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.
Monday, February 15, 2010
Do not ever take your water for granted
Day 15. Mosquito bites: significantly LESS!! Symptoms of GI upset...more than you want to know.
It occurred to me that maybe it is a bit forward to discuss my upset stomach, but then I figured the point of this blog was to not only remind myself of everything I'm going through but to give those of you at home a first hand experience. Every day is a challenge, a challenge in remembering what I should and should not eat. It is a challenge to remember to bring a bottle of water with me, in the states I would refill my water bottle with water from the fridge or kitchen sink even. That is completely unheard of here. But without a constant source of water I become easily dehydrated, especially since it's starting to get a bit warm here. I woke up this morning and literally sprint to the bathroom...this occurred about 5 times in total, meanwhile im literally chugging glasses of oral saline, I popped a flagyl, then another...and oh also I was in the midst of getting ready to visit Osmani Medical College and Hospital to go see some patients. It is difficult to describe the feeling I had all morning, I was physically a bit unstable, I had to remember to stand up slowly so I wouldn't keel over. My mind was a bit cloudy, my lips wer dry and cracked, I felt like I hadn't drank a glass of water for days even though I was drinking oral saline continuously. And worst of all, my stomach was making this gurgling sound...which in bangla we say "gur gur"..because that's literally what it sounds like. That gurgling sound, as my father explained to me, is a sign of volume loss but not externally, instead, internally somewhere--which is worse because you are unaware of the volume loss--and so it is imperative to continue to rehydrate even without loose stools, because by the time you begin to have diarrhea you may have already lost a significant enough amount of fluid.
About 12 hours later now, I am doing better, unable to really eat anything I think more so in fear of not being able to digest. But my new motto is life's occurrences are no accident so learn from them what you can...and so here is the lesson from my awful experience today...the patients I am seeing, the poor people of this country, they are suffering about 1 million times more than I am. Cholera, Typhoid, TB, etc, going untreated, unabated, and causing such terrible dehydration which eventually because of such horrendous electrolyte imbalances, leads to death. Any patient I ever treat with diarrhea, vomiting, etc, I will remember how I felt today and remember that what they are feeling is probably much worse and to treat them with the utmost care.
Rewinding to the beginning of the Sylhet trip, the first day was spent in a remote village area called Gwainghat. The purpose of the village visits was to see the public health work that is being done in remote areas such as these. The main goal is to reduce neonatal and maternal mortality rates through prenatal care counseling and postnatal care counseling sessions. In the two years that this Access program has been in effect the observed mortality rate has actually decreased in this village area. The basis of these counseling sessions is to defy old fashioned birthing methods and teach traditional birthing attendants safe and sanitary methods of birthing. Just to give you an idea of what was being done...During labor, birthing attendants would tie rope around the apex of the belly thinking that this would help push the baby towards the birth canal, when in fact it is quite detrimental. Mothers would be fed hair or cow dung in an effort to bring forth afterbirth more quickly. Or the placenta would literally be ripped from the womb by unsanitary hands, the umbilical cord would be cut too long-cow dung or ginger root would be rubbed on the area of the umbilical cord of the baby causing him/her severe burning pain, in efforts to increase healing time...none of these methods are logical nor do they actually work. Mothers would be left to hemorrhage or die of infection because of unsanitary practices. The counseling sessions are geared towards educating women and their birthing attendants of danger signs during pregnancy, danger signs during labor, danger signs after labor--allowing for families to know when to rush to the hospital. Because many of the target population here are illiterate, picture books are used to explain everything and it is surprising how much these women retain. I attended a community mobilization meeting which is geared towards women mostly. The women of the village are brought together to identify the challenges they face in their village which are contributing to the mortality rate. Things such as birthing practices, or transportation to the hospital, or support from religious leaders, etc, are common issues brought up. These meetings and this program is run by Friends in Village Development Bangladesh (FIVDB) an NGO based out of Sylhet which has impacted the surrounding villages immensely. These mobilization meetings are held numerous times over a span of 8 months in order to work on improving the issues brought up. Counselors provide support but no money or objects are donated—the challenges are faced by the villagers with their own means within their own capacity. This public health program is awe inspiring. The key here is prevention--educate the people, prevent the preventable tragedies...improve the general health of the population. If preventive medicine can work in a remote village it sure as hell can work in an industrialized, developed nation like our own. This trip to Gwainghat completely rejuvenated my passion for public health and preventive medicine--I am excited to pursue my career knowing that somewhere some how the system is working!
I also visited Shamsuddin Hospital, named after my courageous grandfather who was killed in the liberation war after being literally pulled out of the operating room, then shot down by firing squad along with a number of other brave health care workers who were present in the hospital with him. I visited the Medicine and surgical ward at this hospital-a 100 bed hospital with cases running the entire gamut. I also visited Osmani Medical College and Hospital where I saw a range of patients--the most interesting thing I saw was the entire spectrum of presentations for Tuberculosis, ranging from TB meningitis, to TB arthritis, to TB of the lungs, TB intestinal disease, to TB of the bone! This is the stuff we read about in the states but do not see as much.
Furthermore, Osmani Hospital is government run, therefore in the same state as Dhaka Medical. Patients need money for supplies and medications and the "Poor Fund" they have is limited. My hope is to create a small NGO (I'm open to suggestions for names) which will raise funds for the government hospitals in Bangladesh, where the poorest of the poor go to receive treatment. I will get in touch with a major pharmaceutical company here (obviously with the help of family/friends who have the proper connections) to arrange for a direct transfer of money so that medications can be delivered to these hospitals. This is a work in progress, and idea at best right now, which will be up and running before the summer time hopefully! A little bit goes a long way here, I can attest to that personally and I am going to make sure that this message is spread to all those who are willing and able to help.
quick note: I asked about active clinical research studies today, the answer was that research is hard to come by in Bangladesh mostly due to funds and proper tools to conduct research--I am curious about epidimiological studies, as well as case reports on which medications are of use here, as in which meds patients respond well to vs not (for example first line hypertensive agents, or diabetic medications, etc.).....I'm out of my league here but would like to increase interest in possible research topics.
Medical Inventory:
1. Neurofibromatosis type I (First time I've ever seen this disease outside of Harrison's Internal Medicine Book)
2. Acute glomerulal Nephritis, pt presented with severe Hypertension
3. Cor pulomonale in life time smoker, on physical exam could clearly see clubbing.
4. Obstructive jaundice most likely from chronic liver disease
5. TB arthritis
6. Chronic liver disease, presented with distended abdomen (fluid) and Right upper quadrant pain
7. Peripheral vascular disease-->amputation
8. Hepatocellular carcinoma (x5 patients, one of them had an ulstrasound done showing space occupying lesions in the liver, definitive diagnosis by biopsy, another patient had a hepatic bruit a clinical sign which usually caused by primary hepatocellular cancer versus metastatic)
9. Toxic thyroid adenoma, pt presented with exopthalmos (bulging eyeballs), palpitations, heat intolerance
10.Empyeme in lung, due to TB
11. Hydropneumothorax due to TB
12. Exfoliative dermatitis (x 3 patients) due to severe psoriasis
13. organophosphate poisoning (quite common here)
14. Dermatomyositis in a 12 y.o. boy (SLE is on differential diagnosis), presented with malar rash, joint pain, proximal muscle weakness, history of oral ulcers, heliotrope rash, shawl sign, alopecia...yes, I saw all of this on physical exam!!!!!
15. 9 y.o. boy with acute glomerular nephritis history, presented with chicken pox (? maybe due to immunosuppressed state?)
It occurred to me that maybe it is a bit forward to discuss my upset stomach, but then I figured the point of this blog was to not only remind myself of everything I'm going through but to give those of you at home a first hand experience. Every day is a challenge, a challenge in remembering what I should and should not eat. It is a challenge to remember to bring a bottle of water with me, in the states I would refill my water bottle with water from the fridge or kitchen sink even. That is completely unheard of here. But without a constant source of water I become easily dehydrated, especially since it's starting to get a bit warm here. I woke up this morning and literally sprint to the bathroom...this occurred about 5 times in total, meanwhile im literally chugging glasses of oral saline, I popped a flagyl, then another...and oh also I was in the midst of getting ready to visit Osmani Medical College and Hospital to go see some patients. It is difficult to describe the feeling I had all morning, I was physically a bit unstable, I had to remember to stand up slowly so I wouldn't keel over. My mind was a bit cloudy, my lips wer dry and cracked, I felt like I hadn't drank a glass of water for days even though I was drinking oral saline continuously. And worst of all, my stomach was making this gurgling sound...which in bangla we say "gur gur"..because that's literally what it sounds like. That gurgling sound, as my father explained to me, is a sign of volume loss but not externally, instead, internally somewhere--which is worse because you are unaware of the volume loss--and so it is imperative to continue to rehydrate even without loose stools, because by the time you begin to have diarrhea you may have already lost a significant enough amount of fluid.
About 12 hours later now, I am doing better, unable to really eat anything I think more so in fear of not being able to digest. But my new motto is life's occurrences are no accident so learn from them what you can...and so here is the lesson from my awful experience today...the patients I am seeing, the poor people of this country, they are suffering about 1 million times more than I am. Cholera, Typhoid, TB, etc, going untreated, unabated, and causing such terrible dehydration which eventually because of such horrendous electrolyte imbalances, leads to death. Any patient I ever treat with diarrhea, vomiting, etc, I will remember how I felt today and remember that what they are feeling is probably much worse and to treat them with the utmost care.
Rewinding to the beginning of the Sylhet trip, the first day was spent in a remote village area called Gwainghat. The purpose of the village visits was to see the public health work that is being done in remote areas such as these. The main goal is to reduce neonatal and maternal mortality rates through prenatal care counseling and postnatal care counseling sessions. In the two years that this Access program has been in effect the observed mortality rate has actually decreased in this village area. The basis of these counseling sessions is to defy old fashioned birthing methods and teach traditional birthing attendants safe and sanitary methods of birthing. Just to give you an idea of what was being done...During labor, birthing attendants would tie rope around the apex of the belly thinking that this would help push the baby towards the birth canal, when in fact it is quite detrimental. Mothers would be fed hair or cow dung in an effort to bring forth afterbirth more quickly. Or the placenta would literally be ripped from the womb by unsanitary hands, the umbilical cord would be cut too long-cow dung or ginger root would be rubbed on the area of the umbilical cord of the baby causing him/her severe burning pain, in efforts to increase healing time...none of these methods are logical nor do they actually work. Mothers would be left to hemorrhage or die of infection because of unsanitary practices. The counseling sessions are geared towards educating women and their birthing attendants of danger signs during pregnancy, danger signs during labor, danger signs after labor--allowing for families to know when to rush to the hospital. Because many of the target population here are illiterate, picture books are used to explain everything and it is surprising how much these women retain. I attended a community mobilization meeting which is geared towards women mostly. The women of the village are brought together to identify the challenges they face in their village which are contributing to the mortality rate. Things such as birthing practices, or transportation to the hospital, or support from religious leaders, etc, are common issues brought up. These meetings and this program is run by Friends in Village Development Bangladesh (FIVDB) an NGO based out of Sylhet which has impacted the surrounding villages immensely. These mobilization meetings are held numerous times over a span of 8 months in order to work on improving the issues brought up. Counselors provide support but no money or objects are donated—the challenges are faced by the villagers with their own means within their own capacity. This public health program is awe inspiring. The key here is prevention--educate the people, prevent the preventable tragedies...improve the general health of the population. If preventive medicine can work in a remote village it sure as hell can work in an industrialized, developed nation like our own. This trip to Gwainghat completely rejuvenated my passion for public health and preventive medicine--I am excited to pursue my career knowing that somewhere some how the system is working!
I also visited Shamsuddin Hospital, named after my courageous grandfather who was killed in the liberation war after being literally pulled out of the operating room, then shot down by firing squad along with a number of other brave health care workers who were present in the hospital with him. I visited the Medicine and surgical ward at this hospital-a 100 bed hospital with cases running the entire gamut. I also visited Osmani Medical College and Hospital where I saw a range of patients--the most interesting thing I saw was the entire spectrum of presentations for Tuberculosis, ranging from TB meningitis, to TB arthritis, to TB of the lungs, TB intestinal disease, to TB of the bone! This is the stuff we read about in the states but do not see as much.
Furthermore, Osmani Hospital is government run, therefore in the same state as Dhaka Medical. Patients need money for supplies and medications and the "Poor Fund" they have is limited. My hope is to create a small NGO (I'm open to suggestions for names) which will raise funds for the government hospitals in Bangladesh, where the poorest of the poor go to receive treatment. I will get in touch with a major pharmaceutical company here (obviously with the help of family/friends who have the proper connections) to arrange for a direct transfer of money so that medications can be delivered to these hospitals. This is a work in progress, and idea at best right now, which will be up and running before the summer time hopefully! A little bit goes a long way here, I can attest to that personally and I am going to make sure that this message is spread to all those who are willing and able to help.
quick note: I asked about active clinical research studies today, the answer was that research is hard to come by in Bangladesh mostly due to funds and proper tools to conduct research--I am curious about epidimiological studies, as well as case reports on which medications are of use here, as in which meds patients respond well to vs not (for example first line hypertensive agents, or diabetic medications, etc.).....I'm out of my league here but would like to increase interest in possible research topics.
Medical Inventory:
1. Neurofibromatosis type I (First time I've ever seen this disease outside of Harrison's Internal Medicine Book)
2. Acute glomerulal Nephritis, pt presented with severe Hypertension
3. Cor pulomonale in life time smoker, on physical exam could clearly see clubbing.
4. Obstructive jaundice most likely from chronic liver disease
5. TB arthritis
6. Chronic liver disease, presented with distended abdomen (fluid) and Right upper quadrant pain
7. Peripheral vascular disease-->amputation
8. Hepatocellular carcinoma (x5 patients, one of them had an ulstrasound done showing space occupying lesions in the liver, definitive diagnosis by biopsy, another patient had a hepatic bruit a clinical sign which usually caused by primary hepatocellular cancer versus metastatic)
9. Toxic thyroid adenoma, pt presented with exopthalmos (bulging eyeballs), palpitations, heat intolerance
10.Empyeme in lung, due to TB
11. Hydropneumothorax due to TB
12. Exfoliative dermatitis (x 3 patients) due to severe psoriasis
13. organophosphate poisoning (quite common here)
14. Dermatomyositis in a 12 y.o. boy (SLE is on differential diagnosis), presented with malar rash, joint pain, proximal muscle weakness, history of oral ulcers, heliotrope rash, shawl sign, alopecia...yes, I saw all of this on physical exam!!!!!
15. 9 y.o. boy with acute glomerular nephritis history, presented with chicken pox (? maybe due to immunosuppressed state?)
Thursday, February 11, 2010
secret to survival here
Spoke to my dad today and we've concocted a theory-dehydration is the major reason some of us feel so "unwell" when we come to Bangladesh. In an attempt to keep our bowels moving normally we avoid certain foods and may not have ready access to bottled water. Oral Rehydration Therapy is widespread here, with the use of a solution called orsaline, a packet of mixed ingredients including mostly sodium chloride, potassium and glucose--which if mixed with 500 ml of water will readily replace the losses seen with diarrhea/vomiting. This is incredibly important here in general because of the rampant cholera and other diarrheal diseases that claim thousands of lives purely b/c of the inability to replace rapid losses of electrolytes and fluids. The use of orsaline has saved many lives since its inception and with a cost of about 3 tk (1 usd=80 tk), it is absolutely affordable. Why I bring this up is that while here I"ve been regularly attempting to consume one packet of orsaline a day. Over the last few days i've been unable to keep up with that and have been developing a morning headache, dry mouth..general feeling of uneasiness which is alleviated when I consume a few glasses of water and have something to eat, my guess is that I am generally a bit dehyrated and daily usage of orsaline is a great way to maintain my volume status...it's a theory..the idea came more or less from my dad but i'm attempting to experiment on myself while here, see if there's any validity to it.
No work today on account of the fact that I was sick myself...and saved with the use of orsaline...an unexpected twist to the story...i'm feeling better, and will be off to Sylhet tomorrow to make some village visits and see a few aspects of public health medicine with respect to pediatrics. Probably will not be able to update from there, I'll write everything down and will definitely update when I return in a few days.
No work today on account of the fact that I was sick myself...and saved with the use of orsaline...an unexpected twist to the story...i'm feeling better, and will be off to Sylhet tomorrow to make some village visits and see a few aspects of public health medicine with respect to pediatrics. Probably will not be able to update from there, I'll write everything down and will definitely update when I return in a few days.
Wednesday, February 10, 2010
Plain Xray: 60 Tk, approx 1 USD
One of the biggest roadblocks on this trip has been the language barrier with patients. The thing about this hospital is that it is government run as I've mentioned before, diagnostic tests are subsidized and so are at a much more affordable cost for the patients, and there are no admission costs or any additional costs for surgeries etc. For this reason patients are coming from villages outside of Dhaka, making long trips to be seen by a physician here. This poses a challenge for me because although the basis of the language is the same all over, there are different dialects spoken. Certain words are pronounced differently or certain objects have an entirely different name. Furthermore, although I am fluent there are certain phrases or idioms that I do not know. For example...the word for urine is "peshap", well I had a patient who kept saying "poyshap" and I was a bit confused at first but was able to use context clues to figure out what she meant. Usually an intern is with me in order to help translate but when things are busy I'm on my own, but the best way to learn something is through your own experience which includes being confused and making mistakes and then making sense of things after. In another case, also related to urinary output..the mother of the baby told me that the patient wasn't really making any "peshap", in my head i'm starting to wonder, ok, this could be obstructive, there could be a posterior urethral valve as we've seen in so many patients already..let me ask a little more, I asked her to elaborate and she said "amar bachar peshap top top kore ashe"....ok..well in my head the translation went like this: My baby's urine comes out.."Something". I had no idea what the heck "top top" meant...so I asked her "Top Top mane ki?" (what does "top top" mean?) she looked at me, I looked at her...we both had the same exact confused face--like many other circumstances I was saved by an intern who was literally on the floor laughing, she told me that top top meant dribbling. the baby's urinary flow was dribbling! I started to feel the frustration I'm sure foreign medical grads feel when they come to practice in the U.S. as we have a lot of slang terms as well!
THe patient with the Wilms Tumor from an earlier post-with the inoperable tumor-has been on our ward since the operation. There is absolutely nothing we can do for him, and even worse there is some confusion regarding whether palliative care for children even exists in the hospital. The patient wants to go home, we clearly cannot send him home with hopsice care on board..so we had to figure out what we could do to make the dying process a little bit more bearable--injectable opiods are not an option, the shear cost and maintenance are not within reason for this family. The only option really are oral opioids....but the availability is not great according to our attending. Watching the family carry their son out of the ward was so heartbreaking-he probably lost another 5 pounds while here, I could easily count his ribs and see the contours on them, his face was so incredibly sunken in, his limbs were frail and he could barely keep his eyes open. His parents would turn their heads to wipe their tears and plaster a smile on their face everytime they looked back at him. I cannot imagine the pain of losing your own child.
New Admissions:
1. 4 mos female, watery stool for 4 days, baby is lethargic, presents with signs of obstruction and hx of not passing urine or stool for the last two days after having had the diarrhea.
2. acute abdominal pain, possible appendicitis
3. suspected Hirschsprungs
4. suspected septic arthritis, with possible septicemia, p/w respiratory tract infection
THe patient with the Wilms Tumor from an earlier post-with the inoperable tumor-has been on our ward since the operation. There is absolutely nothing we can do for him, and even worse there is some confusion regarding whether palliative care for children even exists in the hospital. The patient wants to go home, we clearly cannot send him home with hopsice care on board..so we had to figure out what we could do to make the dying process a little bit more bearable--injectable opiods are not an option, the shear cost and maintenance are not within reason for this family. The only option really are oral opioids....but the availability is not great according to our attending. Watching the family carry their son out of the ward was so heartbreaking-he probably lost another 5 pounds while here, I could easily count his ribs and see the contours on them, his face was so incredibly sunken in, his limbs were frail and he could barely keep his eyes open. His parents would turn their heads to wipe their tears and plaster a smile on their face everytime they looked back at him. I cannot imagine the pain of losing your own child.
New Admissions:
1. 4 mos female, watery stool for 4 days, baby is lethargic, presents with signs of obstruction and hx of not passing urine or stool for the last two days after having had the diarrhea.
2. acute abdominal pain, possible appendicitis
3. suspected Hirschsprungs
4. suspected septic arthritis, with possible septicemia, p/w respiratory tract infection
Tuesday, February 9, 2010
an NGT as a catheter?? why not.
Day 9...mosquito bites 1,000,000, New Bangla words learned 10, number of patients lost...1. I was following a patient with suspected Hirschsprung's Disease, which is basically a disease of the larege intestine in which the nerve cells that allow for motility are missing, this is a congenital anomaly and can present with abdominal swelling, vomiting, constipation, basically signs and symptoms of obstruction. The patient passed this morning from an undetermined cause...the team believes it may have been aspiration pneumonia.
Yesterday a 7 y.o. boy presented in front of me with blood dripping from his groin, his entire genital area was wrapped in gauze which was drenched in blood. His father told me that they had him ritually circumcised by the Hazam of their village. From what I can gather this is the equivalent of the muslim priest (imam) who performs this ritual...although these men are not doctors they have some experience with performing this procedure and can even give local anesthetics if they choose to do so, but often do not place any stitches. In this case, the foreskin was literally sliced and diced leaving a completely botched circumcision. The child was then brought to us to have it fixed. I cannot place judgement on this process but I do think that if these guys are going to perform off the books surgery in their villages they should learn the proper technique! This kid was losing copious amounts of blood and had to travel about two hours from his village just to be seen in our ward!
In other news-the mother of one of my patients keeps pulling out the catheter when she's washing and dressing the baby..like many of the patients she's not very educated and has difficulty following instructions. She was asked to acquire a new catheter and when she returned she tracked me down and handed it to me. the bag said "feeding tube"...I scratched my head thinking..umm...wrong end of the body....I looked at the feeding tube again and thought..well i guess it kind of looks like a foley catheter just doesn't come with a bag for urine collection, but she had that already from the previous catheterization...one of the senior residents must've caught me looking completely confused and walked over--he said that the feeding tubes are much cheaper than the catheters and they basically work the same, they can be connected to the collecting bag with a 5 cc plastic syringe...and voila you have a urinary catheter...I placed the catheter without a problem and started to realize that in these circumstances it is extremely important to be creative and think outside the box in an attempt to reach treatment goals with such limited supplies.
Realized something kind of intresting today--most of the patients we see here at Dhaka Medical College Hospital present in the later stages of their respective disease processes. The reason I bring this up is because the concept of the "appendiceal lump" came up today. A patient presented to our ward with abdominal pain for approximately a week's time. The pain was described as very severe, on physical exam everybody kept asking if I could feel a "lump"--if so then the treatment would be conservative no questions asked. As far as I can remember from my surgery rotation...there was no mentioning of a "lump"..although i shamefully will admit that I often had "lecture narcolepsy" so maybe I missed this. In any case upon asking this "lump" was described as the body's response to so called "chronic appendicitis". The omentum (junk surrounding the intestines) basically formed a capsular ball around the appendix thereby creating a palpable lump on physical exam. The reason this is treated conservatively is that there is a high risk of intestinal perforation upon surgical removal of the appendix. However the patient should be monitored closely for abscess formation or signs of infection. Usually from my experience patients come running to the hospital right away when they have any kind of pain,real or imagined...but here cases such as testicular torsion (twisting of the testicles, Extremely painful) or necrotizing fascitis are seen when there is not much that can be done but damage control. In one case of testicular torsion the scrotum was opened and the most horrible smell erupted...the testicle was completely necrotic (rotten)!
On a completely non-medical note. I think coming to Bangladesh on my own was a huge step for me-exploring my own interests here, thinking of my own projects, creating my own connections. The upper level residents took us to the canteen (cafeteria) for some coffee and sweets. We refer to them as bhaiya/apa (older brother/sister). This creates a very family oriented feel, so much so that everyone is very protective, they create a great learning/working environment and I feel completely comfortable. The culture here is incredible. No one will eat in front of you without offering or insisting that you eat with them. Our attendings will have us meet in their office for some shingara and cha (spicy, salty potato pastry thing, and tea) while we discuss an interesting case or new admissions. But at the same time when it comes to business everyone is extremely serious, minor mistakes are considered major teaching points and everyone is accountable.
Yesterday a 7 y.o. boy presented in front of me with blood dripping from his groin, his entire genital area was wrapped in gauze which was drenched in blood. His father told me that they had him ritually circumcised by the Hazam of their village. From what I can gather this is the equivalent of the muslim priest (imam) who performs this ritual...although these men are not doctors they have some experience with performing this procedure and can even give local anesthetics if they choose to do so, but often do not place any stitches. In this case, the foreskin was literally sliced and diced leaving a completely botched circumcision. The child was then brought to us to have it fixed. I cannot place judgement on this process but I do think that if these guys are going to perform off the books surgery in their villages they should learn the proper technique! This kid was losing copious amounts of blood and had to travel about two hours from his village just to be seen in our ward!
In other news-the mother of one of my patients keeps pulling out the catheter when she's washing and dressing the baby..like many of the patients she's not very educated and has difficulty following instructions. She was asked to acquire a new catheter and when she returned she tracked me down and handed it to me. the bag said "feeding tube"...I scratched my head thinking..umm...wrong end of the body....I looked at the feeding tube again and thought..well i guess it kind of looks like a foley catheter just doesn't come with a bag for urine collection, but she had that already from the previous catheterization...one of the senior residents must've caught me looking completely confused and walked over--he said that the feeding tubes are much cheaper than the catheters and they basically work the same, they can be connected to the collecting bag with a 5 cc plastic syringe...and voila you have a urinary catheter...I placed the catheter without a problem and started to realize that in these circumstances it is extremely important to be creative and think outside the box in an attempt to reach treatment goals with such limited supplies.
Realized something kind of intresting today--most of the patients we see here at Dhaka Medical College Hospital present in the later stages of their respective disease processes. The reason I bring this up is because the concept of the "appendiceal lump" came up today. A patient presented to our ward with abdominal pain for approximately a week's time. The pain was described as very severe, on physical exam everybody kept asking if I could feel a "lump"--if so then the treatment would be conservative no questions asked. As far as I can remember from my surgery rotation...there was no mentioning of a "lump"..although i shamefully will admit that I often had "lecture narcolepsy" so maybe I missed this. In any case upon asking this "lump" was described as the body's response to so called "chronic appendicitis". The omentum (junk surrounding the intestines) basically formed a capsular ball around the appendix thereby creating a palpable lump on physical exam. The reason this is treated conservatively is that there is a high risk of intestinal perforation upon surgical removal of the appendix. However the patient should be monitored closely for abscess formation or signs of infection. Usually from my experience patients come running to the hospital right away when they have any kind of pain,real or imagined...but here cases such as testicular torsion (twisting of the testicles, Extremely painful) or necrotizing fascitis are seen when there is not much that can be done but damage control. In one case of testicular torsion the scrotum was opened and the most horrible smell erupted...the testicle was completely necrotic (rotten)!
On a completely non-medical note. I think coming to Bangladesh on my own was a huge step for me-exploring my own interests here, thinking of my own projects, creating my own connections. The upper level residents took us to the canteen (cafeteria) for some coffee and sweets. We refer to them as bhaiya/apa (older brother/sister). This creates a very family oriented feel, so much so that everyone is very protective, they create a great learning/working environment and I feel completely comfortable. The culture here is incredible. No one will eat in front of you without offering or insisting that you eat with them. Our attendings will have us meet in their office for some shingara and cha (spicy, salty potato pastry thing, and tea) while we discuss an interesting case or new admissions. But at the same time when it comes to business everyone is extremely serious, minor mistakes are considered major teaching points and everyone is accountable.
Saturday, February 6, 2010
Congrats Dad!
First and foremost--have to remember to congratulate my dad on becoming a full professor at Drexel!! This is a HUGE accomplishment and we are all very proud of him--if you pass him in the hallways at Hahnemann be sure to give him a high five or a congratulatory handshake!!
It is Saturday here in Bangladesh and I had to work this morning much to my chagrin at first--realizing that I would only have one day off a week seemed like a punishment but I'm beginning to realize that a month here is SO short, time is flying by and I'm soaking up so much clinical knowledge on a daily basis I almost want to come 7 days a week...but, I'm not crazy. I have to stop saying that my days are interesting, I should start to mention when they're not, because those will truly be an anomaly within this amazing experience.
Started the day off with 8am rounds, then was given a "short case" in which I had to present the salient features of a particular patient and have the audience glean the diagnosis. It's painfully obvious how much more adept the interns and residents are with respect to the physical exam and findings. Nonetheless, I presented my findings regarding my patient with posterior urethral valves-it went ok, I was grilled by the attending, able to answer a majority of his questions and then took my seat with the remainder of the interns. A smile crept onto my face when I realized that my sneakers were the only thing that still made me stand out-because I underwent the rapid fire questioning, and survived, just like everyone else I was now one of them.
Worked in the outdoor clinic (what we know as the outpatient clinic)...which is comprised of one single room, with a desk, a sink and an examing table. You wouldn't believe how efficient this clinic runs though! Patients are called in by the "secretary" two sets of Upper level residents (Clinical assistants) see patients in the room together, sharing the one exam table and the one desk. In a matter of 45 minutes there were about 30 patients seen in that room...a mix of hernias, anorectal malformations, an umbilical granuloma (more on this later) and a few cellulitis cases. In a quick minute the decision was made, admission or no admission. Regardless of the fact that some patients are sharing beds or laying in the halls on the floor--they are getting seen they are getting treated, they are being HELPED, there is no refuting that.
A quick note-I attended the intern induction here today. Just to clarify, Medical School here is five years, then you have one intership year and then are free to pursue any specialty you like. The induction today was really touching. Pieces of a few speeches stand out in my mind...one speaker mentioned that as a profession we try to bring light into peoples lives, but where does that light come from? It comes from the fire that burns within each of us for the work that we do which stems ultimately from our love for mankind. Furthermore someone mentioned that without taking on responsibility as new doctors, we cannot expect to learn anything. Another speaker mentioned that we are made into decent human beings by the people who raised us, in my case my parents, grandmother and the remainder of the ahmed "village"--the efforts they put in to making us who we are were not done solely for our benefit but so that we could benefit mankind, contribute to humanity and make the world a better place. I'm reminded of the responsibility we all have to contribute to our fellow man if we have the skills/power to do so--and furthermore that even the smallest contribution can make a world of difference and so there is no excuse not to do so.
Medical Inventory: (new since last post)
1. Suspected Hirschsprungs dz, rectal bx inconclusive, prep for definitive dx and possible loop colostomy
2. newborn w/ jaundice, bowel obstruction, abnormal limb movements and PDA murmur...
3. cellulitis of great toe, post traumatic
4. inguinal hernia (x2 cases)
5. Femoral hernia
6. bleeding per umbilicus (poss. umbilical granuloma)
7. intestinal TB leading to need for ileostomy, now pt returns for closure if ostomy
8. hydrocoele
9. blunt abdominal trauma from a fall
10. RBPR along with fleshy mass protruding upon defecation...possible polyps
It is Saturday here in Bangladesh and I had to work this morning much to my chagrin at first--realizing that I would only have one day off a week seemed like a punishment but I'm beginning to realize that a month here is SO short, time is flying by and I'm soaking up so much clinical knowledge on a daily basis I almost want to come 7 days a week...but, I'm not crazy. I have to stop saying that my days are interesting, I should start to mention when they're not, because those will truly be an anomaly within this amazing experience.
Started the day off with 8am rounds, then was given a "short case" in which I had to present the salient features of a particular patient and have the audience glean the diagnosis. It's painfully obvious how much more adept the interns and residents are with respect to the physical exam and findings. Nonetheless, I presented my findings regarding my patient with posterior urethral valves-it went ok, I was grilled by the attending, able to answer a majority of his questions and then took my seat with the remainder of the interns. A smile crept onto my face when I realized that my sneakers were the only thing that still made me stand out-because I underwent the rapid fire questioning, and survived, just like everyone else I was now one of them.
Worked in the outdoor clinic (what we know as the outpatient clinic)...which is comprised of one single room, with a desk, a sink and an examing table. You wouldn't believe how efficient this clinic runs though! Patients are called in by the "secretary" two sets of Upper level residents (Clinical assistants) see patients in the room together, sharing the one exam table and the one desk. In a matter of 45 minutes there were about 30 patients seen in that room...a mix of hernias, anorectal malformations, an umbilical granuloma (more on this later) and a few cellulitis cases. In a quick minute the decision was made, admission or no admission. Regardless of the fact that some patients are sharing beds or laying in the halls on the floor--they are getting seen they are getting treated, they are being HELPED, there is no refuting that.
A quick note-I attended the intern induction here today. Just to clarify, Medical School here is five years, then you have one intership year and then are free to pursue any specialty you like. The induction today was really touching. Pieces of a few speeches stand out in my mind...one speaker mentioned that as a profession we try to bring light into peoples lives, but where does that light come from? It comes from the fire that burns within each of us for the work that we do which stems ultimately from our love for mankind. Furthermore someone mentioned that without taking on responsibility as new doctors, we cannot expect to learn anything. Another speaker mentioned that we are made into decent human beings by the people who raised us, in my case my parents, grandmother and the remainder of the ahmed "village"--the efforts they put in to making us who we are were not done solely for our benefit but so that we could benefit mankind, contribute to humanity and make the world a better place. I'm reminded of the responsibility we all have to contribute to our fellow man if we have the skills/power to do so--and furthermore that even the smallest contribution can make a world of difference and so there is no excuse not to do so.
Medical Inventory: (new since last post)
1. Suspected Hirschsprungs dz, rectal bx inconclusive, prep for definitive dx and possible loop colostomy
2. newborn w/ jaundice, bowel obstruction, abnormal limb movements and PDA murmur...
3. cellulitis of great toe, post traumatic
4. inguinal hernia (x2 cases)
5. Femoral hernia
6. bleeding per umbilicus (poss. umbilical granuloma)
7. intestinal TB leading to need for ileostomy, now pt returns for closure if ostomy
8. hydrocoele
9. blunt abdominal trauma from a fall
10. RBPR along with fleshy mass protruding upon defecation...possible polyps
Thursday, February 4, 2010
"Do you have HIPAA?" "um. Like the giant jungle animal that resides in water?"
Woke up this morning to the sound of a mosquito buzzing by my ear, I "Mr. Miyagi'd" the crap out of it and started my day. Did not expect to have the day I had, that's for sure. Started with seeing our new admissions. 2 y.o., posterior urethral valves with severe reflux, signs of chronic cystitis and evidence of renal dysfunction. The urethrogram done was so obvious it practically smacked me in the face. This kid's ureters look like loops of bowel that's how dilated they are and they are lit up like a christmas tree from the reflux.
Another admission: 5 y.o. boy with signs of intestinal obstruction, I performed a Digital Rectal Exam....and out came a worm. No I did not stutter..yes a worm. Im still scratching my head and wondering how the heck I kept down my breakfast after seeing that. By the way that's not such an abnormal finding..since worms are pretty common here.
yet another admission: prune belly syndrome..5 day old baby, mom noticed that the belly was distended. On exam the babys stomach feels like a water balloon with large lumps on either side. Furthermore, I couldn't appreciate any testes. The syndrome is comprised of complete abdominal muscle defect (hence the pruny look of the abdomen bc there is no real structure), bilateral undescended testes (testes in bangla are "beechi" the english translation is seeds, which is quite appropriate i suppose), and hydroureteronephrosis, the two lumps felt on either side were massively enlarged kidneys. I can't upload pics on this site from the computer i'm using, i will try to get an album on facebook of some of this stuff as soon as I can.
The latter half of the day I spent doing follow up work on the remainder of our patients. One in particular had to be seen by the general peds team, the baby is 6 days old-came in because of an anorectal malformation, is blind in one eye, is found to have shortness of breath and cough over last two days. Well..I wrote out the referral/consultation request and then put it in the chart..I thought that was the end of that..turns out you have to physically walk the patient over to the department, have them seen, wait with them and then report back. Clearly..it is taking some time to figure out the system here.
Starting a new project today..compiling a list of most common supplies needed by patients. The hospital is government run, which means here that the building is supplied, the beds are supplied and a handful of some common things used on the floor. However, even normal saline, or nasogastric tubes are left to the patient to supply! This is quite the walking contradiction since most of the patients are dirt poor and that's why they came to this hospital to begin with. Many times the residents and attendings will pool together some cash to help out some of the needier of the needy..but that's inconsistent at best. I am donating money on behalf of my family and Drexel but on my return I'd like to start a actively running fund for common supplies required.
Another admission: 5 y.o. boy with signs of intestinal obstruction, I performed a Digital Rectal Exam....and out came a worm. No I did not stutter..yes a worm. Im still scratching my head and wondering how the heck I kept down my breakfast after seeing that. By the way that's not such an abnormal finding..since worms are pretty common here.
yet another admission: prune belly syndrome..5 day old baby, mom noticed that the belly was distended. On exam the babys stomach feels like a water balloon with large lumps on either side. Furthermore, I couldn't appreciate any testes. The syndrome is comprised of complete abdominal muscle defect (hence the pruny look of the abdomen bc there is no real structure), bilateral undescended testes (testes in bangla are "beechi" the english translation is seeds, which is quite appropriate i suppose), and hydroureteronephrosis, the two lumps felt on either side were massively enlarged kidneys. I can't upload pics on this site from the computer i'm using, i will try to get an album on facebook of some of this stuff as soon as I can.
The latter half of the day I spent doing follow up work on the remainder of our patients. One in particular had to be seen by the general peds team, the baby is 6 days old-came in because of an anorectal malformation, is blind in one eye, is found to have shortness of breath and cough over last two days. Well..I wrote out the referral/consultation request and then put it in the chart..I thought that was the end of that..turns out you have to physically walk the patient over to the department, have them seen, wait with them and then report back. Clearly..it is taking some time to figure out the system here.
Starting a new project today..compiling a list of most common supplies needed by patients. The hospital is government run, which means here that the building is supplied, the beds are supplied and a handful of some common things used on the floor. However, even normal saline, or nasogastric tubes are left to the patient to supply! This is quite the walking contradiction since most of the patients are dirt poor and that's why they came to this hospital to begin with. Many times the residents and attendings will pool together some cash to help out some of the needier of the needy..but that's inconsistent at best. I am donating money on behalf of my family and Drexel but on my return I'd like to start a actively running fund for common supplies required.
Wednesday, February 3, 2010
STERILE procedure, old school
Scrubbed in or "washed" for a few cases today. Let me paint a picture of this. There are no blue shoe covers when you enter the Operating Room area (or as they call it here, the operating theatre), so we are required to REMOVE our shoes, i was wearing SANDALS! So i'm hoofing it, kind of grossed out, but slowly getting over it. given a pair of rubber flip flops to wear with my scrubs..entered the OR. Was told to scrub, looked for a scrub brush, was directed towards a bar of soap used by many, and a bottle of hand soap. After washing up, I was met by the scrub nurse, they are all referred to as "sister", all the nurses are, it's kind of endearing. She took a long pair of tongs, reached into a bucket of sterile cloth gowns, handed me it and said, use it to dry your hands then put it on. I'm still in flip flops by the way. Proceeded with the days cases just like anywhere else. One exception, there was a lot of care taken to save every piece of suture thread so as not to waste anything. The tools used by the surgeon were his own set that he kept locked up in his office, as were some of the more expensive tools, i.e. cystoscope, laporoscope, etc. The day only got more interesting with the cases I saw....
Case 1: Wilms Tumor metastasized to Liver, Spleen, Gut, Bone....no lie.
Pt was imaged with CT scan and bone scan, known mets, patient's mother wanted the surgeon to open him up and try to remove as much as possible. The boy is ten years old. His abdomen was so full of tumor that it was misshapen. Upon midline incision his insides literally busted out, tumor coming out head first. I stuck my hand into his abdominal cavity, felt tumor on his liver, felt tumor on his spleen and surrounding his gut. He was so emaciated you could actually see the mets to his frontal bone in the skull. Any part of the tumor we touched bled to high holy hell. Pt's father wanted to see him, he was brought in, and stared at his son and his busted open abdomen while he was told that if we continued there was a high chance he would bleed out and die...he asked the surgeon to put his faith in god and decide for himself what he thought was right. It was decided to close and try chemo/radiation again (although pt failed first round).And so he closed up the abdomen, using the toughest of sutures. I got to close with the superficial sutures, which is a small contribution but it felt nice to be able to do something in the OR...the great thing is that I actually remembered how to throw some knots...lucky for me because I didn't look like a complete idiot.
Case 2: Cystoscopy, pt is 5 y.o., mom complains of stool like material passing with urine, suspected fistulous tract between Urinary Tract and Rectum. Suspicion confirmed by cystoscope.
Case 3: 10 y.o. boy with extensive polyposis coli in descending colon down to anus, biopsy confirms dysplastic changes, ileoanal pull through performed...did I mention the patient is ten? Yea, crazy.
Case 1: Wilms Tumor metastasized to Liver, Spleen, Gut, Bone....no lie.
Pt was imaged with CT scan and bone scan, known mets, patient's mother wanted the surgeon to open him up and try to remove as much as possible. The boy is ten years old. His abdomen was so full of tumor that it was misshapen. Upon midline incision his insides literally busted out, tumor coming out head first. I stuck my hand into his abdominal cavity, felt tumor on his liver, felt tumor on his spleen and surrounding his gut. He was so emaciated you could actually see the mets to his frontal bone in the skull. Any part of the tumor we touched bled to high holy hell. Pt's father wanted to see him, he was brought in, and stared at his son and his busted open abdomen while he was told that if we continued there was a high chance he would bleed out and die...he asked the surgeon to put his faith in god and decide for himself what he thought was right. It was decided to close and try chemo/radiation again (although pt failed first round).And so he closed up the abdomen, using the toughest of sutures. I got to close with the superficial sutures, which is a small contribution but it felt nice to be able to do something in the OR...the great thing is that I actually remembered how to throw some knots...lucky for me because I didn't look like a complete idiot.
Case 2: Cystoscopy, pt is 5 y.o., mom complains of stool like material passing with urine, suspected fistulous tract between Urinary Tract and Rectum. Suspicion confirmed by cystoscope.
Case 3: 10 y.o. boy with extensive polyposis coli in descending colon down to anus, biopsy confirms dysplastic changes, ileoanal pull through performed...did I mention the patient is ten? Yea, crazy.
Tuesday, February 2, 2010
Ready set DRAIN
Day 2 of work, mosquito bite number 2,005, symptoms of parasitic disease 0.
Have to say..of all the years of travelling to Bangladesh I've somehow avoided the "hole in the ground" toilet..UNTIL TODAY!!! Lets just say..it was a success and I think it was necessary for my initiation into working at Dhaka Medical College Hospital.
Got down to work today...if you get grossed out easily do not read on. Had a 3 year old patient who fell on his right side, developed a large bruise/hematoma which developed into a multiloculated (multi-pocket) abscess...which had to be drained. Well...local anesthetics in this case are not that great..and well, we didn't really have anything on hand to drug the kid...so about four people held him down while I slit a nice big hole into this sucker and squeezed all the blood and pus out!! Then, I stuck my finger in this nice big pocket and ripped apart all the septae which created the multiple pockets..it's a very brutal process but in the end the patient feels MUCH better. Then I stuck a large piece of guaze in this hole in this kid's hip and handed him some antibiotics which cover Staph and Strep. Basically, Think of the largest zit you've ever had, multiply it by about 1000 and then imagine you popping that. We were in a substerile room, i was wearing a rubber gown which I retrieved from a room with a giant dead cockroach in it, which I mistook for a cat because it was so big. Some people may understand this..others may not, but this was by far the highlight of my day...as a medical student in the U.S. we don't really get as much hands on experience as many of us would like. I have a feeling that will not be happening here.
Today's Medical Inventory:
1. unilateral congenital blindness, baby born without palpebral fissure
2. Neonatal jaundice (3 cases), 1/3 was choledochal cyst
3. large hemangioma on scalp of new born
4. hypospadias in 5 y.o. patient, NO circumcision performed so as to save skin for reconstructive surgery
5. SBO vs. APPY (TBD tomorrow, most likely appy based on si/sx)
6. Multiloculated abscess
7. multiple polyposis coli at level of anus in 7 y.o. presenting with RBPR
8. 8 mos pregnant woman, fetus shown to have omphaloceole per u/s, plan is to wait for delivery, determine size of omphaloceole, work in conjunction with pediatrics to determine whether child is candidate for surgery depending on size of defect.
Have to say..of all the years of travelling to Bangladesh I've somehow avoided the "hole in the ground" toilet..UNTIL TODAY!!! Lets just say..it was a success and I think it was necessary for my initiation into working at Dhaka Medical College Hospital.
Got down to work today...if you get grossed out easily do not read on. Had a 3 year old patient who fell on his right side, developed a large bruise/hematoma which developed into a multiloculated (multi-pocket) abscess...which had to be drained. Well...local anesthetics in this case are not that great..and well, we didn't really have anything on hand to drug the kid...so about four people held him down while I slit a nice big hole into this sucker and squeezed all the blood and pus out!! Then, I stuck my finger in this nice big pocket and ripped apart all the septae which created the multiple pockets..it's a very brutal process but in the end the patient feels MUCH better. Then I stuck a large piece of guaze in this hole in this kid's hip and handed him some antibiotics which cover Staph and Strep. Basically, Think of the largest zit you've ever had, multiply it by about 1000 and then imagine you popping that. We were in a substerile room, i was wearing a rubber gown which I retrieved from a room with a giant dead cockroach in it, which I mistook for a cat because it was so big. Some people may understand this..others may not, but this was by far the highlight of my day...as a medical student in the U.S. we don't really get as much hands on experience as many of us would like. I have a feeling that will not be happening here.
Today's Medical Inventory:
1. unilateral congenital blindness, baby born without palpebral fissure
2. Neonatal jaundice (3 cases), 1/3 was choledochal cyst
3. large hemangioma on scalp of new born
4. hypospadias in 5 y.o. patient, NO circumcision performed so as to save skin for reconstructive surgery
5. SBO vs. APPY (TBD tomorrow, most likely appy based on si/sx)
6. Multiloculated abscess
7. multiple polyposis coli at level of anus in 7 y.o. presenting with RBPR
8. 8 mos pregnant woman, fetus shown to have omphaloceole per u/s, plan is to wait for delivery, determine size of omphaloceole, work in conjunction with pediatrics to determine whether child is candidate for surgery depending on size of defect.
Monday, February 1, 2010
Watch out for the people in the halls
Day 1 at Dhaka Medical. Eye opening to say the least!
Started out by meeting the principal of the medical college and was escorted to a meeting with the "curriculum committee" or equivalent of rather. The topic of this morning's discussion was Problem Based Learning, a very familiar topic for me since I enrolled in that PBL curriculum at Drexel my first year. The purpose of the meeting was to convince the other staff members that this type of learning/teaching is quite necessary to produce well rounded clinicians who can use clinical reasoning on the first day of their clerkship rotations. The committee was more than open to the idea of problem based learning but had no idea how to initiate such a curriculum. All of a sudden the microphone is thrust in front of my face and in front of a crowd of 25 attendings I proceeded to explain the success stories of Drexel's PBL program. In fact it seemed as though it really made a difference in the presentation to know that there was someone sitting in front of them who is a product of such a curriculum. I think this will start an open communication with DMC to adopt our methods of teaching from Drexel as a part of their curriculum. This is really exciting stuff for Drexel as they can call themselves a pioneer and a leader even more so now as they will be the shining example for this medical college to follow.
Off to the wards for rounds! It was a very hectic morning for everyone, and more or less gut wrenching for me. Walking through the corridor from the medical college to the hospital I was greeted by absolutely nothing familiar except for the sight of an IV bag hanging from a metal pole. I was told today that DMH sees approximatly 3000 patients...wait for it..A DAY. This hospital is the epitome of a Public Health oriented hospital. Most of these patients cannot pay for the services they are acquiring, the surgeries the supplies, etc. I'm curious as to how long term follow up is in a population like this? Does the U.S. and Bangladesh suffer the same problems across the grid with respect to underserved populations?? With the knowledge that this hospital is government run..it was no surprise that the upkeep of the place was, well, nonexistent. THAT is definitely somethng that Government run U.S. hospitals have in common. For example, today we examined a woman with a bartholin cyst in a room where the window grate was half missing..and looked like it had been missing since the liberation war from a bomb blast, more reastically it may have been rust over time. Needless to say..I guess that hole allowed more light in..
As I transitioned from pediatric rounds to adult surgery rounds, from one end of the hospital to the next I passed dozens of patients waiting in the halls, with only an IV bag to hold them over. Each Ward is wide open with beds lining the walls and the center (see pics attached) Tomorrow I'd like to find out what the admissions process is like. Some of the hall-waiters looked like they were dying, others were holding their sick children, and still others were sitting around smiling and laughing even in their state. I walked the halls with my salwar kamiz (traditional clothing) my swiss back pack and sketchers, sticking out like a sore thumb...getting stared at by the patients and medical students/staff alike. It was quite the daunting experience.
Couple of things our systems have in common. Rounds are pretty much the same and treatment options are fairly similar. It is the actual inventory of cases seen that is DRASTICALLY different (as I will recount below) Each specialty service sticks to their knowledge base and shares the patient, for instance. A woman 28 weeks pregnant was referred to peds surgery bc her child was found to have gastroschisis, a defect in the abdominal wall allowing for the gut contents to float around in amniotic fluid. the prognosis for the child is not great however currently there was not a lot peds surgery could do except send the patient back to OB/GYN and ask that the child be seen on delivery for surgical options. Orders are written out in much the same way and carried out by the intern and resident. Usually by the middle of the day the attendings finish rounding and head out to see their private patients-probably the source of their real income?
Below i'm going to list all the cases I saw today, if you're interested take a peek, it's mostly for my bookkeeping, feel free to ask questions and make suggestions. I'm curious if anyone in the medical field reading this has any specific questions about the health care system, the hospital etc., the more input I get the more questions I will know to ask in order to gather more information! If you're not going to read below, I will fill you in on the most interesting thing I saw today..Rice mills are a huge deal over here seeing as how the economy is agriculture based. One of the female patients was collecting rice from underneath the rice mill, her hair got caught in the rotating mill and her entire scalp was ripped off! Her head was wrapped in bandages, couldn't see much, but she was in a lot of pain and will most likely never grow her hair back again. I can't imagine how traumatizing that experience must've been, but certainly not something we see in the U.S. as often.
Today's Medical Inventory:
On Peds Rounds...
1. 2 y.o. w/ congenital hydrocephalus p/w phimosis
2. 7 y.o. w/ thalassemia
3. imperforate anus (x3 cases)
4. vestibular anus
5. 5 y.o. with cholelithiasis and negative w/u for hemolytic d/o (apparently pretty common occurrence in Bangladesh)
6. appendicitis, dx clinically, tx conservatively, discharged home as per "hanif" protocol, if problem arises will have emergent surgery to remove appendix
7. Meconium Ileus found in new born , ileostomy performed, temporary will be reversed in 6 months, pt now passing meconium! this baby was the success story of the ward today
8. Hirschprung's dz
9. SBO
10. hypsopadias
11. b/l hydronephrosis secondary to posterior urethral valve
Adult surg rounds...
1. Gastric Ca x 3 cases
2. Obstructive jaundice x3
a. pancreatic Ca
b. gallstones
c. stricture secondary to iatrogenic cause
3. anorectal cancer x2
4. bartholin cyst
5. hydrocoele (dx by flip test, pts scrotum was flipped upwards towards abdomen, if it touched the abdomen it was differentiated as a hydroceole vs. inguinal hernia...transillumination was negative b/c pt was older and has had hydroceole for long enough time that the scrotal skin has thickened)
6. Machine injury from rice mill, i've never seen a rice mill..so hard to guage the situation, woman was gathering rice, hair got caught in the mill, entire scalp ripped off, she will never grow her hair back.
7. ventral and inguinal hernia, repaired in similar way as in U.S., mesh is used
8. pt with left lower extremity amputation secondary to peripheral vascular disease, usually these patients are found at the gangrenous state whereas in the U.S. grafts are performed much more regularly. IF these patients are caught in early stages, tx is similar, mostly medical treatment.
Started out by meeting the principal of the medical college and was escorted to a meeting with the "curriculum committee" or equivalent of rather. The topic of this morning's discussion was Problem Based Learning, a very familiar topic for me since I enrolled in that PBL curriculum at Drexel my first year. The purpose of the meeting was to convince the other staff members that this type of learning/teaching is quite necessary to produce well rounded clinicians who can use clinical reasoning on the first day of their clerkship rotations. The committee was more than open to the idea of problem based learning but had no idea how to initiate such a curriculum. All of a sudden the microphone is thrust in front of my face and in front of a crowd of 25 attendings I proceeded to explain the success stories of Drexel's PBL program. In fact it seemed as though it really made a difference in the presentation to know that there was someone sitting in front of them who is a product of such a curriculum. I think this will start an open communication with DMC to adopt our methods of teaching from Drexel as a part of their curriculum. This is really exciting stuff for Drexel as they can call themselves a pioneer and a leader even more so now as they will be the shining example for this medical college to follow.
Off to the wards for rounds! It was a very hectic morning for everyone, and more or less gut wrenching for me. Walking through the corridor from the medical college to the hospital I was greeted by absolutely nothing familiar except for the sight of an IV bag hanging from a metal pole. I was told today that DMH sees approximatly 3000 patients...wait for it..A DAY. This hospital is the epitome of a Public Health oriented hospital. Most of these patients cannot pay for the services they are acquiring, the surgeries the supplies, etc. I'm curious as to how long term follow up is in a population like this? Does the U.S. and Bangladesh suffer the same problems across the grid with respect to underserved populations?? With the knowledge that this hospital is government run..it was no surprise that the upkeep of the place was, well, nonexistent. THAT is definitely somethng that Government run U.S. hospitals have in common. For example, today we examined a woman with a bartholin cyst in a room where the window grate was half missing..and looked like it had been missing since the liberation war from a bomb blast, more reastically it may have been rust over time. Needless to say..I guess that hole allowed more light in..
As I transitioned from pediatric rounds to adult surgery rounds, from one end of the hospital to the next I passed dozens of patients waiting in the halls, with only an IV bag to hold them over. Each Ward is wide open with beds lining the walls and the center (see pics attached) Tomorrow I'd like to find out what the admissions process is like. Some of the hall-waiters looked like they were dying, others were holding their sick children, and still others were sitting around smiling and laughing even in their state. I walked the halls with my salwar kamiz (traditional clothing) my swiss back pack and sketchers, sticking out like a sore thumb...getting stared at by the patients and medical students/staff alike. It was quite the daunting experience.
Couple of things our systems have in common. Rounds are pretty much the same and treatment options are fairly similar. It is the actual inventory of cases seen that is DRASTICALLY different (as I will recount below) Each specialty service sticks to their knowledge base and shares the patient, for instance. A woman 28 weeks pregnant was referred to peds surgery bc her child was found to have gastroschisis, a defect in the abdominal wall allowing for the gut contents to float around in amniotic fluid. the prognosis for the child is not great however currently there was not a lot peds surgery could do except send the patient back to OB/GYN and ask that the child be seen on delivery for surgical options. Orders are written out in much the same way and carried out by the intern and resident. Usually by the middle of the day the attendings finish rounding and head out to see their private patients-probably the source of their real income?
Below i'm going to list all the cases I saw today, if you're interested take a peek, it's mostly for my bookkeeping, feel free to ask questions and make suggestions. I'm curious if anyone in the medical field reading this has any specific questions about the health care system, the hospital etc., the more input I get the more questions I will know to ask in order to gather more information! If you're not going to read below, I will fill you in on the most interesting thing I saw today..Rice mills are a huge deal over here seeing as how the economy is agriculture based. One of the female patients was collecting rice from underneath the rice mill, her hair got caught in the rotating mill and her entire scalp was ripped off! Her head was wrapped in bandages, couldn't see much, but she was in a lot of pain and will most likely never grow her hair back again. I can't imagine how traumatizing that experience must've been, but certainly not something we see in the U.S. as often.
Today's Medical Inventory:
On Peds Rounds...
1. 2 y.o. w/ congenital hydrocephalus p/w phimosis
2. 7 y.o. w/ thalassemia
3. imperforate anus (x3 cases)
4. vestibular anus
5. 5 y.o. with cholelithiasis and negative w/u for hemolytic d/o (apparently pretty common occurrence in Bangladesh)
6. appendicitis, dx clinically, tx conservatively, discharged home as per "hanif" protocol, if problem arises will have emergent surgery to remove appendix
7. Meconium Ileus found in new born , ileostomy performed, temporary will be reversed in 6 months, pt now passing meconium! this baby was the success story of the ward today
8. Hirschprung's dz
9. SBO
10. hypsopadias
11. b/l hydronephrosis secondary to posterior urethral valve
Adult surg rounds...
1. Gastric Ca x 3 cases
2. Obstructive jaundice x3
a. pancreatic Ca
b. gallstones
c. stricture secondary to iatrogenic cause
3. anorectal cancer x2
4. bartholin cyst
5. hydrocoele (dx by flip test, pts scrotum was flipped upwards towards abdomen, if it touched the abdomen it was differentiated as a hydroceole vs. inguinal hernia...transillumination was negative b/c pt was older and has had hydroceole for long enough time that the scrotal skin has thickened)
6. Machine injury from rice mill, i've never seen a rice mill..so hard to guage the situation, woman was gathering rice, hair got caught in the mill, entire scalp ripped off, she will never grow her hair back.
7. ventral and inguinal hernia, repaired in similar way as in U.S., mesh is used
8. pt with left lower extremity amputation secondary to peripheral vascular disease, usually these patients are found at the gangrenous state whereas in the U.S. grafts are performed much more regularly. IF these patients are caught in early stages, tx is similar, mostly medical treatment.
Sunday, January 31, 2010
Ive reached the motherland
"Welcome to Dhaka, Bangladesh" Says the captain and I'm overjoyed..and yet unable to see the ground from my window seat..and wondering how the hell this man is going to land the plane. "Quasha!" says the guy next to me..meaning FOG!...hence the poor visability. But without a problem the pilot landed the plane safely. It's been two plus years since last I was here and a lot has changed. The airport has been renovated to my surprise! But it took two hours to get through immigration, for two reasons. 1. about 20 people cut in front of me in the most strategic and shady way possible, it's quite a skill and I plan on picking it up. 2. no rennovation can improve the lack of organizational skills at the airport and as soon as the immigration officer realized I am originally from Bangladesh he decided to strike up a conversation (where's your family from, is this your first time, are you fluent in bangla, etc.)..this is probably the third reason immigration takes two hours to get through! there is an upside here, I met two wonderful people, one from Canada who is coming to Bangladesh with Doctors without Borders and the other from D.C. working for the "Save the Children" organization. We all briefly exchanged our purposes for visiting/working here and then exchanged cards--two great connections for me to have in some future endeavors here in Bangladesh!
Couple changes I've noticed here already...
Traffic has gotten WAY WAY worse in two years. A trip which should normally take 15 min took 45 min. The dust/pollution is a lot worse despite efforts to reduce carbon emissions (this is a problem the country is actively trying to alleviate). Thirdly..the mosquitos actually wasted no time to start chomping on me, my first bug bite occurred as I walked through the exit ramp from the plane!! Lets hope I don't join the ranks of my father and aunt who got Dengue while they were here ;) Jk, i'll be fine.
Jet lag has been vanquished. Work starts early tomorrow as I partake in a seminar with the medical students at Dhaka Medical College to discuss integrated learning/teaching (a testament to the problem base learning program at Drexel which we are trying to get started here). Hopefully the first day isn't too traumatizing...real accounts and pics from the wards starting tomorrow!
OH also if anyone was curious (JUSTIN especially since we have the worst luck in recorded history) but I of course was seated next to screaming children the ENTIRE way...and then next to two Bangladeshi guys who spotted my stethoscope as I pulled out my headphones from my bookbag and started to tell me about his persistent cough and showed me his prescription for his workup...and then asked if I could fill out his disembarkment card b/c he didn't really understand everything on it...Anyone that knows my handwriting is probably in shock that anyone would allow me to fill out any paperwork for them...
(Note to self: Please make sure to get in touch with the Save the Children lady, her efforts with Adolescents and family planning andthe anemia investigation will be very helpful for DCI and FIDVB)
Couple changes I've noticed here already...
Traffic has gotten WAY WAY worse in two years. A trip which should normally take 15 min took 45 min. The dust/pollution is a lot worse despite efforts to reduce carbon emissions (this is a problem the country is actively trying to alleviate). Thirdly..the mosquitos actually wasted no time to start chomping on me, my first bug bite occurred as I walked through the exit ramp from the plane!! Lets hope I don't join the ranks of my father and aunt who got Dengue while they were here ;) Jk, i'll be fine.
Jet lag has been vanquished. Work starts early tomorrow as I partake in a seminar with the medical students at Dhaka Medical College to discuss integrated learning/teaching (a testament to the problem base learning program at Drexel which we are trying to get started here). Hopefully the first day isn't too traumatizing...real accounts and pics from the wards starting tomorrow!
OH also if anyone was curious (JUSTIN especially since we have the worst luck in recorded history) but I of course was seated next to screaming children the ENTIRE way...and then next to two Bangladeshi guys who spotted my stethoscope as I pulled out my headphones from my bookbag and started to tell me about his persistent cough and showed me his prescription for his workup...and then asked if I could fill out his disembarkment card b/c he didn't really understand everything on it...Anyone that knows my handwriting is probably in shock that anyone would allow me to fill out any paperwork for them...
(Note to self: Please make sure to get in touch with the Save the Children lady, her efforts with Adolescents and family planning andthe anemia investigation will be very helpful for DCI and FIDVB)
Friday, January 29, 2010
the final US post!
Sitting at JFK...surrounded by the smell of american-borne bangladeshi cooking mixed with the hopes of delicious REAL bangladeshi food. its amazing that when one person hears another speaking bengali they automatically want to adopt you! This is great since I'm travelling almost 24plus hrs alone, which can get quiet. However I will say, I've already prayed that the already-squealing children waiting to board are not boarding my flight!!! With my luck ill be in the new-born baby section of the jumbojet.
I'm excited to see Dhaka, and family and get down to business at dhaka medical college. The most daunting obstacle that lies ahead...JETLAG!
I'm excited to see Dhaka, and family and get down to business at dhaka medical college. The most daunting obstacle that lies ahead...JETLAG!
Wednesday, January 27, 2010
T-2 days!
Leaving for Bangladesh in TWO DAYS!
Weather today in Dhaka (the capital city) is 80 degrees with a low of 55 at night! I can get used to that for a month as the east coast transitions from winter to spring!!
News of the day in Bangladesh: five of the ten men who killed Sheikh Mujibur Rahman (the "father of the nation") were hanged today. Their bodies were escorted by Police back to their respective villages. The end of this trial comes 34 years after the killing and still remains a very controversial topic as Sheikh Mujibur Rahman and his ideals were controversial themselves. However it does not excuse the brutal killing of this leader and his family. I believe the nation finds itself a bit torn as the men who murdered SMR were freedom fighters themselves and bled for the nation during the liberation war.
Weather today in Dhaka (the capital city) is 80 degrees with a low of 55 at night! I can get used to that for a month as the east coast transitions from winter to spring!!
News of the day in Bangladesh: five of the ten men who killed Sheikh Mujibur Rahman (the "father of the nation") were hanged today. Their bodies were escorted by Police back to their respective villages. The end of this trial comes 34 years after the killing and still remains a very controversial topic as Sheikh Mujibur Rahman and his ideals were controversial themselves. However it does not excuse the brutal killing of this leader and his family. I believe the nation finds itself a bit torn as the men who murdered SMR were freedom fighters themselves and bled for the nation during the liberation war.
Monday, January 25, 2010
The first blog.
Monday Jan 25th...blog day 1.
Zack matched with Temple by the way!! So everyone congratulate him!
Four days until I leave for Bangladesh!! So this is how this is going to work--I'm going to try to access this blog every day more so for my sake so I can keep track of my own activities but if anyone is interested and wantsto keep up with what I'm up to over the next month please feel free to read along :)
The goal of this trip is to establish my own goals in Bangladesh. I am embarking on an awesome rotation at Dhaka Medical College..of course after I embark on the almost two day long journey there! My Dad and I came up with the idea for this rotation mostly because I've been wanting to rotate there on official terms for years now! With his help and the help of a lot of people at Drexel we've established an International Rotation at Dhaka medical college which is officially a Drexel rotation and students can get course credit for it. I am more or less a test case but this is exciting nonetheless.
There are a few kinks to work out, which I"m sure i'll take care of when I get to Bangladesh. The housing situation isn't completely worked out so I'll be staying at a family-owned apartment. I have to admit that I am a bit nervous on multiple levels. I am travelling to Bangladesh for the first time without my parents which is nerve racking because they usually take care of everything once we get to Dhaka. Also..my dad kind of warned me that I'd see a lot of greusome stuff, I'd learn a lot but I might get a little freaked out. Don't get me wrong, I knew all of that in the back of my mind and i'm excited to really make a difference where it matters..but I'm nervous about how I might react. The state of the health care system may be in shambles here...but I suppose things could be worse as I'm about to see.
I'd love to keep in touch with everyone so please send me an email so I have yours. (Mine is Nha0300@gmail.com). In the mean time..let the countdown begin!
Zack matched with Temple by the way!! So everyone congratulate him!
Four days until I leave for Bangladesh!! So this is how this is going to work--I'm going to try to access this blog every day more so for my sake so I can keep track of my own activities but if anyone is interested and wantsto keep up with what I'm up to over the next month please feel free to read along :)
The goal of this trip is to establish my own goals in Bangladesh. I am embarking on an awesome rotation at Dhaka Medical College..of course after I embark on the almost two day long journey there! My Dad and I came up with the idea for this rotation mostly because I've been wanting to rotate there on official terms for years now! With his help and the help of a lot of people at Drexel we've established an International Rotation at Dhaka medical college which is officially a Drexel rotation and students can get course credit for it. I am more or less a test case but this is exciting nonetheless.
There are a few kinks to work out, which I"m sure i'll take care of when I get to Bangladesh. The housing situation isn't completely worked out so I'll be staying at a family-owned apartment. I have to admit that I am a bit nervous on multiple levels. I am travelling to Bangladesh for the first time without my parents which is nerve racking because they usually take care of everything once we get to Dhaka. Also..my dad kind of warned me that I'd see a lot of greusome stuff, I'd learn a lot but I might get a little freaked out. Don't get me wrong, I knew all of that in the back of my mind and i'm excited to really make a difference where it matters..but I'm nervous about how I might react. The state of the health care system may be in shambles here...but I suppose things could be worse as I'm about to see.
I'd love to keep in touch with everyone so please send me an email so I have yours. (Mine is Nha0300@gmail.com). In the mean time..let the countdown begin!
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