up to ensure that the patients will succeed in their destination country.  Every physician I have encountered has asked repeatedly what can be done to better facilitate the medical transfer and to educate the patients about healthcare in the United States.  I was able to reassure them that (at least in Minnesota) >95% of patients have a follow-up visit within the first few months of arrival.  However, it is very telling that one of the universal concerns about patient health is how to best transfer medical information from one healthcare provider to another.  Consequently, we are currently brainstorming ways in which physician-to-physician communication could be improved throughout the process.  

On an exciting note, several of the healthcare providers at the IOM are planning to visit Minnesota later this spring to learn about refugee care in the US.  I am hoping they will time their trip so I will be back in time to return some of the hospitality they have shown me.  Until then, I plan to continue soaking up knowledge, eating plenty of momos (Try some!  They are awesome!), and appreciating this beautiful country.


Elizabeth
My arrival at Life Line Hospital, where I was greeted by Dr. Surya and the staff
Annual board meeting at Life Line. I got a chance to speak and introduce my role in Nepal as well as the University of Minnesota
The TB isolation center for the IOM
Spending spare time sampling local foods with friends

Monday, March 9, 2015

Final update from Med/Peds Resident Ryan Fabrizius during international rotation in Arusha, Tanzania



"Asante"

Jambo from Arusha (actually waiting in Dar es Salaam airport at the moment)! Today marks the beginning of my journey back home. The past two months have so quickly passed, and this week has been one of good byes and thank yous. I had the chance this week to do some home visits with the Hospice team. Unlike American Hospice care, the hospice team at Selian visits homebound patients regardless of their life expectancy. For example, most of the patients that we saw have HIV infection as their primary debilitating illness, which, we hope, will not be life limiting if they are able to receive their medicines and routine HIV care regularly. The particular patients were selected because of their poor overall condition and lack of family support and resources. It was a wonderful chance to see a broader picture of the daily experience of these patients, seeing their homes, families, and neighborhoods. In health care, we like to think that the clinic appointments, hospital visits, and medicines prescribed make a big difference in someone's overall health, but seeing the patient's living conditions and imagining their daily life, I can see how far downstream we are from the roots of their problems. 

The last word in this series is actually one I have mentioned before, but it is so nice I'll use it twice. "Asante," as I have mentioned, means thank you. I have so much to be thankful for at the end of this two month experience. It has been a great joy to work alongside the Tanzanian medical staff at Selian, to experience their hardships, the challenges to caring for patients in this environment, and the camaraderie of sharing our knowledge, experiences, and goals. To let me follow along on their hospital and clinic rounds, my Tanzanian colleagues gave up their time and departed from their routine. But on top of that, I feel more than just a collegiality was fostered, that it was a lasting friendship. For that, I am thankful. Asante does not seem to explain this gratitude deep enough, but it is the best that I had to offer in return. Asante has been offered so many times during my stay here, both from me and to me. It is often for ordinary services, such as at a store or restaurant. It has been offered from our patients, often the most fervent "asante" coming from the patient and family for whom we have no good option to left. However, when I consider how much I have received during my time here, I wish I had more than just one word. I wish I had the power to help my friends accomplish their goals. I wish I could take the stories that I have seen and strike the problems at their roots. I wish we could all have equal opportunity to quality health care and the basic needs that would sustain that health. But for now, I offer thank you, and resolve myself to not forget what I have seen and the people I have shared life with here in Tanzania.

Final update from IM resident Joe Messana during international rotation in Chang Mai, Thailand



This week’s clinical responsibilities were unfortunately abbreviated secondary to illness. A learning point from my own case of bacterial gastroenteritis deals with the antibiotic recommendations that we are instructed to follow in America. We are told that due to give azithromycin as Campylobater resistance to fluoroquinolones is 20% in the US and is likely higher when infections are acquired during travel abroad. However, physicians in Chiang Mai typically still start with ciprofloxacin for traveller’s diarrhea initially and may give azithromycin if there is no clinical response. I had two days of azithromycin treatment without clinical improvement, but my fever broke 6 hours after ciprofloxacin. Notably, there were two formulations of ciprofloxacin I could take which were available at the local pharmacy without need for prescription. One was cheap, had higher rate of GI side effects, and was less potent, while the other cost 90 baht a pill (~@$3) and was much more reliable. My course also drew my attention back to how remarkable antibiotics are. I think I may have forgotten this fact as we prescribe them routinely, but my disease was controlled in a matter of hours. They are such powerful tools when used appropriately. It also harkens back to the talk I gave the weeks before regarding antibiotic resistance, and how that prospect is so frightening. 

In clinic, I’ve been participating long enough to start seeing patients for follow-up, which is rather gratifying. One repeat patient is seropositive with Hep B coinfection, and she came back for follow-up and vaccinations prior to her leaving for an extended trip in the US. It was interesting to think about this case from the opposite side of the ocean – thinking about people traveling to the States as opposed to the VFR that I see in my continuity clinic back in Minneapolis that are leaving the US for a period of time. 

Working with Dr. Parichat in outpatient clinic, I saw 3 AOID patients in just one day! This phenomenon is so intriguing. I’m eager to do more research about it. Apparently it is also prevalent in Taiwan.

This week marks actually marks the end of my infectious disease exposure at Maharaj Hospital. I start a stint in nephrology next until I leave for the states. Time is so relative, and just unceasingly seems to fly forward. It feels like I just arrived here a week or two ago. Being in this community where Buddhism is so prominent, you could definitely feel the increased “tone” of mindfulness in the general population. Hopefully this exposure left a long-lasting imprint that I will take back with me to the states.

Update #5 from IM resident Joe Messana during international rotation in Chang Mai, Thailand



Recently we’ve seen some fascinating cases, both things that are common in Thailand but also diagnostic dilemmas that reveal the intellectual prowess of the faculty here. 

This week we also saw 3 cases of synergistic gangrene. This is a post-surgical infection where the patient can have multiple expanding gangrenous lesions caused by either bacteria or fungus. Swabs of the skin lesions are taken and the patient is treated based on these culture results. Cultures are specifically used to determine if there is reason for antifungals or MRSA coverage. These patients require a long course of antibiotics, and the consequence of nontreatment is certainly very grave.

Working in Chiang Mai is a special place to practice ID because they it’s catchment area brings in the very rural diseases in the context of a functional university hospital system. It just makes one think, that our careers are so dependent on the clinical environments on which we are borne, and for obvious reasons. But by extension, I think ID would be a much more sought after specialty if the case load in the US was similar to that of Chiang Mai.

Update #4 from IM resident Joe Messana during international rotation in Chang Mai, Thailand



(apologies for the delay in posting)

This week is Kristina’s final week, and marks my half-way point of my Thailand immersion. I’d just like to say she has been a wonderful travel companion: kind, supportive, energetic, curious, and fun. It’s been a wonderful month acclimating/assimilating into Thai culture with her and she will certainly be missed!

We both prepared discussions this week that supplanted the fellow’s monthly lectures. Kristina talked about medicine and the media. She focused on how providers can better navigate this relationship and underscored the importance of doing so. She also gave instructions on how to speak to the media with about 10 recommended rules to follow. I gave a case presentation on lamivudine toxicity causing rhabdomyolysis with a short discussion about the differential for rhabdo afterwards. Then I gave a thorough review of HAART medication side effects in the major drug classes. In preparation for the discussion we had to buy a thumbdrive. We had an encounter with a saleswoman that just again underscores the generosity of the Thai people. She owns a small store at the corner of our soi (road/street), and sells several knick-knacks, but apparently not thumb drives. She has seen us walking back and forth daily and recognized us when we asked. She went to the back of the store and brought her own thumb drive and said we could use it as long as we needed! We were just overcome with her kindness. We couldn’t take hers, but now always say hello to her as we pass her corner.

Additionally, we were invited to be a part of a multidisciplinary international discussion panel for a course given by One Health at a satellite campus of Chaing Mai University. The night before we met with Deb Olson, Will Hueston, and other representatives from the group, to discuss the details of our role and the program. The panel of which we would be apart had representatives from nursing, medical research, agricultural industry, and physicians (us). The topic of the discussion was antibiotic resistance, the obstacles to overcome it, the risks of not doing so, and ways of troubleshooting and improving the issue. The panelists were convened to share their experience and give more insight to the people in the course on the topic and also practice in facilitating a panel discussion. Panelists were questioned by members of the class and then participated in several exercises to detail the problem further in small groups. The individual from the research field was German, and he had some fantastic insight into the problem in terms of monitoring and control of antibiotic use. IT was a pleasure to be involved with the course and contribute to the One Health movement. 

On rounds this week we saw a patient with SX linked Hypogammaglobulinemia leading to a cardiac abscess and grade I heart block who had negative blood cultures. We also saw aeromonas peritonitis and two cases of penicillosis!

Update #3 from IM resident Joe Messana during international rotation in Chang Mai, Thailand



(apologies for its delay in posting)

Our clinical work continues to reveal compelling cases, some similar to the “U style” patient in complexity (transplant patients, cancer patients, etc), while others are compelling based on the low prevalence of their disease in the US. 

We’ve been consulted on several similar AML patients which neutropenic fever in the hospital, however, in clinic we see a large population of seropositive patients. Recently we saw a case of pythiosis that required a left AKA. We see many cases of seropositive patients for biannual checkups regarding their medications and checking for toxicities. We see a lot of lipodystrophy with older HAART medications (as we transition from stavudine to tenofovir). There were 3-5 cases of disseminated aspergillosis with abscesses intra-abdominally, all occurring in a seropositive background. The burden of HIV was quoted to be 5% for Thailand but was recently increased to 8% by rough estimates. However, the attendings believe the prevalence to be closer to 15%. The discrepancy is probably due to underreporting/people not regularly seeing the medical system. 

We also have seen more and more cases of an interesting entity called Adult Onset Immunodeficiency  (AOID). These patients are typically from rural northeastern Thailand, present at middle age, and have antibodies to IFN-gamma. They present with recurrent infections equivalent to what would be seen in an immunocompromised/HIV population. 

We’ve been consulted on several cases of candidemia, though they mostly see Candida tropicalis in their hospital, unless they are post-surgical at which point it is usually Candida krucei. 

We have two excellent residents working with us: Jack and Fern. Jack a third year, is in an accelerated program, and Fern worked in a rural community hospital for about 3 years before ceding to come back and complete a residency. Their energy and laughter are infectious, and are always smiling throughout the day. Their English is very good, which allows them to present in English during rounds for our benefit and their practice. We realize however this is a time drain on their work flow and appreciate their effort. 

There was a visiting lecturer on seizure disorders from Texas, I believe Texas A&M. Kristina and I attended the lecture that began with two cases including an extended discussion on pseudoseizures. Thereafter he plunged into the nuances of different anti-epileptics and their interactions/side effects. Visiting lecturers are considered a special event and our attendance was encouraged.

There have been a steady amount of consults on patients injured from motorcycle accidents, which is in-line with MVAs being the most common health issue for travelers. We had one patient whose abdomen was punctured and required an emergent ex-lap. We were consulted later as he contracted acinetobacter meningitis! His condition was thankfully improving.

More to come shortly!