At Korle Bu Teaching Hospital in Ghana, I attended Mortality Review for the Department of Medicine. It was similar to Surgical M&M in that they went through all their cases. In a Medical M&M it is typical to choose one or a couple of cases with salient teaching points to review.
A resident from each ward recounts the total number of admissions for the month and then the total number of deaths. Admissions on average were in the 40s. Deaths on average were in the teens to twenties. That is high! The Fevers Unit for example reported mortality around 30-40%. Most causes of death were determined by autopsy and included pulmonary or disseminated TB, acute hepatitis, dehydration, and cerebral toxoplasmosis. A lot of people had anemia secondary to ART as their listed cause of death which really made no sense. The Attendings present seemed to agree because they really grilled the residents. The whole conference reminded me of surgical M&M because the resident presenting was made to squirm!
I was shocked and impressed at the high numbers of autopsy completed because it’s rare stateside for a family to want autopsy when their loved one dies. I learnt later that families here are told autopsies are compulsory. It makes sense as it seems the doctors really don’t know what’s going on with a patient because of lack of diagnostic resources. The one CT-scanner for instance was out of commission.
I was surprised by the lack of patient confidentiality. The outpatient clinic is set up such that there are two doctors in each examination room. Each doctor is seeing a patient at the same time. No partitions, no curtains, nothing. Just two different consultations going on simultaneously. Each patient can hear what the others business is. At one point one doctor asked her patient if she was coughing, which reminded the other patient that she too had a cough! And they both laughed. The patients didn’t seem to mind this lack of privacy. They were just very thankful for being seen.
Antiretroviral therapy for HIV is begun at CD4 count 350 or at WHO stage II or greater. The patients pay about 50,000 cedis (5-6 US dollars) for a month’s supply of medication, the rest of which is subsidized by the government. All their blood tests are paid for too. They have to pay for any other medications and tests on their own. The routine tests include a CBC, BUN/Cr, LFTs, and a CD4 count every 6 months. HIV RNA viral load tests are just too expensive so they are not used. Most patients on ART seemed to be very adherent.
I had mentioned before that an average of 400 patients are seen daily in the fevers unit. Mind you, there are only 6-8 doctors, and clinic sessions are mostly in the mornings. This feat is accomplished by not doing a full physical exam. Each patient comes in, is asked for their chief complaint which for the most part is nothing, or a rash, a cough, the catarrh, or difficulty swallowing. Those on ART are asked how they are taking their medications and if there are any side effects. Then their pills are inspected to make sure they are taking them. Their conjunctiva are checked for signs of anemia and their mouth for thrush. It’s only if they offer a complaint will other pertinent body systems be examined. Many had prurigo. A lot of the women had bleached skin, damaged and very thin presumably because the bleaching creams contain steroids.
I haven’t yet been on the wards, so I’m looking forward to that.