Nephrology in a Resource Limited Setting, Gaza Edition

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by Nimra Sarfaraz

What did I expect from the healthcare system going into the Gaza strip, seemingly one of the most inaccessible and dangerous places on earth ?

It’s embarrassing to say that media portrayals played a role in my notions. I was expecting to see a lack of physicians in a weak system with destruction all around. What I saw was simultaneously heartbreaking and comforting. I went with a team from MedGlobal, a non profit aimed at providing sustainable health care services to refugees, the most vulnerable in crisis areas and in low resource settings. Through MedGlobal, a diverse team from a professional, ethnic and religious backgrounds formed. Our team consisted of specialists in pulmonary critical care, Ob/Gyn, pediatrics, colorectal surgery, surgical oncology, anesthesia, pediatrics, nephrology, heme/onc and neurology. The team had clinicians from both the UK and the US with members identifying as Hindu, Jewish, Muslim, Catholic, Christian and agnostic; our unity around a common goal was beautiful to be immersed in. Our goal was to provide patient care, teaching and donating direly needed medical supplies, all of us were there on our own time and paid our own expenses.

On our first day there, we met with officials from the Ministry of Health and heard from leaders in the oldest and biggest hospital, Al-Shifa . What I will always remember more so than the jarring statistics was the sense of pleading to be heard, heard by the global community about what is happening. There’s a mingled guilt and helplessness in situations like this and I always come away wondering what sheer dumb luck has led me to such a position of comfort and privilege to sit across from individuals ever capable and exemplifying resilience. Later in the day the clinicians dispersed to meet with their Palestinian counterparts in one of two of the main hospitals we were working at, Al-Shifa Hospital or Nasser Hospital with the purpose of understanding each specialty’s work flow and assessing needs for future missions. I was paired and rounded with Dr. Riad, a bright nephrologist who had studied and trained in Egypt. We rounded on patients together and saw cases that ranged from run of the mill AKI to more complex cases such as steroid resistant childhood nephrotic syndrome that was now worsening, prompting a change in therapy. We visited the dialysis unit where many patients greeted Dr. Riad more as a friend. At the end of the day, when the group reconvened over dinner, all our experiences were similar – the lack wasn’t of human capital or education, the handicap was in a stifling lack of resources and mobility. Half of basic necessary drugs are at zero stock level, meaning there are not enough essential medications to effectively run a hospital to last through the next month. Astounding. The average amount of electricity per day is 7 hours. Dr. Aarti Garg, who did laparoscopic colon surgery on this trip, witnessed firsthand electricity flickering mid operation: luckily, big hospitals have generators but what of regular people?

What was I able to contribute as a nephrologist ?

Honestly the nephrologists there are capable and bright. They are deft at managing complex cases and have access to medications such as tacrolimus, mycophenolate and steroids. Uptodate is a highly cherished resource. Some of the more expensive medications, such as rituximab, are impossible to access because of the blockade. If a patient needs these medications, they need to be transferred out of the Strip. Transfer to more advanced centers is an onerous process, as on average 43 people are given permission to leave per day. Thinking comparatively to Las Vegas, a city of about the same size, to imagine only 43 people allowed to leave Las Vegas per day is mind boggling. People can’t leave to study, to visit family or to get more advanced and necessary medical care. Kidney biopsies that are done are sent across the border to neighboring countries to be analyzed. There is no doubt room for improvement, though it would be remiss to comment without also noting that these limitations will be difficult to overcome unless the prevailing root circumstances change. One notable example was the number of patients in the dialysis unit and the space each patient was allotted. The dialysis unit was full to the brim with one patient able to reach over and touch their neighbor, privacy and space, you see, is a luxury in a densely populated area with limited resources. Medications such as erythropoietin and calcitriol were not available; many patients asked us if we were able to provide these medications on a regular basis. 

I have gravitated towards point-of-care ultrasound particularly because of ease of use, rapid diagnostic ability and practicality of use, especially in low resource settings. I’ve previously taken a course with MedGlobal and have been using the Butterfly ultrasound probe on a regular basis. The Intensivists at my home institution have guided and taught me along the way as well. I was tasked with teaching a Point-of-Care Ultrasound workshop to the Internal Medicine and Intensive Care physicians at Nasser and Al-Shifa Hospitals; around 35 med students and attendings attended between two hospital systems. The workshop was well received and we did bedside ultrasound on patients in the Intensive Care Unit there. This part of my time there was likely the most beneficial of contributions to the most amount of people as the clinicians there are going to be using what they’ve learned on an ongoing basis. 

I encourage anyone with even a fleeting curiosity to delve for themselves into the complexities of the situation and with intentional conscience not forget the humanity of people, approach learning about this situation with empathy. Often times the most common narrative is not reflective of reality.

#NephMadness Choosing Wisely Campaign (#NCWC) –Women’s Health Region (#WomensHealthRegion)

Blog Post

 

From ‘Prematurity’ to ‘Menopause’, life completes a full cycle in the Women’s Health region of Nephmadness 2018. Let it be the glomerular disease (preeclampsia) or dialysis & transplant (reproductive planning) or endocrine disturbances, this region has something for everyone, including our pediatric colleagues. The fact that all of the players in this region are of vital importance makes the choice even more difficult. 

For me, all are champions in their own way, but let’s try to peep into minds of #Blueribbonpanel (BRP) who will have the final word in crowning the champion. The fact that we have 6 wonderful ladies (out of 9 members) on the BRP is a testimony to the fact that this region is going to make it big.

Reproductive planning Vs Menopause in CKD

None of the BRP members have leaked any clues about how they might vote on the Twitter just yet. Therefore, we decided to do a deep dive and search the #WorldkidneyDay chat. This gives us some important clues. Fiona Loud (@FionaCLoud), Policy Director at Kidney Care UK, who is a kidney transplant recipient herself, has talked about Pregnancy in CKD.

She has actively advocated for the patient’s perspective related to pregnancy in CKD during the World Kidney Day chat (#WKDChat).

So it will be not a surprise if she votes for ‘Reproductive Planning’. Also, Eleanor Lederer (@EleanorLederer) had actively participated in the #askASN Chat and discussed reproductive issues in CKD

And she surely advocates pregnancy in glomerular diseases.

Quotes by Roger Rodby (@NephRodby) on reproductive planning are so famous that he was quoted in a presentation in India.

After reading his paper on “Disease-specific patient reported outcome tools for SLE” we are confident that he will favor reproductive planning. A Twitter and PubMed search for Deidra Crews (@DrDeidraCrews) didn’t reveal any clue directly related to these regions, however she has done some commendable work in the field of disparities in Chronic kidney disease and transplant which makes me believe that she will support reproductive planning in CKD as well.

Thus 4/9 votes for reproductive planning.

None of the PubMed/Twitter accounts of other BRP members had any other clues however, this post by Mark Reid (@medicalaxioms) might be the best clue we can get and is “right” to the point.

Menopause in CKD is an equally important topic addressing harmful effects on cardiovascular risk, bone health and on patients’ quality of life. But we expect ‘reproductive planning’ to be much more popular amongst the BRP. Also, Selection committee member Michelle Hladunewich (@mhladunewich) will try to persuade the BRP in the favour of Reproductive Planning as is evident in her important review on pregnancy in CKD and recently in ESKD.

A battle for the larger Global Impact: Preeclampsia Vs Prematurity

Two of the BRP members Fiona Loud and Mark Reid have a shared their experience with Preeclampsia in these tweets.

Eleanor Lederer has elegantly explained urinary findings is preeclampsia in this paper and she has also addressed this issue on twitter.

Tazeen Jafar’s work on young prehypertensives, on hypertension and cardiovascular health,  and on coronary artery disease in women is likely to make her inclined towards preeclampsia.

This makes it again 4/9 votes for preeclampsia.

The only BRP member who may lean towards ‘Prematurity’ is  Sarah Faubel (@doc_faubel) by the virtue of her work AKI in neonates. Bryan Carmody (@jbcarmody) has made an excellent argument in favor of prematurity in AJKD blog mentioning the long-term kidney outcomes, but unfortunately, he is not on the Blue Ribbon Panel.

Preeclampsia seems to be very popular amongst those who have already filled their brackets.

And that’s my poll for the Women’s Health Region

Bottomline – Women’s health region is here to win. Choose your pick wisely.

Follow #NCWC for daily region updates.

Read the full AJKD blog (and check out the full scouting report for the #Women’s healthregion here).

Submit your NephMadness brackets here.

Do let us know about your choices in the comments.