Very busy day today: I left our usual doctor’s meeting/teaching rounds expecting to see my half of the Male Ward patients that I had rounded on yesterday. However, the physician covering Female Ward called in sick and, since I had been on Female Ward last week, I was asked to cover for her. I was happy (and a bit nervous) to do so, but it was still a bit of a shock going from covering half of a ward to a whole ward, and basically a brand new set of patients at that. I was assigned my own medical student, and she was proved to be very helpful, recording while I interviewed the patients.
Of all the diseases encountered, HIV is by far the most prevalent. On any given day, half to two-thirds of any ward (except NICU) consists of HIV positive patients. Because of the stigma still associated with the disease, it undergoes two pseudonyms in the medical chart: CTRR and ISS. CTRR stands for Counseled, Tested, Resulted, and Reactive. If the patient returns negative, it simply reads CTR in the chart. ISS simply means Immunosuppressive Syndrome.
Caring for HIV patients — many of whom are extremely sick — has been one of the biggest challenges and changes from working in the US. Almost every person admitted to the hospital has a screening HIV test and the majority return positive. Once positive, they receive HIV counseling and are established in the outpatient HIV clinic once they are discharged from the hospital. Many of the patients we see here have Stage IV AIDS under the World Health Organization classification for HIV/AIDS. Stage IV is the worst. Patients are started on anti-retrovirals if their CD4 count (the white blood cells which are attacked by the HIV virus) is under 200 or if they have a Stage IV AIDS defining illness. These include things like cryptococcus and toxoplasmosis. Several of the HIV patients that I rounded on today had CD4 counts below 50. We did see one patient with a CD4 count of 2 yesterday.
TB is another of the frequent opportunistic infections encountered here, and this includes extra-pulmonary TB including Potts disease (TB of the spine), hepatic TB, miliary TB, and lymphatic TB. Pulmonary TB is generally treated for 6 months here and extra-pulmonary for 9 months. The diagnosis is often tricky as it’s very difficult to obtain sputum samples and, at least in HIV patients, sputum samples are often negative for acid-fast bacilli (the test for TB), so the diagnosis is made on a combination of radiographic and clinical findings. Another frequent opportunistic infection encountered here is diffuse candidiasis (a type of yeast causing pathologic disease).
All in all, the day was very tiring, as we had several new admissions as well as several “reviews” sent from Outpatient Department. These are patients who may or may not warrant admission criteria and therefore the ward physician interviews and examines them and determines if they need to be hospitalized. After all this, I was very happy once all the work was done, and dealt with the fatigue the best way I know how: I went for a run.
Which, in and of itself, isn’t that big a deal, but here it’s a rather comic affair for the Ugandans to see a lone white person going for a run. The children become most the most excited and will yell out “Bye Mzungu!” or “Run Mzungu run!” (making me feel rather Gumpish) and sometimes even join in with me for a few yards, laughing all the while. In general everyone, young and old alike, laugh when I run by, but it’s good-natured. Sometime people on the road ahead of me will hear me coming and stop and gape at me until I’ve passed.
An update on the boy with snakebite: He’s being discharged tomorrow. He made a dramatic recovery after his skin infection antibiotic was increased and he was placed on anti-malarials. His leg looks great, and it definitely seems that it was a combination of cellulitis and malaria rather than snakebite. At the end, it’s been a very tiring but rewarding day.