Difficult Cases

May 09 2012

By Catherine Burger, MD
Vanderbilt University: Department of Emergency Medicine
Georgetown, Guyana 

Sometimes the most difficult parts of a job produce the situations you learn the most from. Often doctors will remember their most challenging patients for the rest of their lives and rarely forget what they’ve learned through those interactions. Working at Georgetown public hospital has afforded me a wealth of opportunities such as these in my short time here. 

Near the end of a shift one day I saw a patient with chest pain, a thin, uncomfortable-appearing woman in her 50’s. When asked where her pain was she did the classic motion of waving her hand over her entire chest and abdomen, attempting to help me pinpoint where she was hurting. I started with x rays, an ecg and blood tests but unfortunately these would take quite a long time during this busy day. Hoping for faster results, I looked for the ultrasound machine to assist in my work up. After a long search and a battle to keep the battery on, we had it at the bedside. Looking at her heart, lungs, kidneys, liver, and great vessels with the ultrasound machine gave me a wealth of information. I could see she had fluid around her heart and one of her lungs. That provided me a clear start that ended up guiding much of my treatment for her. Although getting the ultrasound, using the machine, interpreting the US (no Radiology to help interpret the scans) were all much more difficult than doing the same would have been in the United States, I can honestly say I learned even more from the process than I would have in my home institution. The difficulty in getting the machine caused me to use it as a precious resource, getting every possible use out of it that I could for that patient. Not having Radiology back up or easily obtainable diagnostic tests caused me to fully scrutinize every image, think outside the box, focus on physical exam clues, and tested my confidence in my own ability to obtain and interpret ultrasound findings. On top of all that, I got to teach a group of residents and nurses aspects and uses of ultrasound that they had never seen before. The experience highlighted learning opportunities I take for granted working in the United States and helped me develop my own diagnostic abilities.     

Andrew Pfeffer Pic 2

by Andrew Neil Pfeffer, MD
Vanderbilt University: Department of Emergency Medicine
Georgetown, Guyana

Whenever I’ve heard people reflect about their international medical experiences (especially amongst my colleagues who have worked here in Guyana), there tends to be a few common themes that emerge. There are statements about the gratitude of the local population, and their resilience in the face of adversity in nearly every aspect of their lives. They discuss the lack of resources available; how the hospitals/clinics can lack the most basic of amenities (gloves, bandages, water…), or how few and far between medical practitioners are located. Universally, people say the experiences have changed them at their core; they now have a greater appreciation for the resources/opportunities available back in the US, and will continue to work to improve the plight of those less fortunate. 

Looking back upon my experiences here in Guyana, my colleagues could not have been more right. Despite significant influence from 1st world nations, life in Guyana is hard and often unforgiving. Conditions that seem routine back home can often prove fatal down here, and both the medical providers and patients are well aware of this fact. This doesn’t stop either of them, however, from fighting as hard as they can, and utilizing their resources as fully as possible. I feel blessed to have had many opportunities to help care for patients here, and the experience has without question pushed me to higher places as both a physician and a person.

Above all else, my time here in Guyana has left me motivated to come back and do more. The potential that exists amongst the medical community, especially in Emergency Medicine, is quite palpable, and there seems to be a feeling that the tipping point can soon be reached. Once that happens, it could ripple through the rest of Guyanese society and hopefully produce successes and advancements that might have once seemed impossible. Of course, it’s not a guarantee, and many obstacles need to be dealt with. However, there is genuine hope, and that’s often the most important first step. 

By Catherine Burger, MD
Vanderbilt University: Department of Emergency Medicine
Georgetown, Guyana

We are taught during medical training to be very cautious and to only proceed with decisions and procedures when we are well prepared. Putting in a breathing tube, for example, when a patient is having difficulty breathing or has lost consciousness, is a procedure that can be done with just a few simple pieces of equipment. But in an attempt to ensure success, we bring in advanced tools for back up, cameras to get a better look down the throat, smaller tubes in case the size we have chosen doesn’t fit. Once we are prepared for anything we are ready. But in many places around the world, including Georgetown Public Hospital in Guyana, those backups are simply not available.

In so many ways the Guyanese healthcare providers have used their limited resources not as an excuse to give up but as an education in how to efficiently and effectively work with what you have. Although the Accident and Emergency Department has less than 20 beds and staffs only a handful of nurses and doctors they are able to see over 70,000 patients a year, what would be a sizable number for any large tertiary care hospital in the United States. Hallways are lined with chairs for patients who are healthy enough to sit up and often patients walk themselves to the lab to have blood work done or x ray for their imaging. While working in the A&E one day I saw a 21 day old baby with a large infected abscess on his arm. The mother brought the child to my chair where I was doing initial evaluations, after seeing the infection we set the baby on a nearby stretcher, cleaned the area and sprayed it with an anesthetic, used a scalpel blade to drain the infection and wrapped the arm back up. We gave the infant some antibiotics and had them go back out into the waiting room until there was a bed available in the Nursery. Neither the staff working with me, nor the mother, was bothered by our inability to get blood cultures, the lack of a crib or incision and drainage kit, or the fact that they had to wait outside the A&E for a bed. Everyone was just glad this was a child we could clearly help, as opposed to the unfortunately numerous cases where the patients are too sick to turn around.

At times I would find myself frustrated by the lack of certain simple but effective drugs, easily available CT scanners or even ventilators. But then a coworker would teach me about how they have found older, cheaper drugs that works, they use x rays instead of CTs, and they ventilate the patients by hand. It’s not ideal but for the most part it works. It’s refreshing to watch the innovative ways resources are used and how nothing is wasted. Even in the sometimes harsh environment of Guyana the people have remained quickly adaptable to their changing world, generous, and extremely thankful, it is a fantastic privilege to work with them.  

by Bill Frist

The Week

America's national debt is ballooning at a worryingly rapid pace. But some programs ought to be spared the chopping block

POSTED ON APRIL 24, 2012, AT 7:10 AM

Government spending is about to get chopped — no matter who wins the next presidential election. President Obama and his GOP challenger Mitt Romney have both prioritized deficit reduction, which, of course, is a worthy goal. However, not all cuts are created equal. And many surveys put global health at the top of the list of things to slash. That's a mistake, and here's why.

1. Global health initiatives save lives abroad?Investments in global health pay off a lot more quickly and dramatically that you might think. PEPFAR, initiated by President George W. Bush and strongly embraced and expanded by Obama, was the largest direct investment any country has made in defeating a single virus (HIV) or disease. Our taxpayers' leadership has provided 7.2 million people with access to lifesaving, anti-retroviral therapy for HIV/AIDS, 8.6 million with treatment for tuberculosis, and more than 260 million — mostly kids — with anti-malarial resources. This U.S.-led historic initiative to prevent and fight disease has directly saved millions of lives, put kids back in school, and helped rescue entire societies from collapse over the past eight years. 

Saving lives and societies leads to better and stronger relationships for trade, enterprise, and foreign investments. It enables economic growth, democracy, accountability, and transparency in these countries. 

2. Global health initiatives protect U.S. families?Deadly microbes know no borders. They are just one plane ride away. HIV did not exist in the U.S. when I was a surgical trainee in 1981. But since then, it has killed more than 600,000 individuals here (and 25 million globally) and infects another 54,000 U.S. citizens each year. It arrived here from Haiti, migrating there from Africa.  

Imagine the devastation avoided if we had identified HIV and our National Institutes of Health had figured out how to treat the virus a decade before it arrived on our shores. Our current global surveillance and engagement system might have done just that.

3. Global health initiatives enhance national security?A hopeful people are a people who shun terrorism. And nothing destroys hope more than a society without a future, hollowed out by diseases that decimate middle-aged civil servants, police, doctors, and teachers. A bleak and nonproductive future for an individual sets the stage for societal discontent and chaos.

Our investments in public health reverse these tragedies, and fuel the smart power of health diplomacy. Kaiser Family Foundation surveys have repeatedly revealed that more than half the public thinks U.S. spending on health in developing countries is helpful for U.S. diplomacy (59 percent) and for improving America's image in the countries receiving aid (56 percent).

4. Global health initiatives are a bargain?Treating HIV costs a tenth of what it did a decade ago, and the costs continue to plummet. Globally, of the 8 million children under 5 years old who will die this year, half could be treated and cured with a low-cost intervention. Pneumonia, the number one killer of young children in the world, is easily treated for less than a dollar! And the No. 2 killer, diarrhea, can be prevented by increasing access to clean water. The price? For $20, we can provide clean water to a family for 20 years. For $14, we can fully vaccinate a child. 

5. Global health initiatives are simply the right thing to do?I was born in Nashville by the luck of the draw. It could just as well have been South Africa, where life expectancy is only 49 years. We are all the same. Lifting others up no matter where they live is part of what makes us American. It's what we do. Americans overwhelmingly say the U.S. should spend money on improving health for people in developing countries "because it's the right thing to do." Nearly half (46 percent) say this is the most important reason for the U.S. to invest in global health.

Yes, out of control entitlement spending and a deep recession have put everything on the chopping block. But let's be smart about where we cut and where we don't.

Dr. William H. Frist is a nationally acclaimed heart transplant surgeon, former U.S. Senate Majority Leader, the chairman of Hope Through Healing Hands and Tennessee SCORE, professor of surgery, and author of six books. Learn more about his work at BillFrist.com.

Andrew Pfeffer Pic 1

by Andrew Neil Pfeffer, MD
Vanderbilt University: Department of Emergency Medicine
Georgetown, Guyana 

Prior to my arrival, I had the opportunity to spend a considerable amount of time with one of the Guyanese EM residents as they visited Vanderbilt. In one of our various discussions, he brought up a fact that surprised me; the majority of Guyanese in the world do not reside in Guyana. Instead, they are scattered throughout North America, namely New York and Toronto. In his family for instance, only 10-20% remained in the nation, with the rest living in one of New York’s five boroughs. When I asked him if he would eventual join them in the US, he said no. His colleagues, however, had a much different approach.

After being here, I can understand why that sentiment exists. Guyana is a nation in flux. On one hand, it is quite modern; many people has cell phones, internet is widely available (I was in the middle of the rainforest and had WIFI), and the dissemination of information can occur rapidly and quickly (via Facebook, or other methods). Many of the excesses of our time are at the fingertips of a large portion of the population, especially in Georgetown. Unfortunately, it seems luxury has outpaced necessity, with the end-result being a palpable level of frustration. This is quite evident in the sphere of healthcare. The physicians here harbor much of the same knowledge and skills that we possess and they know what interventions are needed to treat the most complicated of medical or trauma patients. However, they have very limited resources in terms of pharmaceuticals, imaging, and surgical support to adequately treat the conditions they see. I’ve only been here a few days and I have often felt handcuffed, I couldn’t imagine how hard it is on the local staff to feel constrained to that degree all the time. When faced with the options of either staying home and going through the growing pains (which may take decades and is by no means guaranteed), or moving to a place (the US or Canada) that has already arrived and that boasts a seemingly thriving ‘local’ Guyanese community, the decision to stay can seem illogical. This is probably why many young, educated folks, especially doctors, leave, which in turn, only serves to delay progression further. It’s a detrimental dynamic. 

He says he’ll stay. Being a part of the construction of not just the specialty of Emergency Medicine, but of his nation, is something he cannot leave. It’s a brave stance to take, and I genuinely think the new residency program in Emergency Medicine will help him avoid succumbing to the temptation to leave. For me, I am honored to be able to help support this institution, even though it’s in a very minor way.

In the end, while it’s a baby step, it’s still a step, and they will eventually add up. 

Ifeoma - Hospital Visit

by Ifeoma Ozodiegwu
East Tennessee State University: College of Public Health
Brazzaville, Republic of the Congo

I paid a visit to the local hospital called Makelekele, the second largest hospital in Brazzaville where  I visited the different sections in the hospital and spoke with the staff. The hospital was a little crowded due to the explosion that occurred a few weeks ago. A number of people are still receiving treatment from the hospital.

My purpose for visiting the hospital was to gain a better understanding of the health status of the Congolese people especially as it regards tobacco-related diseases and view the state of their health facilities.  Following a tour of the hospital I chatted with the exceptionally nice staff and enjoyed an informative discussion the Medical Director of the Hospital, Dr. Loussambou. The Director explained to me that from their observation, the leading cause of morbidity was bronchitis and pneumonia while the leading cause of mortality was malaria and heart attack. He also explained the national strategy to combat malaria. When I inquired about the prevalence of cancer of the lung, he said that it was quite low.

My visit to the hospital opened my eyes to the sacrifices made by the medical personnel in the Brazzaville; they are able to do much with so little. The personnel seemed interested in their patient’s conditions and the well-being of other staff. They also did their work with so much joy such that it was infectious.

Finally, during the week, I completed my research paper on health workforce norms. I am also done with reviewing the monitoring and evaluation committee report. In the next final 2 weeks, I am looking forward to having the employee service event and putting finishing touches to my work.  Expect to see all the pictures from the event.

By Nadine Harris, MD
Vanderbilt University: Department of Emergency Medicine
Georgetown, Guyana

All I can say is, I don’t know how they do it.   I have finished my time in A&E and have been on female medical ward for the last week and a half. The female medical ward is housed in a new facility that opened several months ago.  There are approximately 8 patients per room.  Patients have to bring their own sheets, clothes, toilet paper, water, and any other supplies that they might need.   There are many nurses and even more nursing students around, but I have yet to figure out exactly what they do.  Care by the nursing staff is haphazard at best.

It is so busy here!  There are two interns who take care of 60-80 patients at any given time and every 3rd day they do a 36 hour shift.  Rounds every morning are quite exhausting and interminable.  We either help the interns pre-round (this may involve checking vitals, starting IVs, updating orders) or we round with the sole internal medicine consultant (in the country!) during bedside teaching rounds.   There are about 20 medical students who attend these rounds and it is the only semi-structured teaching they receive during their internal medicine rotation. I spent some time going over a few cases with them and though they are eager and enthusiastic to learn medicine I worry about how they will develop the skill sets needed to identify and manage disease processes.

Unfortunately, because the wards are so busy and it is often only the interns around to manage patients, many things are missed or overlooked.  Labs take a long time to return and once they do show up may be forgotten until the next day on rounds.  A patient’s clinical status may deteriorate without anyone recognizing or alerting a physician of the change for hours.   There is a lot of death and, unfortunately, sometimes it seems all but inevitable.  

Despite all the obstacles present, the best part about being here is the patients I get to work with.  There is such a sense of gratitude and appreciation for the care that they receive and readily acceptance and trust even when things do not go quite right.  There is such strength and resilience in the human spirit.

Yesterday was the last day of the rotation and I spent part of the day in medical records going over a couple charts of patients that I had heard about or taken care of.   As I sat on the hard wooden bench, in the cloying sticky heat waiting for them to pull the records, I looked around and saw the tall shelves of recorded births and deaths at GPHC for the last 50 years.  It was particularly striking to me at that moment that somewhere amidst all of that paper, the record of my birth could be found.  Looking at GPHC currently, it is hard to imagine what it must have been like so many years ago.  Nonetheless, I feel like I have come full circle and I never could have predicted it.  I am grateful for the opportunity to be here and I look forward to creating opportunities to come back to teach, work and help build up the healthcare of Guyana.

by Ifeoma Ozodiegwu
East Tennessee State University: College of Public Health
Brazzaville, Republic of the Congo 

Ifeoma - BrazzavilleIfeoma - WHO Team Meeting

It has been two months now! Yes, Two months! Over the past two weeks, I have focused on writing and designing the layout for country-level reports on the Status of Implementation of the Framework Convention on Tobacco Control (FCTC) for two countries-Madagascar and Lesotho. While writing the report for Madagascar, I observed that the tax on the most widely sold brand of tobacco is 76%. “Impressive”, I thought, given the difficulties and politics involved in the implementation of such tax policy. Upon inquiry, I learnt that Madagascar has the best practice in Africa. Madagascar also has health warnings on tobacco labeling and packaging covering more than 50% of the package and labels. The issue of health warnings reminded me of the events in the US where the implementation of graphic health warnings on tobacco packaging and labels were ruled as unconstitutional by the courts. I hope tobacco advocacy groups continue to fight for the adoption of such policies. Policies recommended by the FCTC has been shown to reduce tobacco consumption and in turn, premature mortality from tobacco use.

The Human Resources for Health Unit has also assigned me to write a literature review on health workforce estimation, with the aim of determining if it can be done on the regional or country-level, for use by the Regional Director. Whereas, the Planning, Budgeting, Monitoring and Evaluation Unit asked me to review their annual report and budget as well as create a summary of performance indicators for Budget Centers (Regional and Country offices) to be used in their annual report. All these have kept me on my toes. 

By Rebecca Pfaff
Meharry Medical College
Riobamba, Ecuador

My first week here in Riobamba, Ecuador has been fantastic.  In the mornings I attend rounds in the pediatric hospital with residents and attendings.  Rounds are a lot like in Nashville except that x-rays are read by holding films up to the light and, of course, everything is in Spanish.  Also, an epidemiologist joins us, and sometimes a dentist, though they rarely contribute to the discussion.  It is amazing what an international language medicine is.  Even with my limited Spanish skills I can follow, and occasionally contribute to, rounds with relative ease.  After rounds I go with Dr. Cruz to his clinic on the first floor of the hospital.  I enjoy working with Dr. Cruz both for his obvious skill as a practitioner and enjoyment of teaching, but also because he speaks very clearly, making it easier to follow him. In clinic we see 8-10 patients to fill out the morning before he and the other pediatricians head to their private clinics in the afternoon.  There are no well child visits in the clinic, only hospitalization follow-ups and sick visits.  Riobamba is the capital of Chimborazo Province and surrounded by mountains populated by small villages and farms.  Families bring their children in from long distances to see the doctors.  Pulmonary complaints are by far the most common with gastrointestinal a close second.  In fact, the hospital has two large main rooms for inpatients, one for pulmonary complaints and one for gastrointestinal, with smaller rooms for infectious disease, neonatology, and other complaints.  There is no importance given to privacy either on the wards or in the clinic. Curious mothers will follow the physicians as they round in the one large room containing 6-8 patients and in clinic other patients, nurses, pharmacy representatives, and administrators all walk into the examination room while the doctor is seeing patients.

 After clinic I return to my host family’s house for the most important meal of the day, lunch.  Everyone comes home from work and school to eat together.  After this I head off to my medical Spanish language course.  We are all in the fourth year of medical school in the U.S. and excited about starting residency soon but enjoying Ecuador a great deal in the mean time.  I can't believe I have already been here a week, these 11 weeks are going to fly.

By Nadine Harris, MD
Vanderbilt University: Department of Emergency Medicine
Georgetown, Guyana

It is good to be back in Guyana.  It has been a week since my arrival and there is a feeling of returning home.  Although I left this country when I was very young, the culture, the food, the sayings, even the hot humid climate and cooling ocean breeze are all so familiar and welcomed. 

I have been working in A&E at Georgetown Public Hospital, the country’s tertiary care center, for the last 5 days.  I am amazed at the broad spectrum of pathology that we see in any given day - some of these have included cerebral malaria, snake bites, herbicide poisoning, tetanus, advanced HIV, acute myocardial infarction, infected diabetic foot ulcers, and strokes.  What is most impressive to me is how many complications I have seen from poorly controlled chronic medical conditions, many of the same disease processes that we deal with in the US.  As an internal medicine resident, I think about my own panel of patients back home and how aggressively we are taught to manage diseases such as hypertension, diabetes, and coronary disease.  Unfortunately, this is not possible in Guyana in large part due to lack of a trained physicians to take care of these people and poor medical records (surprisingly, many of the first line drugs that we use to manage chronic illness are available here).  Guyana, like so many developing countries, continues to struggle with “brain drain” as more and more trained professionals migrate in search of a more economically secure way of life.  In the medical profession, those who are left behind do the best they can, but are often overworked and undertrained. 

Working in a developing country with so limited resources certainly requires that I adjust the way I think about and approach a disease process; this is easier said than done.  The emergency medicine residents do the best that they can to be aggressive in the resuscitation of very sick patients - unfortunately, often with so few ICU beds, ventilators, equipment for monitoring, it is difficult to sustain a high level of care for the critically ill and many do not survive.

There is just so much that we take for granted in the U.S.  I met a 17 year old girl who was brought in to A&E by her parents with 6 months of a progressive motor weakness and spasms that left her wheelchair bound and in significant pain.  She had been in and out of the hospital, with essentially negative work up including lumbar puncture, plain films and CT head.  She had seen a private neurologist and needed a MRI.  Due to the cost she has not yet gotten the test and even with her consultant advocating her case to the ministry of health, the outcome is still pending.  Getting such a simple test that is so easily accessible to us in the U.S. seems an almost insurmountable hurdle to overcome in the work up of her disease.

It is humbling experience to be here and is a great reminder of what a privilege it is to be able to practice medicine and to serve those who need the most help.  I am constantly being reminded to how much I don’t know and how much I can learn from my patients. 

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