Patrick LaRochelle, 2007 CGH University Scholar, discusses his current work in the DRC.
Q: How does your work today connect with your experience at UVA including your experience at the School of Medicine, your global health scholar work, and other experiences?
I have now been in Nyankunde, a small town in the northeastern Democratic Republic of Congo, for 6 months, as part of the Post-Residency program of World Medical Mission/Samaritan’s Purse. The goal of this program is to place doctors who have recently finished residency under the mentorship of experienced missionary physicians and to facilitate this transition logistically, financially, etc. Centre Médicale Évangelique-Nyankunde is a Congolese run Christian hospital with a long history of providing excellent care in this region. It was largely destroyed in a massacre of over 1000 people in Nyankunde in 2002, but is in the process of rebuilding—both structurally and in terms of personnel. As a dually boarded internist and pediatrician, I have had the opportunity to work alongside Congolese doctors and several expatriate doctors in both of these areas. Malaria, tuberculosis, HIV, schistosomiasis and malnutrition are all very common here, as are diabetes, hypertension, and trauma.
I see the work that I am doing now as, in many ways, the outflowing of my education at UVA School of Medicine. My time at UVA fueled my interest in international healthcare, provided me with mentors, and gave me models for healthy, respectful international engagement. Not only did I learn to think analytically about disease processes and treatments; I was also challenged to consider the social determinants of health. With the assistance of CGH, my classmate, James Platts-Mills and I applied for and were awarded the Pfizer-Center for Global Health Research Award in Infectious Disease, which funded research in Lima, Peru, on the sero-prevalence of leptospirosis in a peri-urban slum. This was my first experience conducting research and an incredible learning opportunity—not just about leptospirosis but also about international health, poverty, and not least, about myself. Working with underserved patients at the Charlottesville Free Clinic and working at a clinic in Guatemala as a fourth year further solidified and deepened my interests in tropical medicine and international health.
Q: What process did you follow to get to where you are today?
Medical school and residency do not allow an enormous amount of flexibility; however, given my interests in international health and working with the underserved, I tried as hard as I could to gain experience in these settings, whether by doing rotations or research abroad, finding mentors with similar interests, participating in Center for Global Health events, and volunteering at the Free Clinic. I also worked a great deal to improve my Spanish proficiency to be able to better care for Latino patients. And even though I work in a “bush” hospital now and have not thus far had the opportunity to do research in this setting, I earned an MPH in epidemiology to give me the tools to look beyond my clinical encounters with individual patients to population disease dynamics. I chose to do my residency in combined internal medicine and pediatrics at University of California-San Diego in large part because of its location on the border with Mexico. My time in San Diego, with its sizeable population of Latinos and refugees, gave me the opportunity to do “international health” in the United States. Through UCSD connections, I was also able to spend a month at Maputo General Hospital in Mozambique. This was an amazing opportunity not only to see tropical diseases in some of their more dramatic forms but also to participate in a healthy, mutually empowering global health collaboration between UCSD and Maputo General’s residency program. As for the specifics of how I ended up here in Nyankunde, I simply applied for the post-residency program of World Medical Mission, was accepted, and was given several options of locations. We felt like we were called to serve here in the Democratic Republic of Congo, and after 6 months of language training in France, here we are.
Q: Any advice for specific skills students should develop while in school that would be helpful for this type of work?
Hospitals and health centers in the developing world are very diverse. Some are focused on training and teaching, others simply on providing care to patients. Some hospitals have many resources (technological, pharmacological, and in terms of human capital). But for most, resources are very limited. Ancillary staff are often not as well trained or equipped as those in the United States, requiring more micromanagement of the details that are often taken care of automatically in the United States. Diagnostic modalities are often very limited.
I was told over and over at UVA that the vast majority of diagnoses come from history and physical alone. This is certainly the case in the developing world, where our ability to definitely diagnose conditions is more limited. So, at the most basic level, the more students refine their abilities to communicate with and to examine patients, the more effective they will be in the international setting. Even after spending 6 months in France learning the language, I can only communicate more than at the most basic of levels with less than half my patients, the majority of whom only speak Swahili and tribal languages. When my ability to take a good history is limited, a thorough physical exam is all the more important and often reveals the diagnosis.
Beyond history and physical, procedural skills are essential. In a world where patients wait as long as possible before coming to the hospital (often because they can’t afford medical care), patients often arrive severely dehydrated or floridly septic. Gaining intravenous access on difficult patients is an essential skill. We often receive patients with hematuria after foley catheter balloons have been inflated in their urethras. Basic skills like these are essential, not only for providing direct care but also for teaching others. We see an enormous amount of tuberculosis and schistosomiasis here, and thoracenteses, paracenteses and chest tube placement are essential skills. Compared with most hospitals in this region we are relatively well equipped, but nonetheless, our only imaging modalities are x-rays, ultrasound and endoscopy. Facility with ultrasound in particular is tremendously helpful. Try to ultrasound patients before you send them to radiology, or at least try to learn from the echo tech. And don’t let yourself finish a cardiology rotation without being able to do a basic echocardiogram. We also see all too frequently receive patients who are vomiting blood due to ruptured esophageal varices (often a product of cirrhosis from schistosomiasis). I’ve had the opportunity to learn upper endoscopy and variceal banding here. If you’re looking to save a life, try to get some endoscopy and bronchoscopy experience during your GI and pulmonology/critical care rotations.
Lastly, facility with microscopy will serve you well in a low resource setting, whether for diagnosing scabies or fungal infections, reading gram or Zielh-Nielson (for TB) stains, looking at thick and thin smears, evaluating red blood cell morphology to diagnose the cause of anemia, or examining urine sediment.
Q: What are your biggest challenges in your role and how do you respond to them?
I love working here in Nyankunde. I have the opportunity to care for and (often) heal many of the sickest patients I have ever seen. For many of these patients there is literally no other healthcare option available apart from traditional medical practitioners. As a Christian doctor, I have the opportunity to be the hands and feet of Jesus in a very profound sense.
There are many challenges and frustrations, though. While we are relatively well-equipped thanks to Samaritan’s Purse and connections with doctors and hospitals abroad, we still often lack essential resources. I frequently round on a septic patient and learn (24 hours too late) that the pharmacy has run out of the antibiotic I ordered the day before, and so the patient has received no treatment other than IV fluids. We frequently run out of basic masks and nonsterile gloves, leading to the inappropriate use of more expensive N95 TB masks and sterile gloves. We often have temporary ruptures in supply of TB treatment, and we have no HIV confirmatory testing or anti-retrovirals available at our hospital (though this will hopefully change soon). Our only intracranial imaging possibilities are ultrasound of the optic nerve (to assess for papilledema) or ultrasound of the temporal bone, which can sometimes reveal (or rule out) midline shift or large hemorrhages or masses. We frequently receive hemiplegic or obtunded patients, and our efforts to diagnose and treat are severely limited by the lack of a CT scanner or and MRI.
Perhaps even more frustrating is a lack of urgency and (often) a lack of training on the part of our nursing staff. Most of our nurses have only a high school education, and too often they have too low a view of their ability (and responsibility) to care for patients beyond simply placing IVs, taking vital signs and giving medications. We work on a daily basis to encourage and empower our nursing colleagues to try to interpret vital signs rather than just record them, to talk with and examine patients rather than simply wait for the doctor to do this, to take more of a responsibility in teaching and training student nurses. Not least, we are working to increase the sense of urgency on the part of nurses regarding severely ill patients. It is not acceptable for a patient to be hypotensive or hypoxic all night and not to be informed.
On the part of patients, we too often receive patients who have been made worse by treatments of traditional medical practitioners. We also have a very hard time inculcating in patients an understanding of the concept of chronic disease. Too often patients stop taking antihypertensives or diabetes medications as soon as they start to feel better.
Lastly, it is difficult to reconcile my American ideal of providing whatever care is necessary to whoever walks in the door with the financial realities of a Congolese-run hospital. Though the hospital has received a great deal of support from organizations like Samaritan’s Purse and receives ongoing assistance from the European Union, and though it is a Christian hospital, its financial situation is nonetheless very precarious. Hospital staff often get paid several months late, and there is minimal discretionary spending. Patients often leave in the middle of the night to avoid having to pay their hospital bills or stay in their same room for weeks after their discharge because of an inability to pay. It is an ongoing challenge to balance my responsibility to advocate for patients (many of whom are the poorest of the poor) and do what is necessary to make them better while simultaneously respecting the needs of hospital staff to get paid and of the hospital to remain financially solvent.