A mseleni ward round
Trip Start
Nov 19, 2010
1
11
20
Trip End
Feb 07, 2011
Mseleni, KwaZulu-Natal, South Africa
Thursday, December 23, 2010
I arrived this morning at ward round a bit early this morning to check a couple of things. While I was busy looking at notes all the nurses came in and began a singing prayer. The sound was so beautiful it literally made the hair stick up on the end of the neck and its soberness was appropriate to the suffering in the surrounding beds.
You can tell from the end of the bed that the first patient isn't well. Breathless, cachexic, bloated abdomen from ascites and pitting odema to his thighs. This man is in his early twenties and has end stage HIV. He has tuberculosis (tb) throughout the body complicated with spontaneous bacterial peritonitis which basically means that his swollen belly is such a great place for bacteria to grow that a single bacteria can lead a massive infection. His blood protein is rock bottom so combined with the TB everywhere all of his fluid is leaving his blood and ending up everywhere it shouldn’t. He also has fluid around his heart and lungs. He has so much fluid Vahe and I in tag team (while being supervised) inserted needles into his abdomen and chest to provide some relief. Not many people would be grateful for these procedures under no local anesthetic but he was. He is looking better today with the big gun antibiotics of gentamycin and ceftrioxone but the outlook isn’t good. His family comes to sit with him everyday.
The next patient is a new admission who is not doing much better. This man also has end stage HIV and instead of having fluid surrounding his lungs he has tuberculosis filled "pus" that is tunneling out from his chest through his skin in a fistula. Every time he breathes in you can see his chest wall sucking in. You would think that having a massive hole in his chest would cause his lungs to deflate but in fact the pus has a wall which prevents this happening. He needs a drain inserted tomorrow.
It’s not all HIV on our ward, the next patient is having seizures to the point that when we arrive on rounds there is urine and blood (from a tongue bite) on the bed. He is a known epileptic and an alcoholic we are concerned he might be withdrawing from alcohol. Yesterday when he was admitted I was asked to do a lumbar puncture since meningitis is so common here. It all was going well until when we were half way through collecting the fluid he decided to try and lie down. Not the best with a whooping big needle in your back! Luckily Vahe was able to hold him up while we finished off.
The last patient on this side of the ward is at the end of a long admission for cryptococcal meningitis (CCM) which is a fungal infection that commonly affects people with HIV. The treatment is amphotericin which is pretty much the strongest antifungal you can get. The only problem is that it is so toxic to the kidneys that if the patients becomes slightly dehydrated they can go into renal failure and often do anyway. A characteristic feature of CCM is that more fluid is produced around the brain leading to high pressures, extreme pain and sometimes death. A treatment for this is lumbar punctures to release fluid and pressure which provides pain relief. Sadly this man has had a lot of pain during his admission and dislikes lumbar punctures which I don’t think anyone can blame him for. The pain became so bad yesterday that he begged for a lumbar puncture after he had been refusing them for three days. Although he wailed so all the hospital could hear he felt a lot better afterwards which was great to see.
The next patient is an nkulu which translates to respected old man who has advanced oesophageal cancer. He is not able to eat much as it is painful and oesophagus is largely blocked. His blood potassium which is a mineral that is key to keeping the heart pumping is rock bottom at 2.1. We are slowing increasing this so he can get home to his family for Christmas.
The next bed is a young man with pulmonary TB and a pneumonia which is the closest thing to a New Zealand case that we have on the ward. He is heading home.
Last but not least is another man with Cryptococcal meningitis. When he was admitted his HIV test was negative which was confusing as CCM only occurs in the immunocompromised. We repeated both the lumbar puncture and the HIV test. Sadly for him he was HIV positive. When we came to review him yesterday on the ward he was confused and left pupil was dilated and non reactive to light. We initially thought he was “coning” which means there is so much pressure inside the skull that the brain was pushing into the spinal column which is invariably fatal. There is no ICU in Mseleni and the best thing possible was an “urgent” CT scan in 3 days. Luckily when we reviewed him his pupil had improved and he was responsive. I really hope he gets better.
Today really reminded me how different a Mseleni ward round is to a New Zealand one.
