“Blanket sign is poor”

Today is the last day of our two-week rotation on the Pulmonology Ward, which marks our first glimpse as Yale-trained medical students into the world of health care provision in a tropical setting. The senior residents with whom we’ve worked – Charles and Michael – have been superb at making us feel a part of the team; several times our input (and that of our Oxford Handbook of Tropical Medicine) has influenced decision-making for a patient’s care. Yet, as part of the team, I’ve also empathized with the other side of care provision in Uganda: the stark limitations of poverty. The knowledge and skill of a physician trained at the best medical school in the world is rendered impotent in the face of a lack of medical resources and a patient’s inability to pay for treatment.

There are times when it doesn’t seem too bad. We take a comprehensive history, do a thorough physical exam listening carefully to their chest, and order the labs that are free for patients at Mulago: a sputum smear with Gram stain to check for tuberculosis or pneumonia, a complete blood count, and liver function tests. I eagerly scrutinize results when the patient can afford to pay for a chest x-ray, an ultrasound or a biopsy sent to an outside pathology laboratory to help us make our diagnosis. I let out an internal sigh of relief when there is money and an attendant available to buy the cheap generic drugs we prescribe. Or when all they need are the drugs Mulago can provide for free like ceftriaxone for a community-acquired pneumonia or the four-drug regimen for tuberculosis. We are able to do what we have been trained to do: diagnose and treat illness. The patients begin to feel better and we get to send them home.

Yet there are heart-wrenching days when those stark limitations rear their ugly head, leaving us - and the patients - powerless. This week was particularly tough. Physicians at Mulago have designation to crudely assess the financial means of a patient called ‘the blanket sign.’ Bedding is not provided for patients in the hospital, so if a patient has sheets and a blanket, they have a ‘positive blanket sign,’ meaning they had money to be able to buy the blanket and likely have money to be able to pay for tests and treatment.

Yesterday we rounded on a 25 year-old HIV-negative man who was lying on a bare mattress and had no attendant. He had been admitted to pulmonology because he had a cough, but we quickly found that his blood pressure was 250/140, which is a malignant level (normal is less than 130/80) and he was in acute renal failure. However, he could only afford a less-than-optimal medication for lowering his blood pressure and could not afford a much-needed ultrasound of his kidneys to investigate a cause. He took the medication, but his blood pressure was unchanged. We managed to check a set of electrolytes and found his potassium levels to be dangerously high, which can lead to cardiac arrest. This patient also needed to be placed on supplemental oxygen, but since there were only two oxygen tanks on the pulmonology floor, and there were already two patients on oxygen, we had to take the pulse oximeter and measure all three patients to determine who had the two lowest oxygen saturations - the one with the highest just had to cope without it. We gave the patient some medications to lower his blood pressure and his potassium, and stabilize his heart, but what this man really needed was urgent dialysis and admission to the intensive care unit (ICU). There is one dialysis unit in Mulago, but we were informed that it costs $250/session (and patients usually have three session per week). Our senior resident managed to track down a nephrology consultant, who detailed to us the things that needed to be done. He asked if the patient could pay for dialysis and the resident responded simply, '"Blanket sign is poor." There was little else we could do for the patient. This morning when we arrived the nurse informed us that he had passed away at 10pm last night.

Two days ago we moved to the bed of an HIV+ woman in her 20s who was completely buried under blankets, motionless. Her chart read that she had had negative blood cultures and had received various courses of antibiotics, evidently to no avail. Pulling back the covers, I could see she was emaciated and unresponsive. Her lungs sounded rhoncorous with infection as she labored to breathe, using accessory muscles to take rapid gulps of air. Just as concerning were her hands that were like blocks of ice in the humid tropical air. The resident asked me to take her blood pressure. Though her heart was beating very rapidly, I couldn’t find a peripheral pulse at all – her blood pressure didn’t register on the sphygmomanometer. This woman was in septic shock, her system crashing due to widespread infection. We gave her oxygen and the resident desperately tried to find a peripheral vein that wasn’t collapsed through which to insert an IV and given the fluids her system needed. After half a liter (and 10 precious minutes) it became obvious the fluid was actually infiltrating into the tissue of her arm, causing it to swell, and not into the vein. We found another vein in the opposite arm and put in another liter and a half, but there was little response. And that was it: watch and wait. According to the resident, that was all we could do, and that was how we left her. In the U.S. this woman would be intubated, have labs drawn, receive massive amounts of intravenous fluids, antibiotics, and maybe pressors and steriods to support her blood pressure, among other things. Then she would be admitted to the intensive care unit with one-on-one nursing care and a physician on-call.

In the morning, the patient and her bed were not on the floor when I arrived. She had died during the night.

It is one thing, as a physician, to watch a patient die, knowing you have done everything you can possibly do for them. It’s quite another to watch a young patient die knowing that in another part of the world there is much more you could do and with those resources you might save their life. I was prepared by many people before I came to Uganda that I would see patients die at Mulago: because they are in advanced stages of disease, because they waited too long to seek care, because they have HIV… And, while tragic, it is not so much the death itself that bothers me, but the fact that people die because they are poor and live in an impoverished country. How do we, as a global community, accept the injustice that the world’s wealthy get to live and the poor have to die?