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:

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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