A Sixth Sense

You may wonder how Shirati Hospital cropped up in such a rural and remote area of Tanzania.  It turns out that there was an influx of Mennonite missionaries some 30 years ago and though they have long since left, their legacy remains with support and significant outside contributions.  The physicians and staff that arrive often have a link, at least by word of mouth, with the Mennonite Church.  With their influence the Hospital has grown and has essentially become the “referral center” for the district.  However, there are still very few fully trained physicians permanently stationed here, perhaps 2 or 3 in the entire hospital.  Most of the local medical providers are non-physicians, either Medical Officers (MOs) or Assistant Medical Officers (AMOs) who perform most general surgeries, cesarean sections, and deliver care on the wards.  Specialists arrive a few times a year to supplement the medical care they are able to provide.

All in all, I was impressed with how much care the local staff was able to provide with so few resources.  Yet, there were definitely still some 'what the heck' moments.  For example, intubations were rarely performed in the hospital since there were no working ventilators.  Even in the operating room most cases were performed under spinal anesthesia, perhaps augmented by ketamine.  It was somewhat disconcerting to see patients wide awake as their legs were being amputated or watch an orthopedic surgery drag on for 5-6 hours.  The whole time I was just praying that my spinal had taken full effect and would last for the entire procedure.  On the occasions that we were unable to use spinal anesthesia (abdominal surgery, etc.) we did end up intubating, albeit with sub-optimal conditions.  We used Ether through a pump (hand pumped through a device that looked like an accordion) since there was no ventilator. 

Ether Hand Pump

What's wrong with this picture?

Ketamine and/or Valium were used for induction followed by the paralytic succinylcholine.  However, the biggest problem was that there was no external oxygen source in the hospital.  No pre-oxygenation or apneic oxygenation here.  What generally would be a controlled setting for intubation essentially turned into a harrowing ‘emergent’ intubation every single time.  Presumably the patient was young and healthy and starting at 98-100% O2 saturation on room air.  After inducing and paralyzing the patient the oxygen saturation would immediately begin to drop.  It became a race against time to intubate the patient.  Even if intubation occurred within 10-15 seconds oxygen saturations would routinely drop to 40-60%.  No one informed me of this prior to my first intubation.  My first airway attempt would have been a standard affair back home:  young, healthy skinny man with no predictors of airway difficulty.  His epiglottis was a little floppy but I got a pretty decent view and slid the tube through the vocal cords in about 10 seconds flat.  I looked up at the tiny monitoring device and noted the patient was saturating around 80% which was not to be unexpected considering he had received no oxygen over the past 1-2 minutes during induction, paralyzing, and intubation.  However, despite “bagging” room air (we normally breathe 21% oxygen) mixed with ether, the patient’s oxygen saturation continued to plummet all the way below 40%.  I stared in horror since this was one of the lowest oxygen saturations I had ever seen in a living human being.  At this point I immediately thought of the potential for esophageal intubation (endotracheal tube going down towards the stomach instead of the lungs).  However, the patient had equal breath sounds with chest rise and no rush of air over the stomach.  I had multiple people check with the same result.  I then looked in the patient’s mouth again to verify the correct placement of the tube.  Nothing looked amiss.  At this point, I was still the only person in the room who was nonplussed.  The anesthetist was a quiet fellow and continued to bag through the ether accordion pump while I held a double-handed seal of the mask over the patient’s face.  Ever so slowly the oxygen saturation began to rise but it took over 5 minutes for it to reach 90%.  I would soon realize this to be a common occurrence.  Luckily I did not see any catastrophic consequences of these hypoxic events and patients were apparently none worse for the wear post-op.

The wards in the hospital, like much of sub-Saharan Africa, are big open air wards.  There are female, male, and pediatric wards that accommodate many more people than you think would be possible.  The beds are side by side and so close one could essentially roll from one bed to another and snake his way across the entire ward.  There are no levels of acuity, step-down status beds, or intensive care units.  Patients are sometimes even placed two to a bed.  Patient privacy does not exist and rounds occur with every patient hearing every other’s story.  Basic patient care such as feeding, bathing, and clothing is performed by family members.  Patients don’t get any food unless their family brings it for them.  There are no blood transfusions unless a patient can find a matched donor, usually a family member.  Despite all these difficulties, the staff provides care beyond which one would expect.  They work long hours, manage an unreasonable number of sick patients with unimaginably meager resources, all while wearing a smile.

Nevertheless, there were some tough patient cases and ethical dilemmas.  One particularly striking case involved a 23 year old HIV-positive woman (whom I will call Ms. Khadija) who had just delivered her 4^th child by cesarean section.  She had a post-operative wound infection that required a return to the operating room.  I don’t have the exact statistics for post-operative complications and infections; however, I suspect that the rates are significantly higher in rural Tanzania.  She was taken back to the operating room and found to have extensive infection and pus in her abdomen.  It was cleared out but she was still in dire straits.  Being HIV-positive certainly didn’t help.  Hers was bed #1, the first one you stumble across upon entering the morass that was the female ward.  It was unavoidable. It was the weekend and the on-call doctor had left for the day.  I was now the only physician in the entire hospital.  As I entered, the unmistakable stench of infection permeated the air.  I immediately stopped at bed #1.  Ms. Khadija looked acutely ill.  She was sweating profusely and had a glazed look over her eyes.  She was breathing very fast, upwards of 60 times per minute.  I checked her pulse and it was between 140-160 beats per minute.  Her temperature was 104+F.  Her blood pressure was tenuous.  She had disseminated infection with likely end organ dysfunction (though we did not have any lab tests to confirm), what we would call severe sepsis.  In the U.S. she would be in an intensive care unit with 1:1 nursing (not 1 nurse to 40 patients) with multiple physicians, specialists, and a host of other team members and resources.  She would likely be on a ventilator with central venous access and on many powerful antibiotics and medications to support her blood pressure and help fight the infection.  Here, she only had me and a handful of nursing students.  When I arrived there were no fluids running.  I had another IV line placed and started fluid resuscitation.  She was already on 2 antibiotics.  I added a third.  She was now on all the antibiotics the hospital had to offer.  She had no central lines for large volume resuscitation and we had no pressors to support blood pressure.  All I could muster was to wipe the pus that was still draining from her abdomen and wave the flies away that were slowly starting to settle all over her body.  I held her hand.  All the while, the rest of the ward, including the woman lying a foot away in bed #2 had to watch this cruel death struggle.

I walked over to the head nurse and said, “She will not make it through the night.  But try your best.”  She nodded.

I told the students back at the hostel what was happening in the hospital.  They didn't believe me at first, “Oh she will be okay.  Don’t worry.”  I didn't say anything.  When we returned the next morning the ward was bustling as usual, with nursing students running every which way and a sea of patient faces greeting us as we walked onto the female ward.  All the beds were filled and there was already a new woman in bed #1.  I glanced at the woman in bed #2 and our eyes locked.  We did not speak the same language but her eyes told me the story of Ms. Khadija’s final hours.

Being an Emergency Medicine physician certainly helps one differentiate sick from not sick and we are pretty good at it.  However, working in a resource limited setting such as Tanzania forces one to take gut instincts to an other-worldly level.  In my previous visits to South Africa, I had heard the sentiment before but could never foretell the events myself.  How did they all know a patient was going to die?*  Here there are no lab tests or fancy imaging or complicated diagnoses to hide behind.  No lactate or white blood cell count or CT scans with contrast.  It is just you and the patient.  And you just know.

*A shameless plug for a previous publication in the Lancet-Student regarding end-of-life-care in South Africa told from a medical student’s perspective:

http://www.thelancetstudent.com/legacy/2010/12/10/doctor-please-don%E2%80%99t-leave-me/

Just Another Day in the Village

After an eventful journey from Nairobi to the Tanzanian border I settled into the sleepy village of Shirati for a much needed respite after 48 hours of travelling.  It took an additional two hours over dirt roads and paths winding through various villages to finally reach our destination.  Dr. Esther Kawira had a piping hot meal ready for me when I arrived.  Her story is remarkable.  She is a U.S. trained Family Medicine physician who married a local and settled in Tanzania 30 years ago.  Twenty of those years she spent running the only hospital in the village and has since opened her own rural clinic serving the underserved population for nominal fees.  It is to work with her and the individuals in the hospital that I have journeyed here.

First a little about the village of Shirati.  When I was trying to research the area I could not find it on a map.  I have since only seen it listed on a single map (blown up to include only this province) which belongs to the local historian.  Homes are primarily mud huts with thatched roofs or made from tin.  The wealthier folks can afford small brick houses.  Small bumpy, dusty roads connect the farms in the surrounding area.  Animals roam freely and still see people infrequently enough to stare intently at you as you pass by.  Whenever I ran through the village, children would cheer and join me from each community of huts, slowly forming a flying-V entourage around me.  It reminded me of the Muhammad Ali movie where the whole town in Zaire started running with him yelling, “Bomaye Bomaye” (“Kill him, Kill him” prior to the ‘Rumble in the Jungle’ against George Foreman).

Shirati’s central area is located by the hospital.  It consists of the hospital compound and then a row of shops and fruit/vegetable stands across the road.  Each shop contains essentially the same 10 items with an occasional oddity thrown in.  These include (in no particular order):  peanut butter, medium fat spread, dilute hot sauce, bread, shampoo, coffee powder, washing powder, and fluorescent orange drink concentrate.  One or two shops have a rare refrigerator where you can purchase “cold drinks.”  Fanta gone wild, flavors abound.  Orange.  Black currant.  Pineapple.  Passion fruit.  There is also a fruit and vegetable stand and some streetside grillers of meat (what I have come to call “danger meat” but can never resist since I love street food).  What you absolutely cannot find is anything dairy related.  No milk.  No yogurt.  No cheese.  I repeat, no cheese.  I can survive without tv, internet, electricity, and other niceties of modern life, however, I do not know if I can survive without cheese.

Our village Gas Station

Fruit & Vegetable stand

'Danger' meat

Dr. Kawira’s new clinic is still a work in progress (no power yet) but is shiny and expansive and the patients have started flocking from near and far to see her.  The pathology seen here is distinctly different from that seen in the U.S. and there are very limited resources with which to diagnose and treat many conditions.  Our rapid testing at the clinic was limited to the following:  HIV, syphilis, malaria (P. falciparum), hemoglobin, urinalysis, and urine pregnancy.  We also had a small storeroom of medications, much of which was donated or procured from Nairobi.  After a few days of training under Dr. Kawira I was set off to run the clinic on my own with a band of medical and PA students.  We had a nurse to translate from Swahili (or Luo) to English.  At our disposal was a stethoscope, flashlight, measuring tape, Doppler for fetal heart tones, lubricant, and gloves, but most importantly our clinical acumen.  No imaging or ultrasound.  No CBC or electrolyte panels. 

Sota Clinic

Our Pharmacy

On my first day alone we diagnosed new cases of HIV, tuberculosis, syphilis, malaria, schistosomiasis, dysentery, CHF, and asthma.  There were a few days when we diagnosed half the patients at the clinic with malaria (of the P. falciparum variety) often with varying and very different presentations.  In addition to these “bread and butter” cases I saw even more interesting pathology including lymphatic filariasis, known more colloquially as ‘Elephantiasis,’ hepatocellular carcinoma secondary to chronic Hepatitis B in a young unimmunized man, and even diagnosed my first case of leprosy.  Acutely ill patients could be “admitted” overnight essentially for observation and treatment at the clinic or they could be “transferred” to Shirati Hospital.  Care in resource limited settings is often fraught with ethical dilemmas.  A typical case follows:

~~~~

Case:  65 yo M PMH CHF (congestive heart failure) and PUD (peptic ulcer disease) presents with pitting edema to thighs, diffuse crackles bilaterally.  Previously treated with Hctz, digoxin, and Lasix but lives in extreme poverty with inability to afford meds and has poor access to health care as he lives several hours away from the nearest clinic.  Still has some Lasix remaining but no digoxin or Hctz.

Physical Exam  

Vitals:  37C  HR 120s  RR 20  BP 200/100

Gen:  Appears uncomfortable and short of breath.

HEENT:  PERRL, EOMI, +conjunctival pallor

C/V:  S1S2 present.  Tachycardic to 120s.  Normal rhythm.  III-IV/VI holosystolic murmur loudest at the LUSB

Resp:  Diffuse crackles bl; decreased air movement

Abd:  Epigastric tenderness.  Mild abdominal fullness.  No rebound.  Mild voluntary guarding.  +Fluid wave.

Ext:  Diffuse 3+ pitting edema to bl thighs

Ethical Dilemma:  This patient would clearly benefit from admission to a hospital with aggressive management for decompensated heart failure.  However, in TZ most care is fee for service and this patient is unable to afford admission to the local hospital.  In fact, he is unable to afford observation overnight at your clinic or even HIV/syphilis tests.  The total cost for overnight observation and IV medications and tests would amount to less than $10.  What do you do?

This was a case that I had on one of the days I was running the rural stand-alone clinic by myself.  This is a common example of an ethical dilemma that may arise during a global health elective.  Diagnostics and therapeutics in this patient would normally be straight forward however the waters are muddied when resources are limited.  Issues raised in this case include resource allocation, poverty, and access to care.  Since it would cost just a few dollars to get medications, tests, and an admission the thought of pulling out a few bucks from one’s pocket immediately comes to mind.  We are fierce patient advocates but must be cognizant of the downstream effects of our actions.  How do you decide whom to help and whom not to help?  Will treating this man for one day change the course of his disease?  There are no right or wrong answers but each case is worth analyzing closely.

In our case, the man was able to afford several vials of IV Lasix (40 mg) which I administered to him prior to his discharge.  I was also able to increase his oral Lasix dose and restart his digoxin and hydrochlorothiazide.  The patient promised to return for admission the following week after he returned to his village and gathered more funds.

Monday Market

Open Air Market

Highest point in Shirati (Aboke Hill)

Coming Soon:  Life at Shirati Hospital

Deadly First Day Back in Africa

And so it didn't hit me that I was actually going back to Africa until the night before I left.  The NSICU was a busy month and left me little time to think about the trip.  The last 24 hours were a flurry of activity as usual with various errands, “procurement” of medical supplies, and packing.  I am heading to Tanzania in East Africa, a country that I have visited before, but am hoping to become more intimately familiar with.  Cincinnati to Paris to Nairobi took about 24 hours.  The company supposed to pick me up at the airport never showed so I hailed a random taxi and headed to my lodging around 1AM.  The guard didn't have my name on the books but I got lucky and snagged the last room for a couple hours of shuteye.  At 6AM I headed to the bus station.  As part of the trip I had been encouraged to hire a private car for the long journey to Shirati in rural Tanzania.  However, it would be about $350 for a single person one way.  I thought this was outrageous (I could probably buy a motorbike and drive myself for less than that).  Perhaps a bit of an exaggeration but I opted instead to take a local bus for $10...In addition to the obvious cost savings, the cross country bus is the usual test for any intrepid foreign traveler and I wanted to see if I could still hang.

The cab driver was skeptical when I stated that I wanted to go to the bus station.  I asked him to drop me off but he refused and said he would take me in personally.  “There are bad people here,” he whispered.  I initially thought this was ironic considering the number of cabbies I had been cheated by through the years.  The bus station reminded me a lot of an Indian bus or train station.  A mass of humanity and chaos.   The driver almost immediately got into a fight as the parking ‘managers’ (none official and mostly self-appointed) did not let him park and forced him into the morass of buses and people in the terminal.  After we got to a dead-end jammed by buses on all sides we turned off the car.  I was about to get out but the driver yelled, “Stay here!”  He locked the doors and scurried away.  He resurfaced a few long minutes later and said he had found a bus.  He grabbed me and started running zig-zag patterns through the crowd.  “Follow me!”  The crushing waves of people surrounded me and the hawkers hit me from all sides.  There was even one guy who pointed and yelled, “Mzungu, Mzungu!”  I was incredulous.  Through all my previous African adventures I had largely avoided such designations.  Despite my nearly native dress and confident walk this guy had found me out.  Mzungu literally means ‘foreigner’ but is generally reserved for individuals of much lighter complexion than myself.  This guy was pretty good or maybe it was the long hair that was the giveaway.  Luckily no one else really seemed to mind.

(aerial view of Nairobi bus station) 

As we approached the bus, I tried to hand the ticket guy a $20 bill (I hadn’t gotten a chance to exchange any money since I had only arrived a few hours prior).  He looked at me like I was crazy:  “We don’t take that.”  The taxi driver started to look worried now.  He grabbed my money to go exchange it for Kenyan Shillings in the back alley:  “Stand right here.  Do not talk to anybody!” By now a crowd had started to surround me and the ticket agent.  There was yelling and shouting and pushing.  I was starting to get nervous.  Just then the taxi driver returned with the cash.  He thrusted it upon the ticket agent and then pushed me onto the bus.  “There are no more seats left.  Do not lose this ticket or they will kick you off the bus.  Do not buy anything.  Do not eat anything.  Do not talk to anybody!  I will make sure your bag gets into the boot (aka ‘trunk’).”  Looks like they saved the last seat for the mzungu.  With that the taxi driver turned to leave.  I yelled after him, “Wait!  What’s your name?”  He looked puzzled.  “My name is John.”  I smiled.  “Asante sana, John.”  He nodded and then hurried towards the loading crew.  I've realized through the years that I often have to implicitly trust many of the people I meet in my travels.  And yet I never cease to be amazed by the kindness of random strangers who go out of their way to help and often protect me.

As I began to walk down the aisle I was intensely aware of everyone staring at me.  My trekking pack did not fit down the aisle and I lifted it above my head and scrambled over various packages, bundles of produce, and the errant child.  Much to my dismay there were no chickens or livestock, always the gold standard for a true local bus.  However the bus was packed and at first I did not see any seats available.  I walked all the way to the back and realized the last seat was on the bench at the rear of the bus.  I climbed over several people and squeezed in between 8 other people (7 adults and 1 child).  There was nowhere to put my back (which contained all of my worldly possessions) so I placed it on my lap.  The windows were shut, the heat was stifling, and I was physically sticking to the two individuals beside me.  I finally felt at home.

It took nearly an hour to get out of the literal parking lot the bus terminal had devolved into.  Buses were pointing every which way and interspersed were random cars, motorcycles, and people.  It took hundreds of back-and-forth maneuvers to get out of the bus station without striking any other buses or vehicles.  The bus ride would take 10 hours from Nairobi to the Kenya-Tanzania border.  From there I would have to get on a jeep to make it the rest of the way to the remote village of Shirati in Tanzania near Lake Victoria.  The additional 2 hours were mainly on dirt/mud roads through various villages.

The bus ride started with what I thought was the conductor getting up and telling everyone the rules of engagement.  I thought this was peculiar since I had never heard anyone giving rules/instructions or even names of bus stops during previous African bus trips.  It was all in Swahili so I couldn't make out exactly what he was saying.  However, he continued on and on, getting louder and louder by the minute until he was screaming.  He had the entire bus in a frenzy and everyone had their arms raised.  I finally realized that he was preaching.  This continued for over an hour until his voice was hoarse and sweat profusely dripped from his brow.  He was succeeded by another individual and then another.  I was beginning to wonder what kind of bus I had gotten onto.  Everyone was in a trance and even the little children had their arms raised.  It felt like some kind of cult.  Bits of English would occasionally filter through.  “Today will be the start of a new life!”  “This is a new beginning!”

This would be a fateful day as in the midst of the sermon we heard a loud crash and the bus came to a screeching halt.  Everyone stood up simultaneously.  I heard murmurs at first and then screams as the bus emptied.  I scrambled out into the midday Kenyan sun.  Immediately in front of our bus, a motorcycle had hit a matatu (mini-bus known by various names and seen across sub-Saharan Africa) head-on.  It had been nearly 48 hours straight of traveling and I was dehydrated and delirious.  It felt like a dream.  Despite the glare of the sun, I could make out a body lying spread eagle in the middle of the road.  It was the motorcyclist and he was clearly dead.  Blood and brain matter were scattered everywhere.  I dragged his body to the side of the road while trying to avoid oncoming traffic.  I then ran to the other side of the road.  At first I couldn’t even see the matatu.  It had apparently struck the motorcyclist, swerved, and tumbled off the ravine to the side of the road.  I was horrified.  I had taken such vehicles innumerable times in the past across several countries.  They are generally stuffed to the brim with people, as many as 15-20 at a time.  While usually uneasy when travelling in one (the drivers are generally erratic and speed mercilessly), I routinely do so because it is exceedingly cheap and is the mode of transportation for the common man.  

 (typical matatu)

This particular matatu had rolled off the side of the road and lay about 20-30 feet vertically down in a ravine.  It had tumbled through thick brush and was lying upside down.  As I got closer I could hear the wails of women at the edge of the road crying in despair.  I pushed through the crowd that was quickly forming and started climbing down.  It was incredible to see how quickly people came together to help.  Women who had been working the fields came with machetes and began to cut a path for the men.  As we made our way down the scene turned even more grim.  There were additional fatalities and bodies were strewn everywhere.  We began to carry each bloodied and mangled body up towards the road.  In addition to the dead there were several critically ill passengers.  I quickly began to triage in my mind.  Several black tags already.  Several ‘green’ tags.  One man had clearly broken both legs.  He calmly looked at me, his eyes pleading, and asked, “First aid?  Please?  First aid?”  I put my hand on his shoulder and said, “Please wait.  Help will come.”  In fact, I did not know if any help would come.  I moved on to the ‘red’ tags, critically ill people that had a chance to survive with appropriate intervention.  There were several people that were minimally responsive or altogether unresponsive, likely with severe TBIs (traumatic brain injuries) or intra-thoracic injuries.  Blood was pouring from scalp and other wounds so I had bystanders hold pressure.  Another man was gasping for air as blood was pouring from his mouth.  I didn’t have a stethoscope but he potentially had a pneumothorax (collapsed lung) and or hemothorax (blood in the chest cavity).  In fact I didn’t have any supplies whatsoever.  The motorcyclist could have used a thoracotomy (cutting open his chest) since he was found pulseless within a minute or two after blunt trauma.  All the critically ill likely would have been intubated (with breathing tubes).  The man with the pneumothorax could have used a needle decompression or finger thoracostomy (cutting the chest to relieve pressure from the collapsed lung) and chest tubes.  Many of these patients would have been helicoptered to level I trauma centers in the U.S.  Instead here they were languishing on a rural Kenyan road with no EMS system and no help in sight.  I was reduced to assigning GCSs (Glasgow Coma Scores).  Despite all my years of education and medical training, I felt completely and utterly helpless. 

In the midst of despair the situation somehow worsened.  The crowd surrounding us had enlarged and was growing angry.  They were trying to stop vehicles and buses to help transport the victims as I presume they knew that no ambulance was going to come.  They started banging on cars with windows and windshields beginning to shatter when people refused to stop.  Our bus driver, fearing the growing mob, began to drive away.  All the passengers who were milling about ran after the bus.  Suddenly I was faced with a horrifying split-second decision.  Do I stay or do I go?  In my haste to get to the accident scene, I had left everything on the bus.  I did not have any money, my passport, or a phone.  In fact I had no idea where I was (some 4 hours away from Nairobi and still 6 hours away from the border) besides being somewhere in the rural Kenyan countryside and I did not entirely know where I was going...

...There were again stares as I walked down the aisle (as the bus sped away) but this time it was because there was still fresh blood dripping from my hands and clothing.  I slowly returned to my spot at the back of the bus with a sinking feeling in the pit of my stomach.  I looked out the back window and could still see the blood stain in the middle of the road from the motorcyclist.  I could also see the victims I had left behind, perhaps to die?  Waves of nausea struck me and all I could do was clutch my face in my hands.

Today I failed not only as a physician but also as a man.  Hopefully tomorrow I will do better.