When I offered to help out the NGO I work closely with to deliver some TB in children training for them, in the small hospital on the border I go to once a month, I really couldn't have foreseen the consequences.
In this epic tale of TB in children training, I managed to offend several Cambodians, reveal negligence & lies, have a radical change in my teaching style, finally get around to installing unicode (khmer font reader) on my laptop and become a TB champion.
It all started at the monthly meeting, of the NGO I work closely with, three months ago when it was noted that the budget for TB training at a border hospital had to be used by the end of year 4 of the project. So far it had been cancelled 3 times because the doctor who should have done was too busy to leave his NGO hospital due to the Dengue epidemic. I innocently offered to help out - I am by no means a TB specialist but if I could do it would that be better than nothing? - error number one.
It was agreed at the PNH office I could do this. A couple of weeks of silence. I emailed PNH office asking if they could send me the training materials. The reply was they were in the drop box. In the drop box were 6 lectures all in khmer in a font my computer can not read. I tried to get them printed so I could read the english rendered unreadable by the unreadable & distorted khmer font on my laptop, but was told by the NGO co-ordinator of that hospital it wasn't in the budget - he was as helpful as ever. My VA spent 2 weeks translating them for me & we installed all fonts on my computer just in case but I still did not have 'limon', which is what the training material was typed in. When I could finally read the content I realized that there were some pretty fundamental areas missing e.g. treatment of TB so I sent another email asking for a lesson plan & agenda - not with the training material in dropbox. The lesson plan did not exist, the agenda included 8 further lectures I did not have. I emailed again & was told they were in the drop box - they weren't! I emailed again & finally got the 8 further lectures sent to me, all in khmer - limon font. My VA was busy for a further week. It became apparent to me that the lectures were very poor quality - no learning objectives, confusing slides with too much information on them, irritating animations, no summary slides and no accompanying lesson plan. I voiced my concerns to the PNH office & was told this was MoH material & it could not be changed. A week before I was due to give the training a member of staff from the NGO I was helping out my delivering this training sent me the MoH guidelines on TB in english, which was the reference material for all the teaching slides - better late than never hey!
I was regretting offering to help & then I received an email from the doctor whose job it was to teach the material in the first place, it was the weekend before the training and he was asking me to do some clinician assessments for him whilst I was there. I was put out as last time I checked I am not his skivvy - I would have wrote that in my email reply but I'm pretty sure he wouldn't have understood what I was saying. Instead I wrote a very polite email - J screened it - saying I wouldn't have time & that I was surprised to see on the work-plan that he was going to another small hospital (the week I was training TB) when the only reason I was doing this training was because I had been told he was too busy to leave his base hospital because of the Dengue epidemic. I thought that was slightly odd - my innocent query resulted in him taking great offense. In his response he told me, "I don't know why this activity of mine surprised you, and I went there it did not mean that I did not take responsibility in my job. Please reconsider before talking things that might hurt other's feeling...I asked you for help with that activity and if you could not, just say no, don't say that because I want to avoid my responsibility."
I responded that I hadn't meant offense, I was simply asking the question why was I doing the training when I am a volunteer, its not in my work plan or my scope of expertise, I am not khmer & can't read or deliver the training material effectively & it will take me three times as long to deliver - surely it would have been better if he now had time to do it? Nowhere in my email had I said he was shirking responsibility but I guess sometimes the truth hurts.
The day before the training R & I went through the treatment lecture - R noticed some errors in translation so contacted the PNH office who replied we had the wrong lecture. They sent the correct one - all in khmer & limon font - telling me it wasn't a problem as all the drugs were in english. It was a problem as the treatment regimens & explanations were all in khmer & completely different from the MoH document or my translated lecture. I pointed out to the PNH office that I am an idiot mono-linguist so this was a problem, I never received a reply to that email. I am guessing their silence was assent.
Day one of the training one MA turned up, waited 5 minutes, got a call from someone & left with the handout. No one else came, it rained heavily, the room leaked - this wasn't a failure, it was just meeting our low expectations about the training.
Day two after a telling off from the director 20 nurses & 2 MAs attended the training, we only had 5 hours to cover a 3 day programme - the pre & post test went out the window - the training was designed for doctors I tried to modify the material for a mainly nurse & MA audience. The pre & post test was confusing & covering material I had chosen not to cover in detail as it was too complexed.
I concentrated on training about diagnosing TB - the importance of history including contact of TB in EVERY patient. The symptoms (general signs are night sweats, weight loss or failure to thrive, fever, low energy, etc.) & physical signs of TB, how to diagnose & get samples for investigation and confirmation. This took me all morning. At one point they were talking among themselves & answering their phones, this is when I completely lost it - I told them if they weren't going to listen to me then I was just wasting my time & should leave, I explained I wasn't doing this for me, it was so that they could recognize & treat more children with TB, I asked if they didn't care about children & doing a better job they could just leave now, as I wasn't interested in wasting my time or theirs - they shut up.
As we were leaving for lunch one of the MAs brought her sister in law to the hospital for me to see. She had a 5 year history of right knee pain & intermittent swelling, haemorrhoids and maybe some kind of ovary or hip problem - translation was less than clear. Her question was - was this TB? So although they will continue to neglect their poor patients, at least they will have an unnecessary & needless high index of suspicion of TB in their relatives. That's Cambodia for you.
In the afternoon they all joked that they were in trouble with the teacher that morning, they were taking the piss out of me but they still shut up when I opened my mouth. This is not my normal teaching style but I could get used to it. R went through treatment, surveillance & prevention of TB - this was a lot quicker as translation from english to khmer does add a significantly long time to any training. This meant we also had time to go over pulmonary TB but not to go over the 7 individual lectures on extra pulmonary TB or to do the test.
At the end I asked them what were the keys points to make a diagnosis - silence. What in the history is suggestive of the general symptoms of TB? Their answer - an enlarged lymph node in the neck - I knew then that I had been unsuccessful in training them on TB!
They then kindly confirmed this by mismanaging a patient on the medical ward despite training that week & me having conversations with 3 different MAs and the head nurse about him. The patient in question was a 56 year old man with a 6 month history of fever, night sweats, weight loss, cough, chest pain & haemoptysis. One MA had asked me to examine him - role modeling as always I took a full history first, which is the only reason I knew the history above as well as the history of a TB contact, none of this appeared in his medical notes. I listened to his chest & he had bronchial breathing at his right apex. The MA had written in the notes that his chest was clear. I managed to convince her to go back to listen again - she wasn't convinced I was right but as I always use the cheap, crappy stethoscopes in MoH hospitals rather than my Littman, they can't accuse me of having superior equipment which can hear things they can't. The following day when he had his chest X-ray (below), I spoke with her & another MA that with the history & now X-ray changes (a right upper lobe opacity with right upper lobe collapse) we needed to exclude TB. He would need to provide 3 sputum samples which should be sent to look for the characteristic acid fast bacilli of TB. I used his case as an example for the TB training, then I told the MA on medicine ward that he needed sputum samples sent just to make sure my advice was clear & consistent.
By the end of the week & after the TB training, where the whole algorithm of management for pulmonary TB was reiterated, they had still failed to take any sputum samples. On the Friday before leaving I sat with him & explained that we needed sputum samples & we needed to exclude TB which may take some time. He hadn't been asked for sputum samples & was keen to self discharge as nothing was happening at the hospital - it really wasn't. I spoke with the head nurse & explained that rather than letting the patient go home on amoxicillin as he was planning - there were no doctors in the hospital for 48 hours - it would be better to get the 3 sputum samples as I had already suggested to 3 separate MAs previously. I left convinced he would never receive the investigations or the treatment he needed & deserves.
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| Right upper lobe consolidation & collapseospital has also had this TB training and also there seems to be a completely lack of retention of information or change of behaviour in the management of suspected TB. |
The Hospital I mainly work at also had these TB training delivered by an NGO. Below is an ECHO of a women that presented to ICU medicine in "heart failure" - she was started on frusemide & had an ECG with some abnormal T waves, I was just shocked it had been done. Me & a fellow from a US university - B - who was visiting for a fortnight, convinced ICU to get a chest X-ray. It showed a enlarged cardiac shadow but there was no sign of pulmonary oedema. B was keen to use the ultrasound machine in OPD to do an ECHO. I have suggested this on many occasions previously but it has only when B asked that it occurred to me the reason that they have always refused is to do with conflicting interests, the private ECHO clinic would lose out on money - ECHO is not available at the government hospital.
Dr ON, who will be head of the the Emergency room if it ever opens, already does some ultrasound in OPD and also had been to Singapore the week before on an USS course and had arranged for them to come to BTB and donate equipment. B persuaded him to let him use the OPD USS to do an ECHO, we both convinced him that it's an important skill for him to learn - he bought this.
The USS machine in OPD gives surprisingly clear images & Dr ON picked up the technique of doing ECHO views quickly. What the ECHO showed was that there was a large pericardial effusion with right heart strain & after a week of frusemide she was intravascularly depleted. I asked her if she had a TB contact. Her son was being treated for lymph node TB. Children aren't usually infectious especially if they have lymph node TB but if they have TB then one of their care givers will have TB. Every child with TB should therefore have the source of their infection traced - this had not happened with her son. There was a 99% chance that her pericardial effusion & impending cardiac tamponade was due to TB.
Dr ON & the ICU doctors wanted us to do a pericardiocentesis (drain the excess fluid from the sac around the heart), luckily B repeated my earlier explanation (from a similar case 6 months ago) that as emergency physicians we were happy to do this procedure if the patient was about to die with tamponade, but not if she is stable because the risks of the procedure far out way the benefits. We explained that if she was started on TB drugs the effusion would improve but by just draining the effusion it would just come back without TB treatment. We also explained the frusemide would kill her & it should be stopped, what she actually needed was fluids NOT diuretics.
A week later she was still on frusemide & had not been commenced on TB treatment, so we attempted again to explain to the ICU doctors what her diagnosis was. Obviously it wasn't their fault but they told us we should speak to the TB ward ourselves. We did, the doctor there agreed that the patient needed TB treatment & prescribed it. We tried to explain to ICU medicine that she would also need steroids & an HIV test. Last time I checked this hadn't happened. I suppose I should just be thankful that after a week she was finally started on TB medication & hope that her effusion doesn't get worse before it gets better.
Finally there is the case of negligence & lies. A 10 year old girl from the border came in with a 5 day history of fever, headache & left hemiplegia. She had been started on IV antibiotics for meningitis by the CPA 1 hospital but the MA on duty thought it was Dengue. I tried to explain to her that she should be investigating for meningitis & malaria but my advice, as usual, fell on deaf ears - she stopped the antibiotics. The following morning one of the paediatric all stars had spotted the gross mismanagement of the now comatosed child & done the necessary tests including attempting to do an LP. Admittedly I would have been more cautious about doing an LP on a unconscious child with localizing signs but I think we have established by now I am a crap doctor that no one respects or listens to.
However when the doctor & nurse both failed to successfully obtain CSF from an LP I helped much to the amazement of the hospital staff who I am sure don't even realize that I am a doctor. I got two tubes of clear coulourless CSF with a green needle & non-sterile gloves. Dr M had also referred the child to the TB ward where, without even seeing the patient, the TB doctor had prescribed TB medications. This meant that a CSF sample for microscopy & culture was even more important as otherwise how would we ever know if the child needed just 2 weeks of antibiotic or 6 months of TB treatment. The paediatric staff seemed less concerned about this diagnostic & management conundrum.
At the end of the day I went to check what the LP result was - I saw one of the lab staff writing the form so I left reassured it was all in hand. I am an idiot.
The next day the result was surprising. The White cells were low, the protein was normal & the glucose high. It wasn't really consistent with the clinical picture, so I went in search of some answers. The patient was still comatosed.
Fortunately WHO lab staff were visiting the micro lab when I went to check how the culture was going. What culture? I was asked - they had never received the sample. But it has had a gram stain, I had seen the report. I was told that it was not possible to do a gram stain without a sample being sent to the mirco lab, there was no record or evidence of this so it must have been done in a private clinic. I was able to disabuse them of this theory by revealing I had seen a member of staff from the main lab effectively making up the gram stain result. I'm not sure if this was due to ignorance or laziness but I know that the outcome is negligence. I checked with the TB lab, they didn't have a sample either - they had never received it - so the TB staining negative result was a fallacy also. The samples had now been discarded.
I was angry. The paediatric doctors were amused. Everyone knows you can't trust results coming from the lab, you always just treat based on clinical findings. But they are liars & negligent! I exclaimed whilst ranting to Dr CP (head paediatrican) about the case. In khmer he told me I should talk quietly about these things. 'Its wrong' I tell him '& when something is wrong I will say it loudly & clearly'. He laughed - I am not sure which kind of khmer laugh it is, probably annoyance.
The 10 year old girl is getting better, she is obeying commands & is getting movement back in her left arm & leg. We will however never know whether she has TB or just a normal bacterial meningoencephalitis. She will be on the full course of TB medications & is still getting her Ceftriazone for another week.WHO will bring up the fraudulent CSF result with the head of lab & hospital director.
I am just grateful she didn't cone when I helped do her LP.
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