Day Eleven: Final Bits
Our last day of the course, and the morning prayers were tinged with sadness. It’s been a fantastic two weeks, and I’ve made lots of genuine friends. I’m really going to miss going back to real life…
Claire Fuller gave us our final topic session of the week, based on many years of experience in both the UK and East Africa.
The WHO is working with the Gates Foundation to run a Global Burden of Disease statistics measuring. 600 million cases of scabies worldwide. In the developing world, skin disease is the second commonest reason for attending primary care – but people are still far less likely to attend if they have a rash compared to other types of pathology.
As in many other areas, traditional healers cause many problems – their treatment for lymphoedema is to puncture the legs multiple times to let the fluid out. Sadly, this leaves the door wide open for infection.
Important features to have.
- Suitable location for skin examination
- Satisfactory light
- Examine patient all over – check mouth, nails, scalp, feet, genitalia.
- Distribution of lesions.
The problem is, because don’t want to strip off because the clinic is full of people and no privacy, but then you take them down to the cupboard, and its too dark to see.
Bacterial skin disease
Very commonly this will be impetigo – yellow crust to blisters, generally around nose and mouth.
- They need to wash the skin – with clean waters and disinfectants. Remove crusts, debris and necrotic tissues.
- Apply antimicrobial preparation – herbal, honey, hydrogen perocide, chlorhexidine, topical antibiotic.
- Oral antibiotics – flucloxacillin, erythromycin.
Eczema is very common in the developing world. Can be especially aggressive in African skin. Rather than simply affecting the flexures, it can affect the whole trunk, and can cause very high levels of inflammation, which leaves hypopigmentation after resolution.
Often needs emollients and dermovate.
Scaly round rashes on arms or trunk related to ring worm. Can be treated with topical antifungals. However, tinea capitis – affecting the scalp – will need systemic antifungals. (See image above on right)
Pyoderma, scabies and renal damage
There is an established association between scabies and pyoderma. In those with scabies + pyoderma, 5-10% will have visible haematuria: so it should be treated.
80% of dermatology consists of 8-10 common diseases. If it smells like pyoderma, it probably is.
Medical implications of skin-lightening products
These can cause local damage, with inflammation and awful stretch marks. In Malawi, around 5-10% of people attending our clinic had problems related to these creams.
Patients will deny using the products, so you have to say “I’ve heard that people who use these creams get these problems”, letting them save face.
Having a skin disease is a risk factor for having HIV, from evidence in Tanzania. Multiple dermatoses is quite specific for low CD4 count. In one study, 88% of adolescents with HIV had a skin disease.
The best way to treat the HIV associated dermatopathology such as Kaposi’s Sarcoma is to treat the HIV.
- Treat underlying cause.
- Keep clean without dirsupting healing (antiseptic soaks, water fit for drinking is fit for wound case)
- Treat secondary infection
- Greasy covering prevents adhesion and good for pain relief.
- Compression is very helpful.
Removing suspicious lesions
Skin swells and becomes woody and hard. Smells insanely awful. Basically an end stage lymphoedema.
Usually can be dramatically improved with frequent washing and antiseptic. Get children to wear shoes, prevents the condition occuring.
Our scheme in Ethiopia has led to all who are treated being invited to join the team to teach others. 30,000 have now been treated in the scheme!
Teaching… a workshop
Our closing session was from Vicky Lavy, talking us through the wonderful art of teaching, a key tool for all of us, especially in the developing world.
Many of us have done a fair amount of teaching. As a group we came up with lots of words beginning with E, about the important things that teaching needs to achieve:
- Effect (on patient care)
- Everlasting (sustainability)
What makes a good teacher?
- Clear + interesting
- Love for the subject
- Knowledge + Preparation
There are millions of different teaching styles: Participation, Lectures, Scenarios, Practicals, Groups, Role play, Mentoring, Informal, Teach others, Drama & Song, Quiz, Stories, Bed side, Shared consultations, Video, Books, Online, Visual stuff, Thought exercise, Buzz groups.
One week after a lecture, evidence shows that people often only remember around 20% of the information.
Some of these are very effective in developing settings, others not so well. Generally, developing world cultures are used to very didactic of teaching, which means they can learn by rote, but are not well versed in problem solving.
However, once they get used to small groups, which can take some time, they find them useful also. Good to tell people they can use their own language in the groups.
“I was doing some teaching in china, and trying to ask questions, and just getting blank faces. However, over the 3 days, the group slowly opened up, talking about patient cases. By the end, I found they were very engaged.”
- Dealing with wrong answers - Important to a) not embarrass people, but also b) correct dangerous treatment ideas.
- Breaking up teaching sessions is valuable - to keep people awake. Having a buzz group session between talks is helpful. A buzz group is where someone turns to their neighbour and briefly discusses an issue
- Visual aids – showing pictures, to tell stories. One teacher on this course has showed us the manacles used to hold psychiatric patients to the wall. That kept us awake!
Case example: Teaching student nurses in Uganda about immunisation within 1 hour
We broke into lots of pairs and tried to come up with teaching sessions. Then fed back to the group. Huge variation in styles and approaches. Some groups taught basic practical skills, some came up with dramas, some had very ambitious plans to teach a much more holistic community engagement approach.
Ian’s closing remarks: God did not make us to cope with burdens on our own. Jesus sent people out two by two, not individually. We need to share our burdens together.
We then all held hands and closed in prayer together.
And that’s all folks. Sad to feel we are at an end, but I’ve definitely never enjoyed a medical course, or generally teaching so much. I’d like to give some huge thanks to Vicky and Ian, and the whole of the CMF team. Bless you all!
Day Ten: More Women’s Health
I had a massive lie in today, and then discovered that the traffic at 8:15 around London is rather horrendous. Happily, arrived only 5 minutes late, in time for…
Towards culturally competent care
There has been lots of awareness throughout the course about the impact of culture. Most of the speakers through the last two weeks have mentioned the shocks and surprises of moving between the developed and developing world.
We all contributed things we’ve experienced in different cultures we were not expecting:
- Less personal space: people just turning up at our house.
- Less confidentiality.
- Personal questions: asking things polite British society doesn’t accept.
- Different expectations.
- Facial expressions.
- Hierarchy of generations/roles.
- Family values.
To many people, not complying with their culture is not an option.
I’ve had people who have come to me, and decided they want to accept Jesus. They’ve become Christians, and then said to me “Now I can’t go home”. Breaking cultural norms can lead to beatings, ostracising, deaths…
Culture has 3 layers
- Outer layer – artefacts and products.
- Middle layer – norms and values.
- Inner layer – laws, generational beliefs.
“It was not the women’s ignorance but their intelligence that led to their refusal to adapt or abandon certain habits. They sought to understand the reason for such changes in terms that made sense to them. Not all those put forward by the health care worker did.”
The impact of culture on healthcare can be huge. Pre natal sex selection, communication styles, work force issues, birth marriage and death rituals, issues of consent, organ donation.
Ask yourself the question: Who are you? Where do you get your identity, beliefs, values, skills from? Ethnocentricity is the feeling of “I’m right, you’re wrong”. The feeling that your idea of culture is correct and needs to be taught to others.
We need to challenge ourselves; sometimes the correct thing to do is the culture that has been there for years, not our shiny Western ideas.
Women: Key Issues
- Stewardship of natural resources – women may be in charge of securing food, water, fuel and overseeing family health and diet.
- Reproductive health – issues re-morbitity, expectations of role and childbearing. Could be seen as coercion/force. Infertility is a hugely ostracising problem in some cultures, as is having a female baby.
- Economic empowerment – more women than men live in poverty. potential for economic disparity, less access to food, essential resource for living, property ownership.
- Education empowerment - women do not have access to education: linked to child mortality.
Sociocentricity and Egocentricity is the contrast of being society centred or self centred. The former is often modelled in developing world cultures, with tribes and villages central, rather than the Western individualism. It can be argued that the Socio model is more modelled in Biblical theology and morality: the concern is that there also a huge potential for individuals to be disadvantaged within it.
If used well, Sociocentricity, can be empowering for individuals and communities: its another situation where cultural sensitivity can help us to improve current systems, rather than trying to implant our own.
“We had condom education in our village, and the men came, and demonstrated placing a condom onto a stick. Rather than seeing the example in the spirit it was intended, many people in the village started placing condoms onto sticks.”
Wherever we go, we need to consider: how culturally sensitive are we being, and how can we help by providing culturally appropriate care.
The rest of the day involved workshops of Contraception, Gynaecology case studies & Gynaecology Emergencies. It was great, and very interactive, but sadly not terribly conducive to note taking.
They also told us about Swinfen Charitable Trust, who provide an international medical advice service for professionals – very useful in the field!
Day Nine: Women’s Health
After a late night gig in London, I had a rather late night, followed by getting up at 6am to prepare for speaking at the early morning prayer meeting. I also washed everyone’s feet, which was a real honour for me. The upshot of all this was that I didn’t do my preparatory homework for today’s sessions, so apologies if it seems a bit sparse.
Women’s Health in the Developing World.
- There are 360,000 women dying because of childbirth each year.
- There are 2 million newborns dying within the first 24 hours per year.
- There are 2.6 million avoidable stillbirths per year.
- 2 million unplanned pregnancies per year.
- 70,000 deaths due to abortion per year.
Birth complications means many women end up with fistulas that leak urine and faeces continuously. Women are socially ostracised – we watched the story of a lady called Mastula, and her experience of her life being turned upside down by a fistula.
Lifetime risk of dying from childbirth and pregnancy. In the west it is 1 in 4300. In Afghanistan, it is 1 in 11.
In the UK in 1930, maternal mortality rates were similar to the developing now. The UK changed due to 4 changes in services & skills:
- Midwifery care
- Blood transfusion
- Caesarean section
It is felt that there are three areas of delay that cause many of these deaths: delay in deciding to seek care (due to socio-cultural constraints, values put on women, beliefs related to pregnancy, traditions, non medical attributed causes), delay in reaching facility (financial constraints, poor transportation, no local facility) & delay in recieving care(Lack of staff (24/7), training, equipment, drugs and money).
92% of Bangladesh births are at home, with 89% totally unattended by health care providers. We worked at the only hospital in Bangladesh (population 160 million) that had an obstetric service available 24/7.
What is needed?
- Increase in the value put on women by society/ community
- Increase in community awareness of danger signs and preparedness
- Increase in the community’s confidence in EOC (Essential obstetric care) facilities
- increase in comprehensive and in basic EOC facilities
- Increase in skilled personnel in an integrated system
The LAMB hospital is a mission hospital in Bangladesh. Find out more at LHCF.org.uk.
Bible studies for all staff on created in His image, and violence against women. Teaching on how New Testament teaching on how a husband should treat his wife – “husband ought to love his wife as he loves his own body“.
We’ve seen a drastic effect: people working through the verses together: Christians, Muslims, Hindu, all reading the Bible together, and together coming to an understanding of how things should be.
We work with traditional healthcare attendants, giving them some simple points of when they need to refer to the hospital – the WHO feels this is not an effective policy worldwide, but we find it has been helpful in our area. We also train our own community skilled birth attendants, who receive 6 months training, then return to their villages..
Involvement of mother-in-laws and husbands, as decision makers, is very important; mothers will often agree with all our plans, but do not have the authority to make it happen.
That makes this the third day on this course where mother-in-laws have been recognised as an international threat to health. The hospital uses the community to pay for itself. Subsidies are provided for those who cannot afford. Households donate 1 tk per month (less than 1p), with further donations at religious festivals. We have advanced trained midwifes and advanced anaesthetic assistants – an area of contention at the moment. However, having audited our anaesthetic assistants, we have had no deaths directly due to anaesthesia in 5 years.Appropriate review definitely improves our service quality:
- “No blame”, confidential meetings
- Facilitates interdepartmental communication & teamwork
- Addresses areas for improvement
- Regular review of protocols
- Saving Newborn Lives initiative – pilot project in PNDA
- ‘Verbal autopsy’ of all maternal and child deaths in the community
I joined the “Basics” rather than “Advanced” Obstetrics workshop, which was being taught by Mary Hopper, who spoke on Saturday.
Some useful bits and pieces
- Grandmultigravida – more than 5 births.
“In Zimbabwe, we had one lady who was having her 23rd baby. In the next bed, we had her daughter, who was also having a granddaughter for our original patient!”
- Due date can be calculated: add 5 days and 9 months to the beginning of the last period.
- Foetal heart rate should around 130-140 – in the absence of other tools, using a loo roll over where you think the shoulder of the foetus is.
- Amniotic fluid should be around a litre, and should be strawberry coloured. Polyhydramnios (too much) is often seen in twins, pre-eclampsia, and seems to be more common in congenital abnormalities. Oligohydramnios (too bad), if bad, can lead to baby being held in uterus by adhesions.
Stages of Labour:
Onset of labour: from start of contractions until the cervix is completely dilated. Make a peace sign with your index and middle fingers: the distance between fingertips is around 10cm. The cervix generally progresses at around 1 cm an hour.
Our nurses in Zimbabwe couldn’t say ‘dilated’, so they would run and find me and say ‘The patient is fully delighted!’.
Second stage of labour: from full dilation to delivery of the baby. Once the woman feels she is ready to push, check the cervix.
Third stage of labour: from delivery of baby to delivery of placenta. Breastfeeding releases oxytocin, which will speed this up. Usually takes up to an hour.
Presentation, Lie & Position
- Presentation – what is near the cervix: cephalic presentation, shoulder presentation, breach presentation.
- Lie – Longitudinal or transverse.
- Position – Commonest is OA – occipito-anterior. This means the back of the baby’s head is at the front of the mother. OP is the reverse of this, the occipital region of the baby’s head faces backwards. Often, OA you will easily be able to palpate the back of the baby in the abdomen, and mum will say the kicking is mostly to the sides. OP, you won’t easily palpate the back, and mum will say that kicking is all over the place.
If a cord is visible before the baby, it often means the cord has come out, which means it can get stuck, with the baby squashing it, giving the baby hypoxia. Push the baby back in vaginally with your fingers, and get mum on hands and knees with head down.
Is the cord still vibrating? If not, baby is dead. Very occasionally, the cord can start vibrating again once you apply pressure. If the baby is dead, you need to deliver it, but there is no time pressure beyond keeping mum well.
Baby gets it shoulder stuck in the pelvis vertically. You need HELPERRS!
Help – call for help.
Lift the legs.
Enter vagina – to try to turn the baby.
Remove posterior arm – try to deliver arm through the vagina.
Rotate the mother onto all fours.
Symphesiotomy if not resolved – pop in a solid catheter, so you can move the urethra out of the midline, then cut through the synthesis pubis and pull out the baby.
Our first afternoon session was with Jacqui Hill, who has been in Afghanistan for the last 3 years, working in Obs & Gynae…
Sepsis is a huge killer in maternal deaths – even in the UK, there were 43 maternal deaths in the last 3 years from sepsis, 13 from Group A Streptoccus/
- Sepsis is a systemic infection.
- Severe sepsis is sepsis with organ dysfunction. (40% mortality in pregnancy)
- Septic shock is sepsis with hypotension. (60% mortality in pregnancy)
Sepsis is dangerous in pregnancy, because the woman is under a lot of physical duress, so has more susceptibility, and pathology presents abnormally, so is picked up late.
The evidence shows that the most important treatment is to get antibiotics into the patient.
A pregnancy specific sepsis can be chorioamnionitis. This occurs from rupture of membranes early, leading to infection in the amniotic fluids.
With cases of chorioamnionitis, delivering the baby is going to be better for both the child and the mother. Non delivered foetal survival rates are almost non existent.
Inducing a birth is usually done with medication or pessaries in the UK. One thing you can do in the developing world. Putting a catheter into the cervical os: you inflate the balloon to start stimulating the cervix. Also give an oxytocin IV infusion.
We also had session on haemorrhage and eclampsia. I failed to get many notes, but they were awesome! Then I went for a curry and finally got Peshwari chips for the first time!
Day Eight: Trauma & Orthopaedics
Driving round the North Circular via the world’s most awful roundabout meant that I nearly didn’t make it to the course this morning. Happily though, I avoiding the lorry that tried to crush me by changing lanes without indicating, and I arrived ready for a day of #…
Our first talk came from Chris Lavy, husband of Vicky Lavy, who runs the course. He explained that the reason for his haggard experience was her being away for a week, leaving him alone with the children.
The USA have nearly 1% of the population having an operation each year, whereas in Guyana that figure is 0.002%. There are 1700 surgeons per 100,000 population in the UK, whereas in Ethiopa that figure is around 1 per 100,000.
When I work in London, I don’t even recognise all the other surgical consultants in my hospital. When we lived in Malawi I knew the names, birthdays and spouses of every surgeon in the country.
16% of the global burden of disease is injuries, so we need to take it seriously. The Primary Trauma Care course is basically a very low cost of the ATLS course.
Fractures & Joint Injuries
In the West, it has become common to treat fractures operatively, but in the developing world, conservative treatment is better since it is cheaper, and doesn’t rely on having equipment, with much lower risk of infection.
- Assess fracture, circulation and nerves.
- Reduce the fracture
- Hold or support it until united
- Encourage movement at all stages.
Remember most fractures will heal without your help.
Union = bone moves as one
Consolidation = back to normal strength
Remodelling = returning to normal shape
Non union = still mobile at 6 months.
Mal union = healed in the wrong position.
How long do fractures take to unite?
- 2-3 weeks if metaphyseal eg wrists
- 4 weeks for oblique forearm fracture
- Add 2 if transverse
- Add 2 if lower limb.
Children heal much faster.
These are all conservative solutions, rather than operative
- Clavicle - put in a sling.
- Humeral - back slab or sling. Encourage elbow movements.
- Supracondylar (see above on right) – forearm traction for several day until swelling gone, then treat in sling.
- Olecranon - sling.
- Radial - plaster of paris potting.
- Metacarpal – no fixing, just regularly flex and make a fist.
- Femoral - traction – raise foot of bed and hang traction off end of bed.
- Tibial – above knee cast for 4 weeks, then below knee walking cast if stable enough. If unstable, will need traction.
- Ankle – plaster of paris pot, will need replastering in around 7 day, since the ankle is almost always swollen.
Don’t forget exercises to stop everything stiffening up!
- Wash out wound.
- Debride if needed.
- Put bones in right place.
- Leave wound open but dressed.
Tea break finished, it was time to meet Alan Norrish, and his encyclopaedic knowledge of using drills on people in hot places…
Some Ugandan studies: 3% of all surgical procedures ended up with osteomyelitis, and 18% of paediatric hospital days was related to joint and bone infection.
In the developing world resources are short, so the focus goes on injuries with blood and bones all over the place, rather than long standing musculoskeletal problems that cause a lot of morbidity.
Often there is not enough time or money to operate, but sometimes Alan has found this website rather helpful for giving patients helpful exercises.
Childhood limb specific disorders
Failure of formation
Hemimelia (picture above right) is missing bones or parts of bones:
- Missing fibula
- Missing tibia (autosomnal dominant)
- Missing radius (causes clubbed hand)
- Missing fingers (claw hand)
Failure of separation
- Most common is syndactyly of the fingers and toes.
- Can be simple with bones separate, or complex with bones combined.
- Normally extra fingers and toes.
Amniotic constriction bands
- Need removing before the child grows, as get tighter
Undergrowth of bones
- Shortened femur.
Systemic Congenital Conditions
- Osteogenesis imperfecta
- Fibrodysplasia ossificans progressivica.
- Cerebral palsy
Some people spend all their money trying to find a resolution to a long term problem, and sometimes the best you can do is tell them there is no cure, and then they can spend the money on useful things for their life.
- Common in developing world – 1:1000 births.
- Use serial casting in under 3 years
- 3 years to 8 year, needs soft tissue surgery
- 8 years olds onwards need bone surgery.
- Acute, treatable with antibiotics
- Chronic, will need bone debridement, very difficult to cure.
TB of bones and joints:
- Often present without pulmonary TB.
- Triple therapy is treatment.
Burns & bites:
- Elevate limb and splint joints in functional position.
- The skin can cause a contracture of scar tissue that needs cutting, or serial casting to prevent it limited movement.
- Go and hold the neck. It will increase awareness of the neck to other staff.
- Rigid collar.
- Log rolls for moving patient.
- If facet joint dislocation, you can perform head traction!
It turns out that I am not very good a paying attention to lectures for 8 days in a row. Eyes practically closed, I grab a coffee with ten sugars in time for the final talk of the morning with Sarah Tucker…
Our three key aims with treating burns in a resource poor setting are survival, prevention of disability and effective use of resources.
We did an audit in Nepal that showed that in six years, no one had survived 40% burns on our burn unit.
Painful as it is to say, this means that it was unlikely to be worth the heavy investment in resources treating people with this level of fatal wound. Burns patients die from injection – sadly we had to make the decision to treat anyone with more than 60% palliatively.
Severity of Burns
To assess percentage coverage, we use the rule of 9s – click the image on the right for more information.
The best way of finding out depth of a burn is to see how quickly it heals. Anything that heals in less than 2 weeks is superficial, longer is deep.
You need to perform escarotomies if any circumferential full thickness burns to the limbs, chest or neck, to prevent contractures.
The burn needs to be scrubbed clean, especially if any foreign bodies or chemicals. The burn will need to be scrubbed every few days, this removes dead skin, leaving healthy tissue.
The Ideal Burns Dressing
My pet hate is people arriving from the West with boxes of dressings, that everyone leaps on, gets very excited about, and then runs out. Much better to teach everyone to make local solutions that work well.
- Available and sustainable
- Non adherent
- Reduced need for analgesia
- Reduced need for changing
We started to use banana leaves for burns dressings. They can be autoclaved, boiled and sterilised. They are non adherent. They work better than silicone dressings.
I showed the banana leave dressings to our nurses, then went away for two weeks. When I came back, they had visited all the trees in the area, autoclaved leaves and filled the fridge with them of their own volition – that’s how noticeable a difference they made to the nurses.
If burns are across joints, and the joint is held out straight, inflammation, then scar tissue will cause contractures, which will cause functional problems in future.
There are some finer points, but generally the Edinburgh position (on the right) will prevent the hand losing functionality.
If there are burns on the inside of the hand, you will need to release the splint at night, or splint it straight at night to prevent this.
Practical Skills Workshop
The afternoon was an exciting blend of Plaster of Paris, Disolocations and traction, Skin grafting and Physio sessions. Afraid there’s not much I can say about them – you had to be there! Since you weren’t, you did miss me accidentally removing the skin on my knuckle whilst practicing taking a skin draft on an orange.
Day Seven: Surgery
After a glorious day off, where I mostly read books and used a petrol strimmer to utterly destroy a number of stinging nettles, I returned to the lovely Oak Hill College for the start of week two…
Our first talk today was from Hilary Edgcombe, who started with photos of an elephant and a boa constrictor under anaesthetic, which was cool.
Anaesthesia is the absense of sensation: so this includes local and general anaesthesia.
General perspective on world anaesthesia:
- Good anaesthesia is
- Comfortable for the paatient
- Comfortable for the surgeon
- Preferably simple, economical and fast
11% of world’s disability-adjusted life years are lost due to conditions amenable to surgery. Safe anaesthesia is necessary for surgical care.
Safe anaesthesia is not available worldwide:
- In the UK, anaesthesia related mortality is 1 per 185000
- Malawi central hospital: 1 per 504
- Togo teaching hospital 1 per 133
- South Africa: 1 in 4 maternal deaths anaesthesia related: 90% avoidable
Key causes of anaesthesia related mortality:
- Airway failure
- Aspiration (getting stuff in the lungs, leading to pneumonia or pneumonitis).
- Regional anaesthesia failur (high spinal)
Of 41 anaesthetic clinical officers in Malawi, 5 had seen a failed intubation. 2 had seen a case of pulmonary aspiration. 9 had seen a case of high spinal (requiring intubation)… in the preceding week!
A lot of this is due to lack of equipment – in one study in Uganda, only 23% hospitals had enough equipment to safely anaesthetise an adult, 12% enough to manage a child and 6% enough to do a C-section.
Golden rules for Anaesthesia
- Pre-assess your patient: to optimise their condition, to make a sensible plan, explain/allay fears/concerns.
- Know your equipment.
- Work out what you expect to happen when:
encounters your patient,
with their surgical problem,
and their other comorbidities
- Do a bit of catastrophising: formulate plan B, plan C.
- Monitor your patient: ideally HR, BP, pulse oximetry, and end tidal CO2. Worst case, make sure you are looking at and feeling the patient.
- Remember recovery.
- Don’t get into trouble you can’t get out of: if you think the airway will be difficult, don’t stop the patient breathing, etc.
Hilary then showed us a video about an exciting push to get pulse oximetry machines worldwide:
Oxygen sources and delivery
For the sick patient (who needs more oxygen or who can’t get it to their cells effectively), or for some anaesthetic techniques, oxygen is helpful. It can be difficult getting hold of O2 in the developing world for logistical reasons.
She shared a story of a patient who died due to the oxygen cylinders being full of NO2, and another of a paedriatic ward that had a 2,000 litre cylinder that they used with neonates with no pressure control, so the babies were practically being inflated by the force of gas…
- Lucky you!
- Money – expensive
- Safety – have they been maintained?
- Safety – which gas?
- Safety – what pressure?
- Safety – traumatic injury?
- Need a power supply.
- Reliable if maintained and cost effective.
- WHO standard: operate up to 40 degrees, in 100% relative humidity with unstable mains voltage and dusty environments. Passing military shock, vibration and corrosion tests. Should be supplied with 2 years of spare parts.
- Can supply 90-95% oxygen.
Ketamine is a super drug, its a hypnotic, analgesic, amnesic. It is not a muscle relaxant. It has some weird effects, since it can lead to patients have their eyes open throughout, and causes emergence delirium (the reason we don’t use it in UK).
Other key points, some positive, some negative:
- Tend not to end up hypotensive – slight rise in BP, HR and RR.
- Patients tend to maintain their own airways.
- Probably the least dangerous anaesthetic to use.
- Can cause laryngospasm due to hypersalivation, but less commonly than thiopentone.
- Can cross the placenta, giving you a spaced out baby.
Key Ketamine Safety Points
- Hypersalivation may be minimised with premed atropine 20mcg/kg
- On take excitement and post-op delirium may be minimised with benzodiazepine co-medication
- Remember ketamine can cause apnoea if giving fast IV.
- Avoid in patients with closed head injury, penetrating eye injury, and in whome cardiovascular stimulation would be harmful.
An introduction to spinal anaesthesia.
In an adult, the spinal cord ends around L1/L2, so going in below that, you are unlikely to hit the spinal cord.
There are two types of any spinal drug. Normal, and heavy – the normal types are roughly the same weight as CSF. The heavy types are mixed with glucose, and obey gravity going low. However, due to the lumber lordosis, if you give someone a heavy drug and lay them down immediately, the agent can pool in the thoracic region – see diagram on right.
Common local anaesthetics: lidocaine, bupivacaine, tetracaine. Need to know relative baricity and appropriate doses for the drug. Exclude preservatives: since they can cause neurotoxicity.
In the West, we tend to give some opiates with the spinal, but this is not something generally done in the developing world.
Problems with Spinals:
- Block doesn’t work.
- High spinal (cardiovascular compromise)
- Very high spinal (cardiovascular & respiratory compromise)
- Total spinal (cardiovascular, respiratory and CNS compromise)
- Ongoing nerve damage
- Inadequate facilities -
- Patient refusal
- Raised ICP
- Sepsis at site, or systemic sepsis.
- Abnormal clotting
- Anatomical deformity
- IV access and fluids
- Some sort of vasopressor and atropine
- Someone to monitor the patient
- Resuscitation equipment
- Position the patient well, and use aseptic technique
- To look for delayed hypotension
There is a free Developing Anaesthesia Textbook available at www.developinganaesthesia.org
Surgery for the non-surgeon
John Rennie and Colin Binks shared the next talks about surgical matters. They both apologised for the dwindling capacities of their ageing neurones, but assured us that with enough prompting they would be able to recall the more important arteries, etc.
“You must take your bible, your toothbrush, your anti-malarials and the Textbook of Primary Surgery. It’s brilliant, full of pictures, and perfect for those of you who are far more comfortable cutting sausages than cranial burr holes”.
Does my patient need surgery NOW?
- Bleeding (immediately)
- Strangulated bowel (need to stabilise patient first).
- Peritonitis – perforation, pus (need to stabilise patient first).
Does my patient need surgery at some time?
- Think: what resuscitation or other treatment is needed whilst observing?
- Can I do the surgery?
- Action: Active observation/resuscitation/refer.
Does my patient definitely not need surgery?
- Respiratory problems – basal pneumonia
- Gut problems – gastroenteritis or ileus
- General illness – diabetes, viral infections, uraemia, sickle-cell crisis
- “Surgical” – cholelithiasis, pancreatitis
- Gynae – ovulation pain, salpingitis
- Nerve pain – herpes zoster
- Clinical assessment: if a little dry, potentially 5% dehydration, with very shut down, sunken cheeks, 10%.
- Deficit (ml) = % dehydration x Wt (kg) x 10
- This is 7000 ml for 10% dehydration in 70 kg adult and 1000 ml in a 10 kg child.
- Use N-saline or Ringer’s lactate for deficit
- Resuscitation for fluid deficit will normally take 3-5 hours to optimise patient’s condition.
- Patients with active bleeding need surgery as soon as possible.
How to find a perforation in the developing world…
CT scan– unavailable Bowel sounds– unreliable Rebound tenderness– unreliable
- Loss of liver dullness – a valuable, underused resource. Air in abdomen will reduce dullness on percussion.
In Uganda, there are currently 27 surgeons for 10 million people. Last year in Ethiopia, there was only one new surgical graduate in the whole country.
Differential for Acute Abdomen
How to Operate for Dummies (AKA Medics)
- Get a nice sharp knife.
- Cut through the midline.
- Go through the fat.
- Carefully cut through the rectus sheath.
- Cut through the peritoneum, hold it aside from some clips.
- There will be a big woosh of horrible contents, if there has been a perforation.
- If there is bowel contents in there, use some sterile water to wash it out. If you haven’t got that, tap water is an awful lot cleaner than what is already in there.
- Find the hole in the bowel.
- Gentle drag the omentum over the hole, and put some big loose stitches around it.
- Leave a drain in the abdomen, through a separate hole.
- Using some strong nylon, take all the layers together and close in a mass closure technique. If you have no strong thread, buy some fishing line and sterilise it.
- Put some loose sutures in the skin, closing it properly a few days later.
- Fill them with antibiotics.
“You can do good surgery without electricity, although it is rather nice to have a lightbulb…”
Popping in a chest drain
- Use clinical signs to ascertain which side.
- Use some local anaesthetic all the way through – which then tells you that you are in the right place.
- Wait several minutes
- 5th intercostal space, mid-axillary line.
- Go just above the rib – because the vessels hang underneath the ribs.
- Make a small cut with a scalpel, then push through a Spencer Wells (see right).
- You will go through skin, then fat, then pleural.
- Open the forceps, and pop your tube through the gap.
- There will be pus, fluid or air that comes out.
- Put the other end of the tube under a water seal.
- Keep the underwater seal lower than the patient.
- Needs a full bladder, dull on percussion.
- Find the point an inch or so above the pubic tubercle, in the midline.
- Pop in lots of local anaesthetic.
- Make a small vertical incision – just 2 inches high – but add another inch for each depth of fat in obese people.
- Dissect down through the fat to the lineo alba – a white line down the midline.
- Carefully slice this in half, then hold the two sides apart.
- If there is any gut in the way, push it aside.
- Make a very small cut, and pop a Foley Catheter through the wall of the bladder.
- Stitch it in place.
- Lay patient on side.
- Measure 5 or 6 inches from the midline laterally, avoiding rectus sheath.
- Pop it in.
After lunch, we had an afternoon of practical workshops with the team from this morning. My spinal actually worked!
Performing a spinal
We had a practice at both upright and lateral spinals on some models. Rarely, I didn’t hit spinous processes, and got loads of juice out, and popped some in! Good times…
- Wash out the joint, especially if there is debris in the wound.
- Deal with it within 6 hours, to prevent infection.
- Use anaesthesia.
- Examine blood supply, nerves, tendons, other structures.
- Bone chips should be removed from trauma wounds.
- Tendons and nerves should be tied end to end with silk stitches, and keep the wound moist.
- Give tetanus prophylaxis.
You would often not stitch the wound after you have debrided it, since you need to allow muck to escape. Different areas of the body will have different rules: click picture on right for more details.
- Primary Suture – immediate closing
- Delayed Primary Suture – delayed closing after 3-5 days.
- Secondary Closure – often for older wounds that have began to heal themselves through granulation, and may need skin grafting.
There was also a fantastic Dentistry Basics session, which involved pulling teeth from a pig, and a Suturing Basics session. By the end of the day, I was definitely very ready for a curry. Which was lucky, since I was about to go to the East End for one.
Day Five: Paediatrics
This marked the first day I arrived early enough to
Introduction to Paediatrics Abroad
The first step today was a presentation from the energetic Ian Spillman, with piles of horrific statistics. Sadly, as he said, behind the statistics are real children…
We live in a world of difference. For many families, feeding is a case of “have the rains come?”. 40% of under five deaths are neonatal. If you improve sanitation, you see ~25% improved in under 5 mortality. The most common causes of death are diarrhoea, birth asphyxiation, diarrhoea and malnutrition.
In Malawi, half of all mothers have had at least one child die.
He shared a story of a 1 week old in Uganda that had been 3.5kg at birth, and 2.5kg on presentation. They waited a week, with this child vomiting every feed. The family, both parents teachers, had been to a traditional healer, instead of seeking health care support. There is a cultural problem, complicated all our medical efforts.
One UN Millennium Development goal was to see a reduction by two thirds in child mortality between 1990 – 2015. We are currently about halfway there…
Resus key practical skills
Ian then showed us clips of a video from a APLS course. Key points:
- We saw expiratory grunts, pertussus, inspiratory stridor, don’t forget systemic causes – heart failure, acidosis, ketoacidosis.
- With a neonate, you need to dry the baby immediately.
- Umbilical vein catheterisation. Open it up with forceps, insert a pre-flushed saline catheter and tape in place. You can still access the umbilical vein up to around 7 days.
- Interosseus is inserted into the tibia around 3cm below the top of the tibia, medial to the tibial tuberocity. Ideally used for resus, allowing you to gain venus access.
Care of the Newborn
The next talk was from Hannah Blencowe, speaking on neonatology in resource poor settings.
Globally around 135 million births each year, with around 57% in health facility. The evidence is that birth in a health facility may be safer… but this isn’t really feasible in all settings.
Whilst worldwide, the under 5 mortality rate is dropping steadily, the newborn percentage of that is fairly static: we are getting better at treating the under 5s, but not neonates.
The top 3 causes of death are preterm birth complications, neonatal infection and birth asphyxia.
The majority of neonatal deaths are at home. This is due to delay in 3 areas, only one of which is medical:
- Delay in recognition and decision to seek care.
- Delay in transport to care.
- Delay in receiving quality care.
Resuscitation of babies
- 136 million – normal.
- 10 million – need rubbing and drying to stimulate breathing.
- 6 million – needs respiratory support with bag and mask ventilation.
- <1 million – need advanced neonatal support.
More hospitals in developing countries have neonatal resus equipment than staff trained in neonatal rescucitation. Training would save far more lives than buying new shiny machines.
Many neonates brought in have hypothermia to some degree – some studies in the developing world show a prevalence of 60-90%. Incubators are expensive and can cause infection – the best initial treatment is kangaroo care – baby skin on skin with mother, wrapped in a blanket. Using this for stable babies frees up resources for the more unwell children.
Early and regular breastfeeding is vital. Some hospitals have closed neonatal wards that only allow mothers in every 3 hours, and if they miss their slot, they aren’t allowed in and the baby is fed with water and glucose instead: this should not be encouraged.
Hygiene is important, especially in hospital. Many washing, clean facilities, washing the patient, etc. However, cord care is valuable also, and the recommendations are changing to cord care with chlorhexidine. Remove cannula if not needed, since can be a key focus for infection.
Ideally primary care transfers and patient self referrals to hospital need to increase. However, if this happens, most developing world hospitals will struggle to cope.
Integrated Management of Child Illness & Triage
Integrated Management of Child Illness (IMCI) was started in 1997, and has 3 components :
- To improve case management skills of health workers
- Health care system improvements
- To improve family and community practices
More than 8 million children die each year from just 5 causes. Pneumonia, Diarrhoea, Measles, Malaria, Malnutrition.
Some studies now show that healthcare workers, if using a simple clinical syndromic approach to these key conditions, can provide an equal quality of care as doctor to 50% of patients – sometimes better.
A pneumonia traffic light system:
- Normal RR – no pneumonia: simple remedies.
- Raised respiratory rate - pneumonia: give antibiotics.
- Subcostal indrawing - severe pneumonia: refer, admit, or give parenteral ABx.
(Inabilty to feed, stridor, convulsions, reduced conscious level, malnutrition are all red flag features too)
Whilst IMCI hasn’t been as successful as hoped, it has shown that there have been systemic changes in practice, which has improved outcomes. For example, the evidence showed that after training, staff were going back to their healthcare offices, and attempting to rectify lack of resources, diagnosing more successfully, and assessing better. This did reduce over time, but still clearly showed an improvement.
IMCI can reduce overall costs of treatment despite actually providing a more comprehensive care for the child.
One study in Pakistan, they made of doctors use an IMCI protocol, instead of providing individualised treatment to each patient. The doctors hated this: but they saw their survival rate from Pneumonia increase from 91% to 96%, whilst also seeing their ABx use drop from 52% to 19%!
In other words: you don’t need a stethoscope to diagnose pneumonia.
The problem with IMCI (and all good health care) is it needs frequent retraining. The courses take 11 days. Obviously, this is expensive and so needs. icatt-training.org
Emergency Triage, Assessment and Triage (ETAT) is a process of triaging queues in clinics, to walk around and check for red flag signs regularly, bringing people to the front of the queue in order of priority. With small amounts of training, a low level healthcare worker can provide this service.
Case Studies of Paediatrics
After a practical session involving practising interosseus fluids, infant bag and mask and umbilical cannulation, we had some lunch, then returned for some intriguing case presentations from Ian Spillman.
He took us through a number of conditions in children, that we never see in the West due to screening, folic acid in food, etc:
- Imperforate Anus in Downs
- Spina bifida
- Haemorrhagic disease of the newborn
- Ilial performation in typhoid.
- Pott’s disease
- Cardiac Failure
Beware the damage from traditional healers: some things they use cause blindness, increased infections.
Neglect causes problems, with clubbed feet, neglected osteomyelitis, non healed bones.
Seminars & Case Studies
We worked through some IMCI case studies next with Mark, and then some neonatal case studies with Hannah.
Jaundiced baby – if occurs in first 24 hours of life, always pathological. Common causes haemolysis, infection – syphillis. Treat quickly with light therapy, either phototherapy with special bulb, or put near window. Also use fluids. Aiming to prevent Kernicterus.
Floppy, apnoeic baby after a 3 day labour. ?Sepsis, ?Hypoxic damage. Check hypoglycaemic, with ABx: Pen & Gent. Replace fluids, get breast feeding as soon as possible. If starts feeding, higher survival rate.
After this, we had a final talk from Marko Kerac on Malnutrition. The AC was on full, and I had coffee, so there was at least a tiny chance I would stay awake…
Causes of Malnutrition
Over 50% of developing children are stunted, wasted or underweight. This causes cycles, since it leads to stunted adults, who have deficient babies, who becomes affected adults, who become… etc.
Being malnourished makes conditions worse, worsens mortality and morbidity. See the picture in the IMCI template – it underpins all the child mortality..
Zinc and Vitamin A deficiency kills nearly 1 million children worldwide. Why can’t we resolve this?
Levels and types of Malnutrition
An upper arm circumference (MUAC) of less than 11cm in a 6 month to 5 years child implies dangerously underweight.
- Marasmus: wasting malnutrition. Generally wasted, thin arms (MUAC), thin face, “old man”, ribs visible, sunken eyes, lack of skin turgor.
- Kwashiorkor: oedematous malnutrition. Bilateral pitting oedema, englarged liver, angular chelitis.
Remember the Car
The basic of therapeutic supplementation is to remember a car. If your car is stuck, you can’t just start at 60 and drive off – you need to work up the gears.
In someone chronically malnourished, all their body systems have slowed down: low stroke volume, low renal function, low gastric motility, etc. You need to start feeding them very slowly, or the car will stall, eg. the patient will become overloaded. Their appetitie will slowly return, and this is helpful: it is a good sign that their other body systems are catching up: so you can rev the engine!
Start with an inpatient stabilization, followed by outpatient therapeutic feeds, then outpatient supplementary feeds, as the car becomes able to drive itself.
Mum’s prefer community based approach, takes the workload away from the ward. Some places have managed to make an locally sourced peanut butter based ready to eat nutrition.
UNICEF can help provide ready to eat nutritional supplementation. The Emergency Nutrition Network is an excellent resource to use to ask questions.
It’s all very well worrying about breast feeding passing on HIV. But what’s the point in being HIV free if you are dead?
Important to breast feed babies – dying from malnourishment is not a successful outcome – HIV Free Survival, not just HIV Free.
Day Four: HIV/AIDS
Whilst I drove to Oak Hill College, I listened to Radio 4, with a very relevant Thought for the Day, that I’ve completely forgotten. If I get an opportunity, I will look it up. I then drank lots of apple juice, then sat in the lecture hall…
The Global Picture of HIV
Gisela Schneider opened the day on HIV. She told us two stories, one of a bishop at a national conference, washing the feet of those with HIV, and another, of a pastor apologising, in tears, to a woman who said how she has been unable to speak publically about her HIV status. The pastor apologised, because Christians too easily judge it as a moral problem, and forget that there are people in the midst of it who simply need the love of Christ.
When she first worked in Gambia in the 80s, HIV arrived, but it was simply referred to as “the disease”. No-one would talk about it, no one would accept it, and it was simply hoped that the patients would die and take away the shame from the family. The Lancet article in 1985 was the first to describe a hetrosexual disease spread by sexual contact. At that time, patients simply died.
We have seen a wonderful precedent in the speed that civil society identified that ARVs needed to be patent free. If left to pharmacutical industry, ARVs would not be patent free until 2016 – whereas since 2000 we have actually had more than 6 million people started on treatment.
We asked our clinic users what they wished to be called by us. They did not want to be “patients”, or “clients”. They said “Call us friends”. We must be in a partnership to defeat HIV.
In global politics, HIV is beginning to be seen as a resolved problem: governments are starting to reduce funding, public interest is waning: new causes such as global warming are taking a place on the global agenda. We must fight to keep a public interest alive in HIV. If not, funding will be cut, patients will not recieve medications, and a treatment resistant form of the disease will spread, unopposed.
There have been some successes – 20% reduction in HIV Transmission from 2006-2011. The numbers of infected people are stablising, but there are still 7,000 new infections a day worldwide.
Some examples, of the varying leading risks for infection.
- Lesotho – stable heterosexual couples
- Kenya – multiple partners
- Benin – sex workers
In Lesotho, being married is the best indicator of risk for HIV infection!
Africa is ahead of the game. In places such as India and the rest of Asia, there are some shocking statistics – in Lahore, 82% of sex workers did not think they were at risk of HIV infection.
History of HIV
- 1981: First AIDS case reports
- 1984: First HIV tests
- 1990: First HAARTs
- During 80s & early 90s: the focus was on Prevention. Scaring patients, increasing awareness. This wasn’t terribly effective. Spending on AIDS globally was around 200 million.
- Late 90s & 00s: we began aiming for Universal Access, with a political backing. The key change was DOHA, which created a mechanism to allow WTO members to issue compulsory licences to export generic versions of patented medicines to countries with poor. Spending on AIDS globally is now around 20 billion.
One downside is that drug companies are now showing hesitancy to invest in HIV treatments due to the risk they will have their drugs stolen as generic drugs, and make no money.
Discussion: What are the main challenges in HIV today?
- Western economic crisis, increasing instablity in Africa leads to programmes falling apart.
- Primary Care settings, often the drugs are not available.
- Some places, such as PNG, are way behind the curve.
- Sustaining the enthusiasm politically and locally.
- Treatment has meant that people are less scared of the disease, and more complacent.
- Stigma is still a huge problem.
- Cultural norms, gender inequalities.
Stigma is worldwide. In Germany in 2012, a lady from Togo with HIV and Cervical cancer, wasn’t being treated for the cancer, because the Gynacologists were scared to operate due to the virus.
The New Approach – SAVE
Safe practices – ABC, Circumcision, Safe infections, etc.
Access to treatment – Reduction in Viral load reduces transmission, PMTCT, etc.
Voluntary counselling and testing – Stigma free counselling, etc.
Empowerment of children, women and youth – families, communities, leadership, PLWHA, etc.
“The greatest good you can do for another is not just to share your riches, but to reveal to them their own.”
A tea break, before she sent all the experts out, leaving just the idiots like me who don’t know anything about HIV…
There are a number of different viruses involved, HIV1 M, HIV N, HIV O, HIV 2. The process of CD4 infection is through CD4 attachment, then Co-receptor binding with gp120 joining to surface proteins, with gp41 joining to CCR5 receptors in the cell wall, allowing the RNA inside to be released into the cell.
Once inside the cell, the RNA is integrated into the DNA of the cell, creating provirus. This process takes several days. This is the point at which lifelong infection begins. Once the RNA is integrated into one cell, the virus (currently) cannot be eradicated from the body.
The initial stage, of introduction of RNA to the cell takes around 2 hours – some preventative drugs work on this process – which is why post exposure prophylaxis ideally needs to happen within 2 hours.
Once CD4 cells are infected, they become disorganised. They are still there, but they can no longer react to immune problems correctly. Over the next 12 weeks, the virus is replicated, sometimes causing an acute viral “conversion” syndrome – click the graph on the right for a larger version. There is an excellent explanation of this process that Gisela mentions in her slides at The Naked Scientist.
Testing is a key area of discussion, with the basics of 5Cs – Consent, Confidentiality, Counselling, Correct testing, Linked to Care.
Telling a patient they have HIV is so life changing, so painful, that you should not test patients if you cannot provide them with this fivefold support.
After infection, progression to an AIDS syndrome can take <5 years (10-20%), 7 years (60-70%), >10-15 years (5-10%). Less than 1% do not progress.
She advised us to print this list, and laminate it. We won’t be able to remember it, but we can refer to it as we see patients.
- Moderate weight loss (<10%)
- Recurrent respiratory infections (sinusitis, bronchitis, otitis media etc)
- Herpes Zoster
- Angular cheilitis, oral ulcers and sores
- Papular pruritic eruptions (PPE)
- Seborrhoeic dermatitis
- Fungal infections of nails
- Unexplained weight loss >10%
- Unexplained chronic diarrhoea > 1 month
- Unexplained persistent fever > 1 month
- Persistent oral candidiasis
- Oral hairy leukoplakia
- Pulmonary tuberculosis
- Severe bacterial infections (e.g. pneumonia, empyema, meningitis, pyomyositis etc)
- Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis
- Unexplained anaemia (<8g/dl), neutropaenia (<0.5 x 109/l), thrombocytopaenia (<50 x 109/l)
- HIV wasting syndrome
- Pneumocystis pneumonia (PCP)
- Recurrent severe bacterial pneumonia
- Chronic herpes simplex infection (> 1 month)
- Oesophageal candidiasis
- Extrapulmonary tuberculosis
- Kaposi’s sarcoma
- Cytomegalovirus infection (retinitis or other organ)
- Central nervous system toxoplasmosis
- HIV encephalopathy
- Extrapulmonary cryptococcosis
- Disseminated non-tuberculous mycobacterial infection
Case studies of HIV
Gisela then walked us through some case studies, through common presentations of ?HIV patients. Opportunistic infections - important markers for clinical stages. Need to be treated before initiating ART:
Fever of unknown origin – commonly due to TB, Malaria, PCP, Cyptococcus, Toxoplasmosis.
Focal neurological lesions – commonly due to Toxoplasmosis, Tuberculoma, Primary CNS lymphoma, Brain abscess, Stroke.
Diarrhoea – less common now in areas with high ARV treatment, but in ARV naive areas, commonly due to Cryptosporidium, Microspora, Cyclospora, Isospora.
Basic preventative therapy:
Good studies showing that provision of the following can make a difference – but the community needs to be involved, as had been said all week. Go to a village, given them nets, they won’t use them. Work with a village, if they ask for help, then it becomes part of the village culture.
- CtX prophylaxis.
- Malaria protection (ITN).
- Clean water supply.
- Nutritional support.
Anti Retrovirals Therapy
A 5 minute break during which people laughed on hearing that the BMA just passed a motion calling for Andrew Lansley to resign. Then back to ART…
Nucleoside Reverse Transcriptase inhibitors (NRTI)
- Backbone of therapy.
- Side effects of Anaemia (AZT), Polyneuropathy(D-drugs), lipatrophy, lactic acidosis.
Non Nucleoside Reverse Transciptase inhibitors (NNRTI)
- NVP – Can cause hypersensitivity, lead in. Hepatotoxic
- Efavirenz – Teratogenic.
- 2nd line treatment (but first for HIV 2). More expensive but effective.
- Difficult to take due to side effects – Diarrhoea bad. Also cause hypergylcaemia and hyperlipidaemia, long term cardiac risk.
- Generally two types, combined. Commonly 2 NRTI + 1 NNRTI. Sometimes 2 NTRI + PI.
- Important to avoid some combinations due to side effects.
Response to ART
- Virological – Ideally level falling to an undetectable viral load.
- Immunological – Rise in CD4 count, around 10/month.
- Clinical – Weight gain, Disappearance of symptoms.
Highest risk of ART toxicity will be in the first 1-3 weeks. After this, the next few months 16% of patients in stage 4 starting ART will respond with an IRIS (Immune Reconstitution reaction). Common cause is CMV, TB or cryptococcal disease. Highest risk of death in in the first 3 months, worsened risk by low CD4 count – can be avoided if we start treatment early!
Clinical treatment failure: a new or recurrent stage IV event.
Immunological treatment failure: fall of CD4 to baseline. 50% fall from peak. Persistent low levels of CD4.
Virological treatment failure: viral load > 5000 copies.
Counselling is one of the most important factors in useful ART treatment. You need cultural sensitivity, there must be understanding, real communication and community support. Indigenous health workers are the most effective at this, so they can be the best contributors to good compliance.
HIV in Pregnancy and Childhood
Lots of Quorn sausages later, I walked through the gardens barefoot in the 27 degree heat, chatting about Somalia with a fellow CMFer, and wishing that there was ice-creams. Then we returned to the expert world of Gisela…
“No child should be born with HIV, no child should be orphaned from HIV, no child should die from HIV”
11 year old HIV orphan, Ebube Taylor, speaking to a UN panel
48% of eligible adults are receiving ARTs. Only 23% of eligible children receive ART.
Seven year follow up of Gambian pregnant women living with HIV-1. Mothers who died within 7 years: 34%. HIV infected children who died 69%. Orphans who died irrespective of their HIV status. In other words: being an orphan is as bad for your mortality as being a child with HIV.
Reducing vertical transmission
20% of maternal deaths in Africa are due to HIV. Avoid this by using ART, and aiming for quick normal deliveries, avoiding instrumental delivery. Where feasible, elective CS.
Ideally start combined ART for all pregnant women, continuing for life. Some places use a single dose nevirapine to prevent mother-to-child transmission – but there is a widespread resistance to this. When mother on ART, breast is best, and relatively safe!
Mother on ART throughout pregnancy reduces transmission from 30-40% to 2%.
- Category 1: Die within 1 year. (25%-30%)
- Category 2: Symptoms early in life, die aged 3-5 (60%)
- Category 3: Develop symptoms >age 8. (10-15%)
Test all children with a dried blood spot test with the first review after birth. HIV children present commonly in first year of life with PCP. Treat with high dose ABx.
Treating children is very complex. Much better to heed Ebube Taylor’s words, and prevent vertical transmission.
Palliative Care in Resource Poor Settings
Unsurprisingly, the 27 degree heat, coupled with 5 hours of very intense discussion of medications with long names and scary side effects, I nearly fell asleep. 2 pints of coffee later, and AC turned on in the lecture theatre, I steeled myself for our final lecture from CMF’s own Vicky Lavy.
Vicky spent several years establishing and running Paediatric Palliative Care in Malawi. She then wrote a Palliative Care toolkit for use by others, and much of her teaching is from that.
A nurse we had been working with for several months said “Doctor, I do not see how this Palliative Care can work – the patients, they just keep dying!”
Caring rather than curing. A revolutionary concept to many places in the world.
Palliative care is looking after people with illnesses that cannot be cured, relieving their suffering, and helping them through difficult times. The “care” is key. As Jesus said:
“When I was sick, you looked after me”.
In the developing world, very often Doctors say “There is nothing we can do”. But Palliative Care never says this – no matter how small, there is always something we can do.
Counselling and psycological support is a vital part of palliative care. Often forgotten in favour of exciting discussions of oxycodone doses, but actually is probably more important. Truth is one of the most powerful medicines available to us, but we still need to develop a proper understanding of the right timing and dosage for each patient. Despite cultural differences, there are studies across the world showing that telling patients the truth has a positive medical effect.
Pain management should be done by the mouth, by the clock, by the ladder. Oral, regularly, and according to the WHO pain ladder. Codeine is very expensive, so we usually pass from Step 1 to Step 3 quite quickly.
- Topical metronidazole for smelly wounds. Smelly wounds are stigmatising, but just crush metronidazole can resolve problems.
- Metronidazole pessary for vaginal discharge. Similar to above, with Cervical Ca
- Opiates for breathlessness and diarrhoea.
- Gentian Violet paint for candida and skin sores.
- Prednisolone for mouth ulcers.
- Franjipane juice for Herpes Zoster. Common African flower, sticky juice inside a flower.
Taking a spiritual history
Always something that can be helpful, but a very important part of Palliative Care
- “I ask everyone about this, as part of our routine assessment.”
- Do you have a faith which helps you through difficult times?
- Do you ever pray?
- What helps you make sense of life?
- What things are most important to you?
- Have your thoughts about life changed since you became ill?