Thursday, May 31, 2012


Each year since 1979, The Albert Schweitzer Fellowship has selected four third-year medical students to spend three months working as Fellows at the Albert Schweitzer Hospital in Lambaréné, Gabon on clinical rotations.  Medical Fellows work as junior physicians in pediatrics or medicine rotations, supervised by hospital medical staff.   Many Fellows have found their three months to be among the most valuable of their professional training, and several have reported that their lives and career plans have been changed in major ways by their experiences in Lambaréné.  Upon returning, Fellows join a network of more than 2,000 Lambaréné and U.S. Schweitzer Fellows – the Fellows for Life network – who are dedicated to maintaining service in their personal and professional lives.
                                                                                    -Courtesy of Albert Schweitzer Fellowship
My name is Tracy Cassagnol and I am a third year medical student at Wake Forest University School of Medicine. I am currently serving as a 2012 Albert Schweitzer Foundation Lambarene Fellow in Gabon, Central Africa.
     As a child I visited the Albert Schweitzer Hospital in Deschappelles Haiti, and as a medical student served as a North Carolina Albert Schweitzer Fellow. I continue to be  inspired by the message of Dr. Schweitzer, his message of Reverence for Life and his legacy of service to those in underdeveloped nations. I am honored to have been given this opportunity, and it is with gratitude, faith and deep personal commitment that I embark on this opportunity. I invite you to share my journey through this blog

Tuesday, May 15, 2012

Elephants, Buffalos and Beaches: A Weekend at Nyonie

      The savannah spread out before us, a sea of green interrupted by dense patches of forest. There were no houses, no sea, nothing to interrupt the savannah, and it spread clear across to the horizon.  I turned to my roommate and neither of us could speak, but I knew we were thinking the same thing: “We are so lucky to be here.”
      After six weeks of working in the hospital, we were both ready for a break. We could only do a short weekend trip, so we opted for a visit to Nyonie Wildlife Reserve. The savannah that left us speechless is the center of the park, which also has a beach and more denser forests. The park is located near the capital of Gabon, Libreville and is extremely well organized. Run by a small team, the park arranges every aspect of your visit, including the boat ride across the bay, a safari, a nature walk and all sleeping and eating arrangements. Basically, it was an easy way (and quick) way for us to get a chance to visit a national park.
     In order to go we arranged for a taxi ride from Lambarene to Libreville ($12 each way). Then we spent the night at a hotel in the capital.  I adore Lambarene. I love the river, the villages nearby and our small hospital community. But after six strait weeks, I was so happy to be near the beach and in the city. Our hotel had a small but very nice beach.

      We had a nice meal (first time I ate something other than fish in Gabon) and spent the night there. In the morning we took a taxi to the marina where we took a boat to the park.
     On the way, we came across a swarm of insects (which we assumed where flies).  However as we got closer, we realized it was in fact a swarm of butterflies in beautiful irridescent blues and yellows. We had arrived at the park precisely during butterfly season. As the butterflies surrounded us, everyone on our boat was silent. I assume they were silent for the same reason I was: it was mesmerizingly beautiful and the first of many such moments at Nyonie Wildlife Park. (I apologize for not taking pictures of the butterflies.. I was too stunned to even reach for my camera)
    During our stay, we spent time on the beach and on a safari through the savannah. It was an experience I will never forget. Here are some of my pictures from our trip:


Monday, April 30, 2012

Fever? Malaria.

  In the hospital, the term patients use to describe any fever is palu, a shortened version of the french term for malaria, paludisme. In fact, malaria is so common here that patients assume any fever is malaria. So when a patient comes in and says “Docteur, J’ai palu,” what they are really saying is “Dr, I have a fever.”
     The month before I got here, the hospital was hit with a malaria epidemic. Every hospital bed was filled with malaria patients, and the hospital was short-staffed because half of the nursing staff was also out with malaria. And in fact, every week since I arrived, we have received at least 3 patients with malaria. This steady stream of patients is due, in part, to the fact that February to May in Gabon is the rainy season.
     As a result all patients who arrive to the urgences or ED all receive a CBC and thick smear (the rapid test is too expensive). If the thick smear is positive, the nurses automatically hang quinine and D5. It is routine and common. Plasmodium falciparum is the predominant form in Central Africa and it is the most virulent. Although most of our patients have very strait forward hospital stay, we have the occasional severe case. Usually the most severe cases are among people like me, foreigners who are “naïve” to plasmodium, or very young children. There is a higher risk of fatal complications like cerebral malaria in naïve hosts and children.

Mosquito netting, at home and on the wards. 

      My attending has treated countless students and researchers for malaria. The worst case he has ever seen was the case of a European student who developed a case of cerebral malaria. She had been having fevers for four nights before she realized she was infected. After three days on oral CoArtem (Artemeter derivative), she was rapidly deteriorating. By the time he saw her, she was unresponsive and her parents were boarding a flight to Gabon.  He stayed up all night with her and, despite the worldwide emphasis on Artemether derived medications, he used the old standby, quinine. (For the medical folks out there, he told me that in his experience the most successful way to treat cerebral malaria is to use a huge loading dose of quinine, at least 4 times the normal dose). By morning, she was awake and conscious enough to speak to her parents.

A sign which I spotted in the terminal at Charles de Gaulle. I appreciated the reminder; the risk of developing malaria after returning is not insignificant.

    My attending often shares anecdotes like that one with me, and I have found that Gabon is a wonderful place to learn about malaria. The hospital is home to a world-renowned research center, the Unite des recherches medicales, affectionately called the URM.  The URM is home to research about tuberculosis, HIV, filarial diseases, but the main focus of the center is malaria. Work is conducted by a collection of ex-patriots from African countries (Senegal, Togo, Nigeria) and Europeans (Mostly German, some Swiss, Spanish and French). The center is affiliated with the University of Turblingen in Germany and many of the students come for six months to a year to work on the projects.

The URM, one of two buildings dedicated to research in tropical medicine. 

     Some of the key research going on now is concerned with maternal-child health. There are several vaccine trials for children; the largest is a multicenter trial with sites in Senegal and the DRC. The other regards the use of mefloquine as malaria prophylaxis for expectant mothers. It is exciting work and I enjoy discussing malaria with world-renowned malaria experts at the cafeteria every day.
      A case I witnessed here taught me several very important lessons about the management of malaria. A foreign engineer came to hospital to assess the electrical infrastructure. Originally from Germany, he had traveled widely throughout Central and West Africa and had never taken any prophylaxis. Four days into his visit (after a week of heavy rains), he came to the urgences, with his heart racing, trembling hands and a fever of 103F. His thick smear was negative (and read by the best technician in the lab).  I took several things away from this case, valuable lesions about malaria treatment in endemic areas.
     LESSON 1:  If the thick smear is negative but the clinical picture tells you it is malaria (and you are in an endemic area): TREAT IT! Sounds simple, but I learned it here. Everything about his presentation fit the textbook definition of malaria and the thick smear, while useful and cheap, is not terribly sensitive.  In addition, in naïve patients, a thick smear may show very few parasites when in fact the illness is severe (in contrast to people from endemic areas who may be asymptomatic with a very high parasite burden). As it turnes out, he took a rapid test when he got back to Germany which  was positive.
     LESSON 2: If the thick smear is negative, look at the platelets. If the platelets are low, this could suggest malaria. I don’t know that this would be clinically acceptable in the States, but here there are several reasons the physicians rely heavily on the platelets. First, the most common cause of thrombocytopenia here is malaria. Secondly patients often come from villages far enough away that the clinicians hesitate to send them home without some treatment. The fear is that a patient with a negative thick smear could be sent home, become ill and be unable to return.  In practice it is decision more supported by a public health perspective, taking into consideration factors unique to this clinical setting.
      LESSON 3: Hang quinine with D5 or D10, never with NaCl. I learned this from one of the senior nurses. She saw me reach for NaCl and violently pulled it out of my hands. She gave me a crazy look and said “L’Americaine! Quinine needs sugar! Don’t they teach you that in the US?!” I wanted to say “ Well NO, actually we learned which meds to use, the parasite life cycle and kept going.” But I didn’t, and I will never forget the lesson. Later on, I looked it up in my Oxford Manual and read that quinine is thought to increase the risk of hypoglycemia, a risk which is already elevated by having malaria itself.

      In any event, it was a very instructive case with a happy ending. I saw the same engineer several weeks later, and he was feeling much better. He expressed how grateful he was to have been working in a hospital when it happened and eagerly showed me his newly purchased mefloquine. Smiling, I pulled out my big blue doxycycline pills and showed him. It was a very nice moment, only possible here: an American and a German, sharing our malaria prophylaxis with big grins on our faces.

Tuesday, April 24, 2012

Medicine “Off the Map”: Hypertension and Diabetes

     Last spring, I spent an hour each week watching the ABC show “Off the Map.”  The premise of the show was that three American residents came to the jungles of South America to work in a clinic in the mountains. Written by the same writers who gave us Grey’s Anatomy, the show was full of drama, love triangles and rare “exotic” illnesses. The first episode, a giant sea ray imbedded his tail into a man’s leg. Several episodes later, a young man came in with an allergy to coca leaves..…
     Amidst all the “tropical disease” and “exotic illness” there was no mention of hypertension or diabetes. As my attending once  told me hypertension, diabetes are the everyday constants in our service, the “petit dejeuner or breakfast” he said.

      Real Medicine "Off the map" per ABC.     
     The truth is that, in 6 weeks, I haven’t seen any dengue, no typhoid fever, no injuries sustained during a elephant stampede. There are rare illnesses here, fascinating cases I would never see in the states. But the truth is a sizeable part of our service consists of Diabetes and Hypertension.
     In fact, Gabon is experiencing an epidemic of diabetes, hypertension and obesity. Gabon differs from its Central African neighbors in that the gabonese people are relatively well off. One Senegalese friend of mine referred to Gabon as the “Las Vegas” of Central Africa. The country has many natural resources, the most important being oil.  Money flows into the country and although it doesn’t reach all the way down, most Gabonese people live well. I have yet to see a case of malnutrition, no kwashiorkor and every child I have seen, no matter how small, has shoes. (Shoes are my very not objective measure of wealth)
   For this reason, Gabonese people have access to a wide variety of imported foods: starchy, carb rich, sweets and juices. The Gabonese traditional diet contributes to the problem, consisting of mostly tubercules like manioc, taro root and  starchy foods like plantains and rice, as well as a healthy appreciation for locally-produced vin de palme or palm wine. 

Ogooue Distribution, a supermarket in town, is full of imported goodies from the Middle east, Cameroon and Europe, like potato chips and Perrier. .
      In addition, culturally, a bit of extra weight around the middle is not at all a bad thing. It is desirable and even attractive in certain circles. All of these factors come together to create a situation where diabetes mellitus type II, hypertension and obesity are becoming increasingly more common.

       Gabonese dietary staples: Plantains and Manioc (wrapped in banana leaves).
    The adult medicine service has made several important strides in this area. With the help of American public health fellows they have developed tools to educate patients and some are quite popular. My personal favorite is the “Fiche de la Regime Diabetique.” It is a handout outlining the Diabetic Diet, with culturally appropriate dietary options such as river fish, manioc, plantains, taro root, papayas, wild game and mangos. It divides food into three categories: A volonte (unlimited), En quantite limite (in limited quantities), interdit (Forbidden).   
        Dr. Kombila does the best job of explaining the diet to patients.  He, like Dr. Justin, is Gabonese and understands the culture and eating habits of people here very well. He also has a pretty comical way of describing the diet. I have to fight to keep a strait face once he gets started.
     When he describes how much manioc a patient is allowed to eat per day, he extends his arm dramatically, to represent a baton of manioc. Then he uses his other hand to symbolize a machete and says:
“ You take the machete and cut the baton  in TWO. You eat one for you and the other half you give to your grandchildren and the kids in the village.”

   Then when he tells patients where they can find diabetic sugar at the local market. In Gabon, regular sugar is sold only in cubes. Diabetic sugar, which is imported, is loose sugar.
“Maman, the diabetic sugar is in the form of little little little cubes of sugar.” He says, using his fingers to demonstrate. “They taste like sweet but are not sugar.”
   When he gets to the section discussing food in the “interdit” category, he leans forward and speaks emphatically.
    “Candies, cakes, palm wine, you absolutely cannot eat,” Then he adds. “If you even see people eating it, you should go the opposite direction.”
     In contrast, his discussion of food in the “a volonte” category is much more accepting.
   “You can eat ALL the carp in the Ogouue and there is no problem.”

  Several river eels a patient's family caught for lunch.

    His creative delivery makes me laugh at times, but patients respond to his approach. He explains the diet in a way that patients can understand and emphasizes the important points.  
    In addition to this handout, Dr. Justin holds a Diabetes class for newly diagnosed patients twice a month. I found out about the course when a former student of his was admitted to the Kopp for an episode of hypoglycemia. Dr. Justin walked in and immediately called out to the patient: “YOU are the patient?! How could you forget what we talked about in class. Hypoglycemia KILLS.” 
    Diabetes management, in terms of medications, is similar to the US and the main tools in the arsenal here are Daonil (sulphonylurea oral med), Glucophage and Mixtard (insulin). Because of the cost and limited availability of syringes in rural Gabon, my attendings manage some patients on only Daonil and Glucophage, even if they feel they would be better served by injectable insulin.  As always, many factors contribute to decisions about patient management.

     The foods that can be eaten "a volonte" (unlimited) according to the Diabetic Diet handout. A dried fish from the Ogooue River and eggs.

    Most homes in rural Gabon have small tin bowls or wooden baskets that the family chicken can lay eggs in . 
(Pretty great picture of a chicken if I say so myself!)

       Hypertension is a different problem, because the service is ill-equipped to provide comprehensive education. There are no handouts, and no courses. However, I think that the consequences of uncontrolled hypertension are heartbreaking here.
    I remember one patient we saw several weeks ago. She had been living independently in one of the fishing villages on the river. She stopped taking her medication, Adalat (Nefedipine) and Esidrex (thiazide diuretic) several years earlier and was lost to follow up. Her stroke left her paralyzed, unable to fish, unable to collect taro root and plantains. Her family moved her to the city so that they could provide the round the clock care she needed.  It was the first time she had lived anywhere other than the village in which she was born and raised and in which her parents and grandparents lived and fished before her.
      A stroke can be devastating no matter where you live, but I think that there are unique challenges here. There is no rehab in our province (only one service in the capital) and very limited access for those with a disability. The only handicapped-accessible ramps I have seen in the country have been in the hospital and the modest facility is far from being handicapped-accessible. Small aids like adult diapers and mattresses designed to prevent pressure ulcers are not available here.
       My attendings try to provide some education on how patient’s families can rehabilitate their loved ones. They show  families simple exercises to do at home. However the reality is that patient families are ill- equipped to provide 24 hour care, as well as physical and occupational rehab. As a result, many patients permanently lose much of their function and never again approach their baseline function. 

The 2012 Albert Schweitzer Lambarene Fellows.
From the right: Brandis Belt (Public Health Fellow: Yale), Ayesha Rabbani (Pediatric Fellow: BU), Molly Ryan (Public Health Fellow: BU), and ME!
     The current public health fellows (my roommates Brandis Belt from Yale & Molly Ryan from BU) are working to assist the hospital in developing newer educational materials. They are working on a few ideas and strategies to address both illnesses, as well as working on a new adolescent health campaign. Their hope is that if they can educate young people about their health, they can begin to respond to the epidemic by educating the next generation of Gabonese people.

Monday, April 2, 2012

A Senseless Death: The reality of default from tuberculosis treatment in Gabon

     Two weeks into my time here, a 15 year old girl checked into the Kopp. She was a very young 15, with a thin frame and the face of a 10 year-old. When my attending saw her chest x-ray, he was so discouraged and angry that he tossed it onto the table before I could see it. I was too distracted by the patient herself to look at the x-ray. She had her hands on her knees, and was leaning forward taking quick and labored breaths. Someone had brought the ancient oxygen machine into her room and put her on a nasal cannula, which she clutched tightly behind her ears. She held that cannula in place, I think because she was too scared to miss one second of the air it delivered.
     When my attending had composed himself, he zeroed in on her mother. Although he already had read  the story in her transfer documents, he asked her anyway.
      Her transfer letter from the hospital in Port-Gentil told an unforgivable tale, one that started with her diagnosis of tuberculosis in 2010 in Libreville. The letter than said that her treatment was “interrupted” by her parents inability to pay for the complete treatment. In 2011, she started to feel ill again, unable to sleep due to coughing fits and a fever that wouldn’t abate. Her parents took her to Port-Gentil, where she restarted anti-tuberculosis treatment. Again her six month treatment was again “interrupted” by her parents inability to pay for the trip to and from Port-Gentil for her appointments.
    Now in February of 2012, almost 2 years after she was first diagnosed, she arrived at the Kopp, with a chest-ray that revealed a fatal mix of atelectasis, fibrosis and several cavitations. Her lungs were a mess, and my attending told her mother as much: “Your daughter has NO lungs. She has no lungs. How are we supposed to help you?”
     In the afternoon, when I returned to enter lab results, she was doing worse. The oxygen settings were maxed out and she still couldn’t seem to catch her breath.  Her mother was frantic at this point, coming into the nurses station every five minutes exclaiming: “She can’t breathe. She can’t breathe.” The nurses were empathetic, but weren’t as affected by her sense of urgency.
       I saw her myself. She was scared and tired. Her eyes frantically scanned the room, looking from face to face, from mine to her mother’s to the nurses’, as if searching for oxygen in our expressions. I called my attending on the phone and told him what I saw: She was tiring and seemed like she wouldn’t be able to keep up this marathon breathing for much longer. He listened to me and said only “OK.” I wanted him to tell me to hang something, to change oxygen settings, to arrange a transfer; I wanted him to tell me to DO something. But he didn’t. It is the most frustrated I have ever been with an attending.
     What I didn’t know was that my attending had been in and out of the service all afternoon and had seen her worsen. The nurses knew, the doctors knew and I think even she knew, but when I saw her at 5 o’clock I had no idea. Everyone knew she was going to die, except for me and her mother.
    She died overnight. Too tired to breathe, she died of a curable disease. A professor of mine once siad that it is stupid to die of tuberculosis today. The combo medication of RHZE works and works well. All that is needed to secure a complete recovery is strict compliance with the regimen for 6 months.
   My last memory of her was seeing the fear in her eyes and kneeling in front of her. Her mother, had grabbed my arm and pulled me into the room. As a medical student, with really no idea what to do in the situation, I did the only thing I knew how to do.  I knelt in front of her, put my hands on her knees and said “Its ok. Its going to be ok.” I smiled at her, in an attempt to reassure her. Because she looked like a child, I remembered that in Pediatrics I learned that children with trouble breathing should be kept calm. Her breathing slowed a bit and my last thought before I left was that if she could keep calm, she wouldn’t tire so quickly and would make it through the night.

Thursday, March 29, 2012

The Face of Tuberculosis: Young and HIV negative

       The music drifted through the hallways, past other patient rooms, and through the nurses station. It became the background of our work and, after a time, even the other patients were humming the tune. When we visited the patient in Room 25, his guitar was always in his hands, his mask on his face at an angle. Ever the artist, he wore the mask like an accessory, how a lead guitarist might wear sunglasses or a hat. 
     The only times he was without his guitar were the times he was overcome by coughing fits. Then, the only sound we heard coming from his room were his harsh coughs.

The chest xray of the patient in Room 25.
     Before I came to Gabon, I read about tuberculosis. After reading the chapter in my Oxford Handbook of Tropical Medicine, I formed an image in my mind of a patient with tb. The patient I envisioned was much older than me, frail, ill and HIV +. In my mind’s eye, their already compromised immune system had let the malicious little mycobacterium set up shop in their lungs.  What I found when I arrived, however, were mostly young patients, young enough to be in my circle of friends. They were mostly HIV negative and led very active lives that were only slowed by their disease.
      For this reason, the mood in the tuberculous isolation ward is often light and youthful. The patients spend ten days with us, just long enough for us to get to know them and long enough for them to personalize their rooms. I remember two young men who were admitted on the same day brought a card table and dominoes to their room.  They were always playing and joking, enjoying the break from college studies. In the afternoons, I could hear them playing, the sound of dominoes slamming down on the table.

     Although the mood in the isolation unit is often light,  the tuberculosis problem in Gabon is serious, with an estimated  national prevalence  of 379/100,000. Unfortunately, the public health infrastructure in Gabon is ill-equipped to  adequately address the issue.  The WHO advises that all TB patients should have at least the first two months of therapy observed, in the form of a health official watching patients swallow their anti-TB therapy. However, the Albert Schweitzer Hospital is not adequately staffed to be able to fully apply the recommended Directly Observed Therapy or DOT, recommended by the WHO.  Physicians are forced to rely on the cooperation of infected patients, a challenge when most of the patients are young and otherwise healthy.

 They came to the outpatient clinic with the same presentation:

     “Docteur I cough until my chest hurts,” they said, running their hands across their chest, from shoulder to 
    “Sometimes I cough so much I feel I will throw up everything in my stomach.”
     “I have fevers all the time and I wake up and all of my bed sheets are wet.”
     “He has lost so much weight his clothes barely fit,” from an anxious mother or aunt.

     We asked the three same questions to these patients:  I heard it so many times, in the same order and rhythm, that I turned it into my own song: Delivered in a singsongy voice “Tu tous? Tu craches? Tu a la fievre?” Do you cough? To you spit? Do you have a fever?”
    When they answered “Yes” to all three, we immediately get the ball rolling: Chest Xray! Sputum Examination! HIV test! Admission to the Kopp! 

   Admission to the inpatient service is only the beginning of six month long treatment. The patient I saw today was a young woman who was recently released from the inpatient service after ten days of DOT.  Her story sounded like dozens of others I have heard since I arrived. She came to the clinic complaining of a cough that made her chest ache, fevers and the constant sensation of being exhausted. Her CXR gave us the diagnosis,a perfectly defined cavitary lesion in the apex of her left lung.

  Her chest xray.
     She was admitted and submitted three consecutive days of sputum samples; all three were positive. (The gold standard diagnosis is a culture, but is not possible here due to lack of an appropriate laboratory facility. It is also impractical due to the time needed to culture mycobacterium).
      Her mantoux (PPD skin test) was positive as well. She took RHZE (rifampin, isoniazid, ethambutol, pyrazinamide in a combo pill) and a pyridoxine pill for a total of ten days inpatient. On the ninth day of her hospitalization, we tested her liver transaminases (three of the four drugs in the combo pill, R, H and Z can cause drug-induced hepatitis), then sent her home with a follow up visit in one month and a month's supply of RHZE and pyridoxine.
     Today, I thoroughly examined her and asked if she was tolerating the medication. Then she submitted a sputum sample. I made her another appointment in one month and gave her a month's supply of both medications. She has two more visits like this one as well as an xray and repeat liver transaminases at the end of her 6-month treatment.
     It is a long process, and at each step, the physicians count on the patients to cooperate by taking the medication and coming to appointments. And, although the medications and appointments are free, patients are often lost to follow up. Studies looking at default rates in Subsaharan Africa have found that two of the most predictive indicators of default are age and gender. Young men, like our musically inclined patient in Room 25, have been found to be statistically more likely to  not complete their treatment.

The chest film of a patient with pleural TB, one form of extrapulmonary TB. Patients with pleural tuberculosis have negative sputum and, for this reason, it is thought that  they are not contagious. (We diagnosed this case after examining the pleural fluid: It was exudative with a lymphocyte predominance)

      The day before we were planning to discharge the patient in Room 25, our attending jokingly grabbed his guitar and pretend to play, while he and the other patient laughed. It was a wonderful moment, one I will remember, long after I have left Lambarene.
      I’m always a little sad to see them go; it is like I am saying goodbye to a classmate. I am also scared for them.   My fears are not unfounded. A public health Schweitzer fellow, Meredith Collins, completed a study about tuberculosis during her rotation here. She found that in 2008, 43.5% of tuberculosis patients were lost to follow up. It is a problem all over subsaharan Africa, but the numbers are alarming.
        When we discharge our patients, I always worry that their youth and the feeling of invincibility that come with it will cause them to forget their medications and miss appointments. I worry that the morning they wake up without a cough and able to play soccer without tiring, they will decide they don’t need to take the five pills. And most of all, I worry that they will come back, their lungs filled with bugs that we don’t have the medication to kill. In those moments, I feel so much older than them, the knowledge of all the risks of their infection aging me.
    I’m never sad for long. After our guitarist left, another young man replaced him, this one with a boombox and a seemingly endless collection of American music.  The sounds of Rihanna and Jay-Z filled the hallway for the next couple of weeks, and by the time we discharged him we had started to hum right along to it.

Friday, March 9, 2012

Caring for the Seropositive: On the wards and in the clinic

     Today I find myself in a difficult place. For several weeks, I’ve been collecting stories about what I’ve seen on the wards and clinic, and can’t help but feel a bit hopeless about it all. With each situation I've witnessed , I’ve lost a little bit of hope that Gabonese people will ever be free of the HIV epidemic. It feels like every result I collect is HIV positive.
   This past week at the Kopp has been particularly difficult. We lost two seropositive patients over the weekend. In clinic we diagnosed a whole family with HIV. (The child was diagnosed in the Pediatrics ward and we tested both mother and father and they were seropositive).
      Yesterday morning, when I arrived for morning rounds, the family of another patient was outside wailing and screaming. Minutes before I arrived, our third patient with HIV died. Hers was the most heartbreaking case. She arrived seven months pregnant and very ill, with a CD4 count in the 50s. She went into premature labor and delivered a 1 kilo baby who died in a few hours, only to die herself a dew days later.  That’s all the medical detail I’ve got energy to share at the moment, without reliving it all.
      I can’t help but feel  like Gabonese people are losing this battle. It really seems like HIV is winning here.
    There are no hospital pictures or xrays in this post. Only pictures of the flowers growing on the grounds. They give me hope on the days when I need it most. 

I am not here to judge, but what bothers me is the child.” -Dr. Fany

I only had eyes for the baby. He was everything an eight month old should be, reaching for the pens on the desk with chubby fingers and happily wriggling in his grandmother’s lap.  The image of his wide, luminous brown eyes haunted me for days. I can still see them looking up at us, completely unaware of what we discussed with his mother.
    The little boy’s mother came to see Dr. Fany only after her father in law insisted she see a doctor. Over the past year she had lost so much weight, she was barely recognizable to everyone in her village. She’d been ill every since the baby was born; so ill she struggled to nurse and care for him.
   That day in the office, she was alarmingly thin, a stark comparison to the chubby toddler by her side. I examined her first and saw white filmy plaques on her tongue and lips. I relayed my findings to Dr. Fany and saw the same despair in her eyes that I felt in my heart.
   Dr. Fany questioned her:
   “You were followed at the health department, correct? And what did they tell you there? What did your tests show? They do the same tests for every pregnant woman, for free.”
   She responded: Yes they had taken her blood and had given her envelopes with the results. But she fell on the way back and the envelopes fell in the river. When her father-in-law gave her money to repeat the tests, someone stole the money in the market.
    Dr. Fany persisted:
    “Surely they must have told you the results!”
    She responded “No Doctor, they did not.”
  She never did reveal what truly happened, and we weren’t surprised. She could never reveal to her mother-in-law that she was seropositive. They would never believe that she had contracted the virus from their beloved son. They would never believe that she had been faithful to him since her wedding day. Diagnosed at the start of her pregnancy, she hid the result from her husband’s family. She nursed the baby and cared for him, slowly wasting away until the very people she had lied to insisted she come to the hospital.
    Before coming to Hopital Albert Schweitzer, Dr Fany worked for five years in her native Benin, treating only HIV positive patients. As a young doctor, she learned about the lies, the deception, the pain and the psychology that come with the diagnosis.  Later, after the patient and her family were gone, she shook her head and turned to me, anger in her voice:
    “She nursed that baby for eight months, even though she knew she was HIV positive! She did not take any medication the whole pregnancy! I am not here to judge, but what bothers me is the child.”

“I’m sorry madam but I don’t believe that you love your sister. You can’t love another person. You can’t love another if you don’t love yourself." - Dr. Justin

    She was the height of fashion. Her hair was freshly pressed and curled. I’m a girl who loves shoes and I always notice the really cute ones. Hers were sling back heels, in fashionable burnt tangerine with a matching bag. The hand she used to hand over the envelope had freshly painted red nails and sparkling gold rings.
    I could feel the waves of annoyance coming from the direction of my attending. He looked up from the chart and she withered under his stare, averting her eyes.
    “Madam, the last time you were here was 2009,” he said.
    “Oui Docteur. My sister kept telling me to come. She loves me and I love her. She cares for me.”
      Dr. Justin responded, his booming voice delivering a first blow: “I’m sorry madam but I don’t believe that you love your sister. You can’t love another person. You can’t love another if you don’t love yourself.”
      The second blow came from a half sheet of paper, with lab values neatly typed at the bottom. Her CD4 count had dropped over 300 units. After this blow, any sparkle that was left was permanently extinguished. All the fresh, new and fashionable she had carried with her from Libreville were gone, leaving behind the pale and bleak reality. She was very sick and in her negligence, had let her illness gain the advantage on her.
      Patients come all the way from Libreville, leaving behind the modern and well equipped treatment centers to come to Hopital Albert Schweitzer, with its modest buildings and outdated equipment. They make the four hour trek, to Lambarene, passing government funded treatment centers dedicated to HIV treatment. They bring fashionable tote bags and well-worn book bags to carry boxes of medication.  With the scent of the city on their skin, they wait in the atrium, next to the farmers and fishermen and old mamans with wooden canes.
      I asked one of Dr. Justin’s patients why they came so far for treatment. I pointed out that the HIV medications were free everywhere throughout the country. The patient answered that he preferred the anonymity that Lambarene offered. He could come here with a book bag, get his medications from Dr. Justin and no one in town would know he was infected. After several years of coming to HAS, he felt he had found a home and a good doctor in the frank and experienced Dr. Justin.
      When Dr. Justin came to HAS almost 16 years ago, HIV was not known in Gabon. In fact, he remembers a time when politicians boasted to the public that Gabonese people could NOT get HIV. They made Gabonese people believe that they were immune the virus.. HIV treatment came much later and in 2004 medications were finally available to patients. For 400,000 cfa ($800), the wealthy could begin antiretroviral medication.
      In those days, a diagnosis of HIV was a death sentence for most Gabonese people.
      “I remember when I was working in the capital, a patient jumped out of a window. They told him he had HIV and he killed himself. I will never forget the sight of his body on the pavement outside the hospital.”
      In 16 years, Dr. Justin has developed a keen understanding of what the diagnosis means for Gabonese patients. Born and raised here, he has the added advantage of understanding aspects of Gabonese culture and being able to be here to offer patients some degree of continuity.
      Today, antiretroviral treatment is free for all infected patients in Gabon, subsidized by the government Despite this fact, patients often discontinue their treatment, returning when they are too ill to save.
Our fashionable patient was just one of many cases that are a source of never-ending frustration for Dr. Justin.
     " It is another form of suicide," he said to me one day after yet another patient  (with a CD4 count of 1) died on the wards. " They choose to ignore the illness, don't accept it and die, slowly."
     As he filled out a new page to add to her old file, Dr. Justin was silent.  He started to gather the medications she would need. Without saying a word, he labeled them with a marker and she put them in her bag. I filled out an appointment slip and handed it over.
      He didn’t have to say it, but I’m sure she had heard it before. He says it to almost every patient, every time they come to see him:
      “For as long as I am here, I will give you medications. For as long as the Lord lets me, I will give them to you for free.”

Wednesday, March 7, 2012

A Typical Day in Internal Medicine: Hopital Albert Schweitzer

My path from home to work.
      Each morning, I wake up, eat breakfast, and check if my clothes are dry (I wash my own laundry here). Then I make the 6 minute walk to the adult inpatient ward, affectionately called “The Kopp” after Rene Kopp, a close friend of Dr. Schweitzer. As I walk, I pass all of the school children on their way to school as well as most of the hospital staff on their way to work. Each morning, I call out several dozen sleepy “Bonjour!”s before I make it to work.
     Here medical students do not pre-round and there are no patient presentations. I am responsible for updating the physicians on any concerning lab results and am expected to know the details of every patient’s management. At times I give a brief summary of each patient, mostly to jog my attending’s memory. It is somewhat like carrying all of the patients, with the exception that I don’t have to make any formal presentations.  I update any lab results from the previous day, look over any new cases and wait for my attendings.
    Lab results are in different units here, which made for some hilarious moments in the beginning. A normal creatinine here is 60-120. The first day I saw a patient with a creatinine of 75, I panicked, convinced something horrible was happening to the patient. In addition there are only paper charts, in the form of half page cards held together by staples, glue and yarn. Each lab result is meticulously handwritten (in cursive and in  French) into each chart, as well as all treatment plans and discharge summaries. 
The physician work room.
      I work with two doctors: Dr. Justin Beyeme Omva and Dr. Fany S. Quenum.  Dr. Justin is a Gabonese physician who has been here for 16 years and  has trained countless American, Swiss and German students. Dr. Fany is a new addition to the staff here. She studied medicine in Benin and recently completed a MPH in Belgium.
    We round on all 25-30 patients on our service for several hours in the morning. Rounds here are very similar to the states and consist of the nursing staff, the doctors and myself. 
    Our inpatient service is fascinating, and the cases range from hypertensive crisis to HIV encephalopathy to TB. I made a list of the cases one morning so you could have an idea of what we see on any given day:
The chest film of the patient in room 4 .
            1. Bacterial Meningitis, HIV
            2. Stroke
            3. Sickle Cell: Vaso-occulsive Crisis, Osteonecrosis
            4. Heart Failure
            5. Metastatic Prostate Cancer
            6. Gastroenteritis
            7. Hepatic Abscess
            8-14:  Malaria patients
            15. DKA
            16. hypertensive crisis
            17. tetanus
            18. asthma exacerbation
            19. angioedema
            20. Pancreatitis (secondary to ascaris lumbricoides infection)
            20-26:  Tuberculosis Patients
     My attending, Dr. Justin sharing an interesting film with the team.
The film of the patient in Room 3
      As we round, my attendings order different labs and I fill out the orders. Sometimes, we go over interesting films or attend educational presentations.
     The inpatient ward itself is not very big. There are two patients per room and the nurses try to make each room unisex. There are four bathrooms with multiple stalls in the building and an outdoor area with charcoal for cooking and hanging washed clothing.
     One important difference about our inpatient service is the gardien system. Each patient is admitted with a gardien or guardian, who is responsible for preparing their meals, bathing them, taking their temperature and even dropping off sputum samples. No one can be admitted to the inpatient service without a gardien. This system dates back to the time when Dr. Schweitzer saw patients alone with only his wife to serve as his nurse. He recognized that he could not attend to the daily needs of each patient and called on family members to assist in that regard. The system is still implemented today for the same reason. There are only two-to-three nurses per service. They administer medications, help turn and bathe patients and collect vitals.
     Every so often the nurses walk down the halls yelling for the gardien to do certain tasks.

“It is 8 o’clock, put up the thermometers! It is time to take your patient’s temperatures.” or
 “Rooms 1 and 2, you may use the showers now!”  or 
“Empty all urine bags into the vials!”

    At first I was taken aback by this system, but now I must say I like it. Patient’s family’s are forced to be involved in the care of their loved ones, and are able to observe their patient overnight. They often have valuable insight into the state of their loved one’s condition. It is especially useful in this setting because there are no established mechanisms to provide home nursing. Families learn to care for their family members while they are hospitalized under the watchful eye of the nurses and are then continue that care at home.
 The Rene Kopp building, the Inpatient Adult Medicine Service.
      The downsides to this system are that unfortunately some patients are abandoned by their families. The nurses try to care for them but often are unable to provide optimum care. Also, the economic impact of this system is significant. Family members must miss days and often weeks of work in order to care for their loved one. One particularly heartbreaking situation I saw was one where a family pulled their 12 year old daughter out of school indefinitely so she could care for her ailing grandmother. When Dr. Justin discovered this, he immediately called the hospital social worker to rectify the situation. (There are two social workers in the hospital).
"Weigh all patients Monday, Wednesday and Friday. For the patients on Lasix,you must weigh them every day."

    Often I forget that I am not in the states, because some of the same basic discussions about patient care happen here:
     “This patient needs to be rotated to prevent the formation of decubitus ulcers (eschars).”
     “We need to remove the urinary catheter (sonde) this afternoon.”
    “ I need a better documentation of this patient’s Is and Os!”

The outpatient clinic, or Polyclinique.
      After rounds, I update the service’s registers, assist with discharge paperwork and tie up any loose ends. Then we head to the Polyclinique to see outpatients. On average we see 12-20 patients in the afternoons. I work with both attendings as well as a third physician Dr. Ulrich Davy Kombila in the afternoons, rotating each day. Dr. Kombila is a physician who works in the hospital as well as for the Research Unit here and works primarily on HIV and TB coninfection.
     I feel that I am learning so much at the polyclinique. There are many advantages to being the only student on service. I examine each patient before my attending, relay my findings, then he/she examines the patient after me, confirming or clarifying my findings. Unfortunately by the time patients here seek medical attention, their illness has progressed. However, this means that the physical exam findings here are impressive. In one month, I have palpated more enlarged spleens and livers, auscultated more murmurs, rubs, crackles, and stared at more rashes than I have in six months in the states. I believe that my physical exam skills are benefitting greatly from this experience.
 One afternoon at the Polyclinique looked like this.
            1-4: HIV followup visits
            5-7. HTA/DM follow up
            8. A case of loa loa
            9. Otitis Externa
            10-12: Three pregnancies, one set of triplets (outpatient Ultrasounds for the maternity department)
            13. A newly diagnosed HIV positive patient
            14. A case of malaria(we admitted him)
            15. Chlamydia
            16. A case of tuberculosis

After we see all of our patients around 1400/1500, we head to the dining hall. Then I am free to go home. I come back to the hospital at 1700 to the laboratory to collect lab results. Then I write them in the paper charts and call the night call physician to notify them of any abnormal results.

   At first, I was terrified by this task. I am the first to see any lab results, xrays and ecg for every patient. My attendings trust me to spot anything alarming. The first couple of nights I reported every abnormal result, even if it were only several digits above or below the norm. Over time, I have started to pick out the lab results or findings that my attendings needed to know or that might change patient management in some way. I am having to apply everything I learned about xrays and ecgs. It is wonderful and terrifying.
     My third week here, everything came full circle for me. I was able to contribute to a patient’s care in a a small but important way:

     A fifty year old man came to Polyclinique complaining of severe abdominal pain. He stated that the pain had started a day earlier after an episode of diarrhea. When we saw him, he was in unbearable pain and could not sit still for the echo. His abdomen was hard and distended. My attending saw some nonspecific changes which he thought might point to an obstruction but insisted that we order a abdominal film to confirm.
    After clinic ended, I decided to go strait to the lab to pick up results. That day it looked like it might rain so I figured if I got the results early, I would have less chance of getting stuck in the daily afternoon rain storm.
   Among the results were our patient’s abdominal xray. I hung the film and looked at it. I am by no means a stellar student when it comes to xray but I knew immediately that this was an obstruction. Here is the film I saw:

   Because I am the first to receive all results, I called my attending and told him what I thought I was  seeing. He told me he was on his way and would call surgery. Then I asked the nurses if they had an NG tube, which we placed. Our patient went to surgery that evening.
    I called home that night and gushed to my parents: “Mom, Dad, I saw this xray and I told my attending about it and the patient got surgery! I read the life out of that film!” My parents, in their usual fashion, were not quite sure why I was so excited but listened to my hurried speech anyway.  It was rewarding to contribute to a patient’s care directly, to have to depend on the skills I acquired at Wake and apply them to an actual case, and to have my input lead to a resolution for a patient. It was a wonderful day.