Blanket sign

The first lesson I learned on rounds on the infectious disease service in Mulago hospital, the university hospital in Kampala, Uganda, where I'll be spending the month, was the "blanket sign."  In Mulago, the family members of inpatients sleep on the floor next to their loved ones' beds and serve as their "attendants" while they are in the hospital:  they feed and clean and turn them, and are responsible for giving them their meds, and often leave the hospital to fetch meds at the pharmacy or results from the lab.  There are no hospital issued gowns, no hospital bedding, hot hospital meals, or for that matter, monitors or even really any nurses.  The floor is comprised of several rows of beds with nary a curtain to separate the patients.   The patients who have a family member to attend to them generally also have a positive "blanket sign," meaning they have a blanket and bedding from home, indicating resources and therefore an ability to pay.   This influences how decisions are made about a patient's care:  patients with a positive blanket sign are more likely to be able to afford a head CT, or vancomycin in a suspected staph infection.  The others get empiric or abbreviated therapies.  Even the positive blanket sign patients are subject to the severe rationing of resources:  very infrequent labs, a limited formulary, and a blood bank and oxygen tanks that available to the nearly dead only.

All of this makes the practice of medicine like a high stakes jenga game-- how many blocks can you pull out until the whole tower comes tumbling down?  It makes me realize how many things I take for granted in our incredibly rich system at home.  Starting with the basics of how a hospital works, as a huge team with many players doing specialized jobs to contribute to patient care.  The lack of nurses is the most stark.   The interns and medical students here start all of the IVs, draw blood, administer IV medications and perform basic vital sign monitoring, in addition to carrying out "investigations," procedures like drawing labs and performing lumbar punctures, para- and thoracenteses.  The medical staff do not carry pagers, because there are no nurses or techs monitoring patients or receiving orders that need clarification.  If doctors want to communicate with other doctors, they physically walk to another ward to find the consultant and talk face to face.  If they want a lab result, they draw the blood, bring it down to the lab, and then return later to pick up the piece of paper with the result and put it in the chart.  Or if it's a urinalysis or smear, they run it themselves. 

Needless to say, things don't happen quickly, and vital signs are rarely monitored.  The responsibility of gathering and synthesizing data for the daily ritual of morning rounds falls to the intern and medical students, though the data collection is not always done on the same day as the rounds presentation.   It is not an uncommon occurrence to discover a fever or hypotension on rounds, sometimes on a patient who was "admitted" the day before but was not formally seen until the morning and may have been languishing without any medical attention in the interim.   The intern and medical students will attempt to give a history, and an assessment and plan, and along the way they generally include key pieces of information, like the CD4 count for an HIV positive patient, but the emphasis on data in these presentations is limited.  Instead, empiric decision making prevails and the medical team relies heavily on clinical diagnosis, even when lab or pathologic diagnostics exist.  Incredibly, on the ID ward, it is rare to get simple cultures-- blood, urine, CSF.  They are considered a luxury, to be ordered if people can pay.  It doesn't matter all that much that there are no culture data to use to narrow antibiotics because everyone gets ceftriaxone for bacterial infections anyway (and all hell will break loose when the inevitable resistant bacteria strains emerge, as they're starting to do), but it still feels wrong.    Sometimes, when I feel overwhelmed by this seemingly haphazard decision making based on incomplete data, I remember that the alternative is doing nothing and more people would die than already do, and sooner.   Life expectancy in Uganda is 53.

All of the patients on the ID ward in Mulago are vulnerable, but especially the negative blanket sign patients.  They are utterly alone, without anyone to support them through the horrifying experience of being sick in a limited resource environment, emotionally or in the very literal sense of supporting them to the toilet or helping them to eat.  No one dashes out to get fluconazole for their thrush from the outside pharmacy when Mulago runs out, and during the night, a time I shudder to imagine, if anything happens to them there is no family member by their side to aid or soothe them.  

My friend Alicia told me that she thinks she ran the first ever code blue in Mulago, when a patient was unresponsive, she couldn't find a pulse, and she tried to create a sense of urgency around the patient's impending death and mobilize other people to carry out cardiac life support.  She was somehow able to find a nurse, and somehow able to get the patient connected to oxygen (though this was delivered by blowing the nasal cannula in the patient's face, rather than bag-mask ventilation).  She took turns with others doing chest compressions until they realized it was over, and that even if they could get a pulse back, their efforts were a bridge to nowhere.   There is no code button, no code pager and no code team in Mulago, not only because there are no nurses to monitor to raise the alarm in the first place, nor respiratory therapists or epinephrine or defibrillators, but because when patients die in Mulago, no one is surprised.