Tropical medicine

A busy week of brainwork for me so far.

Today palliative review of a lady on Wallace ward (the gynaecology ward). Another late stage cervical cancer. She was brought in last week, barely able to sit up, let alone stand. 55yrs and her face is resigned, no glimmer of hope from a body that wants this all to be over.
She came in before Christmas and was given a blood transfusion, this time her haemoglobin is 5.9, not low enough to warrant a transfusion here. There is nothing else the gynae team can offer.
I can tell from the smell that she likely has a colovaginal fistula (the cancer has made a hole through from her cervix to the bowel). She is leaking faeces vaginally, the odour pervading through the ward. Her family's main concern is the swelling in her groin, and the fact that she is barely eating. The gynae team wonder if the swelling is an abscess and contributing to her tummy pain, but it is rock hard and craggy, so I suspect more likely to be the cancer which has spread to the lymph nodes. She winces just to move on the bed and any more invasive examination would be unbearable. I had asked for M to give his surgical opinion on the query about it being an abscess for draining, but he concludes that although they could examine her under anaesthetic she is unlikely to gain anything from this process. The palliative nurse H has explained this to her and her family and we agree that she would be better off being cared for at home by her family.
H has explained one of her frustrations in trying to improve palliative care on the wards is the actual administration of analgesia. She all too frequently writes it up, gets the liquid morphine from pharmacy and gives the first dose herself, only to find no further doses get given. She is at a loss knowing how to change this. It does feel that once the patient has been referred to palliative care, that the rest of the hospital staff shrug off any responsibility. It is something I am discussing with Dr A, the medical superintendent, whether any nursing palliative care training sessions would be useful.

Visits yesterday were bittersweet. Beautiful scenery, mango stalls and sheet upon sheet of drying peppercorns adorn our hours drive out into the foothills of the Usambara Mountains to review the lady I had seen before Christmas with what we think is cerebral toxoplasmosis (an infection of the brain caused by a protozoa). You may have heard of toxoplasmosis from the advice we give during pregnancy to avoid cat litter. An infection could harm the baby, though unlikely to cause serious illness in a healthy grownup. In someone with HIV the effects have been devastating. However, this time we are greeted with smiles all round and our patient is already sat in the living room awaiting us. Last time she could barely be assisted out of bed. Her mother beams saying she is eating well, feeding herself and growing steadily stronger. She can answer our questions directly today, her speech almost back to normal. It seems the medication started by Dr K back in October has helped significantly. My research leads me to advise that we continue treatment for another 6 months. We shall check her CD4 count at our next visit (a marker of how her HIV control is).
Our return journey leads us to drop in on another home bound patient. The hospital discharged him last summer following a stroke. He is only 46, and when his family describe the story of sudden onset of severe headache for 3 days, followed by loss of vision and paralysis on one side I assume a diagnosis of a brain haemorrhage (bleed). He is still unable to speak, 8 months later, and cannot move without help. He is incontinent and they have to wash, dress and feed him. They say his communication is very limited; he responds to his name but often appears to have no understanding of what his family are saying to him. They were advised to seek physiotherapy for him but cannot afford it. The burden on his family is huge, his quality of life negligible. The palliative team have been dropping in to offer the family support and a listening ear. The stark and sobering contrast with the stroke rehab on offer in the UK.

Out on Home Visits

Peppercorns drying in the sun

Another clinic patient testing my realms of knowledge is a 36yr old lady, referred to the palliative care team after coming to hospital after 3 weeks of excruciating epigastric pain (the tummy area just below your ribs), loss of appetite & weight loss. She has been seen by a clinical officer who has done a blood test for hepatitis and arranged an ultrasound scan which shows a large liver with multiple nodules. They have written a diagnosis of hepatoma (liver cancer) but have not told her anything more than to now attend the hospice. She is deeply anxious, her husband sitting on the edge of his seat....they fear the worse...I do too.
It takes a while to start from scratch, I am thrown by the certainty by which they have formed a diagnosis. I ask her when she first noticed she was jaundiced - she said no one had remarked on this, though the whites of her eyes are bright yellow, but it started 1 week ago. By brain is whirring through causes of jaundice & hepatomegaly (an enlarged liver) & liver nodules. They have not established her HIV status, though she tested negative during pregnancy with her youngest child, now aged 5yrs. We arrange a quick test which is also negative.
I take a detailed history, examine her and then talk it through aloud to the room now full with the hospice clinical officer, the palliative care nurse and a visiting Australian medical student who this week is shadowing the hospice. The med student's previous degree in environmental health proves invaluable as we work our way through possible unusual infective causes such as brucellosis, leptospirosis, q fever. Could she have amoebic cysts, though I'm sure these are more likely to be singular lesions. I am not clear as to which hepatitis strains they test for here at the hospital. I am also not sure if I can trust the ultrasound report - are there really nodules? Her liver is certainly enlarged, I can feel it myself. She looks very unwell, her pulse is racing and she is painfully thin. I fear a cancer diagnosis may be likely, whether primary liver cancer which I now know is far more prevalent in sub-Saharan Africa than in the UK, or from metastasis (spread from another cancer).
I decided to start her on antibiotics which cover the possibility of  a few unusual infections and give myself time for some homework. We also sorted out some decent pain relief for her. She'll be back in a few days time. Regardless of diagnosis or no diagnosis, she will certainly need the input of the palliative team over the next few weeks. If it is primary liver cancer she won't have long. I deeply miss the ability to talk directly to her, so much is lost in translation. Her 3 children are the same ages as mine.
I ask the clinical officer what he would've done without me....this is the kind of patient he gets sent all the time.... I get whisked off before he can answer. We have so many topics for our tutorials now!