Tuesday, August 28, 2007

TB patients

I was on call tonight and I admitted 4 patients, which is a lot for me. There wasn’t anybody to really help me either… on the pink female side, they have 3 team members all working on the same number of patients. However, it seems like the female side gets many more admissions than the male side. I have a theory about that. I don’t think it’s that different than in the states. Women tend to come in for the health problems and for health maintenance more often, and sooner, than men do. So there are more women admissions. Our lists of patients on the male side also seem to be a lot smaller than on the female side. I think that’s also related to the men not coming in soon enough. So many times we get a male patient that comes in comatose, or barely breathing, and it’s really too late to do anything for them here. So more men die than women, and less men come in the hospital in general, keeping our lists smaller.

It’s pretty sad – the other day, we had a man come in because he was barely conscious, and really struggling to breath. For those of you know what I’m talking about, he was already having Cheyne-Stokes respirations and barely responded to sternal rub. He had this huge mass in his neck that we FNA’d (fine-needle aspirated – it’s a way of taking a biopsy) and stained it to look for AFB (acid-fast bacilli – the sign of TB). And it was swimming in TB. We made a token effort of putting him on anti-TB medications, and giving him oxygen, but really we were just waiting for him to die. It wasn’t worth sending him to the ICU because in this resource-limited setting, only people who have a pretty good chance of making it through an ICU stay go to the ICU. And he was definitely not one of them. Not to mention the fact (as you’ve seen in previous posts) that the ICU doctor is horrible and has no idea what he’s doing, so most patients, even though with relatively good prognoses, rarely make it out of there alive. Anyways, he lasted until 11:30pm that night. And this is a disease that is easily treatable. If only he had come in a week or two earlier. It’s awful.

Tonight I also admitted an XDR TB patient! So a patient first diagnosed with TB is put on first-line anti-TB treatment (ATT). They have to go to the clinic every single day to get their medications, as part of the DOT (directly-observed therapy) program for TB treatment. This program was started because patients weren’t taking their medications, and they weren’t getting better, but more importantly, their bad drug adherence was resulting in the emergence of resistant strains of TB! And we just had a lecture about this – because there’s no money in developing TB drugs, and it’s really a third-world problem, the last effective TB drug was developed in 1960 (or something like that)! So we only have a limited set of drugs to work with. Anyways, so I had a patient who was diagnosed with TB in 2005, was on 6 months of treatment, and then relapsed and was diagnosed with TB again a month later. He probably had multiple-drug resistant (MDR) TB. So in 2006 he was placed on second line treatment for 6 month, got better, and then after another month, relapsed again! They finally cultured his sputum (which is tough to do here), and it turns out he’s resistant to 4 of the 5 commonly-used TB drugs (XDR TB). So now he’s on all these weird medications, many of which aren’t indicated for TB, but probably have some effect. There’s really no other choice for this guy.

However, the problem isn’t that we can’t treat this patient, the problem is that he’s in the hospital! In the states, there are all these negative-pressure isolation rooms that you can put patients in. Here, there is no such thing. There is an isolation room that you put all the MDR patients in, but sometimes patients who aren’t even proven MDR go into the room. And our XDR patient went in there too – meaning he’s probably going to give all the other patients XDR TB. Plus the room is not negative-pressure. We just open all the windows to improve ventilation, and try to keep the patients in the sun for the UV exposure (which actually helps to kill TB). We wear these N95 masks that are supposed to protect us to some extent from TB, but it’s not 100%. If you’re lucky, you can sometimes get your MDR or XDR TB patient put into a private room in the private ward (no such thing in the public wards – there are 10-12 people per large room, or cubicle). But those rooms are still not negative-pressure. I’m not too worried because I’m only working here for 6 weeks, but apparently of the students who have stayed for a year or more, 3 of them (I don’t know out of how many) have converted their PPD – meaning they have TB in their system, although it might not be active. Scary.

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