Bomberg finishes first week at Menominee Tribal Reservation

Posted on behalf of 3rd Year MedPeds Resident Eric Bomberg

Hello all! Eric Bomberg here, just finishing up my first week in Shawano, Wisconsin at the Menominee Tribal Reservation.

The experience here has been fantastic! I work as a Medicine/Pediatric hospitalist in the morning, seeing patients from the Menominee tribe who were admitted.  In the afternoon I go to work at the Menominee Tribal Clinic, where I have my own schedule of patients.

The picture above was taken looking out from the balcony at the home where I am staying.  We're close to the river at home and at the hospital!  We have wireless internet, cable TV, a full kitchen, a laundry machine, and weekly house cleaning services.  They take good care of us here

At the hospital, all of my meals are covered and they even pack me a bag lunch to take with me when I go to clinic.  Because the hospital is small, everyone there knows who you are and they know my food preferences!

The hospital has 25 beds and we take care of everything from newborns to trauma. The patients at the hospital are not all from the Menominee tribe, and there are many other providers there as well.  We admit our own patients from clinic and almost exclusively follow tribal patients while there.

The major things I have taken away so far is what is means to practice in a rural setting (Shawano is the largest town around here with a population of approximately 9,000).  It's not uncommon to see a patient in clinic and then follow them in the hospital.  The experience of practicing medicine in a rural setting first hand is so valuable and I've already learned so much in one week. 

More to come!!! Eric

Satrom Gives a Tour of Elective Site

2nd Year Pediatric Resident, Katie Satrom, recorded a video presentation for the Annual Global Health Grand Rounds: While They Were Away: Resident Contributions Abroad 12-13 held on May 29, 2013.

Satrom Enjoys Some R&R Away From the Wards In Cameroon

The following post was contributed by second year Pediatric Resident, Katie Satrom, on international elective.

Mbingo offers great opportunities for beautiful hikes. Since the hospital compound is about 45 minutes from the nearest town, many of the hospital staff go hiking on the weekend for entertainment and exercise. Here are a few photos from our recent adventure!


Walking in some tall grass


One of the many beautiful waterfalls


Cows being herded by the Fulani people, a nomadic cattle herding group across West Africa


Paying homage to the coffee bean at a nearby coffee plantation


View of the hospital compound

Case Study From Cameroon

These cases were submitted by 2nd year pediatrics resident, Katie Satrom on international elective in Cameroon. Photographs were used with the permission of the family.

CASE 1. Differential Diagnosis of Acute Jaw Swelling

6 year-old previously healthy male presents with 3 days of painful left jaw swelling. The pain is worse with eating and is associated with bleeding from the mouth.

After IV therapy

Outcome: Given extremely poor dental hygiene and initial improvement with antibiotics, the child was continued on IV antibiotics for the treatment of a dental abscess and associated cellulitis.

CASE 2. Fine needle aspiration consistent with Burkitt's Lymphoma

5 year-old previously healthy female presents with 2 weeks of painless right jaw swelling. She was seen by an outside facility where she was treated with antibiotics for a presumed dental abscess without improvement.

After 1 cycle of chemotherapy

Satrom Arrives In Cameroon

The following post was submitted by Katie Satrom, MD, second-year resident in the University of Minnesota Pediatric Global Health Track:

The view from my room

Greetings from Cameroon!

Dr. Tina Slusher and I arrived safely in Cameroon last week. We're working at Mbingo Baptist Hospital, which is a 250+ bed mission hospital in the Northwest Province. There are 45 physicians who work here, 600+ staff, and over 100 volunteers annually.

The pediatric ward consists for 20 general beds and another 6 oncology beds. There are also some children who are boarding in the surgical and ortho wards. In addition, there is a newborn nursery associated with the maternity ward and a very small NICU.

Currently 3 American pediatricians are working at the hospital. They are all recent grads who have committed to working here for 2 years. The hospital has surgical residents through the Pan African Academy of Christian Surgeons (PAACS) program and also a med-peds residency (although they only do 25% pediatrics).

The hospital entrance

Our daily routine consists of morning report from 7am-8am, followed by either rounding in the nursery or seeing some clinic patients. Inpatient rounds begin at 9:30.

The local residents do all of the pre-rounding, documentation, and most of the orders. Later in the afternoon, we will follow-up with any loose ends, see new admits, or spend more time in clinic or nursery.

Our role is more for supervision and teaching, as the local residents do not have much pediatric experience. I am learning a lot from the residents as well, especially about specific endemic diseases and also how to best use limited medical resources.

Drs. Satrom and Slusher with two nursery nurses and another resident, Erin Young

There are a lot of volunteers who are coming and going. Currently there is an American adult nephrologist who is here to help set up peritoneal dialysis. We have had two interesting cases of nephrotic syndrome on the wards, so he has been a helpful consult.

This week, Dr. Peter Hesseling, a pediatric oncologist from South Africa, and his team are here. They have a Burkitt lymphoma protocol to deliver simple, low-cost treatment for children that can be used in rural hospitals. Their team has treated more than 900 cases of Burkitt's in this region of Africa so far.

There is also a 2nd-year pathology resident from Mayo here for 6 weeks, so it's been fun to hang out with her. My husband comes next week to help with some engineering projects, so I'm looking forward to that!

Drs. Slusher and Satrom on rounds on the wards

My first day on the wards, I saw a new diagnosis of Burkitt's lymphoma, intussusception, cerebral malaria x3, acute bilirubin encephalopathy, TB peritonitis, H. flu meningitis, and bilateral retinoblastoma, just to name a few

This 26-week preemie was born here and was stabilized on bubble CPAP, and is actually doing quite well. Dr. Slusher and I check in on her a few times a day and have had to be creative when the power goes out for extended periods of time.

I've also been able to observe and help Dr. Slusher teach the Helping Babies Breathe protocol to the local nurses. One of these nurses is visiting from another city and will bring back what she has learned to teach others. It's pretty neat to watch them learn about simple neonatal care and to know how big a difference that can make in infant mortality if done well!

I'll try to write additional posts with interesting cases and pictures. The internet connection isn't great, so sometimes it's hard get online and especially to upload photos.

Katie

Friedman's Final Week In Cambodia

The following was authored by DeAnna Friedman, 3rd-year pediatric resident:

Our last day at AHC has passed. We helped out on the Low Acuity Unit this week because a lot of the senior doctors were in a training about pediatric critical care that was being provided by some doctors from Australia. The LAU has a bit slower pace, as there are only 10 beds and 3-4 of those children are usually chronic kiddos getting either physical or nutritional rehabilitation.

One of my patients has been in the hospital for almost 2 months because he had encephalitis and now has left hemiplegia. He is improving with physical therapy and now is able to take more food by mouth (he initially had a pretty significant right lower facial nerve palsy along with his hemiplegia), but his progress is slow and steady. We don't know what caused his meningoencephalitis, as is often the case here. No bacteria ever grew in the CSF culture, and we don't have many viral studies available. His mother has been VERY good with him, learning the PT exercises, feeding him slowly and patiently, and always with a big smile on her face. She's easy to laugh and very talkative.

He has a little brother who looks to be about 6-8 months old (it's hard to know here; children range in size very widely) who is often bored while his mother is working with his older brother, so yesterday I just played with him for about half an hour while his mother was taking care of other things. She thought it was hilarious. It's amazing how happy and upbeat people can be in the face of adversity, which is a common thread I've found in all of the places I've worked internationally.

We rarely see a normal CBC here, between the iron deficiency, the malnutrition, the dengue hemorrhagic fever, the leukemias we can't treat, and the high rate of thalassemia. However, many of the children do not have clinical features or need transfusions, indicating that they likely are either nutritional or thalassemia trait (the test for thalassemia takes about 2 months to get back unless they have obvious Hgb H bodies on their smear, so we won't know for sure about many of the children we tested during our month here).

This child had clear signs of beta-thalassemia disease while in LAU this week. Here is a picture of his chest from the side.

The chest x-ray of the child with beta-thalassemia.

He has so much extramedullary erythropoiesis, and his ribs are so large, that he appears barrel chested from his large ribs. He clearly has not had good preventive care for his thalassemia. However, chelation therapy is not available here, so you trade less extramedullary erythropoiesis for increased risk of iron overload. It is a difficult balance here. This child also presented to the hospital by himself. He is 16. The social worker stopped by to talk to him, but it is not clear to me what his home situation is. He may have just come alone because his parents are busy working, but it is still a harsh reality that some of these children travel to AHC to get care alone and stay in the hospital without any family support.

We went around and said goodbye to everyone, and everyone was so nice. They all said that they would love to see us again, or asked when we were coming back. I'm not sure if it will be in the cards or not, but this place is always growing and developing, and it may be interesting to come back someday and see how it's changed.

AHC is currently building a neonatal area for the premature babies that they care for.

While there currently is no TPN, surfactant, or oscillators (so the VLBW babies likely won't make it), they can care for the later preterm babies that just need warmers, antibiotics, close monitoring and NG feeds. And with the sectioned-off area, hopefully the rates of nosocomial infections will decrease in these little ones.

And the hospital staff are looking for ways to improve. It is nice to work in a place that is making the best of what they have, moving forward and learning how to improve as they go. While I won't miss the constant barrage of people wanting to sell me things, I will miss how much less complicated life is here and the feeling that, while you may not be able to give these children everything that is available back in the U.S., you're giving them the best shot they have in Cambodia and how thankful the families are for that.

Vislisel's Final Week At AHC

The following was written by Amy Vislisel, third-year pediatric resident:

Buddha statue at Preah Khan. Like most statues of Buddha at the temples, the head has been removed. The missing faces are actually from a couple of different reasons. First, the temples have changed from Buddhism to Hinduism (and some back again), and the faces of Buddha were removed at those times. Second, people over the years have stolen what faces remained to sell or to place in museums..

I am completing my 4th and final week at AHC, and I was able to spend some time in different areas than in past weeks. Specifically, I spent a day with Dr. Lyda, a pediatric radiologist who has been working at AHC since it was founded. He reads all imaging studies, including x-rays, ultrasounds, and echocardiogams.

I was able to observe several echos, and a new ASD was diagnosed.. Fortunately, a cardiothoracic surgeon will be at AHC in the upcoming weeks and will hopefully be able to close this child's ASD.

Another child with severe mitral regurgitation, however, will not be as lucky. The surgeons will not be able to repair his valve due to the severity of his disease and the poor outcomes they have had so far with bypass surgery. It is difficult to see a child with a fixable heart condition be transitioned to palliative (and soon hospice) care.

I was also able to spend more time in the outpatient unit (OPD). Every day that I have worked in the OPD, I have seen a child with an animal bite. These are usually dog bites, which didn't surprise me at first because there are so many stray animals on the streets.

It turns out, however, that most of the animals were pets and were able to monitored for rabies. This has been true for all but one patient I have seen. For that child, the family did not know the dog, and they thought it actually looked 'crazy' and was foaming at the mouth. There was clearly concern for rabies exposure, and the child was treated accordingly. Her bite was on the thigh, and given the location (a reasonable distance from the brain), AHC protocol is to give only the rabies vaccination. Rabies serum is not readily available and is reserved for people who have been bitten on the head and neck.

During my month here, I have had the opportunity to get to know some of the residents. I have found it especially rewarding working with the interns. Their medical education is quite a bit different than ours. They go to medical school for 4 years, as we do, but have no clinical experiences during this time. We performed a fundoscopy on one patient, and I was able to demonstrate for the interns the proper technique, as well as describe what a normal retina looks like (with the help of the internet).

I think it would be great it future resident volunteers were able to take some of their time to help teach basic physical exam skills, as this is an area where I feel we can be especially useful!

On a different note, I wanted to add some follow-up on a patient I mentioned in my blog last week. The 6 month old with kwashiorkor and zinc deficiency dermatitis is doing well, with remarkable improvement in his dermatitis. It is remarkable what zinc replacement and better nutrition can do!

This was the 6-month-old male with kwashiorkor and zinc deficiency dermatitis, one week after admission. His rash has remarkably improved after only one week of zinc replacement - compare with last week

Tree growing out of a temple at Ta Prohm, well known for being where Tomb Raider was filmed!

The site of our cooking class. We learned how to make fish amok (traditional dish in Cambodia). Hopefully I'll be able to reproduce it at home!

Garden at local house near our cooking class. Some families are able to use PVC piping as planters, which makes the plants easier to water (especially in the dry season).