one muddy brown step forward

Let me tell you; the times are few and far between when we’ve done something actually useful, but today was one of those times.

So we’ve already blogged a couple of times about the mid-30s woman who became septic following an incomplete abortion and went into complete renal failure, making her the second patient ever at Bugando hospital to receive peritoneal dialysis. Well, it had been nearly a week now, and her urine output has started to pick up. We were hopeful that this was indicative of the second stage of an acute, and reversible, form of kidney injury called acute tubular necrosis (ATN). In the first phase, the cells lining the tubules of the kidney die from a lack of oxygen, clump together, and obstruct the tubules, causing the patient to have markedly decreased urine output. In the second phase, the clumped, dead cells begin to clear from the kidney, but the new tubule cells don’t work yet (and their main job is to reabsorb salt and water), so the patient goes from making almost no urine to making a ton of urine. In the third phase, the patient’s kidney function recovers (typically to baseline).

Diagnosis of ATN is often clinical, but can be confirmed by one particular finding, and today, we found it. We discovered that within the ICU there is a centrifuge and a microscope that could be used to look at urine sediment. We then scrounged up some glass slides and cover slips from the lab, put the slide under the microscope, and there it was: a muddy brown cast (when the tubular cells die and clump together, they become very densely packed – thus the muddy brown – but deform to fit the shape of the hollow tube – thus the cast). Clear as day. We showed our finding to Mubarak (an absolutely brilliant resident who is essentially the one man peritoneal dialysis team at Bugando). Unbelievably, we may have managed to use a limited resource in the exact appropriate setting – to temporarily stabilize a patient with a reversible condition. She’s still very sick, and we don’t know if too much damage has been done, but we hope. We hope.

(In other news, we went to an awesome pizza place yesterday, and absolutely gorged ourselves on pizza with a variety of exciting toppings, including: pineapple, spinach, avocado, eggplant. It was sweet.)

code leader?

(First of all, Portishead’s Only You is playing in the ex-pat bar from where I am currently blogging – awesome.)

I asked Annie what today’s subject should be, and she said, “Code dynamics.”

By Code, she means the standardized sequence of events that is classically followed when a patient loses circulation (otherwise known as Advanced Cardiac Life Support, or ACLS). In the US, the success of ACLS is achieved in large part due to implentation of a highly systematic process in which everyone’s role is clearly delineated. A “code leader” stands at the foot of the bed and gives instructions, while nurses and other residents are performing chest compressions, performing bag-mask ventilation, drawing blood, achieving intravenous access, or securing an airway via endotracheal intubation.

So, things run a little differently in Bugando. First of all, the ICU is not consistently staffed by residents. The residents round once in the morning and once in the evening; the remainder of the day, the patients are monitored by the nursing staff. Based simply on who is usually present, the nursing staff classically initiates what they call “resuscitation” when a patient loses a pulse, including fluid administration, cardiac resuscitation, and intubation. But this becomes a problem when a code occurs while residents are present. The reason this is a problem is because (and there’s no other way to really say this) the nurses code patients in a manner that is largely incompatible with any positive outcomes. Resuscitation is often not even begun until the patient has been without a pulse for minutes, and the sequence of events occurs at a painfully slow pace.

So. Situations often occur like this morning, in which a lovely, middle aged woman who was transferred to the ICU in relatively stable condition yesterday was found this morning by a humble visiting medical student to be hypotensive and largely unresponsive, and after recruiting his resident/wife, the patient took 2 agonal breaths and abruptly lost her pulse. Our natural reaction was to begin chest compressions; yet, it was critical for us to successfully attract the attention of a nurse in order to get permission to begin participating in a code situation. Throughout the code, we struggled against the slow pace at which resuscitative efforts were happening (you should all be proud of the multiple ways in which Annie politely asked for a defibrillator without losing her cool), all the while realizing that at this pace, nothing we were doing would be of any benefit, yet we were limited by the culturally established hierarchy on whose totem pole we were woefully low.

Ultimately, our success in this situation, like in a recent situation, came when we were able to partner with the in-house resident when he arrived to prevent a lifeless body from being intubated. However, our attempt to gain permission for an autopsy (the only way that we would ever find out if and how the management of this patient had been misdirected) was unsuccessful, leaving us to wonder if we had made any positive impact at all. Today was the second consecutive day that a patient we hoped would pull through literally took her last breaths in front of us, as we struggled against 2 very different, but equally frustrating limitations: first by the hospital resources, second by our lack of authority.

Not all is depressing, however. In fact, I’m very proud of the fact that our current team, led in tandem by Annie and Meda (our brilliant Tanzanian resident) and supported by Judith (who is headed to MGH for medicine) and myself have been able to promote a systematic approach to daily rounds in the ICU. I think we’ve helped show one of the best senior residents here that a systematic, evidence-based approach can be effective even when optimal resources are unavailable. It’s the refrain that we all repeat to ourselves: that the benefit we are providing is (hopefully) systemic.

In other news, I played soccer over the weekend with a bunch of local Tanzanians and Indians. News flash: people who play soccer often are awesome at soccer. My big success was that I managed to play for a half hour without attempting to strike the ball and completely missing, or committing any abhorrent turnovers. Of course, once I left the field, I had to pretty much go into suspended animation for the next 12 hours to recover enough strength to even eat dinner. Still, it was awesome, and made me even more excited to go see a soccer match (featuring Simba FC, who stand atop the Tanzanian Premier League) this Saturday!

Till next time!

Food

Since Santosh has taken on the responsibility of updating the blog with important things like our medical experiences, etc., I figured I'll take it upon myself to write about something no one really cares about except for me: food.

Things we eat a lot and like:
- mango and pineapple -- WOW is this stuff ever better than what we buy off the street in New York
- rice and beans -- simple, yes; protein, yes; cheap, wowee yes
- carrot and cabbage pizza -- this requires a bit of explanation; at the house where the visiting residents / students live there are three House Ladies who cook lunch and dinner every day; they are very sweet and have decided that we miss Foods of Home, which apparently means Bizarro Italian Food; lots of lasagna (good), pasta (good), but best of all, pizza; they toil over this home-made crust all day (or so we've told ourselves) and top it with the strangest and most available veggies imaginable: carrot and cabbage; the other day we found some lone strands of eggplant; bon appetit!
- peanut butter and bananas on toast -- breakfast of champions, especially when the milk is poison
- stoney tangawese -- ginger beer, and my drink of choice
- passion-fruit flavored fanta -- Santosh's drink of choice
- chili sauce -- this is my favorite thing here; mild-moderate spicy, but more important, has a smokey flavor to it; goes well on rice, pasta, avocado, bread, a spoon... I plan on bringing many bottles home with me in my checked luggage; Santosh only will let me do this if I promise none of his belongings is in the bag I use to transport the chili sauce, since he doesn't trust bottle caps
- TONS of Indian food, everywhere; major Indian influence in the country because of the ancient spice industry on the coast / Zanzibar

Things we try to avoid eating despite the availability:
- ugali -- this is a ball of corn meal that has zero taste; the plan is you dip it in whatever you're eating; but in the end, it is dense and flavorless and definitely has no fiber for those of us concerned (ahem: me); greatly improved with chili sauce (see above)
- mayo -- on many, many dishes; and unlike in Japan, where mayo is abundant and refrigerated, the climate here is quite warm...
- kilimanjaro instant coffee -- BLECH

Things we miss:
- real coffee
- sushi
- non-poisonous milk
- green vegetables

Am looking forward to our first meal home of sushi, spinach, and coffee-flavored ice cream.

Mood swings

Oof. This morning was a challenge. It was yet another reminder (as if we needed one) that the limits on providing care at Bugando extend far beyond lack of laboratory tests, diagnostic tools, or therapeutic interventions. Let’s revisit the last 24 hours!

Yesterday morning, ICU rounds
Patient 1: 43 year old male, recently underwent an exploratory laparotomy for a surgical abdomen (which, incidentally, revealed a liter and a half of fluid that had accumulated for no apparent reason, and of course, did not get sent for analysis), with post-operative severe hypertension.
What we would do in the US: use any number of IV anti-hypertensives at our disposal
What we were doing: using hydralazine, the only IV med we had, while hoping that he would be able to take oral medications before he had a stroke
What happened yesterday: He passed gas! Hooray! We started him on 2 oral anti-hypertensives. By the afternoon he had achieved target BP reduction.

Patient 2: 41 year old male, in the ICU for 3 weeks with severe tetanus.
What we would do in the US: probably run frantically to Up To Date because we have no idea how to manage tetanus
What we were doing: effectively controlling his spasms with a combination of sedating medications. He was past the worst and was getting better every day; the only problem is that he hadn’t had a bowel movement since coming in, and was now starting to eat. We had tried a lot of stool softeners and they weren’t working. This day he had started hiccupping (a sure sign that the gas he was making was coming out the top instead of the bottom), so we asked the nurses to do an enema.
What happened yesterday: he had started vomiting bile, and (understandably) refusing to eat food. We asked the nurses, again, to do an enema.

Patient 3: 37 year old female with a recent self-induced partial abortion, who had developed endometritis, likely sepsis, and complete anuric renal failure with encephalopathy.
What we would do in the US: urgent hemodialysis, imaging, and probable hysteroscopy to rule out retained products of conception.
What we were doing: first, trying massive doses of lasix to try to generate urine output (unsuccessful), then attempting to convince the surgeons to place a peritoneal dialysis cathether so we could perform intermittent PD in the ICU. Oh, all this without any way to objectively measure her renal function.
What happened yesterday: The surgeons took her to the OR! Hooray! We planned for PD overnight.

Patient 4: 39 year old female, known diabetic, who recently went to a healer in Arusha who has been telling people that he can cure 5 common diseases (AIDS, TB, asthma, diabetes, and epilepsy), with a plant boiled for 10 minutes. She had stopped her insulin and presented in diabetic ketoacidosis, as well as neck stiffness, fever, and altered mental status.
What we would do in the US: DKA protocol, head CT, LP
What we were doing: actually pretty close. No imaging, but we started the DKA protocol and did the LP
What happened yesterday: CSF was in the lab for analysis, and her blood glucose was improving. We planned to transition her to an outpatient insulin regimen.

Annie, Judith, and I left triumphant. We had made some big steps forward.

This morning (Saturday), ICU: We walk in to a disaster.
Patient 1 (hypertensive emergency): after stopping the hydralazine drip and starting PO medications, the nurses saw that his BP had rebounded somewhat. Instead of giving him a PRN medication to keep him off the drip, they restarted the drip and skipped his AM medications.

Aftermath: This one isn’t so bad: we stopped the drip, added on more oral medications, and left detailed instructions for the nurses).

Patient 2 (tetanus): continued to vomit bile, refused all oral intake, no bowel movements. No enema done.

Aftermath: Even this one is OK: Annie hovered over a nurse until she did the enema. And he had a bowel movement! Yay! Poop!

Patient 3 (complete renal failure): Mubarak (an amazing resident here at Bugando and the man in charge of peritoneal dialysis) shows up at 11pm to start dialysis and finds the patient in a pool of her own blood (hemorrhaging from her cathether site). He orders an urgent blood transfusion, holds pressure for 2 hours before she stabilizes. Labs from 3 days ago return showing that she is in DIC. This morning, she is stable, but unarousable.

Aftermath: peritoneal dialysis is finally started, but she has lost alot of blood, and being in DIC isn't going to help things.

Patient 4 (DKA +/- meningitis): We show up to find her intubated. The flow sheets show that she became hypoglycemic in the evening, but the insulin drip wasn’t stopped. Then at some point, the drip was stopped. In the middle of the night, she inexplicably became hypoxic and was intubated. This morning, she was back in DKA. Oh yeah. They never sent the CSF.

Aftermath: We took the CSF down to the lab ourselves, and re-started the DKA protocol. Unfortunately, patients who get intubated at Bugando have essentially a 100% mortality.

So. It was rough. Now, as usual, onto some happier items!

1) The boat ride happened!!! It was amazing actually; you can sit on top of the boat and have a completely unobstructed view of Lake Victoria and Mwanza. One of the coolest things we’ve done here.
2) Thursday, we went to yoga, then came back to have dinner at a local restaurant that we all like to say goodbye to Jenny, one of the OB residents who was leaving. It was a blast, until a crazy thunderstorm started and the power went out in the city all within about 3 minutes.
3) Friday, we went back up to Dancing Rock and had a picnic for our friends Sonabel and Nora, Cornell med students from Qatar who left today. Then Annie and I came home and watched West Wing, and I started on The Plague (loving it so far).

This weekend’s big plan: possibly a trip to Capri point (apparently the neighborhood where the wealthy Tanzanians live, with lots of scenic viewpoints).

Oh yeah. Annie and I bought some chocolates for the village kids behind one of the houses, and I got to give them out. I felt like Santa. It was AWESOME.

Till next time!

week 3 shenanigans

Update: our attempt to rescue our young female patient with end-stage renal disease with pulses of high-dose steroids was unsuccessful. With no other potentially therapeutic strategies remaining, the team faced our last challenge: preventing painful, and undoubtedly unsuccessful, attempts to resuscitate this patient when she ultimately succumbed. It’s quite difficult to introduce the idea of palliation here; it reminds me of some of the orthodox Jewish patients at NYU who find the concept of palliation foreign. I think when it seems like the deck has been historically stacked against you, its hard not to see palliation as accepting defeat. But in this case, we convinced the team that attempts to bring this patient back would be categorically fruitless and likely painful (broken ribs from chest compressions, electrical shocks to restart the heart, etc.) She passed away yesterday.

Now, onto other, happier news.

Yoga

We go en masse every Monday and Thursday to Tunza beach, which is about a 15 minute drive from where we stay. I’m not exactly Mr. Yoga (I’m inflexible in both personality and general body habitus), but its difficult not to be relaxed doing yoga on the beach at sunset with Coldplay on in the background. Plus, the guy who leads yoga, Moosa, is an awesome guy who a) plays ultimate Frisbee and b) takes fabric we buy and can make it into bags, dresses, even a surgical cap for one of our friends!

Tanzanian kids are the shiz

First of all, they are all adorable. Second of all, the young kids get very excited when they see us, yell “Mzungu!” (which means ‘white person’ but which they use for pretty much anyone foreign) about 463 times, and once we respond, carefully say, “Good afternoon.” Either that, or they respond delightedly when we try to speak to them with the four Swahili words that we know. Also, a few times a week, they do calisthenics where they run by in big groups, chanting Swahili songs together. It’s amazing. There is a group of about ten young kids behind the house we were staying at who are about to get uber-spoiled with candy, courtesy of yours truly.

I'm (hopefully) on a boat!

Mwanza is on the shores of Lake Victoria, a gorgeous freshwater lake that, unfortunately, is colonized by a certain worm that causes portal vein fibrosis and massive vomiting of blood in a lot of chronically exposed residents (for example, fishermen). But, apparently it also has an unparalleled view of the sunset. We have been trying to find a sunny afternoon when we can go out on a large boat (don’t worry parents, its driven by a captain and we won’t be entering the water, we are equally terrified of schistosomiasis) and see the sunset. The problem is that the weather is erratic here; it rains for about 1-2h every day, which is perfect because it cools the temperature down about ten degrees and is gorgeous the rest of the day, but bad because it is impossible to predict in the morning whether it will be sunny in the afternoon. But we have a plan to go today; fingers crossed!

Family dinners

We all gather in the Serengeti house to eat dinner together. This often consists of a) some form of pasta (spaghetti, pizza), b) a limited range of vegetables (we’ve now seen carrots and cabbage in every conformation from slaw to pizza toppings), and c) fruit (pineapple and mango, to all of our delight). It’s pretty nice to all gather every evening and share stories between medicine, surgery, OB/GYN, and pediatrics. Due to our neurotic obsession with planning, Annie and I are the de facto parents/camp counselors of the group (which we prefer).

Books

So far, I’ve read Atonement, Virgin Suicides, The Wanting Seed, and Rabbit, Run. All quite good, Atonement and Rabbit, Run are standouts (although I’ve rarely been more infuriated by a main character than by Rabbit). I’m starting on Albert Camus’ The Plague today.

Till next time, quaheri!

SAFARI

“When I was a young warthog…”

This past Friday through Sunday we ditched our white coats for sun block and ventured into the Serengeti for our first safari. In brief: awesome.

We left late Friday afternoon with three other visiting residents (Raja, Esther and Brit). After picking up all-important provisions (extra water, Pringles), we spent the first night camping just outside the park. The most terrifying wildlife we encountered at that point was a millipede bigger than my family’s toy poodle.

The next morning we woke up at dawn to head into the park. Our ride consisted of a huge jacked-up truck: seats ten, painted dark green so as to camouflage (ha), and with a roof that rises up about two feet when you enter the park so you can be driven around with the wind in your face but without getting horribly sunburned. This clearly made all the difference between safari and a zoo, because you really felt like you were THISCLOSE to the animals, but at the same time, you could easily duck for cover if one decided to eat you. (Note to Mom: none did.)

Animals seen on Day 1: wildebeests, zebras, elephants, giraffes, hippos, monkeys, a lot of creatures that all looked like deer to me, a leopard that had dragged its kill up into a tree, and our new favorite animal, warthogs.

After a full day of driving around and getting dusty, we “camped” in a luxury tent hotel, which means that every room was like a normal hotel room (tiled floors, nice bathrooms and fluffy robes, mini toiletries) but with a huge overhanging tent as the walls and ceiling. Definitely one of the coolest places I’ve ever stayed. And definitely some of the best sleep I’ve ever had. (Because the hotel is smack dab in the middle of the Serengeti, guests often hear animal noises like lion roars in the middle of the night; I, however, slept like the dead and thus heart no such thing.)

Animals seen on Day 2: billions more zebras, wildebeests, elephants and giraffes; but then came the good stuff – several lions and cheetahs, crocodiles, and best of all, two dead things: a dead zebra that had had its ribcage recently chewed off, and a dead cheetah being eaten by vultures. CRAZY.

Oh, and did I mention that we say baby versions of almost all these animals? Baby warthogs = most adorable animals ever.

Overall, an absolutely amazing, unforgettable experience. If any of you is ever in the neighborhood, we definitely recommend it.

successes and failures

So, on match day, I had 2 very interesting experiences at Bugando. Annie and I encountered the first when we came home for lunch and found one of our housekeepers asleep on the floor of one of the bedrooms. When we woke her, she said she was sick, was visibly sweating, and had a nasty cough. Annie listened to her lungs and heard some wheezing, so at lunch, our group made the executive decision to take her to the hospital (more so because we wanted someone who can speak Swahili to take an accurate history than because we thought she had anything dangerous.) Within about an hour and a half, Judy, Jess (2 of the other med students here) and myself had somehow managed to get her a chest X-ray, blood work, antibiotics, cough suppressants, and an actual face-to-face encounter with an ER doc…mostly by being pushy. It was kind of like a ‘day in the life’ of a Bugando patient, except that in this case the Bugando patient had 3 english-speaking, somewhat medically savvy, highly impatient helpers. We figured it was good karma for match day (turns out, it was!)

The other experience concerned a patient recently admitted to the ICU; a 20 year old woman who presented with shortness of breath, cough, decreased urine output, and a blood pressure in the 200s/100s. It turns out that she had been diagnosed with hypertension at age 16, but was not on medication and a secondary evaluation was not done; she now presented with end-stage renal disease.

People talk about how a uremic death is a peaceful one; that may ultimately be true, but the lead up is anything but. These are some of the unique experiences we’ve had at Bugando – watching the slow inevitable march of uremia in a patient with chronic glomerulonephritis, which you cannot definitively diagnose (because renal biopsies aren’t available), which you cannot cure (as neither are renal transplants), and whose symptoms you cannot even alleviate (because dialysis reagents are sparse and reserved for patients who have reversible acute kidney injury). On admission, she had headaches and signs of cardiac failure (shortness of breath, cough, lower extremity swelling). Yesterday morning she began to develop uremic pericarditis with the loudest and most unforgettable pericardial rub I’ll ever hear. Later in the day, intractable nausea and vomiting began, some blood tinged, no doubt the markings of uremic platelet dysfunction. Today, pruritis set in, causing her to itch as if she had been rolled in poison ivy. It’s true; eventually encephalopathy will set in and she’ll drift into a peaceful sleep. But I wouldn’t call her last 3 days in any way peaceful.

One wonderful thing is that Annie and I are learning to make decisions based on what limited resources we have; we successfully advocated for a trial of pulse steroids in the unlikely hope that she has a reversible inflammatory glomerulonephritis. I doubt either of us has ever advocated for so much steroids with such little evidence, but it’s either that or standing idly by. There are many limitations that are tough to cope with, for sure, but Bugando is an amazing place, with resources that are probably only available in the capital city of Tanzania. Which means that, even in the face of diminishing odds, we've chosen to look around at what weapons we have, gear up, and go down fighting. I should say that we've already had 2 patients (one cardiac arrest, one worsening septic shock) where our efforts haven't achieved much, but I think Gandhi was the one who said "you may never know what results come of your action, but if you do nothing, there will be no result." (Yay, pretentious ending!)

Bugando: first impressions

It's hard to describe our first experiences at Bugando. To say that "things run differently" is a ridiculous understatement. I guess I'll just try to highlight a few things that I have found notable during our first few days.

1. Diagnostic Tools: To be frank, the residents here have to go much further with much less. Routine labs are anything but routine; things we take for granted like CBCs and X-rays take so long (even for ICU patients) that management in large part is based on: history, physical exam techniques, vital signs, and ultrasound (a skill at which we are both hoping to improve).

2. Severity of Pathology: I thought it would be different, but in 2 days I didn't think I'd see this much: a man with stage 4 tetanus with his jaw fixed in the class risus sardonicus lockjaw-grin, a tuberculous pericardial effusion so large that the mediastinal borders took up the entire chest, countless parasitic infections causing liver fibrosis and GI bleeding. But the most difficult, of course, have been the often futile challenges in managing complications which would be routine in the US: appendicitis complicated by an abscess, C-section complicated by peritonitis, a routine anterior myocardial infarction - none of these might even merit an ICU admission in the US, but here the house staff struggles to merely keep them alive (and often fails).

3. Yoga: tried it for the first time yesterday. As expected, it was very difficult, and I was pretty bad. (Annie's good at it though). But the class was on the beach, which was pretty soothing.

That's all for now!

Annie's Addendum

Agree with all the stuff Santosh wrote.
Additional thoughts:
- I have a hunch that sunburn here might be a bigger deal than bug bites. Hooray for the ridiculous floppy sun hat I bought from Kohls!
- It's crazy that I'm overlooking Lake Victoria RIGHT NOW. (When I look up from the keyboard, of course.)
- Just finished reading: The Virgin Suicides by Jeffrey Eugenides. Waiting for Santosh to finish Atonement so I can pick it up next...

First Tanzanian Post!

Greetings from Malaika, where we are spending our Sunday at basically the nicest resort in Mwanza, courtesy of Raja, who is basically the Great Gatsby of Tanzania. He knows everyone, and everyone knows him.

Some initial thoughts:
1. Air Emirates is an awesome way to fly. We watched The King’s Speech on our first flight (amazing movie) and the food was easily the best I’ve ever had on a flight.
2. Dubai airport: overrated. Basically your standard airport, although we did enjoy their lounge chairs while waiting for our transfer.
3. Initial view of Tanzania: reminds me so much of India – the small shops, the population density, the friendly kids running about…its almost like a carbon copy.

As soon as we got in, we were treated to a welcome party (courtesy of Raja, of course), where we got to meet some of the visiting residents and students as well as some of the local interns and residents. My first description of them: friendly, and terrific dancers. They pretty much do whatever comes to mind, and make it look cool.

Current book I’m reading: Atonement, by Ian McEwan

T Minus 1.5 Days

Travel tips from Mom:
- know where to find the embassy
- avoid dirty parrots
- pick up something cute for the dog