Global Health Neurology Program - Michael Ke

Michael Ke’s story

My trip to Harare, Zimbabwe
Stroke unit at Parirenyatwa Hospital November 29, 2013
My name is Michael Ke. Through the Center for Innovative Global Health at Stanford I was given the opportunity to visit Parirenyatwa Hospital in Harare, Zimbabwe from October 19, 2013 to November 15, 2013.

It was an extraordinary experience. The hospitality of the Zimbabwean people, along with richness of their culture, the beauty of the land is one-of-a-kind. New professional connections, as well as friendships were easily made. Returning home after 4 weeks was bittersweet-I missed the daily comforts of home, but saying goodbye to new friends after just learning about their experiences, and them learning about mine, was difficult. There is already a longing to return to see familiar faces, and to continue to provide the much needed neurologic care in Zimbabwe.

I traveled to Zimbabwe in the footsteps of my fellow colleague, and now Clinical Assistant Professor at Stanford, Dr. Nirali Vora.  During her visit to Parirenyatwa about 6 months ago, she worked on the initial stages of establishing a stroke unit in a low resource setting. She worked closely with Drs. Mataruse and Ngwende, as well as Profs. Matenga and Hakim of the NECTAR program. During her visit, Dr. Vora completed a needs assessment of stroke patients at Parirenyatwa, and devised a proposal detailing logistics of establishing a low resource stroke unit at Parirenyatwa Hospital. The proposal was subsequently approved, paving the way for a stroke unit to be formally established. The primary goal of my visit was to continue the efforts of opening a stroke unit at Parirenyatwa. We were fortunate that our goal of admitting the first stroke patient to the unit by the end of my visit was met.

Typical day at Parirenyatwa Hospital

The day started at 8AM, when I would join ward rounds with the C7 team. The ward team was large consisting of three junior doctors (JRMOs) in their first year of post-graduate training, 3 registrars (equivalent to a senior resident), and 10 or so medical students in various time points in their training. The ward team is typically responsible for up to 40 patients each day. They are on-call every 5 days, and during call, will admit approximately 20-30 patients. One of my primary roles at Parirenyatwa was an inpatient consultant, providing assistance in the evaluation and management of admitted patients with neurologic illness. On average, I would see 2-5 new patients each day. In addition, I worked in the Neurology clinic ran by Dr. Ngwende each Tuesday morning, seeing an average 10-15 patients. Other clinical responsibilities including assisting with weekly bedside grand rounds and seeing consultations in outpatient clinics.

On average 3-4 hours per day were dedicated to medical student and house staff education. I provided formal lectures on general approaches to the neurologic patient, fundamentals in the neurologic exam and localization, and basic pathophysiology and clinical management of common neurologic diseases.  In addition to formal lectures, bedside rounds were completed daily to teach exam maneuvers to elicit pertinent neurologic signs. I also participated in grading the OSCE for 5th year-medical students.

The neurologic disease burden is tremendous at Parirenyatwa. I would estimate that up to 1/3 of the admitted patients have primary neurologic illnesses.  Most common are communicable diseases in the setting of chronic HIV infection, such as TB and cryptococcal meningitis. On a typical intake, 1‐3 suspected new stroke patients were admitted. However, there were many patients that presented with subacute, focal neurologic deficits - I saw several cases of spastic paraparesis, multiple cranial neuropathies of unknown etiology during my 4 weeks. Neurologic care was restricted by the lack of resources, as most of the care is based on a fee-for-service, which was inexpensive by Western standards (e.g. 250 dollars for a contrast head CT), but prohibitively expensive to the patient population seen at Parirenyatwa.  Neuroimaging was often deferred, as patients’ families were unable to attain sufficient funds. Even basic laboratory studies, such as CSF cell count and differential were difficult to attain, and even if they were attained, the results were often unreliable. Treatment of neurologic disease was dictated by demographics and disease prevalence - for example, anti-TB medications were empirically started for presumed spinal TB in patients presenting with bilateral lower extremity weakness with upper motor neuron signs, or for TB meningitis in patients with altered mental status, nuchal rigidity, and no clinical improvement on antibiotics or antifungals.

Establishing a stroke unit at Parirenyatwa Hospital

During my visit - several key steps in opening the stroke unit were completed:
1)  Establishing a dedicated geographic unit: Beds with HOB elevation capabilities were moved to two dedicated patient bays in ward C7. These two patient bays housed the 8 beds of the stroke unit.
2)  Training of ancillary services: I lead training sessions in stroke pathophysiology and basic post‐stroke care.  The main session was given to the NECTAR staff, hospital administrators, RNs of the new stroke unit, physical therapists, occupational therapists, and dieticians. Approximately 40 care providers as well as members from the Ministry of Health attended the 4‐hr training session. In addition, a second training session regarding the pathway to admission to the stroke unit was given to the entire Casualty department.
3)  Training of house staff: I also lead training sessions to registrars regarding post‐stroke care, with particular emphasis on stroke assessment with the NIH stroke scale.
4)  Formulating RN flow charts and admission/discharge order sets: One of the key features of a stroke unit is to systematically approach each stroke patient in regards to clinical management and understanding of stroke etiology.  I made RN flow charts, as well as admission and discharge order sets customized to resources available at Parirenyatwa to assist in this systematic approach.
5)  Future plans: To evaluate the role of the stroke unit on patient outcomes, I participated in the initial planning of a simplified stroke registry.  In addition, there was initial discussion to establish stroke office near ward C7
with a dedicated computer station (for PACS, stroke registry, documentation, etc).
6)  First stroke patient admission: I oversaw the admission of the first stroke patient to the stroke unit on November 12.

Dr. Mungwadzi, Registrar, admitting the first stroke unit patient in the Casualty department. He is filling out the admission order set. This order set also assists with documenting a relevant clinical history, stroke risk factors, as well initial neurologic exam including an NIH stroke scale score.

Dr. Ngwende and the sister-in-charge with our first stroke unit patient.  She was a young woman with a right MCA syndrome. In addition, she had a heart murmur and clubbing on exam. Her stroke was thought to be secondary to infective endocarditis