Seattle, Nalgenes and CPAP

I'm back in Winston now after a pretty long trip a week and a half ago that started out in Fort Portal on a Thursday morning around 8AM and ended in Winston on Friday night around 9PM with some extended layover time in Entebbe (where I filled my time by swimming at the Lake Victoria pool and jumping off their 30 ft high dive along with a quick visit to the zoo) and in London-Heathrow (occupying my time by staring bleary-eyed out the airport windows, reading Wind, Sand and Stars and finally giving in and lying down on two chairs). Now it's back to life in the South and almost excessively hot weather already despite only being the middle of March.                                          Picture taken with permission of the mother

After the last post which was pretty heavy, I figure I ought to post a more uplifting post about things I saw in Kiwoko to help balance things out a bit. My last two days at the hospital were spent in the NICU which has the capacity to care for around 30 infants or so. It's actually a pretty modern unit with incubators for all the neonates thanks to support from the ISIS Foundation in Seattle. I hadn't spent much time in the NICU at Wake so it was good to get some exams of these really small babies under my belt. The babies ranged pretty broadly in their acuity and prematurity with the really small ones checking in at under 1 kg and hanging somewhat precariously to life while the ones on the other end of the spectrum were basically hanging out and eating and adding weight every day while they waited to hit the minimum weight needed to be discharged.

There were 22 babies there the first day I was there so examining and writing up the plans along with Jill who was the physician in charge took a while. About the time we had 3 or 4 babies remaining to see, a baby in respiratory distress who had just been born was brought in from Maternity. The baby wasn't particularly premature but had clear signs of respiratory distress (fast rate of breathing, increased work of breathing, nasal flaring, intercostal retractions, supraclavicular retractions). Initially we bulb suctioned his mouth and nose and got a O2 monitor on him which showed sats in the 70's if I remember right (normal would probably be >93% at Kiwoko's altitude.)

He didn't show much improvement so Jill broke out the CPAP (continuous positive air pressure) machine which had just been given to the hospital by the ISIS folks and had only been used once before. It had been developed by some people in the US I believe as a low cost alternative to expensive CPAP machines found in the West. CPAP is designed to help open up and keep open the alveoli that can be collapsed in these little babies. It basically consisted of a Y valve that split the flow from the O2 concentrator and one side went into a 1L Nalgene bottle filled with water and the other side went into the nasal cannula in the baby's nose. The pressure that the baby received was regulated by how deep the tubing was lowered into the water in the Nalgene which had markings that indicated the relation of the depth to the air pressure the infant received. Once the back pressure in the nasal cannula exceeded the marked water pressure, the excess air would flow into the Nalgene and bubble out which operated essentially as a pressure release valve and helped maintain a constant pressure. If more pressure was needed the tubing could be lowered farther down into the water and vice versa.

After only a few minutes of CPAP the baby showed marked improvement, began breathing much more comfortably and had much better O2 saturation. We finished our rounds and went to lunch and when we checked back in after a couple hours he was doing so good that we were able to take him completely off CPAP and off oxygen and he did fine.

It was great to see how such a simple adaptation for the third world could make such a big difference and get the baby over that critical hump in the first few hours of his life. So big props to ISIS and Seattle and the people who designed that basic Nalgene CPAP machine. The one part of the equation that wasn't cheap was the O2 concentrators which are quite spendy and which many poor hospital wouldn't necessarily have. Since this NICU was well supplied, there were a number of them available to use and we actually had to use two in tandem to get the desired pressure. However I just read about a CPAP that uses aquarium pumps that are much cheaper and may be a more affordable solution for many of the third world hospitals out there. http://www.nytimes.com/2011/09/27/health/27breathe.html

HIV

Before coming to Uganda I hadn’t worked with many HIV positive patients in my time at Wake or known many friends who were HIV positive. That changed as soon as I hit the wards in Kiwoko. My first day in the hospital started off pretty routinely as we saw a number of fairly stable patients and discharged a good number before going to lunch. On our return from lunch however, I quickly was hit with the reality of medicine in rural Africa. While we were eating lunch, a 7 year old girl had been admitted with some vague symptoms of fever and diarrhea and not feeling very good for a few days. In this part of Africa, malaria always springs to mind as well as a few other things, one of which is HIV. The mother said the child hadn’t been tested for HIV but that she was negative. We ran some tests and went off to see other patients.

Later in the day, a nurse came up to us and said a patient of ours was ISS positive. I didn’t know what ISS was so I asked Phil, who I was working with, and he explained that it was a pseudonym for HIV positive that made it easier to discuss with patients in front of others. I asked him which patient was positive since we had seen a number of patients and I couldn’t remember who we had tested and what their names were in the busyness of learning a new hospital system. He said that it was the little girl and my heart sank. Her life had changed in an instant with the diagnosis by no fault of her own. Suddenly she was facing a dramatically altered life expectancy, social stigma by some, the need for lifelong daily medications, potential difficulty finding a spouse and facing difficult questions about having kids to name just a few of the issues that accompany HIV. It was tough for me to wrap my mind around the injustice of a seven year old getting that kind of sentence so undeservedly. On further investigation, it was also revealed that her mother and father were HIV positive as well, but the mother had known about her status previously but had been dishonest when questioned.

Unfortunately that little girl is not an exception among our patients here. Since that first day I have seen numbers of patients here who are HIV positive, some of whom are clinging to life by their fingernails while being racked by opportunistic infections trying to take their life. Very commonly in the morning when we round, we’ll hear about another one of those patients who was on the brink who didn’t make it and died overnight. It is really heartbreaking as you see the life and death struggle played out on an almost daily basis with these patients who you get to know as you treat them, pray for them, encourage them and hope strongly that they will recover only to see them lose their battle with the disease.

Not all of the patients who have died since I have been here have been HIV positive but a huge number of the patients seen at Kiwoko are HIV positive (close to 60%) and have an uphill battle when they get sick. This battle is even harder if they forget to take their anti-retrovirals for a few days or don’t have the money or time to get to the hospital to pick up their medications in time and allow the virus to develop resistance to their medications. Once the first line drugs are no longer effective, there is one second line drug that is provided free of charge and after that they are out of options. It becomes a waiting game until they die since there are no free third line drugs available to them.

In spite of this tough reality, circumstances are much better than they were in the early days of HIV when there were zero options for the people of Uganda. Now, if they are adherent in taking their medicines and coming to their clinic visits they can experience a much longer and fuller life as a result of the free anti-retrovirals provided by foreign aid. Still as a health care provider and human being, it is hard to watch these patients die while still only in their 30’s and 40’s because of the effects of HIV.