Day 26. I survived the worst GI upset of my life over the last 36 hours....in the final day of work I was unable to even get out of bed. 4am Thursday morning I started to get sick and by 7am on Thursday morning I was completely listless. I was completely unable to eat, unable to garner enough energy to sit or stand-I felt as though someone was trying to beat the life out of me. Through out the day family members stopped by to see me, and someone said, "you know, I can't imagine you'll ever want to come back after what you're going through right now!" But honestly, that thought never crossed my mind. There have been many roadblocks before even coming on this trip and especially during. One bad stomach bug is not going to stop me from coming back and continuing the work I started on this trip.
Through out the day I constantly tracked my pulse rate, whether it was thready or bounding, I kept track of how dry my mucous membranes were and made sure I wasn't too lethargic...keeping in mind that if anything seemed to be deteriorating I would march myself over to the hospital for IV resuscitation. I kept in mind the patients I saw at the ICDDRB and at Dhaka Medical and how we would monitor them and decide if they were candidates for IV resuscitation. Luckily I started to come around at about 8-9 p.m. and was able to sleep soundly. Today I feel much better, eating solid foods and maintaining my volume status with a maintenance dose of oral saline.
I've learned quite a lot from this experience. The most important lesson I've learned is that by really seeing how things work here and understanding the basic needs of the people and the challenges they face I can now begin my lifelong journey of contribution. Everyone wants to help out in some way or another-and everyone can. No matter which profession or life path a person has chosen there is always an opportunity to give back, whether it is in our own country in the U.S., or anywhere else abroad.
There is no limitation to the helping hand.
Over and out.
Thursday, February 25, 2010
Wednesday, February 24, 2010
MONSOON!!!!!!
Ok so before I even get to the exciting medical stuff from today I have to remember to mention that I got to experience rain here in Bangladesh. That may seem like the most trivial thing but it hasn't rained once since i've been here, and I dont remember it ever raining on any of the other trips I've taken to Bangladesh. Also--this country experiences tropical weather, so when it rains...it RAINS! And today it not only rained quite a lot but we had some "shila brishti" or as we americans call it, HAIL!!! When I actually had the guts to leave the house later this afternoon the roads had collected about 6 inches of rain in some places...now imagine what it might be like during the actual rainy season!! I was so excited I called my mom who then told me a cute little story about how when her and her 6 sisters and 2 brothers (just emphasizing the sheer size of my family) were young they used to collect the hail in plastic bottles...in case the power went out and they couldn't make ice! Now every time it hails she thinks of that...the things we take for granted in the U.S. huh?
Interesting day at work today....started with morning rounds, had a patient who was admitted overnight with abdominal distension and bloody stools. Upon physical examination a very faint mass could be felt in the middle right area of the belly. The child would sleep for a few hours then wake up and cry, pulling her knees in towards her chest. She was too young to really verbalize that she was in pain but it seemed to be quite obvuious. The diagnosis considered at the time was intussusception--which is basically when part of the intestine telescopes within itself, this causes obstruction which leads to belly distension and may cause perforation, sepsis and death if not treated right away. One of the main physical findings that books always discuss is the "currant jelly" stool which is basically stool mixed with mucous and blood...I've only read about currant jelly stool, i didn't actually know what the heck it looked like before today....and furthermore I vaguely recall someone on my peds rotation mentioning that it is rarely even seen and the remainder of the clinical exam and history will dictate the diagnosis. WELLLLLL...today while the digital rectal exam was performed on this patient, out came some currant jelly stool..and it really does look exactly like it sounds. PICTURES TO FOLLOW LATER I PROMISE.
I also went down to the Emergency room today just to check it out. I spent a few hours there and have now realized just a few things. The scope of emergency medicine in this hospital is extremely limited. There is no residency for it here and the ER itself is split up into sections--the medical management section, the surgical management section and the poison section. It doesn't seem like each section communicates with each other. I decided by method of "eenie meenie miney moe" to hang out in the surgical ER area. Boy was it my lucky day. Three out four patients I got to see today were stab wounds from "mara mari" (fighting) out in the street somewhere. I dont know where the weapons were from or what the cuase of the fight was but there was quite a bit of blood shed in the ER Operating room. Being the eager little bear that I am I asked if I could partake in suturing up these slashed patients..and of course, as always the answer was "YES!" I only had time to sew up one particular patient, the worst of the three. His stab wound was about a foot wide and through most of the muscle in his thigh. First things first I injected the area with some local anesthetic meanwhile putting massive pressure on the bleeding...as the 40+ year old man cried and jerked around...mission accomplished then on to the next step, as quickly as possible clean the area ( hydrogen peroxide was use which basically sizzled in the wound area and I almost fainted just thinking of how horribly painful that must be) I then tied off the three bleeding vessels..slowly but surely, sutured the muslces, then fascia then the skin..DONE! Let it be known that I actually hated being in the OR during my surgery rotation mostly b/c I didn't get to do much..here I got my hands dirty in every single case I was involved in--trust me when I tell you there is no better way of learning than by doing. Oh..by the time I was sewing the muscle together the patient was completely passed out snoring..and receiving his second unit of blood. FUN DAY!
After my busy morning I had a lively discussion with an array of medical students from Dhaka Medical College regarding the positive aspects of their program here and the positive aspects of our program at Drexel. We also came to the conclusion that there should be a central site that both Drexel and DMC students can access and interact with each other, exchanging information and ideas regarding all aspects of medicine--this was another purpuse of my trip here and starting this rotation. What good are any of us on our own in the U.S. or in Bangladesh or anywhere? There are so many people immigrating to the U.S. from all over the world, we need to make the effort to understand their medical system and the illnesses that effect the people of those countries. It is time for the people of this world to stop building walls and start building bridges.
Special treat tomorrow: BRAC institute of Public Health!
Interesting day at work today....started with morning rounds, had a patient who was admitted overnight with abdominal distension and bloody stools. Upon physical examination a very faint mass could be felt in the middle right area of the belly. The child would sleep for a few hours then wake up and cry, pulling her knees in towards her chest. She was too young to really verbalize that she was in pain but it seemed to be quite obvuious. The diagnosis considered at the time was intussusception--which is basically when part of the intestine telescopes within itself, this causes obstruction which leads to belly distension and may cause perforation, sepsis and death if not treated right away. One of the main physical findings that books always discuss is the "currant jelly" stool which is basically stool mixed with mucous and blood...I've only read about currant jelly stool, i didn't actually know what the heck it looked like before today....and furthermore I vaguely recall someone on my peds rotation mentioning that it is rarely even seen and the remainder of the clinical exam and history will dictate the diagnosis. WELLLLLL...today while the digital rectal exam was performed on this patient, out came some currant jelly stool..and it really does look exactly like it sounds. PICTURES TO FOLLOW LATER I PROMISE.
I also went down to the Emergency room today just to check it out. I spent a few hours there and have now realized just a few things. The scope of emergency medicine in this hospital is extremely limited. There is no residency for it here and the ER itself is split up into sections--the medical management section, the surgical management section and the poison section. It doesn't seem like each section communicates with each other. I decided by method of "eenie meenie miney moe" to hang out in the surgical ER area. Boy was it my lucky day. Three out four patients I got to see today were stab wounds from "mara mari" (fighting) out in the street somewhere. I dont know where the weapons were from or what the cuase of the fight was but there was quite a bit of blood shed in the ER Operating room. Being the eager little bear that I am I asked if I could partake in suturing up these slashed patients..and of course, as always the answer was "YES!" I only had time to sew up one particular patient, the worst of the three. His stab wound was about a foot wide and through most of the muscle in his thigh. First things first I injected the area with some local anesthetic meanwhile putting massive pressure on the bleeding...as the 40+ year old man cried and jerked around...mission accomplished then on to the next step, as quickly as possible clean the area ( hydrogen peroxide was use which basically sizzled in the wound area and I almost fainted just thinking of how horribly painful that must be) I then tied off the three bleeding vessels..slowly but surely, sutured the muslces, then fascia then the skin..DONE! Let it be known that I actually hated being in the OR during my surgery rotation mostly b/c I didn't get to do much..here I got my hands dirty in every single case I was involved in--trust me when I tell you there is no better way of learning than by doing. Oh..by the time I was sewing the muscle together the patient was completely passed out snoring..and receiving his second unit of blood. FUN DAY!
After my busy morning I had a lively discussion with an array of medical students from Dhaka Medical College regarding the positive aspects of their program here and the positive aspects of our program at Drexel. We also came to the conclusion that there should be a central site that both Drexel and DMC students can access and interact with each other, exchanging information and ideas regarding all aspects of medicine--this was another purpuse of my trip here and starting this rotation. What good are any of us on our own in the U.S. or in Bangladesh or anywhere? There are so many people immigrating to the U.S. from all over the world, we need to make the effort to understand their medical system and the illnesses that effect the people of those countries. It is time for the people of this world to stop building walls and start building bridges.
Special treat tomorrow: BRAC institute of Public Health!
Tuesday, February 23, 2010
Diarrhea, cha cha cha.
Day 22 and 23...Mosquitos really starting to be the bane of my existence, stomach problems leading to hunger strike (which is a crime because the food here is way too good to pass)...pressing on b/c there is still stuff to do and see!!! With every adventure there are few roadbumps but letting them stop you or slow you down is no way to honor the spirit of adventure itself! (so mom, stop worrying I will be fine..if anything a few pounds lighter!)
Today I am visiting my version of "GI Upset mecca"...the institution which invented oral saline. ICDDR,B (International Center for Diarrheal Disease Research, Bangladesh)...opened about 50 yeras ago initially as the "cholera hospital" because of the incredibly high incidence of cholera (a waterborne diarrheal disease--mainly found in places where the main source of water is contaminated). Through both clinical and bench research this institution has done quite a lot for the public of bangladesh and other developing countries around the world. They have invented my favorite/life-sustaining solution (oral saline) as well as a solution called Dhaka solution which corrects for the electrolyte imbalances which occur with severe diarrhea. Interestingly there are these funny looking beds for the patients with a hole in the center connected to a biohazard bag above a bucket..long story short...some patients are so severely dehydrated they cannot even get out of bed to go to the lavatory...ergo..bed with strategically placed hole.
The intake area is run by nurses--a patient comes in they state their name, age and village/city from which they hail..then their duration of diarrhea, what it looks like, have they taken any medications, how many packets of oral saline...and any comorbid conditions. Then the nurse will take a good look at the patient...she/he needs to check a few things off the list
1. eyes sunken in or not?
2. Pulse? Rapid, thready or strong?
3. "Jeeba dhekow" (show me your tongue)..is the mucosa dry?
4. Thirst?
5. lastly..nurse grabs a chunk of skin on the patients belly or arm to see how long it takes for it to return to normal...(do to it yourself, youll notice that you pinch your skin and it immediately returns to baseline..do this in a severely dehydrated patient and their skin has a doughy feel, loses it's elasticity and stays "pinched" for a few seconds)
based on these factors the intake nurse will decide if the patient will go to emergency revival by IV fluids, or to the outpatient area where oral saline and rice are given for a few hours then the patient is released with recommendations. After patients' fluid status is resuscitated they are shipped off to the short stay or long stay unit depending how severe their condition is..at that point they are seen by a physician and "rounded" on. The problems i've noticed during intake is that patients start taking antibiotics not knowing why or if they should..they are overusing or misusing them and this will lead to increased antibiotic resistance in the future (a topic which was touched upon in a noon session i attended that same day)
A couple of novel practices started here...it has been found that the use of Zinc has decreased duration and severity of diarrhea as well as future occurrence in children especially. Patients are given zinc as soon as they present up to 7-10 days after diarrhea has ceased. Also, oral saline has another form called rice-based oral saline. The basic concept here is that rice is a complex carbohydrate and is easy to digest...it is a part of the BRAT diet which is recommended when someone is having diarrhea (Bananas, rice, apples, toast).
ICDDRB is a very interesting place...there is a lot of money that goes into this institution. It has revolutionized the way diarrheal disease is treated here in Bangladesh. furthermore they are the leading institution here in developing such public health gems as the rotatech and rotrix vaccines for the Rotavirus (a leading cause of diarrhea). Treating diarrhea or any disease does not just end in treating the disease itself but finding ways to prevent it. Hence the ICDDRB has developed a public health agenda in which to improve drinking/cooking water...a campaign to educate people on how to decontaminate their water, remind them about good sanitation practices as well. Over time this campaign has been very successful and the incidence of Cholera has drastically decreased (its peak seasons being before monsoon and after monsoon season)..in fact rotavirus is becoming the leading cause of diarrhea here in Bangladesh.
However..interesting fact I learned today...the Leading causes of death in Rural Bangladesh
1. Heart disease
2. Malignancy
3. Respiratory Disease
4. GI disease
5. Diabetes
6.Parasitic and Bacterial disease
...Back to Dhaka Medical Tomorrow....the ER awaits.
Today I am visiting my version of "GI Upset mecca"...the institution which invented oral saline. ICDDR,B (International Center for Diarrheal Disease Research, Bangladesh)...opened about 50 yeras ago initially as the "cholera hospital" because of the incredibly high incidence of cholera (a waterborne diarrheal disease--mainly found in places where the main source of water is contaminated). Through both clinical and bench research this institution has done quite a lot for the public of bangladesh and other developing countries around the world. They have invented my favorite/life-sustaining solution (oral saline) as well as a solution called Dhaka solution which corrects for the electrolyte imbalances which occur with severe diarrhea. Interestingly there are these funny looking beds for the patients with a hole in the center connected to a biohazard bag above a bucket..long story short...some patients are so severely dehydrated they cannot even get out of bed to go to the lavatory...ergo..bed with strategically placed hole.
The intake area is run by nurses--a patient comes in they state their name, age and village/city from which they hail..then their duration of diarrhea, what it looks like, have they taken any medications, how many packets of oral saline...and any comorbid conditions. Then the nurse will take a good look at the patient...she/he needs to check a few things off the list
1. eyes sunken in or not?
2. Pulse? Rapid, thready or strong?
3. "Jeeba dhekow" (show me your tongue)..is the mucosa dry?
4. Thirst?
5. lastly..nurse grabs a chunk of skin on the patients belly or arm to see how long it takes for it to return to normal...(do to it yourself, youll notice that you pinch your skin and it immediately returns to baseline..do this in a severely dehydrated patient and their skin has a doughy feel, loses it's elasticity and stays "pinched" for a few seconds)
based on these factors the intake nurse will decide if the patient will go to emergency revival by IV fluids, or to the outpatient area where oral saline and rice are given for a few hours then the patient is released with recommendations. After patients' fluid status is resuscitated they are shipped off to the short stay or long stay unit depending how severe their condition is..at that point they are seen by a physician and "rounded" on. The problems i've noticed during intake is that patients start taking antibiotics not knowing why or if they should..they are overusing or misusing them and this will lead to increased antibiotic resistance in the future (a topic which was touched upon in a noon session i attended that same day)
A couple of novel practices started here...it has been found that the use of Zinc has decreased duration and severity of diarrhea as well as future occurrence in children especially. Patients are given zinc as soon as they present up to 7-10 days after diarrhea has ceased. Also, oral saline has another form called rice-based oral saline. The basic concept here is that rice is a complex carbohydrate and is easy to digest...it is a part of the BRAT diet which is recommended when someone is having diarrhea (Bananas, rice, apples, toast).
ICDDRB is a very interesting place...there is a lot of money that goes into this institution. It has revolutionized the way diarrheal disease is treated here in Bangladesh. furthermore they are the leading institution here in developing such public health gems as the rotatech and rotrix vaccines for the Rotavirus (a leading cause of diarrhea). Treating diarrhea or any disease does not just end in treating the disease itself but finding ways to prevent it. Hence the ICDDRB has developed a public health agenda in which to improve drinking/cooking water...a campaign to educate people on how to decontaminate their water, remind them about good sanitation practices as well. Over time this campaign has been very successful and the incidence of Cholera has drastically decreased (its peak seasons being before monsoon and after monsoon season)..in fact rotavirus is becoming the leading cause of diarrhea here in Bangladesh.
However..interesting fact I learned today...the Leading causes of death in Rural Bangladesh
1. Heart disease
2. Malignancy
3. Respiratory Disease
4. GI disease
5. Diabetes
6.Parasitic and Bacterial disease
...Back to Dhaka Medical Tomorrow....the ER awaits.
Ekushey February, ami ki bhuli ti pari? (21st of February How Could I ever forget you?)
Sunday, February 21st, 2010: International Mother Language Day...
Today was a National Holiday here and for good reason. For the past 25 years, since my birth, I have lived in the U.S. I have celebrated Bangladeshi holidays in the U.S. not really understanding the meaning behind them nor really feeling any tie to them myself--even though all of the parents in my family have experienced the events of the liberation war first hand. There are many bangla songs written about the the liberation war and about the 21st of february, in 1952 which actually sparked the events of the following 20 years which eventually led to the independence of Bangladesh from Pakistan. There is one song in particular which begs the question, how could I forget you february 21st? Well, growing up in the U.S. i'm sorry to say i've forgotten almost every year until i'm reminded by my parents..that will never happen again because today I've experienced this holiday first hand here and its a bit inspiring to see so many people so passionate about their country.
February 21st, 1952...a time during which Bangladesh was known as East Pakistan and the language forced upon its people at that time was urdu-the bangla language was banned and urdu was established as the official state language. Remember that current bangladesh is separated from pakistan by India...the culture and language in Bangladesh were bound to be different and of their own unique nature. In revolt of the Pakistani decision, on Feb 21st, 1952 student leaders from Dhaka University organized a PEACEFUL rally. The students broke curfew imposed by the government and were representing their right to speak their language. The government ordered its security forces to open fire on the unarmed students as they were trying to march to the assembly building nearby to have their demands heard...in mere 30minutes twelve students and an unidentified rickshaw driver were killed..giving their lives to preserve the Bangla language.
Think about what your language means to you--how would you communicate your feelings, how would you express your intelligent thoughts and ideas. Then think about what your passionate about in your life--would you risk your life for it? That's what these students did. I may not be able to speak Bangla as well as I would like but it is a part of my culture, heritage-it is what connects me to the people of this country, especially the family I have here. and in the spirit of the intentions of these students who gave their lives, as well as the freedom fighters who fought for the liberation of this country-including my grandfather and father and many others-I will make sure to maintain my Bangla language and heritage.
Today was a National Holiday here and for good reason. For the past 25 years, since my birth, I have lived in the U.S. I have celebrated Bangladeshi holidays in the U.S. not really understanding the meaning behind them nor really feeling any tie to them myself--even though all of the parents in my family have experienced the events of the liberation war first hand. There are many bangla songs written about the the liberation war and about the 21st of february, in 1952 which actually sparked the events of the following 20 years which eventually led to the independence of Bangladesh from Pakistan. There is one song in particular which begs the question, how could I forget you february 21st? Well, growing up in the U.S. i'm sorry to say i've forgotten almost every year until i'm reminded by my parents..that will never happen again because today I've experienced this holiday first hand here and its a bit inspiring to see so many people so passionate about their country.
February 21st, 1952...a time during which Bangladesh was known as East Pakistan and the language forced upon its people at that time was urdu-the bangla language was banned and urdu was established as the official state language. Remember that current bangladesh is separated from pakistan by India...the culture and language in Bangladesh were bound to be different and of their own unique nature. In revolt of the Pakistani decision, on Feb 21st, 1952 student leaders from Dhaka University organized a PEACEFUL rally. The students broke curfew imposed by the government and were representing their right to speak their language. The government ordered its security forces to open fire on the unarmed students as they were trying to march to the assembly building nearby to have their demands heard...in mere 30minutes twelve students and an unidentified rickshaw driver were killed..giving their lives to preserve the Bangla language.
Think about what your language means to you--how would you communicate your feelings, how would you express your intelligent thoughts and ideas. Then think about what your passionate about in your life--would you risk your life for it? That's what these students did. I may not be able to speak Bangla as well as I would like but it is a part of my culture, heritage-it is what connects me to the people of this country, especially the family I have here. and in the spirit of the intentions of these students who gave their lives, as well as the freedom fighters who fought for the liberation of this country-including my grandfather and father and many others-I will make sure to maintain my Bangla language and heritage.
a few days seems like a lifetime
I'm a few days behind online but writing down anything and everything that comes to mind! The next three posts will be for each missed day...
Saturday, February 20th, 2010
After hours of preparation I presented my big case during Dhaka Medical College Hospital's verison of a Morbidity and Mortality session. My case was one of biliary atresia, which is when the bile ducts are basically blocked by a progressive fibrosing process. This causes progressive jaundice and clay colored stools in babies almost immediately. Because this is such a quickly progressing disease it is really important to catch it early on and convene surgically, hopefully within the first two months of life or the child may suffer drastically. THe case I presented was a case of missed Biliary Atresia by the Pediatric Medicine team, which was referred to pediatric surgery a bit too late to intervene...the childs family decided not to go forth with surgical management because of the poor prognosis and within a few years the child will probably pass away of fulminant liver failure.
Here's the twist, I presented this case after having read the history of present illness taken on admission by the pediatric medicine team and then that which was recorded by pediatric surgery...the lesson I wanted to impart was the documentation by both parties was HORRENDOUS. Not only was the actual physical finding of jaundice left out but all the dates were mixed up, the patient's file was an absolute mess and not all of the labwork was even recorded. Furthermore, retrieving a file like this is very difficult b/c the patients' files are rolled up and tied together by a piece of string and dumped in a file room. Also, the actual admission records kept by the nurses are terrible as well b/c some patients' intake information is either incorrect or missing all together....This has been very frustrating for me..i dont think i'll ever complain about any hospital filing/medical record system in the U.S. every again.
After the presentation I spent the rest of the day in the Pediatric Medicine ward...a veritable breeding ground for respiratory illness...about 60% of the patients in the ward are admitted with the diagnosis of bronchiolits/Pneumonia as it is the season here as well. Some of the more interesting cases I saw today were Acute Disseminated EncephaloMyelitis...Long name for an autoimmune disease that attacks the spinal cord and brain causing paralysis, difficulty with speech, etc. The patient presented with paraplegia, personality changes, difficulty with speech, involuntary urination. The MRI showed multiple lesions in the brain as well as thickening of the spinal cord (reaction to autoimmune attack).
Another patient-about 6 y.o. female, all smiles, with a skeletal deformity of the Right upper limb leaving her wrist in constant flexion and with one less digit, as well as stunted growth. Furthermore this child has findings of a heart defect(s) called Tetralogy of Fallot...a syndrome in which four things have to present together, Pulmonary valve stenosis (narrowing), Right Ventricular Hypertrophy, an Overriding Aorta, and ventricular septal defect. I could actually make out the murmur for the septal defect, the echo showed hypertrophy, pulmonary stenosis and the overriding aorta along with the vsd. Clinically, the child had signs of clubbing(hyperacute angle between nailbed and nail), which is often seen with disease of decreased oxygen perfusion although the exact cause is unknown....but like I said, with all of this..the child was smiling and laughing and playing with the child she was sharing her bed with (since there are usually two children to a bed).
I also saw three cases of Nephrotic Syndrome (protein losing disease of the kidneys which leads to massive swelling)...all three children presented first with swollen eyes, then swollen belly and then swollen legs..basically complete anasarca (full body edema).
The most astounding case though...the 5 y.o. with active T.B....Child presented with chronic cough, PPD that was placed was blatantly obvious, chest xray showed evidence of T.B....I mean I know it's a problem here but I was just really sad to see T.B. in such small child--The conditions in which most of these patients live or work or both is a breeding ground for any communicable disease..T.B. probably the leading infectious disease of them all.
Saturday, February 20th, 2010
After hours of preparation I presented my big case during Dhaka Medical College Hospital's verison of a Morbidity and Mortality session. My case was one of biliary atresia, which is when the bile ducts are basically blocked by a progressive fibrosing process. This causes progressive jaundice and clay colored stools in babies almost immediately. Because this is such a quickly progressing disease it is really important to catch it early on and convene surgically, hopefully within the first two months of life or the child may suffer drastically. THe case I presented was a case of missed Biliary Atresia by the Pediatric Medicine team, which was referred to pediatric surgery a bit too late to intervene...the childs family decided not to go forth with surgical management because of the poor prognosis and within a few years the child will probably pass away of fulminant liver failure.
Here's the twist, I presented this case after having read the history of present illness taken on admission by the pediatric medicine team and then that which was recorded by pediatric surgery...the lesson I wanted to impart was the documentation by both parties was HORRENDOUS. Not only was the actual physical finding of jaundice left out but all the dates were mixed up, the patient's file was an absolute mess and not all of the labwork was even recorded. Furthermore, retrieving a file like this is very difficult b/c the patients' files are rolled up and tied together by a piece of string and dumped in a file room. Also, the actual admission records kept by the nurses are terrible as well b/c some patients' intake information is either incorrect or missing all together....This has been very frustrating for me..i dont think i'll ever complain about any hospital filing/medical record system in the U.S. every again.
After the presentation I spent the rest of the day in the Pediatric Medicine ward...a veritable breeding ground for respiratory illness...about 60% of the patients in the ward are admitted with the diagnosis of bronchiolits/Pneumonia as it is the season here as well. Some of the more interesting cases I saw today were Acute Disseminated EncephaloMyelitis...Long name for an autoimmune disease that attacks the spinal cord and brain causing paralysis, difficulty with speech, etc. The patient presented with paraplegia, personality changes, difficulty with speech, involuntary urination. The MRI showed multiple lesions in the brain as well as thickening of the spinal cord (reaction to autoimmune attack).
Another patient-about 6 y.o. female, all smiles, with a skeletal deformity of the Right upper limb leaving her wrist in constant flexion and with one less digit, as well as stunted growth. Furthermore this child has findings of a heart defect(s) called Tetralogy of Fallot...a syndrome in which four things have to present together, Pulmonary valve stenosis (narrowing), Right Ventricular Hypertrophy, an Overriding Aorta, and ventricular septal defect. I could actually make out the murmur for the septal defect, the echo showed hypertrophy, pulmonary stenosis and the overriding aorta along with the vsd. Clinically, the child had signs of clubbing(hyperacute angle between nailbed and nail), which is often seen with disease of decreased oxygen perfusion although the exact cause is unknown....but like I said, with all of this..the child was smiling and laughing and playing with the child she was sharing her bed with (since there are usually two children to a bed).
I also saw three cases of Nephrotic Syndrome (protein losing disease of the kidneys which leads to massive swelling)...all three children presented first with swollen eyes, then swollen belly and then swollen legs..basically complete anasarca (full body edema).
The most astounding case though...the 5 y.o. with active T.B....Child presented with chronic cough, PPD that was placed was blatantly obvious, chest xray showed evidence of T.B....I mean I know it's a problem here but I was just really sad to see T.B. in such small child--The conditions in which most of these patients live or work or both is a breeding ground for any communicable disease..T.B. probably the leading infectious disease of them all.
Thursday, February 18, 2010
Smokey the Bear needs to visit Bangladesh
Day 18. Mosquito bites: back up to approximately 1,000,000(on account of accidentally resting my arm all night on the mosquito net which surrounds my bed) Symptoms of Food poisoning: at a minimum.
Day 2 at the Burn Unit. Started with morning report of the overnight events. A patient died overnight, 35% body surface covered with burns, age of the patient was 25--most likely secondary to the patient waiting too long to receive treatment after such severe burns. A few things I learned today at the burn unit: This Burn Unit is the only one of its kind in Bangladesh. It is run by the government (once again, minimal financial help), it is understaffed and overpopulated. There is no sustainable campaign for burn prevention nor is there much counseling done with patients upon their admission mostly because of time constraints and limited staff as mentioned before. Comorbid conditions such as Diabetes, TB, Hypertension, etc., are not always treated properly while patients are admitted and may consequently contribute to decreased survival. Patients are treated with antibiotics immediately because there are no isolation rooms or barriers between patients to decrease cross contamination-this is merely b/c of the patient volume versus space available. Health care is a right not a privilege and so no physician in this hospital can deny treatment to a patient--hence the cycle. Medications for pain management are not always readily available. The idea of palliative care is not entirely established here.
I sat in the Emgergency department today and saw patients with the physicians there. There were three physicians there from 9am to 2pm, after 3pm espcieally there are two physicians to run the ENTIRE hospital. In most government run hospitals the majority of physicians finish rounding and seeing patients by 2pm and then go to a private hospital or private office to see their own patients. In any case, as I examined patients with the other doctors I re-learned the system to estimate the percentage of body surface effected. I learned that the threshold to admit here is >10% burns in children and >15% in adults, admission is mostly to resuscitate fluid status and administer antibiotics. Most of the patients we saw today were presenting days or even weeks after the initial burn. The burn site on most of these patients looked grossly infected. The problem is that most of these patients are travelling from very far to reach this hospital. Once again, they cannot afford the emollients or bandages needed (since the hospital cannot provide everyone with these).
The saddest story I heard today was from a 27 y.o. woman who was burn about a year ago while giving birth. She delivered the baby and meanwhile a piece of her clothing caught fire, her entire right side was burned, the baby too was badly burned. Both the mom and baby were sent to separate hospitals at the time, the mother was discharged a month later the baby was too, six months after the incident the baby died of septicemia--unable to take breast milk from the mom because of the severity of the burns on her chest, the baby was not receiving proper nutrition and could not fend off the infection. The mom presented today a year after the incident with severely thickened scar tissue over the area of the burns, which she could have avoided had she followed up correctly, but unfortunately she lives far away and her husband is not very cooperative and threatens to leave her and marry someone else on a daily basis. But her dad drives a babytaxi for a living and does not make a lot of money so she can't really afford much in the way of treatment anyhow. In lower socioeconomic status couples this tends to often quite commonly because the wife becomes such a "financial burden" that the man cannot afford to maintain treatment, etc.
The power in Bangladesh goes out quite often, this incidentally is a cause of many burns because families without generators will light candles or start up a fire to permit light and stay warm. Furthermore little children of women who work as cooks in houses are burned very frequently because they are playing around the kitchen or boiling water or food is spilled on them. Most of the women I saw today had scald burns from spillage in the kitchen. Because of the mosquitos here coils are burned to keep them away and mosquito nets are draped over beds, often times the net catches fire from the coil and can cause burns that way as well. In the farmlands the rice milll ash is dumped in an open area. Kids often play near them, will accidentally step or run over a pile of hot ash and burn their feet. The concept of fire hazard or safety doesn't seem to be very prevalent. Furthermore the concept of seeking immediate attention and the complications from burns are completely unknown to the uneducated. Skin thickening, keloids, awful scars, infections, etc occur and disfigure people for life. The incidents leading to these burns are not common in the US and so I found it interesting to note them today, furthermore the important thing is that prevention can only happen with an understanding of what risk factors are present in a certain community. It is so important to know the patients, where they come from, what they do, their socioeconomic status etc. Treating a patient is more than just treating the disease.
Day 2 at the Burn Unit. Started with morning report of the overnight events. A patient died overnight, 35% body surface covered with burns, age of the patient was 25--most likely secondary to the patient waiting too long to receive treatment after such severe burns. A few things I learned today at the burn unit: This Burn Unit is the only one of its kind in Bangladesh. It is run by the government (once again, minimal financial help), it is understaffed and overpopulated. There is no sustainable campaign for burn prevention nor is there much counseling done with patients upon their admission mostly because of time constraints and limited staff as mentioned before. Comorbid conditions such as Diabetes, TB, Hypertension, etc., are not always treated properly while patients are admitted and may consequently contribute to decreased survival. Patients are treated with antibiotics immediately because there are no isolation rooms or barriers between patients to decrease cross contamination-this is merely b/c of the patient volume versus space available. Health care is a right not a privilege and so no physician in this hospital can deny treatment to a patient--hence the cycle. Medications for pain management are not always readily available. The idea of palliative care is not entirely established here.
I sat in the Emgergency department today and saw patients with the physicians there. There were three physicians there from 9am to 2pm, after 3pm espcieally there are two physicians to run the ENTIRE hospital. In most government run hospitals the majority of physicians finish rounding and seeing patients by 2pm and then go to a private hospital or private office to see their own patients. In any case, as I examined patients with the other doctors I re-learned the system to estimate the percentage of body surface effected. I learned that the threshold to admit here is >10% burns in children and >15% in adults, admission is mostly to resuscitate fluid status and administer antibiotics. Most of the patients we saw today were presenting days or even weeks after the initial burn. The burn site on most of these patients looked grossly infected. The problem is that most of these patients are travelling from very far to reach this hospital. Once again, they cannot afford the emollients or bandages needed (since the hospital cannot provide everyone with these).
The saddest story I heard today was from a 27 y.o. woman who was burn about a year ago while giving birth. She delivered the baby and meanwhile a piece of her clothing caught fire, her entire right side was burned, the baby too was badly burned. Both the mom and baby were sent to separate hospitals at the time, the mother was discharged a month later the baby was too, six months after the incident the baby died of septicemia--unable to take breast milk from the mom because of the severity of the burns on her chest, the baby was not receiving proper nutrition and could not fend off the infection. The mom presented today a year after the incident with severely thickened scar tissue over the area of the burns, which she could have avoided had she followed up correctly, but unfortunately she lives far away and her husband is not very cooperative and threatens to leave her and marry someone else on a daily basis. But her dad drives a babytaxi for a living and does not make a lot of money so she can't really afford much in the way of treatment anyhow. In lower socioeconomic status couples this tends to often quite commonly because the wife becomes such a "financial burden" that the man cannot afford to maintain treatment, etc.
The power in Bangladesh goes out quite often, this incidentally is a cause of many burns because families without generators will light candles or start up a fire to permit light and stay warm. Furthermore little children of women who work as cooks in houses are burned very frequently because they are playing around the kitchen or boiling water or food is spilled on them. Most of the women I saw today had scald burns from spillage in the kitchen. Because of the mosquitos here coils are burned to keep them away and mosquito nets are draped over beds, often times the net catches fire from the coil and can cause burns that way as well. In the farmlands the rice milll ash is dumped in an open area. Kids often play near them, will accidentally step or run over a pile of hot ash and burn their feet. The concept of fire hazard or safety doesn't seem to be very prevalent. Furthermore the concept of seeking immediate attention and the complications from burns are completely unknown to the uneducated. Skin thickening, keloids, awful scars, infections, etc occur and disfigure people for life. The incidents leading to these burns are not common in the US and so I found it interesting to note them today, furthermore the important thing is that prevention can only happen with an understanding of what risk factors are present in a certain community. It is so important to know the patients, where they come from, what they do, their socioeconomic status etc. Treating a patient is more than just treating the disease.
Tuesday, February 16, 2010
Frustration Station
narrowly escaped passing out in the burn unit today. My belief is that it was low blood sugar...or dehydration...Unclear. I have been chomping on "sweet and salty" granola bars all day (tribute to Europe tour 2007) and of course..my new favorite drink, orsaline.
Had a very long day today mostly because of the frustration I felt as I walked through the burn unit here in Dhaka. I walked into the hospital and was met with a blood curdling scream from a child who's dressing was being changed, frightening way to start the day. Secondly I was informed that this specialized burn hospital has 50 beds..and guess how many patients? 309. 110 of them are young children. The majority of cases I saw today were little children who had scald burns from hot oil or boiling water. The physician I was with today literally said to me, "we are understaffed here, it is difficult to look at the extent of the burns on EVERY child"...so the history is taken from the parent and they are treated accordingly. Many of the children I saw today were not immediately brought to the hospital, mostly because the parents couldn't afford the long trek from their village or the medicines they would require for their child. The difficult thing about this is that the most important part of treating burns is resuscitation with fluids. The first 24 hours is most crucial. The reason this is so important is that your skin not only protects you from external factors but also allows for your body to hold fluids and electrolytes so they dont just constantly leak out of you (which is what happens with extensive burns because your skin barrier is gone). Also, b/c that skin barrier is gone you lose a very important thing called albumin, a protein which helps keep the water where it should be in your body. Most of these children are already malnourished and their protein (albumin) level may already be low and now they have suffered another insult. In light of that the staff here encourages patients to eat eggs and Daal (a lentil soup high in protein) because most patients and their families cannot afford much more than that. Below a certain threshold (20 gm/dL of albumin) patients are infused with human albumin which can cost up to 4000 tk ($60)..this is expensive for the record!
Every child I saw was completely frozen with fear when they would see our rounding team approach. They would start crying immediately because any type of movement causes severe pain. Nalbuphine is a synthetic opioid which is used for pain management, it has the potency of morphine (which is not easily attainable here). I was practically brought to tears by this one little kid who just stared at me, shaking, then darting eyes left to right to see who would be the one to examine him. He sustained his burns from the fire that the family had started to keep warm...imagine that. A part of his clothing caught fire and no one could act quickly enough to save him. This situation happens quite often, especially with women because of the saris they traditionally wear.
Although I've seen very sick patients everywhere else the burn patients are the toughest to see-the burn itself is terrifying-looking usually and then the patients are just in themost incredible amount of pain they cannot help but cry, or scream or both...tough day.
Had a very long day today mostly because of the frustration I felt as I walked through the burn unit here in Dhaka. I walked into the hospital and was met with a blood curdling scream from a child who's dressing was being changed, frightening way to start the day. Secondly I was informed that this specialized burn hospital has 50 beds..and guess how many patients? 309. 110 of them are young children. The majority of cases I saw today were little children who had scald burns from hot oil or boiling water. The physician I was with today literally said to me, "we are understaffed here, it is difficult to look at the extent of the burns on EVERY child"...so the history is taken from the parent and they are treated accordingly. Many of the children I saw today were not immediately brought to the hospital, mostly because the parents couldn't afford the long trek from their village or the medicines they would require for their child. The difficult thing about this is that the most important part of treating burns is resuscitation with fluids. The first 24 hours is most crucial. The reason this is so important is that your skin not only protects you from external factors but also allows for your body to hold fluids and electrolytes so they dont just constantly leak out of you (which is what happens with extensive burns because your skin barrier is gone). Also, b/c that skin barrier is gone you lose a very important thing called albumin, a protein which helps keep the water where it should be in your body. Most of these children are already malnourished and their protein (albumin) level may already be low and now they have suffered another insult. In light of that the staff here encourages patients to eat eggs and Daal (a lentil soup high in protein) because most patients and their families cannot afford much more than that. Below a certain threshold (20 gm/dL of albumin) patients are infused with human albumin which can cost up to 4000 tk ($60)..this is expensive for the record!
Every child I saw was completely frozen with fear when they would see our rounding team approach. They would start crying immediately because any type of movement causes severe pain. Nalbuphine is a synthetic opioid which is used for pain management, it has the potency of morphine (which is not easily attainable here). I was practically brought to tears by this one little kid who just stared at me, shaking, then darting eyes left to right to see who would be the one to examine him. He sustained his burns from the fire that the family had started to keep warm...imagine that. A part of his clothing caught fire and no one could act quickly enough to save him. This situation happens quite often, especially with women because of the saris they traditionally wear.
Although I've seen very sick patients everywhere else the burn patients are the toughest to see-the burn itself is terrifying-looking usually and then the patients are just in themost incredible amount of pain they cannot help but cry, or scream or both...tough day.
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