Lighting A Candle

It's been a challenging few weeks.

I was manning the helm by myself for a little while, and it turns out that there was a lot to do. Mostly, there have been a lot of really sick patients at the hospital, and I've stayed late as we try to take care of them.

I've seen a handful of patients die during this trip in Kenya. They've all had advanced HIV disease, save one. While treatment is advancing by leaps and bounds in the developed world, with sustained hope for an eventual vaccine, the poor are still dying of preventable complications.

With each loss, I see ways we could have done better, and I hope that at the very least we can learn from them and do better the next time. The hardest life to see slip away was an adult man who came in with an allergic drug rash. The condition, called toxic epidermal necrolysis, is a severe form of the blistering condition known as Steven's-Johnson syndrome. He looked like he had been trapped in fire. Almost all of his skin was either blistered, eroded, or gangrenous, and due to the absence of his protective skin barrier, he was battling with a severe bacterial blood infection as well.  He suffered under our care for almost a week as we struggled with IV lines, fluid boluses, antibiotics, and wound care. I went from amazed at his state but hopeful that we might help him, to wondering if I was just extending his suffering by not putting him on end-of-life care. Finally, when his kidneys stopped working, and with his relatives hoping that we would just let him be at peace, we decided with the family to withdraw aggressive measures.  As if he had been waiting for that decision, he began to let go.

May we all take a break, be thankful for what we have, and enjoy the time we have with our loved ones.

Good night,

Jeff

Double The Fun

I received a call from Mercyline, one of the clinical officers, this morning while I was still at home.

-       “Are you coming to the hospital this morning? We have a woman in labor and we need your help with the ultrasound to tell the fetal lie”.

The delivery room

The woman had come in last night after breaking her bag of water, and was having frequent contractions now. But after palpating the maternal abdomen, they couldn’t tell if the head was down in mom’s pelvis, ready to be born “the normal way”, or if the baby was breech, and planning to meet the world bottom first. I was told that the mother’s cervix was 6 cm dilated. Typically a woman begins her contractions with her cervix closed, or at one or two centimeters of dilation. And then with the strong, repeated contractions of her uterus muscles, along with a cascade of hormones surging through her blood stream, the cervix slowly dilates to a maximum of 10 centimeters. Then it’s show time. The door is open for the baby to be pushed out.

Our portable US machine

When I got to the hospital and walked into the labor room that is about the size of a walk-in closet, I found out more details. She was apparently in preterm labor, since by measuring from her last menstrual period, she was only about 34 weeks pregnant. She had ruptured her bag of water 12 hours ago, and she had been in labor for at least the last 8 hours. Her initial cervical exam showed 2 centimeters of dilation, and her cervical dilation hadn’t been re-checked since midnight.  Chance for infection, including passing HIV to the newborn, increases with time. The clock was ticking, and we seemed to be behind the eight ball. We had to ask the laboring mom to get up and walk to another room once we found an outlet to plug in the ultrasound. One look with the naked eye at mom’s abdomen showed that something inside was probably not right. She had a big lump high up, near her rib cage, and when I put my hands low on her belly to feel for the hard, round, fetal head, I couldn’t feel anything for sure. I gave the ultrasound probe to Patrick, one of the clinical officers that specializes in HIV/TB care, and told him we’d find the head together. On ultrasound, liquid is black in color on the monitor, and harder substances, like bone, show up bright white.  He started high, over the big lump, and a bright white ring filled the screen. Yep, the baby was sitting down in the uterus, and was planning on greeting the world in reverse.  Now the mother had already delivered a few children previously, so she could probably deliver another baby pretty safely, even a baby in breach presentation. But a premature infant tends to have a relatively larger head than body, and this can pose a problem. Sometimes, the body can deliver past a cervix, and then the large head can get stuck at the cervix, leaving 2/3^rds of a baby delivered. If the umbilical cord, which is now outside mom’s body, gets pressed between the baby’s hard head and the edge of the cervix, life sustaining blood and oxygen from mom is cut off and the baby is in a lot of trouble.

I took over with the ultrasound to get a quick lay of the land. Not much fluid left in the uterus, consistent with mom’s story of a broken bag of water.  A good, strong fetal heart beat at 140 beats per minute. But yet something wasn’t right. As I followed the head down, instead of seeing the chest and heart, I kept seeing an abdomen first, then the chest. Now, I might not have aced anatomy lab in med school, but I’m pretty sure the chest should come south of the head and north of the belly. Sure enough, following the line of the baby’s body further down, we came upon a bright white ring, low in mom’s abdomen and pelvis. Another bright white ring. 

Mom was having twins.

And she didn’t have much time to digest this bit of news.  The nurse checked her cervix, and it was now fully dilated. Bingo. Time to have a baby. But at this tiny hospital, they don’t deliver twins. They’re not set up to do cesarean sections, they don’t have any consistent fetal monitoring (the baby’s heart rate was last checked 11 hours before I arrived), there is no oxygen in the delivery room, etc. The first twin was head down, or vertex, so should be able to be delivered easily. But the second twin was lying 90 degrees the wrong way, with the head towards mom’s left side and the feet toward mom’s right side. She needed to be delivered in an operating room, so that in case of any complication, she could have an emergency c-section.

The postpartum ward

The first question to the patient blew my mind,  - was she planning on going by public bus to the government hospital, or could she afford the ambulance fee. I quickly nixed that idea. We went back to the nursing station to discuss the plan and get the government hospital’s ambulance on the way. When we couldn’t find the maternity nurse, we realized it was because she was busy delivering the first twin! The team rushed into the delivery closet and found one baby out and crying, and the other twin still inside. A quick look with the ultrasound showed that the second twin had spontaneously switched from transverse lie to breech, great news for the chance of her delivering a healthy baby. I turned away to put down the ultrasound and turned around to find that mom had pushed out the legs, butt, and part of the torso of twin B. Things were going a bit crazy. The closet and doorway were full of people, including the front desk clerk (maybe that's why they have the sign above regarding strictly no admission). I was asking for blankets and gloves and was wondering where all the neonatal resuscitation equipment was.  Benard, the other CO, quickly threw on a pair of sterile gloves. As I watched him do a little tugging, I realized that the head wasn’t coming. Before I could put on my pair of gloves, Benard and the nurse, Maximilla, had successfully delivered a quiet, purple faced baby. Thankfully, with a little rubbing of the baby, he started to breathe and even cry on his own. Two baby boys had been born, and both were looking alright. These little guys, tentatively called Jeff and Benard :), were the first twins born at Sagam for as long as anyone could remember. With some more luck (as we had plenty of it today), and if she diligently takes her medicine, her twins will be free of infection and healthy. 

Two boys in a tree

It hadn't hit me that it was 9/11 until late today. On the day that so many Americans were affected when the Twin Towers were attacked, it's a small but moving coincidence to have been involved in this uplifting twin delivery. On the way home, as the evening storm was rolling in, two boys playing in a tree asked me to take their picture. Hopefully the new twins will have many such happy, carefree times ahead of them as well.  I hope we all do.

Thanks for reading,

Jeff

Teaching About A Tough Case

The highlight today was watching Benard (yep, that's how he spells it), the head clinical officer, lead a continuing medical education activity about a patient that had been at the hospital. Every week this small hospital has a CME activity, and the staff all come, from the nurses to the pharmacist tech to the peer educator. And the free Coke that you get at the end of the session is only a small reason that people show up. They really want to learn and be involved in a multidisciplinary approach to care and learning. I'm especially amazed at the clinical involvement by the non-clinicians. For example, Benson, the executive officer, was raising great points about the need to check for multidrug resistant TB (MDRTB) and to follow-up on records from other clinics to get a better idea of the past treatment history of the patient. And at a previous CME meeting, the laboratory technician was giving treatment advice on a patient.

Today the discussion led by Benard was a mixture of teaching and group discussion on how to best care for this patient. She is HIV positive, and while she had been on the life saving antiretroviral drugs (ARVs) in the past, she had stopped them because she thought they were causing her serious side effects (in retrospect, they were unlikely responsible). Her CD4 count, a measure of how strong her immune system is, was a mere 66 to start with (adults without HIV have CD4 counts typically between 500-1500), and now after being off of her ARVs, it's likely even below that.  And when someone comes off of their ARVs, they are at risk for the virus developing resistance to those medications as their concentrations slowly drop in their blood. Additionally she has a history of tuberculosis that wasn't cured after a round of treatment, and then she stopped taking her second round of treatment. She may very well have MDRTB, as Benson was rightly concerned about. And the third major challenge that she's facing is that she's pregnant. Managing her illnesses and pregnancy in the US would be a huge endeavor. Trying to treat her and prevent her baby from getting HIV and TB in Kenya is an even greater feat. But Benard did an excellent job of listing the issues, the challenges, and what needs to be done to help her.

What was most impressive about the presentation was his teaching style. He is a natural in front of a group, appearing at ease and confident. He repeats the questions that the audience asks him and is respectful of opinions offered up by them. The presentation was case-based, which is shown to be a better way to teach adults than just hitting them with lists of information. He knew his audience, he asked open ended questions, he summarized his talk, and he had an action plan of what the next steps will be after the lecture.

Tomorrow I'm leading a small group discussion on a patient with cryptococcal meningitis. He'll be a tough act to follow.

Some Good News

I'm happy to say that most of the patients that were pretty sick yesterday are doing better. Most impressively, the patient with advanced HIV who had the likely case of severe bacterial meningitis made one of the most miraculous recoveries I've seen. In twenty-four hours, she went from not being able to speak and apparently on the verge of death, to making good eye contact and saying that she was fine. There will still be a fair amount of recovery to be made over the long haul, but she certainly seems to be on the way.  The beaming smiles and vigorous handshakes of appreciation from the family members in the room were genuine and heart-felt. I felt very blessed to be a part of that moment.

Patient Care Challenges

Today was a long day.

We started rounding about 0830, and there were plenty of challenging cases to keep us busy. (Details slightly altered to protect patient privacy). One HIV positive adult had stopped going to her appointments and was no longer taking her life-saving antiretroviral drugs (ARVs).  She was now weak, unable to speak, febrile, hypotensive, and rigid, mostly at the neck. She was also having seizures, and abnormal changes in her eye movements (nystagmus and hippus). I'm pretty sure that she has advanced meningitis, along with severe HIV/AIDS. We started her on treatment for bacterial meningitis as well as for toxoplasmosis, a parasitic infection that can cause a tumor-like mass to grow in the brain. We were able to drive to another hospital and drop off her blood sample for a test that looks for fungus that could be growing in her brain. The test result showed that she doesn't have that infection, so I held off on performing a lumbar puncture, also known as a spinal tap. If she has a pressure-building mass in her brain, either caused by toxoplasmosis, tuberculosis, or cancer, we could cause her brain to herniate if we remove spinal fluid. She is very, very sick.

Another patient has been confused for weeks, as well as having fevers, tender swollen joints, and skin breakdown from being in bed too long without proper care. We pulled fluid from her knee that had some bacteria, and I'm wondering if she has bacteria in her blood that are depositing in her joints.

Another patient came in with what looked like a simple case of diarrhea. He developed acute onset vomiting, weakness, and confusion while in the hospital. The Kenyan clinicians astutely ordered a blood test for malaria, even though his first test had shown no malaria parasites in his blood. He now had evidence of malaria, but also had signs of severe dehydration. When we left at the end of the day, he still had a fast heartbeat, but he looked much better than he had in the morning.

Another man with a foot infection caused by diabetes is waiting to be operated on. His infection had been so advanced that the small toe had to be removed when cleaning the infection. Now, with the bacteria affecting more of his foot, he'll have to go to the operating theatre (as they say here) for further amputation. Diabetes, as I've mentioned before in this blog, is affecting more and more people in Africa, and will be a much worse problem in the future.

The save for the day was the case of a man with HIV who came in with severe headache and weakness. It turns out that he had been diagnosed with a brain infection caused by the yeast called cryptococcus at a different hospital but left during the course of his treatment. Treatment for this severe infection can last for weeks in the hospital, and then for over a year at home, and it's common for patients to get frustrated with the costs and hassles of staying in the hospital. Thankfully, he came back into medical care, and we were able to start the antifungal medicine again. Without treatment, this infection is 100% fatal. After 3 days of treatment over the weekend, he was feeling significantly better. I have high hopes.

Meetings, Patients, and Insanity

Man, time flies. It’s easy to get wrapped up in the day to day and forget to blog. Life continues to be fairly sweet in sleepy Sagam. Since I last wrote, we’ve made some progress in getting the relationship going between MGH/Contra Costa family med residency in NorCal and Maseno University here in western Kenya. We’ve also continued to consult on patients in the hospital

We met the head of the local district level hospital, Dr. Omoto, who is an OB-gyn doctor.  Siaya district hospital is one busy place. They see around 300 patients per day. Besides being plain busy, they had several programs of interest. For one, they were using an electronic health record system that had been put together for them by a programmer in California. Patients were seen by clinical officers, the CO would type the info from the visit into a laptop that was bolted to their table, and with the hit of a button, the prescription from that visit was sent to the hospital pharmacy around the corner. I’m not sure if that definitely will lead to improved patient care, but it was at least neat to see. Impressively, we came to a quiet room where HIV positive patients were receiving chemotherapy for Kaposi’s sarcoma, the blood vessel cancer that I mentioned in a previous post. They also had screening for cervical cancer using VIA, or visual inspection with acetic acid. Many developing countries like Kenya use VIA in lieu of pap smears, since results from a pap smear, if they ever come, can come very late. Using the VIA technique, vinegar is applied to the cervix. Abnormal areas of the cervix, like those that could be affected with the human papilloma virus (HPV), can be biopsied right away, obviating the need for an initial pap smear.

We’ve also had a few meetings with the faculty at the med school. They are interested in a collaboration that involves us helping to teach medical students, train family medicine residents, and help out in other ways. They are a motivated bunch of docs, and there is good potential here.

The patient consultations continue to be interesting. I’m inclosing the picture of a tumor that has been growing out of the head of a patient over the last 4 years or so. The point of view is from above her head – a bird’s eye view. Amazingly, it’s almost as big as her head. We wrote a referral note to the specialists at Moi University, located about 4 hours away by public transport, with the hope that she will be seen by an ear, nose, and throat specialist as well as a neurosurgeon. The mass is almost certainly benign, since the patient is still doing so well despite the large mass.

Other cases have included a very sweet 85 year old woman with an ankle that was shattered and dislocated during a fall. We’ve tried twice to get the ankle back into place by giving her medicine to relax her and take away the pain, and both times, the xray showed that it was still out of place. The first time we tried an intramuscular injection of ketamine, an amazing drug that puts a person into a bit of a trance, in order to do a normally painful procedure like a reduction of a dislocated joint. The second time we injected lidocaine directly into the joint, in order to minimize the pain while avoiding the risks of generalized sedation (she suffers from high blood pressure, a heart arrhythmia, and she had just eaten a big meal, which might complicate things if she were to vomit and aspirate the contents into her lungs). We’ve referred her to the large public hospital an hour away for orthopedic surgery where they hopefully will open the ankle up, reduce the fracture, and then put metal hardware to keep it in place.

Another case involved a young man that ingested large amounts of alcohol as well as probably some sort of poison. He was so sedated from his ingestion that he couldn’t protect his own airway and was at risk of asphyxiating. In the US, where we have a respirator machine that would breathe for him around every corner, I would have intubated him (put a tube down his windpipe).  But here, without a working ventilator, we just watched him closely and hoped. I suppose if he had gotten to the point where he stopped breathing, we could have intubated him and had staff and family alternate squeezing the ambu-bag to breathe for him until he recovered enough to breathe on his own.  He is now awake and conversant, but he has a fever, a fast heart beat, and is breathing quickly. He likely got some liquid into his lungs and basically has a chemical burn and a bacterial pneumonia. Hopefully, he’ll do alright on antibiotics.

We continue to see malaria cases most days, patients with HIV (both new diagnoses and those who come in already on HIV therapy), and tuberculosis. We are definitely seeing lots of diseases of the first world - non-communicable diseases, often related to diet and lifestyle, like high blood pressure and diabetes. We recently had a nice elderly woman who felt fine, but when her blood sugar was checked, it was reading a value of 600. A normal value is usually around 140. We have had a number of patients with infections like gangrene due to uncontrolled diabetes. We are working to improve the weekly diabetes and hypertension clinic, so that fewer people get the complications of these diseases.

Oh, and we're doing some Insanity. That is to say, we stand in front of a laptop, and listen to Shaun T (pictured here) lead a gym full of fit men and women, along with the home audience, through some insane workouts. The Kenyans think we're pretty hilarious, doing high-intensity aerobics on our porch. I think they're right. We look hilarious. But we're preventing diabetes. Actually, I heard that Insanity is huge on the Navajo nation. Supposedly the Navajo, a group of people at high risk for diabetes, hypertension, and obesity, fill a big facility on the reservation and do this ridiculously intense aerobic work-out. Not so insane after all, I suppose. 

Life at the house here in Sagam has been good. We have been whipping up some nice meals. Luke made an Israeli dish last night with bread, lentils, eggs, tomatoes and other veggies. Tonight we're in "finish what's left in the house" mode since we're heading to Kisumu tomorrow. We heated up some leftovers and also whipped up a potato and veggie scramble that was, albeit not as good as what is routinely made on the Dolan Finca, was still noteworthy. 

The weather continues to be quite nice. Even though we pass the equator when we make the 15 minute trip to the med school, due to the elevation, it's not what most people would imagine when you mention equatorial Africa. We get some showers every day, and it rarely gets warm enough to be uncomfortable.  In the mornings, Luke and Michele are usually wearing long sleeves or even a jacket as they eat breakfast on the porch. The rains keep the flowers blooming, and I've attached a few pictures of flowers we've seen in our 'hood. 

Thanks for reading, 

Jeff

Tuesday In Sagam

Here is a bit more info about an average day for me in Sagam village.

Woke up, had some green tea, muesli and yogurt while listening to the calls of the many birds that live in the area. I got online to catch up on the news and look up answers to some clinical questions that have come up over the last few days and weeks (e.g., does malaria infection cause the type of white blood cells called lymphocytes to increase? what is the dosing of rifabutin for HIV positive children also on the drug Kaletra? what, exactly, is the sound of one hand clapping?). Then Luke, the hardest working of our lot, went to the hospital to see patients with the clinical officers. We waited around for the plumber and electrician to come and check out various things around the house (they didn't show up), and to see if we were meeting with the dean of the university (he had to postpone). So we headed into the hospital to see what cases Luke and the rest of the team wanted us to take a closer look at with them.

The cases were interesting and varied.  We reviewed the case of a child with sickle cell anemia (a genetic disorder that developed over the centuries to make it more difficult to be infected with malaria) who came in with severe pain in his sternum from clogging of the small blood vessels in that bone.  We examined an adult with HIV and likely Kaposi sarcoma, a blood vessel cancer that is caused by a virus that affects people with weakened immune systems. The patient seems to have tumors in his skin, lungs, and lymph glands. We saw a young man who we had played soccer with last week that had been in a machete fight and had a blow to his head. There were patients with complications from diseases like diabetes and hypertension, such as gangrene of the toes from a poor blood supply and infection, or a ballooning of the part of the aorta that lies in the abdomen, probably due to long-standing high blood pressure. We also saw a woman that was about 5 months pregnant and taught the clinical officer a little bit about how to use ultrasound in pregnancy for checking the fetal heartbeat, seeing the amount of amniotic fluid that is surrounding the baby in the uterus, and how to measure the head, abdomen and leg length of the fetus to determine how far along the pregnancy was.

We then had a nice lunch of beans, greens, and tasty, greasy chapati. We walked the 15 minute long journey home (included is a pic from the walk, as well as a look at some of the trees on the grounds where our house is), and then had a chance to read, go for a run, and even play a little music (I brought my sax, and so far haven't been thrown out of the house for practicing). Luke whipped up a pasta dinner, with a side of avocado from our tree, and we watched a moving documentary on Darfur, Sudan, that was directed by our new friend Mark.

I'd say, all in all, it was a pretty nice Tuesday.