Sachin Gupta, MD, is a pulmonary and critical care physician with The Permanente Medical Group at Kaiser Permanente San Francisco Medical Center. He and his wife, Ranjani Akula Gupta, who works in the Integrated Marketing and Communications organization at Kaiser Permanente’s national headquarters in Oakland, returned recently from a mission to Kenya on behalf of the Tiba Foundation. Dr. Gupta provided these observations from their journey and mission.
What an adventure we are about to embark on! I feel excited and a little anxious going into this trip. This is a unique opportunity to help our fellow human beings through empowerment. I have participated in “set up shop” clinics abroad where a team brings a bunch of medications, supplies, nurses and doctors and comes to an impoverished city to provide service. This is a fulfilling experience; however, its impact is time limited. On this trip I am tasked with empowering the local physicians and clinical officers (effectively Physicians’ Assistants) by teaching them basic bedside ultrasonography. My wife, Ranjani, will be working on innovations, including leading an innovations workshop, as well as providing recommendations to the marketing/patient experience team for the Matibabu Foundation.
With a visit to Africa once before (to Uganda) I’m not as personally worried about the “unknown” of the atmosphere we are entering. Naturally I maintain a healthy fear of having things stolen or getting an infection such as malaria. I have not been to Kenya. However my anxiety is a bit different this time. Traveling with my wife, unlike previously when I traveled alone and met up with colleagues, I concern myself for her health and that she does not have a negative experience in this her first trip to beautiful Africa. I know she is resilient and has tolerated challenging experiences in India so this shouldn’t be too far off.
Well, sitting at the airport and looking forward to disembarking from San Francisco and arriving (at our layover) in Istanbul! It will be a very long journey but well worth it.
The flight to Kenya was fine. It felt pretty fast actually with movies, naps and the ever exciting mealtimes. Being in the Istanbul airport was pretty remarkable, a hodge-podge of various Africans, Middle Easterners, Indians, Asians and Turks. The colors and styles of dress, including extremes of being covered or uncovered, as well as different accents, scents and attitudes was extremely impressive. New York City on the subways, or in Queens at Jackson Heights didn’t hold a candle to this level of diversity. Chatting about geopolitics with a Saudi and later a Somalian was a unique experience.
Arriving at 2:30 a.m. in Kenya was a breeze, as was customs. Dan Ogola, our liaison and head of the Matibabu Foundation, greeted us and we were briskly escorted to our hotel. Dan is a pleasant gentleman who welcomed us with open arms. Perfunctory exchanges of backgrounds and international experiences were made. The car ride was like many other car rides I’ve had in developing countries with the feel of a tropical climate, the smell of burning wood & trash, and the sight of people on motorcycles, bicycle, and small cars scattered throughout the roads. The behemoth highways of the States with large vehicles and high speeds are countered by a population that has outgrown its infrastructure and resources.
The next day, after meeting with my colleague, Infectious Disease specialist Susan Jacobson, MD, we took a short flight to Kisumu and from there about an hour and a half car ride to Ugunja. We are definitely now in rural west Kenya! I’m excited to see the Matibabu Hospital soon. Sleep, thanks to jet lag, is greeting me early.
Day one in our small hospital provided a vastly different patient panel than what I see in the States. Generally patients are younger and less burdened by core Western diseases.
Aside from the several cases of malaria that were admitted due to high fevers and dehydration there was a case of diabetic ketoacidosis, related to uncontrolled blood sugars, which is a very uncommon problem here. My insight was actually useful on that case!
There was also a case of decompensated heart failure that portable ultrasound helped us determine was related to severe mitral regurgitation. Possibly from prior rheumatic disease I surmise. The ultrasound device certainly has its uses here. In terms of thoracic testing, the main uses here will be evaluation of consolidation and pleural effusion. I think the cardiac ultrasound will be most useful to evaluate valves, where the physical exam fails, and systolic heart failure. Vascular analyses such as the carotids and internal jugular vein has limited utility; however, IVC analysis should be very helpful in determining volume status. Evaluation of skin lesions and abscesses as well as lymph nodes definitely will also be useful here.
Hospital day 2 was notable for a few interesting cases. One is of a patient with malaria as well as decompensated heart failure. We worked on titrating medications such as an ACE inhibitor and diuretics for her while she’s in the hospital so this way in the future she has fewer long-term complications from heart failure. One key teaching point to the Clinical officer was to not start diuretics when someone is spiking temps to 39C (102.2 degrees Fahrenheit)!
Here in the hospital I feel we are needing to manage things completely with the mindset that follow up maybe an issue and therefore starting someone on heart failure medications in the throes of malaria is a necessity.
We do have a slew of cases of possible tuberculosis and my own gut instinct is to be pouring over a chest x-ray and we are making the best of the situation by using ultrasound to look at their lungs. It is interesting in one case where I observed a cavity in this man’s lung. We will need to await his AFB Smear result.
(Follow up note: sputum AFB was smear negative; however, we palpated and then performed ultrasound on an enlarged Virchow’s node, then proceeded to perform an FNA that was AFB smear +++)
While there were many powerful experiences, one story stood out to me.
I was chatting with Ezekiel, our HIV clinical officer after rounds one day. We were discussing the importance of keeping tuberculosis on the differential diagnosis, and the process by which we rule it out in the United States. Really it was a unique opportunity to exchange ideas of practice patterns. He agreed that tuberculosis surveillance needs to be more aggressive in an endemic area like this. He then shared his own personal story of why he is so passionate about this topic. To know Ezekiel’s calm and composed manner is to know how emotional it was for him to share this story with me.
Ezekiel shared, “About one year ago (September 2015) my grandmother was sick with a cough, bringing up sputum and having fevers. She saw a pharmacy-based clinical officer for persistent symptoms. The clinic officer who saw her evaluated her and felt she had pneumonia versus pulmonary tuberculosis based on her symptoms. He gave her some antibiotics and left things alone from there. There were not any tests for pulmonary tuberculosis. She was not assessed by sputum. She did not feel better and her condition worsened. In October, about a month after the initial visit, she went back to the same clinician who evaluated her and felt she had pneumonia versus pulmonary TB again. She looked sick and so she was sent to the hospital for tests. There are they found a large pleural effusion and put in a chest tube until it was drained. They tested her sputum once for TB and the test was smear negative. They told her she did not have tuberculosis.
“My concern was that she had tuberculosis (despite the negative test) and I kept calling and telling my grandmother and mother that I think she needs her doctors the test again for tuberculosis. She and the rest of the family did not believe me and felt I was being paranoid. They only took one sputum and did not run any other test such as Gene- expert on the sputum. I was really worried because she was losing more weight and having drenching night sweats. A few months went by with her deteriorating despite my efforts to push for further testing. She went to the hospital in January with respiratory distress. But it was too late, they could not save her. And she passed away.”
Ezekiel was convinced she passed from undiagnosed and untreated TB and based on his description of his grandmother’s symptoms this was a strong possibility. His voice trembled for a moment as he recollected this story. I had preceded his story by explaining how in the United States our protocol is to test three sputum samples on smear as well as culture. It is likely that her care in a resource-abundant area like the States would have been vastly different and her outcome changed.
For Ezekiel, this experience has taught him the importance of early TB diagnosis and treatment. He is much more aggressive now in excluding TB in his patients. Given he manages a large cohort of patients with HIV, the importance of this cannot be understated. It is sad to me that he had to endure such a tragedy.
This trip has re-emphasized to me the importance of recognizing each human life as precious. Each human being is with a beautiful narrative of life no matter their upbringing or surroundings. I feel my duty as a physician to recognize the individual’s narrative and their relationships (not just the disease) was sharpened by this trip. Like a dive in cold water, the feeling invigorates you to the core. I recommend this experience to all physicians, to all human beings.
-Sachin Gupta, MD