KCH in the time of COVID
This is my 25+ trip to Malawi, my home away from home. I don't know why this year I decided to keep a diary of my daily activities and interaction with trainees and staff. I do mention the doctors by name as it helps me to remember them...working with trainees give me hope and joy both in the US and Malawi.
July 5 - Ethiopian airline, flight 3/4 full, masks not well enforced, little sleep on the plane, watched Just Mercy and Sherlock Holmes
July 6 - arriving at Kamuzu International airport; got letter from Dr. Ngoma, immigration was relatively smooth, long wait for luggage but no complaint from me, just relieved that we got through immigration as the border is closed. The health officer accepted the Lucira COVID test as PCR equivalence.
July 7 - back at KCH, no major change except that nurses, clinicians and staff are all masked. Patients and guardians so so. Rounded with intern Dr. Zai Matemvu. She is quite "switched on," very motivated and hard working. Also met pharmacist Davie Milambe. Several CO students joined us on round.
Memorable patients - seemed like there is an epidemic of pancytopenia. 19 yo girl with history of hematemesis before age 10, has splenomegaly so I'm thinking portal hypertension, chronic liver disease, ?hep B and now pancytopenia. A hematologist reviewed her blood smear and thought that ther were "bizarre lymphocytes" suggestive of lymphoma. This does not fit...need bone marrow. A middle aged woman presented with weakness, tachycardia, dizziness, reactive, +LAM, low CD4, on TB treatment, CSF studies neg, CrAg negative, bilateral pelvic mass, described as necrotizing on ultrasound, been on Cef and metro for almost 10 days, continue to have fever, becoming more unconscious and hypoxic...inquired about blood cultures (yes available, find the bottles...) and pharmacy does have meropenem for special case
July 8 - rounded with intern Dr. M Madalo. She is on the quiet side, loves to learn, very kind to her patients. Got her to round with the GHII lab cart. Rashid helped with password and trouble shooting. The system allows clinicians and nurses to register, print out a bar code to put on the specimen bottles and lab results could be retrived electronically. Some quirks but overall a good system. A woman admitted for meningitis on Cef with little improvement, has the stiffest neck I've seen. Could not find spinal needle and lidocaine, used needle from an IV catheter, the patient kept still while screaming and grimacing. I offered my hand for her to squeeze and squeeze very hard she did...
July 9 - rounded with intern Dr. Frazier Kumwenda. He reminds me of me as a trainee, willing to do whatever however it takes as dictated by patients' needs. We drew blood, chased results, started IVF, adjust oxygen, put in foley for a patient who supposedly refused a catheter and his guardian is certain that he has urinated everyday, found large bladder on exam up to umbilicus. We rounded non-stop from about 9 to 1PM. Couple patients admitted for convulsions without prior history and nonreactive, now better, how detailed should the work-up be (head CT, LP)? If they are better, should we just let them escape from the congested konde, avoiding COVID, TB exposure and pursue more investigation the second time...if we are given a second time. One man, reactive, dx with TB in Feb, took 3 months then stopped, thought that his skin darkening is related, now back with coughing, CXR is c/w prior TB as well as new infiltrates and potential cavitary lesions. Hypoxic to the 70s without oxygen, can't discharge on TB meds yet. He is on a tank, not sure why. Hospital floors are dusted with little oxygen concentrators, thanks to COVID. No home oxygen though...he will remain on the ward for a while. I usually go on a "diet" when working at KCH... just a little bit of coffee in the morning, no breakfast and no fluid until I get home...as not have to use the bathroom for 6-7 hours (why you ask, hard to find a working/clean bathroom and remember to bring your own toilet paper). Did manage to figure out the butterfly for POCUS. It seems to take a while to get started without internet connection and after couple updates it seems to behave appropriately...so that I could see a RLQ mass in a man who is already ravaged by some form of cancer. Found a little ascites pocket to tap but what is the point, can't do cytology, protein...he is chronically ill, no e/o SBP...I'm bordering on clinical apathy.
Weekend reflection - Brady and Gingras in their call for pedagogy and praxis in teaching social justice in health professions education mentioned barriers to prevent health professions students to be able to address the impact of social and structural injustice, such as disciplinary and regulatory standards, time constraints...curricula dominated by positivist/reductionist health sciences..."tell me what I need to know" learning culture and horizontal violence...individualistic downstream practice...discourage critical thinking and penalize nonconformity. Horizontal violence is defined as any “hostile, aggressive, and harmful behavior by a member of a healthcare team toward a co-worker via attitudes, actions, words, and/or other behaviors.” I certainly see all of these in the US, wonder what role do they play and impacts in Malawi. Do trainees think in terms of social and structural injustice or does the day-to-day demand drown out attempts at reflection and question? For me the act of rounding on the wards is witnessing (if not acting out) social injustice. I ask myself, what are my roles and responsibilities in creating safe learning environments in which students may learn about, but not be paralyzed by the enormity and complexity of social injustice? Learning environment? it's an unaffordable luxury here in Malawi.
Had dinner with Alberto and Trish. Alberto is an orthopedic surgeon (Italian/Scottish background) and Trish is EM physician, both have worked extensively in Africa. Alberto's organization has donated money for the OpenO2 project.
July 11 - did round in the HDU with Frazier. New/progress: oxygen is piped into the bedside now, no tank or oxygen concentrator needed. Each bed has vital monitor. Saw a patient with sickle cell crisis, age 51 (that might be the oldest person with SCD I know in Malawi, perhaps SC?). She was in severe pain, chest, abd, on O2, lungs with bilateral crepitus, abd with hypoactive bowel sound, tender/guarding but not rigid, no splenomegaly, no RUQ focal tenderness, had n/v earlier. She is getting morphine po 2.5 mg (I suggested increasing to 5 mg), had difficulty getting pethidine so Frazier called pharmacy to inquire. She probably has acute chest, had CXR but again we can't view without a monitor. Hb 7+ on admission. I think LFTs were not too bad. Abd pain could be from vasoocclusive process, pancreatitis, PUD, cholecystitis...Someone put in a triple lumen and the staff is not very familiar with how to use it, not sure if they could only use one lumen and not the other 2...been a while since I personally flush CVL.
Another curious patient, 15 yo girl, transferred to KCH for a week of fever and convulsions 2 days PTA, note said prior history fo headache. BP 185/127 on adm, started on artesunate, cef, and nifedipine prior to transfer. Day 3: BP 146/97; P 102; arousable, able to answer questions, dry cough noted, nonfocal exam, no pedal edema. Urea 190; crea 10.8; (hydralazine was added); FBC is relatively unremarkable, plt 126, hb 12, wbc 6.1, COVID xpert (-); MRDT (-) malaria. Got head CT on July 9 ?with contrast, I think it was before U&E is back. The outside hospital has concerned about brain tumour/SOL. There is slt dark yellow urine in the bag (not sure when it was last emptied), no u/a yet. I'm thinking did she have a malignant (secondary) cause of hypertension like congenital renal/urologic abn, aortic coarctation, renal artery stenosis, fibromuscular dysphasia (rather than primary hypertension) manifested as hypertensive encephalopathy with headache, seizure? I forgot to check pulses and BP in both arms and legs; renal u/s is pending but need to ask the ultrasound tech about doppler, repeat U&E (she inadvertently got contrast), nothing to suggest HUS, glomerulonephritis, vasculitis, lupus...as primary problem with secondary hypertension. Pheo and hyperaldo less likely. She does not "look" hyperthyroid or Cushing's. Still can't explain fever, we stopped artesunate (very common to empirically treat for malaria), she is afebrile now...had 2 processes going on, less likely...I wonder about her schooling and future...
July 12 - Monday is always hard because most patients are not seen over the weekend. Rounds tend to be more chaotic. It's just me and Moyo on the male side (and 4 clinical officer students, very fresh, they tried to help as much as possible). There are new admissions who are not known to us. Lab results not back. Blood work ordered in the note but not done, Ceftriaxone for everyone. Just have to take a deep breath and say to myself. Things are good right now with lab in full capacity, CT scan working, oxygen available and decent staffing!!! We spent a greater part of rounding drawing blood. This means you have to get the patients registered to get a QR code on their health passport then order in the system (Tim, Gerry and team created this OERR system), draw blood, get bar code sticker on the tube. Patients are incredibly tolerating, one got stuck 3 times by students, one time by intern before they handed over to me. To order CXR, CT or ultrasound, you have to fill out a form then give it to the guardian who will go to xray department to book a time. Because we are out of film, to view cxr you have to go to radiology to look it up on PACS. I miss holding the film up to the sunlight! perhaps it's quintessential "Africa" the only time I could walk to the balcony, look up to the sky and sniff some fresh air to see a cavitary lesion on a CXR:)
2 patients stuck out in my head. One is a 34 yo man dx with HIV last year, not yet on ART, presented wiht jaundice and lethargy. U/S showed e/o cholecystitis and a ?large LN compressing the CBD? queried abd TB? LFTs are c/w cholestatic picture but creatine is 10.7 and Urea 249, making some urine. Starting TB meds might be tricky. I think he will die soon. For all these years, I have not managed to convey how sick a patient is. The guardian could speak English so I said his kidneys and liver are failing, he is very very sick. In my time at KCH, I have never heard any clinician telling pts and families that they are going to die or we don't have any treatment left or they have limited time left, not part of the culture here. If this patient had been in the US, we could dialyze, do ERCP or PTC, buy him more time but the outcome is probably the same?
A 40+ yo man, nonreactive, treated for TB from feb to may this year, stopped taking meds because of skin darkening (he could have a drug reaction which healed causing the skin to have hyperpigmentation?) presented now with productive cough and cavitary lesions on his cxr. We started him back on TB treatment. Pulse ox is 77-80% on RA so he can't go home until his O2 sat is in the upper 80s I think (no home O2 here). I don't think TB meds will work so quickly and he probably would need to stay in the hospital for another 1-2 weeks? The ward is congested and although we try to test as many suspect patients for COVID as we could, an outbreak might be hard to prevent...It's 7:55PM and the dogs are howling, so far they start between 7-8PM, at least it's not in the middle of the night.
July 13 - mostly meetings today, got to see the COVID ward, has 27 patients. The hospital is renovating 2 additional wings for COVID (in case it's needed). The dept is collecting statistics on BID (brought in dead). I guess you can look at it as a series of delays, delay getting treatment, delay with transportation, seeing traditional healers first, denial, etc. but I have often wondered about BID as a last ditch effort, a final show, even when we know it's the end, just don't let this person die at home...Gerry is proposing to link 2 oxygen concentrators together to deliver high flow oxygen instead of oxygen cylinders, particularly for those patients who are only on 10-15L, to preserve the cylinders for those sicker patients?
July 14 - met with a lecturer from the CoM who is based at KCH, Dr. Emanuel. He has already written up 2 proposals--one to characterize patients presenting with DKA in Malawi and their outcomes and the other one is on ECG of DM/HTN patients to look for incidence of ischemic heart disease or arrhythmia as A fib (remember no stress test, no cath, no PCA here). The GH residents and alumni at UPMC have donated about USD 3000 toward COVID relief effort and we are putting the fund toward research and quality improvement projects in the medical department.
An elderly man presented with wasting, cough, SOB, has decreased BS left lung, sating in the low 90s, ordered sputum for AFB, cover with Cef, the usual, took 2 days to get him down for CXR, got it monday, went down yesterday, could not find his film in PACS, This morning he was hypotensive, we hooked up normal saline and continue our rounds. Went down to radiology after rounds, again to search his xray in the system, whole left lung is white out, large mass, pleural effusion? ran up to see him and he was already pronounced dead. Could we have done something if we got the xray sooner? There are at least a few deaths a day in the medical department. I'm still not used to the wailing and crying by family members. The hospital is built with an inner court yard and inner/outer balcony (I think) to amplify the sound and echo the weeping and despair that go on each day. One does get used to it?
July 15 - the number of admissions have come down and there are now some empty beds. I was told that this was what happened in the second wave. Patients are staying away from the hospital for fear of COVID. The number of patients in the COVID unit are also going up. Update: the young girl with ?hypertensive encephalopathy and renal failure is now in the ICU, developed pulm edema and is supposed to be dialyzed today. There are 2 patients in the 30-40s with SC crisis in the HDU, a bit unusual, I do think patients with SCD are living longer in Malawi now. 3 admissions came up to 4B just as Madalo and I were leaving. They all had respiratory symptoms and negative rapid test, had to send them for Xpert which only takes about 1 hour to come back (in Malawi you multiply time by 2-3X to get real time). I went to check out the new cancer center next to KCH, very nice and airy. I was also looking for a middle-aged man with a RLQ mass that the CT read as ?lymphoma so someone discharged him to the oncology unit I was told. I searched for him everywhere but he was not at the cancer hospital. Could they have discharged him home? I'm not convinced that this is lymphoma without biopsy.
July 20 - in a place where there are so many deaths and suffering everyday even before COVID then COVID is just another one on the list. A 30-yo something man admitted for seizure with history of alcohol use (disorder), he also had a cough so COVID PCR was done. He was in the ward past 2-3 days and result finally came back positive this morning. O2 sat was 91% on adm and now 84%. He is not visibly in resp distress. We asked for him to be transferred to the COVID ward (granted you have to go down 4 flights and go across hospital ground to the eye dept where the COVID ward is) but initially we were told (by COVID clinicians) that patient is too well so should be discharged and we told them that he cannot be discharged because his sat is dropping so several hours later, 2 people came all geared up to take him. I understand that they are swamped on the COVID ward. The patient himself refused to put a mask over the nose and his guardians did not seem to understand the issue. None of the patients and guardians surrounding him seemed to be alarmed. The CO student rounding with me did not seem to mind kept engaging the patient even when I advised him to keep physical distance from that patient. Life goes on.
July 21 - a 30+ woman seronegative in the HDU presenting with viral symptoms, mental status change initially and acute renal failure followed by ischemic digits (hands and feet), anemia, thrombocytopnia. She has had some dialysis sessions. She also had a number of blood work done at a private lab (including negative ANA, ANCA? TSH). I only heard about her during handover and got to see her briefly. Most of her digits are blackish with some bullae more proximally on her legs but I did not see ulceration. The bullae might be secondary to leg swelling. The team is thinking vasculitis and has started her on prednisone. I wonder about TTP (would be atypical with ischemic digits and renal failure) or primary/secondary APS. Did not get to inquire about Raynauds, dysphagia, pulm htn, etc. The labs here are not reliable unfortunately. The team is contemplating starting cytoxan. We don't always have rituximab and definitely not plasmapheresis. She won't have a good outcome I'm afraid. Rheumatologic conditions might be the last specialty to get recognition/support in places like Malawi.
Differential diagnosis of splenomegaly in the tropics
| Infection Hyper-reactive malarial syndrome (HMS) Schistosomiasis (Schistosoma mansoni) Chronic hepatitis B with portal hypertension Miliary tuberculosis Brucellosis Splenic abscess Visceral leishmaniasis Other Splenic metastasis Splenic cyst | Haematological Lymphoma (non-Hodgkin's lymphoma and Hodgkin's disease) Tropical splenic lymphoma Leukaemia Myelodysplastic syndrome Thalassemia Polycythaemia rubra vera |
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