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.