Saturday, April 5, 2014

Interview with Dr. Abdurazek Ahmed Abdela (see attached video)

Summary:
1.       Greatest need that our Endocrinology patients have:
1.1.  Educational:
Well designed educational tools in particular for our diabetic patients that can be modified and adopted to our Situation
1.2.  Support for lab Services for diagnosis and follow up:
a.       Development of Hemoglobin A1C that is standardized and available both in the labs and point of care
b.      Hormonal assays for Vit D, PTH, Testosterone, and pituitary hormones.
-          Inconsistently available and sometimes issues with reliability
c.       Cosyntropin Stimulation test
-          Diagnosis of adrenal insufficiency is mainly based on clinical evaluation
d.      Biochemical tests to diagnose pheochromocytoma: not available at all
1.3. Treatment related needs
a.       Point of care HbA1c for outpatient services
b.      Glucometer for SMBG for type 1 diabetic patients in particular and some of type 2 diabetic patients
c.       Glucometer for the inpatients admitted with diabetes mellitus to the ICU, general internal medicine wards, and Obstetric wards.
-          Great difficulty in managing these patients without their glucose being monitored.
d.      Insulin per fusers  for patients admitted to the ICU with DKA or HHS
e.      Diabetic foot ulcer wound care supplies, different dressings for DFU etc.
f.        Antithyroid drugs;
-          PTU is the only available drug, with questionable efficacy of the available products.
-          Great need to have access to Methimazole/ Carbimazole.
2.       Educational Needs:
Access to reputable International Society Guidelines and Journals free of subscription fees.

3.       Greatest health care challenge in Ethiopia

-          Although there is improvement from the situation few years ago, health care accessibility is a great challenge because of the limited resources and trained health care workers. The growing magnitude of noncommunicable disease, in particular of diabetes mellitus, had and will be having great impact on the health care system in Ethiopia.                        
Interview with Dr. Helen Yifter Bitew (see attached video)

Summary:
1.      What is the greatest need your endocrinology patients have?

·         Diabetic patients –Blood glucose monitoring supplies, HbA1c, Diabetes education
·         Other endocrine problems- Drugs (Bromocriptine, Methimazole or Carbimazole)
·         ACTH (Cosyntropin) stimulation test for diagnosing adrenal insufficiency

2.      What is your greatest educational need?

·         Teaching faculty- we have only 3 endocrinologists in the country
·         Set up- learning setup where we can see comprehensive and standard endocrinology care
·         Journal access (JCEM, Endocrine Practice)

3.      What is the greatest health care challenge in Ethiopia?

·         Access to quality care
·         Functioning health referral system

·         Shortage of trained health professionals at every level

Open Letter to Dr. Helen Yifter Bitew and Dr. Abdurazek Ahmed Abdela
April 5, 2014

Dear Helen and Abdurazek
I have just spent 2 amazing weeks with you and, although I am happy to be returning to my home, I am sad to leave you and to end this extraordinary experience.  I believe that you are both remarkable physicians. You are extremely intelligent – that is obvious. But in addition you are so very kind and devoted to your patients. You have taken on a great responsibility in caring for this large number of poor and needy patients. Your medical skill, hard work and dedication provide a great, great service to them. They are blessed to have such devoted and wonderful physicians caring for them. The future of Endocrinology and Diabetes care in Ethiopia is very bright because of the work you are now doing and the good work that will follow from the many fellows who will train under you when you soon become a faculty at your great institution. I am certain that you will be excellent mentors just as you are outstanding physicians.  It was truly an honor for me to work with you for the past two weeks. I have learned very much and have benefitted greatly from this experience. I wish you both the very greatest of success and satisfaction in your careers. You are now and always my highly valued colleagues.

Michael McDermott MD
Summary of the Endocrinology Program at Black Lion Hospital, Addis Ababa, Ethiopia
Faculty:
Dr. Ahmed Reja, Division Head
Medical School: Belarus
Medicine Residency: Addis Ababa University
Endocrinology Fellowship: Sheffield, UK

Dr. Tedla Kebede Geletew
Medical School: Addis Ababa University
Medicine Residency: Addis Ababa University
Endocrinology Fellowship: Birmingham, UK

Fellows (2012-2014)

Dr. Helen Yifter Bitew
Medical School: Gonder College of Medical Sciences, Gonder, Ethiopia
Medicine Residency: Addis Ababa University
Endocrinology Fellowship: Addis Ababa University (2012-2014)

Dr. Abdurazek Ahmed Abdela
Medical School: Kartoum University, Kartoum, Sudan
Medicine Residency: Addis Ababa University
Endocrinology Fellowship: Addis Ababa University (2012-2014)

The Diabetes Clinic was built in 1994 by generous contributions from Lions International. It has now served this community for 20 years. There are 4 diabetes clinics per week (2 general diabetes, 1 diabetes in pregnancy, and 1 diabetes foot clinic; a total of about 250 patient visits per week) and 2 general endocrinology clinics per week (a total of 40-50 patient visits per week).

Diabetes testing and monitoring
A1C testing is not available.
Self-monitoring of blood glucose (SMBG) is not done by most patients but a few do.
Glucose control is assessed by a single fasting blood glucose before or during each visit and by asking patients about the frequency of hypoglycemic symptoms.
A serum creatinine, urine protein, and serum lipid panel are done annually in most diabetes patients.
Retinal photography is done in clinic by 3 trained nurses annually in most diabetes patients.

Endocrine testing and monitoring
Tests available: TSH, T4, Free T4, T3, Free T3, Cortisol, ACTH, Testosterone, Estradiol, Progesterone, LH, FSH, Prolactin
Tests not usually available: PTH, Growth Hormone, IGF-1, Cosyntropin (ACTH) stimulation testing

Imaging
Thyroid ultrasound and US guided FNA are done in radiology, not Endocrinology
Nuclear Medicine exists but thyroid uptake and scanning and I-131 treatment is usually not available due to lack of isotope availability
CT and MRI of the brain, chest and abdomen are available

Medications available to these patients:
Diabetes medications: Metformin, Glibenclamide, NPH Insulin, Regular Insulin, 70/30 NPH Regular Mix.
Blood pressure medications: Enalapril, Captopril, Losartan, Nifedipine, Propranolol, Methyldopa, Hydrochlorothiazide, Furosemide, Spironolactone
Lipid medications: Lovastatin, simvastatin
Thyroid medications: Thyroxine, Propylthiouracil, Propranolol
Adrenal medications: Prednisolone

Greatest current needs:
Clinical Care: A1c testing, SMBG meters and strips, Cosyntropin (ACTH) stimulation testing,
Neck ultrasound for clinic and training in ultrasound guided FNA, Patient education materials
Education: journal subscriptions, visiting professor programs


Summary of Week 2:
2 diabetes clinics, 1 diabetes in pregnancy clinic, 1 diabetes foot clinic, 2 general endocrinology clinics and rounded once in endocrinology inpatient consults. 250 (add Friday totals) outpatients and 11 inpatients were seen.
Six education sessions were given (5 by Mike McDermott, 1 by Katy Brown). Total sessions for 2 weeks: 12.

Dr. Ahmed Reja and Dr. Tedla Kebede Geletew asked if I could develop 10-25 multiple choice test questions for their first ever Endocrine Board Exams to be taking two weeks from now but the two fellows, Dr. Helen Yifter Bitew and Dr. Abdurazek Ahmed Abdela. I agreed.

Friday, April 4, 2014

Friday afternoon endocrinology clinic. About 40 patients were seen by Drs. Helen Yifter Bitew, Abdurazek Ahmed Abdela, 4 Medicine residents, Katy Brown and Mike McDermott.







I hope these rocks hold this bus because I am standing behind it.

Going to lunch.







Friday morning diabetes foot clinic. Drs. Abdurazek Ahmed Abdela, Helen Yifter Bitew. Katy Brown, some Medicine Residents, and Mike McDermott.





Have a seat. I hope you like our new stone seat chair.


Interesting structures on Addis Ababa University campus.


Thursday, April 3, 2014

This Volkswagen has had better days. But that is true for many of us.


Do you have some extra room? I need a ride to my hotel.


Special Lecture to Medicine Residents by Mike McDermott. Type 2 Diabetes Mellitus: Pathophysiology and Treatment Strategies. I rate the speaker (me) 5 on a scale of 10 but I rate the audience 11 on a scale of 10 for attention, interest and questions. Great group.

What? You want this to be evidence based?

Here is what I am going to talk about in this post-lunch lecture. Please stay awake; I will try to be interesting.

I have no conflict of interest. This is not to suggest that my life is not complicated.

The diagnosis of diabetes. Hang in there. It gets better. At least in my opinion.

If I hold up my hand, it implies that I am making an important point.

It appears to me that you are enthralled. But why are you all wearing hearing aids? Are they really hearing aids? Are you guys listening to the soccer game through your i-phones? Give me another chance, please. I can make a Thursday afternoon post-lunch lecture interesting.

Katy Brown seems interested. But is she thinking about climbing Kimimanjaro next week?

Here is the issue. Preventing diabetes is vitally important so that we don't have to treat it later. Alternatively, let's consider: what is the meaning of life? Any comments?

Here's my question now. Would I be more interesting if I chewed some Chat?

Lecture over. Great questions from a resident identified by the faculty as brilliant. It is great to have such insightful questions from a great resident regarding a lecture that, even though I was the speaker, I didn't entirely understand.

This is the neurology waiting space, empty for the first time since I've been here.

This way to the Department of Medicine Lecture Hall.

I really want this Land Rover. Wouldn't it be fun to fix this one up in the garage?



Pharmacies here are independent. No chains.


Libyan Embassy.

Monument to Coca Cola.

Let sleeping dogs lie?

Yes, we have no bananas. Well, maybe a few.