Catch-22

25 Nov 2008:

Today, like last Tuesday, we headed for the airport to join Dr Caldwell on a Red Cross flight as part of a community outreach effort to help provide health care to more rural areas of KZN (KwaZulu-Natal, the province that Edendale is in). While the skies were again overcast, the clouds were higher this time and the rain less, so we were able to get off the ground, unlike last week.

The trip (to a small town hospital in Dundee, northern KZN) was memorable. We (Dr Caldwell, Rachel, I, and a general internist from UC-Davis doing a sabbatical at a TB hospital near Durban) accompanied one of the two medicine residents at this underserved hospital on his rounds through two different wards for which he was responsible (probably a total of 50 patients). From what I gathered, it was at least the only time that week that he would see an attending-level MD for advice, and possibly the only time in a month. He presented what he knew of each patient, we put together what we could from the chart, and we made what recommendations we could, anything from tweaking medications to suggesting more diagnostic tests to recommending transfer to Grey’s or another similar “step-up” hospital.

At every point, our input (very much including that of Rachel and myself) was valued, and it really felt like we were making a contribution to the care of the patients there (a feeling I have only occasionally have gotten at Edendale, for various reasons). We started on the women’s ward, which was teeming with sick patients. The first one we saw was 30 yo, HIV positive, with an enormous mass in her left hip that, on X-ray, had eroded nearly all of that side of her pelvis and caused tremendous pain. Apparently she had had this mass for a year, went to a hospital in Jo’burg 6 months ago for a biopsy, but never followed up as instructed in clinic; several days ago, the pain became unbearable so she came in to the clinic. The list of possibilities here is quite short (summarized by Dr Isaacs, the UC-Davis doc: “1. Primary bone cancer, 2. Primary bone cancer, 3. Primary bone cancer"). We added TB to the list, just to hold out some hope of recovery, but TB doesn’t usually do this to bone; her left hemi-pelvis was entirely absent. We advised that as usual in these cases, “tissue is the issue”, so the resident planned to arrange for a surgical biopsy and transfer to Gray’s for whatever orthopedic stabilization of the joint might be possible for palliation. He was also going to try to track down the results of last year’s biopsy, but nobody was too optimistic that we would find anything. We saw a handful more patients on the women’s side, all of the ones he was having difficulty with, then saw a few more on the men's ward. For each one, we had some type of intervention to suggest, most of which I am hopeful will actually be of benefit.

The workup at a hospital like this proceeds at a VERY different pace than I am used to in the US. Especially in these rural settings, lab tests take days to come back, imaging studies (except for plain films) take a week to arrange, any more specialized studies (biopsy, MRI, even many consults) require a hospital transfer. In the meantime, all that is left in the absence of diagnostic certainty is to treat empirically for many possibilities. What this does to drug resistance among local microbes is concerning, though in truth, we in the US see many more problems with multiply-drug resistant bacteria (though obviously TB is a different animal here…). Also, with fewer interventions available, the number of things one does for a patient are fairly limited, so it seems that really, we scratch our heads and check HIV status, start empiric TB treatment and antibiotics, occasionally antiepileptics or antifungals, decide between fluids and diuretics (though a disconcerting number of times people here are on both), and wait for things to evolve. Not always, but often. One of my favorite quotes about medicine is from Voltaire; to paraphrase: the job of a doctor is to entertain the patient while time cures his illness. Here, the docs have less tricks with which to entertain, but the patients are certainly used to waiting longer without active entertainment. And I would amend the quote to say “while the disease runs its course”, because certainly time does not cure all the things seen here.

Another issue that arose here that I somehow hadn’t focused on before was the Catch-22 that arises when a patient is uncommunicative due to altered mental status from a sequela of HIV/AIDS. By South African law, a patient may not be started on anti-retrovirals without completing counseling and a course on how to reliably take their medications. This is a public health measure to reduce the chances of sporadic medication adherence leading to viral resistance to the affordable medications. It seems to be quite effective; it is pretty amazing to me that the entire nation seems to treat HIV with only three first-line regimens (Ia, Ib, and II, each of which is a three-drug combo of fairly common agents). We encountered a huge downside of this policy, though: a young patient with advanced AIDS who had not been started on ARVs before for whatever reason, who was now too confused to participate in counseling and classes. By law, we were not able to start her on ARVs (even in the hospital) because of her clouded mental status. But without these medications, she will never regain mental status (whereas with them she might have some, admittedly perhaps slim, chance). Difficult trade-off; I’m glad I’m not the one making decisions like that.

This hospital had many more female than male patients. Probably because Edendale always runs at capacity on both sides, I have not noticed this trend there. In thinking about why, I asked about the HIV prevalence among men and women in South Africa; sure enough, infection rates are much higher among women. I suspect (though I can’t recall statistics on this) that the US has the reverse rates. The ratio in South Africa makes good biological sense in a culture where heterosexual transmission is the norm; females are statistically much more likely to be infected during heterosexual intercourse than are males. Still, I find this difference between the US and Africa interesting: why is it more established in heterosexual populations in Africa than in the US? Conversely, why does the US see more homosexual and IVDU related infections? Or am I mistaken in my assumptions; is my perception simply a result of stereotypes in the US that have broken down or never existed in Africa in the face of the overwhelming, undeniable disease burden?

When all the problem patients were seen, we gathered with the local housestaff for lunch and an impromptu teaching session led by me on sepsis management. It was loosely based on a talk I'm preparing for the end of my Edendale stay, but I wasn't forewarned, so it wasn't all that organized. Luckily, I'm a ham when I need to be (the ludicrous length of this blog is proof enough), and the residents got engaged, and Dr Caldwell and Rachel pitched in, and it was very well received and, I'd like to think, helpful for them. After this, we looked at a peripheral blood smear from one of the patients we had seen earlier (no blasts!) and headed back to the airport to wait for the plane. Turned out the weather in Pietermaritzburg was "on the deck" (read: bad), so we had to divert to Durban and get a ride back to PMB; the evening ended later than we're used to here (back home by 9 pm, again through the nightly rain and mist).

On the plus side, I got a good chance to read a book I picked up here, one I've read long ago: Cry, the Beloved Country by Alan Paton. It is beautifully written; I remembered this in abstract but had forgotten all of the particulars of both the writing style and the story (which is good when one is rereading a book!). Like when I read "Dharma Bums" on a solo backpacking trip in the California Sierras, it has been particularly moving to read it so close to the place where it is set (I drove past a road to Ixopo today, as well as on Alan Paton boulevard - Paton was born in PMB). The writing style is in parts simplistic and in parts beautiful; it reminds me of "The Old Man and the Sea" in some ways. As I have learned a handful of phrases in Zulu, I am able to appreciate the dialogue between the Zulu characters (written in English, but with Zulu turns of phrase) more... much like, I think, Hemingway used direct translations of Spanish phrases into English. Anyway, I finished more than half of it today and can't wait to finish the rest. Can't recommend it enough to anyone who hasn't come across it.