My Friday morning started as usual, sitting on my porch reading over coffee, catching up on the latest in the US presidential primaries. It had been a busy but great couple of weeks of teaching and learning, to be capped off with the Medicine team leading Journal Club at 8 a.m. So I set off a bit earlier to ensure I was at the board room on time. As I walked onto the hospital grounds, I noticed two of my three medical officer interns (who were supposed to be presenting) were standing outside the medical ward. I figured that was a bad sign. I asked why they were not preparing for the start of Journal Club and they informed me the third intern would present for us while they took care of two unstable patients.
I sat down in the board room and before the first Powerpoint slide I got a call on my little Nokia. “Dr. Travis, please come, we have a code in the male ward.”
The interns were running a code, doing chest compressions on a very sick patient. He had Diabetes that was poorly controlled. Well, it was not controlled at all – he had never taken his medication. He had now been admitted with extremely high blood sugars and a foot in which he had lost sensation giving rise to a deep wound causing a severe system-wide infection. The code went a little over 30 minutes with a few rounds of adrenaline, potassium, bag-valve-mask ventilation to help the patient breathe, and intravenous fluids running into both arms. His random blood glucose was now just above the normal range. We had finally controlled his sugar, but his anticipated amputation had not occurred soon enough. He passed away and we de-briefed on how we performed in the code.
Valuable lessons can usually be learned after a poor outcome. But that outcome has to be identified before one can know the sequence of events that led to the teachable moment. A frustration when working in a low-resource setting is that we many times do not end up with a firm diagnosis. Autopsies are extremely rare (I have not heard of one done in the last three months). Laboratory investigations can be unreliable. So, without a definitive answer, we are left to clinical patterns and team deliberations to decide the lessons learned, or what was missed, following a difficult case.
“This ward is so discouraging.” One of my favorite senior nurses was down after another death.
We returned for the finale of Journal Club, where the entire room discussed the (largely detrimental) useof steroids in HIV-associated Cryptococcal meningitis. As our team left, we reviewed the previous call night and our plan for rounds that morning. We arrived back onto the male ward and the same nurse notified us that our previous patient’s neighbor had passed. The patient in the bed right next the patient we coded had died while we were out at Journal Club, and because of his poor prognosis due to metastatic prostate cancer, there were no plans for resuscitation.
Rough start to this Friday!
One early traumatic death. One expected, seemingly peaceful death.
Teaching is not easy. It requires patience and organization. Preparing a quality lecture takes time. Arriving at a plan for any clinical scenario takes guiding a young physician without taking the reigns. This is one skill I have been taking time to develop while here, and it is an effort that has given me a renewed respect for teacher friends and my professor father.
Two weeks ago I gave a lecture on depression. With infectious threats under better control, non-communicable diseases are on the rise. Mental health issues are commonly underlying forces driving patient behavior and many times they manifest in physical signs. Perhaps our diabetic was not compliant because he did not believe he had the disease or did not understand the diagnosis or was down about managing a chronic illness for which he could not afford the long-term treatment.
The recent announcement ofincreasing suicide rates in the US alongside recent writings of the stigmaassociated with mental health issues in Kenya, in addition to my experience in managing chronic depression and anxiety among other diagnoses, made me think it was an appropriate and timely topic to discuss with the residents. Poorly controlled mental health diagnoses lead to poor compliance with treatment regimens, decreased productivity at work, increased absenteeism, and an overall lower quality of life. No matter the label you put on the patient, there are always psychological issues that could be better addressed to improve their lives. But our society and our employers sometimes ignore their importance. One need to look no further than daily current events such as the Germanwings pilotwho flew a plane directly into the ground or the multiple shootings across the US each month to realize one major thing: we are not adequately addressing mental health issues worldwide.
Teaching about depression in an area that does not typically focus on mental health issues gives rise to interesting discussion. The overall goal is to simply have the residents be aware of mental issues surrounding each case so that discussions with the patient and their families may address some potential barriers to care beyond the hospital.
In the US at least, we do not value teachers near as much as we should. American society rewards certain types of business and entertainment, but fails to invest in some of the most critical vocations or professions. And our healthcare system fails to direct resources towards issues sometimes difficult to address, such as mental health.
So many people say how important mental health or primary care is, and they say how important teachers are, but words do not incentivize sharp students to become and remain teachers and they do not pay off the massive educational debt of primary care physicians or psychiatrists and they do not form the necessary teams to manage the ignored despair that affects almost everyone, worldwide, on a daily basis.
This morning before leaving a patient’s room on the private ward, he asked us to sign the Guest Book. “Like a hotel?!,” I asked confused. He was blind, due to poor diabetic control, and this teacher (more educated than our average patient) wanted to be sure he had a log of those health workers who had cared for him. What an excellent idea, I thought, as the three of us signed before exiting.