Third Year EM Resident Connor Schweitzer on his time in Blantyre…

It was amazing how often we heard those words during our trip. Stunning landscapes?
Welcome to Malawi. Luggage get lost? Welcome to Malawi. Medical license approval delayed?
Welcome to Malawi. Those words would play on repeat for 4 weeks, a refrain for everything I
experienced during my first global health trip to Africa.

As happens on big international trips, we didn’t have the smoothest start to our journey. A long delay in Ethiopia due to weather, bags that didn’t make it all the way to Blantyre, and far too little sleep left us thrilled to finally be on the ground. Having never been to Sub-Saharan Africa before, I wasn’t sure exactly what to expect. Driving from the airport to our home for the next month, I was struck by how green everything was. Hilltops covered with lush forest blanket the landscape during the rainy season. Farther on, we were treated to the bustling city of Blantyre and learned about the city, local mountaintops, and culture from the man driving, Zack Brady.

Zack and Carly Brady have lived and worked in Blantyre for the last 5 years after Carly completed her EM residency and Global Health fellowship in Columbia, SC. She took a job in the emergency department (AETC) at Queen Elizabeth Hospital (Queen’s) in Blantyre. Carly helped start the country’s first EM residency program. As people go, they don’t get much better than the Brady’s and their kids. They’ve built an incredible community in Blantyre and graciously helped us with every aspect of our rotation.

Without too much delay, we toured the Queen’s AETC. I was equal parts excited and apprehensive. However, upon entering the AETC for the first time, I recognized the familiar rhythm of the emergency department and felt more at home.

About a week and a few days later, I was working my first non-buddy shift in their high acuity zone (Resuscitation). At 07:30 AM, I took sign out on 5 acutely ill patients and proceeded to put my head down to take care of many new and existing patients. Thank goodness the nurses were experienced and helped me interpret for patients, order labs, dose medications (I was surprised at the amount of my dosing knowledge that is from an EMR), and overall keep everyone stable and alive. We succeeded as a team, and it was a great shift. After what felt like a little over a day’s worth of work and with 9 active patients under my care, I looked at the clock and noted the time.

It was 11:00 AM. Welcome to Malawi.

I had come to Malawi to be challenged, to learn, to improve my skills, to work hard, to broaden my outlook on medicine, and to hopefully help some folks along the way. After a few chuckles and some introspection, it became apparent I was getting exactly what I asked for.

The next couple of weeks went by in a flash. Each shift brought new opportunities to learn and grow as I treated diseases we rarely see in the US such as malaria, TB, bacterial meningitis, organophosphate poisonings, and more. Equally, I spent time learning from the nurses, interns, registrars (residents), and consultants (attendings), about how to practice medicine I thought I knew well in a different way.

Each shift brought new challenges and more than a few obstacles. By the last week, it felt like I was functioning as a real part of the Queen’s AETC team. We had built rapport with much of the staff. I had several significant emergencies while the sole doctor in Resuscitation that ran smoothly thanks to the amazing staff. Then suddenly, we were at the end. We celebrated with the people we had met from the AETC, had a wonderful last day of fun with the Brady’s, and our month in Malawi was over.

Global Health work can be complicated. You want to fill a need for people without infringing upon their established structures and cultures. Hopefully, you use your time and skills productively without imposing upon them. Ultimately, you’d like to collaborate, build community, and leave something that lasts and makes their lives genuinely better.

My time in Malawi felt exactly like a global health experience that produces the kind of lasting, profound change that these types of experiences should strive for. And it had nothing to do with me or the one month I spent there. Instead, it’s a product of the hard work from people like the EM Consultants in the Queen’s AETC, the global health faculty at Prisma, the EM registrars and staff at Queen’s, and many others whose partnerships, hard work, and tireless advocacy make the world and their communities a better place.

I can’t imagine a better experience to make me want to continue Global Health work in the future. Admittedly, I had begun to experience some burn out after nearly 7 years of medical school and residency training. Turns out, what I needed to lift my spirits was a Welcome to Malawi.

After 2 years of being thwarted by COVID, our residents, fellows and faculty were able to return to Masindi, Uganda to provide patient care and a long-delayed ultrasound training. PGY3 Will Fraser shares his experiences in Masindi…

Arriving in Masindi brought us into a world in and of itself. From the vibrant colors of the clothing to the impressive hand manufactured furniture that lined parts of the main road throughout the city, it was clear that we were surrounded with a hardworking and passionate culture. Our first introduction to the medical system was at One World Health’s self-sustaining hospital, Masindi Kitara Medical Center (MKMC). A testament to the hard work of the area’s physicians and staff, the hospital functions as an affordable tertiary care center with an operating theater, obstetrics and medicine ward. The clinical staff ranged from physicians to clinical coordinators and nursing and with every person I interacted with, it was clear that there was a uniform pride and desire to learn in order to improve the lives of their community.

After touring the main hospital, we were able to return to the hotel and inventory our supplies for the next five days of work in the community. As my first medical trip in Africa, I was excited but still not quite sure of how the clinics would run or how we would be received in the communities we would travel to. The next morning assuaged any feelings of apprehension when we arrived at a church approximately an hour outside Masindi where we were greeted by a line of two hundred people waiting to discuss their symptoms, many who had never met with a physician or nurse before. Immediately upon arriving, we got to work. With the help of the locals, we were able to arrange the inside of the church to accommodate a triage section, a physician section, a pharmacy station, a reading glasses zone, and even an examination table where we could utilize point of care ultrasound (POC) for bedside echocardiograms, obstetric screenings, and various other point of care diagnostics. The day flew by. We treated over 250 people, including our translators who graciously helped us throughout the day, and learned a significant amount about Uganda and its rich culture.

The next day, we travelled to a village with a more remote commute. I had the opportunity to ride in the van with our local outreach team and they showered me with information of the surrounding villages, farmlands, major exports and even the major slang. I learned some surprising terminology– like the fact that “malaria” and “syphilis” meant fever and rash, respectively. I then spent an inordinate amount of time attempting to learn some of the different animal names in Swahili and the 90-minute ride to the next village passed in a flash. Again, we were greeted by over 200 people. The day was split with a lunch time break where one of the translators graciously swapped lunches with me and I was able to enjoy some matoke (steamed bananas), “irish” (potatoes) and chicken. The day once again passed quickly, and we were able to see and speak with everyone who came and wrap the day up with a nice dinner at the hotel in Masindi with the whole group.

The clinics continued through Friday. Through the week, we examined over 1000 patients, educated on nutrition and medicine, and were educated on local traditions, languages, and lifestyle. We had multiple cases where we utilized the tertiary care centers in both Masindi and Kampala, and we were able to arrange transport for patients who would have never otherwise had the opportunity to be treated with a higher level of care.

Transitioning from work to relaxation, we then packed up some essentials and took the vans to Murchison Falls National Park for a safari. Expecting to possibly see a giraffe and have dinner beside the Nile, I was blown away when we were greeted by an African Elephant, within an arm’s reach of a lion, surrounded by Giraffes, watched by hippos and trailed by pumba (the Swahili translation for warthog – Disney was teaching while entertaining). The safari was so much more than I had expected and would have been an incredible trip in and of itself.

Arriving back in Masindi, we prepared ourselves for 3 days of ultrasound teaching. With the goal of establishing a readily available POC ultrasound program with the ability to upload and review images in real time, the opportunities are vast in an area without an accessible CT scanner and limited radiographs. The staff learned quickly and the physician on staff was able to convey how useful the technology could be, especially for fetal heart rates, sometimes difficult to detect manually. Ideally, we’ll continue this project and see if it makes a clinical impact in the upcoming months.

As we said goodbye to our fellow Richlanders, I stayed back with a coresident and conquered one more Ugandan goal… rafting the Nile. A daunting experience after seeing the animals that frequent the Nile during our safari, we booked the excursion and quickly found ourselves rafting through the Nile rapids. We did flip the raft, but no harm done, and we were able to see the beautiful landscape of some of the Ugandan villages where life is nourished from the river.

The trip to Uganda was an incredible experience. Given the opportunity to see the success that an NGO can have in creating a functional and sustainable healthcare system and meet some of the incredible people living and working in Uganda was an unparalleled opportunity, as well as some of the most fun I have ever had.

After the busy holiday season settled down in my final year of emergency medicine residency there was discussion about a new virus emerging from Wuhan, China.  Feeling so far away from the United States it did not seem like a big deal, and I didn’t think about how much this would impact my near future.   I remember jokingly practicing donning and doffing PPE with our nursing educator while on shift in February 2020.  I never imagined having to wear a mask in public for the next 2 years let alone an N95 to work every day. But my residency all came to a crashing halt when I first faced this virus.  Outside of a tiny negative pressure room in the high acuity area of the emergency department I donned a gown, n95 mask, gloves, and face shield.  I entered the room and remember being struck with fear.  Is my patient going to die?   How contagious was this?  Am I going to bring this virus home with me?  Am I going to get sick?  It’s daunting facing the unknown, but that is what makes medicine and especially global emergency medicine so unique.  Initially the ED slowed to a snail’s pace as the community stayed home. I called it “coronacation” as we closed sections of the ED at night. But as COVID-19 started to spread and we got busier than I had ever expected. Our residency graduation was cancelled and I entered fellowship, without the promise of doing the most vital opportunity of it, traveling. 

Over the first 6 months of fellowship, we continued to make travel plans for them all to be cancelled when traveling internationally was near impossible.  December 18^th 2020 was a life changing moment; I got my first COVID-19 vaccine.  It felt like I could see a light at the end of the tunnel.  In the Spring of 2021, and 4 COVID tests later, I was able to travel to Uganda.  It was a short trip, but it felt great to make up for lost time in my fellowship. I was mostly ecstatic that I didn’t get stuck quarantining in a hotel in Uganda.  With a vaccine and the world being more open to traveling, I felt like more of a global health fellow.

I had my eye’s set on Malawai ever since my first trip to Uganda in March 2019.  Our first global health fellow, Dr. Carly Brady, had made the long move with her family to Blantyre, Malawi and helped to develop the countries first emergency medicine residency program. I’ve unintentionally been following behind Carly for most of my medical training.  When I was a 1^st year medical student at Marshall University she was a 4^th year heading to Palmetto Health (now Prisma) Richland for her Residency in EM.  I don’t think it was a coincidence that I also matched at Palmetto Health. Although we were never residents together, I remember working with her as a fellow.  Dr. Brady, is a small chaotic ball of energy, with a passion for emergency medicine and global health that is inspiring to all who she comes in contact with.  It was only natural after being her shadow in medical school, residency, and fellowship that we finally get to work together in Malawi. 

In September 2021, Malawi finally lifted their international travel ban and I was off.  Malawi was a true emergency medicine experience.  I worked as a visiting emergency medicine consultant with Carly.  The country, thanks to a large effort from Carly, has started their first ever Emergency Medicine Residency.  I was able to work in an emergency department with EM residents in Africa.  The acuity is high and resources are low.  We can easily get basic labs  and imaging such as XR, CBC, Malaria testing,  and a urinalysis, but to get electrolytes, BUN, creatinine, LFTs, ABG and a CT scan can be a much more difficult task.  On my previous trips, there was not much emergency medicine and I felt like more of a primary care physician than an ER doc. In Malawi I was able to use my specialty to directly impact patient care.  In addition, I got to teach residents, interns, medical officers, and clinical officers. 

One of the best parts of Emergency Medicine is that the principles are the same from Malawi to the United States.  There was an older lady who presented in the chaotic evening at the Adult Emergency and Trauma Center (AETC) in Queen Elizabeth Central Hospital.   Chief complaint of: dizziness, every EM docs favorite complaint (sarcasm.)   It was pretty clear why the patient was so dizzy, her heart rate varied from the mid 30s-40s and her blood pressure was in the 80s systolic.  Getting an EKG at the AETC is possible, but there is no EKG paper to print on.  So I hooked up the EKG machine and took screenshots of the EKG monitor and tried to read what her underlying rhythm was.  Initially it looked like a 3^rd degree AV block, but was difficult to tell from the 5 pictures I took of a moving EKG machine.  We also struggled with IV access, a common problem in the United States as well.  Dr. Brady and her residents struggled with a central line while the nurse was finally able to establish peripheral access.  We were able to start some peripheral epinephrine to temporize the patient and try to figure out what her rhythm was.  Fortunately, we were able to get a cardiology consultation, who though it could have been a 3^rd degree block, but also wasn’t completely sure.  A 3^rd degree AV block isn’t great news in the US, but patients can at least get a pacemaker placed.  In Malawi, without a cath lab or cardiac enzymes, her prognosis was grim.  She was admitted to a “step-down” unit, or one level below the ICU.  The next morning during morning report we found that on further investigation of her health passport, a small book that patient’s have which reports their past medical history, she had been placed on increasing doses of metoprolol for her hypertension.  This women’s bradycardia and hypotension was due to an iatrogenic beta blocker overdose.  She was eventually transitioned off her epinephrine drip and was able to go home.  The next week during the resident’s academic day, I lead a journal club discussing a clinical trial of beta blocker overdose treatment that we had discussed during my residency journal club.   We discussed improvements that we could have done with this patient and how we could have managed her better. It was nice to practice emergency medicine during my global health fellowship.  It was nice to see how emergency medicine can be translated across international borders.   The experience with Dr. Brady at the AETC is one I won’t forget, and I plan on returning for a longer trip this spring.

COVID has been a large obstacle during my fellowship, but as the world becomes more connected, it really matters to the world what happens in a city you’ve never heard of in China.  If anything, COVID, has taught the world is that global health is important and matters.  Until he next pandemic…

-Amanda Stratton, MD

Prisma Midlands Global EM Fellow

Carly Brady, MD is our first global health fellow and will be finishing her 2 year fellowship in July 2019.  She is originally from West Virginia and completed her residency at Prisma (Palmetto Health) Richland as well as her GH fellowship.

January 29^th2019 my family and I packed up eight suitcases with all our belongings and moved to Blantyre, Malawi. With six months left of the Global Health Fellowship, I was finally headed somewhere where I could couple both my passions, Emergency Medicine and Global Health.

Queen Elizabeth Central Hospital in Blantyre, Malawi has had a functioning Emergency Department (known as the AETC- Accident and Emergency Trauma Center) since 2011. It’s an imperfect system, (as all systems are) but compared to the facilities in the surrounding areas we are light years ahead in developing their acute care system. It is the only Emergency Department in the country staffed by Emergency Medicine trained physicians. We have x-rays and ultrasound most days. I can always get a CBC, thick and thin smear, and HIV testing. I can sometimes get urea and creatinine, LFTs, Hepatitis screen and CSF cell count/diff. If the urine pregnancy tests and urine dipsticks haven’t gone missing, I can usually get those as well. I have epinephrine as my pressor of choice, (commonly called Adrenaline here) and I can intubate as long as I call down to the ICU first to make sure one of the four ventilators are available. If I know who to sweet talk, if it’s a full moon, and if I have a patient with the right type of lateralizing signs I can occasionally beg for an MRI (available primarily for cerebral malaria research) or CT from the local private hospital.

Those of you who met me before I left know that this has been my plan for a while – fifteen years actually. So, oftentimes people back home will say, “Carly, you are really doing it. You are living the dream!” Then others will ask, “What does your regular day look like now?”

However, as any emergency medicine doctor knows, every day is different. That’s why we chose EM. The thrill/fear of never knowing what might walk/roll/fall through that door always keeps us on our toes. There are no “normal days” for us.

So, one Sunday, my first weekend “living the dream” on call (what an oxymoron), I drove in to the department expecting a slow morning. Malawians take their weekends and holidays very seriously so the AETC is usually relatively calm. As the day team started bedside handoff with the previous night’s team, we were all notified that a poly-trauma had come in to the department.

Unfortunately, this is not an uncommon occurrence. Minibuses filled with fifteen to twenty people or flatbed trucks providing cheap transportation for the masses often wreck resulting in 8-10 casualties and an equal number of traumas rolling through the door at once. As one of the only functioning emergency departments in the country we are often notified when these incidents occur as far as 2 hours away. Often, we wait on standby to hear whether the accident is closer to us or Lilongwe, the capitol city, wondering which hospital will receive the surge this time.

On this particular day it was an even stranger story. 24 hours prior a minibus was traveling from South Africa to Blantyre, Malawi. While in Zimbabwe the driver swerved to miss a pedestrian causing the entire vehicle to flip. I was never given a final number of casualties, but many died at the scene. The remaining fifteen were taken to the local trauma center to receive initial treatment.  After twenty-four hours in the Zimbabwean hospital they packed all the surviving trauma patients into a minibus and drove them the fourteen hours to our hospital.

So, this is how we started our “slow morning,” with fifteen trauma patients dropped in our AETC who had just driven 14 hours in a minibus after being stabilized in another country. Needless to say, we do not have fifteen trauma beds. We immediately converted our short stay unit into a mass casualty unit and begin assessing each patient one by one.

My first patient had a right arm amputation performed immediately prior to being stacked in the transport minibus, less than 24 hours ago. My second patient had a right arm amputation performed prior to transport, my third had a right arm… you get the point. Seven patients had at minimum a fresh right upper extremity amputation. All were at the midshaft of the humerus or higher.  I can only conclude everyone sitting on the right side of the vehicle had their arm out the window. It actually got to the point where the first thing I would do when seeing a new patient was pull back the sheet to see how many amputations had been performed. The remaining eight patients were a mixture of sorts: skull fractures, bilateral open tibia fibula fractures, pelvic fractures, femur fractures, degloving injuries… the works.

“Get a set of vitals on everyone! Make sure we have IV access!! And get me a sheet of paper so I can figure out how to keep track of these people!!”

Wounds/surgical sites were undressed, irrigated, and redressed. Everyone was given antibiotics (not inappropriately I might add…) fractures not going to the theatre immediately were splinted and pain medications administered to essentially anyone who asked.

Thank goodness for helpful consultants. The Orthopedic and surgical teams were notified immediately, and they came to the AETC at once.  In the next two hours we sorted through all fifteen patients, developing a new list: to OT immediately, to OT round 2, to floor then to OT round 3, and admit to trauma floor for OT sometime in the future not yet determined. Did I mention how strange it was for everyone’s primary injury to be right upper extremity?

Mind you, in the middle of all of this, we were trying to keep the remainder of the department running with one syncopal and unresponsive patient here and another hypoglycemic patient there. Our Magnesium and Aminophyline combo almost came too late for the poor asthmatic whose exacerbation happened to coincide with the arrival of the trauma patients.

Somehow, slowly, we got everyone taken care of.

First to the theatre, then to the floor, slowly they dispersed until all we were left with was the “regular” busy department. It was quite a day, to say the least. At the end of it I thought, “I don’t know if I can do that again… what kind of dream is it I’m living here?”

However, I was recently talking to a friend and said, “I guess moving here made me realize, you never ‘live the dream.’ You dream dreams, you live reality.” That’s the only choice we get. Some days are better than others. Sometimes I fight for 6 hours to get a CT on a patient, transport her to the private hospital for scanning only to have her die less than an hour after getting back to the emergency department. Some days I diagnose ectopic pregnancy with ultrasound and get the patient to the operating theater within an hour.  Some days I argue with ICU about why I keep sending them critical patients that often die. Some days I get the femoral central line in a dying hypoglycemic patient and she walks out of the ED less than 24 hours later.  Some days radiology accidently locks the keys in the department, and we go without x-rays all night. Some days I treat a crashing CHF exacerbation with severe hypertension with 10mg of Labetalol, 5L of oxygen and a prayer… and he gets remarkably, inexplicably better… until I don’t even need him to go to the ICU anymore.  Some days all of my patients that die are younger than me. Some days I have three patients with a GCS of three in the resuscitation bay, and then the third one wakes up and starts moving his extremities as we are performing the lumbar puncture and removing 40cc of cerebrospinal fluid causing increased ICP.

Some days I wonder if I’m even making a difference and other days I know I am. This isn’t a dream. But it isn’t a nightmare either. This is their reality and now it’s mine too. But I’m not done with my dreaming either. We are already in the process of starting a formal EMS system and currently have one ambulance staffed with trained paramedics! In the next year we are starting an Emergency Medicine post-intern training program with the plan of eventually developing the first Emergency Medicine Residency in the country. Just last week I was asked to consider being the Head of the Emergency Medicine Department at the University of Malawi College of Medicine – which was pretty amazing considering the fact that some days I can’t even tell if I belong here or not. I still have some time to decide, but the offer has opened a whole new range of possibilities.

Whether it’s a good day or a bad day, the kind of day where I wonder what in the world I’m doing, or the kind of day where I can’t imagine myself anywhere else. Every day is different. That’s why I chose EM.

 

By Guest Blogger: Carly Brady (Palmetto Health Global EM Fellow)

It was the last night for the OneWorld Health medical outreach team in Masindi, Uganda. To celebrate, the hotel arranged for a local dance team to demonstrate some of the local tribal dances and music. Shell covered hips and legs provided a gentle shushing noise while the clapping and stomping created a more clearly defined rhythm. Grass skirts accentuated hip movements so that a simple shifting of weight created a rapid and wild swing of the skirt, capturing the audience’s attention.  Auditory and visual stimulation merged into one. It was a far cry from the ballet and tap routines I had grown up trying to master in small town West Virginia. I was simultaneously filled with the desire to join this mass of bodies and movement while also overwhelmed by the strange and different nature of the dance patterns.

Then they asked for volunteers. One of my comrades bravely stepped forward and he was graciously received. They gently draped a grass skirt around his hips and began directing him in the most basic of movements. More and more volunteers added to the dancing mass until finally I could no longer resist the urge. My curiosity outweighed my fears of embarrassing myself and I stood up and allowed myself to be drawn into the madness. Rapidly we danced in circles and I focused intently on mimicking my partner’s moves exactly. In my mind it was like a scene from Footloose, Ugandan style.

And then we were done. The music stopped. Now the sound of heavy breathing and sweat permeated the open area. Some serious dancing had been done. I prepared myself for them to be impressed. I knew I had danced my little heart out. They asked for a photo to be taken with me. I imagined it was because they didn’t know an American could dance like that. Then… they said it, “Thank you for trying.”  Not, “What incredible dancing legs you have!,” or “ Please come back and dance with us again.” It was like the Ugandan version of the “Heart and Hustle Award.” There was no indication I had done any decent dancing at all, just appreciation for an honest effort.  After laughing about the event numerous times with my team, I began to think a little more about the whole experience and how I felt that it applied on a greater scale to the realm of humanitarian aid.

When humanitarian aid first came in vogue, aid workers were glorified. They were treated and received like saviors. As time progressed, and people began to evaluate the repercussions of some of these aid attempts, books like “When Helping Hurts” drew attention to the reality and severity of the situation. Good intentions are not enough to stop bad things from happening.  We must educate ourselves and allow the communities where we are working to help determine the mode and means of intervention. As result of this conundrum, many people have begun to shy away from the idea of short-term trips or medical outreach in general.

However, as this pendulum swings, first towards focusing on the purity of the acts and then on the imperfections, I believe that our approach and the subsequent dialogue surrounding these aid attempts needs to lie somewhere in the middle. While we must always strive to make our programs better we must also not allow ourselves to be incapacitated by the fear of failure.  I am concerned that in a society where we are conditioned to measure quantitative data and measure success purely by objective calculations, we can find ourselves hesitating and missing opportunities as we pursue guaranteed success. If you want to dance, you must first step out onto the dance floor.

My dancing was severely lacking. I am now aware of that. My hope is that it will at least be slightly better the next time I return. With each attempt I will continue to make an effort to improve. I understand that we cannot be this laissez faire when dealing with human lives. The truth is that some individuals are still dealing with the repercussions of other people’s good intentions from fifty years ago. As a result, I fully believe that you should heavily research any team that you are considering joining.  Study the pertinent historical aspects of the country you will be traveling to. It is impossible to know the mountain range until you understand which tectonic plates set things in motion long ago. Be prepared for poverty and devastation like many have never seen. But in the end, remember that it is impossible to steer a vehicle if it isn’t moving and so your first action must be to move. Step out and go.

After you have gone, when you are compiling all of your information for a retrospective analysis of the trip, remember that whether your objectively measured quantitative data calls it a success or not, those people who you took a chance on will absolutely look at you, know that you considered them valuable and worthy and they will say, “Thank you for trying.” Some would argue that this is not enough. I would agree that if we allow this brief “thank you” to be the final end goal then it is wholly inadequate. But ultimately, I believe that the first step towards becoming a participant in the world around us is actively and intentionally stepping into the lives of the people we want to help. That relationship has to start somewhere and I believe that if you can come each day and say to people “Your life is equal to my own and I am going to do what I can today to show you that,” then there is something small in that very moment which is being accomplished.

Screaming loudly, “The system is broken!” will not fix the problem, nor will pretending that the brokenness isn’t there.  If our options are anger, apathy or active participation then I think there is only one logical conclusion ,even if this means accepting that our participation will not be perfect. Walk onto the dance floor with what you have, knowing that it will not be enough, and for the time being, find a way to make yourself okay with it.

It’s early morning and the emergency room is finally quiet, having settled from the shuffling chaos of illness and injury that the daylight hours inevitably bring.  A car screeches to a stop in fro…

Source: The Woman Who Changed My Life…Whatever Her Name Was

It’s early morning and the emergency room is finally quiet, having settled from the shuffling chaos of illness and injury that the daylight hours inevitably bring.  A car screeches to a stop in front of the main entrance and the charge nurse yells for the physician on duty to come to the resuscitation bay.  A young, pale woman in her mid-twenties lies on the stretcher sweating and writhing in pain.  It takes only a few minutes for the emergency room physician to ascertain that the young women is suffering from a ruptured tubal pregnancy and is near death from internal bleeding.  She needs an immediate life-saving blood transfusion, but the blood bank is empty.  There is no blood.  The patient is taken to surgery but dies shortly after.

This scenario does not occur in the United States due to the 9.5 million individuals who donate blood in this country each year.  Unfortunately, it is an all too common occurrence in many developing countries.  According to the World Health Organization, only 40% of blood that is donated each year is collected in developing countries, however, these countries represent 80% of the world’s population.  The situation is particularly dire in Sub-Saharan Africa where the HIV crisis makes suitable blood donors difficult to find.  In addition, testing for many blood-borne infections that can be passed through transfusion are not available in many low-income countries, leaving those who do receive blood transfusions vulnerable to contracting HIV or Hepatitis.

Global health funding has largely neglected transfusion services.  Lack of publicity and difficulty defining the scope of the problem are likely major reasons this issue has remained greatly overlooked.  Most of the major areas of global health funding from the United States government is channeled toward HIV, malaria, tuberculosis, child and maternal health, family planning, and sanitation.  Many would argue that global health dollars are better spent addressing these global health targets than recruiting blood donors and investing in expensive laboratory equipment for better blood testing.  But there is a critical and understated link between improving blood transfusion services and decreasing morbidity and mortality from at least half of these global health targets.  As children suffering from malaria-related anemia and mothers with post-partum bleeding represent the most common recipients of blood transfusion in Sub-Saharan Africa, investing in child and maternal health means investing in better transfusion services.

Several African countries have greatly improved their available blood supply through simple cost-effective donor recruitment campaigns aimed toward recruiting young donors at low risk for HIV and other transfusion transmittable diseases.  Groups such as Zimbabwe’s Club 25 encourage secondary school students to donate blood at least 25 times in their lifetime and have been quite successful.  Organizations, such as The Safe Blood for Africa Foundation, assist African countries in developing national transfusion services and improving blood testing, collection, and distributing blood products.  Safe Blood for Africa does receive multiple grants from USAID, but certainly more federal government dollars and more organizations like this one are needed to make a significant impact on this massive problem.

About 10 years ago, I met a young South African in her mid-twenties.  I was a fourth year medical student on an elective rotation in rural South Africa and she was bleeding to death.  And although I do not remember her name, she changed the trajectory of my life.  She was not my first patient to die, but hers was the first death I couldn’t live with.  Her death was stupid and preventable and unfair.  She changed the way I saw the world and planted a seed of anger that grew into a passion for global health.  So, to prevent another stupid, preventable, unfair death; I ask you to consider donating blood and supporting your local red cross.  Contact your legislative representative and ask them to support funding for a safe and adequate blood supply in Africa.  Be thankful for a blood bank that might run low, but never runs empty.  And remember those who might find themselves in a different situation, in a quiet emergency room, in the middle of the night, saying goodbye to a loved one because the blood bank in their country is bankrupt.

George passes the chart for me to review. There are two plain white pieces of legal paper stapled together with a short note scribbled in blue ink. “34 year old with four days of weakness. Fever and vomiting. Feels cold. No medical problems suspect malaria.” Below the note, orders for five medications are written – an antibiotic, antimalarial medication, a steroid, and two medications for stomach ulcers. The note was written two days ago. I ask George why a steroid was ordered, but he doesn’t know. The patient is thin and pale as she looks up at me from the hospital bed, her child sitting quietly on the floor next to her. A clinical officer initially evaluated her in the outpatient department, wrote the initial orders, and admitted her.   Clinical officers have two years of formal medical training and are similar in equivalency to physician’s assistants in the United States. No one saw the patient on rounds yesterday and she has not seen a physician since she came to the hospital. George leans over the patient and says something to her in Swahili. She doesn’t understand. George is a clinical officer employeed at the government district hospital but he is not from this area of Uganda and doesn’t speak the local language.

 

We moved down the long line of patients, one by one. An elderly lady with an acute stroke did not respond to Lasix well to treat her high blood pressure. Her blood pressure was dangerously low two days ago when she was seen on rounds. At that time, the medication was stopped and she was given a bolus of IV fluids. Her blood pressure has not been checked since. George inflates the blood pressure cuff and listens intently with his stethoscope pressed to her upper arm. Luckily, her blood pressure has improved today. We move on to the next patient, a young woman badly beaten by her husband five days ago. She complains of abdominal pain. A complete blood count had been ordered but has not been done, the machine in the lab is broken again. George presses on the patient’s abdomen as she winces in pain. He decides to send her to another medical center to get an ultrasound. The ultrasound and xray machine at the hospital have been broken for weeks. We review the patient’s orders. George asks if the pain medication has been helping. She states she hasn’t been given any medications since she arrived yesterday evening. Dr. Kayumba joins us, finally free from an emergency c-section case in the operating theater. We move on to the next patient.

 

This is how I spent my morning at the district hospital in Masindi, Uganda. It has been a few years since I had visited an African district hospital. I have been spoiled by NGO sponsored hospitals that boast modest but available staff and supplies and had forgotten how dismal the conditions can be (and usually are) in the district hospitals. Broken equipment, drug shortages, and inconsistent training frustrates the already overburdened and poorly staffed health care providers. Physicians and nurses choose their occupation based on a desire to help, to take action, to intervene. Instead, these providers are forced to stand by and watch as patients die of curable diseases for which they have the knowledge, but not the ability to treat. Their hands are tied. There is nothing more frustrating. Expect, possibly, knowing that they will most likely one day be patients in the same system, helplessly stuck and powerless.

 

The last patient on rounds today was an elderly lady with sepsis secondary to a tooth abscess. One of the pharmacy students who came along with me asked Dr. Kayumba if the hospital had the antibiotic clindamycin as it would cover the most common bacteria that might be causing her infection. Dr. Kayumba smiled and then laughed as he said, “In Uganda, we survive.” I am amazed by how much Dr. Kayumba and the staff of Masindi District Hospital have been able to do with so little. And more so, I am amazed by the generous, optimistic attitude the staff has managed to maintain despite their working conditions. As I was leaving today, I shook Dr. Kayumba’s hand and said the only thing I could think to say. “Keep fighting the good fight.”

Palmetto Health Emergency Medicine Residents are finding that the skills they have learned during their residency in Columbia are making lasting impacts across the globe. The EM department has 13 residents participating in global health trips during the 2015-2016 academic year which are as varied as teaching emergency medicine to physicians in India, treating patients in mobile clinics in Tonga and Nicaragua, training Tanzanian physicians to use bedside ultrasound, and managing emergencies in Haiti’s only critical care hospital. As global health opportunities such as these become increasing available, more of our residents are participating, even if it means they are using their vacation time to do so. Nearly all of the EM residents are participating in some type of global health experience during their residency with increasing movement towards longer term, sustainable activities. The EM department is also forging partnerships with hospitals in rural Uganda and Tanzania to improve patient care and knowledge exchange.

Global health electives provide residents with exposure to disease pathology rarely seen in the US and experience practicing medicine in resource constrained environments. As one of our recent graduates Dr. Jo Innes noted, treating the same condition in Haiti and the US varies greatly, but not necessarily the outcome. “A patient in acute on chronic CHF didn’t get an EKG, chest x-ray, CBC, BMP, BNP, troponin, coags, and cardiology consult. He got an EKG, a bedside ultrasound and lasix. And he got better. And he was grateful.” Residents are working within fragmented healthcare systems with very limited resources and frequently find that basic health education is the most useful skill they have to offer.

Dr. Luke Husby and Dr. Leslie Osborn noted about their time providing care in mobile clinics in Samoa; “All in all we held 6 clinics and saw over 1200 patients, dozens of which ended up hospitalized for various injuries or illnesses and at least one woman was rescued from an abusive situation. A great deal of education through pharmacy, wound care, nurses, the Christian based team, and the practitioners was probably the longest lasting effect we had, although whenever possible the positively screened patients were able to be referred to local physicians.” Although practicing in these environments can be frustrating, such experiences give residents a new perspective and a renewed sense of what it means to be a physician.

Thank you to Palmetto Health for seeing the value global health experiences have in resident education and patient outcomes in some of the poorest regions of the world.