How Did I Get Here?

When you are travelling (especially on a medical learning trip), it seems that you sometimes find yourself in the most bizarre scenarios, usually wondering to yourself “Just how did I get here again?”. From this trip:

• … squished into a mini-van with fifteen plus other people (and a goat?) bouncing down treacherous roads
• … being quizzed on the philosophy of aesthetics and beauty, along with two Dutch medical students, by a visiting gynaecologist from New Zealand.
• … asking how the patient sustained his supra-humeral fracture, and receiving the answer “lion bite”.
• … holding the foreskin of an under-anaesthetized teenage Maasai, helping the surgeon perform an elective (yes, elective!) circumcision.
• … changing (or rather, helping the driver change) a flat tire on the safari vehicle, not 50 metres from a crowded hippo pool.
• … watching a surprising number of egg-looking objects being extracted from a cyst (since there was no pathology department, the identity of these oddities will forever remain a mystery).
• … keeping the room door securely shut, lest the baboons make another attempt to invade.

Kilema Hospital

The next location, where we spent an additional two weeks, was Kilema District Hospital. Kilema is located high up on the slopes of mount Kilimanjaro – a very bumpy hour’s drive from Moshi town. The hospital is small, usually averaging 80 in-patients per night. There are male and female medical wards, a labour & delivery ward, a small paediatrics department, a busy out-patient clinic, a counselling and testing centre for HIV, and a two-theatre operating room. Given free-reign to visit any department of interest within the hospital, we spent most of our time observing with the staff medical officers. These two weeks carried a lot of new experiences for me e.g. first witnessed delivery, first witnessed C-section. Above and below are photos taken from the small hill just behind the hospital, where on a clear day there were stunning views of Kilimanjaro, the Pare mountains in the distance, and the surrounding plains.

Pamoja Tunaweza Women’s Shelter

Phew! Ah, the joys of being showered and in clean clothes once more!

Having returned yesterday from Tanzania, I’ll be publishing a short series of posts documenting my time there. They will all be written in retrospect, since internet was virtually inaccessible from where we were staying in Tanzania.

Travelling with three of my classmates from Queen’s, we spent the first two weeks at Pamoja Tunaweza Women’s Centre in the town of Moshi, northern Tanzania. Possibly the first centre of its kind in Tanzania, Pamoja Tunaweza seeks to specifically help women who have been marginalized, in what is usually a male-dominated society.

Small and still growing, the centre offers assistance according to individual needs. Some women are given support to start their own business. One woman who we met had started up a fruit stand, and another was hand-knitting hats for sale. Pamoja Tunaweza offers a few classes in business management, and once the women have drafted up a business proposal they can receive a small loan to make a the initial investment and get started. The Centre also has a shelter upstairs where women or girls can stay, especially if they are escaping from a violent  situation.

During our brief two weeks at Pamoja Tunaweza, we developed some health information hand-outs as an additional resource for the Centre. We tried to cover medical issues that would be relevant to the women who visit the Centre, such as women’s reproductive health, menopause, and common illnesses their children may need care for.

For more information on Pamoja Tunaweza, visit their website.

Off We Go!

Hmm… so in about an hour my flight leaves for Tanzania, where I will be volunteering in a hospital/clinic, and hopefully learning some medicine for six weeks. Although I don’t know what my internet connectivity will be like, I will try to update this blog on the way, or alternatively once I get back.

Week in the Country

“Welcome to Lanark – Population 800″; I spun my head around to read the sign as we drove by. I had not previously appreciated that when my preceptor referred to Lanark as “the village”, this was not merely a metaphor of endearment – she had meant it quite literally.

“Week in the Country” is a program sponsored by the government of Canada to entice medical students towards rural family practice. Every medical student is required to spend at least one week shadowing a rural Family Doctor. Almost all expenses are covered, as our government is desperate to meet the growing need for doctors in under-serviced rural areas.

Lanark has one major road running through town. We were lodged extravagantly at a bed & breakfast (see photo above) on one side of town, and walked into the Community Health Centre on the directly opposite edge. The walk across all of Lanark took no more than 20 mins.

4 year-old male presents with left ear pain lasting five days, and other non-specific symptoms of an upper respiratory tract infection – our first patient. It is surprisingly difficult to look into a squirmy child’s ear! Otitis media; Amoxicillin 50mg/kg/day TID x 10 days. After Week in the Country, I can now write that with some confidence! In fact, the week was extremely valuable for gaining some proficiency at triaging common complaints, and I am now more confident in differentiating sore throats, sinus infections, headaches, and common skin rashes.

Perhaps the most memorable patient, for me, was an admirable young man trying to quit smoking. He had impressive resolve, but was profoundly impeded by addiction. I cannot imagine the frustration of fighting a war with your own brain. I learned about the arsenal of medical tools available to help. More powerful, however, was when my preceptor offered to make an appointment with this patient every other day on his way to work for the next month – a brief check-up, so that every two days there would be someone asking “Have you had a smoke?”, and “How is it going?”. What a privilege to be that source of accountability and motivation in a person’s life.

In Lanark this week I didn’t get into the OR, or the ER. We didn’t see anybody who was mortally ill. We didn’t perform any cowboy, daring, rescue procedures. But I’m not in the least disappointed. I learned how to swab a throat, how to give a vaccination, and how to detect pneumonia without the luxury of an x-ray. Less romantic perhaps, but unaccountably more useful.

 

Reflections on a Year

With one last stroke of the pen, I close the exam booklet, and exit the classroom door into the brilliant sunshine of a summer well-earned! Alright, so maybe it’s actually miserably cold and rainy outside, but to me it couldn’t be sunnier!

Tomorrow will be May 15, marking exactly one year since the medical schools sent out their acceptance emails (and for me, a waiting-list notification). May 15 one year ago finds me in central Sudan – getting stung by a scorpion, and wondering what the future might hold. Tomorrow, the upcoming class of ‘Queen’s Meds 2013′ will recieve their good news! So, it seems a fitting moment to reflect upon a year of much change.

They say about medical school that “the days will be long, and yet the years will be short”. How very true so far! Glancing back in my memories reveals a whirlwind of adventure, growth, and adaptation; a breakneck ride, too exhilarating to have possibly dragged on for an entire year.

Yet I marvel at how far our class has come! I remember walking into the lecture-hall on a crisp Fall day, and nervously meeting one another for the first time. That same week, we purchased our first white coats and took up anatomy with earnest in the cadaver lab.

We are a different group today. We speak a new language, and possess a new library of knowledge. We’re not as scared of the patients anymore! In fact, many of my class are budding artists in the fine skill of physical examination. We have bonded well as a group, not least of all due to shared duress. We are finding purpose, and have begun developing dreams for the directions in which this wild ride could be headed. There is no doubt in my mind that medical school profoundly changes a person.

I also now believe in the system! Noticing the growth that Queen’s has fostered amongst us in just one year, it finally seems conceivable that in three more of the same, we might actually emerge as doctors. There are many long days still to be endured (and the trial of clerkship hasn’t even started yet!), but I now believe that we will make it. 

And now… to the sunshine, to feeling like a human again, and to summer!

Tragic Simplicity

Every year internationally, 1.5 million children die from diarrheal dehydration. That’s more children dying than the total number of Canadian children under 5 years old. What’s truly tragic is how preventable these deaths really are. In studying today, I ran across a set of guidelines published by the WHO for case management of diarrhea:

1. Prevent dehydration by educating parents on how to treat diarrhea at home (fluids, and good nutrition)
2. When dehydration occurs, treat with oral rehydration solution.
3. Feed appropriately both during and after diarrhea.
4. Provide antibiotics for suspected cholera, shigella dysentary, or typhoid fever.

It has been estimated that these four guidelines could prevent 90% of deaths from diarrhea dehydration. That’s 1.35 million children. So simple (no special training required for the first three guidelines, and the fourth can be performed by just about any healthcare worker), yet the barriers are numerous. Some obvious barriers are the lack of access to clean water for rehydration and inability to pay for good nutrition.

Swine Flu: Keep A Watchful Eye

Many of you will have heard on the news about the recent spread of a new Influenza outbreak from Mexico. Some have probably been wondering “what’s the big deal?” With 59 deaths reported by the WHO as of April 23, and less than 1000 cases of swine flu, this disease is, so far, a small player. So I’ll do my best to explain why this disease is getting infectious disease experts stirring, and why it will be one to keep a watchful eye on over the next few days and weeks.

From the days of the Ancient Greeks, the Influenza virus has infected people. But the genetic identity of the Influenza virus today isn’t the same as for the virus that caused the flu 100 years ago. In fact, it’s not even exactly the same virus as it was last year. The reason is that the Influenza virus mutates rapidly, generating new strains.

From year to year, the changes in the Influenza virus are known as genetic drift. Because of genetic drift, each flu season there are a new handful of Influenza strains that predominate. Genetic drift explains why you have to get a new flu shot every year. In the Fall, the WHO makes predictions of which five strains of Influenza they think will be the most prevalent, and those are the strains that go into the vaccine.

In addition to genetic drift, every so often there is a more significant mutation in the Influenza virus. We classify Influenza strains according to two proteins that are expressed on the virus capsules: hemmaglutinin (H) and neuroaminidase (N). For example, H5N1 is the subtype name for a strain of bird flu that is being watched globally for pandemic potential. The recent swine flu in Mexico is H1N1. Genetic drift from year to year doesn’t generally change the HxNx classification of the virus, and so over time the world population builds up some immunity to strains that are prevalent.

Every once and awhile, however, there is a chance recombination of the virus that results in a new subtype becoming infectious in humans. Often these recombinations come from animal strains of the flu, because animals suffer from different subtypes than we do. Many animal flu strains can be transmitted to people, but generally you need to have contact with the infected animal, and it won’t spread from person to person. If an animal flu recombines, however, to be transmissible from human-to-human, it might potentially create a new subtype to which we have no global immunity. This sets the stage for a global pandemic. Over history there have been regular, periodic pandemics of newly recombined Influenza strains the most notable being the Spanish Flu, which killed 40% of the global population.

Perhaps now it is clearer why there is so much fuss over the emerging swine flu epidemic. Swine flu has existed in pigs for forever, and there was always pig-to-human transmission. The new event, is that this H1N1 strain of swine flu has recombined to be infectious from human-to-human. It now fits the criteria for what we expect a pandemic-causing virus to look like. Will swine flu be the cause of the next Influenza pandemic? That will depend on many factors including the transmissibility and virulence of the virus itself, and how effectively it is contained by WHO efforts. It will be a disease to keep a very watchful eye on over the next few days and weeks.

An Intimate Privilege

After observing for a day with the General Surgery service, I’m struck by what a trusted privilege the surgeon is given to enter within the body of a patient. Cutting through the protective layer of skin that separates the ‘us’ from the ‘outside’, the surgeon enters the most intimate recesses of a person – the cavities and tissues of their body. Such intrusion; such vulnerability. Yet every day, patients entrust surgeons with this privilege, literally bearing their inner biological lives on the table.

What an intimate privilege to enter within a body, and I’m so immensely grateful to have briefly had the opportunity today. Shadowing a general surgeon, I was allowed to witness a superficial parotidectomy (removal of the superficial lobe of the parotid gland), a lumpectomy (breast-lump removal), and  a lumpectomy with axillary dissection (removal of lymph nodes from the armpit). Those last two cases were for women with confirmed breast cancer. My role was, of course, exclusively to watch the procedures, but they did ask me to retract here and there, or cut stitches. I think they wanted me to feel included!

Surgical dissection can be exquisitely precise, and particularly for the parotidectomy it was important for the surgeons to identify numerous nerves and arteries as they slowly worked around the resection. Damage to any of these nerves could have resulted in paralysis of the patient’s facial muscles – a horribly debilitating and life-changing complication. Once a nerve was located, the surgeon would electrically stimulate it to observe for an effect. For example, if he stimulated a nerve to the orbicularis occuli muscle, the patient’s eye would squint.

Practising medicine is surely a privilege – to have the invested trust of patients for their lives and well-being. But the intimate privilege granted to physically enter within the body is greater yet.

Mathematics of STI Spread

(DISCLAIMER: This post is a little more technical, and hopefully will be enjoyed by my dear friends in math, engineering, or computer science).

Let:

R° = the average number of secondary cases infected by each person who has an STI (units: people)

β = the percentage probability that a person with an STI will spread the infection to a current susceptible sexual partner.

c = the average number of new sexual partners made (units: people/month)

D = the average duration of infectiousness for a particular STI (units: months)

M = the average number of people with an STI cured from infectiousness each month by medical intervention (units: people/month)

The change in prevalence of an STI in the population is determined by R°:
- If R° < 1, the STI is declining in prevalence
- If R° = 1, the STI is in equilibrium
- If R° > 1, the STI is becoming more prevalent 

R° can be expressed in terms of the other variables: 
     R° = βcD

Given a particular M, and noticing that β and D are constant for each STI, R° varies with c. Studies of sexual practices show that c follows a Poisson distribution that is heavily skewed towards the left. Thus:
- In most populations (the left-skew of the distribution), c is low enough that R° < 1
- There exist “core” populations (the right-sided tail of the distribution) where c is high enough that R° > 1. 
- Demonstrated core populations are: young people, sex-trade workers, and drug users.
- By estimating β and D, we can determine the threshold c for which R° = 1 (c = 1 / βD), and above which there is increasing prevalence of the STI. 

Some interesting research findings regarding core groups and epidemics:
- Like-with-like sexual activity (= within a core group) is a risk factor for a fast-developing, but limited STI epidemic.
- When core groups are small enough, there is self-limiting of the epidemic since sexual contacts become very likely to have previously contracted the infection
- Like-with-unlike sexual activity (= between a core group member and non-core group member) is a risk factor for a slow-developing, but ultimately more prevalent epidemic. 

STI prevention focuses on:
- Increasing M, which causes a decrease in D
- Advocating safe-sex and protective behaviours that reduce β
- Identifying core groups for focused medical attention and STI screening

Whoever said that mathematicians have no hope of ever becoming familiar with sex ? Course this isn’t quite the type of familiar I think they were hoping for…