Medical update

The past few weeks have flown by as we prepare for the final step in our transition to being the new medical directors- Jeevan’s departure. He flies home to his wife Amy, their two dogs and a new fellowship in hematology-oncology on May 7^th . Paul and I feel so lucky to have had such a long orientation with him. He’s been a great teacher to us and to the staff and a very funny and easy man to live with. We’ll miss our card games, our shared meals, our memorable ‘60’s style “rap” sessions where we solved all the problems of the world, our movie nights, his smooth moves on the dance floor and his wonderful, exuberant laugh. Tomorrow we’re planning to take a final day trip to a nature preserve and a couple other sites with our “guide” Daniel, who is on the staff here.

So many of you have asked us what kinds of things we see in the clinic and what do we do day to day besides nap and chase the cats with our blow darts. I’ll try to answer some of your questions in this blog.

Paul was asked to focus his attention on our PSC- the Patient Support Center- the clinic that cares for our patients with HIV and/or TB. Jeevan spent his time here building the foundation for the program which is currently caring for 400 patients a month. The goal is to increase that number to 1000 by the end of 2008.

The clinicians see patients in all stages of the disease in the PSC and are challenged to provide good care without the benefit of having routine labs and other diagnostic studies we have in the US. We’re lucky to have an array of antiretroviral and TB drugs available to our patients. This was a huge step forward in HIV care in East Africa. For the rest of 2008 Paul will work with the staff and Community Health Volunteers to track patients who have disappeared or stopped taking their medications to get them back into treatment. Paul and the staff will also find ways to increase HIV testing in villages and to refer newly diagnosed patients into care. He has a lot of good ideas to motivate the CHV’s and to get their communities more involved. One of our biggest challenges will be to try to get a pediatric HIV program off the ground as part of the PSC. I’ll write more about that in coming months. It’ll be an interesting year for him. He’s also in demand as the teacher for our beginners computer classes and will offer other educational topics to the staff throughout the year.

My focus will be on the main clinic and our outreach sites. Rather than see patients myself I’m in the role of a collaborator and consultant to the clinicians. The nurses function as nurse practitioners or physician assistants but they lack the education and training in some cases to fully fulfill the role. Much of what they learn is on the job so they look to the American volunteers to provide ongoing education and clinical supervision.

The clinic usually has 3 clinicians on duty during the week and they see up to 100 patients a day. They see a variety of illnesses but most are far from the everyday garden variety we'd see in most US clinics. Kids don’t come in with just colds and ear infections.

Some of the patients we saw last week…a 7 year old girl who was so anemic that her nails and tongue were pearly white. She had sickle cell anemia. I looked at a slide of her red blood cells and she had very few normal cells. Most were the characteristic shredded, comma shaped cells. Her blood count was very low but not low enough for her to qualify for a blood transfusion at the hospital. We treated her with folic acid, vitamins and updated her immunizations. We’ll try to see her on a regular basis.

A woman needed stitches yesterday after being slashed with a panga by her husband’s other wife. A young man had big sores on his body for 5 months- he had undiagnosed HIV. Our staff was called to transport a couple of kids who were poisoned from eating a plant called cassava. They suddenly were unable to walk but luckily are doing fine after their stomachs were emptied. What else? Let's see...there are often people who come in with poisonous snake bites. One tragic case we saw a week ago was a woman who was 32 weeks pregnant and started having seizures at night. By the time her family brought her to the clinic the next day she was unconscious and had dangerously high blood pressure. She had eclampsia which is a frequent cause of maternal deaths. Paul rode with her to the hospital but the woman and her baby died later that day.

A 9 year old girl was brought in by her mom with a report of sudden onset of weakness in her legs and difficulty walking. She needed support to stand and had to walk by rocking back and forth on her legs. After gathering what information we could by our history and exam we suspected that she may have TB in her spine. We sent her for an x-ray at the hospital.

There's occasional cases of malnutrition but in general we see very little of it. Usually we find the moms are young and are poorly informed about the nutritional needs pf their infants so they feed them too many starches and not enough protein.

The everyday things we see here are unusual in the States. Malaria, worms, measles, whooping cough, rabies, even the various types on TB are a rare diagnosis at home. So I’m also a student and the staff my mentors.

The last thing I'll mention is the program to prevent transmission of HIV to infants during pregnancy and after delivery. It's shocking to have so many of our pregnant moms test positive for the virus. We don't have a clear picture of how many infants have been infected but we hope to have a better idea as we move forward with the Peds program. So I'll work with the staff to strengthen that program.

So that's a little taste of what we're doing here. As the year goes along we'll provide updates from time to time but we also enjoy your questions and com.