PDF report

Frances Wensley
Imperial College London
Final year Graduate Entry Medicine
Elective April 20 to June 12 2015
Medical Student Elective Report
For my elective, I travelled to two countries, the United States of America and Ecuador. In the US, I
visited John's Hopkins University Hospital in Baltimore, Maryland. In Ecuador I travelled to the
Cuyabena rainforest and worked in local communities with an organisation called The Spirit Tree
Foundation. Each of these experiences was challenging and rewarding in its own way. Baltimore
During my time at Hopkins, I gained experience in paediatric anaesthesia. I was primarily based in the operating
theatres, assisting with cases and learning about the physiology, pharmacology and practical aspects of
anaesthesia. Compared to previous rotations I have done in anaesthesia and paediatric anaesthesia, I did very
little, mostly observing interactions and cases. However the experience gave me tremendous insight into a very
different healthcare system and often a different approach to medicine and surgery. Hopkins is, without a doubt a
spectacular institution and the cases I observed were often complex and high risk. The paediatric team were
incredibly skilled and many of the anaesthetists (anesthesiologists) had a background in paediatric medicine. I
spent a lot of time comparing my experience at Hopkins to a placement I completed in 2013 at Vancouver
Children's Hospital (BCCH) in the same specialty, as well as to my general experience in surgery and anaesthesia
in the UK. At both paediatric institutions I saw complex neonatal cardiac surgery and a fair amount of ENT and
maxillary facial surgery. I also followed the emergency teams. At Hopkins however I was struck by the sheer
volume of cases. There are 12 paediatric ORs and most days they were all in use. The types of cases seen were
reflective of the interest of the attending (consultant) surgeon rather than perhaps the local demographic. This
system is much more entrepreneurial system than the NHS. In other words, rather than having centres of
excellence, the hospitals hire surgeons who become individual experts, creating competition between individuals
rather than institutions. Surgeons would often have patients from across the country and sometimes
internationally. This placed a lot of pressure on surgeons and I saw various advantages and disadvantages
compared to the UK. My day generally started between 6 and 7am with pre-op assessments and often teaching. Unfortunately due to
the size of the department it was difficult to get to know any attendings well enough to be able to do my own preop assessments. This however was something that I received a fair amount of practice doing previously at BCCH.
There were separate consents for anaesthesia and surgery. The forms used for anaesthesia consisted of detailed
checklists covering relevant medical issues. Patients arrived throughout the day depending on their case.
Therefore the resident I was with often did only one or two pre-op assessments and then the remainder would be
done by the attending or a float anaesthetist while the current case was underway. An advantage of this was that
it allowed the list to move quickly, however it sometimes meant that the anaesthetist doing the case did not
always know the patient as well as if they had done the pre-op themselves. The level of detail on the forms
however made this less of a concern. Each day I would be paired with either a resident typically in their final year, a fellow who had completed their
anaesthesia training and was sub-specialising in paediatric anaesthesia, or a certified registered nurse
anaesthetist (CRNA). CRNAs are nurse practitioners (NPs) who have undergone additional training in general
anaesthesia. Their training is shorter than for doctors and more focused on practical application than underlying
processes or pathology. Each state in America utilises NPs differently and individual hospitals often have their own
guidelines. In Maryland, one attending is allowed to supervise either four CRNAs, thereby running four separate
ORs, or two residents. Hopkins typically had a much lower ratio in the paediatrics department. There is a lot of
politics between the CRNAs and anaesthetists and I met fellows who were sub-specialising in paediatrics purely
to make themselves more ‘marketable’. During my experience, I found in general that the anaesthetists had a
much stronger knowledge base and were also more interested in the underlying physiology and pathology related
to each case. The CRNAs had excellent practical skills and knew their procedures very well but by and large were
not as interested in the theory. Their role was much more focused on the technical side of anaesthesia and
importantly, they usually had someone to call on if complications arose with a case (although this may not be true
in all hospitals). I did of course meet many exceptions to this as well. Depending on the list, there would be between one and four to five cases in a day. Some examples of cases I saw
were spinal fusions, bladder exstrophy repair, mandibular osteotomies for infants with Pierre Robin syndrome,
cleft palate repair, neurosurgery, coarctation repair, hernia repair, trauma cases, anaesthesia for MRI, laser skin
treatments, bronchoscopy and loads more. Many of the residents reflected that through their training at Hopkins
they gained an inaccurate impression of what is "common" due to the higher prevalence of rare disorders treated.
For example, bladder exstrophy occurs in 2.15 per 100,000 live births (weighted incidence, Nelson CP. J Urol
2005;173(5):1728-31) in the USA and yet the specialist team at Hopkins will do 50 plus repairs a year. Most of
them felt however that this training prepared them very well to work in private institutions or to continue at big
centres in the US, such as Hopkins, Boston or Children's Hospital of Philadelphia (CHOP) - the East Coast has a
very high prevalence of major teaching hospitals. It definitely made for some interesting cases! Something I admired and appreciated during my experience at Hopkins, was the use of clear handover guidelines
for patients both in post-op and in PICU (see below). They used a systems-based approach, starting with
induction and airway, then working through neuro, cardio, resp, gastro, renal and so on. Working like this it was
easy to cover everything. A separate heading was added for pain just to emphasise it's importance. Anaesthetic
drugs were typically included under neurology, fluids under renal and anti-emetics under gastro-intestinal. By this
approach, any special considerations were also less likely to be missed. I appreciated how I was able to develop a
good structure under which to consider all aspects of my patients on the wards. While I feel that such a structure
is obvious it is not always articulated so clearly. During my days in the OR, I would finish between three and seven depending on the number and complexity of
cases. From five, any theatres still running were relieved by the late staff, typically comprising of CRNAs, fellows
or attendings. The great lifestyle of an anaesthetist was regularly pointed out to me! Interestingly, several of the
female staff were pregnant or had young children, which stimulated many discussions about women in medicine
and particularly poignant in the US, maternity leave; apparently the 12 weeks offered by the department was very
good! Calls
Apart from spending time in the OR, I also rotated through several other parts of the department, including acute
pain and paediatric intensive care (PICU). I joined the adult anaesthesia teams for blocks (epidurals, abdominal
[TAPS], etc) and for general OR calls, as there weren't paediatric resident calls. There was always a paediatric
fellow and an attending on call, but they would only come in to the hospital if there was a case, so I was would
stay with the general on-call team and attend all the paediatric cases. I typically did this on a Friday night so I
would go home for an hour or two in the evening and then come back to the hospital for the overnight shift, thus
doing almost 24 hours in total. Acute pain
One of the highlights of my visit was meeting the paediatric pain team and rounding with them in PICU and on the
wards. Hopkins was one of the first hospitals to actively manage paediatric pain, particularly in infants and
neonates. Groundbreaking research by Professor Myron Yaster in the 1980s demonstrated than good analgesia in
infants reduced post-operative morbidity and mortality and improved recovery time. While this seems obvious
today, because of concerns regarding the effects of narcotics on paediatric patients, many children would be
given only paracetamol to manage post-op pain. Hopkins provided not only excellent research in this field but
also led the way by creating a focused paediatric pain team to care for patients. PICU
I spent a week with one of the PICU teams. The unit was incredibly busy and it was not easy to get involved but I
saw a lot of different things and eventually had the opportunity to participate in the management of less complex
patients, including presenting to the consultant on the morning rounds. One of the most interesting aspects of this
part of my elective was that it gave me the opportunity to follow some of the surgical patients through their acute
care. For example, a boy came in with a traumatic injury to his neck, causing a tracheal tear that resulted in an air
leak into his mediastinum, spine, brain and around his lungs. I was in the OR when he came in at midnight. The
following week I was part of the team that managed his care in PICU. Then I spent a day with the anaesthesia
team in MRI and we repeated his scan before taking him back to theatre to remove the endotracheal tube. He
recovered well and we sent him off to the ward and then home. This happened with several other patients
throughout my visit. The PICU is divided into three teams, green or cardiac, blue, which is predominantly neuro but covers everything
non-cardiac and red, which acts as a back-up team, usually accepting short-stay cases, providing cover for the
other teams during ward rounds and organising patient transport. The medical teams are comprised of an
attending, a fellow, NPs and sometimes residents. There are also nurses and respiratory therapists at the bedside.
The NPs and residents provide the frontline patient care, placing orders, examining and monitoring between three
and five patients each. NPs work three 12-hour days each week, while the residents spend a week on each team
and a week doing nights. PICU is one of their busiest rotations. The fellows cover all of the patients on their team
with varying input from the attending, depending on their experience and the individual preferences of the
attending on for that week. 3
During my time in PICU I had the opportunity to go with the paediatric transport team to pick up a patient from
another hospital. Unfortunately it wasn't a helicopter transport but it was exciting all the same! We travelled to
Annapolis, sirens blazing, to bring back a girl with haematemesis from oesophageal varices. I again had the
opportunity to follow her care as she had an operation for a congenital vascular malformation in her liver. A day
later her repair thrombosed so she was taken back to theatre for emergency laparotomy and removal of the clots. Training days
Every second Thursday the residents were excused from clinical duties for a day of training. This to me seemed
like a real privilege as specialist trainees in the UK and US have very demanding schedules. However it was
considered an important part of their programme. The days typically involved a couple of hours of lectures on
pharmacology and/or physiology, with some sort of simulation session. On one day we did complex airway
management. Here we rotated through stations, doing cricothyroidotomies on pig necks, fibre optic intubations
and video laryngoscope (C-MAC) intubations. Other times we did group simulation exercises, such as transport
and pre-/peri-operative management of a paediatric burn patient. Both of these types of sessions involved
extensive debriefing discussions to identify strengths and weaknesses and clarify any questions people had about
procedures, etc. There was often some sort of informal teaching session or meeting over lunch, followed by an
hour of self-study or group project time and then journal club in the afternoon.
In addition to the focused days, there was a huge effort amongst the attendings to provide regular teaching to
residents. We had daily afternoon teaching during my time with the pain team, despite there only being one
resident on the rotation. In the ORs, attendings would run teaching sessions two to three times a week before the
start of cases. Typically three or four first year residents doing their first paeds anaesthesia rotation would be
around for these. All of these were formal, structured sessions to cover specific topics relevant either to pain or
general anaesthesia. Baltimore
For the duration of the elective I stayed in a medical student residence organised by the University. It was located
a five minute walk from the hospital within the security-protected East Baltimore campus. I found it hard to adapt
to having a security guard on every corner and even more strange to have the national guard stationed outside the
hospital during the riots. The area itself was a concrete desert. I walked all over my first day and couldn't find
anywhere to buy fresh groceries. Fried chicken on the other hand... Over the past ten years, Baltimore has become more and more gentrified. The waterfront area is lovely and it is
now a safe area to wonder around during the day. Plus there was a Whole Foods there (my nearest grocery store,
although very expensive!). I was very impressed with the Baltimore Museum of Art, which contains one of the
largest collections of Matisse paintings and loads of other famous works. I visited several other galleries and sites
such as Fort McHenry, where the lyrics to the American national anthem, the Star Spangled Banner, originated. During my stay I had an opportunity to visit friends in New York. I only had a night there but managed to see
Central Park and the Empire State building amongst other sites. And I had lunch in my cousin's restaurant in the
East Village, highly recommended! I also spent a night in Washington, DC. Walked and cycled the city seeing all
the monuments, getting an awful sunburn. And visited the Smithsonian Air and Space Museum. It was surprisingly
easy to get around the East Coast using buses, trains, Uber taxis and Car2go. In between Baltimore and Ecuador I had a one week holiday in the Galapagos Islands. While expensive, it was a
worthwhile experience to see the wildlife and stunning scenery. 4
The second part of my elective was meant to be spent working in a hospital in the Galapagos. Unfortunately due
to a family illness and some concerns regarding the organisation I was meant to travel with, the opportunity fell
through. However I still needed to complete the remainder of my elective. So after a much-needed rest travelling
the Galapagos Islands with my father, I went to a lodge in the Cuyabena rainforest in Ecuador, the basin of the
Amazon river. Here I met a team from the USA and Ecuador who were
going into communities to undertake health checks and provide antiparasite medicines and vitamins. The whole process was slightly
peculiar. I asked a travel agent in Quito whether he knew of any
volunteer projects I could join that were healthcare focused. He had
heard of a team of "doctors" in the rainforest that were doing health
checks. So he made a few calls and that night I was on a bus to Lago
Agrio near the border of Columbia. I travelled overnight with a tour group
from the hostel to a rest area where we slept in hammocks before being
taken by bus to El Puente and the Rio Cuyabeno (river). From there we
took a 30km boat ride down the river into the rainforest to Caiman Lodge
on Laguna Grande. It was here that I met the team. Julie is a nurse practitioner from Virginia,
US. She has been travelling to Ecuador for three years now with her
husband, Chuck, a physicist. Chuck had an undergraduate research
student, Matt, who studies Environmental Science. They'd visited a
village outside of Quito to set up a solar power project. The fourth
member of the team was Peter, who runs a Foundation in Ecuador that
works with indigenous communities to try to preserve the culture and
save the rainforest. There were two Ecuadorian guys, Franklin, who worked for Peter's Foundation and Javier, who
is a member of the Special Forces in Ecuador and our bodyguard until we were well on our way safely back to
Quito. The recent history of the rainforest and by extension, these communities, is heavily intertwined with the oil
industry. There are five different populations that live in this area, including the Siona and the Cofan. Since the
1960s when oil companies first arrived in Ecuador, the population of the Siona has declined from 35,000 to fewer
than 1000 individuals. Once a nomadic tribe, they now reside in semi-permanent settlements in what remains of
the rainforest in the northeast corner of Ecuador and parts of Peru and Columbia. In other words, with the loss of
over 90% of the Ecuadorian Amazon, there was a similar decline in the population. This has happened to all the
communities. Peter's foundation is involved in protecting the indigenous communities and the rainforest, often in
direct contradiction with the oil companies. Furthermore, this area is very close to the border of Columbia and was
an important route for drug trafficking to the coast. Thus the Special Forces. For each community, we worked with the leader of that community, whether it be the Shaman or another
administrative figure, to set up a one-day clinic. We arrived and set up medicines and basic equipment. Then we
waited to see who would show up. Julie and Chuck have records of people they have seen on previous trips, so
when they arrive, Chuck registers them and gives them their cards. Then Julie or I did a basic health check, asking
about any medical problems then listening to the heart and lungs, checking blood pressure for adults, doing a
brief abdominal exam and having a look in the ears. For the younger children we also inspected their feet; I spent
a fair amount of time cleaning between toes and applying anti-fungal cream! Once we had done a brief
examination we handed out a course of anti-parasite treatment. The drug was called Secnidazol, We gave a 2-day
dose to children (500mg / day) and adults (1000 mg / day), and a single infant dose. If the women were pregnant
or breastfeeding we withheld the anti-parasite treatment. And I got to do lots of pre-natal checks!! One of the
most concerning issues we identified was that many of the women were getting regular urinary tract infections
and possibly also vaginal infections. In one community, several of the women reported
that they had taken several courses of antibiotics from the local clinic but that the
infections keep returning. It was heartbreaking to not be able to help them more. We
gave advice on good hygiene practices and explained that if possible, they needed to
ask the clinic to test their urine or at least trial different antibiotics. Unfortunately though
I am not sure that this is even an option. There were several frustrating moments like this, where I felt like I needed to run through my list of differentials
and decide, without any diagnostic tests, whether someone needed urgent care. There was a really sweet girl who
was in the third trimester of her pregnancy and had been having trouble with itchy skin. My immediate concern
was that she had some sort of gallbladder or liver pathology associated with her pregnancy. However for her to
get to hospital would have been very difficult. So I needed to run through my differentials for pruritus of pregnancy
and decide, based on her history, whether it was really necessary for her to seek medical attention. These
situations were challenging as I could see that this woman was in discomfort and had she been in the UK we
would have run a series of tests to ensure there was no underlying problem and probably given her something to
help her feel better. All I could say here however was that if she experienced any additional symptoms indicative
of liver failure then she should go into hospital immediately. Again, there wasn’t a lot we could do.
There were also some really inspiring moments though. As my Spanish is almost non-existent, Peter acted as my
translator for complex conversations. A woman came in holding an obviously disabled child. We started talking
and she explained that he was a normal boy until he developed meningitis at the age of three and a half. This
caused severe developmental decline and he since hasn't walked or been able to talk. His overall mobility and
cognitive function were very limited. The doctors had checked his ears and reported his hearing to be OK.
Apparently his vision was good too but he had some oculomotor dysfunction. I examined the boy (who is now 10)
and other than a bit of a flow murmur, found no acute medical problems. Amazingly, he barely had any
contractures either. I talked to the mum and she said that he had started to develop
contractures but that she stretched him every day and did simple physiotherapy
exercises so that his arms and legs remained mobile. I was blown away when I
considered the amount of time she must have spent to achieve his level of flexibility.
All I could think was that she was doing more for her child than any doctor ever
could (and more than most children get in the Western world). I told her how
amazing she was and gave her some zinc cream for his nappy rash, daily vitamins
and the infant liquid parasite medicine as he was unable to chew (“mastico”). It was
heartbreaking but incredibly inspiring at the same time. In the more rural communities it was very rare to see children or adults with
disabilities. This is because they would not be able to survive the rainforest life. The
communities were very dependent on manual labour, whether it be hunting,
gathering plants, farming, cooking or building. It was unclear what happened when
people weren't able to contribute anymore, but it was apparent that they did not survive very long. It was only
when we visited the community near Lago Agrio, with access to a small medical clinic and bigger rural hospital
that we saw people with disabilities.
The Shaman
I met two shamans during my trip. Dalio was part of the Siona and Aurelio was from the Cofan. Both of them are
the last of their kind.These men start studying from the age of five or six years old and do not become shaman
until they are in their forties. That's almost forty years learning about the rainforest. They recognise every sound,
every plant, every movement. We would be driving along in the canoe at high speed and they would signal to
stop, spotting an anaconda asleep on a branch in a tree by the river. Or a rare bird sat in a tree a hundred feet
above us. Their role in society is first and foremost that of a spiritual and medical leader and healer. There are only a handful
of species of plant in this part of the rainforest that are edible, the other thousands of species have
pharmaceutical properties. In other words, they're toxic. The shaman is responsible for knowing all of these plants
and what they can be used for and how to prepare them into paste, tea, or some other concoction. In addition to
this role, shamans are also important political figures in the communities. Typically they would work with the
governor as leaders and to maintain relations with other communities. In recent years however, with the reduction
in population, the shaman may take on the role of governor as well, rather than have a separate figurehead. This is
the case with Dalio. His governor passed away recently so he became the governor as well as the shaman. An important tradition is that the role of shaman is passed down from father to son. There are no female shamans,
although there are female healers who play an important role in childbirth amongst other issues. One of the most
heartbreaking things I encountered here was
learning that the sons of the shamans were not
interested in continuing the tradition. Aurelio's
son had converted to Christianity, while Dalio's
sons were interested in Westernising and had
refused the opportunity to become shamans.
Therefore, Aurelio and Dalio are the last two
shamans of these communities. A similar thing
is happening across South America; with the
introduction of Christianity and the increasing
Western influence, these communities are
losing their heritage. Just as concerning
however, is the fact that the entire world is
losing a valuable source of knowledge. The
rainforest remains the most diverse place on
earth. The Western pharmacopoeia
already has a range of compounds
that were first identified in the
rainforest (and other endangered
areas!). We have no idea how many
more opportunities there are for us,
awaiting discovery. If, that is, we
don't destroy the ecosystem first. The morning we left the rainforest,
Aurelio, the Cofan shaman who, at 86
is the oldest in the region, took us on
a walk through the rainforest. He
showed us plants used as a sleep aid
for children, treatments for fluid
overload (natural diuretics), menstrual
pain, pruritis, urinary tract infections
and loads more that I’ll never
remember. The most spectacular part
of the walk however was visiting the
Soba, or “spirit” tree. This particular
Soba is an 800-year-old tree that
Aurelio uses when he wants to get in
touch with the spirits. He was telling us he used to climb the tree, although at 86 I think he’s finally retired to the
ground! One of the most moving moments of my whole trip was when we arrived at the tree after a 45 minute walk
through the biggest rainfall I’d seen all trip, Aurelio removed his poncho, walked over and stood next to the tree
smiling. He was waiting for a photograph. So, completely overwhelmed with admiration, I passed my camera to
Julie and stood next to Aurelio for the picture. Then we had a group photo to finish off the trip it also provides
some perspective to the size of the tree! This experience was enlightening and incredibly motivating. I left wanting to learn Spanish and develop simple
tests for drug sensitive pathogens that could be used in tropical climates. I want to return with more medicines
and work with the Shamans to identify how their techniques can be applied in alignment with our treatments. If
people can employ local resources then they don’t rely on us returning every few months or years with more
supplies. There was this interesting mentality that foreigners have introduced certain problems to the
communities, either indirectly by destroying the rainforest habitat, or directly via pollutants. Therefore, these
problems can only be solved by Western
medicines. That is one of the reasons I
think they allowed Western doctors to visit
in the first place. It is an interesting
perspective but I am not entirely convinced
of it’s truth. Unless there is money to import
medicines or other resources, then there is
more benefit to finding local solutions.
Furthermore, using local resources might
help to encourage further preservation of
the already fragile ecosystem. Anyway,
after many fascinating discussions and
hundreds of lessons learned, I travelled
back to Quito and spent a couple of days
being a tourist in the highest capital city in
the world, before heading back to London.