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?)