TIA

14 Nov 2008: TIA

First of all, thanks to everyone who’s commented and encouraged me to keep writing; I still feel like I write too much but I’m glad to hear that people are enjoying it. That makes me more likely to keep doing it. I have a lot of medical stories from Friday in the hospital that I feel like sharing, mostly because they are unusual compared to what we see in the states. But I am aware that one of the less charming traits of a med student and/or physician is to overuse medical stories, so here’s what I’ve decided: I’ll start today’s entry with my general reactions to the day in the hospital, and then I’ll indulge myself in some of the medical stories. For the non-medical types who are following, forgive me. I will try to explain as much as I can, but feel free to not read that part.

I learned a saying during my travels from the good folks at Buccaneer’s Backpackers in Cintsa: “TIA”, which stands for “This is Africa”. They use it often and in many circumstances; one example is when a guest might ask about a certain amenity that is not available, or if there is an extended power outage… TIA. I must say, it is a phrase that has never been far from my mind since I first set foot in Edendale Hospital; at no time am I able to forget it. It can be a reaction to nearly every situation I have encountered. In fact, I think it can even become a crutch that could prevent one from trying to act, though the benefit is that it helps one to retain one’s sanity in some ways when reacting to conditions that are sometimes hard to fathom.

One interesting theme that came up during discussions today was how disparate the conditions are at different hospitals in the same country. The public-private divide is tremendous, as I discussed yesterday (“chalk and cheese”, remember? Janina set me straight; I had reversed the order). But even within publically financed hospitals, there are considerable differences from what I hear. Edendale is one of the most resource-poor of the hospitals in South Africa, I gather. Before I leave I plan to visit a couple of others and will have more basis to evaluate this claim.

Even more, it is amazing how resources are distributed not just within the health care system but within the nation. South Africa is hosting the World Cup in 2010, and massive financial and manpower resources are being sunk into stadia to host these games: in Durban, in Cape Town, in Port Elizabeth, and in other cities as well, huge fields are being built to host the world’s favorite sport. They hope to recoup some of their investment in tourism dollars, but in the meantime, hospitals like Edendale feel the crunch. Edendale has been told that they are “over budget” as a hospital, so many supplies are limited and will not be refilled. Even the equipment for basic procedures such as lumbar punctures (aka “spinal taps”… by the way, done an estimated 10 times per night by the two admitting interns, with over 50% positive) is often lacking. Many people here feel that the real reason the hospitals are being told they are running over budget is that money is being diverted to finance the World Cup stadia (which are also 2-fold over budget, to the point that the local papers are calling FIFA “bullies”). It is probably not a stretch to say that people are dying every day because of this distribution of resources. And nobody will use these stadia once they are complete… Not to mention that even if some of the cost is recouped from tourism, I doubt too much of it will be funneled back into health care in settings like Edendale.

At this morning’s intake meeting, one of the hospital administrators attended as a guest. He requested a few minutes at the end of the meeting to give a pep talk to the housestaff. He basically said that he recognized that times were tough, worse than at this time last year. To paraphrase, he said, “Trust me, things were much worse 20 years ago, so knuckle down and do the best you can with the system and resources you have in front of you. Just think of the patients, and do your best for them, and don’t worry about what you can’t control.” The whole thing came off from my perspective as much more depressing than rousing or motivating. I was reminded of Animal Farm: he wanted everyone to be Boxer (“I will work harder”), and he spurred everyone on by reminding them how much worse things used to be in the bad old days. TIA.

Warning: now for the medical part (with translations into plain English as best as I am able)…

I spent the morning tagging along with one of the interns, reading charts as she checked in on the patients, and discussing the management plan with her after I got to know a bit about the patient. The first interesting case we saw together was a young gentleman in his 20s who came in with 3 months of headache followed by one month of lethargy. He had reportedly been diagnosed with tuberculous meningitis (TB infection of the sac that holds the brain and spinal cord) several weeks earlier at another hospital, but we had no records of how this diagnosis was made. All we knew was per the family, he had been told to take TB medicines, which he had reportedly been doing for about 3 weeks. When I met him, he was looking better, apparently (i.e., not as lethargic). He spoke a little English and was clearly interactive, though not exactly sharp; this apparently was a big improvement from the day before when he was admitted, at which point he was barely responsive. An LP (aka spinal tap) done on admission, though, was completely normal (no white blood cells, normal levels of glucose and protein), so the TB team didn’t think it was likely to be tuberculous meningitis after all, since they didn’t think the spinal tap would become normal that quickly after starting treatment. His gaze looked disconjugate to me, and I suggested that we take him through as much of a formal neurological exam as we could (we got a Zulu-speaking nurse to help us). It was immediately obvious that he was unable to look to the left with his left eye, indicating a problem with his 6th cranial nerve on the left side. This cranial nerve courses through the brainstem, suggesting that he had a lesion there (a somewhat alarming place to have one, since critical things happen in the brainstem). He may have also had a slight facial droop and slight deviation of his tongue when it protruded. He also clearly had left arm weakness, both proximally and distally. It was impossible to tell how long he had these symptoms; he could not tell us and an exam from admission the day before did not include a clear neurological exam. The best clue we had is that he did not report dizziness or double vision despite his disconjugate gaze; this suggests that the process is not acute (though it could also mean he was too confused to report such a symptom, or that something was lost in translation). I asked the intern why she thought he had improved from one day to the next; she wasn’t sure. We looked back at what they had treated him with: only the TB meds (which he had been on for 3 weeks already with progression of his lethargy during that time; this didn’t seem likely), steroids that had been started on admission, and ceftriaxone, an antibiotic in case of bacterial meningitis. Given the lack of fever and (especially) the normal spinal tap, bacterial meningitis was vanishingly unlikely. So the only treatment to which we could ascribe his change in course was the steroids. The intern was happy to see him better; I was concerned, though, since steroids decrease swelling (probably explaining his improvement) but do not actually treat essentially anything that could be causing his symptoms. In fact, if it is an infection causing these symptoms (as is most likely), then in the long run the steroids will make it harder for his body to fight the infection. He needed them, I suspect, since his lethargy was probably caused by brainstem swelling that was affecting his level of consciousness, but at best this is a temporary stop-gap for a problem that needs definitive treatment. The things I can think of to explain his symptoms are TB meningitis (treatable, but he’s been on the right treatment and worsening), and three things that presuppose that he has HIV (we can’t test because he hasn’t been able to consent; even in Africa, though impressively not in California, HIV tests require patient consent): PML (progressive multifocal leukoencephalopathy, a brain disease caused by a virus known as JC virus that attacks severely immunocompromised people; would be treatable with HIV therapy), cerebral toxoplasmosis (treatable with antibiotics), or brain lymphoma (much more common in HIV; treatment would be very difficult, particularly in Africa). I’m sure there are other possibilities I’m missing. What he needs is an MRI to help with diagnosis, but hey, TIA. The nearest MRI is in another town, and the hospital that has it is not accepting transfers this week because of a bed shortage caused by construction in their cardiac and neurology intensive care units (which means, by the way, that anyone in this region that has a heart attack or stroke requiring ICU level care basically dies while the construction is happening; this is the only cardiac ICU anywhere nearby). He could have gotten a head CT, which is poor for showing the brainstem but might be able to locate and help identify a clear brainstem lesion, but again, TIA. Edendale Hospital’s only CT scanner has been broken since yesterday, and might be fixed by Monday at the soonest. He cannot be transferred because he does not qualify as an “urgent” CT, essentially because he is now too awake. So instead, his only diagnostic test is my imperfect neurological exam and partial knowledge of neuroanatomy and likely distributions of the various possible diagnoses that I can think of. Since Neuro consultants only visit this hospital on Wednesdays, I called an overseas consult by emailing Michael Wilson about the case. Left to my own devices, I still favor TB. We may never know; for all I know he might be dead before Monday when I return. TIA.

The broken CT scanner actually had quite an effect on patient care. One gentleman in his 50s who came in with abdominal pain, found to have a belly riddled with TB but also incidentally found to have a renal mass that did not look like TB on ultrasound, was discharged home on TB treatment and told to come back in two weeks for a CT to characterize his renal mass; hopefully by then the scanner would be working again. Other patients who were relatively well but awaiting a scan were similarly sent home. Those who were not well enough to be discharged but needed scans were just sitting around waiting. “Urgent” scans could be obtained by hospital transfer, but again, to qualify for an urgent scan, you had to be kinda, but not totally, comatose: too awake and you weren’t urgent (no matter what the clinical situation), but too comatose and you were too unlikely to recover no matter what the scan showed. This rule even affects scans within the hospital when the scanner is working; a man with new onset blindness earlier this week was put in a queue rather than getting a same-day scan because he was too lucid; when he became comatose the following day, he was scanned and cerebral toxoplasmosis was finally diagnosed with a 3 cm mass in the occipital lobe, the part of the brain that controls vision, that was causing swelling that had ultimately caused his depressed level of consciousness. He was treated and improved, thankfully; he can now see again.

Later in the day, I went down to the ED (“Resusc”) and saw a woman who came in with several months of worsening headache and focal seizures. She had seen a doctor in clinic about the headache a while ago, and he had recommended a painkiller. Shortly after this, she began having seizures at home, but she did not seek medical attention again for several weeks until her family insisted. I saw her have three seizures in about 30 minutes; each time we gave a medicine (diazepam, or Valium) to help stop them. This knocked her out for a while, but when she awoke again, she would begin to seize again (rhythmic left-sided facial twitching and deviation of the head to the left). The most common cause of new-onset focal seizures in this part of the world is cerebral toxoplasmosis caused by HIV. She had no known diagnosis of HIV, but she is probably about to get one. Incidentally, she is also diabetic (recently diagnosed) and had a sky-high glucose and ketones in her urine, indicating that her diabetes was raging dangerously out of control as well, possibly because of this infection. Yet again, she very much needed a head CT to help with diagnosis. I discussed the patient with one of the good attendings I’ve encountered, and he was going to call over to the neighboring hospital and argue as best he could to get her transferred for the CT. If that didn’t work, we would just start treatment for cerebral toxo, test for HIV, and hope we were right. We also gave her insulin and fluids to help treat her diabetes, and started her on a longer-acting medicine for seizures. I left for the weekend before this case was completely sorted out; I had to go pick up the other resident at the airport. It was not without a hefty dose of guilt that I stepped out of the hospital, to return on Monday. The patients will see no doctors over the weekend. TIA. Some people refer to the weekend as a “stress test” for the patients; if they survive, you know they weren’t all that sick…

I will spare you some of the other cases I saw, but suffice it to say that nearly every one was managed differently in fairly major ways than I am used to. But still, it is fun to engage people in discussions about the patients, because (a) I think it is a valuable part of patient care that does not always happen, certainly not every day with every patient, and (b) it reminds me that at some level, medicine is still medicine; the diagnostic thought process is similar even if the steps you are able to take are different.