When helping helps

Just a prescript - internet and electricity are still intermittent so please be patient with correspondence!!!

Perspectives #3: Halfway through the wonderful read “When Helping Hurts.” I not only agree that it is a book that all Christians should read before they go into missions, but I would even argue it’s a good book for already well-seasoned missionaries.

Most foreigners and wealthy Mozambiquans employ various servants. The couple I am living with are no different in that they have an embregada (maid who cleans, irons, etc) and guards (sometimes sleeping but in charge of watching the house, gardening, washing cars, etc). Our embregada has HIV, as does one of her brothers likely, and she infrequently has to miss work because of the large sores she gets on her legs. I write that only to give you a picture of how health needs from the clinic are just as common at home as at work.

Claude and Marilyn asked me to look at our guard’s foot this morning as we were leaving. It was definitely warm, with pus visibly oozing from a wound in the webspaces between his 3^rd and 4^th toes, with a well-circumscribed erythematous edema covering half his foot with visibly tightened skin. Not unlike what I’ve seen multiple times at the clinic, I could have written erythromycin and paracetamol for him if I’d had a prescription on hand. (People here can buy whatever medication they want over the counter, so really I could have just told him what to buy.) Yet it occurred to me that I would just be a quick fix and that essentially the man in front of me needed a much more fundamental prescription. Here indeed is what sustainable missionwork is all about. I, as the wealthy foreigner with supposedly all the answers, by circumenventing the entire clinical set-up of native medical workers, would have done more harm than good by a quick prescription. What the man in pain in front of me needed (tied with medication) was a lesson in trusting his own people in a healthy clinic to treat his medical problems long after I left. He needed medical help that neither witch doctors with their scarring marks nor neighbors’ recommendations of over-the-counter antibiotics would help with. He needed to see a doctor who could be trusted to give him a full exam that he could trust to visit the next time, and the next time, and the next time that he gets an infection or gets sick. 

The line from the book that resounded so much to me today was: “Avoid paternalism. Never do for someone what they can do for themselves.” In this case, it was not to do for the guard what his own country’s doctors could do for him. The Chinese proverb is: “Give a man a fish and you feed him for a day. Teach a man to fish and you feed him for a lifetime.” It takes longer to teach a man to fish than to give a fish. Similarly it took longer to take our guard to the clinic with me, to walk with him as he limped across the field. I got quizzical looks from the medical students and staff who wondered why I had brought him instead of treating him at home. He waved to me from the waiting room as I stood talking to other physicians but didn’t even seem to notice me as he was visibly engrossed with talking to his doctor when I randomly stepped into his visit to grab a blood pressure cuff. Indeed I became invisible as sustainable aid surrounded him with care. Isn’t that one of the points of medical missionwork? Not to put a “bandaid on a broken leg” – but to teach people how to diagnose and how to heal with their resources so that they can continue to heal long after the mission has ended.

You know what, our guard still got his medications. Beyond that he also found out he has HIV and will now undergo treatment. Instead of getting treated for a day by me, he will indeed be treated for life. And I hope he has a long healthy life.

Medical Mondays #3

Malaria

Woman with malaria

500 million clinical cases annually

1.5-3 million deaths annually (largely African infants and young children); 90% of deaths in Africa

5 types of protozoan species; P. falciparum is the worst because of how it quickly creates a density of # in the blood and sequestration in microvasculature (severe malaria)

Transmission
Anopheles mosquito transmits the sporozite through its saliva. This travels to the liver cells and becomes a schizont. The liver cell ruptures and releases thousands of merozoites which infect red blood cells causing all the symptoms and signs of the disease.

Characteristic	P. falciparum	P. vivax	P. ovale	P. Knowlesi	P. malariae
Incubation period (d)	8-11	10-17 or longer	10-17 or longer	9-12	18-40 or longer
Severity of 1’ attack	Severe	Mild-severe	Mild	Mild-severe	Mild
Periodicity (h)	/	48	48	24-27	72
Untreated duration (wk)	2-3	3-8	2-3	unknown	3-24
Untreated infection	6-17 mo	5-7 yr	12 mo	Not available	20+ yr
Parasitemia (per mm2)	>= 20000	10000	9000	Unavailable	6000
Anemia	Frequent,severe	Mild	Mild	Mod-severe	Mild
CNS	Yes, severe	Rare	Rare	possible	Rare
Nephritic syndrome	Rare	Rare	No	Probably common	frequent

Diagnosis: blood smear or rapid antigen detection (RADs) tests but have less accuracy and false positives; also RAD's can be falsely negative in the first 24 hours

P. vivax P. ovale P. malariae P. falciparum P. knowlesi

Child with malaria

Acute symptoms: Classical paroxysm (3 stages) lasts 6-10 hours
1.‘Cold’ stage- rigors and shaking
2.‘Hot’ stage – T > 40’; restless, vomiting, convulsions
3.Sweating stage – sleeping

For 3 days possibly asymptomatic, or with headache, cough, myalgias, fever, chills, diarrhea, mild jaundice, vomiting, nausea, anorexia

Chronic symptoms: Anemia, hepatosplenomegaly, weight loss, diarrhea, increased susceptibility to other infections
2’ complications: Burkitt’s Lymphoma, Hyperreactive Malarial Splenomegaly, Quartan malarial nephropathy

Same child but trying to capture typical way to carry babies

Pregnancy: low birth weight, fetal distress, premature labor, stillbirth, congenital malaria along with common side effects in the mother of anemia, hypoglycemia, and acute pulmonary edema

Severe malaria is most serious outcome
Cerebral: 20% mortality with retinal hemorrhages, coma, convulsions, focal neurological symptoms. Sequelae can be transient or permanent with hemiparesis, cerebellar ataxia, cortical blindness, hypotonia, mental retardation.

Treatement:
Thanks to Dr. Chris Milner, an English doc who has the most amazing encyclopedia brain of fun facts I'm going to talk a little about the history and making of what is really an incredible treatment for malaria.

Malaria treatment goes back to the 200 BC when Chinese herbalists used the herb artemesia.  In the 1970's a Chinese researcher stumbled upon the derivative artemisinin in wormwood and found that it had an amazing ability to clear malarial parasites from the blood.  Apparently the herb has been used on and off throughout history as even in the 1840's French troops were using it in fortified wines to treat malaria.

Fun Fact #2: The same family of herbs is used in martinis, so if you've ever had Absinthe, you've had a wee bit of an antimalarial concoction.  Even though I've never liked martini's it's an interesting fact they have health benefits in some ways.  :)

Now, because of increasing rates of resistance, artemisinin is used in combination treatments or "Artemisinin- Combination Therapy" (ACT).
-Standard treatment used to be chloroquine at 25 mg/kg for 3 days, but it has had increasing resistance and is no longer used in many parts of world.  Additionally, it doesn't work for the hypnozoite stage of the lesser common types of Plasmodium for which primaquine at .5 base, .325 mg/kg dosing is used.  Primaquine is an antioxidant contraindicated for G6PD deficient folks.
-Coartem (Artemether/Lumefantrine) at 6 doses of 4 tabs each for 3 days is completely efficacious here and our standard treatment here in Mozambique.  The national policy requires a positive rapid antigen test (which can be negative for the first 24 hours) in order to treat.
-Artesunate/Mefloquine is also effective but expensive
-Artesunate/Sulfadoxine-pyrimethane has high resistance and less used now.
-Artesunate/amodiaquine is only effective in West Africa
-In pregnancy: Quinine/Clindamicine in the 1' Trimester after which any standard ACT is okay
Severe Malaria:
-Artesunate IV - decreases relative risk mortality by 35%
-Quinine IV - careful use because hyperinsulin hypoglycemia especially in pregnancy and special renal dosing
-Artemether IM has irregular efficacy
-Quinidine - cardiac monitoring, yes this is an antiarrhythic usually (note its enantiomer cousin quinine usual use in malaria)
-or the ever possible rectal dosing of artesunate

Prophylaxis
-Atovaquone-proguanil (Malarone) - expensive
-Mefloquine - can be used in pregnancy not in neonates, and watch out side effects
-Doxycycline - sun sensitivity, GI side effects, no preggers
-Primaquine- no go preggers or G6PD
-Proguanil - resistance limited
-Chloroquine - no, don't really use this.

Medical Monday #2

S: 6month African female presented emaciated with failure to thrive.  Mother is HIV+.  Mother says baby has been losing weight regardless of normal appetite.  Patient has had a nonproductive cough for 4 weeks and fever on/off with diarrhea.  Pregnancy history and delivery unremarkable.  Mother is unsure of sick contacts and TB exposure.  Mother denies pertinent past medical diseases, surgeries, family history, allergies, or current medications. 

O:  VS: Temp: 38.4, RR: 22, HR: 92, BP: not taken, wt: 3.5 kg (birth weight 2.2 kg)
General: extreme cachexia, alert
HEENT: Normocephalic, mildly depressed fontanelles, non-injected conjunctiva, no scleral icterus, EOM grossly intact, normal pupillary reflex, CN 2-7 grossly intact.  Pharynx nonerythematous with sublingual pallor
Chest: Lungs - CTAB; Heart: RRR, no murmurs, rubs, or gallops
Abdomen: Non-tender, non-distended, no palpable masses.  Hepatosplenomegaly.
Extremities: no gross abnormalities

Labs: Malaria rapid antigen test - negative; HIV rapid test +

A/P: 1.  HIV/AIDS - given the mother's seropositivity and HIV+ test this is the most likely cause of the baby's failure to thrive.  Other causes on the differential of FTT would be social (lacking food, neglect), cardiovascular abnormalities, metabolic abnormalities, liver and kidney problems.
 - CD4, hemogramma, Cotrimoxazole prophylaxis (refer to hospital central)
2.  Failure to thrive - Patient is well below the 5th percentile in weight only 7.5 pounds at 6 months
-nutrition supplementation


Perspectives: 7.5 pound baby at 6 months old.  We dont know hunger and we dont know suffering like this.

Ghonºs complex, right middle lobe in child

Possible Kaposiºs sarcoma in HIV+ pt

Superficial infection "pioderma" seen frequently

Pt treated for Pottºs disease - TB infection of bone (lumbar region x-ray)

Medical Mondays #1: Ultrasonography 101

Initially I thought I would do a case presentation each Monday, but there just hasn't been enough time to put together a quality SOAP note.  Instead, (and as advance warning for future Mondays that might contain more photographs of items less interesting to the medically-less-inclined and more graphic) here I'll ease in with a note about one of the technical skills I'm learning here.

Our clinic has certain capabilities.  We can do a variety of tests: rapid malaria, rapid HIV, blood sugar, wet mounts, PPD, etc.  However, a wonderful tool without the accessibility of an immediate x-ray or CT scan is the ultrasound.  In a primary care setting in Africa, we see loads of patients with vague pain in the chest, breast, abdomin, and pelvis.  Beyond doing a FAST ultrasound in the ED or ob/gyn ultrasounds, I was previously clueless as to the multiple uses of this amazing tool.

Ultrasound liver/major vessels/lymphadenopathy

Take for instance the snapshot I grabbed on the right.  For my 29 year old extremely cachetic HIV+ patient - this clued us in to extreme lymphadenopathy in the paraortic lymph nodes.  In the left part of the image is the liver the two large dark spots in the center-bottom the SVC and aorta.  The milieu just northeast of them is a confluence of nodes that told us that our patient likely has abdominal Tuberculosis.  She was one of two patients with abdominal TB in the clinic this week so far.

X-ray of fibrocavitary/cavitary/infilitrates

The x-ray on the right also is a patient with TB - though with the classically more apparent pulmonary presentation.   This 9 year old HIV+ cachectic patient had a productive cough and so we sent him for an x-ray.  Right apex, left upper lobe possibly have cavitary markings and middle left has possible infiltrate.

Some of the numbers so far:
HIV 24
TB 14 + 3 extrapulm
Malaria 13
pioderma 12
sore throat/cough 19
DUB 2
STDs 7
angina 1
pneumonia 8
pregnancy 17
hypertension 14
hep A 1
bells palsy 2
......
loads of others (URI, musculoskeletal, anemia)... I have gotten lazy with tallying them all.

Most interesting differentials (as in these made me think a little harder) for me have included: unilateral periorbital edema, fever with cardiomyopathy on echo, jaundice

2nd Day: Sink or swim

Walking across the field to the clinic at the beginning of the day; people are already waiting

Here's to immersion.  The senior medical student who spent 2 seconds in the room with me this morning as I was interviewing a patient told me my portuguese was good enough to start seeing patients on my own.   The pharmacist did come and ask me to change one dose because medications are different here, but beyond a few extended explanations for words I didn't know, it went fine.

At the end of the day

Patient room with a microscope

Two of my patients today were given new positive HIV results.  The first one I had to grab a medical student to explain the results because I felt terrible stuttering through something as grave as that diagnosis, but gave the news myself for the second.  I hope this gets easier as I feel terrible in feeling like a passerby of a hit-and-run that I was powerless to prevent.  [Note: My now cemented goal with patients is, regardless of the amount of time it takes, to do education on disease.]  Yes, I love public health in prevention of, as opposed to retroactive treatment of diseases.

Incredibly a soda pop that aids against malaria (it has quinine antibiotic in it!!) I had to take a picture.

First day at the clinic and Perspectives #1

Today I finally got to work at our clinic (Clinica Saude de Medicina Sao Lucas).  It was a busy day since apparently Wednesdays are the mornings when HIV patients come in for their CD4 counts.  I should have gotten a picture of the clinic as I arrived as there were people sitting everywhere - and then it got so busy I didn't have time to grab any pictures. (sorry! :() We saw at least 20 patients, which is impressive only because the last 10 or so took twice as long because I was allowed to stutter through Portuguese with them.  I have no doubt the my translator and medical student Jabulani would have seen many more patients in that period of time.

Here are my initial impressions:

Facilities: First of all, I came in with low expectations, so perhaps to some of you it doesn't mean much, but I was super impressed with the facility having air conditioning.  (Seriously! Not expecting that!) It was also newer in construction and contained many amenities more culturally American (Welch Allen opthalmoscopes, thermometers), hand sanitizer dispensers, and even a few computers.  So all that's superficial, but worth noting in that it makes life on the medical caregiving side easier. 

Patients: During this first day, I saw fewer patients with HIV than I had anticipated - this could be due to just the random collection of patients we were given in that only 15% or so were positive.  The seropositivity is 40% in the city, and with underreporting I really thought every other patient would be positive.  However, one patient with STD symptoms we had to tell had a new positive HIV test - and his hopeless expression and quiet reception of the news grieved me in knowing how utterly and completely the diagnosis would shape his life.  I would hope it was a false positive test result but that's not likely.

Almost all the patients with fever and other cold symptoms were screened for malaria.  The most seriously ill patient was a 1y9m baby below the 5th percentile by a full kilogram with bumps throughout the occipital cranium and face with a nasty cough most likely TB.

Perspectives #1  In waiting for a ride after work, I sat stumbling through portuguese with a staff-woman from the clinic.  In just asking her a few questions it reminded me again of how ravaged this whole country has been by famine, disease, violence, malnutrition, and willful ignorance by most of us.  She told me that she was a single woman in her 40's who only had one son that died when he was 24.  She had 6 siblings, but only 3 were still living.  In hearing about her son, she said she was glad she 24 years with him, that that's more than some people get.

Can you imagine?!  Take half your family and one of your closest loved ones and imagine life without them.  All my siblings, my parents, aunts, uncles, and cousins (minus one) are living.  I've known all my grandparents and one great-grand.  Life would be so different without them, it gives perspective to the suffering that not just the poor but most people have gone through here.

The setup

The decision to go to Africa was a long process that involved prayer, talking to a lot of people, lots of applications/paperwork/emails, prayer, more paperwork/emails, hiccups, more prayer - and finally decision time. 

Most of the decision traces itself back to working under my mentor Dr. John Umhau two summers ago in DC.  He was the initial person to tell me about the MAP International Fellowship that pays for airfare for fourth year medical students to do a minimum of 8 weeks of clerkships under a Christian physician overseas.  Dr. Umhau is a strong Christian who did MAP in Africa when he was in medical school and recommended me applying.  I was a bit apprehensive because my last overseas medical mission to India (with a secular program) was extremely exhausting and spiritually the opposite of encouraging.  However, because of his praise for the program I went ahead and applied - only to find out that my interviewer was Dr. Steve Roskos who I knew from my church and from faculty at my school.  He again had positive recommendations and a strong testimony to its role in his own life.  So I began moving forward in earnest with plans.

The doctor and his wife, whom MAP had gotten me in touch originally (the Meyers - serving with World Ventures), were enthusiastic about my coming.  However, after the joyful surprise of discovering they were pregnant and due at the same time as my stay, regretfully decided to deliver in the US.  Fortunately, another American doctor Dr. Peter Millard was able to step in as preceptor for my coursework there.  The plan is still to stay with the Meyers' parents Claude and Marilyn Meyers who are now retired missionaries from OMS working with a school in educational administrational roles.

Here's an overview of the whats-its: (or you can scroll to the bottom to upload my prayer request and overview pdf)

Where I’ll be working: Beira is the second most populous city in Mozambique with a population of approximately 450,000. Beira serves as the major port along a shipping corridor to inland African countries which contributes to its high HIV prevalence (40% seropositive).

            Clinic stats: 1) ~25,000 patient consults per month

2) common diagnoses: hypertension, URI, malaria, HIV, pioderma, gastroenteritis, parasitosis, micose, pneumona, abscess, fever, cough, pain, etc

3) focused research on HIV prevention

What I’ll be doing: I am doing two international rotations in infectious disease and family medicine in Beira, Mozambique at a Catholic Hospital and medical school.  My time will be spent between a hospital clinic called St. Lucas, an orphanage on the edge of the city, and possibly rural clinics in the northern part of the country.

Please join me in prayer!
1. Mission: that the Gospel would be shared through the medical work with patients and amongst the staff
2. Work: for the patients that they would heal quickly, have openness to hear our message, and for staff to work together well
3. Health and safety: working around a higher prevalence of infectious diseases and foodborne illnesses that the staff (including myself) would keep in good health
4. For me: That communication in Portuguese would develop quickly, that medical skills would grow quickly, and that I would grow in grace and faith as I serve and share the story of Jesus.