Inside Bugando

A typical day on the internal medicine service at Bugando begins at 8:00 a.m. at morning report. Sitting in the front of a 10x20 ft room filled to capacity with residents, interns, AMOs, medical students, and one or more attendings ("specialists" as they are called here), the intern who was on call the previous night briefly outlines the presenting complaints, physical findings, laboratory results, working diagnoses and treatment plans for the patients he or she admitted during the night. Questions may be asked of the intern regarding thought processes or treatment options and interesting teaching points may be highlighted during this time for the benefit of students and young physicians. After morning report rounds are made in the ICU with Dr. Peck, the resident covering the ICU that day, and any residents and students who are interested in joining rounds. At about 9:45 rounds in the separate medical wards begin. On Mondays and Thursdays all of the patients are seen. On other days only the sickest patients are seen. After rounds the treatment plans agreed upon on rounds are carried out (medications administered, procedures done, tests ordered) and some residents and interns who have to be in clinic leave for those duties. Residents, interns, and AMOs trickle out of the hospital as they finish their duties and the intern and resident on call for the night settle in for the long haul. A typical night is quite busy on the medicine service- often an intern admits twelve or more patients in addition to taking care of issues that may arise with patients already admitted. But if the internal medicine department is busy, the pediatric side is crazy. The average number of admissions is about 15. Several days ago the intern on call admitted 22. I have heard of as many as 27 kids being admitted in one night.

I expected to encounter significant pathology here, and it did not take long for my expectations to be confirmed. On my first day rounding with the ICU team three of the five patients had presented almost identically: 25-35 year-old male with altered mental status. One was a known HIV patient and an x-ray revealed a classic pattern of "miliary tuberculosis" with small nodules scattered throughout the lung fields. Suspicion was that he had developed cryptococcal meningitis, a fungal infection of the fluid around the brain that is common in HIV patients. He was started on an antifungal drug, but as we are seeing with many cases of cryptococcal meningitis he passed away about a week later. The second patient had had a seizure associated with his decreased level of consciousness. I was surprised to find that the hospital has its own CT scanner (though the patients' families have to pay for its use which often precludes us from obtaining CT images) and imaging of this patient's brain showed "ring enhancing lesions" classically associated with toxoplasmosis, another infection of the brain that I had not yet seen but that is fairly commonly seen in HIV infection. We subsequently tested the patient for HIV and his test was positive. He was recently sent home on treatment for his toxoplasmosis and will come back to be started on treatment for his HIV. The final patient with altered mental status had had multiple attempts to obtain spinal fluid to determine whether he had an infection around his brain as well but all attempts to get fluid were unsuccessful. A day later he developed multiple vesicles in his mouth consistent with infection with herpes virus, which gave an indication that he could be suffering from meningitis caused by the same virus. He was started on an antiviral medication and within several days was much better and has since been transferred out of the ICU.

Patients on the general medical wards are not as critically ill, of course, but quite sick just the same. I was shocked at how many of the patients we rounded on the first day had tuberculosis, HIV, or both. My guess would be that approximately 60% of the patients in one ward were HIV positive. Probably half as many had confirmed or suspected tuberculosis. Isolation rooms would be prohibitive in cost and insufficient in number and therefore do not exist here (each ward consists of 4-5 large rooms that hold 10-12 beds each) and so there is no recourse but to have patients with active TB share a room with patients who have HIV with dangerously low CD4+ counts (leaving them particularly susceptible to infections such as TB, certain pneumonias, fungal infections, etc). I have yet to see anyone, patients or health workers, wearing TB masks. Malaria is one of the most common diagnoses made both on the internal medicine and pediatric services. Whether or not the blood slide indicates malarial parasites most people who come in with a fever are treated with quinine or artemether emperically. Indeed, I have never felt so many large spleens before (a common result of chronic malaria). Schistosomiasis is endemic to this area and is an infection of the gastrointestinal or urinary tracts caused by a worm that lives in fresh-water snails (quite common in Lake Victoria) that invades the skin of people who may wade or swim in infested waters before making their way to their body system of choice. The infection often goes unnoticed for years (aside from some itchy skin) before causing liver and spleen congestion, kidney failure, or bladder cancer. In pediatric patients Burkitt's lymphoma (a disease I have never seen in the U.S.) is exceedingly common and, fortunately, quite sensitive to common chemotherapeutic agents.


But not all of the medical problems we encounter are tropical infections that I have no experience dealing with. I have been surprised at the commonality of hypertension, renal insufficiency, congestive heart failure, stroke, and arthritis. Although I spent much of the first several weeks uncertain of the role that I was meant to play at Bugando and feeling that my experience treating the types of diseases commonly seen here was grossly inadequate, I slowly settled in and realized that I was able to contribute to discussions regarding the plan of care for some of our patients who had disease processes that I was familiar with. I am grateful for Dr. David (ward clerk) and Dr. Onesmo (intern) (pictured below- Dr. David on the right) in particular for letting me join them in caring for their patients on ward J5 for the past few weeks and for teaching me about some of the diseases that I am encountering for the first time.