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.