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.