From Dupont to Abdoun

Ibrahim

Tue, 14 Apr 2009 09:17:54 +0300

Just wanted to share a short story about a patient of mine, Ibrahim. At the time he came to our clinic, he was 10 months old and suffering from 3 day old burns he incurred after getting himself into a little trouble with a pot of boiling water on the floor of his home. This little guy was amazing. Although the total size of his burns probably encompassed less than 5% of his total body surface area, in the US, he would have been hospitalized because of both the location - hands and feet - and the nature of his burns - deep partial thickness burns. And a third reason to consider hospitalization may have been the uncertainty about follow-up and lack of education about how to change dressings at home.

As it was, Ibrahim was sent home from the ED with some bandages, and was left to follow-up with us at our clinic, where we are open only twice a week, do not really have sterile capabilities, and have nothing more than tylenol for pain control during dressing changes.

And this is what was amazing about Ibrahim, whose grandmother dutifully brought him in for twice weekly dressing changes -- he cried and moved so little during his debridement and dressing changes with only a tylenol suppository and a bottle of milk to keep him “comfortable”. At first I was worried that his burns may have been full thickness, but with enough prodding and by the look of the burns, he was clearly experiencing pain and the burns didn’t seem to be full-thickness.

What it boiled down to (no pun intended), was that he was just one tough little boy who somehow knew he needed to sit still. You can imagine this was a huge benefit to me. Trying to debride his wounds with a blade practically the size of his hand is not only difficult, but dangerous, with an unhappy, screaming, and kicking child. Thanks to the nurses and his grandmother who helped to hold him down.

On his second visit, Ibrahim came back and had managed to pull off his “mitten” and had clearly been sucking on his fingers, which now had impetigo. So we started him on antibiotics and when he came back for his next debridement, the infection had cleared almost completely.

Almost 3 weeks to the day of his initial presentation to our clinic, Ibrahim’s burns had healed completely, with really minimal scarring. Having never cared for a burn patient before, it seemed a miracle. It truly is amazing what the body can do.

I also learned a lot about being resourceful through my twice weekly debridements and dressing changes with Ibrahim. We did not have silver sulfadiazine or even bacitracin at our clinic. Instead I powdered formula of neomycin and polymyxin B and combined it with a zinc ointment we have for treating diaper rash, and used that for prophylaxis against wound infection during those 3 weeks. I had a 23-blade and a hemostat that I used to debride dead tissue not removed by a soft debridement. I learned to make do with whatever bandaging I had in the cabinet, and Dr. Anita showed me a neat trick using a pair of pants to make gloves that Ibrahim couldn’t chew or wiggle off. This kind of “improv” is what I think makes medicine fun. And I imagine I’ll have the chance to do this even more in emergency medicine, especially out in the field.

some soft debridement with saline and gauze of Ibrahim’s left hand. this was his “good” hand, as the burns on the right were much more extensive.

SUCH A TROOPER!

Pediatric Cardiology in Jordan, Part 2

Mon, 13 Apr 2009 17:06:33 +0300

The much anticipated discussion to Pediatric Cardiology in Jordan, part 1 is finally here. Because it includes references, I’m not able to copy & paste it into this blog, but please click here to read.

Part 3 to follow...

1st Annual Hoop For Hope

Wed, 8 Apr 2009 17:26:10 +0300

GOLA’s 1st Annual Hoop For Hope 3-on-3 basketball tournament was a success! I was a little nervous about the tournament from the beginning, knowing we didn’t have a lot of time to get sponsorships and pull everything together. But, thanks to many generous volunteers who organized and helped out on tournament day, we raised over 2500 JOD, which is almost $3600 USD. GOLA president, Rudy Habesch says that is enough money to pay for two visits to the cath lab, for 3 kids and their mother’s to travel to Amman roundtrip from Iraq, or for a substantial portion of an open heart surgery.

We had 12 teams, each player of which payed a 20 JOD registration fee for a guaranteed 3 games, t-shirt, and gym bag, donated by Fitness First. Prizes were awarded to the top 4 teams. In addition we held a raffle, which raised well over 1000 JOD on its own. Lastly, there was a bake sale, which I’m quite surprised to say brought in 130 JOD!

So we, at GOLA, were very happy with the successes of our 1st Annual Hoop For Hope Basketball Tournament. Next years should only be bigger and better!

Some pictures from tourney day:

Me, stickin’ the jumper in Fares’ face...well, not really. But take note, that Fares is displaying the tournament t-shirt quite nicely.

Semifinal game between Team Awesome (that’s my team!) & The Mix

Two of the Peace Corps teams duke it out in round robin play

Before and After

Sun, 1 Mar 2009 14:59:59 +0200

I’m a little slow in getting these pictures up, but thought I’d post some before and after heart surgery pictures of GOLA’s kids.

Baylasan (pictured above), who we operated on in April 2008, still amazes me the most. This is what she looks like 10 months after her surgery. I didn’t even come close to recognizing her:

Julyana came back this year for her second surgery, which included a pulmonary arteroplasty (to reduce the size of her pulmonary arteries), VSD closure, and extracardiac placement of a contegra graft (bovine jugular vein) between her right ventricle and pulmonary arteries. This picture was taken of Julyana after her surgery last year, in April 2008:

This is Julyana before her surgery this year (actually looking pretty good!):
And Julyana, after surgery this year:

Halima had a total TOF repair last April 2008 and came back for the reunion this February. I made a home visit with the GOLA team before her surgery and took the picture below. Come to think of it, it wasn’t actually her parent’s house. They borrowed Halima’s uncle’s house since it was more convenient for us to get to. I’m constantly amazed by the grace and selflessness of these families.

This is Halima, with Dr. Anne, at the reunion this year. notice how pink her lips are!

Well, that’s enough for now. For more pictures and stories from this year’s mission, you can always check out the Heart Mission 2009 blog.

GOLA Mission 2009

Tue, 24 Feb 2009 01:10:25 +0200

I know this is cheating, but since Dr. Anne Farrell of Riley’s Children’s is keeping up a blog of GOLA heart mission 2009, I figured why not refer you to hers! Since I can’t seem to remember my camera, I highly recommend you check out the blog. She has some great pictures and talks a bit about the patients as well. And be sure to check out pictures from the reunion, I didn’t even recognize Baylasan (above). She’s pink and chubby! Truly incredible.

Hoop For Hope

Tue, 10 Feb 2009 09:25:50 +0200

On April 3, 2009 the 1st Annual Hoop for Hope 3-on-3 Basketball Tournament will take place here in Amman in an effort to raise money for one child’s heart surgery. Read our information sheet to learn more.

A Little Rest & Recuperation

Mon, 9 Feb 2009 08:37:11 +0200

It’s been 3 months since I last looked at this blog and a lot has happened since then, including EM residency interviews in the US and a European ski adventure (no that’s not a picture of me or Jack, but it is a picture of Chelan Babineau in Backcountry Magazine, skiing at Bridger Bowl in Bozeman, Montana -- we’re proud to say that we skied 4 days with Chelan and he didn’t dump us for more exciting skiing, which is apparently what usually happens when he skis with his girlfriend, Piper’s, friends. For much less exciting pictures of Jack and I skiing in Europe, check out our blog).

Already 2 months into 2009, I feel my time quickly wrapping up here in Amman so I’d like to refocus my goals for the remainder of my blogging life as I know it in Jordan. Stay tuned over the next 3 or 4 months for:

The much anticipated posting of parts 2 and 3 of the “Cardiology in Jordan” series
A case study on the use of Diamox among our group of 12 hiking Mt. Kilimanjaro
A brief synopsis on the state of emergency care in Jordan, including experiences from the Al-Khaladi ED
Perhaps a guest entry or two from Dr. Brie Todd, my friend and OB/gyn resident who is coming to Jordan for the month of March to experience life in Labor & Delivery at the Jordan Red Crescent
Pediatric eye emergencies -- if I encounter any during my time with a Jordanian pediatric opthamologist
Continued stories and interesting findings from the Iraqi refugee clinic
More children’s heart stories from GOLA Heart Mission 2009, to start this February 21
And finally, stay tuned for results from the Hoop for Hope 3-on-3 Charity Basketball Tournament on April 3 to raise money for the beloved Gift of Life Amman

As always, thanks for reading.

*Picture taken from Backcountry Magazine. Click on picture for original context.

SurgeXperiences 210

Sun, 9 Nov 2008 14:35:26 +0200

I didn’t do an adequate job of pushing my agenda to talk about surgery and charity, but at least I had an excuse to put up a picture of Bono. Really, the charitable part of this Grand Rounds is the contribution made by all of you to the medical blogosphere. Thanks to all of you for your submissions. Hope you enjoy!

Physician’s Corner

Buckeye surgeon relays a once in a lifetime case of mesenteric ischemia, not to mention a great review of gastric vascular anatomy. He also reminds us that anything is possible - even necrosing a stomach.

In light of Halloween, and in the spirit of pumpkin carving, Suture for a Living reviews fingertip injuries, including classification of the injury and techniques for repair - very thorough with fantastic demonstrative drawings.

White Coat Rants helps out the linguistically challenged in “I Don’t Speak French” when he teaches us another name for the plafond fracture. Find out what a plafond fracture is and why it’s also known as a “Don Juan” or “lover’s fracture”.

Just when you thought Hallway Four was gone, her ghost returns as a guest host at Ten Out of Ten. Hallway Four talks about a surgical hernia case encountered in the ED…or is it really a hernia?

Science-Based Medicine thoroughly explores the advantages and disadvantages of circumcision in “Circumcision: What Does Science Say?” A good read for both physicians and parents before deciding what to do for their patient or son.

If you’re worried that a spreader-graft widens the nose, Beverly Hills Rhinoplasty Surgery Blog tells us that unless you’re a robot, the difference can’t really be noticed…what is noticeable is the improved breathing and improved aesthetics.

The Scalpel’s Edge writes why she isn’t so hard on her “stupid” burn patients anymore after her son’s incident with some hot porridge. “The other side of the waiting room” reminds me of an old book by Dr. Edward Rosenbaum, "Taste Of My Own Medicine: When the Doctor is the Patient".

Odysseys of George gives a radiology quiz that reminds us the importance of history taking skills...I could see this being a House episode where Dr. House tells his team for the 100th time, “the patient is always lying!”

The Online Cancer Blog discusses individualized treatment strategies for patients with renal cancers and why a nephrectomy even for localized tumors might not be enough…depending on the patient.

Written by a patient, every nurse and surgeon should read The Orton Family’s story of how patients should NOT be treated post-operatively.

Delhi With Avinash & Friends writes a fascinating article on the differences between near death experiences and out of body experiences, including a discussion of neuro-scientific theories to explain such phenomena.
http://delhiwithavinash.blogspot.com/2008/11/life-after-death-part-xxiii-has-science.html

Ethics & Surgery

Respectful Insolence discusses the fine line physicians must walk to lead and sometimes persuade patients to make the right choices, while also respecting their autonomy. The article is based on Orac’s quite comical story of an emergency physician who gives new meaning to the term “informed consent” when he bluntly details what will happen to a young patient who refuses emergency surgery.

Chloroform Rag carefully and thoughtfully discusses the problem of drug addiction among anesthesiologists in “One-Strike-Your-Out”. The article sheds some light on why denying a second chance at anesthesiology might be the better way to provide a second chance at life.

Thanks to Chloroform Rag, I’m reminded of a book by Dr. Abraham Vergehese - The Tennis Partner: A Doctor’s Story of Friendship and Loss. It is a moving account of the author’s personal encounter with a fellow friend and physician who succumbs to a drug addiction. It’s definitely worth reading.

Read this article about a transplant surgeon accused of hastening a patient’s death for the purpose of organ procurement. Who knows, but it’s seed for thought about the ethical boundaries transplant surgeons are faced with on a daily basis.

Other Things Amanzi gets caught up in Pretoria gossip and rumors without saying a word and shares why it’s never worth it to participate in work place gossip.

The Online Nursing Degree Guide posts a hundred resources for educating yourself on the issues surrounding health data privacy and security in the electronic information age. The articles are categorized according to: opinions, HIT, HIPAA, CCHIT (Certification Commission for HIT), EHR/EMR/PHR Information, Patient Safety, Privacy and Empowerment, Health Care Law and Policy Blogs, Specialty Health Law, eHealth, and Helath 2.0.

Surgery in the Media

Plastic Surgery 101 sheds some light on recent media coverage of nipple sparing mastectomy techniques – why make things more complex than they need to be?

An article in the Jordan Times about pyloric stenosis. It’s the result of a Family Health Project conducted by the partnership of Jordan Ministry of Health, USAID, and John’s Hopkins University.

Patient Corner

Tales From My Tiny Kingdom shares about her 24 year journey from Harrington rods to jazzercise.

Stephanie from How to Evict Your Useless Colon gives a pictorial account her most recent fight against ulcerative colitis – a colectomy with ileostomy. Her blog is a great resource for patients with inflammatory bowel disease, and interestingly, note in the comments section that there is a clinical trial to test the efficacy of online nursing care for ostomy patients. Great idea!

Colon of Carmen chronicles her ileostomy takedown and J-pouch procedure starting with the day before surgery through post-op day 3.

UC to J-pouch story provides a photo diary of living with an ostomy bag and actually has some great tips for how to hide the bag. You’d never know he lives with one. Thanks for sharing, Mark. Really, his entire blog is another fantastic resource for patients living with IBD.

Money Blue Book shares his experience with Lasik Eye Surgery and his story is a great resource for those who are considering Lasik.

World Dental discusses the various treatment modalities for oral cancer – surgical and otherwise. It’s a useful link for those patients and families dealing with oral cancer.

And Women’s Health Zone explains Metabolic Syndrome.

Training & Education

Monash Medical Student reflects on how he might choose a specialty. Needless to say, I’m a little disappointed that he didn’t even mention emergency medicine! With sincerity, please keep us posted! And for those trying to decide what specialty to pursue, this is good food for thought.

The Sterile Eye, a medical photographer and videographer, shares some of the challenges of working in the surgeon’s domain, but then shares why it’s worth it – all you need to do is to watch some of his videos – a diagnostic endoscopic ultrasound, a transhiatal esophogectomy, and esophageal stenting. Videography has tremendous educational value.

Saif, a premed student at UC Davis who is abroad for a Latino health internship, tells a story about shadowing a surgeon in Mexico City, and the comedy of errors that happen for a student in a new place, different culture, and speaking different language before he finally gets to where he wants to be – in the OR for a vertebral fusion surgery. Way to be persistent Saif!

Training to be, or interested in becoming a midwife? USPharmD+ posted 100+ Essential Online Resources for Midwives.

Surgeon or not, elearning gurus suggests we drop our backpacks and take a look at the compilation of internet tools available to enhance our e-learning experience with regard to research, studying, teaching, and organization. I especially like the free bibliography tools listed under “writing tools”.

Bonus

Be a plastic surgeon without the six to seven years of training. All you have to do is pay $9.95. Sweet.

SurgeXperiences is a blog carnival about surgical blogs, wherein surgical experiences are shared. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit. The next edition of SurgeXperiences (211) will be hosted by The Scalpel is Mightier than the Sword on 23 Nov, 2 weeks from now. Be sure to submit your post via this form.

Medicine pro bono

Sun, 26 Oct 2008 12:56:04 +0300

For the first time, I’ll be hosting SurgeXperiences Grand Rounds on Sunday, November 9. During my time in Amman, I’ve encountered a number of different non-profit organizations as well as lone physicians providing free or discounted care to the poor. As such, I thought it might be interesting for this grand rounds to carry a loose theme of surgery and charity. Anything from personal experiences of patients or providers with charity work to discussions about the ethical obligations of physicians and anything in between would be appreciated. Of course I’d like to include as many articles as possible so if yours doesn’t quite fit into this theme, please send it anyway.

**I will be traveling on Sunday Nov 9 so I kindly request that all entries be submitted to carolinevines@gmail.com by Thursday, Nov 6. Thanks!

picture from www.u2.com

Pediatric Cardiology in Jordan

Mon, 6 Oct 2008 19:51:52 +0300

This is part 1 in a 3 part series:

Introduction

The objective of this article is to describe a pediatric cardiology practice in Amman, Jordan and to discuss the educational value of a medical rotation with a pediatric cardiologist in the private sector. Amman has two private sector pediatric cardiologists, whom patients from all around the region travel to see. Recently, I spent a month with one of those cardiologists, who completed his pediatric residency and cardiac fellowship in the United States. After graduating from Jordan University of Science and Technology, training in pediatrics at the University of Nebraska and cardiology at the University of Cincinnati, Dr. Khaled Salaymeh, a Kuwaiti born Palestinian from Hebron, returned to the Middle East to practice medicine.

From a medical student’s perspective, the rotation was educational on both clinical and cultural levels. Over the course of 20 days, I saw 210 patients in the clinic, performed over 100 echocardiographic exams, started 19 central lines in the cath lab, placed one chest tube, and participated in post op care of 14 surgical patients. The opportunity to work one-on-one with the physician allowed ample time to discuss culture, religion, and politics in addition to medicine, which will be the subject of a future article.

Methods

I spent 4 weeks with a pediatric cardiologist. For 20 days, I recorded outpatient clinical encounters, cath lab procedures, and surgical procedures for patients to whom we provided pre- and post-op care.

Results

I saw 210 patients from countries throughout the region, including Sudan, Yemen, Syria, Iraq, Palestinian Territories, and Saudi Arabia also from many ethnic backgrounds, including Arab, Circassian, Assyrian, and Kurdish patients. Patients were of an age range of 2 days to 30 years old.

Of the 210 visits (table 1), 40% of visits were for follow-up, 26% were new visits resulting in a cardiac diagnosis, and 28% were new visits with no cardiac diagnosis. Additionally, 5% of patients were Iraqi patients with known congenital heart disease who were sent by the Iraqi government to Amman in order to receive surgical care not available in Iraq.

New Visits

Of 112 new visits, 54 resulted in a new cardiac diagnosis. The most common primary diagnosis was VSD, although VSD was on at least two occasions a secondary diagnosis as well. PDA and ASD were the second and third most common diagnoses, while vascular rings were a close fourth. The remaining 58 visits (52%) did not result in a cardiac diagnosis. The most common reason for visits not resulting in a cardiac diagnosis was evaluation of a heart murmur.

Heart murmur was the most common reason for a new visit to the cardiologist (table 2). Out of 42 visits to evaluate heart murmur, 21 resulted in a cardiac diagnosis, while 26 resulted in no cardiac diagnosis. Cyanosis, either at rest or during feeding, was the second most common reason for a new visit to the cardiologist. Five of those visits resulted in no cardiac diagnosis compared to 3 that resulted in a diagnosis of complex congenital heart disease (table 3). This excludes the Iraqi patients who were sent to Amman with known congenital heart disease, in which 9 of 11 patients exhibited central cyanosis. Chest pain was the third most common reason for a new visit to the cardiologist. All 5 visits for chest pain resulted in no cardiac diagnosis.

Follow-up Visits

Reasons for follow up visits were many and varied. The most common reason was follow-up of a known VSD at 9 visits, followed by 8 visits for rheumatic heart disease and 8 visits for dilated cardiomyopathy.

Iraqi Patients

Eleven Iraqi patients with known congenital heart disease were flown to Amman in order to receive treatment for their conditions (table 4). Age range of these patients was 1.5 to 27 years.

Procedures performed

In 18 trips to the cath lab, I performed 19 central access procedures under the supervision of the cardiologist . Eleven of the 19 were femoral arterial lines and 8 were femoral venous lines. The weight range of these patients was 8kg to 33kg. I observed the placement of one subclavian venous line.

Under the mentorship of Dr. Salaymeh, I performed over 100 echocardiographic exams in an outpatient setting. By the end of the month, I was proficient at obtaining parasternal long and short axis, apical, subcostal, and suprasternal views, differentiating between normal and abnormal, identifying pericardial effusions, and measuring pressure gradients across valves and septal defects.

Additionally, under supervision of a pediatric cardiac surgeon, I performed a right-sided chest tube placement after watching the surgeon place a left sided chest tube on a 12kg patient.

Discussion

This will be part 2 of the 3 part series. Please stay tuned!

Thank you Monash Medical Student

Wed, 1 Oct 2008 15:33:15 +0300

Thanks to Monash Medical Student for introducing me into the medical blogosphere and Grand Rounds community. Grand Rounds is a weekly compilation of articles written by bloggers in the health care arena, including providers, patients, students, businessmen, policy makers, and anybody that has anything to say about health. Check out Grand Rounds, Vol. 5 No. 2.

Ramadan Kareem

Wed, 17 Sep 2008 16:38:46 +0300

Recently, the father of one of my Yemenese patients who came to Amman to get heart surgery, gave me a book titled, “A Brief Illustrated Guide to Understanding Islam”. It was really a neat gesture. The pediatric cardiologist with whom I was working explained that in their faith, they earn points for good deeds, and working to spread Islam is one of the more important things you can do. It makes sense. It’s the Muslim version of Evangelism.

As it is the holy month of Ramadan, which began this year on Sept 1, I thought I’d read what the book had to say about fasting during Ramadan, which is one of the 5 pillars of Islam. No food, no drink (not even water), no smoking, and no sex from sunrise to sundown. The book explains:

“Although the fast is beneficial to health, it is regarded principally
as a method of spiritual self-purification. By cutting oneself off
from worldly comforts, even for a short time, a fasting person
gains true sympathy with those who go hungry, as well as
growth in his or her spiritual life.”

In particular, I found the part about being “beneficial to health” interesting. In listening to my Jordanian friends describe Ramadan, many say they actually gain weight. They talked about how unproductive everyone is, cranky drivers in nicotine withdrawal, sweets and pastries galore, and sleep deprivation.

The other day in clinic a patient with poorly controlled diabetes on two oral medications told me that she is fasting for Ramadan. When I explained to her that she is exempt from fasting because of her diabetes, she told me, “Khaifa Allah,” or “I fear God.” It is true that the sick, the elderly, the young, and travelers are generally exempt from fasting obligations, but many fast anyway.

And then they gorge themselves. And they don’t exercise. An article in the Herald Tribunes’ Daily News Egypt, referenced Jordanian health officials’ concerns for the increase in “heart attacks, strokes, diabetes, and simple indigestion cases seen at hospitals” during the first week of Ramadan. I don’t think there is any official record keeping, but wouldn’t that be a good study to do?

Interestingly, it is debatable about whether pregnant women are exempt from fasting. I would have to check with my ob/gyn friends, but common sense says to me that it’s not appropriate for pregnant women to fast for 12 hours a day. At least in some countries (although not Jordan), Daylight Savings Time was suspended early this year in order to shorten the long days of late summer. With each year, Ramadan, which is based on a lunar calendar, falls eleven days earlier than the year before so that when it falls on the long, hot days of summer, fasting becomes more difficult than ever.

Of course I love the fact that people can’t smoke during Ramadan. The problem is that those who do abstain from smoking during the day, light right up again once the sun goes down. Unfortunately, their smoking habit is never really broken. Furthermore, people smoke lots of tobacco via the narghile (aka sheesha, hookah, or hubbly-bubbly) during Ramadan. It would be interesting to know if the use of narghile, an already popular aspect of Arab culture, actually increases with the nocturnal festivities of Ramadan. Despite popular myths that using a water pipe to smoke tobacco is less toxic to our lungs, Dr. Rosenow, a pulmonologist at Mayo Clinic refutes this.

I do believe there are ways to make fasting during Ramadan a healthier practice...for those who are healthy enough to do it (ie, not my diabetic patients at clinic!). For example, a cycling group here, Cycling Jordan, has Iftar rides, in which they ride at least an hour to a restaurant or home where they have Iftar, or breaking of the fast, after sunset.

I’m from the country that has “de-fatted” everything, even fat itself. I’m not endorsing this is as a healthy eating style, but surely there are healthier ways to prepare the traditional Ramadan meals and desserts, such as baking instead of frying. Focusing on not overindulging at Iftar by eating slowly, and eating fiber and protein rich foods at sohour (pre-dawn meal) should give people more energy during the day, maybe even making them more likely to exercise.

Quitting smoking during the day is great, but why not use Ramadan as an excuse to quit altogether?!

These are just a few thoughts for healthier Ramadan living. The problem seems to be that most people just don’t think this way. It’s not that they want to be unhealthy, they just haven’t been educated about healthy living, and for many, like my clinic patients, concepts like exercising aren’t a priority when they are focused on the day to day struggle of just getting by.

So I think there’s a lot of work to be done here in educating patients about healthy living during Ramadan and after. In the meantime, I just hope I can convince my diabetics it’s better for their health to not fast!

Ramblings on Episiotomies and More

Tue, 29 Jul 2008 13:51:39 +0300

So the last I wrote about labor & delivery at the Jordan Red Crescent Hospital (JRC) was after my first day there. I recently completed my rotation in the department, and thought it appropriate to follow up with some final thoughts before moving on. The following is a rambling on some of differences I’ve noticed between life at the JRC and my experiences in Washington DC, as well as some of the things I’ve learned along the way.

So let’s start with a bang – episiotomies. I talked about this in my first entry. The midwives at JRC do episiotomies on every primigravida or first time delivery, and the majority of second-time deliveries. The indication at JRC: to prevent more complicated vaginal tearing by making a clean cut instead. Historically, the routine use of episiotomy has been practiced in the US as well, but has become very controversial. ACOG now recommends against the routine use of episiotomies and advises the use of clinical judgment to decide whether the procedure is necessary (see ACOG NEWS RELEASE). The main reason for this seems to be that past evidence largely underestimated the adverse outcomes of the practice – third and forth degree tears, anal sphincter dysfunction, and painful sex. Historically, indications for the procedure have been non-reassuring fetal heart rate, forceps or vacuum delivery, shoulder dystocia, or any abnormal labor progression. The idea is that the episiotomy expedites delivery and reduces the risk to mom and/or baby. Despite increased research regarding the topic, there still seems to be a lack of consensus regarding indications for the procedure. So in that sense, practice at JRC, isn’t necessarily that far off (I’m guessing there are practitioners in the states that still do routine episiotomies) – the difference is there is no discussion about the topic. At JRC, episiotomies are done for the sake of tear prevention (when in fact they increase chances of more severe tears!). If you’re interested, see the AHRQ website for a VERY detailed discussion of the evidence.

On the bright side (maybe not for the patient), I had the chance to see not just my first, but many episiotomies and repairs, and there has certainly been educational value in that. Furthermore, I’ve found that when I distrust practice methods that I witness – such as routine episiotomies, the use of Valium as a first-line drug (as if using it at all wasn’t enough) for the management of hypertension in pregnancy, or the treatment of first trimester bleeding with hydroxyprogesterone, beta-HCG and Valium – then I’m more likely to read about it and learn the topic better.

After interning with AHRQ last summer, the concept of patient centeredness as a pillar of quality care was ingrained in my brain. Not that US health care has even come close to mastering the practice of patient-centered care, but it has certainly become a critical component of medical education, and many hospitals have adapted policies to facilitate the delivery of such care. At JRC, and still, although to a lesser degree, in Amman’s best specialty hospitals, the patient sometimes barely seems a part of the equation as nurses and doctors chat and laugh amongst each other while the patient is writhing in pain in the bed. Or even worse, patients were sometimes treated like an inconvenience. There were multiple occasions where nurses yelled at screaming, un-anesthetized patients (not just epidural free, but not even local anesthetic) during an episiotomy repair and told them they weren’t in pain, but that they were just afraid. And these women had delivered children of their own (how quickly we humans are capable of forgetting)!! There’s also a different method for breaking bad news here. I remember one young woman who came into the antenatal clinic for vaginal bleeding. The ultrasound showed a missed abortion and the first words out of the physician’s mouth were related to the cost of the D&E the patient would need.

So I have a couple of thoughts as to why this is – lawsuits and the desert. The development of medical litigation in the US, as ludicrous as it can be at times, I think has been a driving force in the development of methods that keep patients from suing doctors. Americans, as patients, rightly have high (although sometimes too high) expectations of their medical system, but Arabs on the other hand have the “insha’ allah” attitude, which means their expectations are generally low, they tend to accept things the way they are as “God’s will”, and they don’t ask a lot of questions. Because of that, I think there is less drive to change the paternalistic style of practice that has evolved so much more in the western world (or at least in parts of it).

What’s the desert got to do with it? Well, I’ve realized that living in the desert is a tough lifestyle. I don’t mean because the aridity dries out your skin or exacerbates your allergies, but I mean the stress it exerts on those who live off the land as the Beduoins do. You can see it in their faces – a 20 year old woman looks like she’s 45. Arabs were historically nomadic, and living in the desert where there is a huge shortage of resources (I just returned from the lush pacific NW where brown hardly exists) and as a result, I think the Arab disposition has evolved into one that emphasizes self and family or tribe and doesn’t at all foster a sense of community within western constructs (Nations and work environment). The concepts of empathy or sympathy seem less incorporated into how people relate to each other in a non-familial community. As such, concepts like patient-centeredness don’t come naturally.

Which leads me to my next point – professionalism in the work environment. My experience at JRC was quite interesting in this regard. Most people were friendly to me, and some were incredibly hospitable. I shared meals with some of the nurses, which started an exchange of cultural foods among us (and no we did not eat in the designated break room – an OSHA hazard, for sure). The doctor who ran the antenatal clinic and oversaw all deliveries was very kind, allowing me to ask all the questions I could think of, teaching me techniques in obstetrical ultrasound, medical management of complicated labor cases, and of course episiotomy repair! Although the staff came to depend on me for doing H&Ps, I think most viewed me more as a guest and less as a team participant. Because among one another it was like having a bunch of siblings work together. People fought, yelled, and cried in the open on a regular basis. I recall a staff meeting that lasted an hour and although my Arabic wasn’t nearly good enough to understand what was being discussed, I don’t think I would have known even if it had been good enough, because people yelled at each other and cried for over an hour and a half – literally – and I don’t think anything was accomplished or that anybody was listening to what anybody else had to say.

The final difference I’m going to discuss is the issue of safety in the work environment. The discovery in the 80’s that diseases like HIV and Hepatitis C are transmitted through blood and other bodily fluids revolutionized the way we approach safety in the health care environment. For example, the use of gloves, face masks and eye protection when conducting procedures that expose the provider to bodily fluids, the development of safety devices on needles and proper disposal of sharps, and eventually the development of post-exposure prophylaxis. Every hospital in the U.S. must comply with these standard Universal Precautions that are meant to minimize the health risks faced by health care providers and deal with them in the event of an exposure. The first time I scrubbed in on a c-section at JRC, nobody had protective eyewear (myself included) and both the surgeon and scrub nurse were squirted in the eye with blood. Me – I went against the everything I was taught by the first surgeon I ever worked with who said, “A good surgeon always moves toward the blood,” meaning that when an artery squirts out blood at 120+ mmHg, a good surgeon will look to the source so she can stop it. Well, I think what that surgeon forgot to mention is that the good surgeon he was referring to also wears protective eyewear. Jack, my husband, and a his fellow foreign service officer were so disturbed by this that they found somebody to bring protective eyewear used by military personnel in Iraq (for artillery, not for surgery) on the next flight from Baghdad to Amman. And you can bet I’ve been wearing those ever since!

So yes, there are many differences between JRC, one of Jordan’s poorest hospitals, and the tertiary training centers in which I have trained in the greater DC area. No big surprise, I guess, but it’s interesting to discuss it nonetheless. And ultimately, I’ve realized it’s true that people do in fact, “try their best.” My favorite attending in medical school said that once (referring to patients, but aren’t we all at some point), and I totally disagreed with him at the time. Me, being the hard-core nut that I am, thought it sounded weak and was just settling for being sub-par. I interpret the comment now, not to mean that everybody actually is trying their best (I believe we humans often underestimate what we’re capable of doing) but, that it’s what we have to believe of others, because if we don’t, we’ll never make change.

Can you imagine if I walked into JRC as a 4th year medical student (ok, i’m technically a 6th year med student) and pointed out all the things I thought they were doing wrong and told them they needed to do better? It’d be insane if an outside physician who’d been practicing for forty years did that, let alone a 4th year know-it-all. The same goes for patients. Why should they listen to you if you’re accusing them of not caring about themselves. For most, I think it’s they don’t know any better. At JRC, people are just doing what they were taught, to the best of their ability, and they’re working with the resources they have (which happens not to include epidurals, labetelol, or hydralazine). I think people are much more receptive to changing if they feel understood and not accused. At the same time, I think it’s so important that we always are questioning the way things are and working to improve on the norm because I think in reality, we can always do better.

So when I was asked by one of the long-time physicians at JRC what I thought of the care provided by the hospital, I was as honest as I could be without focusing too much on the negatives, and said, “I think the care you provide here helps a lot of people who wouldn’t have care otherwise and I’ve really learned a lot from my time here.” You might think that was a weak response, and in a way I agree – it didn’t do a whole lot to improve care for those women at JRC on a large scale, but I also don’t expect that what I as a 4th year medical student would say in a sentence is going to change anything. Change takes time, requires relationships to be formed, and has to come from the right person. This time around, I wasn’t that person. In the future, I hope to be.

Potash? Do you smoke it?

Tue, 22 Jul 2008 13:48:45 +0300

A 16 yo known diabetic patient comes in to your ED obtunded with vomit on her shirt. She has a fever of 101.5, pulse 115, BP 100/75, she’s breathing rapidly (RR=25) and deeply. Her finger stick glucose is 337 and you notice her breath smells fruity, a nice change from the usual. It’s an easy diagnosis of Diabetic Ketoacidosis (DKA) and the stellar nurse rapidly gains IV access and hangs a bag of normal saline while you’re scribbling orders for the IV fluids and a cbc, chem10, serum ketones, foley catheter for urinalysis and microscopy, EKG, and an ABG, which you masterfully perform yourself. Since the patient is febrile and obtunded, you also consider a full septic work-up, thinking her infection is what sent her into DKA in the first place.

In the meantime, your ABG results are back and show a potassium of 4.5. Even though this is a normal value, you know that total body stores of potassium are depleted in DKA and the normal value is there only because of the ketoacidosis, which shifts hydrogen into the cells and potassium out. So you order a KCl drip at 5 meq/hr along with the first bolus of insulin (0.1 units/kg) followed by an insulin drip (0.1 units/kg/hr).

And now, all you can do is wait for the labs to come back and monitor the patient closely with regular glucose and electrolyte checks, waiting for the serum ketones and bicarb to normalize. SO you have some time to think, and you wonder....where does potassium chloride come from anyway?

And the answer is POTASH! Sounds like something people smoke, but in fact it is one of Jordan’s largest exports. Driving along the south Jordan side of the Dead Sea, you can see the Arab Potash Company (APC) plant, which in Jordan oversees the production of 250-300 million tons per year of Dead Sea brine. Potash refers specifically to water soluble potassium salts, which is only a small percentage of all the Dead Sea minerals that are mined by APC. The term potash actually comes from pot + ash referring to the discovery that wood ash contains potassium carbonate. Today, potash refers to any kind of water soluble potassium salt (potash is where potassium derives its name), and it is sold to fertilizing, chemical, and medical industries among many others.

So next time you’re about to hang that bag of KCl (or doing a KOH prep to test for a candidal vaginitis) , think of the Dead Sea - the lowest point on earth - and remember that it sacrifices its water supply (which given Jordan’s rapidly declining water supply is a whole other issue for another time) to help save your DKA patient (even if your potash probably came from somewhere else).

Tetralogy of Fallot (GOLA, part 6)

Thu, 5 Jun 2008 13:25:41 +0300

Basima is from rural Iraq. She is 7 years old and came to Amman for surgery to correct a problem known as Tetralogy of Fallot, also known as “Tet” for the four defects found in the heart, as depicted below.

The most amazing thing about this condition is that despite all these problems – VSD (remember our little blue-eyed Fadi), RV outflow tract obstruction, RV hypertrophy, and an overriding aorta – a single surgery can correct this condition (although sometimes really sick infants need a palliative surgery before full correction, and sometimes kids need surgery afterward for complications). Assuming it’s a straight forward case of “tet” and repair was done without complication, then these kids have a life expectancy almost as good as normal kids their age (in fact, a 1989 study at the University of Alabama-Birmingham indicated that survival rates at 1, 5, and 20 years post-op were only slightly less than those of an age, race, and sex-matched control population. With improvement in operative technique and post-op care, the discretion is probably less today, if existent at all).1

Here is an example of why congenital heart surgery is so incredible. Notice her blue lips before (left) and how they are PINK afterward (right)!

Unfortunately, what the pictures don’t capture is her energy level. More than any of the other “tet” kids operated on during Heart Mission 2008, Basima’s energy level drastically changed, perhaps because she was the oldest of all the kids at 7 (70% of “Tet” kids die by the age of 10).1

In this picture, taken before her surgery, Basima is squatting. Big deal, you might think. BUT, for a budding physician like myself, this is very exciting because I’ve always read about kids with this condition squatting, but I’ve never seen it. The reason “Tet” kids squat is that the action of doing so will actually increase systemic vascular resistance (the pressure against which the heart has to pump) and by doing so, will decrease the amount of blood that is bypassing the lungs in a right to left shunt through the VSD. These kids learn to do this because when they start to feel tired or short of breath, squatting will actually make them feel better by forcing more blood to go through the lungs where it can be oxygenated!

Another thing that Basima displayed beautifully (from the medical perspective) is clubbing. Not let’s go dancing clubbing, but rather a sign found on physical exam that can be found in patients with congenital heart disease.

Clubbing is a condition in which the distal segments of the fingers and toes are enlarged, the soft tissue at the nail bases has increased ballotability (in other words it’s squishy), and the nail has increased convexity (more arched) and the angle normally present between the nail and the cuticle disappears. For my medical colleagues, the result is a positive Schamroth’s test, depicted below. Why these club-shaped fingers? The mechanism is debated, but most researchers agree it’s related to vasodilation in the distal segments of fingers and toes, which is thought to be caused by circulating vasodilators normally inactivated in the lungs.2 In the US, we don’t usually find this in our peds cardiac patients because they usually get treatment before this condition has time to develop.

Basima has since returned to Iraq with her father to join her mother and 6 siblings. Here are a few more pics of Basima and Abooki (her father), who absolutely adores her.

References:
1. Jacobs, Jeffrey P, et al. “Tetralogy of Fallot: Surgical Perspective.” Emedicine. Sept 2006.
2. Schwartz, RA, et al. “Clubbing of the Nails.” Emedicine. April 2008.
3. Pictures: please click on diagrams to see original context.