Duke Cardiology Fellowship
Elective Rotation in Global Cardiovascular Health
1. Description
1a. Background
Advanced fellows in the cardiovascular medicine fellowship training program can elect
for a global cardiovascular health rotation. Fellows will rotate in the Hock Family
Cardiac Care Unit (CCU) and the Cardiovascular Diagnostic Unit (CDU) at Moi Teaching
and Referral Hospital in Eldoret, Kenya. The CCU in Eldoret was created in part with a
donation from the Hock Family under the administration of the Hubert-Yeargan Center
for Global Health. The CCU is the only public CCU west of Nairobi (the capital of the
Republic of Kenya) and serves a catchment area of approximately 30 million people.
The CCU is the clinical educational platform on which the cardiology fellowship training
program at Moi Teaching and Referral Hospital is based. The CDU is home to the
echocardiography and electrocardiography laboratories.
1b. Patient Care in the CCU
The CCU footprint is a 10-bed unit. The nursing: patient ratio is currently (September
2013) 1:1-2 and there are 4 beds running at 100% occupancy. Cardiac monitors are
present at each bed for monitoring heart rate, blood pressure, respiratory rate,
temperature, pulse oximetry and cardiac rhythm. Continuous intravenous medications
are infused via bedside pumps. Vasopressors are commonly used, as are intravenous
anti-hypertensive and anti-arrhythmic drugs. Defibrillators are present at the bedside.
Nursing documentation and charting is done via paper flowsheets based on USstandards for CCU care. Echocardiography and electrocardiography laboratories are
readily accessible across the hallway from the unit.
1c. Imaging in the CDU
The CDU staff performs ~3850 echocardiograms and ~3000 electrocardiograms per
year. The echocardiography capabilities include portable machines using digital
acquisition of retrospective (or prospective) digital loops, and employs 2-D, Doppler
and myocardial strain imaging techniques. Currently, there is one Philips CX-50 and
one GE Vividq machine in the lab storing images in DICOM format. Electrocardiograms
are usually performed with unipolar leads generating “one strip at a time” and are
subsequently pasted together to form a full 12-lead electrocardiogram. Suction cups
are normally used, in contrast to adhesive electrocardiogram electrodes commonly
used in Durham. Thus, the CDU experience exposed cardiology fellows to a broad array
of cardiovascular imaging using technology at the cutting edge as well as that seen in
resource-limited settings anywhere in the world.
1d. Wide Spectrum of Cardiovascular Disease
The clinical exposures in the CCU include, but are not limited to, management of acute
coronary syndromes, ST-elevation myocardial infarction, cardiogenic shock, acute
decompensated congestive heart failure, symptomatic arrhythmias, hypertensive crisis,
infective endocarditis, pericardial tamponade, and pulmonary embolism. Owing to the
healthcare system in Eldoret, the presentation of these conditions is usually more
advanced than in Durham and causes represent conditions increasingly uncommon on
US-based training programs. Thus, the CCU experience in Kenya represents a unique
training opportunity to broaden the clinical exposure for Duke cardiology fellows.
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2. Fellows educational objectives
Objective #1: To understand the clinical presentation and management of a broad
spectrum of cardiovascular diseases by
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Assisting in management in the outpatient cardiac clinic
Assisting in management of inpatients on the consult service and CCU
Evaluating patients with HIV and TB-related heart disease, uncorrected adult
congenital disease, severe rheumatic valvular disease, right heart failure related to
pulmonary hypertension, medically managed acute coronary syndromes and heart
failure form a variety of causes
Obtaining a history and performing a complete cardiovascular physical examination
on patients in Kenya
Acting as a consultant to other physicians and having direct, supervised patient care
responsibility in proportion to his or her experience and qualifications
Reviewing echocardiograms, as well as perform urgent bedside echocardiograms on
inpatients
Interpreting ECG and stress tests on patients with HIV and TB-related heart disease,
uncorrected adult congenital disease, severe rheumatic valvular disease, right heart
failure related to pulmonary hypertension and heart failure form a variety of causes
Participating in pediatric cardiology clinic with an attending pediatric cardiologist
Objective #2: To recognize the significance of the history and physical exam in a
technology challenged environment while adhering to the highest standards of
cardiovascular care by
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Discussing with local preceptors the basis for their diagnoses and treatment plan
without the benefit of various diagnostic testing and supplies
Objective #3: To understand the structure of medical care delivery and education in the
local health care facility in a culturally sensitive and appropriate manner.
Objective #4: To gain insight into the role of culture in communication and health care
by
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Reading a history of the country they are visiting, discuss with faculty preceptors the
relationships of social, political, and economic factors to health in the country, and
reflect on the differences and similarities in the American and local systems of
health care delivery and education
Objective #5: To demonstrate effective cross-cultural communication skills, knowledge,
and attitudes by
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Developing a rudimentary ability to speak the local language
Objective #6: To identify, describe, and discuss the global health landscape, and why a
global perspective is need to solve public health problems.
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3. Description of Training activities
3a. Cardiac Intensive Care Unit
 Daily morning and evening rounds
 The clinical exposures in the CCU include, but are not limited to, management of
acute coronary syndromes, ST-elevation myocardial infarction, cardiogenic shock,
acute decompensated congestive heart failure, symptomatic arrhythmias,
hypertensive crisis, infective endocarditis, pericardial tamponade, and pulmonary
embolism
 Supervision by Duke Cardiology Faculty and Adjunct Faculty. Cardiologists from Mt.
Sinai School of Medicine and critical care physicians from Duke will also be onsite to
provide supervision
 Common procedures include placement of central venous catheters and
pericardiocentesis using echocardiographic guidance
3a. Ambulatory, Outpatient and Follow-up Care
 1 full day per week in cardiology clinic
 Wide age range of patients: male and female, adolescence through old age, wide
spectrum of cardiovascular diagnoses, including post-operative patients, patients
with congenital heart disease, and patients for evaluation and management related
to pregnancy
 Supervision as in 3a
3b. Electrocardiography
 ECG laboratory reading 3 afternoon sessions out of the week
 Supervision as in 3a
3c. Echocardiography
 Echocardiographic imaging performance and interpretation 3 afternoons per week.
 Performance of 2-D and Doppler echocardiography on a wide range of patients (see
1c)
 Bedside echocardiograms on CCU patients
 Use of Doppler techniques for non-invasive hemodynamic assessment of critically ill
patients
 Supervision as in 3a
3d. Didactic educational sessions
 Daily morning report prior to CCU rounds in conjunction with Moi cardiology
fellowship educational activities
 Learner as well as teacher roles
3e. Weekly journal club
 One morning per week
 Critical review of cardiovascular literature in conjunction with Moi cardiology
fellowship educational activities.
4. Requirements
 Advanced (3rd year or greater) cardiology fellows at Duke University
 Emotionally maturity and flexibility
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At least 2-month commitment to time spent in Eldoret
One Cardiology Grand Rounds presentation in Eldoret
One presentation for Imaging Grand Rounds in Eldoret
Adherence to the weekly schedule of activities in Eldoret
Compliance with the rules for residents of Indiana University House in Eldoret
Case presentation (supported by imaging, if available) upon return to Durham
For further reading
1. Bloomfield et al. Chronic noncommunicable cardiovascular and pulmonary
disease in sub-Saharan Africa: An academic model for countering the epidemic.
Am Heart J (2011) vol. 161 (5) pp. 842-7
2. Bloomfield and Huffman. Global chronic disease research training for fellows:
perspectives, challenges, and opportunities. Circulation (2010) vol. 121 (11) pp.
1365-70
3. Riviello et al. Critical care in resource-poor settings: Lessons learned and future
directions. Crit Care Med (2011) vol. 39 (4) pp. 860-7
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