Sunday, March 28, 2010

Of death and dying, ICU, and codes

The ICU on the medical ward is located in the middle of the single long hallway, directly across from the nursing station. The ICU has 5 beds total, 3 of which have monitors. One never forgets any first deaths: during medical school, in residency, and now in Liberia.

It was my 2nd week in Liberia when my colleague and I were curbsided by the ED intern, who asked us to evaluate a septic patient. The man presented with history of several days of abdominal pain. Other than that, we knew nothing else. Altered, dyspneic, and deteriorating in front of us. Agonal breathing, apenic, pulseless. ACLS started. Crash cart. Respiratory therapist called. Epinephrine 1mg iv x1. Pulse regained! Attempted intubation...unsucessful after multiple attempts. continued ACLS protocol...must have been almost 1 hour+ of trying to resuscitate this young man. Finally called it. The wife was asked to return to the ED. When she heard the news, became hysterical, in shock, and began wailing uncontrollably and started singing a (mourning?) song.

If the patient survives even triage in the ED and make it to the medical ward or ICU, the chance of survival still does not increase by much. Patients are given time to declare themselves, for which way their bodies have already determined to take despite us throwing antibiotics, fluids, diretics, and other medicines at them.

Overall, ICU is a challenging place. Mainly, the patients who have survived the ICU have been DKA patients. Mainly, the bottleneck is respiratory support. Thus, septic patients, severe CHF exacerbation, flash pulmonary edema, patients hang onto life only by the skin of their teeth if they can.

The many deaths I have encountered here have been incredibly frustrating and sad. Not only do I walk into rooms on my rounds, to find patients apenic and pulseless without any prior notification, but that even if a patient suddenly crashes, there seems to be a lack of urgency to do something about it. And even if CPR is started, the lack of resources (vasopressor, ventilator in the medical ICU) truly prevent a good attempt for resuscitating patients. Two observations of this common situation to comment upon: first, it appears that patient who are younger may tend to get more attention and resuscitated earlier. Otherwise, elderly, HIV, and stroke patients (high aspiration risk) are less able to fend for themselves, with poor reserves to begin with, and thus less attended to.

Here, there is no requirement or obligation to ask about a Code Status, compared to the common practice in the US. I have heard that in the UK and in Hong Kong, it is a similar practice. Patients are not asked, "would you like to be resuscitated and to what extent...with intubation and ventilation, with pressors, etc." In the US, I question the ethics of resuscitating a person who is with irreversible altered mental status, end stage disease, or end-stage dementia so that they can live out the rest of their days on life support and be visited upon by their family members. Here, I intially noticed my urge to start ACLS, whether it was out of habit when seeing a crashing, apenic, or pulseless patient, or else it was out of the feeling that it was the only thing I could possibly DO. Generally, I think doctors hate sitting around and not being able to DO something to help their patients. And thus for so many of my patients that I feel helpless about, due to them presenting in such advance stages of their disease or else the medicine required does not exist, ACLS became my default for actually being able to perhaps do something for them, to prevent death. Yet, as I stepped back and thought more of my patient panel...strokes with major neuro deficits, HIV encephalitis, end-stage renal disease, end-stage heart failure patients, perhaps its more than ok to let them go. For sake of quality of life and not just for management of resources. Palliative care and hospice would be an amazing addition to patient care here.

Monday, March 15, 2010

Taxi ride down Tubman Blvd, one of the main streets connecting downtown to area of the hospital and onto the airport. Video of the streets near the hospital.

Photos

1. wooden carving depicting reconciliation of the multiple ethnic tribes (the middle section of people embracing each other). The 3 warlords during the civil war embracing each other in the lower corner of the carving. (Liberia National Museum)

2. Traditional African instrument (will try to download the audio later on).

3. typical patient room on medicine ward

4. map of liberia: Monrovia along the coastline. Names of the different counties throughout the country.

Sunday, March 7, 2010

Week 2: part 2 of random thoughts

To admit or not to admit:
Clinic here is not necessarily too different than from clinic at home. However, if I order labs during the clinic visit, the patient needs to return the next day to bring me the result for review. I'm not sure if they need to pay twice.

In the US, for the most part, I have always considered care over cost. Thus if I think the information acquired from a test will help me in better managing the patient, then I just go ahead and order it. Here, I find myself debating and thinking two, three times whether a test is absolutely necessary as health care is so expensive here for most people.

Here, I feel like I have a higher threshold for sending people to the ED from the clinic or else to admit them to the ward. Example of people who walk into the clinic with systolic pressures of 80s to 90s. Maybe slightly dehydrated. Will they be okay with just a prescription of ORS? or should I send them to ED for IV rehydration? One of the good things about being here has been developing a heightened sensitivity for the "eyeball test" and clinical judgment based on just history and physical.

The medicine attending here reminded me that as a physician, he doesn't think about the cost; if the patient needs the test or treatment, then go ahead and order it. As for the rest, leave it to social work to deal with.

I will take this advice with a grain of salt.

Sample fees:
CXR = 250 LD (liberian dollar)
Chem 4 (Na, K, Cl, Co2) = 600 LD
Clinic visit = 50 LD
ED triage =100 LD
Ward admission = 2500 LD
Ward deposit for treatment = 2000 LD

There is also a fee to pay to remove a body from the morgue when a patient dies. It is sad and ?unethical to hear (from my pediatrics colleagues) that some parents were advised by other parents to carry their sick child home when they are almost about to die, as to avoid the morgue fee.

Survival of the fittest:
I'm convinced Darwin/Spencer's coined phrase of "survival of the fittest" exists here. And I'm grateful for it. Otherwise, my time here would be much sadder with a higher death rate. There must be some in-grain resilience that runs through the genes here. If the life expectancy in this country is so young, then anyone who's passed that expected age essentially "passed the test".

One success story---actually, a real miracle---is of a 70-something-year-old guy who presented to the ED in flash pulmonary edema, oxygen saturation at 33%. Extremely tachypneic and dyspneic. Diuresed him crazily, slapped on nitro, and actually survived the night with partial ambu-bagging and nonrebreather mask on 5L (that's the max), satting at 55% to 65%. Still oriented. Day 2, O2 sat came up to 70s-80s. Day 3, O2 sat to 90%. ...Amazing, something I'll never quite wrap my head around unless the objective data I was getting was false, but still, quite a miraculous case. Now, 10 days later, will send him home soon with outpatient rehab. Yeah!

Week 2: a rough week (part 1)

Over the weekend, my colleagues and I were invited to attend the LMDA (Liberian Medical and Dental Association) at the Firestone Hospital. Yes, Firestone---as in the headquarter plantations of the US rubber tire company of the same name. We saw never ending hectares of rubber trees being tapped for latex. I got to see some greener parts of the country outside of Monrovia. It was refreshing. I heard that upcountry land is even more beautiful.

Modes of transportation
I just realized that there are no traffic lights or stop signs anywhere in the city or from between the city to the airport. Thus, one always hope that cars would yield if one is trying to make a turn or else crossing a street by foot. The roads have significantly improved over the past 2 years already by being paved and with street lights installed. There are still many parts of downtown and smaller streets with pot-holes and unpaved areas. Motor vehicle accidents, similar to global statistics, is not uncommon and likely near #1 cause of death. 1 month ago, a public bus driving across town rammed into a gas tanker that was on the side of the road. The mass casualty caused chaos for the hospital ER. I think 1/2 of the busload survived. One unfortunate evening, had to ride in a semi-stationwagon-like taxis with 9 other people (3 in the front, 4 in the back, and 3 in the hatchback trunk---absolutely crazy). Apparently this happens also not uncommonly. I'm just glad I wasn't one of the statistics.

My frustration with X-rays
This week has been one long mission on getting chest x-ray for my patients. First, the x-ray machine was not working. Then the x-ray machine was fixed but no films were available. My patient who had a pneumothorax, PNA, and pleural effusion, with chest tube was unable to get a CXR until almost 1 week later. Thank goodness he's okay. Chasing after labs...also another similar story.

The rest of week 1: a brief summary

Dear family and friends,

So the rest of the week breezed by quickly. On my first day of rounding with my team of interns and medical students, I learned that it was the last official day of school for the 3rd and 4th year students before they enter their 1 month study period prior to final exams in April. How disappointing! I barely got to know them and now they're leaving the wards. However, a smaller team does have its advantages too, so I'm looking forward to working with my 1-2 interns for the rest of my time here.

A bit about the medical school: it appears to me there is only 1 medical school in the country. Studies and training were heavily disrupted by the war. Thus, the current class of interns consists of 13 doctors, but the 4th year class will be graduating close to 30 students and same with the 3rd year and so forth. After medical school graduation, internship at JFK requires 2 months rotation through medicine, surgery, ob/gyn, peds, ER, and other subspecialty. Then there is a several months period where they get further procedural/surgical training to prepare them for their time upcountry or in the bush, when they became the generalists who will head the clinic in the bushes. I'm not sure if this upcountry posting is required or not.

One of the reason I chose to work in Liberia was so that I could better communicate with my patients without a translator. For the most part, that has been the case. However, I'm sure there's much more to learn.
(Medical) Liberian English:
-small small- can mean slowly or better
e.g. doc: "how are you feeling today?"
patient: "small small" = "I'm feeling a little better"

-Spot positive = HIV positive
-Koch's disease = TB
-feeling hot = fever
-stomach running = diarrhea

The pathology is quite varied. Many malaria (the great mimcker here) cases as inpatient and OPD(clinic). Quinine is the 1st line drug used here. Almost everyone who comes in complaining of feeling "hot" gets a malaria smear and widal test (typhoid). Many new diagnosis of hypertension (high blood pressure) and diabetes.

Other cases seen thus far:
-pulmonary tuberculosis, abdominal tuberculosis, tetanus, pyomyositis, rhabdomyosarcoma, schizophrenia, pyelonephritis, pneumonia, bronchitis, congestive heart failure, liver cirrhosis, acute renal failure, oral candidiasis, kaposi's sarcoma, diabetic ketoacidosis, flash pulmonary edema, urinary tract infection, hypertensive urgency/emergency, post-traumatic stress disorder, etc.

A lot of pleural effusion and ascites. Learned to put in a chest tube.

And a few even more interesting cases:
-persistent hiccup
-a girl who presented to clinic with h/o intermittent "barking like a dog". Diagnosis made by referral doctor was rabies (but girl was bitten 10 years ago). My colleagues and I think it may be tic disorder/tourette's syndrome.

The weather is very hot and humid here, even though the hospital is 2 blocks away from the coast. Occasionally there is a breeze that comes through. So many people are dehydrated, coming to clinic hypotensive or constipated that I'm mainly telling them they need to drink more water besides prescribing bisacodyl (the only laxative on the formulary). Even my CHF patient I'm telling them to drink more water.

Again, thanks for your prayers and encouragement. I'm very thankful to be happy, healthy, and safe. I'm still working on posting photos (I'll have to shrink the files cause they are do big to upload).

Saturday, March 6, 2010

Day 3: Hospital tour

The medicine ward is divided into 2 sides with 1 team on each side. Today, observed medicine rounds. DKA apparently is quite common here as the first presentation of a diabetic patient since routine labs and check ups are extremely rare. There is a lady in the ICU with a chronic hand ulcer and presenting with DKA. This is not necessarily anything new, but the degree of infection and ulcers/abscess/wounds people present with is mind-boggling at times. Why were they unable to come into the hospital earlier? Many people try "country" medicine first because it's cheaper, thus one reason for the delay to coming to the hospital.

I will try to post some pictures soon (I think the photo files are too big and the internet is slow here).

Heard about hospital admission costs: (conversion rate 1USD = 70LD)
ED fees = 100 liberian dollars
Hospital admission: 2500LD (plus 2000LD in advance for meds and supplies)
ICU admission: 4500LD

Patients need to pay upfront before they can even enter the ED triage or whereever they need to go. There was a highly publicized case of a young man who was very ill, came to the ED, could not pay his triage fee, and was refused admission and literally DROPPED DEAD outside of the ED. The family refused to take the body away until the press came.

And once they are admitted, they have to pay their hospital fees before being discharged. If unable to pay the fee, then they can't leave the hospital and continue to accrue further debt while they stay in the hospital. There is a lady who owes 34,000 LD, and I wonder when she's ever going to leave. I hope the hospital social worker will be able to help in cancelling her debt.

Tuesday, March 2, 2010

Day 2: getting to know the hospital and people

Day 2:
I decided to immediately dive-in to get to know the system. Luckily, I did not suffer much significant jet lag. I was also fortunate to have a fellow internal medicine resident, also from California, to work with me for the 4 out of the 5.5 weeks that I will be in the country. Though the hospital was relatively big, I quickly found my way around places and soon met most all the attendings, resident, interns, medical students, and administrators.

The day started with morning report, where the post-call intern and PA gave a brief report of the overnight events, including deaths and new admissions. Then the 3rd year student presented the full H+P and impressions---or essentially the problem list. Thereafter there was the monthly grandrounds. The topic of that day was by the opthalmology dept on ectropion and entropion.

In the afternoon, one of my colleague's patient died of septic shock from an incarcerated umbilical hernia. Surgery wouldn't take her to the OR beforehand because of her massive ascites. Overall, it sounded like all parties were limited to do much more for her.

The hospital tour: JFKMC is a good-sized hospital w/ 4 floors (out-patient dept, Med, Peds, Surgery, Ob-Gyn/OR/L+D), though not all areas are completely renovated and operational yet. OPD (out patient dept) is huge with separate areas for pediatrics, ob-gyn, surgery, and medicine. I heard from someone that 1000 patients are seen daily. There is also a surgery/trauma and medicine/peds emergency room.

The hospital was established in 1968 and was the country's largest referral center up until the time of the civil war that took place between 1989 to 2003. The conflict took much toll on the hospital and now it's still in recovery mode. It is still the major referral hospital for most of the local clinic and smaller hospitals in-town and up-country. There are maybe at least 10 other public/private hospitals in town?

Finally in the evening, I got to meet the rest of the HEARTT (http://www.heartt.net/) volunteers and learned to play a scrabble-related game called Banangram. Currently, I'm with 1 med resident, 1 peds attending, and 1 ER resident. They are really a great bunch, and I already like them a lot. Earlier in the month, there were also some ID attendings visiting. I heard that next month there will be a few more ER and pediatrics residents coming. This is exciting because I got the impression that not many people rotated through this place, but apparently HEARTT has volunteers from many other places in the US besides the J+J scholars program.

Day 1

Day 1:
Exhausted from the long flight but as mentioned in my last post, arrived safely to the dorms. Also had many layovers en route, but did not get to leave the airport or see much of the land from aerial view since it was either dark or I was sitting in the aisle seat. When I arrived,the immigration officer only stamped my passport for a 30 days stay despite me having a 1 year visa. This was quite unexpected. However, later I found out that this has been the norm for most of my fellow volunteers since late last year. Hopefully, the extension will not be too difficult.

First impressions (from while waiting at the airport to arrival to the dorms):
-very hot and humid (it felt like 40'C)
-lots of UN vehicles and personnel on ground
-very beautiful sunset
-dangerous driving conditions

Slept very well that night.