A New Level of Illness

After a while in the US you get used to the variety of conditions that you see in the hospital. Many people present with typical symptom sets, such as a gastrointestinal bleed, pneumonia or septic shock. Of course most of the time it is not quite so simple, but you have a variety of tests and procedures that you can do to try and figure out what is going on. Not so in Mbarara.

People present very sick. I can think of one man in particular, lying on the floor on a foam pad since there were no beds available. The medical ward consists of two separate wings, male and female, separated by a triage area, something like an emergency room where patients are stabilized and the initial history, physical and examination are performed. Each wing has approximately 18 beds, lined 9 to a side along a long corridor. I first saw this patient during post-take rounds in the morning, where the interns present the patients that have arrived overnight. Immediately after looking at him, my first thought was ‘this man is going to die.’ He was, as the interns put it here ‘wasted.’ This is a slight understatement for the cachectic man that was lying on the floor without the strength to move over on his side. He presented with several months of nausea and vomiting, subsequently unable to take food or any of his medications. He was NYY which here is code for HIV positive (y/n). They do not use the actual term HIV or AIDS since there is a stigma attached to it. In an open ward where patients are required to disrobe in front of the entire ward for the doctors to examine them, in full view of other patients and attendants, it seems like a small item of privacy to try and protect. Since he had been unable to eat for the past several months, combined with his HIV that was ravaging his body, he had severe temporal wasting, a condition where the muscles and fat at the side of your skull atrophy, which brings the zygomatic arch into sharp relief, giving the patient a cadaverous look. He also had an abdomen that was caved in, showing his ribs in sharp detail. Coming from a place where obesity is endemic, and most patients that you see have a comfortable amount of padding around their midsection, it is a very sharp distinction.

People present in late stages of their illness, or with severe ramifications of their disease. Most of the people are quite poor even by Ugandan standards, unable to afford medications or many lab tests. Diagnosis in the United States usually involves running a battery of tests to try and determine the source of infection, how the various organs are functioning, or looking for evidence of infection or anemia. The tests they have here, by necessity, are extremely limited. All tests require the patient or their family to pay out of pocket, meaning that while you may suggest one day that the patient has a chest xray or a complete blood count, you may very well come back the next and see that this has not been done. You can get a chest xray if the patient is well enough to be taken into town. Complete blood counts are also available, as are thin and thick smears where the blood is spread out on a slide, important given the prevalence of malaria. HIV tests and CD4 counts are also readily available; important since such a large percentage of the population seen is NYY. Coming from a location where the first thing you do after seeing a patient is shoot off a variety of tests it is a dramatic change.

Patients will often present with characteristic symptom sets, either weakness, fevers or abdominal pain. Given that tuberculosis, HIV and a wide variety of tropical diseases are so rampant, there is a whole different differential diagnosis than that present in the United States, and your hands are often tied in that the tests that you would need to confirm the diagnosis are either not available or too expensive for the patients. I have to give credit to the doctors working in the hospital, though- while there are fewer lab tests available, the ones that are available are certainly high yield, and they have gone through great efforts to make available the necessary tests to evaluate the conditions that they see commonly. When so many patients present with malaria or HIV, it is a little more important to be able to check their HIV status and white blood cell (CD4) count than it is to look for celiac disease. The doctors here, both the interns and the post graduates (PGY’s, or what we would call residents) are very knowledgeable about the things that they see, many conditions I have only read about in textbooks, such as brucellosis or an actual case of tetanus. The first few days have been a learning experience…