Cough, cough.

Wednesday, March 28

Today was a day full of coughing. Of our ward of about 20 patients, I suspect a fourth or more of them have active tuberculosis. One out of three people in the world are infected with TB, the vast majority of them (us) have silent infection that won't go on to full blown disease. But a significant number of people do, especially those with HIV, malnutrition, diabetes, and those who smoke. In one day, we diagnosed a man with likely cavitary pulmonary TB but with a nearly normal sounding chest on exam, a man with miliary TB (see less than ideal pic), and a man with possible extra-pulmonary TB of the lining of the lung. There are a few more cases of suspected disease on the ward, probably at least one at all times.

It's a bad disease. TB kills more people infected with HIV than any other condition. It's been with us for millennia, yet we still don't have very quick ways to adequately diagnose it or treat it. The patients wear the masks that I have put on them for about 5 - 10 minutes, and the staff allows them to keep them off. I wore a mask today, but none of the other staff do. Since TB and HIV often go hand in hand, I try to make sure all TB suspects are tested for HIV. There is one counselor available to test patients for the whole hospital, and he rarely does his job on the wards. We need to work on that. We also need to work on diagnosis and infection control. Lots of things to address. But these systems-wide changes can make a huge difference, especially if supported by the administration.

I'm off to bed now. And don't forget to cover your mouth when you cough. Thank you. This has been a public health announcement from Juba, South Sudan.

One Week In South Sudan

Monday, March 26, 2012

It's Monday, and I've been in South Sudan for a little more than a week. Which, seeing that it became a country only this last July, means I've lived here for about 3% of its history.

I would like this to be a very thoughtful and detailed blog entry about my initial impressions of South Sudan. But we've been keepin really busy, and I haven't really had the energy to put my thoughts down along the way. This will have to do for now.

South Sudan is about the size of France, which means it's smaller than Texas. Actually, to put it into perspective, it's about 17 Rhode Islands smaller than Texas. It broke off from the rest of Sudan on July 9th, for many many reasons (more than I understand, and too many for a short blog entry).

So it's the newest country in the world, and it has its share of problems.

Maternal mortality, for one, is what some would call high. Actually perhaps it's the worst in the world. Women have about a 2% risk of dying each time they get pregnant. Compare that to the US, where the rate is almost a hundred times lower. So for a South Sudanese woman that has 5 babies over her lifetime, that's a 10% risk of death during pregnancy. And some think that is a conservative measurement.

I've been in Juba since last Sunday. This time of year, the weather is hot. Mostly over 100 degrees hot. It's humid, and at the same time looks and feels a bit like a desert. The rains are supposed to come this month, which should cool things down a little (crossing my fingers for the upper 90s). And the rains should also help settle the dust and clear the air. And there will soon be mangos. Lots and lots of mangos.

There are many different groups of people making up South Sudan. I heard there are around 71 languages spoken by the South Sudanese. I think that might not include the languages spoken by the immigrants, mainly Kenyans, Ugandans, and Ethiopians. The language used on rounds in the hospital is English, but most people communicate with Juba Arabic, a simplified form of the Arabic language. Many patients on the wards speak neither English nor Arabic, and sometimes the South Sudanese health workers cannot communicate with a patient. Most patients come with a "co-patient" that helps communicate for them, goes on runs to the commercial labs and pharmacies when our facilities don't have the necessary tests and drugs, carries them to the bathroom, swishes away flies, and other tasks that the nurses can't or won't do.

South Sudan has about 10.5 million people, and while 250,000 was the estimated population of Juba in 2008, that number is certainly much higher now, after Independence and its associated migration. Besides the walk between my house and the hospital, I haven't seen much of the city. I see the local guys hooping it up on the basketball court on my way home from work. The men of the Dinka tribe are so tall! I've heard that the NBA occasionally has scouts out here...looking for the next Manut Bol or Luol Deng.

The food has been pretty good. Lots of beans, which makes this Mexican a happy man. The Sudanese food so far has been mediocre, though the Kenyan restaurant at the end of my block (I think it's called California Kitchen), with it's delicious chapatti has been pretty good. The main savior has been the Ethiopian presence. Considered the best cuisine in Africa by many, I'm blessed with two restaurants mere yards away from our house.

I've been at the hospital every day since arriving. We are working to train midlevel practitioners, interns and general practitioners on the emergency ward. Basically two long rooms, one each for men and women, these wards hold all the patients with non-surgical issues that are admitted to the hospital, until they are stable enough for transfer to the chronic ward or discharged home. The pathology has been as fascinating as it is tragic. The excitement felt when a patient presents with a physical finding that you rarely see in the States is quickly dampened when you realize that the finding often signifies prolonged pain and suffering due to a dysfunctional health system.

The deaths way heavily on the soul. Many patients come in febrile, breathing fast, with low blood pressure and a look in their eyes that reveals their fear. Some we are able to save. The others die as I stand there, wishing I had more diagnostic and therapeutic measures at hand. Wishing I was a better doctor. It's challenging.

We've had some saves. A woman that we thought had severe anemia due to malaria, did indeed have malaria but also had an abdomen full of blood from ruptured ovarian cysts (picked up on by one of the local docs). She was rushed to surgery, and while in critical condition with a hemoglobin of 2, she was still alive this afternoon.

Another woman came in jaundiced, febrile, and with right upper quadrant abdominal pain. With the help of an ultrasound we performed at the bedside, she was diagnosed with an infection in her gallbladder. She also was hypotensive and confused due to the systemic infection and poor blood flow to the brain. With a lot of fluid, IV antibiotics, and luck, she was well enough to shower today.

All in all, things are good. It was a tough first week, but this week I'm feeling more comfortable in my role. Lots of work to be done here. Hopefully things can change some small bit for the better. But off to bed now.

Not All Things Green Are Good

Saturday, March 17, 2012

For St. Patrick's Day today I had a visit from E. O'coli. This morning while packing up and getting ready to head out of Malawi, I noticed some vague upper abdominal pain. Not much, but noticeable.

Hmmm, that's not good, I thought.

By the time I got in the car for the ride to the airport, things, indeed, were not good. Reminiscent of a wet towel being rung out by Mr. T, I was starting to get hit by waves of abdominal cramps that came every three to four seconds. Probably, my nerd brain distractedly mentioned, in time with the natural peristaltic movements of the intestines. Oh, that's interesting, I thought. I was getting clammy, looking pasty, and starting to wonder if things were about to look like the scene from "Alien". The inevitable self-diagnosis assessment began in order to make order out of this: Hmm, no vomiting, so this epigastric pain probably isn't a small bowel obstruction or a bout of pancreatitis. No high fever or headache (and I've been on prophylaxis), so this shouldn't be malaria. Still a bit of an appetite, so shouldn't be an inflamed appendix. Also probably not a bout of PID (though this, along with a kidney stone, were where Chris placed his vote...as far as I could tell, through his laughter as he drove us to the airport).

Surprised that neither the ticket agent nor the customs official sent me to quarantine (though this might be because it doesn't exist in Malawi), I was able to make it onto the plane. By this time, the preemptive strike of ciprofloxacin, loperamide, and ibuprofen was starting to have a positive effect. And things were best if I didn't move. Or laugh. And this was harder than you might guess, as Chris recounted his best travel diarrhea stories (hang out with anyone who has traveled as much as him, and you'll hear quite a load. Umm, sorry. Couldn't help myself). By the time the one and a half hour flight to Nairobi was finished, I was a new man. What was probably a bacterial infection of the lining of my small intestine that could have put me out of commission for days, was now already being cured with a combination of an antibiotic and an antimotility drug. And without a single trip to the loo.

I'm a lucky man.

Traveler's diarrhea (Montezuma's Revenge, Delhi Belly, Aztec two-step, etc.) is probably the most common ailment faced by travelers. For most, its just annoying, and it can be treated with one to three days of a quinolone antibiotic like ciprofloxacin (though due to high levels of resistant bacteria, especially Shigella, in parts of South East Asia, azithromycin is the recommended agent there). Pop a couple of pills, wait through a little bit (or a whole lot) of pain, and there, you're all better. Right as rain.

But diarrhea for people living in the developing world is a very different story. Most people in countries like Malawi have little access to drugs for this kind of thing. In fact, the World Health Organization recommendations are to not treat diarrhea unless it's invasive (causing fever and bleeding) or has lasted for more than two weeks. Most cases of diarrhea are self limited, even when they are caused by bacteria and not viruses. Treating everybody who has a case of diarrhea haphazardly with antibiotics has lead to a great deal of development of resistance to older antibiotics. So had I been a Malawian farmer working in the maize fields of Kabudula, I would have lived through the pain, had a few days of Malawian March Madness, and gotten on with my life.

But the main problem with diarrhea, and what kills, is dehydration, especially among children. Depending on the year and how the statistics are gathered, diarrhea is the number one or number two killer of kids around the globe, alongside pneumonia. Without water, the body simply can not function. Hypovolemic shock sets in, electrolytes and pH are unbalanced, body systems shut down, and eventually the child dies from cardiac arrest.

A mantra that runs through WAM programs is to provide important, life-changing interventions for relatively little expenditure. Reducing the number of deaths every year from diarrhea shouldn't cost millions. People need education about and access to soap and clean water, a place to dispose of human and animal waste that is away from food and water sources, access to oral rehydration salts to prevent and treat dehydration, and then excellent care at a hospital involving IV rehydration and medications if all else fails. We are starting to help with the last step. Help ensure access to trained personnel and availability of necessary meds and equipment at the hospital level. We also need to look more at systems: why are IV cannulas out of stock again? What needs to be done to prevent this from happening again?

But we hope to also affect change far up-stream from this point. We are finalizing details in a partnership with US Peace Corps to bring in a volunteer who will focus on some of these basic, life-saving interventions. Hopefully with time and a team approach, fewer children in Kabudula will die due to something as preventable and treatable as diarrhea.

Jeff
www.worldalteringmedicine.org

A Turn of Events

Tuesday, March 12

Today was a better day. Staff sign out in the morning revealed no pediatric deaths overnight. The sick 6 year old with meningitis and malaria, though still quite ill, was alive. After sign-out, I gave a brief review of post exposure prophylaxis (PEP) for occupational and sexual exposure to HIV. They have a nice section on it in the Malawian national guidelines, though interestingly they don't discuss PEP for hepatitis B virus, an infection that is much more easily transmitted than HIV and has a prevalence higher in Africa than in the US.

Things were busy in the pediatric ward. I'm glad that we discharged about 10 kids yesterday, because 13 new sick children earned a place on the pediatric ward today. Most children were admitted for severe malaria, and many of the kids admitted for other reasons, like pneumonia, also had mild malaria. Two children had kwashiorkor type severe acute malnutrition. Swollen, infected, and miserable, these kids are often the unlucky older siblings in families with pregnancies too closely spaced. Or in other instances, infections with HIV or TB increase their catabolism while decreasing their nutritional intake since they are ill. Luckily these two kids both tested HIV negative, and they still had some appetite, a big bonus since we didn't have feeding tubes to force feed them if that wasn't the case.

*interlude* It is mildly difficult to concentrate on writing this blog entry with the rat scurrying back and forth in my room. He is very clever, somehow only running around when I'm under the mosquito net. I think he is testing me. With the spiders of various shapes and sizes, the ants in the kitchen, the malaria-ridden mosquitos, the gnats that dive bomb my eyes and uvula while on a jog, and the hundreds of flying termites with wingspans the size of half-dollars, I'm feeling rather like I'm camping. Or in an Indiana Jones film.

Ahh, where was I?

Other interesting cases included reducing a woman's dislocated jaw, a child with sickle-cell anemia, a kid with possible post-streptococcal kidney disease causing facial swelling, and a nine month old who has failed to gain wait over the last five months likely due to being infected with tuberculosis by his mother.

Aubrey was called to evaluate a woman who had a history of a cesarean section and was failing to deliver her baby. Initially a surprise to me, the policy in Malawi is to attempt a trial of labor if a woman has no more than one c-section in the past. Even having one c-section increases a woman's chance for rupturing her uterus during labor, and many hospitals in the States don't attempt this, but instead head straight to c-section. This woman had reached 10 cm of cervical dilation two and a half hours ago and hadn't delivered her baby yet. For unclear reasons, the nurses hadn't been pushing with her the whole time, and her pushing efforts weren't maximized. Aubrey applied a Kiwi brand vacuum to the top of the baby's head in the birth canal in order to assist with her pushing, but the suction wouldn't hold and the vacuum cup kept coming off. He had another type of vacuum available that he knew how to work well, but it was dirty and was receiving a rushed cleaning. Thankfully, we had a fresh Mystic type vacuum that Dan Dewey from WAM had sent along from the US just a few weeks ago. Aubrey hadn't used one before, but I convinced him to give it a try and walked him through it's use. With two more pulls a vigorous, 3+ kilogram baby girl with a sore noggin was brought into the world. Our relief was short-lived as the mom started to hemorrhage after delivery of the placenta. Aubrey went through the steps of adding oxytocin to the fluids as well as an intramuscular injection of this potent medication that causes the uterus to contract, hopefully squeezing the uterine blood vessels and stopping further hemorrhage. Still gushing, we did a thorough exam of the birth canal to look for the likely laceration, but none was found. Vigorous lower uterine segment massage helped, and a dose of misoprostol was also given. This life-saving medicine, which costs less than twenty-five cents a pill, is often absent from a clinic's medicine cabinet as a woman bleeds to death after delivery. There are few things more frightening in medicine than hemorrhage that you cannot stop. But in this case, his efforts paid off. The bleeding stopped, and this newborn baby girl will have a mother to go home with.

A hard day

Sunday, March 11

It's been a tough 24 hours. Yesterday we were called to see a 6 year old in distress. While he was play-fighting with friends, he was stabbed in the neck with a stick. The cut was over the left side of the front of his neck, and amazingly, it missed his carotid artery. It did however reach deep enough toward the midline to enter his windpipe. He was wide-eyed and breathing fast, and this was clearly an airway emergency. I could tell from his lack of stridor, the wheezing noise made when inhaling through an obstruction in the upper airway, that he wasn't in immanent danger. But I knew that he could turn the corner fast if swelling or a blood clot blocked his lifeline to the world. In the US, he would have been sedated, paralyzed, intubated by an experienced physician, and taken urgently to the operating room. Luckily, we have one of the two anesthetist clinical officers that work for the ministry of health in Lilongwe district, a catchment area of over one million. He could manage the airway on the 1+ hr trip to the referral hospital. The big question was whether to intubate before transfer. In the States, we most likely would have, but I've never dealt with this before (I'm wondering what I would have done if the referral hospital wasn't an option). But here, there's 33 km of unpaved, gutted dirt road and a few water crossings before getting to the paved road that leads to the city. Any one of those bumps could dislodge an endotracheal device and spell doom to a sedated kid. We decided to send him with an IV in his arm in case he needed emergent meds (watching Aubrey place the IV was unnerving - the kid started crying and struggling, coughing blood through his neck wound), and send the anesthetist along for management. I found out later, during one of the overnight cesarean sections, that the child made it OK.

Shortly after that child was transferred, I came upon a 2 year old that was breathing quickly in his crib on the pediatric ward. He had a diagnosis of severe malaria, and this could certainly explain his clinical condition, including the fact that he was near comatose. He was also visibly anemic and needed blood, and we weren't sure if he might have also had meningitis to boot. We performed a lumbar puncture, and found that his spinal fluid was under very high pressure, an ominous sign. Later that night I came back to the hospital and heard beautiful singing coming from the darkened outdoor hallways. The dozens of pregnant patients and caregivers that sleep outside due to lack of sleeping quarters were singing hymns as they lay down on the concrete to sleep. I went to the pediatric ward to check on the sick child from earlier in the day, feeling lucky and peaceful, and found that he had passed away less than half an hour after the procedure.

In the morning I found out that another child, one who's mother didn't allow us to examine the child the night before, had died as well, probably due to malaria or meningitis. As I walked onto the wards, I found a worried mom standing beside her seizing, six year old child. The nurse was off the ward getting breakfast. When he was found, we adjusted some meds and calmed his seizures. After rounds we attempted a lumbar puncture to see if he also had meningitis in addition to malaria. Within the hour, despite our efforts to give him oxygen and assist his breathing, he was gone as well.

There's another six year old on the ward tonight with clear cut meningitis as well as malaria. His chances are slim. Times like this, it's hard for me not to doubt my skills as a doctor. It's also easy to feel like our efforts are drops in the bucket the size of the Big Dipper. The day before, I realized that most wards had no soap, and the one that did was using laundry detergent. It had apparently been like that for weeks. Weeks. And everyone was just used to it. Nurses worked all shift long, clinicians saw patient after patient, and almost no one was washing their hands. I walked the 100 yards to the town shop, bought thirty bars of soap for 10 dollars, and delivered them to the wards.

And the question that keeps nagging at me, the one that I don't really like to think about, is am I weakening the whole system by buying soap? Would it be better for the hospital workers and patients to get so fed-up with the system that they marched on the capital and demanded better conditions? Well, maybe the hundreds of other similar Malawian hospitals that don't have support will get fed-up and rise up. In the meantime, for better or worse, the staff at Kabudula will have soap.

Another day

Thursday, March 8, 2012

Today was a good day. Still at the rural hospital in Kabudula (translating to "short trousers" in Chichewa), we saw a variety of cases. First off, it was good to see that the toddler with severe pneumonia was doing better. Her mom was very happy that she seemed to have turned the corner. We saw two women pregnant with twins and tried to decide how far along they were in their pregnancy and when they should deliver. Twin pregnancy increases risk for maternal and neonatal morbidity and mortality, especially in places like Malawi, which has some of the highest rates of mother and baby mortality in the world. We saw a handful of women who were miscarrying and needed a procedure to complete this difficult process. Aubrey saw patients referred to him by the medical assistants with ailments ranging from infertility to hand infections to heart failure. And he handled them all, with three years of post high school education.

I headed to the secondary school after a lunch of rice and beans to meet with the peer counseling group, part of the amazing program that Sarah Greenberg from WAM started. This fantastic group of 16 orphaned or vulnerable kids meet once a week to decide how best to help their peers stay in school. They excitedly told me how they plan to be teachers, nurses, radio announcers, and doctors. The odds are clearly stacked against them. Coming from a school with few books, no lab, no computers, and little support from family, they have a Herculean task to overcome (if you want to learn more check out the KEEP program at www.worldalteringmedicine.org).

Next I gave an HIV and dermatology lecture to the clinicians at Kabudula hospital. No one snored, which means it was a riveting talk. Or that Malawians don't snore when they sleep.

To wrap up the day we saw an ancient woman with undiagnosed Parkinson's disease who fractured both her lower legs when a wall in her house fell on her while she slept. On the way out of the ward, we met a man carrying his fourteen year old daughter toward us. She had a history of epilepsy and had been seizing every day for the last three months since her health center had run out of anti-seizure medications. She now had a new diagnosis of malaria, to add yet another condition to cause further seizures. As I purchase medications that the hospital has been out of (sometimes for months), I'm floored by the price of them. A dose of medicine called misoprostol to stop life-threatening bleeding after a woman delivers costs about 75 cents. The other day, on eBay, someone bought a three-year old Chicken McNugget that resembles George Washington for $8,000 dollars.

If you'd like to support Kabudula, reduce maternal mortality, and put orphans through high school, please be on the look-out for quality McNuggets.

A calling

Wednesday, March 7, 2012

We started the day at the Kabudula hospital shift hand-over. Basically run like "morning-report", events from the previous night are recited in narrative form by the night nurse. One child with severe malnutrition that lead to total body swelling, or kwashiorkor, died overnight. Aubrey, who was senior clinician and second on call, was not notified at the time. One thing that I hope to continue to emphasize is the need to call the most experienced, at any time, when a patient's condition is deteriorating.

After sign-out, Aubrey rounded on some patients. We came to the crib of a 2 year old girl with HIV who was breathing about 60 times per minute. She appeared half awake and was grunting with most breaths. Bacteria had infected part of one of her lungs, and pus, a by-product of the immune system's fight against the infection, was filling up her lung and keeping oxygen from reaching her vital organs. She was hooked up to an oxygen concentrator machine and was using the device donated by WAM that splits the o2 supply between patients. She had just started receiving chloramphenicol, the recommended antibiotic per Malawian guidelines, but an antibiotic that I have only seen in Africa since it was discontinued in the US due to side effects. They had also started her on presumptive treatment for PCP pneumonia, a disease that only affects those with very weak immune systems. Seeing that she was already on life-saving antiretroviral meds for HIV (meds who's supply are threatened due to cut backs in global health funding) and prophylactic treatment for PCP, and had an exam that was more consistent with a typical bacterial pneumonia, we stopped the PCP treatment doses and later added penicillin per the local HIV guidelines. A child that sick would probably be in a pediatric intensive care unit in the US. When we checked on her later in the day, she was looking a little stronger.

Next we saw a beautiful young woman who had labored for 2 days with an infant that probably wasn't meant to come out vaginally. She went to another hospital where she delivered a still-born infant via cesarean section. Some time later, she noticed that she had started to leak urine from her vagina. Due to the prolonged pressure of labor causing tissue damage, a fistula, or abnormal connection, had developed between her bladder and vagina. Now, as urine enters her bladder from her kidneys, it constantly trickles out via this connection. I was happy and somewhat surprised to see that her husband had not left her, a fate faced by many with this avoidable affliction. Aubrey referred her to the central hospital for corrective surgery. As she stood to leave, a plate-sized damp spot was left on the wooden bench where she had been sitting.

We also saw a woman with a history of cesarean section who had labored 3 days at home with her 12th child. She came to the hospital when the fetal heart beat could no longer be found. A cesarean section by the new clinical officer quickly got out of hand and Aubrey was called in. After extensive repair of lacerations and stoppage of life threatening bleeding, the woman was saved. With permission from her husband, her tubes were tied. She is alive and well, and ready for discharge today.

These are the cases that Aubrey sees day in and day out, working without complaining. It is, as he says, his calling.

Back in Kab

Tuesday, March 6, 2012

It's Tuesday, and I've been running errands today in preparation of the journey again to Kabudula. I spent last night at a friend's house, one of the doctors working at the Baylor peds HIV clinic. He had wireless internet, hot water, and a good stove. I was a kid in a toy store. Today I obtained some spending money and would liked to have filled up the tank, buy there is no diesel or petrol to be found. Well, not to be found by ordinary types. Maybe I'm cynical, but somehow I feel there are a certain few individuals that get all the gas they could ever want. The difference between the haves and have-nots in Malawi, like much of Africa, is tremendous. During a long run with Akash, we saw a glimpse into the chasm. We left his house, located in a very nice area where the walls are high and covered with razor wire. Just five minutes on foot we reached a neighborhood filled with tightly packed simple brick houses and open dumping sites. These folks, while living a very different lifestyle from their very near neighbors, still have it much better than the people living in more rural areas of the country. I may have said this before, but Malawi has an estimated 75% of the population living on less than a dollar a day. Gas, when it's available, is about 9 dollars a gallon, and an unaffordable luxury to the majority anyway. Car insurance, which I was dealing with today, is about $350/yr, much like many policies in the States, and therefore more than most Malawians make in a year. Cable television is available, for $75/mo. A lot of food grown in the country is affordable, but food imported from South Africa is too expensive for the majority of the country. The president, who recently said that NGOs that unfairly criticize his government as autocratic can "go to hell", owns a helicopter and a private jet.

Ahhh, well...

I'm bringing some supplies to Kab today. We bought an electric kettle to boil water to make special formula for the malnourished kids, some jugs to hold boiled water, measuring cups, and amoxicillin syrup. It really seems tiny, but these things will make a difference. They need beds, sinks with soap, a more consistent supply of specialized formula, to name a few. I hope to do a refresher training on malnutrition while I'm here.

Tonight I cooked food for Aubrey, the 25 year old clinical officer that runs this 100 bed hospital. Two high school students that WAM and Aubrey are helping to support were helping around the house, so I showed them how I cook. They had their very first bites of garlic, bell pepper, and hot sauce! One of the students, Chris, had quite the hot sauce-face-of-surprise. Chifuniro showed me which young pumpkin leaves were the best to pick for cooking.

It's 9:35p here and the town seems pretty quite. Well, that is, except for the dozen or more dogs howling like we were in Transylvania. On call with Aubrey tonight, so better try for zzzz's while I'm able.

Thanks for reading.

Jeff
www.worldalteringmedicine.org