Case Presentation 3

(If you are squeemish, please do not click the pictures below.)

Patient is a 47yo male with no past medical history who presents with one month history of rash. He denies any "hotness of body," nausea, vomiting, or other symptoms. He states the rash started on his hands and feet and have now spread to the rest of his body including his face and scalp. The rash is itching and sometimes painful. He has come in now because his feet have started cracking and weeping. The patient's vital signs are within normal limits and he denies any other systemic complaints. His DTC was negative as was his VDRL. His hemogram was normal. Please see pictures below at your own risk.

Discussion:

This is a case of Norwegin Scabies. When I first saw it, I thought about syphilis, but with the negative VDRL and the lack of other symptoms (such as a preceeding chancre), we took that off the list. This is pretty much the worest case of scabies I've ever seen. He also has a bacterial superinfection on his feet too. We wanted to start him on Ivermectin and dicloxicillin, but unfortunately the pharmacy doesn't carry Ivermectin. In those cases, we write a prescription and the family members have to pick the medication up at an outside pharmacy. To my knowledge, we are still waiting for the Ivermectin...

Another point this brings up is in infection control. There are very few measures taken on the wards to keep patients from infecting each other. The doctors all walk around with individual hand sanitizer, but I'm pretty sure the nurses wash their hands a few times a day (mostly before eating). There are some gloves available, but they are often difficult to find, and each glove used are charged to the patient. So our patient is probably sharing his scabies with the rest of the ward.

It makes me itch just thinking about it.

Mobile Clinic

Gatithi Medical Clinic

This week, both Christina and I were able to help out with the HIV mobile clinic. Basically it is like the Comprehensive Care Clinic that has been loaded into a land rover. On the day we helped out we stopped at Gatithi, a small town about 30 minutes outside of Tumutumu. There is a small clinic there that is still under construction. There we unpacked large boxes of medications, patient files, equipment, and other various paperwork. We even took our own table and chairs.

The idea of the mobile clinic is to create a satellite of the CCC that is more accessible to the patient population. Even though Tumutumu is only a 30 minute drive, many people do not have cars and do not have the money to pay for the matatu to the hospital. Without this service, many of the people would be non-compliant with their medication regiment, an act that would not only be dangerous for them, but also for the rest of the community.

The people walk from their homes to the clinic and line up hours before the team arrives. The patients check in with a nurse who weighs them, takes their vital signs, counts their pills, and provides teaching on their medications. Education is really stressed and patients are expected to know what medications they are taking and at what times. The nursing staff is fairly aggressive and will chastise those patients who fail the quiz.

From there, the patients see the doctor and describe any symptoms they might be having. Mostly the patients were complaint free, but occasionally we would treat a simple upper respiratory or skin infection. There were also a variety of muscle and joint complaints although no seriously ill patients. After seeing the physician, the patient goes to the mobile pharmacy and picks up their HIV medication and any other antibiotic or pain medication prescribed. This is where Christina worked and it kept her pretty busy. The pharmacist provides further counseling and education on their medications. Again, all the anti-retroviral medications, multivitamins, and antibiotics are free to the patients and provided by USAID.

The mobile clinic is a great addition to the CCC and an invaluable resource to the patients it serves. We saw about 50 patients, many of which were either pediatric or elderly and would not have the time or the energy to get their badly needed medication. It was also a great opportunity for Christina and me to see the patients out in the community and to see the patients in their home environment. The poverty was sobering. There were fewer nice suits and dresses, which you see a lot of at Tumutumu, and more tattered, second-hand clothing (one 45 year old gentleman had an "Ohio State Grandma" sweatshirt). It was a chance to reach out to the community at large and witness their daily struggle first hand.

Matthew and a Medical Officer evaluating a patient.

Patients waiting to be seen.

Patient signing a compliance contract stating that he understands the medications being prescribed and will take the medications.

Comprehensive Care Clinic

Today I had the opportunity to help out at the Comprehensive Care Clinic (CCC). This clinic serves individuals with HIV and Tuberculosis. Mainly, this is clinic provides free medications to those with HIV and TB and follows up on routine concerns such as CD4 counts and treatment failures. As part of the CCC, community workers even visit the homes of patients to ensure medication compliance. The workers often go on daily runs and has a fleet of bicycles, motorcycles, and a vans to accomplish this task. Fortunately most people are very reliable and appreciative of the care that they receive.

The clinic sees an average of about 50 people a day. Most of the visits are very short and consists of checking vitals, refilling medications, and occassionally checking CD4. However, a few patients do require additional testing to evaluate for pneumonia or other infections. These tests and their medications are all provided at no additional costs to the patient and is funded by USAID (United States Agency for  International Development).

Clinicians will take bicycles and motorbikes into the community to find non-compliant patients. 

It was a good chance to see many different members of the community. Even some of the Tumutumu hospital employees frequent this clinic. The patients were all very friendly and grateful to be seen. Often times working in the emergency department is a thankless job... it is nice to be able to provide care to patrons who truly appreciate it.  

Case Presentation 2

Patient is a 57 yo who has ISS and TB who presented with confusion and decreased intake. The family states the patient was started on medication for the above diagnoses about 2 weeks ago. Patient has become more and more confused and has not said anything in the last 24 hours. He seems to have "hotness of body" and hasn't had anything to eat or drink in 2 days.

When we evaluated the patient, he was not febrile but was minimally responsive to pain and verbal stimuli. He was tachycardic and appeared very dehydrated. He was found to be tachypneic and his oxygen saturation was 92%. The patient was given IV fluids and started on Co-tramazole, Ceftriaxone, and Acyclovir. ECG was performed to evaluate his tachycardia. Complete hemogram, UEC, and chest xray were ordered and a lumbar puncture was performed.

Discussion:

There are a few points that I would like to discuss about this patient. The first is the fact that the patient is "ISS." This stands for "immuno suppression syndrome". There is such a stigma here in Kenya against HIV that even doctors can't discuss this openly with patients. It goes so far that you cannot order a rapid HIV test. Physicians instead order a DTC-diagnostic testing and counciling. Even the HIV clinic has a euphamistic name- the Comprehensive Care Clinic. Apparently if it was called the HIV clinic no one would come. That's not to say that we don't have a stigma in South Carolina as well, but I feel that in SC we can speak more openly about the subject.

This is one of the sicker patients that I have seen here. In the emergency department he's what we would call an easy admission. With the limited resources, it makes it very difficult to treat the acutely ill. We were able to obtain an EKG, but this took several hours. The machine is not very portable and is almost on par with putting the patient's hands and feet into buckets of water. Acutally there are clamps that are attached to the limbs, and the precordial leads are held in place by bulb-suction devices. The leads are printed out one at a time and the clinical officer has to cut them all out and tape them onto another sheet of paper to place in the chart. The process takes anywhere from 30-45 minutes from start to finish not including the cutting out (and you thought it took awhile to get one at Richland).

Oxygen is often difficult to get onto the patient and tanks have to be wheeled to the bedside. This takes a lot longer than you would really want and sometimes makes me nervous, but often there just isn't a tank available. These tanks are not very portable which means if a patient is needs O2 they can't go anywhere. Even getting a simple chest xray is impossible. Forget a stat CT- that requires raising funds and a day of travel. Sometimes I forget how easily these diagnostic studies are obtained at home.

The patient is currently being treated for TB and I asked about placing him in isolation. Basically there is no isolation here. The doctors practice on the theory that it is basically endemic to Kenya. "Everybody has TB here, just not everyone shows it," is what the intern told me. To which I replied, "I don't have TB!" She simply shrugged and told me not to breath too deeply.

We were able to obtain CSF and it was actually negative. I was able to walk the clinical officer through his first successful LP (or more likely he succeeded despite my misdirection). The lumbar puncture kits are very simplistic and they cannot get an opening pressure or perform cultures. However, they can obtain cryptoccal antigens studies and these were negative as well. Still, we threw everything but the kitchen sink at this guy. In addition to antibiotics, patient received IVF and tea through NG tube. Apparently it is customary to place an NG twice a day to make sure the patients get tea time.

Over the last few days, the patient has done very well. He is now off oxygen and has vastly improved, although still confused. We still don't know the underlying eitiology of his illness although the current theory is either sepsis (unknown sources) vs IRIS- immun-reconstitution syndrome. I am glad to see him improve everyday even if he has no idea who I am.

Case Presentation 1

Case 1

25 yo female with no PMH presents with convulsions. She has been in her usual state of health until the day of presentation. She has spent the day travelling on a bus from the Rift Valley to Karatina. She states she packed her own food and did not eat anything offered to her on the bus. On arrival to Karatina she had a convulsion as described by the fellow travellers. Patient was admitted and was witnessed in hospital to have several more convulsions that started with facial spasms and generalized to tonic clonic convulsions. The convulsion lasted for "a while" and was broken by giving 30mg of diazapam slow IV push. Patient returned to baseline and was noted to have brusing on her tongue.

ROS: + for HA on and off for the past month, relieved with paracetomal. No HOB, no blurriness of vision. Otherwise negative.

PMH:-

FMH:-for epilepsy

Social: Denies EtOH, tobacco, drug use.

Medications :none

Allergies: NFDA

PE: T36.7 P80 R20 BP: 140/60

General: Well developed African female, NAD

Head: ATNC

Eyes: Conjunctiva pink, sclera anicteric, PERRL, EOMI

Neck: No menignismus, Fullness of R thyroid with no appreciable nodules.

CV: RRR, no MRG; peripheral pulses present, symetric; cap refill <2sec

Resp:LCTAB

GI: AB S/NT/ND/BS+

MS: FROM

Skin: No rashes/bruises/lesions

NEURO: CNII-XII intact; sensation intact B/L; strength is 5/5 throughout; no dysmetria; abulation without difficulty; A&Ox3

A/P: 25yo with new onset convulsions

Obtain full Hemogram, UEC's and Pregnancy Test. Order CT head for masses/bleeding. Admit for observation. Diazapam PRN for seizures, PCM for headaches. Re-eval in AM.

Discussion:

This was an interesting case for me, not because of the medical aspects itself, but it brings up some important social issues. As is probably evident in the case, Kenyan's don't really use the term seizures, but convulsions. It's really a minor difference, but there are many of these language problems I've run into during rounds. They tend to call congestive heart failure (CHF) congestive cardiac failure (CCF). Fevers are hotness of body (HOB). A basic metabolic profile (BMP) is equivalent to a urea, electrolytes, and creatinine (UEC). They are very subtle differnece and it's not difficult to adapt, but they use abbreviations as commonly as we do and I feel I slow down discussion some by asking what each of these mean.

As mentioned above, the patient had an enlarged thyriod that was picked up on physical exam. After more discussion with the patient we found out that it was evaluated several years ago at an outside hospital. She was told then that she needed her thyroid taken out. This I actually seemed very familiar to me. I can't count the times that patients have been told they needed a procedure, a scan, an xray, or just follow-up and haven't- either because they were scared or just couldn't afford it. Strangely, I felt reassured that somehow all people are alike.

The patient did very well and had no more seizures throughout her hospital stay. However, the CT was never performed for 2 reasons. One was that she was afraid of what the scan might due to her. The other was that she and her family could not afford the test. While many of the service Tumutumu provides are cost-reduced (such as medications, laboratory tests, and meals) any of the tests obtained outside of the hospital (such as CT's, MRI's, Ultrasounds, and EGD's) are paid for in advance by the patient. Ultrasounds cost about 2,000 shillings (about $25 US) and CT's cost about 10,000 ($126). Although that doesn't sound like much but the average salary in Kenya is $730 US. Often patients have to call family and friends to help come up with the money. Often this can delay the test (and often diagnosis) by days.

Our patient ultimately decided that she did not want the test and wanted to be discharged home. This comes up alot here and seems to be to be a real contrast to how we practice in the US. Here in Kenya, if patients want to stay, the doctors are not really apt to forcing them out. If they want to go, there is no discussion on leaving against medical advice and documenting risks as we would in the US, patients are just discharged. That's not to say that the patients aren't informed, it's just that there isn't much malpractice out here to worry about.

I really hope that the patient does well, and hope that she follows up in clinic. I think many patients are lost to follow-up because of distance, time, and cost. I guess like many things out here in Kenya, it's out of our hands.

First Impressions

4.13.11

Tumutumu Hospital is definitely an interesting place to work.  After spending 3 days in the hospital I have a somewhat better understanding of how this place and the Kenyan health system operates. Tumutumu hospital's inpatient service is divided into 4 teams- internal medicine, general surgery, pediatrics, and OB/GYN. I am currently placed on the internal medicine team. On the team is an intern, a clinical officer, a consultant, and often a foreign medical student.

The intern is a recent graduate of medical school in Kenya and serves for a year here at Tumutumu. She rotates through the 4 sub specialties in 13 weeks blocks. Basically she runs most of the service as an upper-level resident. Over the year, not only will she lead the medicine and pediatric inpatient services, she will be requried to perform deliveries, c-sections, appendectomies, hysterectomies, cholecystectomies, open reductions with internal fixation, ect. For most of the surgeries a consultant  will not be present. After this year, she will chose either to practice medicine as a general practitioner or continue her training as a specialist. Obviously, this is a big contrast to the way we practice in the US and the interns are given a great deal of autonomy at such an early level in her training. And while she has a good knowledge base, the diversity of her education makes it difficult to go in depth in any particular field of interest.

The clinical officer serves in a role comparable to a physicians assistant or nurse practitioner. He has had 3 years of training in medical education and is now fulfilling a year of clinical duties. He is a hard worker and tends to do the brunt of the paperwork and minor procedures. 

The consultant is basically an attending position. They have specialized into an individual field will oversee the intern. Often the attendings are very busy and will cover multiple hospitals in the area. Often times this means he will show up at sometime during rounding and often leave before or shortly after finishing seeing the patients. He is there to help in difficult cases or solve problems that may arise, but generally leaves the majority of responsibility to the intern. Currently our consultant is covering three hospitals and while he is very intelligent and knowledgeable about Kenyan diseases and treatment he does not have much time for formal teaching.

As in the US, there are often medical students that rotate through Tumutumu. Their responsibilities are not quite as intense as the clinical rotations in the states. There is no pre-rounding on patients and no real clinical duties except to be present and participate in discussion if called upon. Currently we have a UK student who is fulfilling her pre-clinical duties after finishing her exams. She is very bright and engaged and often brings up salient points of discussion. She does not have that much clinical experience, but in her defense, she is required to have a minimum of 7 years of post-graduate training before receiving full privileges as a physician.

Rounding starts at 9:00am-ish. Time is sort of relevant here in Kenya. As noted above, there is no pre-rounding and basically the whole team discusses the patient, recent labs, vital signs, and comes up with an appropriate treatment plan. We start on one side of the ward and walk from patient to patient until everyone has been seen. Once finished with the first ward, we take a tea break and then see the second. The second ward tends to be rushed because visiting hours start at 1:30p, so the team tries to see everyone before their families arrive. In general, we see about 30-35 patients per day, so the service stays pretty busy.

I think the team does very well with the resources it has. Thought goes into every patient in terms of evaluating the deferential, treatment of pain, cost of procedure/diagnostic test, and compliance on discharge. It has a well stocked pharmacy and decent lab (we can even get thyroid studies!) However, the hospital does have its limitations. Basically there is very little that can be done for the unstable and crashing patient. Without an ICU, there is no equipment outside of the operating room to intubate a patient. There are no monitors, no pumps, no Bipap. The lab does not have the equipment to measure HCO3 so no way to detect acidosis. I asked if they could run an ABG and the intern laughed.

Despite these setbacks, I think the treatment here is very good. It's definitely been a learning experience in how to make do with what you have. The physician's physical exam skills are expertly honed and I think it shows me what skills I've lost because of the ease of laboratory testing. I hope that I can impart some small amount of knowledge to them as I am very grateful for what they have taught me.

Matthew Weighs In...

4.10.2011

After several days of travel, we can finally say that we reached our destination. We actually reached it on Friday, but this is the first access we have had to the internet since leaving Chicago. It was a fairly uneventful trip although a little exausting. I still feel I am having trouble adjusting to the time change and try to take naps whenever I can.

We had the opportunity to take a brief tour of Tumutumu hospital this weekend and learn more about where we are spending the next few weeks. Tumutumu has approximately 100 inpatients and is housing medical, surgical, gynecological, pediatric, and maternity patients. There is a surgical theater (OR), xray, and ultrasound services that are available on the weekdays. The hospital has no ICU beds and all critically ill patients are transported to the nearby hospital in Nyerie- approximately 30km away. Still, Tumutumu is a referal center for the nearby area of Karatina and cares for the "sicker" patients.

There are only 2 nurses staffed at any time, but Tumutumu houses a nursing school on the hospital grounds and the nursing students do the brunt of the patient care. In addition the hospital hosts a variety of medical students for one month rotations (currently there are 9 Chinese medical students staying in the guest house next door.) The hospital is staffed by 3 physicians- an internist, a surgeon, and a gynecologist. The remainder of services needed a done on a consultant basis with the consultants visiting during the weekdays.

There is minimal staffing at Tumutumu Hospital on the weekend, so my first day at work is not until Monday. I'm not exactly sure what my capacity will be, but  I assume that I will work with the  Comprehensive Care Clinic, an outpatient clinic to treat the large population of TB and HIV patients. I asked one of the nurses to give rough numbers on how many people they see a day and the only estimate that I got was "a lot."

Currently, I am struggling with my role as a physician and "missionary" here. I know this has a lot to do with the fact that I have not started work yet, but it still is a source of some anxiety for me. One of the joys of emergency medicine is that EM physicians are highly adaptable to most situations. While there is no formal emergency room here, I feel that my training will allow me to help out in a variety of areas here. And while I have had experience in treating both HIV and tuberculosis, I feel that there will definitely be a learning curve as to how best to diagnose and treat with the resources avialable. There are also a variety of disease that I have no experience treating (I honestly can't say I've ever seen a case of yellow fever or African sleeping sickness in South Carolina!).  I expect to learn much from Dr Kariithi and the rest of the Tumutumu staff.

My wife and I are currently reading a book by Henri J.M. Nouwen entitled Gracias! A Latin American Journal reccommend by our friend Sarah Cooper Searight. Nouwen is a Catholic priest who travels to South America to minister to the poor through the church in the 1970s.  In Gracias! Nouwen describes the changing face of mission work.  This passage spoke to Christina and I:

"It is hard for me to accept that the best I can do is probably not to give but to recieve. By receiving in a true and open way, those who give to me can become aware of their own gifts. After all, we come to recognize our own gifts in the eyes of those who recieve them gratfully. Gratitude thus becomes the central virtue of a missionary."

I hope that through this time I can help as I'm able and most of all be grateful for those that teach me through our fellowship.