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Tuesday, August 12, 2014

Tanzania, part 2

Being a doctor is an adventure, or so I thought when I started medical school. It has, in fact, never been boring and has often been exhilarating. But 25 years ago what I longed to do was to go to exotic places where everything was different than it is at home and where I could be really useful. After raising 2 children and doing primary care for about 2 decades, I’ve finally found enough spare time to go to Africa and it has been pretty great.

I just returned from Tanzania about 2 weeks ago after accompanying 11 University of California at Irvine medical students on a project to teach basic ultrasound skills to physicians and clinical officer students in Mwanza, a major city which sits on the shores of Lake Victoria. Using ultrasound at the bedside by a non-radiologist caregiver is gaining acceptance in the U.S., but still runs into resistance because of issues of competence and training and billing and turf.

In Africa, though, you will find good consensus that it is life-saving. The students have designed a curriculum that teaches how to use an ultrasound machine, how to recognize anatomy and obtain adequate images, and then additional training for second year students in identifying common pathology. The African students have excellent book understanding of anatomy, but don’t have the opportunity to use cadavers for dissection so lack the 3 dimensional understanding that U.S. medical students get. Ultrasound is a wonderful way to appreciate how the body works, and sets the students up to be able to become more skilled in using ultrasound diagnostically.

Being able to see if a pregnant woman has a baby with a normal heart rate, identifying the position of the baby near delivery and seeing the placenta is potentially life-saving for both baby and mom. Ultrasound can identify bleeding in the lungs or abdomen in patients who have been involved in motor vehicle accidents, extremely common in Tanzania, and a quick exam that can be performed competently by a medical provider with a few hours of training can lead to emergency surgery in time to save someone involved in a collision. It is simple to identify a pneumothorax (punctured lung) with ultrasound and that exam can save someone who has been stabbed or shot or whose broken rib pierced the lung. In the last 2 years, the students have taught basic ultrasound to about 180 doctors and clinical officer students. It is unclear exactly what impact that will have long term, but it is certainly a project that has the potential to keep on giving.

The American students involved in the project had completed their first or second year in medical school in an institution that teaches bedside ultrasound as an integral part of anatomy, physiology and pathology. After their first year they are quite good at performing basic ultrasound, and after teaching it in Tanzania and developing lesson plans, recording podcasts, creating and grading exams and practicing on each other so as to be able to teach, they are stars. My job was to review their material for accuracy and clinical relevance and answer clinical questions as they arose. We also attended rounds at the district hospitals as much as possible and sometimes contributed to diagnosis and treatment of patients. It was great to be able to work with Tanzanian physicians and the bright and well prepared clinical officer students. Having the small, portable ultrasound at the bedside allowed us all to look at what was going on in the patients, which helped us cross cultural and language barriers to really understand what was going on.

This year’s project was, in fact, crazily complex. Surprisingly enough, and thanks to tireless and skilled organizational efforts by all of the students, it all came off. There was the basic ultrasound first year class. There was the second year introduction to ultrasound pathology class that had to be given at four different district hospitals where the second year clinical officer students were doing rotations. There were hospital rounds, which happened at various hospitals. And there was the schistosomiasis project. I wrote this about it before we really got into the gathering of data. The towns and islands on Lake Victoria have a really high incidence of Schistosoma mansoni and Schistosoma haematobium. The parasitic disease schistosomiasis is caused by a fluke that lives in the lake, harbored by snails and infecting swimmers and workers and fishermen and women as it burrows through the skin and takes up residence in the blood stream. The eggs of the fluke are very irritating and cause damage to the intestines, liver, kidneys and bladder in some people.

We visited Ukerewe Island where it is said that about 100% of the population is infected with schistosomiasis. Many receive free treatment through schools, but although this program is supposedly available to everyone, quite a few children and most adults do not get the drug. Praziquantel, a big white pill, can be dosed once according to weight. It has occasional side effects of nausea or fatigue, but will kill the parasite and may reverse the symptoms which can include bladder dysfunction, cancer and kidney failure as well as liver dysfunction and liver tumors.

Patients with schistosomiasis can also be anemic due to blood loss from ulcers in the intestines and have bowel troubles. We conducted ultrasounds of the liver, kidneys and bladder of all kinds of people and the lab checked their stool and urine for schisto eggs. Very few of the patients we saw were desperately ill, but a surprising number had intestinal distress and bladder abnormalities. In a place where people live, basically pretty healthily, with schistosomiasis, it appears that ultrasound may be able to help us identify which patients are developing problems which may cause longterm damage. If that is true, ultrasound might be able to help focus therapy on those people who really need it, since treatment of the whole population appears to be impractical.

It’s so good to be back. I met wonderful people, saw birds of incredible variety, ate good food (especially the deep fried rice blobs—those were great), saw diseases I never see here, learned a little Swahili, visited tropical islands, slept in Dubai, got uncomfortably close to a hippopotamus, didn’t get dysentery. I observed medical students being awesome and encouraged their awesomeness. I learned a little bit of how a country with far too few physicians does a reasonable job of taking care of patients while using minimal resources. Now I can drink the tap water, walk on my familiar mountain, pet my dog (who is not infested with parasites), and sleep in my own bed. I can even speak the language fluently. It is wonderful to go adventuring, but possibly even more wonderful to come home.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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