The first day on ward rounds, anywhere, in any hospital, is always a challenge. New admissions and new consults. Patients just plain "new to you" as the rounding physician.
I looked at this photo of Mt. Kenya from my flight into Kenya this morning to remind myself of the "mountain" I was to climb as my first day on rounds began at Moi Teaching and Referral Hospital in Eldoret, Kenya.
I met with our clinical officer and nurse at 8:30am in the basement office for the palliative care service, to exchange introductions, discuss the weeks schedule, and run the list of ongoing consults. The clinical officer noted at least 3 deaths over the weekend, and already had calls for 2 new consults today. We gathered our tools for the day - BP cuffs, hand held pulse oximeters, stethoscopes, and some candy for the pediatric patients - and headed to the wards.
The public wards at Moi Teaching and Referral Hospital are open wards, meaning, unlike my home institution with its luxurious single patient rooms with floor to ceiling windows, there are around 20-25 patients per wing, with little more than a sheet between beds. The patients lie two people to a bed, one head at each end of the bed. The only sense of modesty comes from the fact that men and women are segregated to separate wards based on gender. These aspects of the hospital are often striking, but it is not these differences that make the work emotionally challenging.
The burden that the medical staff carry every day here is the obvious suffering of the patients and their families. The public hospital is under immense constraints due to poor access to medications, supplies, adequate staffing, and advanced symptom directed therapies such as radiation treatments. So as we make rounds, these issues are always at the forefront.
One of our first consults of the day is a prime example of the challenges faced with oncologic care in this constrained setting. The most common reasons we are consulted by the oncologists are pain management and assistance with communicating bad news to the patient/family. Our team met with "Patrice" a 24 year old woman sitting bolt upright in bed, with 8 Liters of oxygen flowing via facemask, who was breathing so fast she could barely talk.
Patrice was suffering from an large tumor of her left humerus, medically referred to as an osteogenic sarcoma, which had spread quickly to her lungs and abdomen. She was in obvious pain with each breath. And each breath appeared to require an enormous amount of effort to meet her needs for oxygen. Their was no family at her bedside, as it was explained to me via translation from our RN that she was orphaned. She did not know that she was dying of cancer, as she had not been told her diagnosis. (The withholding of cancer diagnosis is commonplace in Kenya, and a stark challenge for a U.S. trained physician).
We spent the first several moments addressing her severe pain and breathlessness with aggressive titration of pain medications for symptom control. This required a brief teaching session on my part to the bedside RN's about their concern for the doses of morphine for her breathlessness - "Daktari won't this suppress her respiratory efforts?" "Daktari we do not want to make her addicted!" Often quoted concerns by the RN's, based on poor education about the use of opiate analgesics in the control of cancer pain and severe dyspnea. Opiates have time and again been shown to improve cancer patients quality of life, and prior trials have shown no hastening of death related to these therapies. Yet, oncologists, pain specialists, and palliative care physicians the world over are met with these types of questions and trepidation about the use of opiates in pain and symptom management for seriously ill patients.
The patients at MTRH have limited access to pain medications, specifically opiates. In this hospital in Kenya, we use oral liquid morphine at 10mg/mL concentration as our only tool for treating severe cancer pain. We have no IV opiates, no Oxycontin, no fentanyl, no dilaudid, none of these tools which North American patients have the luxury of requesting by brand name back home. Instead, the palliative care team here struggles to get 1mL of this medication scheduled more frequently than every 8 hours due to nursing constraints and access to morphine on the wards (they frequently run out on the night shift and the RN's have to wait to retrieve more from the oncology pharmacy in the morning).
In the U.S. we measure oncologic prognosis in increments often of weeks, months, and years. Here we measure prognosis often in minutes to hours, often due to a significant delay in access to care. For Patrice, I was worried that she had hours at best based on her severe symptom burden. It is this aspect of caring for cancer patients in Kenya that is so challenging.
We are called to the table very late, often to provide assistance at the very waning moments of these patients lives, and it is this very reason that I am here. To move palliative care services as far upstream as possible at MTRH, and if possible, expand this type of service to patients beyond oncology, because all to often, the patient dying in the next bed over, does not have access to the palliative care team, if they are dying of something other than cancer.
