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Tuesday, December 30, 2014

Just got back from South Sudan--thoughts about tropical medicine

I just returned a few days ago from the Republic of South Sudan, where I spent about 3 weeks. Jet lag is fading, and in time I may even stop complaining about how incomprehensibly bad the Juba airport was. Overall the experience was great, though.

My intention was to spend 2 weeks with my friend Jill Seaman, a doctor who has been working in Sudan for decades, primarily fighting tuberculosis and visceral leishmaniasis by establishing  and pushing treatment protocols. Jill now helps run a community hospital in the (usually) tiny town of Old Fangak, on the Zeraf River. The hospital serves a community that usually numbers a few thousand along with anyone who can make their way there, but now Old Fangak has become a busy metropolis of over 30,000 people because of the many people who have fled their homes due to fighting. My job was to help out with patient care and teach bedside ultrasound. The other week of my three week trip is how long it takes to get to and from Old Fangak. I only got 10 days there, as it turned out, since the government has become more strict about flights to and from that area because it is a hot spot in their civil war. South Sudan is a new country, having gained its independence from Sudan in 2011. There was relative peace until last December when violence broke out in the capital between supporters of the ousted vice president and the president over policy disagreements. Since the vice president was from the second largest tribe, the Nuer, and the president was from the largest tribe, the Dinka, the disagreement became a tribal conflict in outlying regions which has been bloody and destructive. South Sudan has had lots of civil war, and this situation is more the norm than peace, which was sort of present for 2 years after independence.

My last visit to South Sudan was a year ago, right before the new civil war broke out, and my timing in leaving was close to perfect, since the whole place became hellish a week after I departed. This time the war was pretty close to Old Fangak, but its isolation, with no passable roads and only access by river, made travel there pretty safe. Still, much of the medicine this trip had to do with wounded soldiers. There was also the usual constant stream of the medically ill and occupationally injured, with their tropical ulcers, parasitic diseases, diarrhea and fevers.  Complications of starvation will set in more substantially due to disruption of farmers and cattle herders, but presently food aid from organizations such as the World Food Program is keeping this partially at bay.

When I got back, the Christmas holidays were quickly approaching. Family from far away were going to descend on our house, and I had piles of journals and notes and bills and certificates on important horizontal surfaces. While taking care of these, I found the notes I took from a brief DVD course in tropical medicine, released by the Mayo Clinic, that I took last year. I don't actually have a place to put hard copy notes where I will see them again and learn from them, other than coffee tables which would look way better without stuff all over them. So I am going to combine what I learned in South Sudan in Old Fangak with my notes as a way of remembering stuff. Here goes!

Poor nutrition, homelessness, poor sanitation and stresses underlie most of the conditions we saw. The vast majority of illness and injury we saw were preventable by clean and adequate water supplies, food and shelter security, good prenatal care, waste disposal and non-violent problem solving. There were almost no uncomplicated conditions. We saw patients in several situations. There were the inpatients, who had beds or pads on the floor of the hospital buildings and were given mosquito nets. They were usually the sickest patients, with problems that were life threatening and sometimes without easy solutions. There were patients with wounds, who were living either somewhere in the compound or in the surrounding village and would come in for dressings and sometimes minor surgical procedures. There were clinic patients who came to the morning, afternoon and evening clinics, staffed by local clinicians (nurses, clinical officers and community health workers) and sometimes by a doctor. Patient visits in clinic numbered around 200 per day. Some of these became inpatients. There were patients with conditions that required less intensive observation but which required long treatment courses, such as tuberculosis, nephrotic syndrome, Kala Azar and Brucellosis. These are exotic and rare in the US and common as dirt in Old Fangak.

Malaria is the most likely cause of high fever. It is the treatable cause which needs to be ruled out first. The test we use is a "paracheck" which is a rapid diagnostic test based on presence of malaria antigens. A drop of blood from a fingerstick is placed on a plastic stick with absorbent paper inside, a drop of fluid is added and lines appear in a few minutes indicating a diagnosis of malaria. This is similar to a urine pregnancy test and can be done in the clinic or at the bedside while the patient waits. The commonest form of malaria by far in Old Fangak is Plasmodium falciparum, the most severe and acute variety. It can present with metabolic acidosis, shock, coma, renal failure, even ARDS. In Old Fangak it can have all kinds of associated symptoms especially nausea and vomiting with diarrhea. Most cases can be treated with oral Artemisin combination therapy though cerebral malaria and other severe presentations are treated with intravenous medications. Somewhat less severe versions of malaria are caused by Plasmodium vivax, ovale, malariae and knowlesi (usually in southeast Asia) and these have different fever patterns. The Anopheles mosquito transmits malaria and is controllable with elimination of standing water (mostly impossible) and use of insecticides. Since these mosquitoes primarily bite as evening falls, use of mosquito bed nets, especially for children, drastically reduces malarial disease. Pregnant women are treated monthly during their first trimester with Fansidar (Sulfadoxine/Pyramethamine) because they are more susceptible to the disease and because it can cause miscarriage.

Visceral Leishmaniasis, also known as Kala Azar, commonly presents with prolonged fever, enlarged spleen and liver, sometimes with diffusely enlarged lymph nodes, and bone marrow involvement which can lead to anemia and low platelet and white cell counts. It often coexists with HIV infection, though not so much in Old Fangak where HIV is still relatively rare. It can be diagnosed with a rapid diagnostic test which detects rK-39 antibodies and is about 80% sensitive. If this is negative, a DAT (direct agglutination test) is performed which should detect 95% of cases. A lymph node aspirate can detect the actual organism, which is helpful when the immune response is not vigorous, like with HIV coinfection. It is about 60% sensitive, and can be used for detection of recurrence, unlike antibody and agglutination tests. Spleen aspirates, also useful in recurrence, have sensitivities as high as 95%. The lab staff is capable and confident in performing lymph node aspirates, which in the US would be a great big deal, and splenic aspirates are performed at the bedside in patients without significant bleeding risks, quickly and nearly painlessly, with vanishingly rare complications. The specimen is smeared on a slide, giemsa stained and examined for the tiny protozoans which look like an eyeball with a dot and are about the size of a platelet. The disease is usually treated with sodium stibogluconate (SSG) and paromomycin injections for about 3 weeks, which often cause nausea and vomiting an can also cause fatal heart arrhythmias and kidney problems. A less toxic but much more expensive option is liposomal amphotericin B which is given intravenously on an intermittent schedule, usually over 21 days. This is used for resistant or recurrent cases and in patients who don't tolerate the SSG/paromomycin regimen.

Back pain and tenderness, prolonged fever with weight loss, chronic arthritic joints in children, unexplained chronically enlarged lymph nodes, especially with fluid collections inside and cough with fluid around the heart or lungs is usually tuberculosis and requires prolonged residence at or near the hospital compound for directly observed treatment. Treatment of TB is effective and lifesaving and most patients comply with medication therapy which is impressive. Worries about contributing to multi-drug resistant tuberculosis slowed the development of programs to treat the disease, but at Old Fangak people are getting appropriate therapy along with nutritional support, blankets, mosquito nets and sometimes shelter and are being cured of their TB.

Nausea, vomiting and diarrhea could be anything, but is often Giardia. In many areas of Africa good sanitation has made this uncommon, but it is pretty rampant at Old Fangak. Despite aggressive latrine construction, babies and children, especially those with diarrhea, leave Giardia parasites everywhere, and though both Sudanese and Americans are clean and tidy in their own homes, the hospital compound seems to be covered with a thin layer of filth. Most floors are dirt. The floors that aren't dirt are mopped daily, but walls are not and small islands of cleanliness do not make a huge overall difference in infection control. Giardia is treated with tinidazole which tastes horrible and is slightly nauseating. It seems that, improbably, most children actually take it when it is prescribed.

Schistosomiasis is probably nearly universal, since most people swim and bathe in the river, which carries the parasite to the skin of the human host, which it penetrates to cause infection. Schistosomes are blood flukes which can affect most body systems, but schistosomiasis is usually either assymptomatic or associated with symptoms that are hard to notice, such as discomfort with urination or fatigue from chronic iron deficiency. The two types present in Africa are mansoni and haematobium. Mansoni is famous for causing portal hypertension with symptoms of liver failure, but more commonly causes chronic intestinal distress and intestinal blood loss. Haematobium is known for causing scarring and sometimes cancer in the bladder. The eggs can be identified in urine or stool, but in Old Fangak it is most often treated when patients present with classic symptoms, since most people are likely chronically infected. Reinfection is nearly impossible to prevent, though in some countries routine and repeated blanket treatment has been tried. Praziquantel, as a single dose, is usually effective in clearing the disease, and is sometimes used prophylactically for children at high risk.

Tapeworms and roundworms are surprisingly rare in our little community, but with the influx of internally displaced people that equation may be changing. These are pretty easily treated with a single dose of a pleasant tasting tablet, albendazole. They can cause intestinal distress and malnutrition and are associated with poorer school performance. I did see one case of an overwhelming infection with Strongyloides stercoralis, a roundworm, in a young woman who was chronically ill with kidney failure and vomiting who had tiny worms in her urine. Despite appropriate treatment, she died. Once this infection becomes so widespread it is hard to eradicate and usually implies an associated immune dysfunction. Malnutrition and kidney failure might have been what made her vulnerable.

Brucellosis is a disease carried by cows and dogs and transmitted to humans primarily through contact with their urine and feces. The cows, which are a common form of wealth and currency in South Sudan, are heavily infected. A vaccination program could be very effective in reducing cow morbidity (primarily abortion and infertility) as well as human disease but hasn't been tried. Ongoing civil disruption due to war gets in the way of all sorts of good ideas. Brucella causes recurrent fevers with nausea and vomiting and overall feeling miserable and can persist for years, causing chronic arthritis of the large joints and the back. Most infection is assymptomatic. It can affect the skin, with rashes, the eyes, causing inflammation and blindness, bladder, testicles and ovaries, lungs and brain. It is diagnosed in the lab with a serum agglutination test and treated with 6 weeks of doxycycline along with 2-3 weeks of gentamicin, which is usually given as a rather painful intramuscular shot. It frequently recurs.

Chronic kidney disease with nephrotic syndrome is surprisingly common and probably related to ongoing immune system activation by repeated infections of various kinds. This is treated with a slow taper of prednisone, which sometimes works. Patients usually present with facial and leg swelling along with frequent urination and fatigue. There is a fingerstick monitor of the creatinine level, something I haven't seen in the US, which is the only available way to document the status of a patient's kidney function. High blood pressure is treated appropriately which helps in recovery or at least to slow the progression of disease. Endstage kidney disease is right now a terminal diagnosis since there is no available dialysis or kidney transplant available to these people.

Late stage cancer is surprisingly common. There was a 17 year old boy with a tumor in the chest that had displaced his heart to the right chest cavity and obstructed blood flow into the heart. It was likely a mediastinal germ cell tumor, since this is not terribly uncommon in young men. It is quite sensitive to chemotherapy, even curable, but this person presented at such a late stage that he would have been lost even in the US. He had been in bed close to a year, had deep bedsores and legs which no longer would straighten. He had devoted parents and a winning personality. He died after a week in the hospital. There was a man who came in unable to swallow. This had progressed over a year, but his esophageal cancer (visible on bedside ultrasound) had now completely obstructed his swallowing and, though he would receive some intravenous hydration, there was nothing we could do for him. In the US he would likely have died, but would have had palliation with radiation therapy and a feeding tube. Esophageal cancer is common in East Africa. A woman returned to clinic after having received radiation and chemotherapy for a tonsillar cancer that turned out to be a lymphoma. With advice from doctors who were friends of Jill's, she received appropriate therapy and was free of disease when she returned. A beautiful young man had a deep and fungating wound of the right groin that was foul smelling and liked to bleed. It appeared to be a squamous cell carcinoma, but we did biopsy it and results are pending from Nairobi. He could get radiation therapy for palliation if transport could be arranged and if he is able to survive that long.

Tropical ulcers are very painful and appear usually on the lower legs after minor trauma. They are inhabited and probably caused by a collection of bacteria and can cause bone infections and even cancer if untreated. These are very common, and are treated with dressing changes, debridement and antibiotics. Presently we are using gentian violet topically which seems to speed healing. War wounds often cause extensive tissue damage and are treated with dressing changes and sometimes delayed primary closure once they are clean and healing. They can be disfiguring and painful. I tried a combination of guar gum (a component of many high tech wound dressings) with powdered antibiotics for some of the more weepy wounds. This was popular with the patients but I wasn't there for long enough to see if it improved healing. It did appear to reduce evidence of infection.

Pneumonia, especially in kids, and diarrhea with dehydration in babies accounted for a reasonable amount of sickness. Most pneumonia is treated, successfully, with amoxicillin, some with ceftriaxone, and diarrhea was treated with oral and sometimes intravenous rehydration, with treatment for the specific cause if that became at all clear, often with antimalarials or antibiotics. Runny nose with runny eyes, especially in the presence of rash was measles and often quite a severe disease in small children. Most medical missions take vaccination of children quite seriously, but most remain unprotected.

In the US I normally see complications of heart failure and vascular disease, primarily related to smoking and obesity, diabetes and its sequelae, chronic lung disease, again related to smoking and infections that are often complications of IV drug abuse. I also see the devastations of extreme old age with dementia worsened by urinary tract infections or pneumonia. None of this is common in South Sudan. In the hospital at Old Fangak the common conditions are about as diverse as I see at home, but the options for diagnosing and treating them are much more limited. For me there was quite a steep learning curve. 

Staff from the community who have little or no formal medical training do a tremendous amount of the work, including diagnosing and treating very significant and, for me, exotic diseases. This is made possible by protocols developed by generations of doctors, including ones working with Doctors Without Borders and especially Jill Seaman who has been doing this kind of thing for a really long time. When no Americans are present, Kala Azar, tuberculosis, brucella and many other diseases are treated effectively and followed appropriately by South Sudanese health workers. They could certainly use more training, but I am in awe of their skills. I saw one of them put an IV in a dehydrated baby with no difficulty which I doubt could have been done with such skill in a US hospital. With access to medical and nursing school, which they do not have, their potential would be tremendous.

Working in Old Fangak is something that doctors dream about. It is expensive to travel there and disruptive to my work schedule, and there are all kinds of diseases that are easy to pick up. There are grouchy people with AK47's wandering around looking twitchy. The medical care requires flexibility and is often incredibly frustrating when lack of resources makes it impossible to solve a problem that is so very soluble if only the situation were different. Still, the company was excellent and the patients were great and the attitudes and skills of people working there were inspiring. It was deeply fulfilling, I learned a ton and have a bunch of great stories. Also... hooray, I didn't die!

Monday, December 1, 2014

In hospital versus out of hospital heart attacks: wow, things sure cost a lot of money!

An article from the JAMA (Journal of the American Medical Association) has been gnawing at my consciousness for the last couple of weeks. Dr. Prashant Kaul and colleagues out of the University of North Carolina reviewed records from hospitals in the state of California from 2008 through 2011, looking for patients who had been hospitalized with heart attacks. Specifically, they were looking for patients with ST elevation myocardial infarction (STEMI), which are generally the most damaging and deadly of the events generally known as heart attacks, due to the amount of damage they do to the heart muscle. The authors compared patients who were already in the hospital for another reason when they had their heart attack, versus ones who were admitted specifically for heart attacks. They found that the patients who were admitted specifically for the heart attacks were generally younger and healthier, more often male, and were much more likely to survive than the ones who were hospitalized with other illnesses at the time of their STEMI. This is not terribly surprising, since people who have some other problem bad enough to put them into the hospital and then develop a heart attack on top of it are clearly at a disadvantage, even though there are cardiologists with magical potions and procedures close at hand.

What was most interesting and disturbing to me was the sheer astounding magnitude of costs associated with these groups of patients. The patients admitted for STEMI stayed an average of 4.7 days and total costs were $129,000. About 9% of them died. The patients who were already in the hospital at the time stayed an average of 13.4 days, their costs were $245,000 and a third of them died in the hospital.

I don't think we should get jaded to numbers like this. This is real money, the kind of money that can buy a house in some places or at least a very hefty down payment, can support a person for years, and the co-pays on which can destroy a family financially. As a person is racking up such a bill, there are days of inadequate food and sleep, indignities of hospital gowns and waiting for someone to come with medication or to allow one to empty bladder or bowels, if it's not already too late. And death, in 9-30% of the people thus cared for. In a hospital. This money is not buying comfort and luxury. What costs so much? I'm not entirely sure. The interventions done on people with heart attacks include bypass operations, which are costly, but happen to very few of these people. There are the "percutaneous interventions" meaning high-tech catheters passed through arteries to place stents in clogged blood vessels in the heart, which are also terribly costly, sometimes as much as $40,000 for placing a tiny metal finger trap in a partially blocked artery. More stents are placed than need to be, per many studies, but an STEMI is definitely a good reason to place a stent and doing so is often life saving.

But why? Why so much money? There is nothing absolutely expensive about any of this. A little expensive, yes, but not hundreds of thousands of dollars. But the costs add up. The equipment is getting incrementally slightly better and is priced somewhere in the ozone. But it's not about raw materials or time or any of the resources that are truly set in stone. The costs just rise to the level that we agree to pay. The many places where money hemorrhages from the system feed our vibrant healthcare economy. We pay huge amounts of money to insurance companies who disburse it to the entities that charge this much. If there were limits on costs, or even goals for cost cutting, I'm confident we could slim down our spending. But there aren't and we don't.

Heart attacks and their treatment are just a tiny piece of the picture. There are still a few good values (a needle and syringe still costs less than $1), but generally everything that has to do with healthcare is overpriced. I learned a new computerized medical record keeping system last week and talked at length to the trainer who had been instrumental in adopting it. I complained because it was clearly clunky and lacking in the subtleties that would have made it really useful. I asked about another program I had heard about which was looked at as the best. According to her, the "best" cost about half a million dollars per hospital bed to implement. A medium sized hospital might be 200 beds. So 100 million dollars. Apparently hospitals, hoping for efficiencies, have gone bankrupt after adopting this Mercedes Benz of medical records. And the other systems aren't much cheaper. How is that even possible? There are almost no fixed costs in computer software. They charge this much entirely because they can.

There are no obvious solutions to this, while we remain attached to a non-centralized third party payment system. Payment structures are changing, but slowly, and the powerful interests who make money off of this system seem to escape ideas made to dampen profits. As individuals, though, it's important to continue to notice that things cost too much, they don't have to, and it's not OK.