Respiratory Failure, Respiratory Success at the Global Health Committee / St. Peter’s Hospital MDR-TB Ward.
Submitted by: Raquel Reyes, MD, MPA, PGY3, Internal Medicine and Pediatrics, Massachusetts General Hospital.
The Ethiopian Global Health Committee (GHC) MDR-TB treatment program is the first and only MDR-TB treatment program in Ethiopia. From an initial cohort of 9 patients in February 2009, the program has grown to include over 200 patients enrolled to date. Approximately 30 of these patients at any given time are hospitalized with advanced disease requiring stabilization and usually remain inpatient until they are smear-negative x 2. The rest are treated as outpatients, following an adapted community-based model of care delivery initially developed by the GHC in Cambodia. The GHC/St. Peter’s MDR-TB cohort, in partnership with the Ethiopian Ministry of Health, is serving as the model for scaling of treatment nationwide and has the potential to inform TB treatment programs throughout Africa. A second site in Gondar (Northern Ethiopia) has recently begun treatment of MDR-TB patients, also in partnership with GHC. (see http://www.globalhealthcommittee.org) I am fortunate to be able to spend four weeks on rotation here, learning about MDR-TB treatment and treatment challenges.
During my first week, I have been able to participate in rounds, admission of patients, and participate in home visits. I have been so impressed with the magnitude of the impact that the MDR-TB program has had in this community. It has truly been life-saving and life-changing for so many already; and there are thousands more people infected with MDR-TB in Ethiopia who need this therapy. Prior to April 2009, there was no Category IV treatment available. This means that these patients have undergone several cycles of Category I and Category II treatments, sometimes failing Category II therapy three or four times, before enrolling in the MDR-TB treatment program at St. Peter’s. Often patients have languished for months and years before arriving. Tuberculosis truly is “consumption”.
Two patients have died on the wards during my first week here, both young males, both of respiratory failure. The first patient I met on my second day on rounds.
The MDR-TB ward is situated above the rest of the hospital (i.e. at higher altitude), which is situated above the city of Addis, heading north out of Addis up toward Entoto mountain. The patients who have not yet had a negative sputum sample are on a wing which is separated from and also slightly above the wing for patients who have converted from positive to negative but who still require additional inpatient therapy or who are not yet ready for discharge for other reasons (e.g. persistent hypoxia, inability to adhere to the medical regimen as an outpatient, etc). Most of the rooms in the sputum-positive wing are single-patient rooms. I met Abde, a 20-year-old male, on this wing.
On admission Abde had had a large left-sided empyema, which had been drained twice (see CXR below). When I met him, he looked relatively well over-all but was complaining of new right-sided chest discomfort and had a pleural rub on that side as well as focal crackles. His left side was slightly dull to percussion at the base with diminished air entry, but clinically he did not seem to have significant reaccumulation of fluid. He had a mild oxygen requirement. He was already on levofloxacin as part of his Category IV regimen. We added IV ceftriaxone for presumed superimposed pneumonia. We wanted to obtain a chest XRay, but there is no functioning XRay machine on-site and the nearby location where St. Peter’s typically sends patients for studies also had suffered a mechanical problem and was not performing XRays. The following morning, Abde looked worse. He was tachypneic and had an increasing oxygen requirement. He was in respiratory distress. We added vancomycin. We tried inhalers (there was no nebulizer available). We purchased ceftazidime (the broadest cephalosporin available in Ethiopia) for $21/gram. He died of respiratory failure around 4:00pm, before he was able to receive the additional antibiotic.
I met Girmay on the sputum positive ward as well. He was 18 years old, so so thin, unable to move due to severe malnutrition and generalized weakness due to his TB. I could basically bring my fingers together in the space in between his radius and ulna. Girmay had been admitted one week previously and was noted to have asymmetric LE edema that turned out to be a DVT. I met him on Thursday. His lungs had bronchial breath sounds and dullness to percussion on the right, as well as some rhonchi. His left was a little crackly at the base but actually sounded fairly clear. His coagulation panel had been sent but was not yet back from the private lab that processes most of the laboratory studies sent from St. Peter’s. When I met him he didn’t have an oxygen requirement, only some shortness of breath and occasional hemoptysis. The next day, (the same day Abde died), Girmay still was stable, and the result still was not back. I was growing antsy. Finally, on Saturday, the result was back. His PTT and INR were slightly elevated (INR 1.6), likely due to his severe malnutrition. We were convinced that a PE would be devastating to him and decided to start the heparin (subcutaneous, gtt not possible for numerous reasons). There was no heparin available in the hospital, so we drove to another hospital to purchase it. The other hospital had only two 5cc vials (5,000U per cc). We bought the heparin and went back to the hospital to get him started. On Monday morning rounds, he was in respiratory distress with an oxygen requirement. We were immediately concerned that he had suffered a PE. Then we heard that the previous day, his heparin had been held due to concern for hemoptysis. He had had sudden hypotension, chest pain, increased work of breathing, and a new oxygen requirement. The clinical picture was completely convincing. Girmay looked like he was dying. His oxygen saturation was 83 or 84% on the 4ish liters of O2 delivered via oxygen concentrator. He was frightened and held my hand tight; looking directly into my eyes, in simple broken English, he begged me to be his mother (whom he had witnessed be crushed by a car and killed a few months earlier after traveling to Addis to get him treatment) and to please not leave him.
Later in the morning the power went out. We got the pulse oximeter and ran down to his room. He was in severe distress, saturating 56% (supplemental oxygen is delivered via oxygen concentrators which require electricity). We were in the process of bringing the one of the two 40L oxygen tanks on the ward to his room and hooking it up when the power returned. We put a mask over his face to pool the oxygen. It took twenty minutes for his oxygen saturation to come up to 80%. We gave instructions to his uncle and to the nurses that should the power go out, he should be connected immediately to the oxygen. I was worried he would die overnight, and worse, that he would feel alone and afraid as he died. He didn’t die until the next day, though. When we rounded in the morning, he was saturating 60% on the 4L available via the oxygen concentrator. We slipped the tubing from the supplemental canister into his mask and turned that up as well, repositioned the nasal prongs, and fashioned a non-rebreather out of a face mask with cut-off latex glove fingers slipped through the side holes and taped down. It’s difficult to explain, but we were able to fashion them to be sort of one-way valves. With all of this intervention we were able to get his oxygen saturation back up to 80%. He tired anyway a few hours later and died. I am so crushed and guilty that I wasn’t there holding his hand and stroking his face.
|Girmay's pulse-ox several minutes into attempt at increasing oxygen delivery|
Despite these sad, devastating outcomes, the majority of patients treated with MDR-TB at GHC/St. Peter’s are incredible success stories, and it is so important to draw attention (yours and mine) to that. Without this program, these patients would have invariably died as well.
Of the 230 patients initiated on therapy since February of 2009, so far seven patients have successfully completed a full 2 year course of Category IV treatment for MDR TB, with cure. Out of 221 patients admitted for care to the GHC/St. Peter’s program over the past two years and 3 months, only 22 have died. Taking into consideration the limitations and challenges of working in a developing country (limitations with respect to resources including laboratory and radiographic studies, available medications, monitoring capacity, etc), as well as the bias introduced by the triage waitlist whereby more severely ill patients are admitted for treatment before the more stable patients, this is an impressive survival benefit and an amazing achievement.
Take for example the case of Yohannes, now a 29yo medical student. He acquired MDR-TB during his early medical school training. He received Category I therapy but failed, and within several months was diagnosed with MDR-TB. At that time there was not yet an MDR-TB treatment program. After several more months, he was sent home from medical school to die. The necessary drugs simply were not available. He weighed less than 45kg. Some months later, over a year after he had first acquired the disease, he became one of the first nine patients enrolled in the GHC/St. Peter’s MDR-TB treatment cohort. He is currently on his 28th month of treatment, is back in medical school and looking forward to completing his degree in one year, and his weight is back up to 60kg.
I am looking forward to the next three weeks of this experience. Tomorrow we will travel to Gondar to visit the MDR-TB Ward that has just opened there and to meet the nurses and physicians who are caring for that cohort of patients. Yohannes the medical student, is back in medical school there at the University of Gondar, and I will get to meet him.
|Me and Yohannes enjoying yummy Ethiopian food|
Next week I will visit the Black Lion Hospital and the Missionaries of Charity to see additional patients and learn more about how medicine is practiced here. I also plan to talk with Dr. Danny (the head physician here at St. Peter’s MDR-TB Ward) about some ideas I have for quality improvement and how we might implement them.
Kris Olson, who travels here regularly and who will be here for another week this visit, is working on a project to study the potential benefits of a portable cool-box in development in partnership with MIT and GHC. The box is designed to not only provide a cooling source for MDR-TB patients on Paser who do not have their own refrigerator (it is able to work with solar power if need be for patients who do not even have reliable electricity). It will also have a counting mechanism that transmits data about how often the box and medications are accessed to the DOTS-Supervisor. Soon they hope to begin developing the survey tool that will be used to assess the benefits and challenges of using the box, and I hope to participate in additional home visits to help design that survey tool.
I anticipate a busy, challenging, and rewarding three weeks with lots of opportunity to learn about MDR-TB and practicing medicine in Ethiopia.