Cholera (aka: The world is f*cked up)

We had our grand round today-both the infectious disease team and the microbiology staff. We went to see a patient, who may well be the first cholera case at Bara, related to the outbreak in Zimbabwe. There have been plenty of cases up in the northern region of South Africa-the Limpopo area which borders Zimbabwe. And there have been a smattering of cases at Jo'burg hospitals (JHB General and HJH), but none at Bara. Which seems a bit unusual... But the cases at the Gen and HJH have been patients who were seen in the MSF (Doctors w/o Borders) clinic in the heart of Jo'burg, and they refer patients to the Gen.

 

So, it was a great bedside (well, not at the bedside, since the voluminous diarrhea makes it somewhat distracting to talk at the bedside) tutorial on Cholera. In addition to all the stuff that would bore most people (pathogenesis, treatments etc) we also looked at the Zim statistics.

 

Consider this:

-only 10% of people with Cholera are symptomatic. There are a reported 30,000 cases of cholera. Which means that that the actual number of cases, based on the reported 30,000 is therefore 300,000 cases. Take into consideration that Zim is falling apart, that there is poor disease reporting, and that people are likely not accessing health care, and the figure of 30,000 reported cases is likely a GROSS under-reporting.

-that the expected death rate of cholera is 1%. It doesn't take any special, drastic measures to treat. Simply rehydration alone, and antibiotics for those severely ill. But, the overall death rate in Zim right now is 5%. BUT the death rate in the community (i.e., those not in treatment centers) is estimated to be 55%, of those who have been diagnosed.

 

I say that this is "aka the world is f*cked up," because there is plenty of bad news in the media these days. (Though I have to admit that I spend less time on my favorite news sources-the BBC and NY Times, and simply look at major headlines to see what new f*cked up problems there are). The Economy. That guy who stole all the money. Gaza. Iraq. Pakistan. Iran. The US. Unemployment. Somali Pirates. Jacob Zuma. The Denver Broncos.

 

But this is f*cked up:

"healthcare" in Zimbabwe-as per BBC

Cholera: 2,204 died since August

Anthrax: Eight deaths since November

HIV/Aids: Estimated 400 deaths a day

TB: Brain-drain has practically closed the national testing laboratory which now has only one staff member

Maternal mortality: Risen from 168 per 100,000 in 1990 to 1,100 in 2005

 

(Please read the full article at http://news.bbc.co.uk/2/hi/africa/7826304.stm and also check out http://physiciansforhumanrights.org ).

 

So, our one patient with probable cholera will have an uneventful course at Bara. He'll get his hydration, and antibiotics, and he'll head home in a few days. But had he been in Zimbabwe, there's a good chance he could have been #2,205...

Ward 15, Bed 14

I got to work an hour early today. I knew it would take me some extra time to get use to the system, the system of actually finding patients. I'm not too sure how many medical wards there really are, but there are quite a few, and they are scattered about.

 

I think there are about 10 general medicine wards, each holding 65 patients. As best as I understand it, each general medicine team has 2 wards, a male and a female ward. Teams are on call every 5 days, and take all the admissions for 24 hours. The day of call, some patients from that team will be sent to wards with free beds to make space for the admissions. And then when the new admits have filled all the beds on the ward, the overflow admissions will go to other wards.

 

The average number of admissions seems to be well above 100 -ONE-HUNDRED, and probably closer to 130+

 

So, I admitted 3 patients last week. One on Thursday, and two on Friday. And it was my goal to locate them all by 8:30 am, and to have hopefully rounded on at least one, or two of them before meeting the consultant at 8:30. I started with what I thought would be the easy way of finding the patients. I looked in the lab results of the computer, hoping that they had labs done over the weekend, and that the lab results would say which doctor (in which ward) had ordered the recent labs. And, so I randomly picked a medical ward to go use the computer. (I had to fight the urge to go back to the pedi admission ward, or even ward 18 to use the computer). As luck would have it, I ran into a resident there who I knew from my time in pediatrics. (She doing her mandatory community service at Bara). And she was kind enough to inform me that the computer in her ward didn't work. So I did the next logical thing, or so I thought, I headed to the next ward, and searched for the computer. Same story, not working. But, while I was there, I skimmed the book to see if the patient was on the ward.

 

The bloody books. The manual record of who is on the ward, or who has been transferred to another ward. The is no computer system to indicate where patients move, but rather one relies on multiple log books of patients. And no success in that ward. So I moved on to a third ward, as I looked at my watch and realized that it would be less likely to see 2 patients before 8:30. Strike 3.

 

Somewhat getting desperate, I decided I would head to pedi land and use the computer there. And as I was walking to pedi, I passed the same resident from earlier, who told me to pop into the medical admission ward and use the computers there. Which I did.

 

Patient #1- no labs since admission. Not helpful.

Patient #2 and #3-no ward indicated on the lab computer.

 

Shit. Now I don't know where they are. But at least I have some lab results.

 

I run into the resident again, and try to figure out how to find these patients. And it's simple. Knowing what day they were admitted, means they were allocated to either the male or the female ward of that team that was on call that day, and then all I need to do is head down there and look in the books to see where they are. And here I've spent the better part of half an hour to learn this.

 

I head to the male ward (16), to see Patient #3. I saw him in the clinic on Wednesday. Nice guy, 52 y/o male. On HIV treatment for 3 months now, and on TB treatment for 2 months. But he's lost 7Kgs (about 15 pounds) in a month, has a horrible cough, and just has that unwell appearance which made me think that something bad is going on, or something is being missed. So, since I saw him late on Wednesday, and they were done drawing bloods in the clinic, I send him out with a lab form and instructions to come find me in the clinic the following day to review his results. To make a long story short, his results were all out of whack, new kidney failure, worsening liver function tests, and he didn't come find me on Thursday. So I called him back and saw him on Friday and admitted him to the hospital. Since his admission, there really hadn't been much progress in his work-up. I find him in the ward, don't really have time to write a note on him, since I haven't even found the other 2 patients yet, but we chat briefly, and I glance through his notes. It'll be nice to come back and see him later and leave better instructions about which tests I'd like done. He likely has either MAC, or MDR-TB, or Non-Hodgkin's Lymphoma, plus his renal and liver issues.

 

Patient #2 was admitted the same day as patient #3-so she must be in the female ward (15) of the team that was on call on Friday.

 

So, on Friday, as I was writing the admission letter for #3, there is a knock at the door, and the sister opens the door.

 

"Doctor, the next patient is sick, can you see her?"

Of course I think "no" let her see a consultant. But I'm here to learn... "Sure, let her stand outside the door while I finish writing this note."

 

I send off patient #3, and then patient #2 is wheeled into the room by her aunt and uncle. And she looks like crap. She will have to be admitted. Turns out she's 26, was seen in the HIV clinic back in October, but then never came back for any visits. And today is brought it to our clinic by her aunt and uncle who are worried about her, rightfully so. Her CD4 count is 60. She has a weeks worth of a horrible headache, as well as she can't swallow anymore because of the pain. She also has Kaposi lesions all over the face and her arms. She's unwell. She's going to need a lumbar puncture (spinal tap), lots of labs, and empiric treatment for a bunch of stuff. I check her vitals (I know-it's a universal... I don't even ask ancillary staff anymore to check vitals.. I just do them myself). Heart rate of 160, BP of 82/54, RR of at least 30. (Ok I didn't formally count the RR, it was at least 30, and I didn't want to know if it was 40, or 50). So I ask the consultant to see her when I'm done with my note, and he agrees, book her for admission.

 

I'm walking into the ward, and I look over her results. Her lumbar puncture is actually bland. Will have to see what grows out on the cultures. I hope they've started her on antibiotics. Her other labs show bad acidosis on admission, which improved a bit as of yesterday. There are blood and urine cultures pending. I'm thinking what my plan will be for her. She's unwell, and needs to get on HIV treatment, fast. But she may need TB treatment for 2 weeks first...

 

I look in the book, and she's in bed 14. So I walk down the ward. Curtains are closed at pts are getting bathed. And I peek behind curtain 14, and the sheet is pulled up over her head. For a minute I wonder if she's been having chills with fever, but then I realize that it's also tucked in around her body, and she's not really moving.

 

She's dead. Too little. Too late.

 

 

home

I am home.

 

Yesterday when I woke up at S&S's place, I was longing for home. Don't get me wrong, it was a great week staying with them, I just longed for home. I was, albeit, slightly confused about where home was. I was certainly eager to get back into my own space, in the Mondeor house, but also had a bit of longing for home. But which home?

 

My definition of home is changing. When I was travelling last month, and people asked where I was from, or where home was, I went into the lengthy explanation. I had to make it clear that I grew up in Colorado (which arguable is the best place in the world to grow up), but that I currently live in Johannesburg, and that I'd be returning to Massachusetts in July. And often times somehow it would come up that I'd lived in Dublin as well.

 

For a while, I defined Home as where my dog lives. Not that she's really "my" dog anymore. After 9 neglectful years of not paying alimony for her care, I'm pretty sure I've lost the right to call her my dog. (I am a deadbeat dad). And then I had this complicated definition of where home was. I'd thought that Colorado was really Home. But Dublin had been a home, just like Massachusetts had been a home. But Colorado remained Home, with the big "H."

 

But waking up yesterday, and longing for home, I wasn't sure where that was. Or rather, felt an equal pull to Colorado, Massachusetts, and even a pull to Dublin. I wasn't able to exactly figure out what I was missing. With the ability to access internet anywhere in the world, I've been able to keep in touch with people easily via email (and facebook); and skype has made it possible to have regular phone conversations with people-a true luxury. I found myself longing for random things yesterday. Seeing the Rocky Mountains. Seeing how big my nieces and nephews and godchildren are getting. Going out to dinner with the work crowd after a busy week in the hospital. Sitting with J&A having way too much coffee, having breakfast, and letting their daughter entertain us. Having a study afternoon with GK at Barnes and Noble. Meeting up randomly at Metro Café, or a drink at The Front Lounge. Ironically, I'm sure that 12 months from now I'll be able to add waking up at S&S's house after a night out having a late dinner (and lots of wine) and then heading out to breakfast at Espresso and watching the crowd.

 

I loaded up the Bakkie with all my worldly possessions in Jo'burg, and drove down to Mondeor. As I pulled down the driveway, I realized I was home. I was excited to be back in this house. I am excited to be back here in Mondeor.

 

As I unpacked yesterday, I realized that I'm fortunate enough to have many places which I could call home, but for the next 5 and a half months, this is Home.

 

200

Wow. Flooded is the proper term. Waiting rooms overflowing, people sitting out on the lawn outside.
 
230 patients in clinic yesterday.
210 patients in clinic today.
 
There are many things I want to jot down, but am a bit short of time right now. And I'm also very sweaty and smelly, and we're going out to dinner soon, so I neet to make myself presentable. I'm sweaty and smelly, by the way, because there is no air conditioning, and when that many people are waiting in a building to be seen, the place gets hot.
 
I'm going to skip patient stories for now, because they are party composed in my brain, and I'd rather save them for later..
 
The clinic, has been incredible. Absolutely incredible. Seeing simple clinic visits which can be done in 10-15 minutes, to seeing sick, sick people. Admitted 1 person with an acute-ish abdomen today, but also saw a sick guy yesterday (who I should have just admitted for his work up) but instead did labs on him, and he failed to show up for results today, and based on his labs alone needs to be admitted to work up his multiple abnormalities.. That's on tomorrow's TO DO list, somehow find the sick guy who didn't show up today and get his *ss in the hospital.
 
I saw my last patient at 5:30 tonight. She arrived at the hospital at about 9 this morning, waited in a queue for a long time to register, and then waited in our clinic for a long time. When it looked like patients weren't going to be seen in time to go get their HIV medicines filled from the HIV pharmacy, they were sent from the clinic with new scripts (and likely waited in line there for well over an hour, maybe 2-3 hours when it was at it's busiest-as there is also pedi HIV clinic so those kids are going for meds today as well) and then back to wait to be seen. But, there were no complaints. Patients were kind and thankful. These docs work incredibly hard, and they just keep picking up charts and seeing patients. It's very rewarding.
 
As for life...
Sadly will be leaving S&S and moving back into my old place on Saturday. Will be nice to be close to work again, but has been great to stay with them.
 
Cheers!

BPB

Back to Adult Land, and more..

It's nice to be back in the land of adult medicine. I feel like part of the team this month. In fact, last friday the clinic director specifically mentioned if I had any ideas on changes that may help their clinic, to please let him know. And then rounding today, when we were at the bedside of the guy with infective endocarditis, (and we were rounding with the microbiologists as well the other ID attendings/consultants) it turns out that just two of them have seen right sided endocarditis from IV drug use before. Now, a couple things to mention. The were still able to quote the current treatment guidelines, discuss the common pathogens, etc etc etc. I point this out because I find it impressive that these guys have seen a case in the past, long ago, but still know current treatment stuff. And secondly, it was odd because I've seen more of this than them. I was slightly jittery when they turned towards me. I had flashbacks to pedi land and was getting ready to brace myself for defending US practices... but rather it was such a pleasant adult conversation about what we do back home in these situations. There were also soooo interested in heroin use, methadone, and these patients back home. They just don't see these patients here. Kind of a cool experience.
 
I like my ID attending. I think we share a similar practical philosophy. Case in point. We were reviewing bacterial meningitis treatment and outcomes in journal club this afternoon. The attending pulled the articles on the use of steroids in treating bacterial meningitis, and outcomes. The mortality rate at Bara is about 55%. I just throw that out as an aside. So we're reviewing all data, which is somewhat mixed, and tough to interpret. You have to factor in HIV/AIDS. Delayed diagnosis and treatment. Etc etc etc. And whereas the literature may be indicating that the use of steroids does not reduce morbidity/mortality (and there are no harmful effects) my attending says:

". . .when you know that more than half the people are going to die it's tough to follow the advice of these articles and hold off on the steroids, I'l still give them. . ."

Ahhhh. Yes. Thank you. If I have bacterial meningitis (heaven forbid) I'll take the steroids too! We're on the same wave-length. He's a practical clinician.
 
And typhoid: There is a 14 y/o boy on the adult ward (which is what happens here), how has ben diagnosed w/ typhoid. Which isn't all that common. Was absolutely superb to be at the bedside and hear the ID and Micro attendings give a lecture, at the bedside, about typhoid. It was just superb teaching. And kind of a lucky event since they don't see that much typhoid..
 
Other stuff of note: One of our attending was the on-call attending yesterday, and did post-call rounds with his ward today. They admitted 135 (ONE HUNDRED AND THIRTY) patients yesterday. Their ward holds 130. It's not worth explaining the logistics. Interns are covering 35 patients.
 
That's it for now. I'm off to read about Typhoid.
Cheers



 

ID Rounds

Keeping this brief (still a bit under the weather-which is perfect for being on the infectious disease rotation)..
 
I roudned w/ another reg today. We say 20ish patients before meeting w/ the consultan, and then re-rounded on the patients.
 
TB.
HIV/AIDS.
MAC.
HIV/AIDS.
TB.
HIV/AIDS.
HIV/AIDS.
Possible cholera.
MAC.
IV herion user with right sided endocarditits.
 
Well of couse all the patients were interesting, but the team was most fascinated with that last one... Here is something they don't see. Infective endocarditits (infection of the valves of the heart) from shooting heroin. In fact, the consultant couldn't really remember the last time he'd seen a case, and the other reg had never seen a case. So it was nice to have a little basis to discuss, and discuss what we did for treatment back in MA.
 
CD4 counts today:
16, 43, 92, 23, 197...
 
More soon.

BPB

Shifting Gears

I asked one silly question today (in the adult ID/HIV clinic), just to prove that I've been in pediatrics for the past 6 months...
 
"Do we give them written appointment cards?"
 
I'm so use to the hand-holding of pediatrics... Do everything to ensure that the parent's fully understand treatment plans, and when the next appointments is, checking if they'll be able to afford to make it to the clinic/hospital etc etc etc.. So the prof looked at me with a small smile.
 
"Nope, their responsibility to keep their appointments."
 
It was a "light" day in clinic today. Jo'burg is still in holiday mode, and the streets are empty of traffic, and most people have been away from work since mid-december, to return sometime between the 5th, and 15th. A light day... we still saw 100 patients today in the clinic. A light day. I didn't ask what a busy day was going to be like.. but I peeked at the patient list from the 30th, and they saw 160 patients that day. Wow, it's going to be busy. And it's going to be a great month..
 
Aside from work, have been fighting off germs that I nicely acquired on my last day in Kathmandu. Am on the mend. Am staying with S&S, and then headed back to my old house a week from tomorrow.
 
Will hopefully have pics up from Nepal over the weekend-need to get somewhere with wifi to upload form my computer. I took about 1140 pics, but have managed to get that number down to 1000. Don't worry,  they are not all going up, but you can rest assured that when I see you next I will make you see all 1000!
 
Hope your 2009 is off to a great start.


BPB