Category Archives: Uncategorized

Performing ultrasound in rural clinics in Loc Tri and Vinh Phu

7/25/2014

Today we set off early to visit two rural hospitals in the countryside of Hue. We were accompanied by some Cal undergraduate students who also helped out at the hospitals as a part of the Volunteers for Medical Outreach (VMO) program. After an hour of dirt roads, we reached our first stop; the Health Care Station of Loc Tri District (Tram Y Te Xa Loc Tri). It was in a very small town sparse with buildings, surrounded by beautiful green fields and hills. When we arrived, there were already around 60 patients, mostly elderly, awaiting medical care. After meeting the 4 doctors who were in charge of seeing the patients, they asked us to set up our machines and ultrasound all of the patients. They asked us to do all our scans on each patient but we quickly realized that the pace was too slow, so we switched to a focused ultrasound scan after briefly interviewing each patient for his/her chief complaint. Meanwhile, UC Berkeley’s VMO team assisted with taking in patients, measuring blood pressures, and distributing medication in the pharmacy clinic. The mobile clinics, supplies and medications were all funded by donations collected throughout the school year.

At first, we were hesitant to ultrasound patients since we were relatively inexperienced in regards to pathology in images, but our previous experience shadowing ultrasound doctors in Hospital 108 actually served us quite well. We were able to identify kidney stones, thyroid cysts, mitral regurgitation, ventricular hypertrophy, enlarged kidneys and masses in the thyroid and liver. As we saw more patients, we became more and more proficient as scans became much faster and easier. After receiving their scan, the patients were sent to see their respective doctors. After a few hours, we had finally finished scanning all 60 patients.

Our next stop was another small rural hospital which dedicated the day to administering Hepatitis vaccines to children, all around the age of 6. The Cal students with VMO conducted dental care lessons for the children after they had received their vaccinations. Nancy conducted one of the lessons on her own, and afterwards, Anh joined her and the Cal students as they applied fluoride gel onto the children’s teeth.

After getting home, we all watched MS2 ultrasound videos and studied as many scans with pathology as we could in preparation for our next and last clinic visit the next day.

The following day, we woke up early again to make our way to the last rural clinic. Although the waiting room was just as crowded as the last clinic, this clinic’s population was much more varied in terms of age, with children, middle aged adults and elderly patients. Our extra studying the night before paid off, as we were able to distinguish kidney cysts from hydronephrosis in a female patient. Again, we saw lots of the same pathology as we did in the previous day, including leaky heart valves, kidney cysts, and masses in the liver. We learned that the doctors working at this clinic were not very proficient with the ultrasound, so they greatly appreciated us being there to help. Although many patients showed up to the clinic, we ended up scanning only patients that were referred to us by the doctors, which amounted to about 30-40 patients scanned.

On our way to the blue mountains “Nilgiris Hills”

We said goodbye to Bangalore after a week full of adventures, delicious “Veg and Non-veg food”, and after seeing our anatomy textbooks come alive in the operating room.
On our way to Gudalur, which is located in the Nilgiris hills of Tamil Nadu, we stopped for a short visit in Mysore a city of palaces at the border of state Karnataka. This was our place to unwind and walk around palaces full of history and Hindu mythology, spice and fruit markets and far away gardens. It was here where we also met Lisa, the last member of our team and where we welcomed the holy month of Ramazan. Once our bags were packed and ready to go, we took a jeep to go across the border of the state of Karnataka into Tamil Nadu by wondering through their magical wildlife sanctuaries. We finally arrived in Gudalur where a homecooked south India dinner and the friendly staff from the Adivasi Hospital welcomed us.

One week down in Istanbul :)

Hello!!!

We finished our first week at Cerrahpasa University School of Medicine in Istanbul. It was such a great week!! We taught around 60 medical students cardiac, GI, pulmonary and FAST ultrasound exams.

Cerrahpasa students are really smart students and pick things up very quickly. In the end, when we compare the test results before and after our teaching, it is awesome to see that students learnt a lot, which means IMG_5591 IMG_5596 IMG_5647 IMG_5555 IMG_5606 IMG_5558 IMG_5549 IMG_5572 IMG_5645

that we did a great job. Also, we were so happy to hear from the students that they really love the program and want us to come back.

Now this week, in addition to teaching students extra ultrasound sessions, we have another challenge to overcome. We are going to teach ultrasound to the anesthesiology residents, attendings and associate deans. We are aware that this is a harder task but we know that we can do it!!

Besides the academic stuff, we are also having a lot of fun in istanbul. We went to all of the historical places like Hagia Sofia, Blue Mosque, Basilica cistern on the weekend as well as did the Bosphorus tour. Last night, we went to Eminonu and ate famous fish and bread with a gorgeous Bosphorus view, and then ate world-famous Turkish baklava.

So, life is awesome here in Istanbul for us!! Stay tuned for our next adventures!!!

Cheers!!!!

Ismail

 

 

An epidemic

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Saludos a todos!

We are on the last leg of our trip, and have learned so much about chronic kidney disease (CKD) in Nicaragua. The purpose of our project was to survey communities affected by CKD as well as gather data from medical records from an occupational health and research clinic in Leon, Nicaragua to determine the relationship between CKD and occupation. Though we began working on this project months before the trip–reading literature and analyzing mortality data–what we learned from the communities ravaged by this epidemic as well as the doctors working diligently to find the cause has been invaluable in comparison.
Here are some of the both interesting and upsetting things that we’ve learned during our time in Nicaragua:

  • CKD is affecting very young agricultural workers, mainly sugarcane workers, which is the primary occupation for men in the communities we surveyed. Many patients are in their early 20s.
  • Though chronic dehydration is thought to contribute to the development of CKD, some of the residents we surveyed were very aware of the importance of drinking enough water and took care to drink a lot of water throughout the day. However, others relied heavily on soft drinks, coffee, and juices as their main fluid intake, assuming that it is sufficient hydration.
  • Many members of the community are convinced that the water at the sugarcane plantation is contaminated with pesticides and are hesitant to drink the water. However, bottled water is too expensive for most of the community members to buy on a regular basis.
  • The families we interviewed were all so kind and open to strangers asking them health-related questions. We are so grateful for their participation because we learned so much from each family. Hearing the stories of CKD patients was incredibly moving and motivating. We hope to help a group of MS1s continue the project next summer, as there is so much potential for this project to continue and grow.
  • There are many projects in progress within Nicaragua–which is very hopeful–and there is room for students from many disciplines to contribute, as this is clearly more than a health issue. It has become a huge political, social, and public health issue that can benefit from a multidisciplinary solution.

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The mere fact that this is also a sociopolitical issue made us realize that, as future health practitioners, we will be caring for patients who might be in similar situations as those we met in Nicaragua. It is these experiences that will encourage us to approach health care in an interdisciplinary way, and utilize our resources to empower our patients and their communities.

We’ve learned so much on our trip and are extremely grateful to UCI and our PI, Dr. Anton-Culver. If you have any questions for us, please don’t hesitate to ask. We would love to talk about our experiences in Nicaragua.

-Sherry, Cristina, Cynthia, Alejandra, Krystal, and Kyle

New update, sorry for the delay

Wow, I can’t believe that we are almost done with our time here in Mwanza, Tanzania. I apologize if some of the other team members have already written about some of the things I am going to write about, but I wanted to provide a different perspective of everything that has happened while we have been in Mwanza, Tanzania.

For those of you who do not know, 7 team members and myself have traveled to a city by the name of Mwanza, Tanzania for 3 weeks. It is the second largest city in Tanzania and lies on the coast of Lake Victoria, which is the mouth of the Nile (and apparently infested with schistosomiasis). Below is a picture of the sunset setting over Lake Victoria. I think the picture describes how incredible Lake Victoria truly is.

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While here, we have been teaching an introductory course to ultrasound, performing ultrasound research on patients who have contracted malaria, scanning pregnant ladies, working in the lab and shadowing physicians. Below is a picture Anjali, Bianca and Dr. Clemont (one of the doctors taking our ultrasound course), scanning pregnant ladies to monitor the Biparietal diameter, head circumference and fetal position of pregnant ladies.

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When we first arrived at Tandanbui Institute, where we are teaching the ultrasound course, we learned that our class size increased from the intended 80 to 140 students. These students range in their academic level from medical school students to doctors to nurses. I’m not sure if our ultrasound course sparked interest in ultrasound or if the students already had an interest in ultrasound, but man does this city love ultrasound. Below is a picture of Anjali teaching students the subxiphoid view, which is on of the ways of viewing the heart.

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Throughout the past couple of weeks I have learned how incredibly useful ultrasound is, especially in developing countries like Tanzania. I think that all of the team members and our students have caught the ‘ultrasound bug.’ Just the other day a couple of us were scanning pregnant ladies and one woman showed up with abdominal cramps. Of course we cannot diagnose, and at most can estimate how many months  the women has been pregnant. However, we thought we thought it would be a good idea to scan anyways. After locating the fetal heart rate we realized that the heart rate was extremely low and so we informed the head doctor, Dr. Clemont, and she was immediately sent to the district hospital. Just a simple 5 minute ultrasound might of saved this woman’s baby’s life. Ultrasound is pretty amazing.

Dr. Janice Boughton was a physician from the states who came with us to help teach/research ultrasound. She has been a tremendous help in regards to our ultrasound course. Also, without her help we could never have donated an ultrasound machine to Tandanbui Institute. The ultrasound machine that we will be donating will be used at a hospital called Mwanaichi, but the director of Tandanbui, Dr. Kavit, purchased a used Chinese ultrasound machine that will be used by the students at Tandanbui Institute. Here is a picture of over 10 students hauling the machine inside. I have a new appreciation for the handheld sonosites.

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Besides teaching, researching and shadowing the team and myself have also had some time for fun. There is a soccer field right down the road from the house we are staying at that is filled with kids every night. And by kids I mean kids as young as 9 or 10 that still kick our butts in soccer. Our host, Brother Erick Oguta, has been a tremendous help and perfectly depicts East African hospitality. I cannot even begin to explain how much he has done for the team and myself to make this trip work out. He is a pastor at a local Nazarene Church. Tanzanian church services are like none I have ever been too. With loud music, dancing and yodeling women it is quite an experience to say the least. The girls and Dr. Boughton (Janice) thought it would be a good idea to bring some soft music to the church and sang ‘Amazing Grace.’ It was amazing, and the church seemed to really enjoy a change in pace. Here is a picture of all of us outside the church with Brother Erick and his wife and of the team singing:

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Allison and Michelle left today to climb Mt. Kilimanjaro, which is pretty surreal. We only have 2 more days of class left and then the students will take their ultrasound final. Neha, Anjali and Gabby will be heading on a safari to the Serengetti and Ngorogoro Crater and Bianca leaves back to the states. I’ll be heading to an island in Lake Victoria called Robondo. It’s supposed to have some pretty diverse wildlife. Here is a picture of all of us at Michelle and Allison’s last day of class:

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Hope you all are enjoying the blog and pictures. Take care.

Blood, guts, a some really big hearts

Words cannot describe our experience at the Christian Medical College in India. Therefore…here are a few photos—

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A few of the highlights over the past few days have been seeing thyroid surgery, an autopsy, pathology museum, and a c-section/vagina birth. The days have been blurred together after having so many new and mind blowing experiences. Never in my life did I ever expect to see an autopsy. The procedures when performing the autopsy are so much different than one would expect. Without going into too many graphic details, I was shocked at the amount of force needed to release the organs from the fascia. Despite the internal mutilation done to the body, the medical examiner made sure to carefully stitch up the abdomen for cosmetic purposes so that the body could be given back to the family. Seeing the fresh organs full of color and form was just so different than what we saw in anatomy lab. I think for anyone even considering surgery, time spent in the autopsy room is indispensable.

The other recently shocking event was our OBGYN rotation. For the majority of the group, it was the first time we’d ever seen birth of any sort. In one day we were able to witness a vagina birth and c-section. Again without going into gory details, it was quite a sight to see and a lot to take in. But watching a new born child take its first few breaths suspends time and reality for those few minutes. Overall, I think the entire session is quite a special experience and a privilege to be present for.

Beyond all the pathology and procedures we’ve seeing, what has affected me the most was the superb quality of physicians that we’ve been exposed to. They have been kind, patient, generous, and engaging. It’s what you should expect from any physician at a teaching hospital, but these individuals have gone far and beyond. We’ve even had the privilege of having home cooked dinner at a their homes. They are not just physicians that I admire in medical practice, but people that I would like to emulate daily life.

Personally, this India trip has far exceeded my own expectations in what I thought I was going to see. It has been, inspiring, humbling, thought provoking, and delicious (I’m obsessed with their chicken and rice dish). Tonight we leave to another city via train. We leave Vellore excited for the next stage of our adventure.

Kevin Ting

The Art of the Physical Exam

Today is the beginning of our second week in India, and I can’t believe how fast the trip is passing. We are starting to settle into a routine that begins with breakfast of idly, dosa, or omlette, and the most delicious milky chai tea. Then we pack in to the student bus surrounded by CMC medical students, the youngest of whom are only 16! At the hospital we shadowed morning rounds in the endocrine surgery ward with an attending and several residents. These doctors are phenomenal and dedicated instructors; they are willing to spend almost an hour on each case, carefully teaching us the pathophysiology of each condition, from basic anatomy to complex diagnostic classification systems. We are all so grateful for their time!

I think the most important thing I will take away from rounding with CMC doctors is the art of the physical exam. I continue to be impressed with how much diagnostic information they are able to extract through basic techniques of palpating, percussing, and auscultating. While examining a patient who presented with swelling on her neck, our attending thoroughly reviewed head and neck anatomy, identifying each boney landmark and isolating each relevant lymph node (we learned there are around 300 in the head and neck!). He then palpated the swelling itself, evaluated the number of nodules, determined fixation to fascia, and described the consistency. From this information alone he was able to diagnose the mass as a tumor and predict malignancy. Only after making this initial assessment did he need to confirm with cytology, x-ray and ultrasound.

This weekend we were able to take a quick break from the hospital to do some traveling. We visited a seaside town called Mammalpuram, famous for the Pallavan architecture of it’s ancient temples. Two highlights were the 1400 year old Shore Temple, which was miraculously untouched by the 2004 tsunami, and the Five Rathas, a series of monolith temples all carved from a single giant boulder. We ended the day with a dinner delicious fried calamari and whole tandori style sea bass at a beach front restaurant. As it got dark a monsoon picked up out at sea, and we witnessed an amazing lightning show.

I can’t wait to keep exploring and learning for the rest of the trip!

– Tanya

Ultrasound Study, Medicine, and Endocrinology

Keeping with the theme of this trip, the last two days have been very busy. Yesterday was the first day of our research project. We made our way around the ICU in teams of 4 or 5 ultra sounding maxillary sinuses to test the efficiency of detecting it using ultrasound. While my team and I made our rounds around the ICU, the physicians would take time out of their day to teach use the individual cases there were there. We saw a hug number of cases ranging from organic phosphate poisoning to extremely complex cases with multiple disease at work in the same patient. The two cases that were most impactful to me was the 15 year old girl that was suffering from organic phosphate poisoning. According to the physicians, this is an extremely common occurrence due to the need for pesticides and how cheap organic phosphates are. It was hard to witness the girl struggling to breath while the toxin was being worked out of her system. While the patient is expected to make a full recovery, the physician said she will likely be back because she will be reexposed to the organic phosphates in her life. The second patient we saw yesterday was a middle aged man that was on life support with pyrexia of unknown origin. For me this was both interesting and humbling because I was witnessing the physicians work through a differential for fever, something I assumed to be simple. After hearing them discuss the vast amount of conditions, diseases, and syndromes that could be at play within this patient I realized how much of medicine I still need to learn.

Today, we got to go around the Internal Medicine ward and Endocrine ward. Within the IM ward, we got to test our diagnosing abilities as the physician guiding us around explained the case to us and guided us through how to think clinically about the patient. The first case we encountered was a 24 year old patient that has had hemolytic anemia since he was 4. This caused a whole host of conditions within this patient including an enlarged heart (twice as big as normal), enlarged liver, and an enlarged spleen (5 times bigger then normal). The case was then further complicated by the fact that the patient was suffering from malaria. As the physician was guiding us through the case he taught us to look at each symptom individually and also to look at them collectively to come to a diagnosis. As we continued through the ward we saw cases of Cushing syndrome (both tumor induced and exogenous), acromegaly, and a superior vena cava obstruction caused by recurring malignant breast cancer. Overall, the day was eye opening to how to think clinically about each patient and how to use the knowledge from previous cases to help you through the thought process of the case at hand. I look forward to the days ahead in India to what we are going to learn next.

-Michael

Public Health and Trying to Blend in with the Public

Today was not quite as eventful as the past two days, since I pretty much just watched a surgery similar to the ones I had seen previously, except that it was a revision, meaning that they had to redo a lumbar disc resection (due to re-herniation). It was twice as long as the other operations because there was a great deal of scar tissue to clean through and discard, and even the suturing took perhaps 45 minutes because there were four layers of sutures necessary (from a posterior approach, you must pass through skin, subcutaneous fat, muscle & fascia, vertebral spinous process, vertebral lamina, and then cauda equina before you can reach the intervertebral disc). That’s probably more detail than I really need to delve into, but you get the gist of it. Unfortunately, there are no pictures allowed in the OR, and so there will probably be less pictures in the next week and a half I have left over here (sorry!).

However, I can perhaps discuss some public health issues that I think China faces (and maybe relate them to the U.S. a bit). Some of the biggest health problems I have noticed are: ungodly amounts of pollution, large prevalence of smoking (even both surgeons I have been shadowing smoke about 1/2 pack a day), growing obesity rates, aging population, huge staffing deficits, inadequate distribution of medical care (very sparse in rural areas), ’empty’ diets, lack of workers (an increase in education is driving young people into more white collar jobs), among many others.

The pollution and smoking are causing some really significant rates of lung cancer and affect every possible organ system indirectly somehow. These are only exacerbated by growing obesity rates as KFC and other fast food chains are growing very popular, and the aging population will make chronic conditions related to all of these trends more prevalent. Those in the countryside have a lack of access to the same medical care as those in cities, though they are in theory covered under the same insurance plan; one patient’s mother traveled 200 km just to get a consult from the doctor I shadowed yesterday. Even in the normal Chinese diets, most of the food tends to be meat and few vegetables with some carbs (typically noodles or rice) in a sauce that is high in sodium. Though this is not usually an excess of calories, some doctors were telling me that it has a reputation for being relatively devoid of significant nutrients. With the lack of workers, the Chinese economy will have to confront a shift in their base, which is now more focused on industrial production, but will have to increase its availability of service-related jobs.

This is a lot to take in, but I think the way China is changing is that the people are becoming less healthy, but are finding medical interventions that help them live longer, and are moving into career paths that are also less active. This means that more of them will also have access to technologies that can perpetuate their unhealthy habits, decreasing the ability to motivate patients to take responsibility for their own health. I’m not entirely sure how physicians and healthcare administrators will approach this, but I think there are some things I have seen that are a good start. Based on the high volume of traffic, many people are commuting via bike or public transport, forcing them to walk at least somewhat daily. There are many public, outdoor events on a daily basis that anyone can avail themselves of, to include public parks that have workout facilities (see the picture below), some very fun line dancing (anyone who has traveled to China can attest to this), tai chi, etc. If China can use its more centralized government (quite an understatement, trust me) to motivate these behaviors and decrease usage of cigarettes, perhaps they long lives they will live will be more enjoyable!

Outdoor Workout Parks for Adults.

Outdoor Workout Parks for Adults.

On another note, the day was quite short because after the surgery, there was just paperwork for the doctors to do, so I had two choices: go home or go into the OR alone into random surgeries using all of my ten words in Mandarin while scrub nurses chased me out of their rooms….needless to say I chose the former. While I got back early, I wanted to make the most of the day, so after an early dinner, I headed out to the “Ancient Culture Street” of Tianjin, which was built in the 80’s but depicts China several hundred years past. This is supposed to also be a great shopping area for cultural types of things. I was at first sad to find that everything was closed with the exception of two or three shops, because there main business occurs on weekends. However, I decided that I was not going to let a small change in plans deter me from enjoying Tianjin at night, and so I just followed a road that crept along the Haihe River that divides Tianjin. I soon came along a little wharf that had some frozen desserts, which I quickly bought since it was still quite hot and humid, even in the early evening. See the picture below to see me by the riverside.

Just after some shopping, enjoying the Tianjin Riverside.

Just after some shopping, enjoying the Tianjin Riverside.

I then crossed over the bridge you see in the distance on the right in the image above (the bridge while I am on it, along with some Tianjin skyline can be seen below). The things I came across as I continued along the riverwalk were quite amazing: line dancing parties, children playing everywhere, a man singing traditional Chinese music while making popcorn (attracting a huge crowd), street dancers, dozens of very small dogs, middle-aged men fishing, many couples taking professional engagement pictures (or perhaps those kinds of pictures are just normal in China), and bootleggers, among many other things. There was even a man on a bike who thought I was Muslim and greeted me with “As-salamu alaykum” and played Arabic music, and after I courteously replied “Boo yao” (‘I do not want’, one of my ten words/phrases), he continued to follow me, switching to a classic Bollywood song on his stereo. I’m not sure what his intentions were, and though he was interesting, I continued on, not wishing to try and find out. The night continued on like that, and I found that not knowing a language makes traveling and learning about culture much more fascinating in many respects: you learn how body language differs in each culture, you are forced to appreciate things based solely on their intrinsic but superficial qualities, and you have the chance to form your own pure opinions about a culture, without the influence of anyone else. I’m not sure which I enjoy more: learning about Chinese medicine or experiencing Chinese culture!

Beautiful Tianjin at night!

Beautiful Tianjin at night!

Goodbye to Israel

We had a great experience in the internal medicine department at Soroka Hospital in Be’er Sheva. The best part of the rotation was working with the professors, doctors, residents, and medical students from Ben Gurion University. They were all so welcoming to us, and eager to educate us on just about anything. They were so helpful in translating patient encounters and making sure we felt included in daily activities. Seeing a diverse group of patients was also a rewarding part of this experience, along with a variety of diseases that we couldn’t see anywhere else. In addition, we met other medical students from all around the world who were participating in the same medical exchange and explored Israel together on the weekends! What a truly international and cultural experience to do a medical exchange in Israel!