RAKCOK

2 March 2021  Yesterday we started testing some of the staff involved in caring for the patients with Covid-19.  Two of our staff were positive.  I felt fine yesterday, though in my exercise, I felt as if I had increased my workout, though it was the same as it had been for weeks.  Also I noticed that the respiratory issues that had been dogging me for weeks were slightly worse.  No difficulty breathing, but a bit more cough and a bit more phlegm.  I knew that this was my day for testing.  I felt a bit of soreness of my muscles, but otherwise fine as the day began, but as the day went on, I felt like I had a fresh cold.  And since others on our ward had the Covid-19, I was fairly certain that coronavirus was the cause of my fresh cold.  A couple of hours later, my suspicions were confirmed.  I have enough to do to keep me from being too bored during this stay, but it is frustrating.  We have a new doctor from Slovakia.  Dr. Daniela will take over my responsibilities for the next two weeks.  Perhaps I can look at some x-rays and answer a few questions, but the reality is that I am shunted to the sidelines.

7 March 2021  The number of cases of Covid-19 has increased significantly.  Staff on every ward has been diagnosed.  Many have chosen not to get tested.  Had I known it was my option, I probably would have chosen ignorance.  I am shunted to a corner of the visitor’s compound and growing in my frustrations.

9 March 2021  I guess with a worldwide pandemic and millions of deaths, I have little room for complaints, but I am a complainer.  I had some high fever for a couple of days and slept a lot, though in fact my respiratory complaints have been minimal.  After about three days I started feeling significantly better, but then I started getting frustrated by what was going on in my ward.  Our surgeon, who is from Uganda, is very quick to refer, at least in my opinion.  There was a 8 yo girl with probable Rheumatic carditis.  I have a lot of experience with those patients, but instead of getting a real description of what was going on with the child, I was informed he referred the patient to Uganda.  Perhaps this family can afford the referral.  Most cannot.  Moreover, we do not have the capacity to manage patients with artificial valves, which are the only valves used any more, so if she does have surgery, she will be stuck in Kampala the rest of her life.  Meanwhile I am shunted away and unable to do anything.

10 March 2021  I truly am shunted in response to Covid-19.  The building where I have been shifted is in the far corner of the Visitor’s Compound so that I see no one unless they come to see me, and that is rare.  Last night, I had an unwelcome visitor.  I have not left the door open for any length of time, but I had a bat flying around my room.  I do not think the bats here carry rabies, but I just do not like them.  I opened the door, hoping the bat would find the opening and leave, but though he flew around and near the door many times, he would not exit.  I had a broom and was finally able to swat him out of the air and through the door.  He was not there in the morning, so I presume I did not kill him.

15 March 2021  I tried to argue that 10 days after the diagnosis I should be back at work, but Dr. Rosario is a stickler (though he did not get tested after heavy exposure).  14 days after the diagnosis I started back today.  The wards were fairly dramatically changed.  A lot did not make sense.  Patients with Covid-19 who were not hypoxic and wanted to go home should have been sent home and I sent several today.  One of the men was complicated.  He was diagnosed with HIV and Pulm TB almost a month ago, but when we started the RHZE (TB meds) he became jaundiced.  We stopped the meds for 2 weeks.  He was restarted on RHZE 2 weeks later (while I was in exile).  A few days later he was diagnosed with Covid-19.  Today he was not jaundiced about 10 days into treatment.  He was not hypoxic.  We have not started the HIV meds, but what we decided today was to bring him back in a month and start them then.  That would give time for complete recovery from Covid-19 and six weeks on TB meds, making it much less likely he would have IRIS (immune reconstitution inflammatory syndrome).

16 March 2021  Medical acuity means the severity or complications of patients.  One of the challenges in South Sudan is that our level of acuity is high, but our resources are low.  I admitted a man today with HIV, Pulmonary and extra-pulmonary TB, and Kaposi sarcoma (KS, a tumor that is primarily seen in HIV patients).  His TB treatment initially failed because after two months (the most intense two months of treatment) he developed TB adenitis.  He had a fluctuant node in his R supraclavicular area that I aspirated and showed TB still present.  That constitutes failure of TB first line medications.  He was started on Streptomycin, but now we are out of that medication, though we are taking steps to get more.  We are also attempting to treat his KS.  Recommendations are for a combination of Vincristine and Bleomycin.  We have a good supply of the former, but no Bleomycin.  What I hope to do with him is use the Vincristine more frequently than usual.  Instead of every two weeks, we will give it every week and see how it works.

18 March 2021  Covid-19 has significantly impacted our hospital.  Close to half of our staff has been infected, though I was probably one of the few who was truly ill.  I had fever and weakness for several days, whereas the majority of those testing (+) were asymptomatic.  The second patient we had with Covid-19 died.  The first patient may have died because he went home before he was ready, but he had stabilized after fluids and steroids and may have done well.  Since then we have had a couple of patients who were quite ill but recovered.  When I came back to the ward, I was unwilling to look at the ward as a jail.  I sent anyone ready home to self-isolate.  Though I am sure that is imperfect, the virus is clearly in the community and enforcing isolation in the hospital will just cause ill-will and reluctance to come.

19 March 2021  A young man (21) came to my office yesterday.  He looked ill.  He had been previously diagnosed with TSS (tropical splenomegaly syndrome), which is a trash term meaning the patient lives in the tropics and has a large spleen, but we do not know the reason.  He had a large spleen (crossing the midline) and a large liver.  He had a high fever.  A CBC showed pancytopenia.  Though he has never been to Malakal or areas endemic with Leishmaniasis, he appears to me to have Kala Azar (visceral Leishmaniasis).  Leukemia is also possible.  The problem is making the diagnosis.  At present we have no diagnostic tests (in Gidel, we did bone marrow aspiration and looked for the pathogens), so taking the next step will be challenging.  I plan on discussing the case with Dr. Rosario.

20 March 2021  Covid-19 has changed the way we do call.  Instead of seeing the patient in the OPD, I have to go to the ward, which means I need to find a bed to examine them.  Two of the patients who have come recently were neonates with fever.  One was 5 days old, and the second  3 days.  Both had high fevers and poor nursing.  In both, their livers were congested, but there was no heart murmur and in fact they were acting volume depleted.  I started IV antibiotics and gave each of them fluid, and they both seem improved.  Could they have had Covid-19?  Perhaps, but I think it unlikely.  One of the mistakes we make during an epidemic is to forget about other causes of illness.  Both these babies had neonatal sepsis and I am hopeful both will do well.

21 March 2021  A man with HIV was recently admitted to our hospital.  He has had cough and fever for the last month.  A sputum for AFB was negative.  When he came to me, his BP was 56/28.  His chest was clear, but he was quite tachycardic.  His abdomen was unremarkable.  His O2 sats were 96%.  Several of our recent patients with Covid-19 had hypotension, so I suspected this man had it and ordered a test.  The lab technician told Isaac Aliap (my student translator) that we should admit the patients because the test takes so long to run.  I refused.  I am all for having a holding area, but to admit them to the ward before we know the results of the tests is calling for disaster.  Why have a ward dedicated to Covid-19 (which we do) if we are admitting the patients somewhere else until we have the test results?  He turned out to be positive.  I gave him fluids and started steroids, though he was not hypoxic.  I am still suspicious he may have TB as well.  Indeed, we have had a lot of patients with HIV, TB, and Covid-19.

22 March 2021  My father recently asked me if we were going to get the Covid-19 vaccine.  I told him there were so many others that we needed much more and were unlikely to get that I figured we would not get the Covid-19 vaccine until 6 months after the pandemic was officially over.  Today I was called to see a neonate whose mother came to the ANC (antenatal clinic), but never got Tetanus vaccines because we were out.  The mother had gone 4 years before conception and went to ANC, but did not get proper care “because we were out.”  The child is a 5 day old who cannot open her mouth to nurse.  The child is balled up with severe hyper-reflexia.  She had a low grade fever and some desquamation of the skin, but in fact this child has neonatal tetanus, which carries a horrible prognosis, because of we were out of the tetanus shots.  Unforgivable.

23 March 2021  A nice somewhat elderly lady was diagnosed with CCF (congestive cardiac failure) and TB pericarditis.  She had stabilized substantially and was transferred to Yirol, St. Joseph Hospital, a TB hospital.  Instead of taking care of the lady, they gave her some TB meds and did not even admit.  She received no cardiac meds after she left us.  She came in with a pulse 192, BP 76/54.  She had diminished breath sounds in RLL and dull to percussion.  The heart was racing and irregular.  The liver was 15 cm below the ribs and she had +4 edema.  She was in horrible failure and almost dead.  Let me learn.  St. Joseph Hospital is a hospital in name only.  In fact, it is a pharmacy for TB.

24 March 2021  Weather wise, this has been a strange year.  Normally the rains stop in late September, but this past year, they continued into December.  Along those lines, malaria has continued to be a big problem.  I have never stopped taking Doxycycline, though usually I get a 4-5 month break.  We started having a few showers a week ago, and last night felt like the start of the rainy season.  Indeed, the large puddles that are present virtually the whole of the rainy season are now filled again.  In some ways, it was nice because we had been getting into some really hot nights, but if the rains have really restarted and malaria season comes back in full, the overlap with Covid-19 could prove challenging.

25 March 2021  Malek 1 and Malek 2 are two young boys who had abdominal tumors.  Both were initially diagnosed with Burkitt Lymphoma, but Malek 1 appeared later to have a Wilm’s tumor, though in his initial ultrasound, the kidney looked normal.  He was never sick, and his tumor shrank, but did not go away.  We ended up referring him to Uganda.  Malek 2 was younger, but essentially the same, with an abdominal mass that appeared separate from his kidney.  His response was dramatic.  After the first round of chemotherapy (Cyclophosphamide, Vincristine, and Methotrexate), the tumor was gone.  I could not find it at all following the second round.  But he has been neutropenic, vomiting, and continues to show severe chemotherapy induced gut injury.  We have checked our math several times and even reduced it 25%, but after 3 rounds we are stopping until his gut recovers.

26 March 2021  There have been some benefits to Covid-19.  Our hospital census is down considerably, but one thing I notice even more is the difference in call.  We have stopped using the OPD area for “emergency” visits.  If someone comes in an emergency, they go to the respective ward.  The advantage for me is that when I was on call before, I would get called to see one patient and end up seeing 10.  The reason was that the people would see the doctor there and it was as though there was a “Welcome” sign posted.  Now that does not happen.  It may be one thing I push to keep after the epidemic subsides.

27 March 2021  I am still confused by my little girl admitted more than a month ago.  She had a chest tube placed, but it had quit draining.  She seemed to be doing well enough.  Her fever was down and her appetite was up, but there was still a substantial pleural effusion on the L, though it looked organized when I repeated an ultrasound.  For the last two days, she has had fever and more difficulty breathing.  I did another thoracentesis and got a small amount of fluid that remained thin, but there was no flow.  Her oxygenation was down.  I got a Covid-19 test that was negative.  I think this is just an intercurrent infection (probably viral) and just shows her vulnerability.  We had arranged to put her on Children’s ward to get oxygen if the Covid test was negative, but I found out in the early evening that the nurses had changed the plans.  That did not sit well with me, and I let them know it plainly.  Oxygenation drops over the evening and night, so I was determined to get her on oxygen before that occurred.  Overall I think she is doing well and I remain convinced this is TB, but she is weak and vulnerable and we have to be careful with her in the interim.

29 March 2021  A 45 yo woman was admitted with respiratory distress.  She was found to have HIV, but she was Covid-19 (-).  There were some scattered crackles, but her CXR showed huge bilateral infiltrates.  Her O2 sats were in the 70’s.  This was almost undoubtedly PCP (Pneumocystis carinii pneumonia).  We started her on high dose Septrim (four times normal doses).  We put her on oxygen and she appeared to improve for a couple of days.  Her HIV viral load was not particularly high.  After four days, her respiratory rate had greatly increased.  I started her on steroids, but she died.

PCP is a common pathogen, but it rarely causes disease except in immuno-compromised hosts.  Once it is in place, recovery is difficult.  I thought for a couple of days we were going to be fortunate, but that fell apart.  Even if we could have ventilated her, she probably would have died.

31 March 2021  On what I consider my first missionary trip, I went to Sarajevo.  One of the things that impressed me was how much easier it is to destroy than to build.  Multi-million dollar high rises were bombed out.  One of the most beautiful cities of the Balkans was destroyed.  Their Olympic village was in ruins.

Malith is one of the assistants in surgery.  He is a quiet young man, very respectful.  He told me today that a youth came to stay with him.  What he did not know was that another youth was battling his friend.  That youth came and burned down both of Malith’s tukels.  We are looking at the rainy season coming (maybe already here) and he needs to build at least one tukel—make the mudbricks and build the tukel, get the materials and build a roof—before more heavy rains come.  He also lost all his stores of food.

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