Overnight Call: Infections, Infections, Infections

8/1/12

Posted by Amanda Thornton, MD (a third year Internal Medicine resident from Kaiser Permanente, Oakland  while on a global health elective in Lusaka, Zambia with University Teaching Hospital).

Today, the team was on overnight call. They work in the “filter clinic,” which is the equivalent of the emergency department in the U.S. There is a resident hand-off of urgent or unstable patients in the morning. Then the call team separates, one to see and review the patients in the hospital and the second to help with admissions.

During the day it was busy, but at night- it was only our team doing all the care in the emergency department and admissions in the hospital. There were three attending physicians who were helping to review patients, and then the interns and medical students take care of implementing plans. There is enormous volume and turn over, especially during the night.

Interns and medical students often place IVs, do blood draws, and schedule imaging. Overnight in particular, I was amazed at how life-saving 1-2 liters of an appropriate fluid given intravenously could change a patient’s appearance and prognosis. Unfortunately, just as in the hospitals in the U.S. patients pull out IVs or the equipment malfunctions, and often if there is a patient who someone is worried about, it is worth checking on them several times through out the night. Almost every patient’s family comes in to supplement care, but they cannot replace the value of having well trained nurses.

There are several nurses, one in the admission part of the filter clinic, and the others spread out constantly taking vital signs, starting blood transfusions and administering medications. There are beds, stretchers, and pallets organized in rows in the three major portions of the ED, but the area is made even more crowded by family members bringing food and medications for nursing administration from home. There is one patient toilet and one “rest room” for physicians with toilets and beds. White coats are worn only by doctors, nurses – called “sisters” have uniforms; people make way as best they can.

There are only 4 beds in the acute care section- reserved for patient’s who are in critical condition or in need intensive monitoring. For example, for a few hours last night, the acute care bay had one patient was in diabetic ketoacidosis, one patient with likely metastatic liver cancer who was very confused and combative and the other two in septic shock. There were many others who were very sick. Then there are 4 beds in the admission/triage section where new patients are seen by physicians and initial plans made.

For me, the most remarkable part is that my every differential (which, given my training, is based on a US population) is weighed against infectious etiology, but here the most frequent cause of illness is infectious disease. Whether it is side effects from anti-retroviral drugs, infectious complications of end-stage AIDS, it seems as if nearly every patient had newly diagnosed retroviral disease or recently started on highly active antiretroviral treatment (HAART)- and interns know the appropriate drugs and their numerous side effects much more thoroughly than me.

While in the U.S., we joke that PE (pulmonary embolism) can be on nearly every differential, here, it seems as if TB (tuberculosis) is never wrong to consider to add to your differential whether it be a patient with clinical adrenal insufficiency, abdominal pain, chest pain, fever, cough, or wasting complaint. Malaria can be considered if the patient has come from an area not close to the city, as well as trypanosomiasis for the patients who are brought in with a very low Glasgow Coma Scale score (a score used in the U.S. used for post-trauma assessment, but here is used as a proxy for mental status for the severely altered patient).

Interestingly, physicians here often argue with patient families about consent for lumbar puncture. Though the procedure samples spinal fluid and may be painful or dangerous for patients (as it is performed without any anesthesia and only local sterization), it provides valuable information on the possible cause of altered mental status- which was by far the most frequent presenting symptom in the filter clinic last night. Even without lab studies, turbid fluid collected at high pressures in a patient with newly diagnosed antiretroviral disease will let physicians know that they need to cover for cryptococcal meningitis, cloudy fluid at lower pressures gets treated empirically for bacterial meningitis, and yellow at lower pressures with “spider-web” clots makes physicians put TB meningitis higher on the differential from the beginning rather than when patient’s fail treatment for bacterial meningitis. Patient’s families see the procedure as intrinsically dangerous- as they see people die after receiving it- instead of seeing the presenting symptom as a very serious complication of an advanced infection with a relatively high risk of mortality.

As for nutritional dysfunction- while in the U.S, obesity is the major culprit, here, malnutrition from AIDs or alcoholism is the most commonly seen. Pellegra is much more common in a population whose stable crop is maize- which lacks a bioavailable form of niacin- my attending physicians grilled the team on physical signs of niacin deficiency when we were admitting a patient who was a known alcoholic found seizing.

We did get a little rest during the night- given my increasingly persistent cough and breathlessness, the residents made me go to bed earlier than they did. Even so, I was exhausted by morning rounds and my head cold had turned into a full blown asthma exacerbation. One of the residents (whose father is the head of the high cost clinic) got me a prescription for steroids and appropriate antibiotics to supplement my albuterol inhaler. I was sent home early- while my team worked on to round on all the patients under their care in the hospital prior to major rounds tomorrow. Before I go to bed tonight though, I hope to have reviewed many of the things I saw and learned about on overnight call.