After two 8 hour flights and a 3 hour jaunt around Amsterdam, I got back home yesterday afternoon. It's nice to be back in a place where I can cross the street while talking on the phone because there are traffic laws that are respected and the general rule is for cars to yield to pedestrians. I still look both ways before crossing of course, but I can still do that while talking to someone on the cell phone.
Coming from one of the poorest countries in the world back to one of the wealthiest neighborhoods in the US emphasizes that a lot of the things we take for granted don't come out of nowhere. I've always been a little amazed at how our country, and many others, manage to pave so much land and build such huge buildings. Clearly that doesn't happen everywhere. People who know more about economics and business probably have a better
view of the flow of resources that allows all of this amazing
infrastructure to develop and facilitate our lives. My sense is that these great things are at built on the foundation of a strong social contract where people buy in to the idea that there are certain things that are in the common good, like education and clean water (and in some places health care) that lead to a better life for everyone in society. I'm sure there are plenty of big books that talk about this in a much more informed way though so I'll stop before I just start ranting with my uninformed opinions.
In any event, it's great to be back in the US. I hope I can visit Uganda again and spend more time with the great people of Mulago and also to see more of the country outside of Kampala. I hear the gorilla trekking is incredible and the pictures of the Rwenzori mountains look amazing, so there are plenty more reasons to go back.
Monday, November 26, 2012
Thursday, November 22, 2012
An uplifting one
Today I spent the morning with an oncologist in clinic, then went to the cardiology floor to see a patient with endomyocardial fibrosis (probably non-existent in the US and I would be surprised if it was ever mentioned in med school), then went to the solid tumor ward to do a history and physical on a patient with esophageal cancer.
In the morning, we saw patients with prostate cancer, ovarian cancer, colorectal cancer and a couple of leukemia cases. This whole week I was particularly curious about how chronic myelogenous leukemia (CML) is managed here because it's an example of a disease for which very effective, and typically expensive, targeted therapy exists in the form of tyrosine kinase inhibitors like imatinib and dasatinib. This morning we saw a patient with CML who had been diagnosed in 2005. He had been receiving imatinib since his diagnosis and was doing great. It's uplifting to see quite sophisticated medications making a major impact on people's lives in a place that's physically and economically so far away from where those advances were made. I think the company that made imatinib (Novartis) was initially quite reluctant to invest in the drug because they didn't think it would make any money. Fortunately the company succumbed to pressure to keep developing the drug.
During one discussion this morning, someone mentioned the acronym 'EMF'. I wasn't familiar with the term so I asked about it and the attending told the students that they had to take me to the cardiology ward to see a case because it's so common here.
After clinic, one of the students took me to the to see a 41 year old man with endomyocardial fibrosis (EMF). He had massive abdominal distension from ascites (fluid in the abdomen), but no leg swelling, which is "classically" how EMF presents. Apparently it's a common cause of heart failure here and typically affects relatively young patients (peaks of prevalence at 10 and 30 years of age according to my quick internet search). Patients with EMF are "classically" people who immigrate to the Luwero district of Uganda, which is just north of Kampala (it's the district where the current Ebola outbreak started). This district grows and consumes a lot of cassava, and one idea is that toxins from cassava cause EMF in people who have some susceptibility. The only "cure" is a heart transplant, but that's not really done here. It's been 3 years since our patient was diagnosed and he's being managed with periodic paracenteses (drainage of the abdominal fluid) and diuretics to try to slow down the rate at which the fluid builds up.
I'm off to Thanksgiving dinner with two Americans, one Swede, two Germans, and one Swiss. We're going to an Indian restaurant and then watching the new James Bond movie.
I hope everyone has a great Thanksgiving!
In the morning, we saw patients with prostate cancer, ovarian cancer, colorectal cancer and a couple of leukemia cases. This whole week I was particularly curious about how chronic myelogenous leukemia (CML) is managed here because it's an example of a disease for which very effective, and typically expensive, targeted therapy exists in the form of tyrosine kinase inhibitors like imatinib and dasatinib. This morning we saw a patient with CML who had been diagnosed in 2005. He had been receiving imatinib since his diagnosis and was doing great. It's uplifting to see quite sophisticated medications making a major impact on people's lives in a place that's physically and economically so far away from where those advances were made. I think the company that made imatinib (Novartis) was initially quite reluctant to invest in the drug because they didn't think it would make any money. Fortunately the company succumbed to pressure to keep developing the drug.
During one discussion this morning, someone mentioned the acronym 'EMF'. I wasn't familiar with the term so I asked about it and the attending told the students that they had to take me to the cardiology ward to see a case because it's so common here.
After clinic, one of the students took me to the to see a 41 year old man with endomyocardial fibrosis (EMF). He had massive abdominal distension from ascites (fluid in the abdomen), but no leg swelling, which is "classically" how EMF presents. Apparently it's a common cause of heart failure here and typically affects relatively young patients (peaks of prevalence at 10 and 30 years of age according to my quick internet search). Patients with EMF are "classically" people who immigrate to the Luwero district of Uganda, which is just north of Kampala (it's the district where the current Ebola outbreak started). This district grows and consumes a lot of cassava, and one idea is that toxins from cassava cause EMF in people who have some susceptibility. The only "cure" is a heart transplant, but that's not really done here. It's been 3 years since our patient was diagnosed and he's being managed with periodic paracenteses (drainage of the abdominal fluid) and diuretics to try to slow down the rate at which the fluid builds up.
I'm off to Thanksgiving dinner with two Americans, one Swede, two Germans, and one Swiss. We're going to an Indian restaurant and then watching the new James Bond movie.
I hope everyone has a great Thanksgiving!
Wednesday, November 21, 2012
The hospital bias
A few days ago I got an email from a friend who read my blog and he (or she) said "This place sounds scary and without your descriptions almost unimaginable coming from where we come from." This got me thinking about a few things that are either directly related or tangential to his (or her) comment.
I definitely agree that most of the stories I have written about are scary. I would be scared to be a patient at the hospital where I have been working. Just to be clear though, I certainly don't want my stories to be an indictment of the people who work there. There are many interns, residents, and some visiting expats who do amazing things with the resources that are available. And of course, like everywhere, including back home, there are people who under-perform and consequently make a negative impact on patient care.
On the pediatric oncology ward I've spent some time with a peds resident from Europe. She works from 7 AM to 1 AM and essential splits the ward of 30 patients with a medical officer (the term for someone who has finished internship but hasn't done residency), who is also very dedicated and talented. It's really amazing to see the dedication she has to her patients and to watch her advocate for her patients in a system where it's easier to just let things slide. Of course, often the battles are lost, but she keeps fighting when most people (myself included) would probably give in. Part of her work here involves trying to improve the organization and recording methods in the ward. She's made spreadsheets to make it easier to record chemotherapy doses and and other medications. Apparently it's quite popular among most people in the ward because it makes records much easier to decipher, but one of the directors has expressed some fairly strong disapproval, preferring to use the older system. Like everywhere, there are people who are constructive and those who aren't.
Which brings me the point I've wanted to make about how, from what I've seen, the students, interns, residents, and consultants (attendings) have been overwhelmingly welcoming of visitors. The team often asks the visiting residents what they think and, save for the example I mentioned in the previous paragraph, I really have only seen constructive camaraderie between the Ugandan team members and visitors. I would have expected at least some occasional hint of resentment or defensiveness on the part of the locals, but they really value and appreciate the help and input from the visiting residents I've worked with. The only hierarchical interaction I've seen is in the interaction between attending and resident or resident and student, but that's just normal for medical training.
Going back to my friend's comment, I should also point out that this blog reflects my experiences with a government-supported tertiary care hospital in a very poor country. Two nights ago a group of us talked about how our perspective of Uganda would be different if we had come here strictly for vacation. We probably would have spent a few total nights in hotels here in Kampala, but most of the time would be spent away from the city, on safari in the amazing national parks and seeing all of the wildlife and natural beauty this place has to offer. And we would have met the friendly, welcoming Ugandans as well as the few who aren't so nice. If we had gotten sick, we would have gone to the nice hospitals. I hear the International Hospital is quite upscale. All in all, it would be a great place to vacation. Certainly further from the comfort zone than more familiar vacation destinations, but it could be quite comfortable nonetheless.
In contrast, being in Mulago Hospital means we have a front and center view of the consequences of limited resources (eg clean water, vaccinations etc), and the political failures that lead to sub-maximal utilization of the limited resources. All of the human suffering that happens is concentrated in one place, providing no shortage of examples of the shortcomings of the system.
So, to wrap up, I would emphasize that the stories I mention here only describe one small part of Uganda. It's certainly an important part, but it doesn't reflect what it would be like to visit as a tourist. Imagine, if someone went to Chicago and worked on the Cook County trauma team, their blog might give on the impression of a society where violent crime is rampant.
I definitely agree that most of the stories I have written about are scary. I would be scared to be a patient at the hospital where I have been working. Just to be clear though, I certainly don't want my stories to be an indictment of the people who work there. There are many interns, residents, and some visiting expats who do amazing things with the resources that are available. And of course, like everywhere, including back home, there are people who under-perform and consequently make a negative impact on patient care.
On the pediatric oncology ward I've spent some time with a peds resident from Europe. She works from 7 AM to 1 AM and essential splits the ward of 30 patients with a medical officer (the term for someone who has finished internship but hasn't done residency), who is also very dedicated and talented. It's really amazing to see the dedication she has to her patients and to watch her advocate for her patients in a system where it's easier to just let things slide. Of course, often the battles are lost, but she keeps fighting when most people (myself included) would probably give in. Part of her work here involves trying to improve the organization and recording methods in the ward. She's made spreadsheets to make it easier to record chemotherapy doses and and other medications. Apparently it's quite popular among most people in the ward because it makes records much easier to decipher, but one of the directors has expressed some fairly strong disapproval, preferring to use the older system. Like everywhere, there are people who are constructive and those who aren't.
Which brings me the point I've wanted to make about how, from what I've seen, the students, interns, residents, and consultants (attendings) have been overwhelmingly welcoming of visitors. The team often asks the visiting residents what they think and, save for the example I mentioned in the previous paragraph, I really have only seen constructive camaraderie between the Ugandan team members and visitors. I would have expected at least some occasional hint of resentment or defensiveness on the part of the locals, but they really value and appreciate the help and input from the visiting residents I've worked with. The only hierarchical interaction I've seen is in the interaction between attending and resident or resident and student, but that's just normal for medical training.
Going back to my friend's comment, I should also point out that this blog reflects my experiences with a government-supported tertiary care hospital in a very poor country. Two nights ago a group of us talked about how our perspective of Uganda would be different if we had come here strictly for vacation. We probably would have spent a few total nights in hotels here in Kampala, but most of the time would be spent away from the city, on safari in the amazing national parks and seeing all of the wildlife and natural beauty this place has to offer. And we would have met the friendly, welcoming Ugandans as well as the few who aren't so nice. If we had gotten sick, we would have gone to the nice hospitals. I hear the International Hospital is quite upscale. All in all, it would be a great place to vacation. Certainly further from the comfort zone than more familiar vacation destinations, but it could be quite comfortable nonetheless.
In contrast, being in Mulago Hospital means we have a front and center view of the consequences of limited resources (eg clean water, vaccinations etc), and the political failures that lead to sub-maximal utilization of the limited resources. All of the human suffering that happens is concentrated in one place, providing no shortage of examples of the shortcomings of the system.
So, to wrap up, I would emphasize that the stories I mention here only describe one small part of Uganda. It's certainly an important part, but it doesn't reflect what it would be like to visit as a tourist. Imagine, if someone went to Chicago and worked on the Cook County trauma team, their blog might give on the impression of a society where violent crime is rampant.
Tuesday, November 20, 2012
No clinda part 2
Yesterday was my first day on the oncology (cancer) ward. I did pediatric oncology yesterday and today and then I'll do adult oncology for the rest of the week.
The first patient I saw yesterday was an 9 year old girl who had a right above the knee amputation for a rhabdomyosarcoma (cancer of muscle cells). After the amputation she developed osteomyelitis (infection of the bone) at the site of the amputation and improved on the antibiotic clindamycin, the same antibiotic that was out of stock on Friday when I was on the adult ID ward. The same shortage of clindamycin hit the pediatric oncology floor and the girl couldn't get her clindamycin doses. I didn't round on her today to find out if clindamycin was now available or if they had started an alternative antibiotic. Tomorrow I'm going to get an update.
Today, like yesterday, I rounded on kids with various types of cancer like Hodgkins lymphoma, non-Hodgkins lymphoma, acute lymphoblastic lymphoma etc. One kid, a 12 year old boy, has refractory Hodgkins lymphoma and needed to have fluid from his chest drained because it had accumulated to the point that it was making it hard for him to breathe. The general surgeon and a visiting student came to place the chest tube early in the afternoon. Curtains were placed around the bed so that they blocked the view from the foot of the bed but kids and parents in the same row as out patient had a front and center view. Outside the window, people were having lunch and occasionally looked in to see the procedure. While the people outside seemed generally unflustered by the boy's screams, some of the kids inside looked pretty uncomfortable to horrified.
During the procedure, the mother of the boy sat at the foot of the bed, trying to comfort her son. Aside from screaming during the entire procedure, he bravely kept his body steady, not once flinching at the pain. Once the tube was placed, the surgery resident realized that he had forgotten a suture to tie the tube to the chest wall to keep it from slipping out. One person went looking for a suture in the building and I went to try to find some in the orthopedic surgery ward. After walking to a few buildings in the general vicinity of where I was told the orthopedic department is located, I found someone to help me. Unfortunately, the person who had the key to get into the area where the sutures are stored had gone home for the day and the only suture available otherwise was the wrong kind. So I walked back to the pediatric oncology ward, the boys screams leading me in the right direction, hoping that someone else had found the right suture. Fortunately I found the surgeon in the process of tying the tube in place, even if it was resorbable (wrong kind) of suture.
The first patient I saw yesterday was an 9 year old girl who had a right above the knee amputation for a rhabdomyosarcoma (cancer of muscle cells). After the amputation she developed osteomyelitis (infection of the bone) at the site of the amputation and improved on the antibiotic clindamycin, the same antibiotic that was out of stock on Friday when I was on the adult ID ward. The same shortage of clindamycin hit the pediatric oncology floor and the girl couldn't get her clindamycin doses. I didn't round on her today to find out if clindamycin was now available or if they had started an alternative antibiotic. Tomorrow I'm going to get an update.
Today, like yesterday, I rounded on kids with various types of cancer like Hodgkins lymphoma, non-Hodgkins lymphoma, acute lymphoblastic lymphoma etc. One kid, a 12 year old boy, has refractory Hodgkins lymphoma and needed to have fluid from his chest drained because it had accumulated to the point that it was making it hard for him to breathe. The general surgeon and a visiting student came to place the chest tube early in the afternoon. Curtains were placed around the bed so that they blocked the view from the foot of the bed but kids and parents in the same row as out patient had a front and center view. Outside the window, people were having lunch and occasionally looked in to see the procedure. While the people outside seemed generally unflustered by the boy's screams, some of the kids inside looked pretty uncomfortable to horrified.
During the procedure, the mother of the boy sat at the foot of the bed, trying to comfort her son. Aside from screaming during the entire procedure, he bravely kept his body steady, not once flinching at the pain. Once the tube was placed, the surgery resident realized that he had forgotten a suture to tie the tube to the chest wall to keep it from slipping out. One person went looking for a suture in the building and I went to try to find some in the orthopedic surgery ward. After walking to a few buildings in the general vicinity of where I was told the orthopedic department is located, I found someone to help me. Unfortunately, the person who had the key to get into the area where the sutures are stored had gone home for the day and the only suture available otherwise was the wrong kind. So I walked back to the pediatric oncology ward, the boys screams leading me in the right direction, hoping that someone else had found the right suture. Fortunately I found the surgeon in the process of tying the tube in place, even if it was resorbable (wrong kind) of suture.
Monday, November 19, 2012
No clinda
It's been hard to get a computer and internet service that loads up blogger, hence the lack of posts in the past few days.
Friday was my last day on the adult infectious disease ward. It was yet another reminder of the lack of resources here. The 30 year old woman I wrote about last week, the one I said would probably not make it until the morning, was still hanging on on Thursday. She was still just lying in bed with her eyes open and a frightened expression on her face, but her blood pressure was up to 110/70 (from 75/55 on Wednesday) and she was getting the antibiotics she needed. On Friday morning we checked up on her and her blood pressure was down to 85/55. Apparently she hadn't gotten any doses of clindamycin or IV fluids since 6 PM the night before. Clindamycin, we found out, is out of stock. The lack of IV fluids can just be attributed to insufficient nursing coverage overnight, or poor communication to the night staff of the precarious condition of this particular patient, who can't drink or eat on her own and is entirely dependent on IV fluids to keep her hydrated and for treatment of sepsis.
Though I was uncomfortable with the fact that she didn't get her doses of clindamycin overnight, I could understand that it simply wasn't available, and therefore beyond the power of the night staff or the patient's attendants to administer the antibiotic. Of course it would have been good to start treating with an alternative antibiotic, but that decision could arguably wait until the morning. But the lack of IV fluids didn't sit well with me. It just highlighted the fact that the system could so easily lead to the neglect of a patient that requires one of the simplest and oldest medical interventions available. The bottles of normal saline, D5half etc were all just a few meters away in another room, but no one bothered, or to be more fair, no one was available or informed, that this patient needed to be on maintenance IV fluids overnight.
On Friday there was some discussion about how patient care is handed off to the night team. Apparently, for some patients, the transfer is done by word of mouth, but for most patients, the night team just reads the notes in the patient's charts, which sit on the patient's beds. That means the night intern(s) have to go around the ward and decipher what is going on with each patient based on the notes. And it's not like back home where vitals are obtained every few hours, which at a minimum would give the night intern some indication about whether a patient requires some urgent attention.
Given the high rate of communication errors back home, despite verbal signouts on every patient and the help of electronic medical records (with all its benefits and drawbacks), I think it's a safe assumption that the rate of errors that happen here is significantly higher.
Today was my first day on the pediatric oncology service. I write about that next time.
Friday was my last day on the adult infectious disease ward. It was yet another reminder of the lack of resources here. The 30 year old woman I wrote about last week, the one I said would probably not make it until the morning, was still hanging on on Thursday. She was still just lying in bed with her eyes open and a frightened expression on her face, but her blood pressure was up to 110/70 (from 75/55 on Wednesday) and she was getting the antibiotics she needed. On Friday morning we checked up on her and her blood pressure was down to 85/55. Apparently she hadn't gotten any doses of clindamycin or IV fluids since 6 PM the night before. Clindamycin, we found out, is out of stock. The lack of IV fluids can just be attributed to insufficient nursing coverage overnight, or poor communication to the night staff of the precarious condition of this particular patient, who can't drink or eat on her own and is entirely dependent on IV fluids to keep her hydrated and for treatment of sepsis.
Though I was uncomfortable with the fact that she didn't get her doses of clindamycin overnight, I could understand that it simply wasn't available, and therefore beyond the power of the night staff or the patient's attendants to administer the antibiotic. Of course it would have been good to start treating with an alternative antibiotic, but that decision could arguably wait until the morning. But the lack of IV fluids didn't sit well with me. It just highlighted the fact that the system could so easily lead to the neglect of a patient that requires one of the simplest and oldest medical interventions available. The bottles of normal saline, D5half etc were all just a few meters away in another room, but no one bothered, or to be more fair, no one was available or informed, that this patient needed to be on maintenance IV fluids overnight.
On Friday there was some discussion about how patient care is handed off to the night team. Apparently, for some patients, the transfer is done by word of mouth, but for most patients, the night team just reads the notes in the patient's charts, which sit on the patient's beds. That means the night intern(s) have to go around the ward and decipher what is going on with each patient based on the notes. And it's not like back home where vitals are obtained every few hours, which at a minimum would give the night intern some indication about whether a patient requires some urgent attention.
Given the high rate of communication errors back home, despite verbal signouts on every patient and the help of electronic medical records (with all its benefits and drawbacks), I think it's a safe assumption that the rate of errors that happen here is significantly higher.
Today was my first day on the pediatric oncology service. I write about that next time.
Thursday, November 15, 2012
First code
Today was another busy day on the adult ID ward. I started off helping out the interns by doing a couple of lumbar punctures and some blood draws and then the team rounded on all the patients. Rounds here are a little different than back home. We start off by seeing the new patients or the ones on the high dependency area. Also, during rounds the team takes vitals and starts IV fluids if indicated.
Other than the patient with hyperactive delirium who kept saying that the American resident was telling her lies and that I was her white father, the most memorable event of the day was being involved in a code for the first time. I was just about to draw blood on a patient when an attendant said to me, without any apparent concern in her voice, "She has arrested." At first I just looked up and asked "She's arrested? What do you mean? Who?" The attendant pointed at a patient three or four beds down the row from where I was standing and I looked and tried to make out what was going on. I couldn't really see the patient breathing so I went over and checked and her chest wasn't rising and she didn't seem to be moving air. Her hands were cold and I couldn't feel a pulse.
I told the nearest doctor I could find, who was the American resident on the team and he came over and started chest compressions and told me to get the other resident. Because there was an infant, probably a 1-2 year old, playing on the floor next to the patient, right behind the resident who was doing chest compressions, the first thing I did was try to find a place for her where she wouldn't get stepped on or have body fluids or a needle land on her. The mother didn't want her on the bed, probably out of fear of getting her daughter sick, so I looked around and thought of putting her on an empty bed but no one was there to make sure she wouldn't fall off. Finally someone in the room realized that I needed someone to take the infant.
Finally I found the senior house officer and the intern and we all started running a code. For about 25 minutes we did chest compressions and bag ventilated the patient and that whole time we tried to get IV access and failed until we finally got a femoral IV line and gave epinephrine at about 20 minutes. After 25 minutes without any sign of a pulse or heart sounds, it was pretty clear that continuing was futile, but we moved the bed to another room that had suction to get rid of some of the gastric contents that had come up.
All of this happened in a room full of other patients and the family members watching. As I was doing chest compressions, I was using the song "Stayin' alive" to keep the right rhythm because I've heard that it's a song that plays at the ideal beat for chest compressions. It seemed to keep me at the right rhythm, but having an upbeat song running in my head while running my first code seemed to make for a strange combination emotions.
The American resident, who had rounded on the patient earlier, said that the patient had been responsive earlier in the day. She was in her 20s and had known ISS (immunosuppression syndrome = AIDS) and had come in with abdominal swelling. She was in kidney failure and she was acidotic (bicarbonate of 11) so it seems like she likely had a pulseless electrical activity (PEA) arrest due to acidosis. But, given that there was no EKG, we have no idea what sort of heart rhythm she had.
Other than the patient with hyperactive delirium who kept saying that the American resident was telling her lies and that I was her white father, the most memorable event of the day was being involved in a code for the first time. I was just about to draw blood on a patient when an attendant said to me, without any apparent concern in her voice, "She has arrested." At first I just looked up and asked "She's arrested? What do you mean? Who?" The attendant pointed at a patient three or four beds down the row from where I was standing and I looked and tried to make out what was going on. I couldn't really see the patient breathing so I went over and checked and her chest wasn't rising and she didn't seem to be moving air. Her hands were cold and I couldn't feel a pulse.
I told the nearest doctor I could find, who was the American resident on the team and he came over and started chest compressions and told me to get the other resident. Because there was an infant, probably a 1-2 year old, playing on the floor next to the patient, right behind the resident who was doing chest compressions, the first thing I did was try to find a place for her where she wouldn't get stepped on or have body fluids or a needle land on her. The mother didn't want her on the bed, probably out of fear of getting her daughter sick, so I looked around and thought of putting her on an empty bed but no one was there to make sure she wouldn't fall off. Finally someone in the room realized that I needed someone to take the infant.
Finally I found the senior house officer and the intern and we all started running a code. For about 25 minutes we did chest compressions and bag ventilated the patient and that whole time we tried to get IV access and failed until we finally got a femoral IV line and gave epinephrine at about 20 minutes. After 25 minutes without any sign of a pulse or heart sounds, it was pretty clear that continuing was futile, but we moved the bed to another room that had suction to get rid of some of the gastric contents that had come up.
All of this happened in a room full of other patients and the family members watching. As I was doing chest compressions, I was using the song "Stayin' alive" to keep the right rhythm because I've heard that it's a song that plays at the ideal beat for chest compressions. It seemed to keep me at the right rhythm, but having an upbeat song running in my head while running my first code seemed to make for a strange combination emotions.
The American resident, who had rounded on the patient earlier, said that the patient had been responsive earlier in the day. She was in her 20s and had known ISS (immunosuppression syndrome = AIDS) and had come in with abdominal swelling. She was in kidney failure and she was acidotic (bicarbonate of 11) so it seems like she likely had a pulseless electrical activity (PEA) arrest due to acidosis. But, given that there was no EKG, we have no idea what sort of heart rhythm she had.
Wednesday, November 14, 2012
Adult Infectious Diseases
This week I've been on the adult ID ward. Overall, my time here has been an incredible learning experience, but this week I really felt like I've been able to contribute to the team in a significant way.
The team I'm working with, which is responsible for about 40 patients, has two interns and, like the rest of the hospital, severely lacks enough nursing staff. Because of the lack of nursing staff, dosing decisions for medications are adjusted under the assumption that doses of medications will be missed. For example, for treatment of presumed or confirmed bacterial meningitis, which is probably 25-50% of the patients, they give double the normal dose (2 grams, twice a day) so that if the patients only get one dose they still get the "full" recommended dose.
The severe shortage of interns and nursing staff means that visiting students, residents and nurses can really be a significant help in taking care of the patients. Yesterday I did several blood draws (including my first femoral), 4 lumbar punctures (only 1 successful), hung bottles of IV fluids and placed urinary catheters from 8 AM to 7 PM. It was really the first time since I've been here that I appreciated how much anyone with some fundamental skills can help out here. And because the patients here are often very sick (to the point where in the US they would be in the ICU), getting things done in an expedient manner feels like it might make a difference.
This morning, one patient, who is HIV positive (like most of the patients) with a CD4 count of 10 who is essentially not responsive (likely due to meningitis suspected tuberculosis, cryptococcal meningitis, syphilis etc) had a blood pressure of 75/55, heart rate of 130, a respiratory rate of >30 and a sodium of 168. This patient would likely be in the intensive care unit in the US but here that's not an option so we just hung a bottle of IV fluids, which even with the line fully open was not going fast enough to catch up. We tried to put in another IV line but failed and the team went on to the next patient. I would be surprised if she's still in the ward tomorrow as she looks sicker than a lot of the patients that I saw one day and were gone the next.
On a lighter note, the teaching on the adult ID service has been excellent. The SHO (senior house officer) that I've been working with constantly elicits the students' opinions both to teach but also to guide treatment.
That's all for now.
The team I'm working with, which is responsible for about 40 patients, has two interns and, like the rest of the hospital, severely lacks enough nursing staff. Because of the lack of nursing staff, dosing decisions for medications are adjusted under the assumption that doses of medications will be missed. For example, for treatment of presumed or confirmed bacterial meningitis, which is probably 25-50% of the patients, they give double the normal dose (2 grams, twice a day) so that if the patients only get one dose they still get the "full" recommended dose.
The severe shortage of interns and nursing staff means that visiting students, residents and nurses can really be a significant help in taking care of the patients. Yesterday I did several blood draws (including my first femoral), 4 lumbar punctures (only 1 successful), hung bottles of IV fluids and placed urinary catheters from 8 AM to 7 PM. It was really the first time since I've been here that I appreciated how much anyone with some fundamental skills can help out here. And because the patients here are often very sick (to the point where in the US they would be in the ICU), getting things done in an expedient manner feels like it might make a difference.
This morning, one patient, who is HIV positive (like most of the patients) with a CD4 count of 10 who is essentially not responsive (likely due to meningitis suspected tuberculosis, cryptococcal meningitis, syphilis etc) had a blood pressure of 75/55, heart rate of 130, a respiratory rate of >30 and a sodium of 168. This patient would likely be in the intensive care unit in the US but here that's not an option so we just hung a bottle of IV fluids, which even with the line fully open was not going fast enough to catch up. We tried to put in another IV line but failed and the team went on to the next patient. I would be surprised if she's still in the ward tomorrow as she looks sicker than a lot of the patients that I saw one day and were gone the next.
On a lighter note, the teaching on the adult ID service has been excellent. The SHO (senior house officer) that I've been working with constantly elicits the students' opinions both to teach but also to guide treatment.
That's all for now.
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