Posts filed under ‘University Teaching Hospital (Lusaka, Zambia)’
My previous blogs have focused on the medical side of my time in Zambia. In this post, I’ll try to show the rest of the things I’ve been doing. I thought that it was very important, from the beginning, to make a real attempt to understand the background of my patients at UTH- where they lived, what their shared experiences were and what they expected from health care. I also tried to explore the medical culture here- how the training for residents and physicians work. I’m not a native Zambian and there’s no way I can absorb all the cultural knowledge that comes from living here for longer, but I learned a lot.
First- my parents requested that I mention any traditional medicine I have seen here. There are only two signs of traditional medicine that have been pointed out to me- both not accepted at all in the medical community. Sometimes when a patient comes in and on exam, it is discovered they have a string tied around the part where pain started. So patients with pelvic or belly pain sometimes come with a band tied tightly around their abdomen, patients with a foot ulceration come with a band tied around their ankle. This has not been looked upon positively by the physicians- it does not seem to relieve the pain and can occasionally cut off precious blood supply. The second is black scratches in rows, neatly done with a razor blade dipped in “medication” over the affected organ- a lady with chest pain or hypertension might have them on her chest. Traditional healers make these sharp cuts in the surface of the skin to apply their medication- unfortunately they do not always change their blades and sometimes patients who frequent traditional healers contract hepatitis B.
For the most part I’ve seen few people refuse Western medical care- other than performance of lumbar punctures- however some of my attendings have pointed out that traditional healers are more accessible to people, have more time to spend with their patients and are no where near as expensive. One of them also mentioned that there were several religious sects in some portions of Zambia who refused all vaccines, including ones for measles and as a result, there have been outbreaks when herd immunity no longer was effective.
I’ve learned a lot from my fellow residents and medical students, many of whom are native Zambians, both through discussion and by listening to what they tell me about their training. My American manners- my directness and unbridled inquisitiveness without fear of appearing ignorant- are very different from manners here, where people are soft spoken as a rule and no answer is better than the wrong answer. The culture in the hospital is traditional and occasionally intimidating to medical students, but that does not stop anyone from applying to shadow or work at UTH. Whether they are training in another country and wish to practice in Zambia or completed with their training and trying to obtain and internship at UTH- an assignment in the hospital is considered very prestigious and the best training to be had in Zambia.
If a medical school graduate is accepted to an internship at UTH (by navigating through an interview process including an oral exam on commonly found conditions in patients here), they have a 4 month provisional period to learn the system before they start to receive payment for their services. Many physicians from the Democratic of Congo have migrated to work in Zambia due to civil unrest, and native Zambian medical students may train in Russia, China, or elsewhere before coming to UTH- so this interview and provisional process is meant to ensure that all physicians have comparable training prior to being able to operate without supervision.
The intern year here is actually 1.5 years, and physicians in training rotate through all the major sections in the hospital: surgery, obstetrics, pediatrics and internal medicine. Then they receive a rural placement, where they are expected to see adults and children and where, according to my attendings, their independence truly begins. Then these post-graduates can apply for positions at hospitals, including UTH- where every physician who practices in Zambia should have rotated through at some point during their career. From there, if they are interested, they can try to write papers or do research to demonstrate interest in a subspecialty such as neurology or oncology before they apply for further specialized training.
I have not spent all of my time in the hospital, and I have not been idle during the days I did not have work. On the first weekend, I took the bike from my host family house and went on an epic search for a map and a bike lock. The roads are not equipped with bike lanes or shoulders and there are only occasional sidewalks which were often too rough for even my Zambike. Only a few Zambians know how to ride and bikes are nearly prohibitively expensive and frequently stolen. It was perilous to bicycle at all because people driving cars are not used to sharing the roads with bicycles, and not all the street names are labelled. While Googlemaps shows many roads, the ones shown have only a passing resemblance to the actual places. There is a local saying here: As long as you have a mouth, you a never lost. I learned to ask for directions.
On my search for a bicycle lock the first weekend, I ended up getting horribly lost in the shantytown part of Kalingalinga. During the dry season red dust blows everywhere and anyone who doesn’t have a car is covered in it from head to toe within a few hours of washing- I learned that this makes it very easy to tell who is privileged and who is not. No one paid any attention to me even deep in the poorest part of the town. This is possibly because I am mixed- according to my host, not too many years ago, children would have followed me around yelling “Za yellow,” a slang word for mixed race people. Later in my stay, as my grasp of the local accent improved, people would ask what tribe I was from- and laugh at my confusion.
Every time I got the chance, I spoke to people- taxi drivers, medical students on my team, and people I met asking what they thought about the health care system and how they used it. Most people with well-paying jobs go to private clinics prior to going to UTH, but very few people purchase health insurance. Everyone I spoke to is aware of the effects of HIV and AIDS- in fact it was rare that someone I spoke to had not had a family member or friend die from the disease as it decimated families. My heart went out to the AIDS widows who had seen or provided care for their husbands or fathers as they died, sometimes in great discomfort, and were resigned in their fate to follow them.
Though everyone agreed that HIV was a very big problem, no one was sure what the best solution was. The culture is not one that is naturally open about talking about sexual activity, condom use and frequent testing is low within married couples in whom fidelity is anticipated but not always found. Even within families, HIV status may be kept private as a stigma still remains.
While I was here, I also joined an Ultimate frisbee group full of Americans, South Africans, British and Zambians. They proved to be a wealth of information as well- many worked in health care or health care data, some in government agencies. They taught me a lot about the slang used here and the intricacies of being a foreigner.
I’m indebted to my host here for suggesting that I join- and to her family for sharing their cooking knowledge. I learned how to make nshima- a thick paste of boiled millet flour which is eaten with nearly every meal and “rape” cooked tangy dark green leaves which I suspect have no American equivalent. In return, I taught my hosts how to make the brown bread I’ve been making here as I could find no whole wheat bread in the supermarket- only brown flour.
I’d mentioned in past blogs that since I cannot draw blood or do some of the medical history taking work that the medical students do because of the language barrier, I’ve been working on patient counseling. There are still a lot of pit falls for someone as American as I am- though I am not without sensitivities. I can tell when I have said something wrong, but often I am at a loss as to what it is.
Some of the time, patients are confused by my attempts to initiate the free-flowing interaction between patient and physician expected in American medicine. Here, physicians take a much more paternalistic approach- a kindly father, but still the authority with significant amounts of power. I have been told by Dr. Yumbe that patients’ reticence to enter into an open conversation with physicians is left over from Zambia’s colonial period, where any questioning of authority would be met with immediate loss of status, financial power or job status.
My parents, from their experience here in the 80s, also added that no one is willing to go into the intricacies of having other obligations for their money and when certain relative luxuries (compressive stockings for ladies with swollen ankles for example) cannot be afforded. The residents have been filling in the prices for many of the procedures, medications and laboratory tests that patients must fund- and even though I can translate into American dollars by dividing by 5,000 (which is a dreadfully awkward number)- I don’t have the fine understanding of what each profession makes and what one can reasonably expect one’s family to raise which would allow me to push certain treatments as cheaper or affordable.
It really is ingenious the kinds of things that they use here at the hospital as cheap alternatives to expensive medical equipment. For example, a patient with pneumonia in the U.S. is given an incentive spirometer. But here, a patient showed me the version the nurses and physicians had come up with (pictured below with permission of the patient).
Still, my lack of familiarity with many aspects of life around here does make it more difficult to give appropriate advice- I have to look around at the faces of the listeners to figure out if they can actually take the advice I’m doling out and then readjust if it can not be taken or doesn’t seem well received. Usually, if I’ve been nice and approachable enough, someone will tell me why something is not feasible.
For example, there is currently a shortage of blood from the blood bank at the hospital. I was (very) surprised to discover this is because the schools are out of session- according to the intern on my team children as young as 10 years old can donate blood and stock the blood bank- my host here says she has only seen blood drives in colleges, where the population is over 18 . In a country where HIV is as prevalent as it is here, persons who have the possibility of being sexually active have greater risk of contracting HIV and donating blood in the undetectable period- where viral load is high but seroconversion has not occurred (and tests to detect infection may be less accurate). Logically, a younger age makes sense, though recruiting heavily in schools continues to make me nervous. I think the minimum age for blood donation in the U.S. in some states is 16 (in the UK it is 17) and there is also a weight and a blood count requirement, but here in Zambia, there are not as many healthy people to donate.
Still, when a patient presented with dysentery and Hemoglobin of 2.8… there are very few solutions other than blood transfusion. A hemoglobin of 2.8 is lower than I have ever seen before coming here- the normal range is 11-18 (the exact ranges vary by age and gender). I have to admit, I was surprised he walked into the filter clinic at all… I have never seen grey gums on a living person before looking in his mouth. We had been told by the blood bank that there was absolutely no blood available and to suggest that patient’s friends or family donate blood specified for patients. However, when I suggested that to the patient, he admitted that he was HIV+ as was his wife who was willing to donate for him. Even though her blood type was appropriate, to further complicate matters he was on antiretroviral treatment, but she was not- the risk of mixing a wild-type HIV with one treated is not one the blood bank would take or I would recommend. He asked me if he could pay anyone to donate for him or if it was possible to buy blood anywhere.
In the U.S., when blood banks were stocked by paid donation, the rate of infectious complications of blood transfusions were much higher, and that is one of the reasons donations are all voluntary now. Even though I am unaware if that is the case here, I told him it was safer to have a volunteer. He said there was no one other than his wife, and family members whose HIV status he did not know and could not politely inquire. I told him I would try to figure out what to do, and took the problem to the intern and then we took it to the attending who had a friend in the blood bank and managed to get blood for our patients with the lowest hemoglobin levels that night. A lot of things work by friendly connections here- everyone befriends lab technicians, nurses and orderlies who might be able to work the system when our hands are tied- and sometimes I think our patients are lucky that our team is so personable.
Some kinds of counseling are intrinsically difficult- and usually reserved for doctors specializing in psychiatry or psychology in the U.S. We had what seemed to be to be an excessive amount of suicide attempts in the filter clinic- though when I asked my resident, she shrugged and said it seemed average to her. It was time to work on another one of my weaknesses- since the toxicology screens are not rapid around here and there is no toxicologist on call- the clinical signs of poisonings (whether ingested or from animal or insect venom). Around here the poisons of choice for suicide (or homicide when added to beer, as apparently occurs relatively frequently), are either rat poison (warfarin- causes severe bleeding 24-48 hours after ingestion) or insecticide (usually containing high levels of organophosphates which severely weaken nerves and eventually lead to coma and death when ingested in large quantities).
Since I have gotten a reputation for effective counseling (though I strongly suspect that this is based solely on my available time and lack of other blood drawing and IV placing talents), I was directed to counsel a young woman and her husband after a suicide attempt. The patient would be discharged via psychiatry, but we wanted to make sure that the attempt would not be repeated. They had recently lost a newborn- and I struggled to get the patient to speak to me at all.
At least partially, I can blame this on culture- talking about death at all here is taboo. Late on our call night, nursing called for a (dreaded) “change in status” consult on a patient in the intensive care unit with new onset Cheyne-Stokes breathing. When we arrived, I recognized the colloquially termed “death rattle,” the sound made when saliva accumulates in a person’s mouth when he is no longer swallowing. After we reviewed the case which had several indications of severe organ dysfunction for which there was no solution, I asked if the patient’s wife at the bedside was aware of the seriousness of his condition and when the nurse questioned her (she spoke the tribal language of the patient’s wife), she was not. I asked if we should discuss the possibility that he might pass overnight, at the least to encourage family members to assemble given the seriousness of the situation, and my resident was aghast. I asked if we discussed palliative care (given that I have seen a few patients from hospice centers as well, and I know that not everyone is treated aggressively) and my resident said it was tricky, and typically not brought up by physicians.
While I think that discussing it might, at the very least, decrease the volume of the wailing and sobbing from the entire assembled family that occur every time someone passes (one of my hosts did a eerie mimicry of the exact sound which made me realize that it too is regional), I have recognized in families who have immigrated from other countries and from American families when discussions are unwelcome, and given my relative cultural ignorance I didn’t push the matter further. Besides which, I felt that directing the nurse to tell the patient’s family that the situation was grave and the solutions were few would at least give them warning. I was gratified to find (when I checked on the patient the next day) a small crowd of family members at the bedside.
However, in the case of a patient with a suicide attempt, there is no way I could imagine to have an effective discussion without speaking of death. At least, the fact that Zambia is a “Christian” nation helped- I could at least tell the patient to ask for support from church, friends and family- which would be overwhelmingly pro-life given the culture. But I don’t typically inject religious leanings into my patient discussions, the thing I probably did the most naturally was offering sincere sympathy and empathy- reflecting on the difficult time they had had and how important it was to keep as busy as they would have been with their newborn had it survived. I watched their faces to know when I’d given them enough of an idea of what might help and added that this was well within the natural mourning period and that if the feelings did not start to lift in the next few months, they should return without hesitation.
In the U.S. – I admit- I would have tried to do more of an assessment of their belief system as it would have have had more variability. But here, there is more homogeneity in some things, and hopefully the more directed approach was the most effective one.
With the changing attendings, I now have a female physician, Dr. Yumbe, as part of our team. It is very interesting to get a different perspective- in particular as she trained at UTI as an intern and has now returned.
On our last call day, we admitted a middle aged male with recently discovered positive HIV status who had travelled out of Lusaka to visit family. 5 days after his return, he presented to his local hospital with cyclic fevers, darkened urine and confusion. His blood smear showed 4+ parasitemia- likely plasmodium falciparum the parasite causing the more severe forms of malaria, including cerebral malaria. Because of he also presented with severe jaundice and elevated creatinine (a sign of partial renal failure), we were concerned that he would develop “black water” fever where hemolysis (destruction of red blood cells caused by parasite release) is so severe that the patient’s urine turns black and kidneys fail. Given his risk factors, my attending immediately admitted him to the ICU, despite his stable blood pressure and respiratory status. He did well, was transferred from the ICU and discharged within the week.
Since I was following the patient, we discussed him at length, including her rationale for transfer to the ICU. She said that in Lusaka and surrounding areas, malaria is rarely seen, but when it is, they don’t even do plasmodium strain identification- it is assumed to be falciparum and almost always a very severe case. Furthermore, malaria and the mosquito population used to be under better control than it is now. People with frequent exposure to malaria are thought to develop at least partial immunity- but in the past 20 years, since the control has been good, the community’s immunity is thought to be waning. Furthermore, in people with newly diagnosed HIV have their own risks with malaria. Studies performed Zambia showed that those with an initial CD4 count <300 are prone to increased risk of malaria infection, increased parasite load, and increased risk of recurrent infection.
Here many people present with AIDS defining illnesses as their first sign of HIV infection- as people did in the height of the AIDS epidemic in the US. I have seen now disseminated Karposi’s sarcoma, Herpes Zoster, HIV wasting syndrome, persistent diarrhea, vomiting, fungal nail infections, neutropenia, anemia, thrombocytopenia, and CNS toxoplasmosis all in patients with newly diagnosied HIV. I almost feel like I am beginning to be able to look at a patient and suspect HIV positive status just from their ill health and presenting complaints.
There are many other ways that the high rate of HIV infection and AIDS has affected the Zambian population- and none more ever-present than its potentiating effect on tuberculosis. One of the Zambian characteristics I have noticed is to be soft spoken and very calm, even about things that are very serious. When I asked my attending about the effect of HIV and TB on the disease climate and the recent trend, my attending said- “No, it is not very good. It is in fact, very serious.”
She explained that because initially HIV was diagnosed with AIDS defining illness (including those outlined in the WHO guidelines for identification of HIV positive individuals in areas where HIV testing is not available) and antiretroviral treatment only started when patients were severely ill, the patients were very compliant in taking their medications. However, now, with the ability to check CD4 counts and discuss when to start antiretroviral therapy, people have started on antiretrovirals without severe or debilitating conditions and the compliance to the medication regimens has decreased. There seem to be more antiretroviral therapy defaulters (what the hospital calls people who have stopped taking their medications) who present with AIDS defining illness and then are must start on second or third line treatment.
Tuberculosis was always difficult to treat, and decreasing exposure is thought to be tantamount in decreasing the chance of infection. With the number of persons with immune systems suppressed by HIV infection and developing infectious TB, there is more community exposure. The group of patients who present with serious tuberculosis infection- the classic wasting and night fever lung infection, Pott’s disease- TB in the bone, or milliary TB- where it has spread to multiple organs, now includes all people with suppressed immune systems, newly diagnosed HIV cases, the elderly and the young. And there is, of course, the slow and insidious increase in the rate of multiple drug resistant tuberculosis strains as people fail to complete their treatment and spread bacteria which has been exposed and developed resistance the first line tuberculosis treatment.
Though more eloquent people than I have spoken about the disastrous effects of high rates of HIV positive individuals in a population, especially on the control of tuberculosis, at UTH it is demonstrated daily. People come in very sick and here, we treat the infection prior to starting antiretroviral therapy to avoid precipitating IRIS (Immune reconstitution syndrome, where patients with a previously suppressed immune system will respond well to antiretroviral treatment and then develop serious or morbid complications from the body’s response to infections that the immune system previously lacked the strength to attack). This means they must survive the initial infection to start HIV treatment, or, in cases where concern for TB is high, they must survive 2 weeks of antibiotics for tuberculosis in order to start on highly active retroviral therapy. That does not always occur.
These difficulties are compounded by the fact, now that I am getting to know the population we see a bit better, that people here only come into the hospital when they are very close to death. This is particularly frustrating for the physicians who may find a woman with low blood pressure and newly diagnosed HIV who actually has Addison’s crisis due to TB infection of the adrenal glands rather than sepsis, and for whom emergent treatment may be less effective had she presented and been diagnosed with TB or HIV prior to her symptomatic hypotension.
I have also been working for long enough to see the number of patients who are severely ill and pass even while hospitalized. Sometimes, as for my patients with CLL with conversion to ALL who I wrote about on a previous blog, a nurse will come get the physician for a “change in status” and it is unclear how the event occurred. Sometimes the physicians and nursing will be present at the bedside. Last week we attempted CPR and resuscitation on a patient who had a change in status right after returning from a procedure. Though we had all the knowledge and everyone was trained in what to do, the patient still expired.
The physicians here work very hard to take care of their patients, and they have a huge number of very ill patients for which to care. On the cheerier side, glucose strips are restocked, and my new nick name is McGyver because I’ve always got my (bottomless?) bag of medical tools. I’ve also had the pleasure of seeing several of the patients who we had recently discharged or admitted, going home much improved or even seeing them for a follow up visit looking remarkably well. It is very satisfying to see life-saving medicine working even on severe and serious cases.
And now, I’ve taken enough time to write this entry and I should be getting back to work. My team (now down to just one intern and one attending due to a partial strike in the hospital) will be working the overnight admission shift.
The late morning after my call day, I went with one of my attending physicians to a outreach clinic in an underserved area outside of Lusaka. To understand the clinic- you have to first understand how the health system is organized here. The WHO guidelines rule health policy- which is, again, different from the relative freedom we have in the U.S in choice of treatment. I’ve been memorizing the WHO guidelines on malaria treatment, Tuberculosis and HIV management because they are the backdrop to every physician’s training here and I’m far behind. According to my attending physician, for every 1,000 people, there is supposed to be at least one health check point or clinic which is staffed by at least one medically trained person. If the problem identified at the clinic cannot be handled by the clinic, then the patient should be referred to the hospital or secondary clinic, for which there should be one for approximately every 10,000 people. Then for every 100,000 people there should a tertiary hospital like UTH which has advanced medical technology such as imaging (CT and MRI), dialysis and surgery- and the secondary clinic has the ambulences to take sick patients without trainsport there.
So this clinic was created with funds from the pediatric department- in an area where the people are too cash poor to afford the bus that stops in the middle of the village for the regular check ups children need during their development. I had initially thought that this meant that people would be starving, but actually, it just meant that they grew the food they needed, and most of their solvency was tied into the land and the house they were living in.
Though the clinic started seeing only children, frequently the women and the grandmothers who brought the children would ask the pediatricians for advice, and so the department at UTH requested that an internal medicine or family medicine practitioner also see patients once a week.
Because the clinic is only open for a few hours once a week, when we arrived, there was a reception office full of people. Furthermore, because the pediatrician who usually accompanied my attending had other commitments which precluded the 50 minute drive over difficult terrain it takes to get to the clinic, we saw women, men, children and infants.
The building itself was small. There was one waiting room which took up half of the floor space, one pharmacy/all purpose room. There are two examination rooms- without electric lighting. The shy girl who demurred an examination by my male attending but agreed to be examined by me had to be examined in the light of the window; obviously the clinic is only staffed in the daylight.
The clinic has two nurses who help run it as well. They took vital signs before patients were sent in to see us- and were in charge of the limited but comprehensive pharmacy formulary. The clinic pharmacy had an ubiquitous all purpose cough syrup, which given the changing weather around this time of year and the likely codeine and acetaminophen combination components, nearly every patient had brought their own container to fill. It also had anti-inflammatories (ibuprofen and prednisolone) and salmeterol (in pill form). For antibiotics, this week, they had erythromycin, ciprofloxicin (incredibly cheap around here- it serves the same as amoxicillin-clavulonic acid does in the States, and is used more broadly for urinary tract infections and gastrointestinal infections as well) and amoxicillin. There was only one thing for hypertension- a diuretic, and the formulary apparently changes depending on what is most cheaply available.
It was a relief to see people who were suffering from lighter complaints than those I see on a regular basis in the hospital. Anyone who is seen in the clinic has a medical record written in a inexpensive children’s journal which the clinic keeps- and some people had been seen regularly for a few months and had several visits filled in.
Nearly everyone had “the flu” which is what people here call an upper respiratory infection here. Some of the children also received antibiotics- those suffering from the complaint for more than 1 week or with copious greenish secretions. My attending corrected some of my more conservative antibiotic prescription patterns- when treating people of unknown antiretroviral status who you may never see again and who do not come to the doctor unless their illness is seriously affecting their work, you cannot afford to undertreat. If you do, there’s a risk of the person who reported ear pain or a persistent sinus infection may show up in the filter clinic with meningitis.
The clinic has no lab facilities or imaging- we referred a few people to UTH for imaging. It also has no real facilities to deal with emergencies- the old woman (who didn’t know her age- actually fairly common in people who were born before the revolution, especially those in the country, who count their age by events) who presented to the clinic with hypertensive urgency/emergency was sent to the nearest secondary hospital. The patient with the asthma exacerbation- no peak flow meters in the clinic- was handled fairly effectively as well, though the patient was encouraged to present to the nearest hospital for further problems.
The clinic also does not provide prenatal care- and I was surprised to note, abortions are illegal in Zambia, even ones very early in gestation. Women with unwanted pregnancies have very few legal options- and their options are handled by the prenatal clinics.
All in all, it was a great experience, and I can see why Zambian physicians would be happy to volunteer there. It’s part of the slow process of changing the culture of patterns of medical access- showing that doctors can help with concerns that are not life threatening… yet… and keep people in better health for longer. My attending just published a paper on patients with stroke- and he reported that no one in the hospital had come in sooner than 12 hours than the neurologic deficit started. This would mean a woman with hemiparesis would be brought in by her family nearly half a day after the deficit started- and not because the family lived far away or did not have access to transportation. People here seem to come to the hospital when they’re afraid they might die otherwise- which is several hours to days to weeks after physicians would prefer to see a serious medical problem.
The hours after I wrote the last blog were very tough. We work from 7-8am on call days until we are finished implementing plans the next morning. And this particular call day, we were all already tired due to Sunday’s call. Usually, when there are 4 interns, they take shifts, with each one taking 4 hours off through the night, and then when rounds start at 4:30am, everyone feels… well, if not rested, not desperately fatigued.
It’s not out of some sense of machismo that the residents and attending physicans work so hard and long here- it’s because there is a desperate need for more physicians and support staff in order to keep up with the increasingly complex admissions for poor patients with complications of advanced antiretroviral disease. The work to be done is not simple, must be performed with an eye for cost and understanding of the limited lab and imaging resources and cannot be handled by staff who are not at least partially trained physicians.
This is best demonstrated by the report of one of my attending physicians on going to help out at a clinic set up for a cholera epidemic. There had been a partially trained medical assistant who had set up and was running the clinic, and though he was doing the best that he could, when the physician went to help, he discovered that patients were receiving fluids through small bore IVs not keeping up with their large volume fluid losses and the patients themselves were not organized into wards that facilitated easy triage or treatment. There was no lack of funds or medical supplies, but still, patients were dying. I, admittedly without too much thought, asked why wasn’t the clinic only stocked with large bore IVs and support staff to insert and maintain them so the one with the most medical training could see new patients and answer questions- and the physician said- “Do you know why you say that first? Because you’re trained as physician- we all think that way.”
I hadn’t really thought about the process that took place in medical school and the way it changed how I thought about the body and problems of the body, but in terms of that particular sort of problem solving it’s true. There are special skills that we stop thinking about when we graduate from medical school and enter our clinical training because we (rightfully) assume that all of our peers have them. It’s part of the specialized training in medicine.
In any case, one of the interns had a needle stick injury the day before and was feeling poorly due to the protective antiretrovirals prescribed to decrease the chances of HIV transmission from the accident. After trying to work through the queasiness and achy flu-like side effects, the intern (with the whole-hearted support of the entire team) asked for sick leave and went home.
With that intern off on sick leave, the remaining hours were divided between the two remaining interns… but it was quickly discovered, around midnight, that the steady stream of admissions were too much for a single intern to handle. As tends to happen- as anyone who knows who has worked a very difficult call night- is that very sick patients keep coming, and then patients who had a single problem that can be fixed with a simple procedure or medication don’t get treated as quickly and the whole system backs up.
Around 8pm, I slipped back into the hospital to get evening blood sugars on two of our diabetic patients who would be able to leave the next day if their blood sugars were controlled with their new insulin regimens- due to the glucose test strip shortage, nursing had been unable to do the blood sugars before. There are TVs on each floor of the female and male wards, and I had to smile at my patient, a gangly 19 year old who had come in severely jaundiced and was developing purpura (reddish-brown bruises which are a dreaded complication of very low platelet levels) sitting inches away from the wards TV glued to an egregiously dubbed Spanish soap opera. She was obviously feeling better than she had been when we did work rounds this morning- but as one of the sicker patients on the floor, she was also conveniently right by the nursing station for monitoring while receiving her blood product transfusions. By the time I got back to the filter clinic, the attending physicians had finished their second set of rounds and the interns were in the admissions clinic working on admitting the 15 patients waiting in the lobby.
And the stream of admissions never slowed down. At one point, I was sitting with the intern, helping to collect all the material for a history, and there were screaming patients on the other side of the curtain (which separates the admission clinic from the rest of the emergency room). Though you wish you could go out and help who ever is making the noise, we had 4 full beds with patients who were not stable in the admission clinic, and we still had to make runs back into the main part of the hospital for supplies. We had two patients sitting on chairs instead of beds because we were so backed up- and, as one of the attendings pointed out the next morning- the patients who are well enough to make a lot of noise can sometimes wait longer than the ones who are slumped over, not moving and barely breathing.
Our team has medical students as well as several people who have graduated from medication school and are on the 4 month unpaid provisional training before they are accepted into a residency program. I went with one of the provisional interns into the main hospital looking for a catheter to perform a thoracentesis (removal of fluid which had collected in one of our patient’s lungs), only to have nurses stop us and request that a patient, who had been waiting for a paracentesis (removal of fluid in a patient’s abdomen) be started. The provisional intern performed the tap and I waited, exchanging the deflated IV bags we use for fluid collection, until we’d removed the 3 L the team and planned to drain while he went to look for another catheter for our patient in the filter clinic.
Around 2am, I went again with one of the interns to the intensive care unit, which stores the EKG machine as we had two patients with chest pain who needed EKGs sooner rather than the morning. Neither one of us were feeling quite up to the task, and after we’d gotten the machine, we stopped by the cafeteria (thankfully, open all night- though typically the fridges are stocked with Coca Cola and other sodas) to pick up something sugary so we could keep going.
It’s odd, here none of the residents have pagers. The team communications are all via cell phones- and between the cell phones of the patients and the residents- even in the worst of times there’s always the moment when someone’s cell phone rings with a recognizable or incongruently cheery tune and everyone has to break for a minute and smile. There is absolutely no effort to make the cell phone ring anything but personalized and upbeat- I’m beginning to think it is a cultural preference for the Bantu part of their love for joyful life.
At 2:30 am, when I finally crept into the Doctor’s Rest Room (which is what they call the call rooms- where physicians can sleep in close proximity to the nursing and their sickest patients) the TV in the filter clinic, again- only tuned to the fluff on the Zambian airways- was showing nature facts. Did you know that giraffes have no vocal cords? I certainly didn’t.
Though I’m feeling a bit better from my cold, it’s been a rough few
days at UTH. This weekend was a long weekend due to the Farmer’s
Holiday, (which allowed residents of Lusaka to attend the annual
Agricultural fair) but my team was on call Sunday. I went during the
day, but because I have no taxi to return to the hospital at 4am for
morning rounds and the uncertainty of transport home on the holiday- I opted to go home and not return until today, our next call day.
Sunday was particularly hard as several of our patients in filter
clinic passed abruptly and our teams are in the process of shifting
attending physicians and interns.
I have been doing my best to see all the facilities that UTH has- by
following a select few of my team’s patients as closely as my schedule
allows. I’ve been following a 30 year old female with hypertensive
kidney disease on dialysis. She presented a few days before I arrived
with acute on likely chronic renal failure. Although she did
not have funds for dialysis, a physician donated a dialysis catheter
and the first 10 rounds of dialysis in the hopes that her renal
function would eventually improve or (as the family promised, given
the extra time) steady funds would be raised for her to continue
She goes to dialysis 3 times a week (from the low cost wards) through
the donated temporary port, but there are no physicians to construct
fistulas at this facility and she will have to get a permacath (more
permanent dialysis access) placed if she continues on dialysis. I
visited the dialysis unit (and waved to her while she was getting
treatment) where I saw the recognizable machines with good staffing
with trained nursing. I was told that there are a few perotoneal
dialysis patients who get home treatment, but otherwise hemodialysis
takes place at UTH three times a week- and patients pay out of pocket.
Nephrologists are consulted on on the wards when patients might
require dialysis- a 22 year old patient from our team with TTP
(thrombotic thrombocytopenic purpura) of unknown etiology has not been improving with supportive management. Today we called the
nephrologist to our work-rounds at the bedside to discuss the
indications for potential dialysis.
Some things are very familiar here, though the resources are
different. Another one of our patients, a 70 year old male with
cardiomyopathy who presented in cardiogenic shock has been having
difficulties weaning off dobutamine in the intensive care unit. Dr.
Chenyenu (the clinical Internal medicine department head) and Dr.
Chimanu (one of the internal medicine team leaders)- shown below-
discussed the patient’s management and the possibility of needing to
have the patient transferred to South Africa to get a cardiac
catheterization or further investigation into the possible causes of
our patient’s heart failure. Because there are sometimes as few as 5
attending physicians for as many as 300 medicine beds in the hospital,
the hospital could not run without such a spirit of cooperation
between physicians and difficult cases are frequently discussed
between attending physicians so that the hospital resources can be
The intensive care unit has patients who are stable on continuous
infusions, unstable or require artificial ventillation- there are many
nurses, doctors and physiotherapists (physical therapists) who come
through at regular intervals. One of our patients, a male in his 30s
who presented with tuberculous meningitis spent over three weeks in
the intensive care unit before being transferred to the high cost ward
(where his family pays for treatment). During his ICU stay, despite
the nurses and physician’s best efforts, he developed a severe
pressure ulcer and a methylcillin resistent staph aureus bacteremia
(MRSA blood infection). Here the lab does not do drug levels, nor
does it have the capacity to process daily creatinine- physicians
treat MRSA with 5 days of vancomycin based on an initial assessment of
renal function and the follow up blood cultures and kidney function
after treatment has been completed. For our patient, his meningitis
has improved, but he is severely cachetic and at risk for further
iatrogenic complications. We brainstormed ideas at the bedside on how
to avoid continued fecal contamination of the pressure ulcer and
improve healing so that he would be well enough for discharge.
In the mean time, I have been trying to figure out the ways I can be
most helpful to my team when I’m not learning about the presentations
and treatment of tuberculosis and complications, advanced AIDS and the art of physical exams. I’ve done some patient counseling (which is
interesting, usually it has to be performed through an interpreter and
there are many cultural things which I often need to have a medical
student explain to me). I’ve also been taking pictures of the
informational posters which are hung up around the hospital, though I
have discovered that few of the patients and families are able to read
well enough that a poster replaces the need for verbal reinforcement.
My team is on call tonight, but I’ve written this journal from the
library where I’m reading (again) about the many presentations of
tuberculosis during a lull between seeing hospitalized patients and
when we do our official rounds in the filter clinic (Emergency room
equivalent). My single goal tomorrow is to head to the clinic where
Dr. Mukumena sees patients in an under served area close to Lusaka-
and he has also promised to speak to his wife, who is a physician at a
community hospital nearby, about the possibility of my visiting there.
He has introduced me to several of the physicians who do research at
University Teaching Hospital- my hope is to be able to connect with
the infectious disease department head and work on a patient
presentation or a brief study to round out my experience at UTH.
But for now, lunch and then overnight call…
The internal medicine department head has been called away briefly to help organize for the the Ebola outbreak in Uganda- and the medical students still have their exams today. So major rounds were cancelled, and I went on work rounds with the interns.
As a resident, you always have to deal with work-arounds. You know, the shortest distance between point A and point B is a straight line, but somehow you are thwarted and end up doing spirals before you can make it to point B. These aren’t even worth telling your attending about- it’s just the things you do to work with what you have.
And what we have here is completely different than what I’m used to.
There haven’t been test strips for the glucometers for the past 2 days. We’re waiting for a shipment. In the meantime, the poorly controlled diabetic in the low-cost ward for whom we’ve been adjusting her insulin for the past two days wakes up with a head ache and feeling shaky. Her blood sugar hasn’t been tested in the past two days since we increased her insulin (for blood sugars in the 300s). Do we want to tell her to eat to insure that her symptoms aren’t hypoglycemia and hold her insulin until lunch? The intern asks how frequently she’s urinating overnight- 5 times- then starts her on intravenous fluids and increases her insulin again.
Then, another patient, this time a 17 year old male, presented with a wasting disease which the team had initially assumed was new onset RVD (the shorthand for retroviral disease or AIDS that we use in the chart to prevent immediate identification by nursing and nosy family members) but was diagnosed with adult protein-calorie malnutrition. I had come in early to pre-round and talked to him about what foods he was and should be eating, only to discover that he had only been eating bread. I suggested chicken or eggs. He said his family had them, but he didn’t eat them. I suggested beef, beans and nuts- and he shrugged.
Frustrated, as he has the puffy cheeks, and cadaverous frame I’ve only seen on female anorexics in the U.S., I waited until we came around with a medical student who spoke the teen’s tribal language. The resident questioned his sister, who had come in for the formal rounds. Apparently when he was younger, he had a few “fits.” They had taken him to a traditional healer who had told him to avoid eggs and chickens- which besides maize were the family’s major source of protein. The fits had never returned, so this was seen as a sensible solution by all involved. When the problem was explained and the importance of alternative protein sources emphasized, the patient agreed to peanut butter and multivitamins and was discharged that day.
Another patient, a pretty unnaturally pale-brown skinned woman in her late 30s, who I first met last week on the last major rounds, has been diagnosed with CLL for more than a week. Her family had been raising money for the chemotherapy- but the pharmacy only had half of the necessary drugs, no matter the money available, and the rest were only orderable from South Africa and have not arrived. In the meantime, her lymph node biopsy site still had stitches in place. When I saw her in the morning, she told me that they were supposed to have taken out the stitches 6 days ago, but no one has come by. I had watched the intern make the surgical consult for suture removal during the last rounds- but I have also never seen a surgeon in the internal medicine low-cost wards, likely because they are simply overloaded with surgeries.
I feel entirely comfortable with both my simple suturing and suture removal skills, so I asked the nursing for a suture removal kit- only to discover there were none, but that they might be able to get a surgical blade from surgery. They dispatched one of their precious few nurses to attempt to get one, and I tried to loosen the stitches, which were now all infected. One of the medical students said she knew where to get surgical blades, and arrived back with one precious sterile blade (handle-less). Using gloved fingers and the tiny blade, I took out the stitches. Firm pressure around the site yielded pus, which I removed as much as possible… and told the family to wash the wound in a diluted hydrogen peroxide solution which I had learned was cheap and easily available from the pharmacy.
Following up on the wound for the next 2 days, I was pleased to discover her face healing well- and her chemotherapy will progress without delay with the available medications. It’s easy to get discouraged in the face of the number of deaths of young patients with treatable and preventable diseases from the filter clinic, but from following the lead of the attendings and the residents, I’m learning a lot about operating with the minimal amount of waste, allocation of resource, and triumphing in the successes of every patient discharged healthier than when they came in.
And I bought a stash of 50 glucose test strips from the pharmacy after one of our adult male diabetics stridently refused to have his blood drawn for a serum glucose measurement- $26 is a relatively small cost if it means we can properly titrate insulin and get someone out of the hospital a few days sooner. Between that, my personal blood pressure cuff, forehead thermometer, pulse-oximeter, and stash of non-latex purple gloves, everyone is beginning to get used to my ever-present bag and my bulging white coat pockets (containing my notes and references to look up relatively rarely seen conditions and convert nearly every medication and lab test they talk about to an American equivalence that I know how to interpret).
Today, the team was on overnight call. They work in the “filter clinic,” which is the equivalent of the emergency department in the U.S. There is a resident hand-off of urgent or unstable patients in the morning. Then the call team separates, one to see and review the patients in the hospital and the second to help with admissions.
During the day it was busy, but at night- it was only our team doing all the care in the emergency department and admissions in the hospital. There were three attending physicians who were helping to review patients, and then the interns and medical students take care of implementing plans. There is enormous volume and turn over, especially during the night.
Interns and medical students often place IVs, do blood draws, and schedule imaging. Overnight in particular, I was amazed at how life-saving 1-2 liters of an appropriate fluid given intravenously could change a patient’s appearance and prognosis. Unfortunately, just as in the hospitals in the U.S. patients pull out IVs or the equipment malfunctions, and often if there is a patient who someone is worried about, it is worth checking on them several times through out the night. Almost every patient’s family comes in to supplement care, but they cannot replace the value of having well trained nurses.
There are several nurses, one in the admission part of the filter clinic, and the others spread out constantly taking vital signs, starting blood transfusions and administering medications. There are beds, stretchers, and pallets organized in rows in the three major portions of the ED, but the area is made even more crowded by family members bringing food and medications for nursing administration from home. There is one patient toilet and one “rest room” for physicians with toilets and beds. White coats are worn only by doctors, nurses – called “sisters” have uniforms; people make way as best they can.
There are only 4 beds in the acute care section- reserved for patient’s who are in critical condition or in need intensive monitoring. For example, for a few hours last night, the acute care bay had one patient was in diabetic ketoacidosis, one patient with likely metastatic liver cancer who was very confused and combative and the other two in septic shock. There were many others who were very sick. Then there are 4 beds in the admission/triage section where new patients are seen by physicians and initial plans made.
For me, the most remarkable part is that my every differential (which, given my training, is based on a US population) is weighed against infectious etiology, but here the most frequent cause of illness is infectious disease. Whether it is side effects from anti-retroviral drugs, infectious complications of end-stage AIDS, it seems as if nearly every patient had newly diagnosed retroviral disease or recently started on highly active antiretroviral treatment (HAART)- and interns know the appropriate drugs and their numerous side effects much more thoroughly than me.
While in the U.S., we joke that PE (pulmonary embolism) can be on nearly every differential, here, it seems as if TB (tuberculosis) is never wrong to consider to add to your differential whether it be a patient with clinical adrenal insufficiency, abdominal pain, chest pain, fever, cough, or wasting complaint. Malaria can be considered if the patient has come from an area not close to the city, as well as trypanosomiasis for the patients who are brought in with a very low Glasgow Coma Scale score (a score used in the U.S. used for post-trauma assessment, but here is used as a proxy for mental status for the severely altered patient).
Interestingly, physicians here often argue with patient families about consent for lumbar puncture. Though the procedure samples spinal fluid and may be painful or dangerous for patients (as it is performed without any anesthesia and only local sterization), it provides valuable information on the possible cause of altered mental status- which was by far the most frequent presenting symptom in the filter clinic last night. Even without lab studies, turbid fluid collected at high pressures in a patient with newly diagnosed antiretroviral disease will let physicians know that they need to cover for cryptococcal meningitis, cloudy fluid at lower pressures gets treated empirically for bacterial meningitis, and yellow at lower pressures with “spider-web” clots makes physicians put TB meningitis higher on the differential from the beginning rather than when patient’s fail treatment for bacterial meningitis. Patient’s families see the procedure as intrinsically dangerous- as they see people die after receiving it- instead of seeing the presenting symptom as a very serious complication of an advanced infection with a relatively high risk of mortality.
As for nutritional dysfunction- while in the U.S, obesity is the major culprit, here, malnutrition from AIDs or alcoholism is the most commonly seen. Pellegra is much more common in a population whose stable crop is maize- which lacks a bioavailable form of niacin- my attending physicians grilled the team on physical signs of niacin deficiency when we were admitting a patient who was a known alcoholic found seizing.
We did get a little rest during the night- given my increasingly persistent cough and breathlessness, the residents made me go to bed earlier than they did. Even so, I was exhausted by morning rounds and my head cold had turned into a full blown asthma exacerbation. One of the residents (whose father is the head of the high cost clinic) got me a prescription for steroids and appropriate antibiotics to supplement my albuterol inhaler. I was sent home early- while my team worked on to round on all the patients under their care in the hospital prior to major rounds tomorrow. Before I go to bed tonight though, I hope to have reviewed many of the things I saw and learned about on overnight call.
I had my first clinic here on Monday. Each team admits patients one day of the week, and each team has one designated day for seeing patient’s in clinic. We see as many patients that have appointments- which can be around 15-20 in the morning per attending. The interviews are done in a mixture of English and the two local languages, Bemba and Nyanja, which the attending, patients, and medical students all speak with various skill levels. Between 4 members of my team that morning, we had speakers of French, Russian, Bemba, Nyanja, Chinese, and English!
Some patients come in for hospital follow-up and some have chronic conditions which are not severe enough for admission but still need regular appointments. Some patients are referred from other clinics for the speciality of internal medicine- like the 22 year old HIV+ on antiretroviral treatment with new onset renal dysfunction and 2 months of right hip pain who was sent from orthopedic clinic due to concern for skeletal tuberculosis- in a slightly atypical location. She had brought her hip images with her demonstrating bony destruction, however, a careful history taking yielded a story of migratory poly-arthritis not consistent with TB as an etiology, as well as new renal failure after starting a tenofovir based anti-retroviral regimen, which raised the possibility of gout as a possible etiology.
I was just surprised at how young the patients’ were- despite the regular hypertension, diabetes and post-stroke presentations. The average age is certainly well below 40, and around an even mix of males and females. The soonest follow-up day available is usually 7 days in the future, and if the patient needs follow up sooner, physicians may have to make special arrangements.
Also, I noted (as seen in the picture below- an advertisement for free adult circumcision) that public health continues to be focused on stemming disease spread- HIV in particular. I have also seen several billboards encouraging regular HIV testing and condom use. Given the multiple complications of antiretroviral disease and extremely high prevalence in this population, circumcision seemed a sensible suggestion, but my hosts told me that it was more likely guided by grant money from the CDC and other venues which supported adult and infant circumcision as the best way to stem the spread of HIV- and they had seen other attempts pushed and fail.
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.
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.
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.