Case Spotlight

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In May 2019, the specialty of OB/GYN was utilized almost 20 times over the course of the month, making it our 3rd highest needed medical specialty this month. This is almost four times as many OB/GYN consultations than we facilitated in April. When we receive this type of case, we work hard to get it to a qualified physician as quickly as possible because we know that the health of the mother and fetus heavily depend on receiving quality care. In Kenya, the country from which the majority of these cases originate, the maternal mortality ratio is 510 deaths per 100,000 live births, compared to the world ratio which is 216 per 100,000 live births and world’s lowest ratios in Scandinavian countries that are 3/100,000. Often many of the women presenting to our partner clinics are very ill and do not receive regular prenatal care and monitoring. With a very small cohort of 4 OB/GYN trained physician volunteers available to us, this group of specialists goes above and beyond normal “volunteer” duties to get answers to referring clinicians and their patients as soon as possible.

One such case came in earlier in May, when a clinical officer in Kenya encountered a woman who was 26 weeks pregnant and reported feeling ill, which included complaints of headaches, fatigue, and vaginal itching. This experienced clinician knew to do some initial evaluation and performed a urinalysis, fasting blood glucose test, and confirmed fetal heart rate and movement. Upon analyzing the results of the testing, the clinician quickly understood that something was amiss. The patient’s urinalysis showed high levels of sugar, while her blood sugar reading was well above normal at 305. Unsure with how to proceed, he submitted an OB/GYN Referral to The Addis Clinic.

Understanding that this patient needed intervention and oversight by a clinician experienced in managing complicated pregnancies, we allocated this patient’s case to one of our OB/GYN volunteers who is also certified in Maternal Fetal Medicine. She was gracious to take the case very quickly and responded that her initial assessment was that the patient has either gestational diabetes or overt diabetes mellitus that was undiagnosed before pregnancy. The vaginal itching was probably symptomatic for a yeast infection that is common in diabetics, especially in pregnancy. The specialist also noted the patient’s elevated blood pressure. and laid out a plan of care to address all concerns.

She first recommended the start of a diabetic diet, checking glucose four times a day along with instructions, and directed the start of insulin with detailed guidance on what kind, when, and how much. She also recommended the treatment of the yeast infection with a topical cream and oral medication, and careful monitoring of the patient’s blood pressure. This was just the type of systematic, specific and appropriate guidance our clinical partner needed to start his patient on the correct treatment regimen. We are hopeful that by following this advice, the referring clinician will preserve the health of his patient and her baby throughout the pregnancy.

Graph of the Month

It seems that lately we have been calling every month "record-breaking", because that has been the truth! May 2019 was no exception, as we reached 112 patients across Kenya, Cameroon, Ethiopia & Haiti with almost 200 tele-consultations.  We brought on 5 new clinical partners in Kenya, and added two new physicians to our team - an adult endocrinologist from Australia and a general pediatrician in Addis Ababa, Ethiopia. Compare this to May 2017, when we only reached about 20 patients.  We are more motivated than ever to keep this momentum going and can't wait to see where we are in May 2020!

One big change this month was the jump of OB/GYN to become one of the top 3 specialties utilized! As a result we are ramping up efforts to recruit more of these specialists. We are especially grateful to our small team of women’s health experts who worked “overtime” this month to meet this unexpected need. Thank you!

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Case Spotlight

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We are often asked, "How do you utilize surgeons in asynchronous telemedicine?"  as we have a variety of surgical specialties on our team of volunteers to include general surgery, orthopedic surgery, breast specialists and even a neurosurgeon.

Early in April, The Addis Clinic received a case from a health worker in rural Kenya. A 9-month-old boy was brought to him in distress. Three months prior, the boy had a cerebral shunt placed to manage his hydrocephalus, a condition in which excess cerebrospinal fluid builds up within the brain and may increase pressure within the head. The shunt was meant to move the excess fluid in the brain to the boy’s abdominal cavity. In the days preceding his clinic visit, his mother noticed he was more irritable, and there was “swelling on the area overlying his shunt”. Far from the urban center in which the surgery was performed, the health worker looked to The Addis Clinic for guidance and expertise. Thankfully, just a few months earlier, we brought on a neurosurgeon working in Addis Ababa, Ethiopia who wanted to volunteer with our organization. He was eager to take this case and provide any guidance he could from a distance.

After examining the pictures and history provided by the health worker, the surgeon concluded that the area around the shunt was infected, and the shunt needed to be removed immediately. Knowing this would mean a long trip to the hospital where the surgery was performed, the surgeon provided advice on how to manage the acute needs of the patient. He recommended getting a Shunt Series of X-rays , as well as starting IV antibiotics at a dose high enough to prevent infection from affecting the brain, and finding a clinician in the area who was trained in tapping of the shunt (removal of a certain amount of cerebral spinal fluid to decrease intracranial pressure) which would give the boy some symptomatic relief.

This was a very complicated and serious case, and without the availability and input of this volunteer neurosurgeon, our partner clinician would have no one else to turn to for guidance. The rest of our team of surgeons provides advice similar to this every month, and our partners are always grateful for their expertise.

Graph of the Month

We broke the previous record of 15 needed medical specialties that we set in March 2019 by utilizing 16 specialties in April!  Almost 100 patients across East Africa and West Africa were positively impacted by the over 120 teleconsultations provided by our volunteers.  Additionally, we brought on two new Kenyan clinical partners and 6 new physician volunteers in the fields of internal medicine, general surgery, pediatrics, and critical care in April.  This consistent expansion increases both our reach and capacity to serve communities around the world without access to physician-level healthcare. 

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Case Spotlight

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Our March cases required the expertise of more specialties than ever before! One of these cases was a very ill 6-year-old girl with sickle cell disease. Her family brought her to a local clinical officer in Kenya because she was in intense pain, and suffering from headaches, exhaustion, fever and dizziness. Upon examination the clinician also discovered multiple ulcerations in this girl’s mouth. In his small health center the clinical officer tested her hemoglobin level, which was quite low, and then submitted the case to The Addis Clinic. He asked us to connect him with a physician more experienced in treating this type of patient.

Thankfully, we have a physician volunteer specialized in pediatric hematology, and she quickly agreed to take the case. Our volunteer hematologist reviewed the thorough case history and examination results submitted by the clinical officer and responded with a number of possible differential diagnosis. Her first thought was a viral illness due to the fever and mouth ulcerations, though she did not rule out bacterial infection, acute chest, or an aplastic crisis (temporary stop to the production of red blood cells). Her responses helped guide the referring clinical officer through the next steps to take in the patient’s care. Our volunteer physician recommended a blood culture and IV antibiotics if the girl’s fever increased to a certain point, a chest x-ray, and treating the patient with medication for her fever, as well as IV fluids and pain control. She also recommended testing the patient’s hemoglobin level at regular intervals to watch it improve.

Without The Addis Clinic, this patient would have had to wait weeks to be seen by a physician with this type of knowledge. Additionally, the cost of travel for the patient and the cost of the visit would be prohibitive for her family. Instead, she received top-notch care from her local provider, who had the knowledge of a specialty physician from a world class institution behind him. We look forward to sharing this young girl’s recovery story on social media very soon!

Graph of the Month

Wow! Not only was March our month for the most amount of teleconsultations provided by our physician volunteers (117), but it also holds the record for the largest diversity of medical specialties utilized (15 different specialties!).  While the typical "favorites" remain family medicine, pediatrics, and internal medicine, we also facilitated consultations that needed the assistance of cardiology, neurology, psychiatry, pulmonology and hematology specialists.  We are lucky to have each of these physicians, as well as many others, who are ready to be utilized when a case comes along that requires their expertise.  

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Case Spotlight

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The majority of our cases are referred by frontline health workers, yet we do receive a number of cases each month from physicians who need second opinions from physician volunteers. Providers who operate in large hospitals or outpatient clinics have constant access to professional colleagues with whom to share ideas, discuss patients and collaborate on treatment plans, but this is not the case for our partner physicians.  They are usually the only doctor at a rural hospital with hours of travel between them and another colleague, so they rely on The Addis Clinic teleconsultations for virtual professional discussions. 

A 5-day-old infant was brought by his parents to a rural hospital in East Africa because he seemed quite sick. The physician on duty immediately completed a full assessment, noting that the baby was having difficulty breathing, was grunting, and irritable.  His heart rate was elevated, and upon examination of his lungs, the physician heard crackling sounds. He initially suspected severe pneumonia, and started the patient on two different antibiotics, a nebulizer and a pain and fever reducer. However, after 3 days of this treatment the patient was not improving.  This East African physician transcribed the details of the case into our telemedicine platform and sent us the case, asking for pediatrician input.  A pediatrician volunteer with significant global health experience immediately responded that the baby seemed very sick with neonatal sepsis and pneumonia.  She recommended changing one of the antibiotics to one more appropriate for a newborn and asked some additional questions about the baby’s heart sounds, recommending referral to a larger hospital if the referring doctor heard a murmur.  Our volunteer pediatrician also recommended starting the baby on some IV fluids with dextrose until he was able to nurse or take a bottle. 

 While this case was just referred, and we do not yet know the outcome for this patient, we do know that the referring physician learned something new and now has the expertise of a pediatrician at his fingertips thanks to our telemedicine system and volunteers. 

Graph of the Month

As in most months, pediatric and family medicine physicians were our top utilized volunteers in February, though 17% of our cases were consulted on by dermatologists, making this specialty come in #3 in the rankings. We facilitated the diagnosis and treatment of scabies, infective dermatitis, tinea pedis and eczema among various other skin conditions.  To meet this increased need for dermatology consultations, we have been working hard to recruit new specialists and are excited to have added another dermatologist to our volunteer team this week!

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Case Spotlight

In the final days of January, we received the case of a 28-year-old male in Cameroon with “wounds on his legs”.  Eager to find out more about this patient and how we could assist the referring health worker, our staff replied with additional questions about the patient’s medical history, current status, and asked for pictures to help us better understand his status. What we received back showed a young man in need of urgent wound care and the assistance of a physician volunteer.

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When a case comes in on a weekend we often have to work harder to find an available volunteer, but when we saw this case we knew exactly who to ask. The Addis Clinic is lucky to have a number of very dedicated volunteers who make time for our partners no matter the day of the week, and the experienced emergency medicine volunteer who was assigned the case quickly responded that he would be happy to take it. 

 

The history provided by the referrer revealed that 8 months ago the patient noticed swelling of both lower extremities.  He sought out local treatment and the left lower leg swelling subsided, but the right lower leg developed sores that now engulfed the entire leg extending from the foot to the knee.  When the physician reviewed the picture sent by the referrer he saw a large granulating ulcer and determined that it should be treated as a second-degree burn and should heal with conservative treatment.

 

In an educational and thoughtful response, our volunteer not only provided guidance on how to manage the man’s wound, but also discussed the potential reasons behind this man’s chronic ulcers and requested additional information so he and this health worker could get to the bottom of this together.   We look forward to learning more about this patient and his progress as this volunteer and dedicated health worker work to treat his acute complaint as well as manage his ongoing health.

Graph of the Month

In January 2019 The Addis Clinic provided 129 volunteer physician teleconsutations on 93 cases submitted by our clinical partners across the globe. This is the same number of cases that we received in the first THREE months of 2018. With news of our positive work spreading, we are thrilled to meet the needs of so many frontline health workers and their communities. Even as we continue to bring on new partners and train new frontline health workers, the type of need remains the same. Family Medicine (30%), Pediatrics (23%), Internal Medicine (20%) and Dermatology (10%), continue to be our most utilized specialties.

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