(Copied from an old blog http://cumcedendale.blogspot.com/ done between December 30th -- Jan 9th).

Thursday, 9 January 2014

Yesterday started with a typical morning of rounding in an under-served hospital with really sick HIV/AIDS patients.  The middle consisted of a shock back into the reality of modern medicine with a teleconference with Columbia presenting cases from South Africa.  The day ended with the slaughtering of 30 chickens, on a hill, at midnight...Let me explain.

Since the new interns have started, the chief of medicine has given small introductory lectures each morning.  This morning he discussed how the hospital came to be such a challenging environment to work in.  Its mission was always to the under-served, and in a place like South Africa, that seems equivalent to under-funded.  However when the AIDS/HIV pandemic hit South Africa in the late 1990s, the hospital was in the thick of the action, the patient presentations were novel, they were sick, the hospital was unprepared and not well funded and many died.  It became such a challenging, hard place to work that many doctors and nurses left thus depleting the hospital even more.  In fact, in the room with us, there was only one internal medicine physician that was present during the start of this pandemic that is still working at Edendale today.   Never-the-less outside funding finally came in, new staff were hired and it seems that most of the energy was directed towards the most dire needs, HIV/TB and complications from these diseases and not so much to systems improvement and expansion in the hospital.  Hearing the chief of medicine speaking about the timing of HIV, I finally came to understand how new this disease truly is.  

Rounds started and we were post call.  As we walked to the admitting area to see our patients it was a mess.  200+ people were in the waiting area (I had to put my N95 mask on early) and it was impossible to tell who were the patients, the family and the friends.    Yet somehow there was some order to the madness and thanks to the help of some well placed nurses we found our patients.  They were on cots, by the wall, waiting to be told they had a bed so their family member could transport them upstairs.  The first patient we came upon was the sickest.  She had defaulted on her ARVs, had the most profound cyanosis I had ever seen and likely had PCP pneumonia.  She had decompensated quickly since her initial evaluation and by the time we saw her in the AM, we all knew her prognosis was poor.  While the team moved on (they had to secondary to the sheer number of patients) I volunteered to get IV access, ensure her meds were given and watch her status.  It became clear by midmorning she either needed to be intubated or made comfort care.  Unfortunately an ICU consult was less than helpful.  They have only 6 vent beds for the entire 900+ bed hospital.  She was not a candidate for ICU.  She was too far gone and deemed not fixable. She passed by noon that day.   

In the early afternoon after rounds had finished it was my responsibility to present cases from Edendale hospital in a teleconference with the medicine residents at CUMC along was an ID MD and a pulmonologist.  As I presented numerous chest x-rays, cases on cryptococcal meningitis, TB and aspergillus I was asked about bronch capabilities (none, they are transferred out), pleural biopsy (yep…but booked for several months away and I doubt with VATS) and culture data (sparse, there is no official micro lab with microbiologists).  Hearing these questions, it again dawned on me how much the medical house staff and consultants are asked to do on a daily basis without the benefit of ever present specialists, diagnostic tests and rapid lab turnaround time.  How under-served and resource limited the hospital is and much they are asked to do, with less.

After conference it was time to go to Krista’s (the head of ITEACH and the person who helps set up my time in Edendale) for dinner.  On arrival I was greeted by her and the chief of medicine at Edendale and was asked a simple question.  Would I like to go with them at night to the middle of a township on top of a large hill to watch 15 traditional Zulu healers perform a traditional ceremony?  Ummm yes.  The two questions I had were:  1, is it safe?  Yes absolutely, no one in the township would dream of ever harming anybody associated with traditional Zulu healers.  And 2, what does this entail?  These traditional Zulu healers had been working with Krista and ITEACH on the acceptance of ARVS into the community.  These Zulu healers were branching out on their own to start a new ARV integration program where they would promote amongst other things these ARVS and to help with their acceptance. They were performing a ceremony to ask their ancestors for help and good luck in this endeavor.  Krista (and by proxy us) had been invited because of her previous relationship with many of the healers.  Oh, and by the way, 30 chickens were to be sacrificed (2 per person). But don’t worry, we weren’t expected to bring our own chickens.  I proceeded to ask if anybody had ever seen Major League the movie where a practicing voodoo baseball player on the Cleveland Indians demands he sacrifice a live chicken before a high stakes game?  Instead he is brought a fried chicken from KFC.  There are crickets in the room, no one thinks it is funny and I can only imagine the look my wife would be giving me right now.

After dinner we leave for the township.  It is dark, misty and visibility is only 10 feet in either direction.  As we pile into Krista’s old, beat up range rover and drive into the township I start to question this whole safety thing.   

 We end up picking up two of Krista’s associates; fortunately one is a spiritual healer in training and has been “chosen.” He is able to direct us.  We head up a long, steep, rocky hill with drop offs on either side and mist in all directions.  The pitch on the range rover is intense and at times I think we are going to tip over.  Finally we can’t go any further and we head out.  There are drums playing in the distance and on our approach we spot several fires surrounded by 15 people and 30 live clucking chickens. They were waiting for us and we are greeted warmly, all of us like friends with huge hugs and warm smiles.  It doesn’t matter that we don’t speak Zulu and very few speak English. 

The ceremony begins with dancing, singing and drums blaring, the ritual sacrifice of 30 chickens commences and it appears much like a koshering.  While chants are sung the throats are slit, the blood drained out, the chickens plucked and tossed into a pin and salted.  The gallbladders however, are removed.  The Zulu healers believe that the souls of their ancestors reside in the gallbladders and these are to be saved. 

 Finally around midnight, after enough dancing, singing and drum playing Krista, myself and the chief of medicine at Edendale have to leave.  It is late and while the healers will be there all night, we have work the next day.

As we head down the hill getting intermittently lost in the township and dealing with the same rocks and pitch I start reflecting on what I had just witnessed.  This was a very spiritual and old ceremony revolving around something extremely modern and contemporary, ARV compliance.  I think about many of the patients in Edendale and those who do or don’t take their meds.  How much work has actually happened in Kwazulu-Natal and that the mortality curves for HIV and TB are finally flattening. Krista had explained that the first modern ARV attempts in South Africa weren’t until the very late 1990s into the year 2000.  That she was there for major role out in 2004.  It has finally occurred to me that this disease is still so new and when it hits resource poor, underdeveloped nations like South Africa, perhaps what is happening here could be much worse.  People are actually getting there medications, mass treatments with standardized approaches to medication availability, acceptance and adherence are happening and people are getting better.  And I think the take home of working at Edendale hospital is that while it is happening at the population level there is still a lot of work to be done for it to happen at the individual level.

The best quote I have heard so far while here:  “Just another day in Africa”

Monday, 6 January 2014

January 7^th, the official start of the new year and the hospital is back in full swing.  The previous one minute it took to get through the security gate now takes 20 as cars line up to be searched prior to a wave through.  The wards, previously devoid of techs and nurses are now swarming with never before seen ancillary staff.  And finally, new interns, new medical registrars, and new medical officers have arrived which has coincided with the post holiday patient rush as those who had attempted to minimize illnesses over the holidays have now been admitted over the weekend.  The hospital is chaotic.  But surprisingly it is a controlled chaos and could have been a lot worse with all of the new interns.

The Iteach office is now open as well and I have been introduced to the entire staff who are all extremely friendly and helping me plan my cultural and community outreach trips.

ITeach Office:

Today seemed to be an acute hepatitis day.  At least 4 patients had LFTs into the 1000s.  One patient we were able to make the diagnosis of acute Hep B (something I have not yet seen in the states).  Others unfortunately did not have hep labs drawn so they will be discharged with follow up of labs on d/c.  The new consultant I am with also seems to have a better grasp on antibiotics than the previous ones and feels comfortable stopping unnecessary meds.  Patients on a seemingly common combination Augmentin/Flagyl for CAP are finally having the flagyl dc’d.  Bactrim has been dc’d on at least 5 patients with CD4 count s that have been > 200 for months.  We also had one patient who was in status right in front of our eyes and the consultant was able to counsel the new intern/medical officer team on how to get an expedited head CT that day (in a sense what we do at CUMC, don’t take no for an answer).  Finally he discussed appropriate fluid usage and transfusion goals with the new intern and medical officer.  The take away from this, even in resource poor situations, without readily accessible internet, without the appropriate speed for diagnostic tests, it is possible to practice reasonably evidence based medicine if it comes down to the basics such as appropriate antibiotic usage, appropriate fluid content and correct transfusion goals.

Edendale Hospital:

 

 

Sunday, 5 January 2014

 

For Eric's last weekend, we went to St. Lucia (again copying Dave and Christine J) and stayed at a very nice beach getaway called Lidiko Lodge.  St. Lucia seems like a major resort town although I think because the holidays just ended it was a little quieter than usual.  It kind of reminded us of the Caribbean but with signs all over the place saying "beware of the Hippos".  We had some great food, and went on a game drive.  Not nearly as good as Rob’s, but we did see some elephants, plus we had a killer lunch of steaks and South African sausage.  

No Hippos :(, it was too hot.  Eric and I have both decided that the South African diet is very meat heavy.  During our drive home we stopped in a cheese shop.  When parking, my car got stuck in a ditch and I had to get it towed out… South Africa 2, Mike 0.   I think I'm at my limit for uploading pictures, see FB for the car getting towed out.  Luckily the cheese shop was also a farm which had a trailer hitch!

Thursday, 2 January 2014

During one of my last conversations with the chief of medicine, he has been working desperately to improve the quality of nursing care at the hospital.  While interns are responsible for all IVs and blood draws, the chief has been attempting to at least have successful daily vitals and ordered daily medications actually given.  In one example, I spent some time in area R (where patients go for medical care by the interns after triage before getting a bed on the ward) and had participated in a patients care.  The pt came in screaming with severe abd pain, no bowel movements in a week, tachycardic and possibly febrile but no temperature had been done.  A floating consultant walks in, sees the patient, and immediately asks the nurse for a temperature and help with management.  He gets a long blank stare with no movement from the nurse and 30 seconds later is told the patient will be wheeled back out down the hall to the thermometer in a little bit.  The consultant then walks off and 20 minutes later comes back with the thermometer, the temp is 38.  This consultant seems different than the others.  Instead of accepting the status quo he took action.  I ask the intern who he is, and the intern says this consultant mostly works for the CDC and “is a little scary at times.”  I try to offer other, non-intrusive ways to help such as suggesting fluids, antibiotics and a pregnancy test.  The pregnancy test is still pending…

I have other examples, but they probably are not appropriate for online posting.

 The clinical case presentations in the hospital are usually quite dramatic.  Most patients are pancytopenic, many have crypto meningitis and the default diagnosis for a headache, neck pain and a negative bacterial and crypto LP is TB meningitis.  Frequently, if the patient does not fit into an HIV, TB or pneumonia mold, they become a mystery and a work up is pursued only if it is worth keeping the patient in the hospital.   It seems that answers can take weeks to happen, as CT scans, biopsy results and esoteric labs can take weeks to come back.

Today on rounds, I was with a very thoughtful consultant and two British registrars who had trained in the UK and came to South Africa as they enjoyed overseas work.  We discussed how I still can’t get over the way sepsis is treated.  At least three times now, sepsis was managed with no fluids, either dobutamine or epinephrine, very little re-rounding and the same antibiotic – ceftriaxone.   As it turns out, they are actively studying the problem and agree it is not a resource problem but systems problem.  They are planning to report on their results soon and the chief of medicine is apparently very open to improvement and change but we all have a feeling the hospital mortality rate will be high. 

I went on an amazing game drive at the lodge I am staying at.  See pictures below!

 

 

Tuesday, 31 December 2013

As a disclaimer - Eric didn't proof read this!

I rounded today with the chief of medicine and learned the history of the hospital. Edendale Hospital was designed as a 900 bed public hospital built in the 1950s before Apartheid.  When the laws came into existence it turned into a public black hospital.  Funds were not allocated for support nor resource development and it essentially remained untouched until the late 1990s/early 2000s when at the end of Apartheid a CT scanner and new electronic core/pathology lab was added.   A very small ED has since been established with a main entrance still undergoing renovation and current planned renovations include a new psych department and a renovated area for medical evaluations prior to admission.   At least in medicine, computers exist only on doctor's smart phones which they use to connect to the core lab to see results. 

Zebras

Entering the wards feels like entering the 1950s.   The medicine wards on the 5^th floor are separated by sex and essentially look identical.  There are approximately 6 sections separated by chest high brick walls and each section has 8 beds.   There are no curtains, private restrooms, tvs, phones or privacy.  As a patient, you get your bed, hospital gowns, food, a small night table and of course medical treatment.   Rounding with the chief of medicine was a very pleasant experience where we discussed the differences in test ordering and time to completion.   For example, a CT and MRI can take a maximum of one day at CUMC (which we still find difficult to tolerate) whereas in SA it can take weeks. Because of this, endocarditis is ruled out by stethoscope, not echo.  Bilateral crackles and no fever is pulmonary edema and does not require a CXR.  While I cannot comment on exam skill level, I can say there is a much higher level of comfort using exam skills to rule in or out disease.   

The prevalence and incidence of disease also plays a huge role in diagnosis.  Given the high HIV burden, LPs are done like blood draws and a brisk flowing CSF is assumed to be crypto meningitis until proven otherwise.  A CXR with multifocal pneumonia is miliary TB because of possible small nodular opacities.  On rounds, I also noticed the high burden of ETOH abuse and THC but very few patients because of cost use heroin or cocaine.  The THC is grown by farmers in the surrounding area but in Lesotho the farmers alternate a row of corn with a row of THC to prevent police airplanes from seeing the crop. 

No procedures today L.  I was going to do a blood draw but then realized….That is the one thing I don’t need practice on

 

This weekend (copying Dave and Christine’s itinerary to the point) Eric and I travelled to Kestell to the Drakensberg Mountains and for a hike up to the Amphitheatre to see the start of Thukela Falls.   We stayed at a very homey backpackers where a jolly, slightly obese elderly South African women hosted guests and provided unlimited supplies of homemade jams, coffee, tea and hiking route advice.

The hike the next day was 6 hours round trip and included a 2km hike up to a set of chain linked ladders leading to a large flat plain which extended 1km to the start of Thukela Falls. Despite the threat of rain including thunder, the weather cooperated and Eric and I made the 6 hour round trip hike in 5 hours.

See pictures below:

 

Posing on the way up!

 

 

The water fall

 

 

Eric, Myself and our German hiking friends

 

Monday, 30 December 2013

In order to make the South African elective more generalizable to our CUMC IM program, the department has asked the residents going abroad to revive a blog that was started several years ago (but no longer updated) about the resident experience in South Africa.   

Arriving in South Africa after a long, 33 hour flight including a 10 hour Munich Layover, I was met by Sipho the ITeach driver who gave me a warm hug, guided me to the rental car agency and led me to a grocery store which much like in the U.S., was packed with throngs of people on X-Mass eve.  Driving on the wrong, aka left side, of the road is not a new experience to me but disorienting nonetheless.  Everything has to be flipped in your brain and one constantly thinks of the reverse.  While I am now an excellent left sided driver, on day 1 (see below) I unfortunately failed.

Day 1 started on x-mass day with me misjudging the entrance gate.  Upon driving up the poorly paved back road to the hospital my car was stopped, searched, and subsequently allowed through a set of gate doors.  Unfortunately, the guard refused to open up the second gate and I ended up denting and scrapping the front part of my bumper;  South Africa 1, Mike 0…  After parking, wandering around for an hour or so, I was met by a very kind, soft spoken chief of medicine who came in specifically to orient me to the hospital.       

The Hospital gets the majority of its patients as referrals from local clinics.  These patients are sent to a waiting room and triaged by a registrar/medical officer (medicine resident). Should the patient need admission they are sent to another back room where two interns (doctors who are doing two years of work prior to deciding on any specialty;  surgery, medicine, optho etc…) perform all of the necessary paper work, blood draws, IVs – scut work.  If the patient is too sick to stay in the waiting area until a bed opens up on the wards, they are sent to the medicine emergency department to be further triaged to the ICU, wards or referred out to a subspecialty service at another tertiary hospital which only takes referrals called Greys Hospital.   

After seeing the hospital, learning the above, and meeting some extremely nice registrars who were dumb-founded that I came in on x-mass day despite my explaining I did not celebrate, it was suggested that I not come in on Thursday and present Friday for a resumption of the regular schedule.

 

A view from the Lodge where I am staying!

Friday, day 3 was my first real day which started with morning report going over cases from the day before.  Eric (my pod mate) had flown in to join me for several days and we were assigned to the post call team to round which consisted of a consultant, a variety of registrars/interns and the consultant’s younger brother who had come to observe.  Rounds started in the ED where two patients had been assigned and admitted by a team, but no beds were available and where thus being co-managed by the ED consultant (Attending) and medicine team (This all sounded too familiar!!!).  Patient 1 had intentionally overdosed on combined organophosphate/synthetic warfarin pills and had improved somewhat on an atropine drip but now had a heat rate in the 150s (more on this later).  Patient 2 had AIDS and had been admitted and treated recently for cryptococcal meningitis.  While it is unclear how she re-presented, on morning rounds in the ED she had an SBP in the 60s, febrile, altered, and anuric AKI with a k that eventually came back at 6.  Her LP was normal and her lungs clear.  The consultant saw this data and stated the patient needed antibiotics, a renal consult for peritoneal dialysis, no fluids as the patient was anuric and she didn’t want to volume overload her and then requested that an inotrope, dobutamine be started.  She debated about Lasix to induce urine but the hypotension prevented this.    Eric and I stood there, still unsure what our role/responsibility was in all of this.

Rounds eventually went to the 5^th floor where an intern asked us to come over and help manage a patient in cardiogenic shock 2/2 to afib with RVR with an SBP in the 70s, altered mental status and a HR in the 190s.  This required multiple shocks and while sedation was given the patient was in an incredible amount of pain.  The consultant’s younger brother then asked if we couldn’t “hit him over the head to knock him out.”  I just stared…

Rounds ended and Eric and I circled down to the ED to check on the overdose and septic shock patients.  On our way down we tried to remember back to 2^nd year of medical school, the cholinergic effects of organophosphates and why this patient was tachycardic and not bradycardic.  The ED consultant stated “in Edendale Fashion” the atropine drip had been ordered off 24 hours ago but was turned off only minutes ago, thus he was now suffering from atropine overdose.   He was also altered and the patient could not go to the medicine wards until a head CT was done to r/o bleed given the warfarin OD and coags that were still pending .   As for the septic shock patient, renal had recommending a non invasive CVP which was 0, the ED consultant gave 1L NS and switched to epinephrine and the ICU had declined the patient 2/2 to no beds.   In addition to a failed LP on a patient which the intern then got in 1 stick, it was a fairly eventful Friday.

More later with pictures on our trips around SA, the hospital itself and our lodge.

Sowubona...Edendale

The first drive can be simultaneously the longest and the shortest - long in the sense that you wonder with anticipation what turns are coming next and when will you arrive at your destination, yet short because of the new sights upon sights that you pass in a hurry without being able to stop and admire.

Before I know it, into the doors of Edendale Hospital we step. Our footsteps sound a little hollow in the still not fully awake building. We walk up the stairs, meeting Dr. Wilson on the way.

First stop of the day, morning report - or 8 am conference. Held in a small room, a case is presented from overnight, a middle aged man with RVD and epilepsy who presented with seizures. The ensuing discussion is quite academic and similar to our morning report cases. Lots of question and answer, generating differentials and talking physiology. We determine a preliminary course of action for this patient – some labs, some meds - then all disperse to their respective morning duties.

Onto the wards: we rounded in the H ward, female side. My first impression of the ward was its size. Not big, but set in a fairly large room with windows along the side walls, filled with 36 beds arranged perhaps 2-4 feet apart from each other (I am a poor judge of actual distance). No curtains. There is a naked woman sitting in her bed near the back of the room, her bottom half wrapped in a blanket, her top exposed. She is yelling - to me, incomprehensible because it is in Zulu; to the staff, also incomprehensible because, I was told, her words were nonsensical. She lets out an intermittent holler or sings a few musical words, piercing above the hum of the room. It is almost comical. Later, I learn that H ward often houses the psych patients who are undergoing medical evaluation.

Next, the infamous 5B1 ward. We only see half the patients, as is the routine here. The consultant and/or registrar rounds every other day, leaving the intern alone on the alternate days to round, manage, and discharge. The first row of patients are the most acute, though as we move further, we find that is not always the case. If you need oxygen, you need to be in the first row. Even then, there may not be enough oxygen connections or tubing to ensure a constant supply of O2 therapy. The theme of the day: cryptococcal meningitis, viral meningitis, nephrotic syndrome and renal failure, PCP/pneumonia.

The Time Factor...

Monday starts as usual with morning report, which turns into a town hall meeting of sorts by the end. We are in the midst of a lab strike! The lab, operated by independent organizations, has gone on strike with workers demanding an increase in pay. The situation has worsened from having two remaining technicians processing really urgent samples to the entire lab being closed with doors locked. Things are at a standstill, yet there is nothing that hospital administration can do. We have no idea what is the status of negotiations. Is there legal action that can be taken? It seems our hands are tied. The situation persists for another week; during this time our skills are tested on the wards. Hemoglobin low? Check the conjunctiva. Renal failure? Check for worsening swelling (urine outputs are not charted). It's satisfying to make use of that armamentarium of physical exam skills we are taught in medical school, like the way all the older docs know how to do. It's almost embarrassing, though, because a feeling of uncertainty still lingers, the side effect of what we're used to back home - data, data, and more data.

After the meeting, I proceed to round with the intern on 5B1. We come across a 15 year old girl who presents with shortness of breath. She has no known past medical history, but things are suspect. Her x-ray tells the story before her. The ARV warrior is at her bedside. All are awaiting the results of the rapid HIV test kit that lies open on the table. Two pink lines; it is positive. The ARV warrior tells the patient in Zulu her diagnosis. She seems to take the news without much reaction. I am told she will tell her mother; her father was HIV positive. Age of consent is 12. Now we await the TB test. She stays for the next week on the wards. The ARV warriors visit her often; she is still waiting for her mother to come to the hospital.

Comparisons...

Not knowing really what to expect at Edendale, I spent the first week trying to just observe and walk around, get situated. Oddly enough, I didn’t feel too weird being here. At first glance, the wards and physical facilities are clearly very different from what we see at home. Each “ward”, which would be the equivalent of a floor, really is just one big room. They are first and foremost divided into male and female wards. There are minimal patient dividers, so every bed is located only several feet away from the other. Patients are examined and undressed while trying to provide as much privacy and draping as possible using whatever blankets and sheets are available. Most of the time, this is not really complete. No one seems to mind, however. Patients look on while their neighbors are being examined. There is no shame or judgment. Patients visit with one another and really try to look out for one another.

I definitely do not sense as much hesitation to talk about HIV/AIDS here in Edendale, which is encouraging. Yet patients are not immune to stigma. People learn to identify those who look ill, those who are weak, emaciated, those they assume have the RVD, even if that is not the actual diagnosis. With the help of education and outreach efforts, people have learned to not shy away from medical care. Some, however, especially men, often refuse treatment and follow-up.

Patient education. That is a theme constant here as well as back home. We need patient education. While the literacy level is not low in Zulu, understanding medical conditions and the necessary steps for help maintenance is a harder task. This plays a huge role in follow-up rates and treatment adherence. In fact, we had a young woman in her 20s who presented with DKA multiple times in the setting of insulin non-adherence. I realized that the medical staff just don’t have time to sit down and have extended conversations with patients about why they did not take their meds. Even ordering a psychiatry consult could take days to happen. The result? We hope the patient listens when we round for those brief 10-15 minutes at the bedside, and that she will follow-up in clinic as told.

The population here at Edendale hospital, while being quite sick, are also some of the friendliest, strongest, grateful people I’ve worked with. They tolerate, rarely complain until they cannot bear it anymore. When asked, “how are you?”, they may say “well”. You must ask, “how are you feeling today, what is bothering you?” Their answers are often brief, you need to ask further and draw out more symptoms. Maybe it is a reservation towards doctors or an expectation that patients should not be too forward. Even if pain medications never arrived, most will not say anything negative about the doctors or nurses. They are at the mercy of the system.

Daily life for patients at the hospital is fairly routine. Morning, a breakfast meal of pap with milk. The nurses, called "sisters" and "sirs", make their medication rounds. One nurse from each side of the ward rounds with the intern/registrar. The patients are mostly up by now. Their sheets are still pulled, each bed has a thick fleecy blanket - provided by individual patients' families especially for the hospital stay. The patients have their few personal belongings tucked away in a small drawer by the bed. There are no TVs, no phones. When visiting hours come around, the ward changes and starts to hum with the voices of all the patients' family members coming to check in on their loved ones. It's not noisy, but rather a lively vibe. Scents of home cooked meals can sometimes be caught wafting around the corners. By mid to late afternoon, a heaviness settles back in, the floors start to echo again. The sisters are mostly gathered in their conference room, wrapping up the day; patients move back from their chairs into the beds; the doctors have gone.

Swings and Waits...

The first time the intern told me that a patient passed away during the night was a blow. She was an elderly woman who had a history of breast cancer and returned with a new left sided pleural effusion. She was clearly tachypneic and hypoxic. She needed a therapeutic thoracentesis, which we did, but we were only able to drain 500 cc of fluid. The needle/cannula was too short to really be effectively secured to her back. Not surprisingly, she became progressively more short of breath over the next few days. She needed another thoracentesis, and a chest tube was planned this time. The next day we come in and we’re told that she arrested and died during the night. Hearing the news, I just felt kind of empty inside; it was a feeling hard to describe, like we had let the patient and her family down.

Perhaps one of the most frustrating and sad parts of medicine and being a physician is dealing with poor patient outcomes. Here, I feel the burden is exceptionally great. Coming from a health care system and hospital where blood work and radiology studies happen expediently with usually minimal delays, it’s very painful to watch patients wait days and days for even small things such as viral load tests or urine studies. An “urgent” chest x-ray for a status post thoracentesis patient gets done in maybe eight hours time. If a study is ordered in the afternoon, that essentially means it will happen tomorrow. Hence, we have many patients on the floor, in distress or pain, or simply not improving, while we await their imaging, which is needed in the diagnostic process.

Revisiting my Dominican ghosts

Almost exactly one year ago I met a patient in the medical ICU at Columbia who has stayed vividly in my thoughts throughout the ensuing months. She was an older Dominican woman, in her eighties, diagnosed recently with a rare inflammatory disease causing shortness of breath and nerve damage in both legs. Before this bizarre disease had come her way, she had been an active and vibrant woman, with very strong ties to her family including children and grandchildren in the United States and in the DR. She was now much more limited in her independence and mobility, though her mind was not at all touched by the disease. I didn’t know this when I first met her, only later. When I first saw her, she was a frail, tiny figure, intubated, illuminated by the garish lights of the ICU, surrounded by tubes, lines and beeping machines, with, every moment, at least two members of her family keeping watch.

At the time, we thought that she either had an infection or this was a rapid progression of her inflammatory disease. We treated her with antibiotics and kept her oxygen levels up with the use of the ventilator. After a few days, she seemed to be improving and we began to talk about removing the breathing tube. As we went through all the necessary protocols to ensure that it was safe to take her off the ventilator, her nurses approached us and told us that they were getting the feeling from her that she did not want to be on the ventilator. At this point, I’m not sure anyone had the chance to ask her if she wanted to be on a ventilator: her family had no memory of talking with her or her doctors about her wishes and when she arrived at the emergency room this time, she had been too sick to answer any questions. Her family had made the decision that we should do everything to help her recover.

Now that she was a bit more awake, she seemed to be trying her best to communicate that she wanted the tube out as soon as possible. She passed all the necessary tests for a safe extubation, but we all knew there wasn’t a 100% guarantee that she would do well. We prepared to take out the breathing tube and initiate a conversation with her about whether she would want the tube again if she got worse. The answer we got was not in the least equivocal. She did not ever want to be intubated again. Even in the haze of the ICU and her recent overwhelming illness, there was no hesitation in her choice. She contemplated the question carefully, silently, and then told us no.

Sadly, the relevance of her answer became almost immediately apparent as her shortness of breath quickly returned and worsened. Immediately, her family, led by her daughter, intervened. Obviously, we had made

a mistake when we took her off the machine. Now, we needed to put her back on. I told them that we had to follow her wishes above all else. Her family then flocked to her bedside to try to convince her to change her mind, to convince me that she didn’t know what she was saying, or to do anything to get us to intervene. At this point, I remember worrying that she would change her mind under all that pressure and then I wouldn’t know what to do. I was even worrying that her daughter might just tell me she had changed her mind when she hadn’t and with all that Spanish flying over the bed between her and her

family, I might miss whether this was true.

But the patient was steadfast. She remained silent for long periods of time, thinking calmly despite her shallow breaths. I asked her again, did she understand that if she didn’t have the breathing tube again, she would likely die? She answered me the same as before: that breathing tube is the worst thing that ever happened to me. In the end, after almost 24 hours of attempts to make her better without the ventilator, we started a morphine drip and let her rest.

She stayed in the ICU on the morphine drip for almost a week before she died. Her family remained completely furious with us this entire time, constantly attempting to renegotiate her care with less morphine and more antibiotics and transfusions and on and on and on.

An unexpected question

One late night during this last week, her daughter called me into her room to discuss a transfusion that I thought was futile and she felt was necessary. As had been the case for days, the tension was palpable in the room before either of us spoke.

When the patient’s daughter finally spoke, she asked a surprising question of me. “Doctor, do you plan to work in the developing world?” I was taken aback for a second: how did she know that I wanted to work abroad? Why did this seem to make her more angry?

“I do,” I answered tentatively, “I worked in South Africa for a few years and would love to continue that work in the future.”

This was obviously not the answer she was expecting and I realized her initial question had been rhetorical. She assumed since I was working now among the cacophony of the ICU that it was not possible I would ever want to work anywhere else. Now this unexpected conversation was on unexpected ground for us both.

The daughter continued, “Do you think they would do this to her in our country?” At least this time I recognized that she did not expect me to answer. “They would not do this at home. They would not treat her like this.” My mind was spinning with all the possible things she could be talking about: the ventilator, the morphine drip, the transfusions, the young and petrified doctors like me manning the controls at night.

I don’t remember much of the details of what came next. I do remember that I said I was sorry, as I always did in conversations with her, sorry that she was in so much pain, that she was so unhappy with the way that we cared for her mother. I also tried to address her question delicately, knowing that I was very unlikely that I could do anything to make her feel better. “From what I’ve seen in the developing world,” I said tentatively, “I don’t think she would have been better cared for at home. I think she would have been asked to pay before receiving any care and I think that is not at all better than what we have here.”

Pretty quickly, she gave up on the developing world line of inquiry, but she clearly did not feel any better and the end result of the conversation was that I acquiesced to ordering the transfusion.

On shaky ground with myself

This conversation and all the other interactions I had with this patient and her family made me realize something incredibly powerful but also confusing: I do firmly believe in our protocol for making end of life decisions and the ethical principles behind it. But, do I think this is the only way of making this decision, the clear choice for every culture, every medical system? Absolutely not.

It was clear in the eyes of this patient’s daughter that what we were doing was not at all the obvious way to do things. Faced with the loss of her mother, there was basically nothing I could say to convince her that our value system— autonomy, free will, the importance of the individual—was fair to her mother or her family as a whole.

Since that time, I have been haunted by the idea that my lack of understanding of Dominican culture resulted in me somehow failing this family when I could have helped them. I was reminded of this case when I first visited Santiago and saw several severely ill older patients who seemed to be receiving what I would consider rather aggressive care, especially when it came to feeding tubes. I began to wonder if attitudes towards end of life care were so different in the Dominican Republic, just as this patient’s daughter had told me that late night in the ICU.

My very own panel of experts

I had the chance this past week to address my nagging fears. I prepared a teaching conference for the geriatrics residents and decided to present this patient’s case and get their opinion on how she might have been cared for differently in the DR.

In the days leading up to the presentation, I got a bit of cold feet about the questions I was getting ready to ask. Given the financial situation of most of the patients the residents were caring for, my questions about a patient with a rare inflammatory disease that likely could never have been diagnosed in the DR seemed like they could fall completely flat. Not to mention the fact that a few residents asked me what I was going to present and when I tried to describe it, I got some pretty strange looks.

I restructured the talk a bit so that the first half addressed the diagnosis of the rare inflammatory disease, engaging the residents in some Columbia-style morning report questioning and participation. I felt like I earned their trust a bit in the first half, or at least garnered their attention. Then I dove into the details of what had happened with the patient and her family, pausing a few times to ask what would they would have done if the patient had been under their care (this required a rather terrifying trip into the Spanish subjunctive tense, but I did my best!).

The first question I asked involved the point at which the patient was first intubated in the emergency room. What would have happened to her at the residents’ hospital, Santiago’s public hospital? My audience literally laughed with disbelief. “She would die,” said several people at once.

But, why not intubate her? I pushed again.

Then, came an answer more practical than I could have even imagined: “we don’t usually have available ventilators. There are 10 in the whole hospital and most times they are in use. “

The residents and faculty went on: the general approach to the care of patients like my patient was that, for better or worse, economics drive the way decisions are made in the Dominican Republic. At the public hospital, I was not surprised to hear, patients are asked if they can pay for the ventilator before they are intubated, then charged a large daily fee for its use. For most, the fee is so high, they would never even consider saying yes.

Surprisingly, according to my colleagues, the situation was exactly the same at the private hospitals, possibly even more driven by money than in the public sector. There were some interesting nuances to what was described. Because it is the family who pays for medical services for older Dominicans, it is the family who makes the decisions. It is not that family ties are valued more than individual choices, but logistically, doctors cannot expect the family to pay for something to which they have not agreed.

Furthermore, because so much money is on the line, families are much less likely to agree to an expensive treatment that may or may not work. This brought to mind an interesting parallel with criticisms of our current health care system where there are virtually no direct consequences of how much we spend and therefore, some would argue, skyrocketing health care costs with little benefit to patients.

The conversation continued for another twenty minutes or so. The residents told me that the legality of end of life care decisions is never something they worry about: there are actually no laws in the DR dictating who can make these decisions and who upholds them. When I asked if these discussions ever happen when patients are healthy, they shook their heads. There are no health care proxy forms or living wills. The faculty members had seen these forms because sometimes well-educated Dominicans bring them from the United States, but they have never used them. I couldn’t quite get them to tell me why these discussions couldn’t happen in advance, but they did not seem optimistic about including them in their regular care.

Overall, I learned a lot. I had wondered beforehand if the doctors were the ones charged with making these difficult decisions in the DR, not individuals or families. But, clearly, families were the center of the decision, and not completely unexpectedly, the economics of the decision seemed to trump all else. I came away from the talk feeling less torn about the experience of caring for this patient at Columbia, mostly because I now had a dozen Dominican doctors who also recognized the complexity of her situation and the difficulty of making the decisions we did.

I also now understand a bit better the challenges I face in explaining our decisions to Dominican families who have experienced a system driven primarily by economics. When the economics are taken out of the equation in the United States—as they essentially are in an emergency, in the ICU and for patients with insurance—the decision making process changes greatly and I imagine, can seem totally inexplicable. It’s possible that if I had this insight before I took care of this patient, I might have been able to explain to the family better our reasoning.

Or, maybe nothing, not even flying in my new team of Dominican advisors, would have made them comfortable with what happened. At least now I can lay my concerns about my failure somewhat to rest. My inability to ease the pain of this family was less likely a sign of cultural differences and more a sign of culture universality: the loss of a loved one hurts deeply, inconsolably, in every imaginable part of the world.

Confusion Immersion

In the past two weeks since I arrived in the Dominican Republic, I have spent more time confused than in the last five years of my life.

Sometimes I don’t understand what people are saying, the conversation flashing past me in accelerated Dominican Spanish. Sometimes I don’t understand what people are doing: I follow people when I’m supposed to stay where I am just as often as I stay where I am when I am supposed to follow. But, worst of all, nearly all the time, I don’t understand what people are thinking.

This is not all together an unfamiliar sensation. I experienced this kind of confusion when I lived in South Africa, when I visited Santiago earlier this year and often when I interact with patients from various cultures and with variable levels of health literacy in New York City. But in recent years, as I have become more comfortable as a doctor and, really, as an adult, these times when I have felt completely out of my element have become increasingly scarce.

A worthwhile return to the basics

Though I don’t have this sensation as much as I used to, in the last few days, I have come to the conclusion that surrendering to my limited ability to understand the motivations of those around me is liberating.

Here is a example from last week: I attended a teaching conference for Geriatrics residents at the hospital where my rotation in based. A resident was presenting on an article from a medical journal. She began with the title of the article, an unbelievably long phrase which I could barely finish reading before she was onto the next slide. Soon after, however, she was interrupted by Dr. Medrano, the head of the residency program who sits in on most of the conferences. I didn’t catch every word that he said, but he seemed annoyed and then she seemed embarrassed and apologetic. As her presentation went on, he continued to interrupt her with questions and comments. At the end, he made a summary statement about the poor quality of something; this seemed to refer to the article, but also might have referred to the translation of the article or to the presentation.

Throughout the thirty minutes of the presentation, my mind was flitting all over the place trying to interpret what was going on in front of me. Was the resident unprepared? Was Dr. Medrano being malicious? Was this the usual teaching style for medical presentations in the DR? Or, was it something completely different, like the article was bad?

Despite my confusion, I noticed I was extremely engaged in trying to interpret what was going on. I used all sorts of observation techniques that I don’t often call upon explicitly when I’m in a comfortable situation: I paid close attention to facial expressions, body language, the reactions of the others in the room to the back and forth between Dr. Medrano and the resident. I’m sure these kinds of observations factor into my understanding of all situations, foreign and otherwise, but the way in which I was using them consciously made me realize how often I don’t listen to these observations closely enough.

If I had witnessed this situation at Columbia, I might have observed only for a minute or two before deciding that the resident was inexperienced or unprepared, or that the attending was a particularly engaged teacher or just cruel. Because I don’t trust my judgments here in Santiago, I kept my mind open to observe the situation for much longer.

In the end, was I able to reach a conclusion on what was going on? No. But I did succeed in lengthening the list of possible factors contributing to the interaction: the journal played a role, the translation, the structure of the presentation, the resident, the audience, the attending and on and on. As I participate in these teaching conferences during my time here, I can take this list with me and both refine it and, inevitably, expand it, as I continue to try to make sense of everything new and unfamiliar I am observing.

Taking this message home with me

There is an obvious parallel between my attempts to understanding the motivations of individuals in this foreign setting and my similarly challenging attempts to understand my patients in New York City who come from vastly different backgrounds. In my outpatient clinic, when I urge my patients to follow my instructions (to take their medication regularly, to check their blood sugar, to follow a particular diet), I know I often jump to conclusions when things don’t seem to be going well:

This patient is never going to understand how important it is to take their blood pressure medication.

This patient’s life at home is hopelessly complicated and preventing them from following a healthy diet.

This patient clearly does not believe a word I’m saying.

These interactions are layered with complexities that I cannot even begin to characterize—language, education, culture, life at home. Yet, I jump at the chance to label the reason behind my failure to communicate even when I know there’s a good chance there is much I don’t understand about the lives of my patients. My experiences this past week have made me think that I need to surrender more to my inability to quickly and easily understand my patients.

When I know things are not getting across, I need to acknowledge it and tell myself it’s possible I do not possess the tools to understand exactly why. If my time here is any indication, I should then be able to continue to brainstorm the reason behind the obstacle. Rather than shutting down the process before I get anywhere, I can put it on hold until my next opportunity to interact with the patient and keep thinking broadly. Ideally, this approach will enable me to catch the opportunities that do pop up for improved understanding of my patients. If nothing else, I will stop fighting the confusion and stay engaged in the conversation.

From Jess: Community Health Centers

While we spent most of our time with the Geriatrics residents, Dr. Medrano thought that it would be a worthwhile experience for us to be exposed to the Family Medicine Residency Program so we spent a morning learning about their Community Health Centers. We visited a Health Center in a community in Santiago called Korea.

I thought that by far the most interesting part was the second year experience: essentially each second year Family Medicine resident is assigned a small community in Santiago or the surrounding area and is responsible for the health of that community. The resident sees their patients both in the hospital and in their homes; what better way to really understand your patients? Each resident makes a map of his or her community and denotes with push pins the medical problems that each member of the community has – for instance every one with HTN gets a red pin, everyone with DM gets a green pin, etc. The maps make for a unique representation of the health of each resident’s community. Based on the diseases prevalent in their community, the residents (with assistance from their community health workers) develop educational sessions to improve health literacy and the general health of their community. I loved the maps – here are two of my favorites with close ups of the legends.

I wonder how much better I could care for my outpatients if I visited each of them once in their own homes? I think in addition to demonstrating to the patient that you truly care about them as an individual, you get a sense of whether they have a system for taking their medications, what type of food they have in their fridge, if they have shaggy carpet and exposed wires contributing to their fall risk, the list goes on... I know that we have VNS that can go out into the community and ascertain some of this information for us, but I feel like seeing firsthand how your patients live is pretty powerful. Time constraints of residency make it impossible to see all of our patients in their own homes but when I got back from the DR I was inspired to contact one of our attending who makes home visits to the homebound elderly to set up a few home visits so I can learn more about some of my geriatric patients that I am most concerned about.

From Jess: Consulta (aka Outpatient Clinic)

I spent the first morning in consulta, or outpatient clinic with one of the fourth year geriatric residents. After inpatient morning rounds we slowly meandered downstairs to the first floor where the outpatient clinics are located. The resident that I was paired with, FiFi, picked up a stack of blue and pink cards with patient’s names on them and then we proceed to walk back to the clinic room and call the first patient.

The clinic room was simple. There were 4 chairs, 2 on either side of desk. There were no computers but there were several stacks of unorganized forms on the floor. (When I asked what the forms where for, Fifi told me that she didn’t actually no, she had never needed to use them.) The room had an exam table, a sink and a scale. The air conditioner was on full blast and there was seemingly no way to control the temperature.

We called the first patient. She was a 73 yo woman with pink card and history of stroke, DM and HTN who came to clinic with her husband and her family. Her blood pressure was 130/90. No one in the room (patient, family, or doctor) knew which medications the patient was taking because most patients don’t have a clinic chart. Fifi named some medications for the family and they agreed that HCTZ sounded the most familiar so she grabbed the equivalent of a prescription pad and wrote a script for HCTZ and told her to take one pill once a day. Then Fifi filled out what was essentially an order sheet and told the family the patient should get her fasting glucose checked before the next visit.

After the first few patients I learned most of the basics: the pink card meant the patient had no insurance, the blue card meant that the patient had government insurance. The interview consisted of figuring out what conditions the patient had, what pills they were taking and sorting through the stack of papers detailing lab results for any new or pertinent data. Not one of the patients that we saw that morning had a complaint about pain, no one was dizzy, and if any one had depression or mood symptoms, we didn’t talk about them. The exam was BP, HR, listening to the heart and lungs, and checking for edema. The visit concluded with the resident filling out the prescription form (note that the form only has space for three medications, none of the patient’s were taking more than three pills so we never had to give any patients more than one prescription) and an order form for diagnostic tests (which typically included things like a fasting glucose, BUN/cr, urine dip, and total cholesterol).

Besides the lack of somatic pain complaints, it could have been AIM clinic at least in terms of the diagnoses. The second patient was a 76 yo man with DM and after sorting through the records that he brought with him we realized his fasting glucose was 178 so we started a sulfonylurea. The third and fourth patients just got refills of there antihypertensives (the families of both patients brought in a copy of the prescription from the last visit so we were a little bit more confident about the medications that the patients were actually taking). The fifth patient was an 80 yo man with HTN who had new lower extremity edema and his family volunteered that he had been sleeping sitting upright in a chair for the past few weeks. His BP was 130/90, lungs were clear, and he had 2+ pitting edema to the knees. Fifi stopped his HCTZ and started him on lasix for what was presumed heart failure. No further work up was needed she told me, it would be too expensive and wouldn’t really change what would be offered to the patient. The sixth patient was an older woman who present 10 days earlier with dysuria and had a positive urine dip so was started on ciprofloxacin twice daily. She returned to clinic now with continued symptoms and the results of her urine culture (which was ecoli sensitive to cipro). Some detective work eventually revealed she was only taking the antibiotics daily, she thought the cipro was too strong to take twice a day. The last two patients were 95 and 105 year old, and both suffered from “la memoria”. Fifi asked the caregivers if the patients were eating well enough, sleeping well enough or agitated at night. Both patients were quite pleasantly demented and doing quite well at home with a tremendous amount of attention and dedication from their families. The last family gave Fifi a basket with cheese and crackers to thank her for the care she had provided to their loved one.

After we had seen all 8 of the geriatrics patients who were waiting to be seen, Fifi asked me what I was scribbling in my notebook. I explained I was writing a little bit about each patient and keeping a running list about how things were similar and different between her clinic and AIM clinic; most of them I’ve already touched on above.

Similarities	Differences
*lack of temperature control in the rooms	*no PIC, no attending involvement
*patients and family members often have no idea what medications they are taking	*no patient records
*same diseases (DM, HTN, CVA, MI, dementia)	*many fewer labs ordered, many fewer diagnostic tests
	*patients take many fewer medications
	*no ancillary staff other than 1 woman who seemed to be registering patients for all clinics
	*no continuity, patients see different resident each visit

From Carrie: First impressions

Rhea, Jess and I also had the opportunity to travel to Santiago. We were in the Dominican Republic for 2 weeks in the beginning of April. We were hosted by Dr. Martin Medrano, head of Geriatrics at the public hospital in Santiago, who also hosted Janina. The public hospital, Hospital Universitario de Jose Maria de Cabral y Baez, provides free care for those without insurance and for the underinsured (often with the government insurance).

Our first day on rounds with the Geriatrics team was interesting, we saw a wide array of patients, many of them hospitalized for similar reasons as our patients at Columbia, although the plan of care often differed due to resources. The layout of the Geriatrics floor consisted of 2 large rooms, each with 4 patients. There was a nursing station outside in the hallway, so if the patient or families needed anything there was usually a nurse nearby. The nurses usually knew where to find the doctors if they needed help, they didn't use pagers!

Vital signs were taken by nurses on a regular schedule (2-3 times every 24 hours), and by the interns when pre-rounding. Records were all kept in a paper chart which was often at the bedside. The paper record included much of what we have in the computer: progress notes, consultant notes, a list of medications (updated daily), allergies, vital signs and blood glucose levels, blood and urine test results, as well as notes from ancillary services such as PT, OT, and nutrition. One thing I noticed about having a paper chart, and few computers, was that it brought care back to the bedside. Compared to our normal days at Columbia, the doctors were more likely to go into a patient's room to find information, and follow up rounds were at the bedside. This also made communication more frequent between the patient families and the medical team.

There were often multiple family members with patients at all hours of the day. Instead of being a burden to the nurses or doctors, these family members were expected to be there. On the rare occasion when family was not present, it was usually a sign of severe poverty and even neglect. While family members were throughout the hospital with patients on all services, there seemed to be the greatest number of family members present on the geriatrics floor. The family members were responsible for providing information on rounds (such as overnight events, current state compared to baseline, and ability to pay for future tests) and were in charge of the patient’s lab results and radiology films (which were often stored under the mattress). Families also helped with much of what we view as nursing activities, including chest PT, exercises, and helped to prevent falls in high risk patients (there were no nursing 1:1s).

I wondered, was the family presence in the hospital a Dominican thing, or was it only at the public hospital? According to my host mother, Bienvenida, there were more family members with patients at the private hospitals because there was more space and private rooms! So it was definitely a Dominican thing...

This made me think of the large families which often visit my Dominican patients at Columbia. My experience at Columbia is that when large numbers of family members arrive, the staff often gets overwhelmed and the family is asked to leave, particularly if it is late at night. Often there is at least one family member who stays as long as possible with the patient, but at times this person is thought to be checking up to make sure that everything is done correctly, or wanting it done in a different way. My experience is that this type of family behavior is the exception at Columbia instead of the norm. Looking back on it, the Dominican families must feel a bit helpless, as they are not counted on for lab results, x-rays, or PT, they are not always included in the minutiae of the daily plan. This has made me recognize that the family’s presence in the hospital is a cultural expectation, nothing more and nothing less than a demonstration of their love and respect for the patient.