My thoughts about the wards at Korle-Bu Teaching Hospital in Ghana have been a long time coming. I have tried to figure out how to summarize my opinions without being too critical. As previously mentioned, there are 26 inpatient beds in the Fever’s Unit. There are 2 beds in each room, 2 drawers, and a TV. There are no curtains or partitions so once again no privacy for the patients. Every patient in this Unit has HIV and it seems over half of them are co-infected with TB.
Clinical bedside rounds are held Tuesdays and Thursdays. It consists of the ward house officers presenting the patients to a resident, the medical students, and the nurses. I found myself in a group of 10 or so huddled at the bedside of the patient being discussed trying to listen to the presentation and ignoring that I was baking in my white coat. So hot! Of course there’s no A/C which I didn’t expect there to be but the fans are so measly they might as well be off.
During rounds, we spend upwards of 30 minutes at the patient’s bedside listening to the presentation of the history & physical or hospital course, occasionally taking glances at the patient who is either attentively or bewilderingly looking at the group. For the most part the patients do not understand English well let alone medical jargon. The rest of us comment on the case and ask questions of the presenter ignoring the fact that the patient is right there. Only after the presentation is over will the resident examine the patient ever so curtly and then come up with the plan for the day.
I must say things could be better run. I understand there’s a lack of resources but it seems the staff is crippled by this lack such that even the basics eg. blood pressure, finger-stick glucose, daily baths, daily meals, are also neglected occasionally. Either that, or the staff just don’t care enough. I will elaborate in a bit.
There was a patient presented as a transfer from an outside hospital for septicemia, yes to the medical ward because there is no intensive care unit, yet in her approximately 18 hour stay so far she had not yet had a blood pressure recorded.
Another was a young woman with no prior medical history who had been transferred from a psychiatric hospital after presenting with a week of inability to walk, disorientation, and weakness all of which supposedly had been sudden in onset. She had been there for 2 weeks before being found to be retroviral positive (HIV positive) prompting her transfer to us. Her symptoms were unchanged. Nonverbal, minimally responsive, mild facial palsy, and limb tremors. Meanwhile the report received was that she feeds herself. I think not!
The differential diagnosis, which appears to be the same for everyone with mental status change, was cerebral toxoplasmosis, tuberculous meningitis, and bacterial meningitis. Yet, she had been with us for about 12 hours and had not had a lumbar puncture. In fact, it was not performed until the next day. She did get started on empiric treatment for toxoplasmosis at the time of admission. The plan was to review CSF analysis results, which would take another 4 days to receive, before deciding to start anti-TB medications if warranted.
We would also have to wait about 4 days to get her CD4 count. Typically, at this point, the patient and a family member will go through counselling before being started on HAART. Unfortunately antiretoviral therapy is not part of the plan for this patient. She is in no shape to take part in counselling as you can clearly see. Head CT? Out of the question! Why waste such a valuable resource on an HIV patient who is soon to die anyway? If by the miracle of God she is able to walk out of here the plan will be to have her return to the outpatient clinic where she will be plugged into HIV care.
And so rounds go. If the main complaint is cough, the differential diagnosis is pulmonary TB, miliary TB, or bacterial pneumonia. Antibiotics will be started and the regimen switched intermittently while pending a sputum sample which patients are too weak to cough up. Co-amoxiclav (amoxicillin-clavulanate) is used often. The TB clinic, which is a different facility, will not release anti-TB medications without sputum. No-one seems able to induce sputum from the patients so we wait. I don’t even want to think of what the antimicrobial resistance patterns are in the Fevers Unit and in the broader Korle-Bu Hospital. There is no antibiogram to guide therapy choice.
Some patients who are ready for discharge cannot walk so they cannot leave. Physical therapy services at Korle-Bu is for the stroke/trauma unit. For everybody else, it is expected that a family member comes to get them out of bed and to bring food to feed them. This is true in both the Fevers Unit and the general medical wards. But imagine the patient with HIV in a society which is yet to overcome the stigma associated with the virus and with AIDS. It’s common for such a patient to just lie there becoming deconditioned and malnourished during their hospital stay.
When I first arrived in Ghana I thought there wasn’t much stigma related to HIV/AIDS. Boy was I wrong. Yes, the nurses and house officers in the Fevers Unit are actively taking care of their patients but I get the impression that minimal effort is applied. I mean they are going to die anyway right? I gained a better appreciation for the mortality percentages and listed causes of death such as anemia and dehydration that had been presented at Morbidity Rounds during the early days of my clinical rotation.
My biggest shock, not confined to the Fever’s Unit, or to Korle-Bu alone, was anti-malarial prevention on the wards, or rather the lack of it. It hadn’t even crossed my mind until I saw mosquito repellent coils at patients’ bedside. It suddenly became clear that there were no screens in the windows and no nettings for the beds to prevent mosquito bites. Remember, there’s no air-conditioning. A whole hospital in a tropical setting where malaria is prevalent?! It didn’t make sense. How possible?! So I asked around and yes, it is very common for patients to be admitted to the hospital for one thing, say a fractured leg or a term pregnancy, and become infected with malaria during their stay. The medical staff just write for a course of antimalarial medications typically Coartem (artemether-lumefantrine) Wow! No wonder the war on malaria is going nowhere!
Enough with my rant as I am crippled and useless on the inpatient side. I am too bewildered by the lack of resources and lack of empathy. Luckily, I have begun seeing patients on my own in the clinics as one of two doctors sharing a room. I am learning a lot, teaching a bit, and feeling like I’m making a small difference. So that’s satisfying!
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