First Patient Enrolled - Nate Herr (PL2)

Posted on behalf of Nate Herr (PL2)

With nearly perfect triumphal timing, it's my final week here and we just enrolled the first patient.  The process went smoothly, and in observing it all, it felt good see the family acting quite content and pleased to be receiving quality care and attention to detail both now and over the next year. 

They weren't the only ones pleased.  Many members of the NDI study team stopped by to say hello; from the lab technicians to the home visit coordinators.  The first enrollment is always a big day!

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GHU NDI Project Director, Ruth Namazzi, and Medical Officer, Denis, go over the enrollment forms in the consultation room.  (patient and family not photographed)

Also, I must note that Ruth is an excellent Ugandan pediatrician and is the Project Director here for the NDI study.  If you're in Minnesota this month you'll have the chance to meet her on April 29th when she presents her results on "Change in Hemoglobin concentration of Children with Severe Anemia at Mulago Hospital: A Prospective study."  It's her first time visiting Minnesota and the presentation will be at Dr Cindy's house at 6:30pm.


GHU Study Group Photo from Nate Herr (PL2)

Posted on behalf of Nate Herr PL2

Fantastic group shot of the GHU study group retreat Nate recently posted about on the blog!

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Posted on behalf of Danielle Dhaliwal (PL3)

Medicine at Selian hospital in Arusha has truly proven to be an exercise in delivery of care to children in a resource limited setting.  I have several cases to share that I have experienced while here that I believe demonstrate this concept well.

The first case was of a child who was born prematurely at what was estimated to be between 26 to 28 weeks gestation.  The mother presented with premature onset of labor and, despite bed rest and tocolytics, she dilated quickly.  She was able to receive two doses of prenatal steroids prior to delivery of the infant (hydrocortisone is used here vs betamethasone - not sure of the difference in lung maturity outcomes with this).  We were called to assess the infant soon after delivery knowing that it was possible, and likely, that if the infant was 26 wks it would likely not survive.  But also knowing that dating was just as likely to be inaccurate.

Immediately after the infant was born she was cyanotic, hypotonic, and grunting with poor respiratory effort and an initial Apgar score of 4.  For me previously in the NICU this would be a routine resuscitation requiring temperature stabilization, blood cultures and antibiotics, close oxygen monitoring, CPAP, possibly some manual breaths, and likely surfactant administration.  Here these options were not readily available so creativity and temporary stabilization until the infant was able to transfer to higher level of care was all we could hope to achieve.  

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Our infant ambubag was broken and we had no ability to titrate the oxygen percentage so could only deliver 100% oxygen.  Despite giving the best breaths we could the infant's perfusion was worsening and her heart rate began to decline.  Joseph (the pediatric registrar) began doing CPR while I continued bagging the infant.  We did not have any umbilical catheters and instead used a small 4 fr nasogastric feeding tube and gave a 10 mL/kg NS bolus.  I attempted to draw up epinephrine to give however noticed that the only vials we had were 1:1000.  To deliver the correct dose I needed to dilute this to 1:10,000 - I learned to never do math under pressure!!!  (by the way, mix 1 mL of 1:1000 epinephrine with 9 mL NS and this makes 10 mL of the 1:10,000 concentration - estimating the weight at 1 kg you would then give 1 mL of this solution)    The infant's glucose was also low so we wanted to give a dextrose bolus.  We had D50 so Dr. Swanson had to quick figure out how to dilute to the proper concentration while Joseph and I continued CPR.  Thankfully the infant's heart rate and color improved and she began spontaneously breathing although she continued to have significant grunting and hypothermia and so we decided to transfer her to ALMC where they have a NICU and ability to do CPAP.

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Me warming the baby until she was stable enough to go skin to skin with mom

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Getting ready to transport infant to ALMC 

In prep for transport I ran through a checklist:

  • Oxygen - check, no,wait - tank is empty and need to get a new one
  • Ambu bag- check. 
  • Pulse ox - check. Adult sized but will fit over entire foot and work, hopefully.  
  • Thermometer, check. Given disease rates and reuse of thermometers between patients, only rectal and oral temps are taken. 
  • Planning to have mom do skin to skin throughout the bumpy ride.  
  • Stethescope - check.  
  • Unfortunately our low UVC fell out so I had IV epinephrine in my pocket ready to inject directly into the heart if CPR and bagging were not working.  
Thankfully HR and sats were stable the whole ride!

I checked on this infant yesterday and she is doing great!  Still below birth weight but otherwise a successful resuscitation and one that reminded me of the basics of infant resuscitation and taught me how to do so with limited resources. Helping Babies Breathe was a great resource as well.

Here are some closing pictures of the hike I mentioned in my last blog post to Mt. Meru.  

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View of Kili from top of Mt Meru

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Nate Herr (PL2) on Getting an R01 Study Launched

Posted on behalf of Nate Herr (PL2)

After the safari, I returned to my routine of rounding in the PICU and stabilization room 2-days a week.  The remaining days of the week were dedicated to the various and many research study tasks surrounding getting a new R01 study launched.  This study will follow a spectrum of children admitted with severe malaria-- taking detail to discover more about the causes and outcomes of the different types; Coma, Seizures, Anemia, Acidosis, and Prostration.

Chandy John, Director of the Division of Global Pediatrics at UMN, had arrived in Uganda while I was out on safari.  In the next 3 weeks that he was here he facilitated meeting after meeting on his multiple clinical studies here-- including the NDI study I've been working on and described briefly above.

To answer a question, you need data.  And to get data you need forms.  The forms for our study collect somewhere around 7,000 variables per patient.  With our goal to take in all comers with severe malaria, we are expecting a lot of variables and a short and fast enrollment period-- both of which called for efficiency in the data collection and verification process.

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Karen Hamre, MPH, a PhD candidate at the UMN and current Fogarty Fellow, arrived 2 weeks ago and brought her skilled eye for detail and perspective of data analysis to the group.  It took almost a weeks worth of revisions and multiple rounds of feedback from everyone.  We spoke with everyone from the bedside nurses to the principle investigators to create a set of forms that we believe will efficiently and accurately collect the information we'll need. While it brought on headaches, it was great to have the many perspectives involved early on before the actual roll our of the study.

At the end of Chandy's time here, we weren't yet ready to enroll any patients, but we had made much progress in ensuring that the process would be smoother when it happens.  That last weekend he was here, the Global Health Uganda staff from across the country met for their annual retreat, and ventured out to an island in Lake Victoria.

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For most it was their first time at the island, and for many it was their first time on a boat.  With the entire GHU staff at the island you soon saw how they were a big family, enjoying the company and friendships build over time as the NGO approaches 15 years.  It's been a great privilege to work with them as it's apparent to all that they strive for excellence in whatever their task or role.

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The retreat did it's job in bringing rest and relaxation, something we needed with the multiple studies set to launch this spring.

Nate Herr's (PL2) Safari Story in Pictures

Posted on behalf of Nate Herr (PL2)

Hello again from Uganda!  I realize now that it's been a month since last checking in with our blog-- sorry about that!  I've been quite busy with a few things.  Chandy John has been on site and we've had productive meetings, and have been working on editing of forms to make our data collection more efficient.  Look for an upcoming post with more details.  

Since arriving back in mid-February for my 2 month rotation there was time to fit in a visually breathtaking safari.  

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I took some of my PTO in early March when Abby came to visit for a week. While we did spend a couple days around Kampala and at the Mulago Hospital, we first went up north on a 3-day safari.  Our main stops along the way were the Ziwa Rhino Sanctuary, where they're reintroducing them back into their natural habitat after being poached to elimination years ago, the big Murchison Falls Game Park, and the Budongo Forest for chimp tracking.  

Pictures say it all, so here they are! 

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Sunrise

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Rhinos resting in Ziwa Rhino Sanctuary

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A view of the Murchison Falls Game Park

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Antelope at the Murchison Falls Game Park
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An elephant at the Murchison Falls Game Park

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Giraffes at the Murchison Falls Game Park

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A hippo at the Murchison Falls Game Park

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Warthogs at the Murchison Falls Game Park

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Cranes at the Murchison Falls Game Park

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A crocodile at the Murchison Falls Game Park

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A mahogany tree

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A chimpanzee at the Budongo Forest

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Hope you enjoyed the photos!
-Nate

Danielle Dhaliwal (PL3) describes her time in Arusha

Posted on behalf of Danielle Dhaliwal (PL3)

Jambo from Arusha!

The house we are staying in in Arusha is up a steep hill away from town but it is on a bustling street - between barking dogs, nightly music, honking horns and pouring rain we are thankful to have ear plugs to allow some quiet sleep .  The house is adorable and we are currently sharing it with a 3rd year medicine resident from Denver, CO.  A medical student from Australia will also be joining us this week. 

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The living room in the Exempla House where we are staying.

In Arusha we began our time at Selian Hospital.  As Danielle and Emily mentioned, it is about an hour and a half walk up a muddy hill but, fortunately, there is a retired Medicine physician from MN, Ron Eggert, who is here for the next year and he and his wife are kind enough to pick us up and drop us off on most days.  
 
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The walk to work this morning.

Ron's wife Ingrid works at the Plaster House, and we had the privilege to get a tour of the facility the other day - what a beautiful and inspiring place.  The Plaster House is a home in Arusha for children from around Tanzania to recover in after they have had corrective orthopaedic surgery, plastic surgery or neurosurgery for a disability.  The Plaster House is particularly busy this week - a group of surgeons just arrived last evening and will be performing a number of complex surgeries over the next 4 days.  

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The Plaster House

Today was the screening clinic and Dr. Swanson and I helped in seeing some of the pediatric cases to ensure they were safe to proceed with anesthesia.  We saw so many children today who will benefit immensely from their being here, I was so happy to be a part of it.  A majority of the cases were cleft lip/palate and burn contracture revisions.  One of the cleft kids was referred to us for a heart murmur.  Not only did she have a 6/6 holosystolic murmur but she had a webbed neck, short stature, shield chest, and other features possibly suggestive of Turner's syndrome. Another child had fallen several months ago onto her chin.  She had fractured her mandible at bilateral TM joints and without proper physical therapy her TM joints fused and she was unable to open her mouth and her mandible growth had been stunted.  Another child had sustained burns to the back of her legs and sadly developed severe burn contractures and was only able to walk with both of her knees bent.  

One patient had been seen by the plastic surgeons however was referred to us because of severe and poorly controlled atopic dermatitis.  The patient had been seen in clinic before and was diagnosed with urticaria but had not received topical steroids and has since developed superinfection of many lesions and possibly eczema herpeticum.  

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Poor guy was so itchy and uncomfortable and so inflamed that I could feel almost every lymph node he had.  It was my first time feeling epitrochlear nodes.

We prescribed a number of medications and to ensure that this infant received what we had prescribed I walked with her and her child to the pharmacy down the street.  Between the topical steroids, antihistamines, emollients, and antibiotics the bill at the pharmacy was 45,000 Shillings (the equivalent of ~$30).  Given that most Tanzanians make less than 5,000 shillings a day this family was unable to pay and so Dr. Swanson and I split the cost for the medications.  I only hope that when the time comes for refills they will be able to do so on their own.  I am having them follow up with me in two weeks so I will let you know how he is doing. 

We do often walk home and when we do we are always called into the home of an elderly man sitting on his porch.  He has severe bilateral lower extremity pitting edema, JVD, and a necrotic ulcer on his calf.  We gather from these findings and what we can understand of his Swahili that he was diagnosed with diabetes, hypertension, and heart disease but only was able to pay for one month of his medications and has not been seen in clinic since.  He is such a sweet man and clearly is suffering despite the fact that the hospital is a 20 minute walk from his house.  Treatment and monitoring of chronic medical conditions is something that we struggle with even in the US, however in Tanzania it is profound.

We spent our first weekend here in the Zanzibar archipelago.  Stone Town is the main city.  It is a UNESCO World Heritage Site due to its being a former center of spice and slave trade and it is rich with diverse influences of Swahili culture with a mix of Arab, Persian, Indian and European influence.   We spent most of our time soaking up the perfect weather and relaxing on the beaches of Jambiani. 
 
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This is actually a real picture I took

I have so many more stories to tell but I need to finish packing.  Tomorrow morning we head out on a three-day hiking expedition up Mt. Meru, a volcano that looms in the distance at 14,800 ft. Can't wait!

-Danielle

Mike Taylor (PL3) settles in to his 2 months with MAP Bolivia

Greetings from Bolivia, land of Lake Titicaca, lots of smiling children and a fully functional integrative health clinic in the heart of Chilimarca & Cochabamba.

After a couple of weeks settling in I have found some time to share my experiences with you all. So far, I have been splitting my time at the clinic and the nearby primary school while living just up the hill from the compound in a beautiful and simple bungalow.

MAP Bolivia is a truly unique organization that embodies what it means to be integrative in health. Located in Chilimarca, a low income suburban community about 20 minutes by car outside of Cochabamba, the "Centro de Salud Integral Chilimarca" boasts a community level clinic with emphasis on prevention and early detection of disease, a primary school, community library, and the office space for "Aprendiendo de las Diferencias" or Learning About the Differences. This latter program is a community based initiative aimed to better integrate community members with physical and mental disability into the homes, schools and public spaces of Chilimarca by working to improve understanding of disease, reduce stigma and normalize diversity in its numerous senses.

All of these programs are run on a minimal budget funded primarily by MAP International with assistance from the Bolivian federal government. MAP is an organization founded by a Chicago born christian philanthropist in the 50s that has expanded to a half dozen sites around the world. MAPs roots are in donation of medications donated from pharmaceutical companies, as well as bought with money donated by other organizations and individuals. 

Although MAPs collaboration with the local government largely guarantees the clinic's survival, several newer projects are funded by outside NGOs. One such venture is C.U.B.E. which stands for Centro Una Briza de Esperanza or A Breeze of Hope. This affiliated organization is run by Dr. Jose Miguel´s daughter Brisa and her husband Parker and aims to provide safe shelter for victims of sexual abuse and their children, as well as raise awareness to the problem on a local, national and international level. I had the pleasure of providing well child care one day to over 30 children involved in this program. If you are interested in learning more they have created a lovely website with opportunities for internship (I believe predominantly in law) here: http://www.abreezeofhope.org/index.html

My role here so far has been predominantly as a provider at the clinic and well child care for children in the school. We have slowly been working our way through all the grade levels checking anthropometrics and treating low weight or height with vitamin supplementation and antiparasitics. In the afternoons I have been working in the clinic where I´ve seen numerous common childhood illnesses, namely lots of colds and diarrhea. I´ve had the chance to confirm the etiology of a couple of the diarrheal illnesses under the microscope which has been fun.

Finally, for my academic project, I brought about 100 books at Dr. Jose Miguel´s request (courtesy of Reach Out and Read and Dr. Howard) and have been working slowly but surely to give them all away. I designed a questionnaire for the families to get a baseline on attitudes and habits surrounding reading to children. The initial results do seem to show that there is a lot of work to be done regarding getting books into the homes earlier and educating parents on their value for early cognitive development. I have heard from the teachers in the school that a couple of the children absolutely love their books and bring them with wherever they go. Hopefully, as the parents see this enthusiasm, it won´t be difficult to get books into every household regardless of age.

With Carnaval coming up next week, well child care has taken a turn for the hilarious with whole classrooms of kids covered in confetti and wearing a variety of masks and costumes (spider-man seems to be a favorite). Pictures to come as soon as I can figure out how to link my phone to the computers here!

Cheers,
Mike
Posted on behalf of Nate Herr (PL2)

Beth Thielen invited me to try rafting with her this past weekend. (Beth is in the UMN Med-Peds program and is here working on the adult side of Mulago hospital on the ASTRO-CM trial with Dr. Boulware).  

With a few recommendations we decided to go with Nile River Explorers, an established rafting company here in Uganda.  Our raft guides, safety kayakers, etc, were all Ugandan, who have grown up into and thrived in the development of adventure tourism and sports.  Several of them, including our raft guide Juma, have competed at the international level in whitewater kayaking-- representing Uganda and Africa all through the energy of waterfalls and rapids in the backyard of their home village.

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The fun and adventure of rafting with excellent guides

By the end of the day we were exhausted, sun burnt, and winded from the three times our raft flipped in the rapids. But, all-in-all we were glad to be able to experience the thrill of the Nile river rapids.  These rapids have been sequentially disappearing with each installment of hydro-electric dams on the Nile, built to fill the need of reliable electricity in a developing country. A third dam is currently being proposed and depending on the height, additional habitat, communities, rapids, and tourism economies will be displaced or eliminated.  A petition is circulating both in hard copy in communities and online internationally to encourage the building of a smaller hydro-dam that would preserve the remaining falls and rapids on the river.

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Flat stretches of water were time for discussion and brainstorming

On the flat stretches between the rapids, we talked these issues of the Nile and more.  I also found out that it's hard to escape healthcare all together, even on your weekend off.  The two guys in the front of the boat were logisticians with MSF, in Uganda for a 2-week training session.  On the water and in the rafting truck we were discussing the challenges behind ensuring a cold-chain to deliver vaccines and the future promises of mHealth, the later which got me thinking-- a lot. mHealth is a broad term to describe mobile phone technology interfaced with healthcare and I see great potential for it here and elsewhere around the world.  If anyone has any experience or ideas on mHealth, please email me. It's hard to imagine future implementation research without it.

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Getting a bit wet after one of those flat stretches

Posted on behalf of Nate Herr (PL2)

I've alluded to some of the pediatric clinical research and collaboration happening here in Kampala, it's really quite extensive and thorough.  I'll do my best to summarize.

Malaria has long been a common disease in the equatorial tropics.  It has a spectrum of severity, depending on the type of malaria one is infected with and the age and health of the person infected.  The most severe form of malaria is cerebral malaria which involves a patient in coma and is fatal if the malaria is not treated.  This is thought to be from the parasitized red blood cells sequestering in the blood flow to the brain or due to inflammation, the answer is not yet clear.

Earlier, the same collaboration group with UMN and Mulago Hospital, studied and compared two types of severe malaria.  One that I mentioned, Cerebral Malaria, and Severe Malaria with Anemia.  They followed the children through their illness and after they went home.  They did continued EEGs tracking seizures, neuropsych and cognition testing and found that children with anemia and no initial brain involvement with their malaria still had deficits and disability down the road.  These disabilities are a big problem in Uganda and sub-saharan Africa and already the research group here is studying to see if rehab programs can help children regain their abilities.

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What is about to start is a broader look at children with milder forms of malaria to see if they also have disability from it.  In this study, blood tests will also be done to look for clues as to what is actually causing it.  Home visits and clinic visits will again follow the children after their initial illness.

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Ahmed, Denis (our two medical officers with the study) and Dr. Postels

Our Ugandan Medical Officers are a critical part of this.  We held a training session today with Dr Doug Postels, our Michigan State collaborator.  He lectured on the neuro exam then afterwards the medical officers practiced, asked questions, and gave much needed feedback on the forms and documentation that we've been editing and creating these last weeks.

Every day I'm learning another piece of what it takes to get good information to answer good questions for the betterment child health care.  Nothing is ever simple and straightforward and the best insight comes from looking at the problem from all angles-- with medicine being only one of the angles.

Nate Herr (PL2) tells us about The Container

Posted on behalf of Nate Herr (PL2)

This is the building we affectionately call 'The Container" because, well, it's a shipping container.  Granted, it has a few upgrades since its shipping days including a roof, windows, WiFi, a water cooler, and thankfully an oscillating fan. 

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This is one of the hubs of research collaboration with Makerere University in Uganda, the University of Minnesota, and Michigan State University.  In it you'll find medical students from the UMN-- Nick Sausen is here putting together donated EEG machines to help better define EEG changes in cerebral malaria and correlate it with the neuropsych testing that's being done.  Remember Tundun Williams?  She graduated from our Peds Residency last year and has been here since on a Fogarty Fellowship working on a clinical trial regarding sickle cell disease treatment in Africa.

While there's no room for me in the container, I'm often working nearby with others in the Global Health Uganda team on their both ongoing and upstarting malaria research projects.  More on that later. for now, please take a moment and send some cold Minnesota vibes to those working in the container.

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