Lupus and Ectopics in the Dark

I have only 2 more days left in the hospital before I head to Kampala and then home. Just as my time is coming to an end I am feeling increaseingly useful here. I have gotten to know the nurses, I know a little more about what the hospital can actually do and what care plan is realistic in this context. And I learned something about tropical disease as well. Dr. Welishe leave tommorrow for Kampala do give some lectures at the main medical center (Mulago), so I will be without my mentor here for the last 2 days. But I have his phone number and I can always consult him by that. We are getting dinner together tonight. He has taught me a lot and been a very patient and gracious attending physician. I hope I get to return to work with him in the future.



Today was my OR day. It started with a cyst removal, then a femoral hernia repair, and then a cervical polyp. We finished those cases by noon and I was planning on seeing patients in the female medical ward. I got a call from Dr. Welishe that there was a woman in the female sugical ward admitted with lower abdominal pain, tachycardic, with a low blood pressure. Her physical exam suggested ectopic pregnancy (when the developing fetus is in the fallopian tube instead of the uterus - dangerous because they rupture and bleed inside the abdomen). Pregnancy test was positive and an Ultrasound revealved free fluid, and a left adenexal mass, and an empty uterus. Dr. Welishe was calling me from home and asked me to get the patient to the OR and start the surgery. I went to the ward to see the patient. I was a little anxious, thinking about doing a laparatomy and removing an ectopic pregnancy on my own. Dr. Welishe had told me he would be there in one hour. I saw the patient. The nurses had not started IV fluids yet. She was tachycardic, BP was the same as previous but still low, and she was very tender and had a mass in her left lower abdomen.

I went to the OR and tried to hurry the process of getting the patient there. Anesthesia was ready, but the instruments were not and the OR nurse was insisting on getting lunch first. I told them we had to start immediately, but my demand was basically ignored. They did however eat a very fast lunch while I saw one other patient and then we were ready to start.

I was feeling anxious but since I felt like the diagnosis was a sure bet and the patient would benefit most from immediate surgery I was telling myself that I could do it on my own.

But, to my relief Dr. Welishe showed up before the surgery started. He allowed me to be primary and it was actually a very straightfoward sugery.

The abdomen was full of blood. About 1 liter came out after entering. Some clots. And there was a bleeding ruptured ectopic on the left. Dr. Welishe had to leave as soon as we got the bleeding controlled and I closed the abdomen. Right after he left, the lights went out. The main OR is really dark, but thankfully, I had my headlamps. (thank to the Ritchies!) So I got to finish the surgery by headlamp light.

And right after the lights went out Jackie, the scrub nurse, slipped and fell backwards pretty hard on the floor. So I was without a scrub nurse, operating by headlight in the dark with a thunderstorm shaking the roof. It was a little crazy.

Yesterday, while rounding on the female medical ward I was asked to see another patient in the male ward. This was a young boy who had all the symptoms of tetanus. I was surprised that I was seeing this again, espescially in a 10 year old boy as they are supposed to be vaccinated. But I can certainly imagine how some people would miss their vaccines, or get incomplete series. Anyways, he certainly had tetanus and his painful spasms were very impressive with some arching of his back. He improved very quickly after some diazepam. Again, there is no anti-toxin immunoglobulin to give but I gave antibiotics and cleaned the wound out.

I am seeing so many patients with AIDS. It is very frustrating becuase the tools to diagnose certain oppurtunistic infections are not there. I can do a spinal tap thankfully becuase cryptoccoal meningitis seems to be one of the most common infections. But there are several patients with pulmonary processes and often you can not even get a chest x-ray. Dr. Welishe says they don't see lots of Pneumocystis but then again they don't really have the tools to establish a firm diagnosis (it seems crazy but they very often can not even get a chest x-ray or an O2 sat). TB is extremely common and I have not gotten any information about how common other oppurtunistic pulmonary infections are. So I have been struggling to get a few tests and then treating very broadly empirically.

Regarding TB. I think this country is going to experience huge numbers of multi-drug resistant TB. Welishe says he has reffered several people to Mulago to have sputum cultures taken because they continue to produce AFBs (the TB bacteria) in their sputum several months after starting treatment. There is very poor drug adherence becuase people and their suppliers run out of the medicine all the time. It is really bad for children who need specific formulations. And there is no effective isolation of patients so it is spread everywhere. I think it is a setup for resistance and with the HIV co-infection rate it is pretty scary. This hospital needs a seperate inpatient ward for TB or suspected TB cases and REALLY needs some more lab support so you can at least get a timely AFB on sputum and maybe even do cultures. It is the refferal hospital after all. (not to mention they need a functioning x-ray machine).

On monday I saw a very interesting case in the female medical ward. The chief complaint was "filled with evil spirits from Kenya". A late 20s year old female who had been working in Kenya returned home with behavioral changes. She also had a malar rash (facial rash), rash on palms, in her more lucid moments she complained of joint pain and had joint swelling, and some oral lesions. She was anemic with some blood on the urine dipstick. Looked like Lupus but I did not really know that Lupus caused behavioral changes. Luckily there are some good medical texts around and it turns out Lupus can cause CNS effects and this usually means it is severe disease and the prognosis is not as good. Dr. Welishe had a friend who has more experience with rheumotological disease and he called him over to examine the patient. He agreed with the diagnosis and we started steroids and anti-malarials (which are one thing we have plenty of).

It really seems like there are disease states here that we regularly see in the states they are just much more advanced. It make the diagnosis easier but the prognosis worse. One expects to find all rare tropical disease but that is really not the case. There are a lot of common internal medicine problems that just present in a very different way. And there are many of the same surgical problems just in different ratio. Lots more ruptured spleens, a lot less acute appendicitis. Lots more incarcerated or stragulated hernias.

I am going to start my last day rounding on the male medical ward now. Should be interesting. Off to Kampala tommorrow afternoon.

Thanks for Helping Tororo Hospital

To all the folks who donated to Tororo Hospital the staff here says THANK YOU!

As I mention in the post below, I used the approximately $3000 dollars to buy 2 complete C-section surgical instrument sets, 4000 IV cannulas, 100 naso-gastric tubes, 200 foley cathers, OR gowns, BP cuffs, thermometers, and several other items specifically requested by the hospital staff.

Here is part of 1 of the new c-section sets displayed.

I want people to know that I got a great deal on the supplies through an organization called "Joint Medical Store" that has some affiliation with a catholic church and provides discount quality medical supplies to non-profit organizations. Your donation has gone a long way. Thanks again.

Busy week...

(Dr. Welishe and I at work in the Male Ward)

Last week went by very quickly. I have been very busy doing rounds, operating with Dr. Welishe, and coordinating the purchase of supplies with the donated funds. It has also been a frustrating week. Two patients (that I know about) who I was following died this week of totally treatable illness. Their deaths were a consequence of late presentation to care becuase there is so little access to health services here. Basically, they both died of poverty, and they were both young - 30 years old and 2 years old.

To start on a happy note... Dr. Welishe and I have been arranging and distributing the supplies I brought from MedShare international and the Contra Costa Medical Center. The equipment is being used on the wards and in the OR. We went to Kampala yesterday, Thursday, to the "Joint Medical Store", a not-for-profit medical goods supplier that helps supply NGOs. They had excellent prices. I had to wait for 5 hours after putting in my order becuase I had not made a order the day before. A little frustrating, but in the end I got all the equipment.

Thanks to all the people who donated money, I had a little over $3000 to spend on supplies. That bought 2 entire OR instrument sets of C-sections, 4000 IV cannulas, 50 urine catheters, 100 nasogastric tubes, a abdominal retractor, some assorted OR instruments that the doctors specifically requests, 10 OR gowns, clothe for OR drapes, thermometers, BP cuffs, and a quality stethascope for Dr. Welishe.

This cabinet was nearly empty before I arrived with the MedShare equipment:

Monday was a very frustrating day. I rounded on the female medical ward. The clinical officer was very breifly there and we divided up the work before he headed back to the outpatient area. Most of the clinical officers do not make rounds on all the patients in the area they are assigned to. They are paid very little and because of that they have other jobs that they want to get to quickly. Many of them work in the HIV clinics that are funded by NGOs and pay well. It is good to have increased HIV care, but frustrating that there is no money to pay people to treat less internationally recognized illnesses.

Anyways, I spent most of the day rounding with a woman training to be a nursing assistant. Basically, the lowest level of training in the hospital. There were just 2 nurse trainees for the entire ward (40 beds, and at least 10 people on the floor). I was assigned to see the "complicated cases".

My first patient was a woman with HIV was was unconscious with labored breathing. She had been unconscious for about 12 hours and was brought from the village. Her last CD4 count was 4 months ago and was 67. Exam revealed a wasted female with increased respiratory rate, high fever, oral thrush and marked pallor. No history of convulsions. I did a lumbar puncture, sent a malaria smear and blood count, sent sputum to test for TB, started broad spectrum antibiotics, anti-malarials, septra (per NG), and fluids with glucose. She responded well, I think primarily to the fluids and glucose. She was awake within 2 hours, but still unable to sit up. The x-ray is down still unfortunately. The blood smear was positive (4+) and she was very anemic (though not the worst I have seen). She got further anti-malarials and some blood. Severe malaria is not as common in adults but HIV changes that.

Many of my other patients on monday had fairly complex medical problems. Several had renal failure. One of them was unable to tell me when she last urinated, had edema up to her chest, and a cardiac rub. The family can not afford to get a creatinine measurement, let alone dialysis.

There are several women with cancer - mostly cervical, a woman with heart failure, a few more with renal failure, and many with HIV/AIDS. I ended up carrying out many of the orders I wanted done becuase there was simply not any available nursing staff. That meant frustrating trips to the pharmacy and lab to get supplies and drop of samples. I had to call Dr. Welishe in to review a few complicated cases.

Tuesday was a little more enjoyable. I did a c-section for a mom with twins. Dr. Welishe assisted and supervised. The 1st twin was breach, the 2nd transverse. The 2nd was difficult to get out, but eventually came out vertex. They were both healthy and the mother is recovering well. I also assisted on a hernia repair.

I spent the rest of Tuesday in the male ward which was totally insane. There was a "floor patient" at the foot of each bed. I almost laughed a little at the sight. At home we call "floor patients" ones who are on regular floors without special monitoring. Here, it means they are sleeping on the floor. And by the latrines in the back an older man was vomiting bilious matierial all over himself in the dirt. I would estimate there were 60 patients and there were 2 nurses and a handful of nursing students who can not give IV treatments. One man with HIV died of cyrtococcal meningitis (I think) while his father held his hand and alternated between asking us what else could be done and thanking us for helping. He was recieving non-standard of care treatment as it was the only available. And he had terrible diarrhea (that was being treated) so who knows if he ever absorbed any of the treatment.

I did get to see the man I diagnosed with tetanus again and he is improving day by day. I am very pleased by that. He is taking a full liquid diet.

Wednesday was more time in the OR with some alarming cases. The first was a terrible necrotizing breast cellulitis / mastitis / abcess that had been lingering in one of the villages for a week. She presented to the hospital 2 days ago and the clinical officer put her on gentamycin - because that and penicillin is pretty much the only antibiotic that most of them use. Dr. Welishe rounded on her the next day and changed antibiotics to something appropriate and scheduled debridment and drainage of the abcess. The skin of this poor woman's breast was totally necrotic. It sloughed off entirely and there was 2 large abcesses. It was terrible. And she has twins so needs to breast feed. Her twins are already losing weight and there is no money for formula.

The next case was a cervical biopsy on someone who obviously has advance cervical cancer. This is incredibly common here. There is no screening by pap smears and no HPV vaccine.

Thursday I was in Kampala getting the equipment.

Today (Friday) I was back on the pediatric ward. The nurses and I have worked out a triage sysem that is working well and the nutrition officer has me see all the children in the malnutrition unit and we come up with plans together.

The first case was one that I was familiar with. This child has a familiar story. The mother died of TB - suspected to have HIV. The child has been living with his mostly blind grandmother. The child is 1 years old and as you can see severely malnourished.

The child is testing HIV negative. The last time I saw the child I wrote detailed orders and only about 1/2 of them were carried out. This time, I did most of the urgent stuff myself with the nurse in the room. Again, the nurses in pediatrics have the worst staffing ratio of anywhere in the hospital and are paid poorly so you really can't expect more than 1 or 2 things to be done for a child, even a critically ill child, in one day. Getting a daily weight is a big deal.

Since you can't reliably expect a weight and height on each child (which is needed to calculate WHO weight to height ratio for diagnosis of malnutrition) I use the Mean Upper Arm Circumference. The malnutrition officer has these. Anything under 11.5 cm in a 6 month to 5 year old child is considered severe malnutrition. It has the same accuracy at predicting mortality as the weight to height ratio. As you can see this patient is clearly in the red zone at 9 cm.


For this patient, I placed an NG tube and started the high-calorie formula feeds, continued broad spectrum antibiotics as the patient was still hypothermic. The big problem is that this child only caretaker is mostly blind and at this point the child needs feeding of small volumes at least every 2 hours. During the day today I showed kitchen staff woman how to give the feeds through the NG tube and she did it every 2 hours. [just to give a sense of the difference between what should be done daily for these children versus what actually is done, the pre-printed order sheet I made up for this takes up a full page of order in small font - and is pretty unrealistic]

The majority of children with malnutiriton are not doing as poorly. Most actually present with edema instead of generalized weakness. Actually most seem to present with some change in status that seems likely due to infection. You can see the edema below (not that great of a picture). I have made an indentation in the skin on the dorsum of the foot with my finger and it stays that way for a while.

The child whose foot is above also lost their mother and lives with a neighbor. Her diet consists almost entirely of rice. So this is protein malnutrition and it sets the children up for severe infections. They seem to respond much better however to the formula and antibiotics, etc. then the children with total calorie malnutrition.



The second child I saw this morning was a non-malnourished 2 year old child without HIV who presented with high fever. She had had 2 convulsions. The child was lethargic, eyes open, but not really aware of her surroundings when I saw her. She was very cute and her mother was crying quietly. The child had presented the night before and was tested for malaria. The smear was full of malaria parasites. When I examined the child she had very rapid breathing and SEVERE pallor suggesting severe anemia - the most common cause of death in severe Malaria in children. I gave a shot of glucose, a dose of IV quinine, and had the nurse draw blood for a type and cross to transfuse. The nurse went to the lab to run the test and get the blood. The child died right after the blood arrived. The nurse literally was about to hook up the IV with blood. No code blue. Just a calm announcement that the child had passed... and back to work. The mother carried her little girl out with a clothe over her face.


I was able to help many of the other 15 or so other children I saw today. Mostly they had severe malaria. When I get labs on them, hemoglobins of 1-3 are routine. I am amazed that they get better when they do.

1 more week in Tororo.

Tetanus, AIDS, and Malnutrition

This last Thursday was my first full day in the men’s ward. It is in the most dilapidated building on the hospital campus and may have the worst overall staffing for the level of acuity (although pediatrics rivals it). It is separated into the medical and surgical wards, with about 40-50 patients on each side. Each side is one large dorm room with all the patients in old, dirty beds within arms reach of each other.

In the Tororo hospital there is serious shortage of trained personal (or, more accurately, a shortage of money to hire and retain them). The majority of medical management is directed by clinical officers in conjunction with the nurses. Some clinical officers are skilled, such as the officer was works in the malnutrition ward of the pediatric unit. Dr. Welishe has made it clear that others are either not well trained or simply lack essential knowledge or skills.

As I said, there are about 40 patients in the male ward. The overwhelming majority of them were receiving treatment for severe Malaria with quinine. Right away, this does not make much sense. Severe Malaria is much less common in adults than in children because immunity to P. Falcipurm is built up during the repeat episodes of malaria during childhood. Adults do get malaria, but it is usually not severe and it can generally be safely treated as an outpatient (per Dr. Welishe and the hospital director and my limited experience).

Also, for reasons that were never fully explained in any of the patients messy and disorganized charts (which as actually small, tattered school notebooks) many of the patient who were diagnosed with malaria were receiving Gentamycin in addition to Quinine. Gentamycin is a older antibiotic with several dangerous side effects that is very important and used frequently here but has specific indications. And none of the patient had an infection that should be treated with gentamycin as far as I could tell.

Anyways, I did do rounds on about 30 of the 40 men on the medical side of the male ward. I worked with the head nurse, 2 nursing assistants. Dr. Welishe came by twice to check on me and was always available by cell phone. Most of the patient had very clear presentations of advanced illness. Here are some interesting examples:

A 28 years old who was diagnosed with insulin dependent diabetes 10 or so years ago. He used to get insulin with the help of a wealthier friend but over the last year or two had been unable to get it. He had been admitted to the hospital "many times" in the last year with same cluster of symptoms, which sounded like Diabetic Ketoacidosis. Each time his blood sugar was over 400 and got better after getting insulin one way or another. This time he was admitted with rapid breathing and was diagnosed with pneumonia and put on gentamycin. I got a Random blood sugar and it was 450s. I ordered IV fluids and the nurses had a conference with some family members about how to obtain insulin. Randomly, there was a very small amount of Lantus insulin (which is a newer type of insulin) available at the hospital so I gave him that. And the family is hopefully going to buy more, so he can get started on his previous dosing schedule. The man is bare-bones wasted so I am not sure how much longer he will survive with only periodic treatment. Not ideal treatment, but even if we had regular insulin to give IV I would be very nervous as there is essentially no nurse monitoring and he could easily become hypoglycemic. Actually, I am not sure how this patient is alive currently. He must get insulin just enough or produce some small amount of his own still.

The 4th or 5th case of the day was maybe my most interesting so far during this trip. A 50ish year old man presented with a history of 3 days of inability to eat. Further questioning revealed that 3 days ago he was unable to open his mouth all the way and this progressed to being unable to open his jaw at all and being unable to swallow. He presented the night before I saw him with these complaints plus he had periodic, intensely painful spasms of his muscles. He was yelping in pain every 3-5 minutes. And if you made a loud noise he would yelp in pain. On admission he was diagnosed with Malaria. This really makes no sense at all. So he was on Quinine. When he would yelp in pain his arms would arch out and on his right forearm there was a three inch wound leaking pus. He had cut himself in a field 1 month ago and never received treatment for the wound.
I opened my MSF field manual to the chapter on Tetanus and it seemed that this patient was a textbook case. I called Dr. Welishe and he said that this was not common, but not so rare. The treatment is to partially sedate using valium, place in a dark isolated room and minimize sensory stimulation, debride and irrigate the wound, give human tetanus immunoglobulin or equine tetnus antitoxin (neither available at the hospital or in the referral hospital), and treat with metronidazole, an antibiotic against the clostridium tetani bacteria (which is available).
Apparently people can take weeks to recover and the risk is death by asphyxia as a result of laryngeal spasm.

I debrided the wound of necrotic tissue which actually went pretty deep and cleaned it antiseptic from the OR. And gave the valium, another muscle relaxant not used in the US, and metronidazole. I checked on him yesterday and so far the treatment appears to be working very well. He has fewer spasms, still can't open his jaw or swallow saliva but was speaking more clearly.

Many of the rest of the cases blend together in my mind when recalling them. The most common case by far was NOT malaria as in Pediatrics. It is advanced AIDS with severe opportunistic infections. I saw 4 patients with AIDS who had the exact same cluster of CNS symptoms - photophobia, headache, neck pain, fever, body ache, with no focal neurologic signs. Crytoccocal meningitis is one of the most common opportunistic infections here. I did a lumbar puncture on the first patient I saw with this. No way to measure opening pressure unfortunately. The CSF was yellow but not too cloudy. Microscopy showed "pus cells" per the lab report. They can do an india ink stain and a serum test of crytoccocal which I had not previously heard of., but they could not do either that day. So I decided to empirically treat all the patients. The less than ideal treatment that is offered here is fluconazole . No amphoteracin or flucytosine to start with. And doing one lumbar puncture took about 30 minutes for me to organize and gather the appropriate materials, so diagnostic or repeated taps would be difficult. Only one of these patients had a CD4 count. It was 16! (thats really low = Bad AIDS)

I would say about 1/2 of the ward is HIV positive and most of them have AIDS. Most of them have oral thrush. Many have diarrhea, and all of them are wasted to the point of looking like skeletons. 2 of them were unconscious but would respond slightly to pain.
The Anti-retro viral treatment available is Douvir-N, a combination pill with Lamuvidine, Staduvidine, and Nervaripine. Getting a patient started on it is possible but takes some logistical work. I have to talk to one of two nurses who can sign people up for appointments at the treatment center in the outpatient center of the hospital or at an organization across the street called TASO. So I started people on treatment with Fluconazole, Septra, or whatever seemed appropriate for their oppurtunistic infection and got a CD4 count and asked the nurse to make them appointments. I also ordered AFB on sputum for about 6 patients and talked to the TB clinic nurse about starting one on therapy who had active TB and AIDS.

The crazy thing is that all except one of the patient with advance AIDS that I saw were being treated for Malaria and "Severe infection" with Quinine and Gentamycin. They simply don't have the appropriate staffing for the high level of acuity and huge patient load.

*****

On friday I did inpatient rounds in the pediatrics ward. There are two clinical officers in pediatrics (they seem to alternate doing outpatient and inpatient) and one officer for the malnutrition ward. The person for the malnutrition ward seems very knowledgeable and the place is set up pretty well. He is really more of an administrator than a clinician, mostly in charge of getting the therapeutic feeds in stock and organizing the ward. The nurses do most of the care after the other two pediatric officers admit the patients. Again, I think there may be overuse of quinine for malaria, but it is not as alarming as in the adult ward because many of the children meet the diagnostic criteria for severe malaria. This Friday, both the pediatric clinical officers were in a training session in the administrative wing of the hospital.

I went over the malnutrition worksheet I made with the nutritionist officer. We made some corrections to make it more realistic for their facilities and capabilities. Then the head nurse set me up in a room and had me review the inpatient cases. Again triage was ineffective at first. The more forceful, English speaking, perhaps more well-to-do mothers sat up front with their plump, breast-feeding children, while the shy mothers sat in back with small babies covered in blankets with emaciated limbs sticking out. I talked with the head nurse and she actually proposed a triage system. It was not 100% effective, but basically worked. So I saw probably the 15 sickest children in the unit.

The first two children I saw had the EXACT same story. They were both over a year old but looked to be the size of newborns. They were emaciated beyond recognition, unable to even hold their heads up to feed. The mothers of both of these child had died sometime in the year after their birth of complications from AIDS (both had TB). They were both in the nutrition program but losing weight. Neither had NG tubes, though this is indicated for feeding by the WHO criteria. The caretakers (extended family) were hesitant to place NG tubes as here is taken as a sign that someone is near death (probably because it seems to be a sign that someone is near death). But that was the only way to get them children fluids and nutrition. There is no monitoring of IVs, so besides shots of glucose, which I gave to both of them (assuming hypoglycemia) I was hesitant to give IV fluids. And actually determing hydration status in a malnurished child is very difficult and IV fluids are very dangerous. So the NG tubes were placed. Both children were on penicillin. I switched to Amp + Gent on both. I got HIV test on both. One had oral canidiasis. One was hypothermic at 94 degrees and we put the child skin-to skin with the care-taker and covered them in thick warm blankets.
By the time I left the unit they were both getting NG tube feeds of the F-75 (a high calorie formula with vitamins and minerals mixed in) every 2 hours per WHO feeding guidelines and not vomiting. So I am somewhat hopeful.
The other malnourished children mostly have protein malnutrition. The edema seems to resolve quickly with the formula diet and they are sent home on the "plumy nut bars" ("Ready to Use Theraputic Food" - RUTF).

There were several unarousable children with either severe malaria or meningitis. I did a spinal tap on one 2 year old child with clear meningeal signs. Again this took a lot of effort to organize . The fluid was yellow and thick and I could not get microscopy on it because the one lab tech who can actually do microscopy on CSF was gone. Apparently she can do cell counts as well, but none of that was actually necessary as the diagnosis was clear. The treatment recommended by the WHO for this setting is chloramphenical and ampicillin and I gave this. Most all the other children got treatment for BOTH severe malaria and meningitis.
Chloamphenical is a older antibiotic with a broad spectrum and it is recomended by the WHO for meningitis. But it has a potentially deadly side effect so it is never used in the US. It feel strange writing for it (or actually giving it as I have done), but everything I read confirms the practice of using it routinely.

There are a lot of other children who have malaria (with positive blood smears) who have severe anemia. Hemoglobin of 2 and 3 are the very common. The patients’ tongues and conjunctiva literally look like sheets of white paper. I give them all blood transfusions, treatment for malaria, and treatment for hookworm.

I am taking the weekend off. I need some time to read more and I am going to hang out with the group of American doing a research project on Malaria and pregnancy who are based at the hospital. We are going to climb "the rock" near town for the view into Kenya.

Week In Review

It has been one week since I started my rotation here. Dr. Welishe established a work schedule for me last friday. I round on different wards each day and on wednesdays I do "cold" (aka non-emergent) OR cases with him. The schedule is frequently interupted but more or less works well.

I rounded again on the pediatrics ward over the weekend. There is no clinical officer or doctor assigned to round on the pediatric inpatients on saturdays. The nurses asked me to see patients in the treatment room, so I sat at an old school desk and about 50 mothers and their children lined up outside the door. They had been sitting around the yard or inside the ward. It was immediately apparent that there was no effective triage system in place. I would see one baby who was smiling, breast-feeding, afebrile or otherwise looked well and seemed to have a decent treatment plan in place (or maybe should not have been admitted in the first place) and then 2 children later a shy mother would come in with a lethargic, pale, comatose or otherwise critically ill child. I asked the nurses to bring the sick children to the front of the line, but that was only minimally effective. There are 2 nurses and one aid (and an enlisted teenage boy who translates for me) working the ward. That gives a patient to nurse ratio of about 1:30. The other big problem also stems from this poor staffing and that is you can get NO nurse monitoring or charting. No vital signs at all. I brought a digital thermometer with me and besides my stethoscope it has been my most useful tool. The most common diagnosis among the children is Malaria. Many have severe malaria as a consequence of infection with Plasmodium falciparum. This is complicated by coma or listlessness (with inability to feed), GI symptoms with fluid loss through vomiting and diarrhea, and the most mortal of complications - severe anemia. The conjuctiva, gums, and palms of some of these children are ghost white. I ordered blood for one child and it was actually given. Another child had got blood at admission as his hemoglobin was 2.6 (which I previously thought was not consistent with life). Dr. Welishe explains that repeat infection with malaria, and hookworm infection, and malnutrition combine to make children chronically anemic and then a attack of severe malaria pushes them over the edge. Most of the children who die here of malaria die due to anemia. The treatment of the malaria is IV quinine. Artemenisin based combinations should theoretically be given when the child can take pills or solution but the one available "Co-artem" is expensive. I am giving a medication called "Fansidar" (sulfadaxone-pyrimethamine) or switch to PO quinine. Neither is really first line, but that is what is available.

As I mentioned before I am also seeing malnutrition. All cases I have seen thus far are kwashiorkor type, which means the primary problem is protien and micronutrient deficiency. I can see why, as most people eat mostly 2 foods in this region. "Posha" which is ground corn meal, and "Matoke" which is boiled and mashed plantains. Some people eat some beans. And there are eggs, but not much. Anyways, the children have wasting of their chests and upper extremities but pitting edema in their lower extremities. They get sores on their legs with skin breakdown. Many are lethargic. It is actually a really scary sight and I did not know how to manage them at first. I spent a lot of the weekend reading WHO guidelines on severe malnutrition and it was really helpful. They are written for people working in a setting just like I am in (though they always seem to assume there is better nursing care available). I rearranged the recommendations into a quick guide and made an easy order sheet I can use. It is step by step and hopefully with help me keep focused and actually give emergent care that is useful. I posted it on the CCRMC global health portal for people who want to see. It is called the "Quick guide - Malnutrition". http://sites.google.com/site/globalhealthccrmc/neonatal--childhood-illness
I am talking with Dr. Welishe more about this and I still have lots of reading to do on the topic...

On monday I did rounds on the women's medical ward (adult women with mostly internal medicine problems but some gynecology). I was with a clinical officer who Dr. Welishe has told me is new and has not ever done adult internal medicine. He is not a fan of this particular clinical officer. There are some he thinks are good. Anyways, I was taken around by two nurses who had arranged for me to review the charts and examine the sickest patients on the ward.
Some of the interesting cases I have seen are:

50 year of patient with 9 months of vomiting. She appears completely wasted. No fat left. Dehyrdated on admission. It is her third admission for the same problem. There is some blood streaks in the vomit but mostly undigested food. She does also complain of some dysphagia. I thought of obstruction - upper GI. Maybe gastric outlet. Maybe she has/had a gastric of duodenal ulcer and had a resulting obstruction. Maybe a gastric cancer or esophageal cancer. Dr. Welishe thought outlet obstruction was most likely by history. So, what do you do??? No endoscopy. Apparently there is a private radiologist in Mambali (40 minutes away, if no rain). He can do an barium swallow. If there is evidence of obstruction and peptic ulcer disease she will need a laparatomy with relief of the obstruction (maybe gastrojejunostomy or pyloroplasty). I gave triple therapy for peptic ulcer disease with H. pylori. She may not get the barrium swallow study because it cost 40,000 ugandan schillings ($20 USD). Her family is considering selling a goat. So there is a lot of pressure that getting the test was the right decision. Dr. Welishe reviewed it and he agrees with the impression.

I saw another patient with edema to the sacrum and oliguira. All sudden onset. The urine is "tea colored" (their spontaneous descripting, not mine). The UA shows "epithelial cells and ++pus" but it is blank where there is a line for RBCs or casts and the nurse says this was not reviewed?? Seems like glomerulonephrtis and Dr. Welishe says the most common causes are Malaria and post-streptoccocal. So she is getting treatment for both. I ordered a creatinine and potassium. These have to be done at the private lab across town. They were "out of reagent" for the creatinine and reported the potassium as "27.6" with the normal range being 3.5 to 5.5. So, probably hemolyzed but they don't automatically repeat it like they do in the states. Kinda annoyed me, but I discussed with Dr. Welishe and I brought up steroids. He thought we should treat empircally so I started prednisone. The family is going to monitor the urine output in a bin. Apparently dialysis costs a lot per session, so if she does not get better with this treatment soon she will die.

I also saw a woman with MASSIVE ascites and severe anemia. She had been hospitalized twice before with a diagnosis of cirrhosis. But there is no jaundice, no hemotemasis, no spider angiomata. And on exam she had a rock hard matted peri-umbilical node - the "sister-mary-joseph node". It was actually a little sureal that she had that particular sign on exam because as I was examining her these "born again" people were marching around the 40 bed dormatory style ward with their bible held up chanting some prayers. Cervical cancer is common and can lead to ascites in advance stages, but she had no vaginal bleeding or cervical mass. I could not feel any abdominal mass, but it would have been impossible to tell as she has MASSIVE taunt ascites. I am planning on a pericentisis tommorrow (after she gets a blood transfusion, finally). Per report a previous pericentisis yeilded blood stained fluid which I think suggests cancer over chirrosis. We can't send the fluid for cytology and if we did it would be very unlikely she could afford surgery or chemo. Pretty sad case.

I was on Maternity yesterday and got to deliver two healthy babies. Things are done pretty differently here. Women usually are evaluated at presentation and the fetoscope is used to confirm heart tones. Then they walk or lay around the yard outside. When a family member or the patient thinks they are ready, they come into labor and delivery and the midwifes check to see if they are completely dilated. Then they get more active management of the 2nd stage of labor. Talking to the midwifes and Dr. Welishe, the biggest problems by far appears to be:

#1 Obstruction of labor. It is pretty routine for women to present after 2-3 days of labor at home with a traditional attendent. They are completely dilated and the membranes ruptured hours or days ago. There is often fever. I examined 2 women with this story and both had this band-like contracture across their abdomen that the midwifes said is a sign of obstruction. One of these women had a prior "Ceaser" (c-section). And the consequence of all this is that uterine rupture (even without a previous scar) is routine. There is one in post partum now who had a BP of 60/40, BEFORE the ceserean-hysterectomy. She got 2 units a blood and lived. The other major problem apparently is bladder necrosis - which I thankfully have not yet seen. But in the one c-section I have assisted on so far the patient's bladder was the most edematous I have ever seen.
#2 biggest problem - SEPTIC abortion. Abortion is not legal here in Uganda and for that reason many women die of sepsis after unsafe abortions outside the hospital. Apparently a type of stick is used for the procedure commonly. There are several women on the ward now who are on IV antibiotics recovering for this. The midwifes are very vocal about this issue and have lots of stories of young girls who did not choose to be pregnant, could not choose to have a safe abortion, underwent a brutal and painful procedure, and then died of overwhelming sepsis upon reaching the hospital or after being admitted.

Between visiting the other wards I was breifly pulled into the mens unit by a nurse who wanted me to see a relative. A HIV positive man with oral/pharyngeal canadiasis, wasting, undulating fever, and cough. I got a CD4 count and AFB test on the sputum. I also ordered a chest x-ray but the hospital's x-ray is broken. I think it is advanced AIDS with TB. We actually will be able to get treatment for both of those conditions thanks to an NGO project across the street from the hospital.
The men's ward is itimidating. It really looks like the worst think you could imagine for a hospital. The building is old, the walls cracked, the floor seems filthy (though I see people cleaning it), the beds and linen soiled, the unused mosquito nets torn and filthy hanging from the ceiling. And there are crowds of families around the patients who generally appear ill, some vomiting or lying listless waiting for attention. The main nurse there seems to me to be the most capable in the hospital I have met so far. She is older and when I asked about another patient I saw she gave me a concise history. She even took vital signs. She had a flock of assistant nurses dressed in pink and purple to designate thier position. The head nurse wears white with a big red belt and has a little nurse cap pinned to the top of her head.
I am assigned to round on the men's ward tommorrow morning so I am little anxious about that. I will probably be on my cell phone with Dr. Welishe for many of the patients.

Well I have been writing for one hour. I am going to try to write up a little quick guide for myself about Malaria as I expect I will need it this friday when I am back on pediatrics and will also be working the pediatric oupatient / ER area.

I have met a group of people from the US doing a research project on Malaria and pregnancy. I got to eat dinner with them the other night and it was great to relax and make and understand jokes. The cultural divide when talking to Ugandans is wide and even if we can understand what each other are saying we often don't actually understand what is being said. My accent is apparently better than many from the US, but still difficult for people to understand.

More in a week.

First Day at Tororo District Hospital

I arrived in Tororo yeserday afernoon after a 4 hour car ride from the capital. I met up with Dr. Welishe immediately and he helped me move the supplies over to the hospital. We took a breif tour of the facilities. The hospital is larger that I expected based on his descriptions. It is spread out over a large area. There are several wards: pediatrics, womens surgical, womens medical, males, maternal (including the labor and delivery area). There are 2 main "operating theatres". Also, there are several outpatient clinics, and one large clinic that functions as an emergency room. I was told the hospital capacity is 200 but there are currently many more people than that here inpatient. Every bed in the pediatric ward was full this morning. The staffing is poor. There are 3 full time doctors and as far as I can tell they spend most of their time in the OR. All 3 are general internal medicine trained - yet they do c-sections, general surgery, etc... Dr. Welishe is family medicine trained. He is not a full time employee of the hospital but works here as a teaching doctor for the university at Makere.

The conditions here are terrible as expected. There not enough nurses or clinical officers. There are large crowds of people waiting to be seen and per Dr. Welishe the inpatients are lucky to see a clinical officer once daily, let alone a doctor. They are out of most medicines in the hospital pharmacy and thus the patients family must buy medicine for the patient at nearby pharmacy even it is to be used inpatient.

I spent 3 hours rounding on the inpatient pediatrics ward today. There was no clinical officer on duty today and no doctor rounding. I saw 6 patients that the nurses picked out for me to see. 2 were severely ill. Both of those were febrile, tachycardic, lethargic (as in NO cry), severly malnurished. One had matted lymph nodes of the neck. I suspected TB lympadenitis and arranged for biopsy. Also, the child will get an HIV test. I asked Dr. Welishe's advice and he thought we would need to arrange for treatment emprically probably before the results of the biopsy (which has to be sent to the capitol to their lab). There is a lack of pediatric formulations of TB medications so this will be difficult.
The other children I saw were all recovering from Malaria. One had had severe Malaria and was still quite ill. Not able to hold his head up and take milk well, but improved from being unconcious at presentation. So I continued the IV quinine on him and on the others transistioned to PO. My guide book says to use an artemisinin-based therapy but the nurse told me that te patient was not buy Co-arthemeter which is the combination available because it is too expensive. So I perscribed PO quinine which is not first line therapy.

Before rounding on the pediatric ward I assisted on 2 appendectomies. One was by low laparatomy as the diagnosis was in question and it was not an appendicitis. We more or less did the surgery as I have been taught, but they do a purse string suture at the base of the cecum and invert or bury the appendiceal stump. The anesthesia tech had quite the challenge. Anesthesia was by Ketamine plus succinylcoline. He intubated with a laryngascope that had no light. And the tube came out halfway through the case and the O2 sat dropped to the 40-50s for over a minute. No one seemed to think that was a big deal. I gave him the laryngascopes I brought and the other anesthesia supplies and the OR team was very pleased.

I will arrange the rest of the supplies in the supply room of the OR this afternoon. It looks like almost everything I brought will be very useful. Unfortunately it will be a small drop in a very large bucket. There was no electricity for the last 2 days and no running water for 5 hours yesterday.

I hope to spend more time with Dr. Welish tommorrow. I got a cell phone here so I can contact him anytime with clinical questions. He seems like he will be very helpful and he is being very generous with his time. I think he will be using the donation for the hosital to buy extra C-section surgical sets as they only have one now and it takes a long time to sterilize between cases.

More updates soon. Exuse the typos, Internet is not reliable so you have to type and post fast.

Ready to GO!

Two days till departure. I want to say a quick thank you to all the people who have contributed to the Tororo district hospital. I have gathered all the supplies that are going with me and I think that the doctors there are going to be very pleased. I have 5 large bags full of suture, IV equipement, sterile gloves, surgical instruments, etc...

I got the supplies from Med Share International. Ellen and I went to their warehouse in San Leandro and I got to pick out medical equipment like a kid in a candy store. The director Chuck Haupt personaly showed us around. The matierials I got will be soooooo valuable. I remember being in a reasource-poor district hospital in the past and the patient had to buy their own suture prior to surgery. I am bringing about 50 lbs of suture of all kinds. Pretty exciting! Big thanks to the awesome people at MedShare, especially Chuck. I found a bunch of spinal needles and some basic anesthesia equipment and lots of other great stuff. Also a big thanks to the folks in sterile processing who sterilized, repacked, and organized tons of instruments from the ER laceration trays for me. I know those will be useful.

And a big thank you to everyone who made a financial contribution. I am bringing $2500 for direct donation to the hospital. Yet to be determined exactly what it will be used for, but I asked Dr. Welishe to think of some options.

Looking foward to posting from Uganda soon!