Complications

7/30/12

Posted by Amanda Thornton, MD (a third year Internal Medicine resident from Kaiser Permanente, Oakland while on a global health elective in Lusaka, Zambia with University Teaching Hospital).

Today I had my first “Major rounds.” On major rounds, the attending physicians, here called “consultants,” go around to each patient admitted to the Medicine service in the hospital and discuss their case at the bedside. They do this with the team 2 days of the week- the male ward on the first day, the female ward on the second. This means they take their time on every patient and our discussions ran from 8am to nearly 2pm. The rest of the week, the interns see every patients and make medical decisions on their own. One of the interns admitted she had seen 24 patients today- which is very different from the limited numbers of patients interns are allowed to see in the United States. I have only seen a maximum of 16 patients a day, and that in the second year of my residency; when I asked if I could see patients with her, she said she would be grateful for the help.

Patients who survive to sit in a hospital bed here are often relatively stable- but the patient I had been assigned yesterday to present this morning had passed 30 minutes before I arrived. She was a 26 year old widow with AIDS and did not have the funds to pay for the high cost ward. Though she had been faithfully taking anti-retroviral therapy for three months and had initially improved enough to take a part time job, she had started to feel overwhelmingly weak 2 weeks before she came to a community hospital. From the community hospital she had been referred UTH for further work up.

When I saw her yesterday, she was surrounded by visitors and was very easily tired from the effort of answering my questions. She told me to come back tomorrow so she could tell her story. She had been losing weight from the time of her diagnosis 3 months ago, and I was very worried that she was suffering from AIDS associated wasting. It sounded as if her infection had not responded appropriately to the highly active anti-retroviral therapy (HAART) she had been prescribed. Involuntary weight loss in advanced HIV infection can be caused by a combination of many different conditions, but it is associated with lower CD4 counts (one of the parameters doctors use to gauge a person’s response to treatment for AIDS and their ability to fight serious infections associated with AIDS) and increases the patient’s chances of dying despite appropriate treatment. She told me that she had felt worse and worse every day she was in the hospital; I was sorry that we could not have helped her more.

It is amazing how much clinicians here have to rely on clinical findings- the physical exam and history of illness the patient reports. In the United States, I have heard residents say that eventually the physical exam and history will be obsolete, and the appropriate interpretation of a battery of tests will be all that is indicated in order to diagnose and treat patients. After having been here for just 2 days, I am even more firmly convinced that it is important to continue to learn how to elicit an accurate clinical exam to be a good and effective doctor. Here the physicians have no other choice- Laboratory exams are expensive and usually take 1-2 days to come back. Imaging is also difficult to schedule and have performed; ultrasounds are read by technicians rather than radiologists, and physicans, like the team’s attending Dr. Mukomena, read imaging at the bedside and use it to directly support the patient’s diagnosis so that treatment is started immediately. The untreated patient has not been helped, he explained to the team, and they come to the hospital for treatment.

For example, today, we had a discussion about a patient with incompletely treated tuberculosis (TB) and HIV who presented to the hospital two days before with shortness of breath, chest pain and hypoxia. She had not improved despite starting treatment for TB and supplemental oxygen. Her X-ray had been performed the day before. We all looked at it in the light of the window, but on listening to the patient’s lungs, Dr. Mukomena called all of the learners on the team to listen at a particular spot on her chest.

“Listen, do you hear it?”
“Almost a whistling?” I asked after listening to the spot he indicated.
“No, not whistling. Like the sound you hear when blowing over the top of an empty soda bottle. Amphoric breath sounds. She has a pneumothorax or a large cavitation.”

The team assembled a needle with a syringe of sterile water, and he inserted it between her ribs, and drew back. “You see the way air comes out and bubbles through the water? There is air outside the lung- she is only breathing with her other lung, this one is not being used.”

We re-examined the chest X-ray on one of the few light tables in the ward (see below)- we had to unplug where a patient had been charging her cell phone before we could plug it in and turn it on. He outlined the large space where he hypothesized that either tuberculosis gradually had eaten away at the lung tissue to form a large hole in the parenchyma (a cavitation) or it had damaged the lung enough for a pneumothorax to form. The intern wrote for a surgery consult for possible chest tube placement and the team moved on.

X-ray of a chest of a 38 year old woman with TB and HIV

This afternoon, I went to the library to investigate TB complications that I was simply not familiar enough with given my experience in treating an American population with relatively low rates of TB. The library was full of medical students and physicians who were “revising” (what they call studying) for major rounds or for exams. Internet bandwidth is limited, and I have not been given access for my iPhone. Today, the desktop computers’ internet was not working at all.

The Library

I found a book entitled “Tuberculosis: A comprehensive clinical reference” (Schaff/Zumla) which reported that pneumothorax is a very rare complication of untreated tuberculosis, only 5% of patients with severe cavitary disease will develop one. Two patients on the service have another complication of TB rarely seen- constrictive pericarditis, on which I read a chapter. Already, I have so many things to learn and I expect I will be coming to the library very frequently the entire time I am here.

Now, two days off before I start in the hospital’s outpatient clinic on Monday. This weekend, I plan to try and connect with Americans here and start a membership in a nearby gym. Next week I will be accompanying Dr. Mukomena to an outpatient clinic he staffs in an underserved area near Lusaka.

Finally Here – Zambia!

7/27/12

Posted by Amanda Thornton, MD (a third year Internal Medicine resident from Kaiser Permanente, Oakland while serving a global health elective in Lusaka, Zambia with University Teaching Hospital).

This elective took several months preparation, all performed while I was still completing my second year in residency.  I applied for the elective, requested the scheduling time and when my elective was approved, contracted a travel agency to book my trip.  That was just the beginning. From there, I talked to other residents who had been on global health electives, to physicians who had grown up in the area and to Ajay- the last resident who had been to UTH to find out what I could expect.  The Kaiser travel clinic prescribed my vaccines and my
anti-malarial medications via a phone appointment. Then I stole time from my busy day managing a Wards team of new interns to be vaccinated and pick up the prescriptions. 

The day after I completed my wards rotation, I packed for 12 hours, cleaned my apartment, stopped my mail and caught a plane to New York. When I arrived in Zambia, I had already been traveling for 2 weeks.  This had been intentional- I took time to visit family in New York, and then stopped in London for 5 days just before the Olympics started.  My sister, who lives in the UK, had scheduled for me to meet with family and friends who had traveled and worked in Zambia.  My parents had lived in Zambia for 2 years before my sister’s birth (My father was a guest lecturer on African History at the University as my
mother completed her PhD research in Angola) but their information was nearly 30 years out of date.  All of the advice I received helped me prepare for a completely new experience in the health care system, and by the time I arrived at Gatwick airport, I was feeling prepared instead of nervous.

I had a delay at the very beginning of my flight to Zambia- the pilot on my Emirates flight fell ill, and by the time a replacement pilot had been found, several passengers had missed the single connecting flight from Dubai to Zambia that day.  The airline paid for us to spend the night in the airport hotel.  

Dubai is Emirate and a city in the United Arab Emirates.  The country is
predominantly Muslim, and is currently celebrating the Season of Ramadan. Ramadan occurs in the 9th month of the Islamic calendar and the whole country observes the day-time fast as part of the 5th pillar of Islam.  Guests in the hotel were not allowed to eat or smoke outside, and were encouraged to dress conservatively. 

I had no trouble with dressing conservatively as the only clothing I had in my carry on luggage was an extra pair of scrubs.  When I ventured outside during the day, the over 105 degree heat slapped my face- worse than the time I spent in deserts in Arizona.  Most of the women who were not hotel staff or foreigners were dressed in the floor length loose abaya and had their heads covered.  Usually foreign women wearing clothing that covers legs and arms are not remarked on, but I as a female traveling alone with skin of an indeterminate brown color, felt a little uncomfortable with the stares of the men in the hotel lobby even in my loose scrub pants and thin long sleeve top. 

I went on a tour of Dubai after sunset, when the heat had decreased to at least 85 degrees.  On the tour I met some of the other groups who were also going to Zambia.  One woman was a Kaiser Physical Therapist who was volunteering on Children of Hope mission trip to meet a child she had been sponsering for the past 4 years.  Another woman was a recently retired nurse from Washington who was going to Southern Zambia to visit a village and help build outhouses that would separate
waste from their water supply. 

The retired nurse commented that it was strange to be going from Dubai which boasts the Armini tower, the tallest building in the world, and all the health benefits of the western world to Zambia.  I didn’t realize how stark the contrast was until I visited the World Health organization website.  United Arab Emirates boasts a life expectancy averaging 78 years and 19.3 physicians per 10,000 people. Zambian people average life expectancy is 48, with 0.6 physicians per 10,000.

Armani Tower

When I wandered past a medical facility within a block of my hotel in Dubai, it appeared organized and modern, with several ambulances in the bay, a bright sign reporting that at least one 24 hour physician was on duty.  Already, after 1 day in Zambia, I have not seen a single ambulance.

Zambian hospital entrance

Instead, today, I saw a patient carried in by a private car filled with family.  The hospital facility at UTH is spread over several buildings, but the internal medicine ward in which I worked today is crammed with more than 6 beds in a small curtained section.  In the hospital, though there appears to be running water, hand washing stations are posted with bottled water.  Hand sanitizer- available outside every room in the Oakland Medical Center is available in the nurse’s supply room. 

In Zambia, where 75% of deaths are due to communicable disease, and 135 people per 1000 are HIV positive, beds at tertiary referral centers like UTH are in great demand.  According to the medical students on my team, patients pay for procedures, labs, imaging and medication if the hospital does not have it in its supply.  The patient’s family may bring in food and supplement the busy nurse’s care. 

Shantytown

Still, today, shopping for supplies in a busy supermarket, I discovered ample food supplies, including luxury items my parents claimed were not available in the late 70s- including cheese and honey.  Watching the national news with the  niece of my host in Lusaka, I heard that Zambia’s prosperity has been improving, but it has not started to decrease the rate of poverty.  I think of the shanty town we drove through on the way from the airport, where my host warned me not to take pictures or we might be stoned by people whose pictures had already been taken to raise aid funds which they never received.  Everything here works
differently and I’m only beginning to see how.

I’m ready to learn.