Quality (of Life) Improvement

This will be my last post from Ethiopia. And it will be a bit shorter than the others, as today is my last day and I have lots of good-byes and packing to do.

Over the past 2 weeks I have indeed been able to achieve the goals I set out for myself in my last post. I continued to see both “old” and “new” patients at St. Peter’s. I went back to the Missionaries of Charity and gave J a big hug. I returned to Black Lion to attend some morning reports, grand rounds, and morning rounds (AB is doing ok; his sputum still has not been sent but at least the communication has been opened and the coordination process is underway). I drafted some Quality Improvement and clinical guidelines for hypotension and respiratory distress for St. Peter’s. I was able to go on additional home visits to see how the patients are doing at home, where they store their medications, and talk to them about the problems and challenges they face. As to the latter, an essential aspect of GHC’s MDR-TB work is social support, including money for transport and food.

This brief post will focus on a new initiative at GHC/St. Peter’s, which is being led by Sister Rosemary Milazzo. Part of my contribution here has been the recommendations I made around quality improvement, which had to do with medication reconciliation, laboratory data review, and set up of critical care rooms. Rosemary’s contribution will be equally if not more important—she is working on increasing social supports while inpatient.

The patients at St. Peter’s are often hospitalized for months. It can be very boring and lonely. Some patients have family who spend a lot of time with them; other patients have no one. Rosemary is gathering volunteers to come to the hospital and companion the patients. She is getting games and books. Bingo was a huge hit! She is planning to start a few projects including potting plants and flowers and making collages. She invited a friend of hers, Costancia who is from Tanzania and who works with a practice known as “capacitar”—a body of holistic mind-body-soul techniques to help patients suffering from trauma and chronic illness, poverty, anxiety, social stressors. (see www.capacitar.org). Costancia has been helping the patients with techniques to alleviate some of their pain, stress, and anxiety. She also had an initial training with nurses, which was lovely. Rosemary’s work is quality of life improvement and I have already seen the positive effects.

Today’s good-byes with the patients were tearful and heartfelt. I have been so glad to see so many of the patients I met a few weeks ago discharged. Today several patients, all of whom have been here for months, were excitedly awaiting their rides home. Many new patients have arrived, bringing the MDR-TB cohort to over 200. And the work will continue.

As for me, I return to MGH and my next rotation will be Infectious Disease. I’ll be cognizant of the privilege we and our patients have when we ask for labs and they are readily available later that day, when we recommend a particular antibiotic and it is administered within an hour, when we recommend additional imaging and we are able to obtain it within the day. And if we have any MDR-TB patients, I’ll be ready.

More than MDR-TB at St. Peter’s, Missionaries of Charity, and Black Lion Hospital

This experience has afforded me the opportunity to see more than MDR-TB, and more than a single health institution. Over the past week and a half, we have traveled to Gondar to visit Gondar University Hospital, where we met with the new CEO and got to see the MDR-TB ward there. We also met with the head of the Department of Pediatrics at Black Lion Hospital, Dr. Demte, and attended morning report and morning rounds. We visited the Missionaries of Charity (from where several of the MDR-TB patients at St. Peter’s were initially referred). We met with the local head of the Clinton Foundation and had the opportunity to discuss their new Maternal, Newborn, and Child Health initiatives. It has been a full week.

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More than MDR-TB at St. Peter’s.

Approximately 1/3 of the patients in the GHC/St. Peter’s MDR-TB cohort are co-infected with HIV. All MDR-TB patients have initial laboratory evaluation including CBC, LFTs, bilirubin, creatinine, potassium, and HIV screening. Some patients are known to be HIV+ at the time of enrollment into a Category IV treatment program.

Such was the case for Zewdu, a 43yo man I met my first day on rounds. He was complaining of some vague abdominal pain as well as nausea, loss of appetite, and bloody diarrhea. His stool had already been sent and was negative for O&P. His exam was notable for diffuse abdominal tenderness to palpation and moderate distention. I looked through his chart and saw that his most recent CD4+ count was 36, down from 54 a few months earlier. I wondered whether he might have CMV. I also wondered about c. diff, as he had been on levofloxacin for his TB for some time. Neither of these were testable. I looked over his ARV regimen which included tenofavir, lamivudine, and efavirenz as well as clotrimoxazole prophylaxis. We sent a viral load. The next day his diarrhea was essentially resolved and he reported ongoing nausea and anorexia but improved abdominal pain. His abdominal exam was still notable for diffuse mild tenderness to palpation most prominent in the RUQ as well as mild distention. He seemed stable overall but he was definitely not thriving. We sent LFTs, electrolytes, and glucose. I wondered about CMV and c. diff (although neither can be easily tested for here). The next day he reported he had been able to take some liquids and was feeling generally better. He remained stable over the next several days.

When we returned to St. Peter’s from our visit to Gondar, however, Zewdu had taken a turn for the worse. We were rounding on some of the patients in the upper ward when a nurse came to us and requested our assistance with a critical patient. As I walked with Dr. Bekele toward the room, I asked for the one-liner. He told me that a patient was in a coma. “A new patient?” I asked. “No, no, you know him.” “One of the patients I know is in a coma?!? Who is it?” “It is Zewdu.” We arrived to the bedside, and there was Zewdu, lying flat, eyes open, with slow, stridorous breaths, not moving. He did not even resemble the man I had met 12 days before. He moaned and grimaced to sternal rub but did not localize. He had apparently been relatively normal about an hour earlier. 40% glucose had already been administered. We asked that an additional glucose bolus be given. His other vital signs were normal. One of his roommates (he was in a 6-bed room) told us that he had been seizing over the weekend. Shortly after he told us this, Zewdu seized; it began with right-sided convulsions and secondarily generalized. We raised the head of his bed and positioned his head. We gave him supplemental oxygen. We administered 10mg IM diazepam in case he was in status. We ordered him for IV dexamethasone, a loading dose of phenobarbital, meningitic dose ceftriaxone, and empiric treatment for toxoplasmosis. LP is not possible at present (due to lack of adequate sterilization of the LP equipment). We asked for CBC, Blood culture, chemistry 20. Zewdu never woke up. He never received the phenobarbital or the pyrimethamine. He expired at around 6pm. His labs still have not come back.

Once again, I want to recall and document that most of the MDR-TB cohort patients, including those with HIV/AIDS, are surviving. One patient proudly boasted to me about his last few CD4 counts, which were initially decreasing on the TB medications (common) and are now on the rise again. I wanted to write about Zewdu because I wanted to highlight the challenges of practicing medicine in a resource-limited setting with such serious illnesses. Physicians here practice with limited diagnostic as well as limited treatment options. And a greater proportion of their patients are so much sicker than the patients we treat back home. I also wanted Zewdu’s story to be told. As I wanted Girmay’s story told. And Abde’s. But GHC/St. Peter’s stories also are the ones that turn out well. In fact, most of them are the ones that turn out well. And these are also fraught with difficulty. People living in tiny single-room homes with almost no ventilation. People without refrigerators or electricity to safely store their medications. People suffering from food insecurity. People who have lost brothers, sisters, parents, children. People who have lost their jobs, their only source of income, due to their illness. And these people are being cured and getting well and their lives are improving.

Mural at the Missionaries of Charity

More than MDR-TB at Missionaries of Charity

On Tuesday we went to the Missionaries of Charity, known for the work of Mother Theresa. At the mission in Addis Ababa, which is near to St. Peter’s Hospital, approximately 900 people live there. Most of them have some form of medical or mental illness and have nowhere else to go. The Sisters of Charity care for men, women, and children with not only tuberculosis, but also different types of cancers and growths, infections (including HIV), disabilities including limb amputations, skeletal deformities, and blindness, severe mental illness, severe malnutrition, seizure disorders, congenital anomalies, and those who have simply been abandoned by all family and cannot care for themselves. There are many orphans and unwanted elderly. It is crowded, with as little as 5 inches between beds, but it is also almost spotless. It is neat and orderly. All of the beds in a given room have the same sheets. All of the equipment is uniform and in good condition.

GHC/St. Peter’s has focused on providing care for patients from the Missionaries of Charity from the very beginning of the program to make sure that the poorest in Ethiopia also had access to care. Some of the first patients to receive Category IV treatment were from the Missionaries. This week we met Helen, a young woman with an 18 month-old baby boy. She has confirmed MDR-TB and is wasting away. After it was discovered that she has MDR-TB, the sisters were able to move the several other beds in her room into another room to decrease the contact between Helen and the other women in the TB ward. Still, to get to her room you have to walk through a few other rooms with 6 or so patients each; definitely not ideal. She was thin, her heart was tachycardic, her respiratory rate in the 30s. Her lungs had crackles on the left and diminished air entry. Her artificial leg (she had to have a left AKA after an infection when she was younger) is causing her significant pain because it was fitted for her when she was about 20kg heavier.

With the arrival of more TB medications, Helen was able to be admitted to St. Peter’s for treatment yesterday. Next week I will go back to the Missionaries to take photos with her boy and bring them to her.

Helen's boy, Josef

More than MDR-TB at Black Lion Hospital

This week we went to the Black Lion Hospital, which is the main teaching and referral hospital for the country. It is large, and right in the middle of Addis.


We met with Dr. Demte, the head of the Pediatrics Department, and attended morning report and morning rounds. There is a NICU and a PICU (although no ability to ventilate patients). The children here are sick, sick, sick. We met one 2 year-old boy, Abu, with suspected MDR-TB (he has continued to get worse despite adequate Category I therapy, with loculated empyema and chest tube in place) and will try to facilitate testing of his sputum so that he can get treatment if he needs it. We also met several children with bacterial meningitis, children admitted with heart failure, renal failure, rhabdomyosarcoma, osteosarcoma, retinoblastoma, severe pneumonia, several children with infected meningomyeloceles, one child with tetanus, three with septic arthritis, several with complicated malaria, a few with severe acute malnutrition.

CXR Bad TB in 2yo boy

CT Bad TB in 2yo boy

The format of morning rounds is by department (i.e. wards, NICU, PICU), with the resident reporting admissions, discharges, and deaths. There are deaths almost every day, which speaks to the degree of illness.
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Over the past week and a half we have also participated in home visits for the MDR-TB patients. We’ve met with officers from the Ministry of Health and the Ministry of Science and Technology. We’ve seen many different aspects of health care and clinical practice at multiple institutions. It has been an extremely worthwhile learning experience.

I can’t believe my time here is already more than halfway finished. In addition to daily rounds at St. Peter’s, my goals for the remaining time are as follows: 1) go back to the Missionaries of Charity to take photos with Joseph, Helen’s son and to let the Sisters know that she is doing well; 2) return to Black Lion to attend some morning reports, grand rounds, and morning rounds, checking on Abu; 3) draft some Quality Improvement suggestions for GHC/St. Peter’s; 4) develop flowsheets/clinical guidelines for the nurses and health workers at St. Peter’s; 5) participate in additional home visits.

Less than two weeks left!

Respiratory Failure, Respiratory Success at the Global Health Committee / St. Peter’s Hospital MDR-TB Ward.

The Ethiopian Global Health Committee (GHC) MDR-TB treatment program is the first and only MDR-TB treatment program in Ethiopia. From an initial cohort of 9 patients in February 2009, the program has grown to include over 200 patients enrolled to date. Approximately 30 of these patients at any given time are hospitalized with advanced disease requiring stabilization and usually remain inpatient until they are smear-negative x 2. The rest are treated as outpatients, following an adapted community-based model of care delivery initially developed by the GHC in Cambodia. The GHC/St. Peter’s MDR-TB cohort, in partnership with the Ethiopian Ministry of Health, is serving as the model for scaling of treatment nationwide and has the potential to inform TB treatment programs throughout Africa. A second site in Gondar (Northern Ethiopia) has recently begun treatment of MDR-TB patients, also in partnership with GHC. (see http://www.globalhealthcommittee.org) I am fortunate to be able to spend four weeks on rotation here, learning about MDR-TB treatment and treatment challenges.

During my first week, I have been able to participate in rounds, admission of patients, and participate in home visits. I have been so impressed with the magnitude of the impact that the MDR-TB program has had in this community. It has truly been life-saving and life-changing for so many already; and there are thousands more people infected with MDR-TB in Ethiopia who need this therapy. Prior to April 2009, there was no Category IV treatment available. This means that these patients have undergone several cycles of Category I and Category II treatments, sometimes failing Category II therapy three or four times, before enrolling in the MDR-TB treatment program at St. Peter’s. Often patients have languished for months and years before arriving. Tuberculosis truly is “consumption”.
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Respiratory Failure.

Two patients have died on the wards during my first week here, both young males, both of respiratory failure. The first patient I met on my second day on rounds.

The MDR-TB ward is situated above the rest of the hospital (i.e. at higher altitude), which is situated above the city of Addis, heading north out of Addis up toward Entoto mountain. The patients who have not yet had a negative sputum sample are on a wing which is separated from and also slightly above the wing for patients who have converted from positive to negative but who still require additional inpatient therapy or who are not yet ready for discharge for other reasons (e.g. persistent hypoxia, inability to adhere to the medical regimen as an outpatient, etc). Most of the rooms in the sputum-positive wing are single-patient rooms. I met Abde, a 20-year-old male, on this wing.

On admission Abde had had a large left-sided empyema, which had been drained twice (see CXR below). When I met him, he looked relatively well over-all but was complaining of new right-sided chest discomfort and had a pleural rub on that side as well as focal crackles. His left side was slightly dull to percussion at the base with diminished air entry, but clinically he did not seem to have significant reaccumulation of fluid. He had a mild oxygen requirement. He was already on levofloxacin as part of his Category IV regimen. We added IV ceftriaxone for presumed superimposed pneumonia. We wanted to obtain a chest XRay, but there is no functioning XRay machine on-site and the nearby location where St. Peter’s typically sends patients for studies also had suffered a mechanical problem and was not performing XRays. The following morning, Abde looked worse. He was tachypneic and had an increasing oxygen requirement. He was in respiratory distress. We added vancomycin. We tried inhalers (there was no nebulizer available). We purchased ceftazidime (the broadest cephalosporin available in Ethiopia) for $21/gram. He died of respiratory failure around 4:00pm, before he was able to receive the additional antibiotic.

Abde's CXRs

I met Girmay on the sputum positive ward as well. He was 18 years old, so so thin, unable to move due to severe malnutrition and generalized weakness due to his TB. I could basically bring my fingers together in the space in between his radius and ulna. Girmay had been admitted one week previously and was noted to have asymmetric LE edema that turned out to be a DVT. I met him on Thursday. His lungs had bronchial breath sounds and dullness to percussion on the right, as well as some rhonchi. His left was a little crackly at the base but actually sounded fairly clear. His coagulation panel had been sent but was not yet back from the private lab that processes most of the laboratory studies sent from St. Peter’s. When I met him he didn’t have an oxygen requirement, only some shortness of breath and occasional hemoptysis. The next day, (the same day Abde died), Girmay still was stable, and the result still was not back. I was growing antsy. Finally, on Saturday, the result was back. His PTT and INR were slightly elevated (INR 1.6), likely due to his severe malnutrition. We were convinced that a PE would be devastating to him and decided to start the heparin (subcutaneous, gtt not possible for numerous reasons). There was no heparin available in the hospital, so we drove to another hospital to purchase it. The other hospital had only two 5cc vials (5,000U per cc). We bought the heparin and went back to the hospital to get him started. On Monday morning rounds, he was in respiratory distress with an oxygen requirement. We were immediately concerned that he had suffered a PE. Then we heard that the previous day, his heparin had been held due to concern for hemoptysis. He had had sudden hypotension, chest pain, increased work of breathing, and a new oxygen requirement. The clinical picture was completely convincing. Girmay looked like he was dying. His oxygen saturation was 83 or 84% on the 4ish liters of O2 delivered via oxygen concentrator. He was frightened and held my hand tight; looking directly into my eyes, in simple broken English, he begged me to be his mother (whom he had witnessed be crushed by a car and killed a few months earlier after traveling to Addis to get him treatment) and to please not leave him.

Later in the morning the power went out. We got the pulse oximeter and ran down to his room. He was in severe distress, saturating 56% (supplemental oxygen is delivered via oxygen concentrators which require electricity). We were in the process of bringing the one of the two 40L oxygen tanks on the ward to his room and hooking it up when the power returned. We put a mask over his face to pool the oxygen. It took twenty minutes for his oxygen saturation to come up to 80%. We gave instructions to his uncle and to the nurses that should the power go out, he should be connected immediately to the oxygen. I was worried he would die overnight, and worse, that he would feel alone and afraid as he died. He didn’t die until the next day, though. When we rounded in the morning, he was saturating 60% on the 4L available via the oxygen concentrator. We slipped the tubing from the supplemental canister into his mask and turned that up as well, repositioned the nasal prongs, and fashioned a non-rebreather out of a face mask with cut-off latex glove fingers slipped through the side holes and taped down. It’s difficult to explain, but we were able to fashion them to be sort of one-way valves. With all of this intervention we were able to get his oxygen saturation back up to 80%. He tired anyway a few hours later and died. I am so crushed and guilty that I wasn’t there holding his hand and stroking his face.

Girmay's pulse-ox several minutes into attempt at increasing oxygen delivery

Respiratory Success.

Despite these sad, devastating outcomes, the majority of patients treated with MDR-TB at GHC/St. Peter’s are incredible success stories, and it is so important to draw attention (yours and mine) to that. Without this program, these patients would have invariably died as well.

Of the 230 patients initiated on therapy since February of 2009, so far seven patients have successfully completed a full 2 year course of Category IV treatment for MDR TB, with cure. Out of 221 patients admitted for care to the GHC/St. Peter’s program over the past two years and 3 months, only 22 have died. Taking into consideration the limitations and challenges of working in a developing country (limitations with respect to resources including laboratory and radiographic studies, available medications, monitoring capacity, etc), as well as the bias introduced by the triage waitlist whereby more severely ill patients are admitted for treatment before the more stable patients, this is an impressive survival benefit and an amazing achievement.

Take for example the case of Yohannes, now a 29yo medical student. He acquired MDR-TB during his early medical school training. He received Category I therapy but failed, and within several months was diagnosed with MDR-TB. At that time there was not yet an MDR-TB treatment program. After several more months, he was sent home from medical school to die. The necessary drugs simply were not available. He weighed less than 45kg. Some months later, over a year after he had first acquired the disease, he became one of the first nine patients enrolled in the GHC/St. Peter’s MDR-TB treatment cohort. He is currently on his 28th month of treatment, is back in medical school and looking forward to completing his degree in one year, and his weight is back up to 60kg.

There are so many other patients like this. I haven’t been here long enough to witness the transformation for these patients as they recover, but I have met several patients already who appear healthy, smiling, happy; they are working or studying, living a relatively normal life (with the exception of having to take their TB medications twice per day) and the doctors and health officers who knew them before are able to tell me how sick they were at the beginning, how malnourished, how uncomfortable. The fact that I can’t even tell that they were ever so ill is a testament to the success of their therapy.
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I am looking forward to the next three weeks of this experience. Tomorrow we will travel to Gondar to visit the MDR-TB Ward that has just opened there and to meet the nurses and physicians who are caring for that cohort of patients. Yohannes the medical student, is back in medical school there at the University of Gondar, and I will get to meet him.

Me and Yohannes enjoying yummy Ethiopian food

Next week I will visit the Black Lion Hospital and the Missionaries of Charity to see additional patients and learn more about how medicine is practiced here. I also plan to talk with Dr. Danny (the head physician here at St. Peter’s MDR-TB Ward) about some ideas I have for quality improvement and how we might implement them.

Kris Olson, who travels here regularly and who will be here for another week this visit, is working on a project to study the potential benefits of a portable cool-box in development in partnership with MIT and GHC. The box is designed to not only provide a cooling source for MDR-TB patients on Paser who do not have their own refrigerator (it is able to work with solar power if need be for patients who do not even have reliable electricity). It will also have a counting mechanism that transmits data about how often the box and medications are accessed to the DOTS-Supervisor. Soon they hope to begin developing the survey tool that will be used to assess the benefits and challenges of using the box, and I hope to participate in additional home visits to help design that survey tool.

I anticipate a busy, challenging, and rewarding three weeks with lots of opportunity to learn about MDR-TB and practicing medicine in Ethiopia.