African Mission Healthcare Foundation

You would think that after seven years of facing the same dilemma in Africa I would have simply adopted an algorithm: An emaciated, feverish and confused HIV-infected patient clearly has something in her brain. All the basic tests are normal. Is it tuberculosis, or is it toxoplasmosis, another parasitic infection? TB is much more common, but toxoplasmosis much easier to treat.

Should I try treating for toxoplasmosis with high-dose Bactrim, and then see if she responds? Or should I take the nine month plunge, including the two months of injections, and treat for TB? Waiting, even a day or two, could be fatal. I fell back on my instinct. TB is more common, and this person was generally very ill. Not only was TB likely in her brain, but in her blood as well.

Now came another problem: How to get her to swallow the medicines? She was agitated and oppositional, and later would become violent. Her mother, a retired nurse, served as her guardian. In Malawi, each patient has a helper who remains on the ward to assist with feeding, bathing and other functions. Yet even her mother could not convince her to swallow the large red tablets. I ordered an injection of a powerful anti-psychotic as a sedative, to little avail. The nurse and two family members held the patient on the edge of the bed while I forcibly inserted a nasogastric tube. She clenched and the tube came out her mouth. I tried again, finally accessing the stomach. The thick, viscous red liquid--crushed TB drugs--was poured down the tube and chased with water. I hurriedly removed the tube and stepped away from the struggling patient.

The next day it was the same routine. Our patient lay tense, arms and teeth clenched, supremely uncooperative. A quick insertion and instillation, then removal. The patient was not happy. Then she began to recover. The heart rate slowed, and she walked on her own--not necessarily a good thing, since she found her way to a vase of flowers and hurled it at the nurse. More sedation was required. Now she swallows the tablets and even says, "Hello, Doctor" when I arrive.

There is a great distance between the state of someone so ill and a return to health and wholeness. In the midst of fatigue and sickness and death, it is quite easy to just give up on the individual patient, to think she will never get better--or, if she does, that the reprieve won't last long. I could not help remembering a similar situation in August 2003. A skeletal figure, pregnant, HIV-infected, in denial. We admitted her for something I almost never do: immediate antiretroviral therapy. (Sure enough, she actually had extensive TB, which roared to life a few days later as the strengthening immune system attacked it.) So thin was she, and too weak to eat adequately, that I insisted on a nasogastric tube for feeding. We left it there for more than a week. She could have removed it, but I uncompromisingly threatened to just put it back in.

That very same patient is right now getting her broken leg fixed at Kijabe Hospital in Kenya--over eight years later.

I finished rounding in the hospital this morning. My newest TB meningitis patient had a rocky night, a fever for the first time in two weeks. Pneumonia? A usual culprit in someone bedbound for so long. I can't do any testing on Sundays, so I administered antibiotics.

Her setback depressed me. Many of the patients are dreadfully ill, a few with just as severe forms of TB. Would any of them recover like my Kenyan patient and go on to lead productive and happy lives? Does compassion really require the toughness to forcibly insert a hard piece of plastic down someone's nose? I sat down to look at the admission register for Partners in Hope. I passed over the names of many who had been critically ill but were now doing well. I counted the admissions and noticed that in 10 months we had raced past last year's 12 month total. We are facing a 30% rise in volume over the past year. When you have only 15 beds (we have squeezed in 20 before) and only so many people and resources, that kind of pace is a little daunting.

But we must be doing something right if the sickest of the sick continue to find their way to us... --

A year ago I wrote about a young woman with lungs destroyed by tuberculosis. She came to Partners in Hope extremely ill, begging for air and for help. It turned out she had a blood clot in the large vein serving the lower part of the body, and this dangerous coagulation had passed to the lung. Safuli, her blood thinned, has recovered nicely and her oxygen levels have approached normal.

I also related the story of a young woman with a deep leg abscess. Your overly intrepid correspondent, facing the absence of surgeon and disregarding his own lack of manual coordination, performed the drainage himself, followed by three weeks of dressing changes on our ward. Our nurse who oversees a satellite HIV clinic near the client's home reports that she has also recovered fully and has even become heavy--a coveted condition in Malawi. Grace, Jon