A Severe Burn Case Presents More Than Just Medical Challenges

Josh, Julie, Adam and Sue working on a severely burned patient

Saturday, January 24, 2009. Today there was a knock on Lonnie’s door and a nurse asked her to come to the out patient clinic to assess a patient with a burn. The nurse motioned to his arm. She said ok, she’d be right there. “I can handle this”, she said to herself, assuming the patient only had a burn on his arm. She collected her medical bag and began to walk over. On the way she ran into Adam, the trauma surgeon here with us, and she asked “hey do you want to see a patient who has a burn in the OPD with me?”, thinking she would be wasting his time. Julie and Josh came along as well, and Sue joined the group when she heard the news. When we all arrived, to our horror the conscious and awake patient had extensive full-thickness burns over 90% of his body including inhalation burns. He had fallen asleep by a fire, warming himself in the morning, and his clothes had caught on fire, waking him, and he was unable to remove them. Family members were able to eventually put out the flames, and transported him to the Hospital from his village, 90 minutes/50 km away.

Many of us have never seen anything like this in our lives. Immediately Adam took the lead and we began our work. Given the fact that he was an 80 year-old man and we are in a country with limited resources, we were faced with many ethical issues. How far do we take his treatment? How much of the hospital supplies do we use? Do we transfer him to RVH in Banjul, which has more supplies than we, but 2 hours away on mostly dirt roads? They may not have any additional benefit to offer him there, and the transfer would be dangerous in his acutely ill state. His family may not be able to travel the 110km to be with him. This is a catastrophic injury, and even in the United States the mortality rate would be high, both early from respiratory injury, and later from renal failure or sepsis. This patient had obvious extensive airway involvement, however we had no means with which to artificially ventilate him for any prolonged period of time. We asked the hospital administrator for permission to turn on the generator in an emergency capacity so that we could administer oxygen to the patient, and we were granted permission. Unable to start peripheral IV lines, we were able to use a large IV to initiate a central line at which time we gave him fluids and morphine, and provided body wide burn care. After extensively cleaning his wounds and applying sterile dressings, we transferred him to the surgical ward here and his family was informed that he was critically ill. After handing the patient’s care off to the nurses on the surgical ward, we all gathered together to discuss all the complex ethical issues mentioned above. Included in the discussion was Lamin Ceesay the senior Gambian nurse of the surgical ward, who, even though he was off duty today, helped us understand the cultural aspects of caring for this patient. In the United States, family members are a huge part of the care of critically ill patients. Long discussions regarding prognosis, need for procedures, the wishes of the patient and the family regarding end of life issues are held, so that they are included in decisions about care, or even withdrawal of care. Here, we are unable to directly communicate with patients and family, as we cannot speak the language, and we are also likely ignorant of cultural practices that can influence care. Lamin helped us to understand that in The Gambia, being able to be with a family member at the end of life is very important, and It was decided that since the patient’s prognosis was very poor at best, we would not transfer him to RVH and we would keep him as comfortable as we could. Every member of the team shared his or her impressions, and we were all on the same page. I feel proud that we provided our Gambian colleagues with an excellent example of teamwork, and feel lucky that we could be a part of the care of this man. With hope our patient will spend the last hours of his life with his loved ones with him.

~Lonnie and Sue

Thank you, Drs. Ed and Gen

The whole DelMed Aid-Christiana Care Residency Team

Friday, January 23, 2009. Today I felt a bit frustrated and for me a bit of homesickness is setting in. I tend to be a very idealistic person and depending on the situation this can work for me or against me. I just never know when. DelMed has partnered with a health care setting in the third world and there are enormous problems. At times it seems overwhelming but I ask, why would anyone come here with the expectation of anything less in one of the poorest countries in all of Africa? The bottom line is I am very fond of Africa and the Gambian people. No matter how complex the issues are, DelMed has decided to face the many challenges found here and will attempt to deliver quality healthcare. We are committed to finding solutions. They may not be or perhaps should not be an Americanized formula but we will strive to find sustainable answers. Our fact-finding exploration including learning Gambian culture continues and we will do our best to work with the administration and staff at SJGH to develop projects to best serve the staff and community. The challenges are immense, but so is our commitment.

∼Lonnie

Also on Friday… Just a sad note about 2 of our number leaving us today… Ed and Gen Goldenberg, our father-daughter team, are heading back to the States. We have enjoyed immensely getting to know both of them in this setting, working closely, dealing with challenges and also just having fun. Ed really made an impact on the staff here, and many of them commented on how sad they were to see him go. I know that his presence here was appreciated, as there has never been a cardiologist at this hospital in its history, and he was able to convey information and skills that had heretofore been unseen. His positive attitude and laid-back approach put everyone at ease, and he seemed to have a smile on his face every time we would see him. He looks at obstacles as “opportunities”, and I really feel as though I have learned so much from him in the last 10 days. He taught me a great deal about cardiology during the 5 years that I was a resident at Christiana Care, and now that we are colleagues here in The Gambia, he has taught me a great deal about humanism. I can’t tell you, Ed, how much we appreciate your being here.

Everyone gathered for a quick group photo, even though the OPD was incredibly busy for a Friday, they spared us for a few minutes to say goodbye.

In the evening, Lonnie, Jason and I brought our friend Modou to the house to show him a treat… He is one of the good friends we made last year, and he is a devout Chelsea Football Club fan – and the country itself is football (soccer to Americans) crazed. Lonnie had downloaded a Chelsea v Fulham match, and we played it for Modou and his friend on the living room wall using the LCD projector. They were so excited, as this is quite a rarity for them, given that there is no electricity in their compounds, and they have only seen one or two games in the last few years when they have had the luck to travel to the city to an establishment that is showing the matches. It felt good to be able to given them that small pleasure. I didn’t let on that I was actually cheering for Fulham…. ☺

∼Sue

US docs + Cuban docs + Gambian Patients = International Medicine

Drs. Goldenberg and Thompson with Drs. Ezcurdia, Hernandez and Ruiz at the Royal Victoria Teaching Hospital, Banjul, The Gambia

Thursday, January 22, 2009. Caution non-medical readers! The following may be a bit dry, but hang in there till the end…

Case of the day: 37 year old female presents to the outpatient clinic at the Royal Victorian Teaching Hospital in Banjul, The Gambia complaining of shortness of breath on exertion and pleuritic chest pain that was gradual in onset and has been worsening gradually for 2 weeks. She has no past medical history. She is thin and somewhat underweight and in mild respiratory distress. Her vital signs show her to have an elevated heart rate of 110 and hypoxia of 87% on room air, blood pressure stable. Heart is hyperdynamic but regular with a systolic ejection murmur, early peaking and radiating to the carotids. Auscultation reveals almost no breath sounds on the right, while clear on the left. Mild neck vein distension, but trachea is midline. Abdomen is scaphoid, with exquisite tenderness in the right upper quadrant over a liver that is palpable 4cm below the costal margin. There is 2+ pitting edema of the feet and pretibial area and mild periorbital edema. The remainder of the exam is normal. Initial CXR is below. No follow up x-ray has been done, and no procedure was performed. An electrocardiogram shows sinus tachycardia without acute changes. Echocardiogram shows a round, homogeneous appearing mobile mass in the left ventricle at the apex. Valves and cavity sizes are normal. There is a moderate sized pericardial effusion, without evidence of RV collapse or paradoxical septal movement. She is treated initially with oxygen and diuretics while the echo is pending, and she improves. Her edema resolves, she is titrated off oxygen and she is in no distress. She continues to have mild pleuritic chest pain.

Diagnosis?

This is a patient on whom Dr. Ed Goldenberg and I were consulted by the ICU attending physicians at RVTH. We had traveled to Banjul for the day for Ed to give his Grand Rounds at the hospital, “Renin-Angiotensin System Blockers in Hypertension and Heart Failure”. We were met by Dr. Manuel Ezcurdia, the chairman of the Department of Medicine, and warmly welcomed into the offices of the medical school. The lecture hall was on the 2nd floor of the hospital, and although not the largest lecture hall I have seen, it packed in the 50 people who attended Ed’s lecture! It was an excellent talk, and attended by physicians, residents and medical students. I suppose the topic was possibly a bit specific for the setting, given that even here in the capital at the largest hospital in The Gambia, they have limited options for antihypertensives, however they were very enthusiastic about the data and information, and current guidelines in clinical practice are relevant regardless of whether or not you are able to practice them.

Following the lecture, Dr. Ezcurdia and Dr. Udi Hernandez asked us to come to the ICU to consult on the above patient. They admitted that they are a bit stumped, and wanted our input. Ed re-echo’d the patient and had to agree, there is a round, highly mobile mass in the apex of the LV that does not appear to have a pedicle, but is flapping so hard in the breeze and not going anywhere that we had to assume it was attached. The doctors were about to start the patient on anticoagulation, assuming it was thrombus. Going through the patient’s history with her again revealed nothing. We made a few recommendations. Anybody know the diagnosis?

I am returning to RVTH on Monday (sadly, without Ed, who leaves tomorrow….), but with Dr. Fox, who will be giving his Grand Rounds on that day, and we are anxious to follow up on this patient. Feel free to send comments with your ideas, or your questions. I’ll let you know what it is next week. Interesting case!

On returning from Banjul, (after running a number of errands including more vegetable and fruit purchasing, which somehow cost us a quarter of what the same amount cost us the first time… how’d that happen? I think I’m a better haggler than Jason and Zeke…) we found Amelia, Julie and Josh performing ultrasounds on a few in- and outpatients, as the power had come on at 7pm. We have been doing a great deal of scanning here, as we are very comfortable with it, and the machine is very good. (Paul, we’ll get you the specs.) Those patients whom we can’t fit in to scan between 10a and 2p during the daytime electricity, we have been asking to return to the hospital at 7p, when the evening electricity comes on. Inefficient, but do-able. Amelia and Jules have been scanning maniacs! They are really doing a wonderful job, and, I believe, contributing significantly to the care of many, many Gambians.

Tonight Zeke prepared a chili dinner from a recipe given to him by his new friend “Chief”, a man who also keeps the boys full and happy with attaya tea in the afternoons. And it has so much caffeine and sugar, it keeps them yapping all night!

Tonight was the first formal lecture of our evening clinical lecture series, which was “Heart Failure: A Case Study” given by Ed, involving a patient that he admitted here to SJGH and cared for with the nursing staff on the medical ward. It was well attended and had a lively question-and-answer session following. I know it was a long day for Ed, but we had to fit in all his lectures before he leaves us tomorrow!

Speaking of which, we are going to be very sad to see 2 of our group leave us tomorrow, Ed and his daughter Gen. I know they are sad to leave us as well, but likely not too sad about the long hot shower they’re going to have when they get home! Bucket baths leave something to be desired….

Until later.
∼Sue

X-Ray from RVTH ICU cardiology consult

The Koffa Club

The Women's Group Meeting

Wednesday, January 21, 2009. Yesterday morning (Tuesday) I traveled to Banjul to pick up two more DelMed volunteers from the airport…Adam Fox, MD and Josh Usen, MD. Ebraima (who works for SJGH security) was my driver for the day. He is married to Owa who works in the maternity ward and is a new nurse midwife graduate. They have three children, two of which are twins.

Not to brag to all of you back at home but the weather here is just beautiful…no humidity, blue skies, sunny and about 80 degrees. At night it’s breezy and cool, perfect sleeping weather! Peter Bakery the Peace Corp worker who lives next door, told me I don’t know the real Gambia as this short dry season (which is winter here), does not in anyway represent typical Gambian weather. He spoke of a two-week period this past summer where he just wanted to die. The temp here at it’s hottest can range from 38-40 Cº (100-104 Fº) with 100% humidity. I think January is a nice time to visit!

My drive to Banjul with Ebraima took about one hour and 10 minutes. Much faster than last year, due to improved road conditions. Along the way we listened to Senegal music and I watched various Gambian daily life scenes play out along the way. It was a bit surreal staring out the window watching kids walk along the road to school, women in their compounds pounding grain with their mortars and pestle, others cranking the well pump for water and passing many piles of produce and firewood for sale. As you speed by the villages with their corrugated metal roofed concrete homes that look desolate, one might quickly assume you’re passing one ghost town after another. But much is happening inside. Intricate lives exist here and interestingly we share some of the same hurdles. Gambians deal with the typical family dynamic issues we all do, including child rearing demands, and daily household duties. They want quality health care and education for their children. To exist here however is not easy. As much as our two worlds are drastically different in some ways they are the same.

Wednesday I was invited by Alex Tatum to attend the local women’s club called “the koffa”. The women gather weekly and each pay dues. They are an entrepreneurial group in additional to a social group…they manufacture and sell antibacterial soap and tie-dye fabric. It was so funny to see them bicker over the dues…who paid and who didn’t. I belong to a women’s club and we’ve bickered over the same thing! They gossiped, laughed and talked about all the usual things women do and it so much was like my own women’s group. I felt so welcome as we gathered in a circle under the beautiful mango tree. They even passed food; some sort of frozen slush treat that smelled like coconut, a women’s group meeting is not complete without sweets! I was honored to be a guest at their meeting.

~Lonnie

Reflections

Lonnie helping train some SJGH nurses

Monday, January 19, 2009. Let’s have an introspective moment. Today was a busy day as usual, but because it was Monday, the Out Patient Department (OPD) was teeming with patients all day. Gen, Julie and Amelia handled all the patients in the OPD with skill, while I joined Ebraima the nurse to see all the pediatric well visits. Well, schmell…! Many of them were little sickies! Poor things. We worked together to get them all seen, scanned, treated, or whatever they needed.

Despite the long day, I had some time to reflect on my own presence here in a larger sense. Sometimes I feel as though we are working harder than any of the staff, nurses or doctors who work here year round, by far. It is frustrating trying to think about making sustainable teaching and change, when as soon as we arrive, many staff members seem to expect us to just take over and do all the work for them. I am here seeing patients, treating the ill. I am trying to teach nurses how to better care for their patients. I am trying to learn from the staff how they care for their patients, how it is different from what I would do, and what is the best route to take. I am also supervising EM residents from my home program while they do the same, trying to contribute to their education, broaden their perspective, and to help understanding this place where we have all come, when I do not completely understand it myself. I am representing Power Up Gambia, as a member of its Board of Directors, and spend time trying to oversee the installation of the solar power panels that is currently in its final stages, as well as trying to identify the problems with the new water system and come up with solutions for the future. Finally, I am here as Chairperson of DelMed Aid for Gambia, through which we have brought multiple volunteers to also treat patients, teach, and get a new and different cultural experience and outlook on life and the practice of medicine. These are a lot of things to do, and lot of directions to focus my attention and time, and it can be a bit overwhelming.

I have been feeling a bit conflicted of late, knowing that I am here because of a passion I feel for the people whom I met last year, who were kind to me, who reached out to me, and who need care so badly, but also realizing that change, sustainable change, is slow and difficult anywhere, let alone a developing country, or the poorest country in Africa. I wouldn’t be here if I didn’t feel that there was something I can do, some way I can contribute. I am entering into this quest with my eyes open, however some days the obstacles seem insurmountable.

I am a runner, and when I am on a long run, I tell myself that there are highs and lows. Highs and lows. When I’m on a high, and feeling good, I tell myself to ride it out and make it last, because soon it will be over. When I’m in a low, I tell myself to hang in there, because another high is just around the corner. Another high always comes.

I’m trying to apply this concept to my time here in Bwiam, thinking of the mission and goals of DelMed Aid for Gambia. Each day we come up with ideas for how to improve healthcare delivery here at SJGH, and each day issues arise that make improvement seem incredibly difficult. Our big dreams of moving forward with new equipment, more wards, an ICU, seem like pipe dreams. How can a hospital have an ICU, if the staff doesn’t wash their hands? We need to start at the lowest level, it seems, such as projects for trash removal, animal containment, and handwashing. Basic infection control measures have become the focus of our attention, and Lonnie and I have decided that an ongoing project designed to facilitate and educate the staff here about these issues will be the current focus of DMAG. It will take a great deal of planning, encouragement, and help from our volunteers, and we’re hoping that others take up the cause with us, with optimism and a positive attitude. It may not be the most beautiful place on earth, it may not be shiny and look like the movies, and it may be that we’re doing most of the work trying to overcome the inertia that exists here, but if everyone gave up hope because things were difficult, nothing would ever improve. And that’s just not acceptable. The people who live here in Bwiam, in all of The Gambia, are just as deserving of the human dignity of medical care as all of us. Therefore, our goal remains to help this hospital and its staff, who work so hard under difficult circumstances, to implement sustainable improvements.

∼Sue

Sue and Modou Lamin Barrow, Pharmacy Staffperson, who is applying for nursing school in 2009