Tamiru weighed 76 kilograms when he first entered our TB program. That doesn’t sound like much by American standards, but our Ethiopian TB patients rarely top 40 or 50kg. He looked tall and well-nourished, and really, not that sick, except for his dry cough and the swelling in his legs. He was diagnosed with pleural and pericardial disseminated TB in Jimma and sent back here, nearer to his home, for anti-tuberculosis treatment. Despite his gentle giant stature and apparent health, Tamiru quickly became very sick.
He developed intractable bloody vomiting just a few days after starting his TB treatment. There’s a lot of things in Ethiopia that make people vomit, and it was possible that his “bloody” vomit was normal vomit stained brick red by the rifampicin in his TB medicine, but to be on the safe side we admitted him to the hospital. The vomiting improved a little but he developed a fever, and blood film showed that he had malaria and possibly typhoid fever also. Then his liver swelled and became painful and his mild cough turned into painful shortness of breath. His right lung was surrounded by fluid. Then his eyes turned neon yellow – jaundice. His condition was getting worse and worse. His face became gaunt and sallow. Per the WHO TB protocols that are used in Ethiopia, jaundice and liver enlargement while on TB medicine is cause to stop the TB meds and refer the patient to a higher hospital, since TB medicines are potentially toxic to the liver. We explained to Tamiru that he needed to go to Bonga Hospital for evaluation. He agreed. We were planning to make a trip to Bonga in two days time, and since his condition was serious but stable, we arranged to transport him in our Land Cruiser at that time.
He almost didn’t make it.
The nurse came to the Big House the night before Tamiru’s planned transfer, asking us to turn on the generator so Tamiru could be placed on oxygen. He was in respiratory distress. Edwin and I were alarmed – he had been coughing and short of breath that day, but not in enough distress to require supplemental oxygen. We went to evaluate the patient. He was gasping for air and unable to speak complete sentences because of his breathlessness. Unlike his previous slow decline, this was a sudden and dramatic turn for the worse. We knew there was a pleural effusion around his lung. Draining fluid from the pleura is dangerous though, because it requires sticking a needle into the lining of the lung without sticking the needle into the lung itself. It is a difference of only millimeters. Poking a needle into the lung would cause pneumothorax, lung collapse, and in this situation, probably death. Unfortunately, Tamiru was pretty near death already. The pleural effusion was crushing his lung. Edwin decided to do an emergency thoracentisis.
Tamiru’s relatives carried his now gaunt frame to the treatment room. We had Tamiru sit on the side of the exam bed, leaning his chest forward onto the bedside table to expose his back. I carefully cleaned Tamiru’s right ribcage with iodine and placed a sterile drape over his back. Edwin climbed onto the exam bed behind Tamiru, donned sterile gloves, and carefully inserted a simple IV cathter into the patient’s back. Not quite the right equipment, not the most sterile technique, but it was the best we could do. Edwin’s hands were steady. If the patient moved, or if Edwin inserted the needle to deeply, the lung would collapse completely. Edwin’s syringe filled with red-yellow fluid. He was in the right place! Using a 50ml syringe, Edwin drained 1500ml of fluid from Tamiru’s pleural space. “How are you,” we asked Tamiru intermittenly to make sure he was ok. “Toruno,” he replied in Amharic. “Excellent.” He didn’t look “toruno” to me, but his respiratory distress quickly improved as the fluid was removed. Tamiru was able to walk back to the hospital instead of being carried. He was by no means out of the woods, but at least he was alive.
Edwin was talkative and lighthearted after the procedure, but the nonchalance could not hide his overwhelming relief. As we cleaned up, Edwin’s steady hands trembled.
He developed intractable bloody vomiting just a few days after starting his TB treatment. There’s a lot of things in Ethiopia that make people vomit, and it was possible that his “bloody” vomit was normal vomit stained brick red by the rifampicin in his TB medicine, but to be on the safe side we admitted him to the hospital. The vomiting improved a little but he developed a fever, and blood film showed that he had malaria and possibly typhoid fever also. Then his liver swelled and became painful and his mild cough turned into painful shortness of breath. His right lung was surrounded by fluid. Then his eyes turned neon yellow – jaundice. His condition was getting worse and worse. His face became gaunt and sallow. Per the WHO TB protocols that are used in Ethiopia, jaundice and liver enlargement while on TB medicine is cause to stop the TB meds and refer the patient to a higher hospital, since TB medicines are potentially toxic to the liver. We explained to Tamiru that he needed to go to Bonga Hospital for evaluation. He agreed. We were planning to make a trip to Bonga in two days time, and since his condition was serious but stable, we arranged to transport him in our Land Cruiser at that time.
He almost didn’t make it.
The nurse came to the Big House the night before Tamiru’s planned transfer, asking us to turn on the generator so Tamiru could be placed on oxygen. He was in respiratory distress. Edwin and I were alarmed – he had been coughing and short of breath that day, but not in enough distress to require supplemental oxygen. We went to evaluate the patient. He was gasping for air and unable to speak complete sentences because of his breathlessness. Unlike his previous slow decline, this was a sudden and dramatic turn for the worse. We knew there was a pleural effusion around his lung. Draining fluid from the pleura is dangerous though, because it requires sticking a needle into the lining of the lung without sticking the needle into the lung itself. It is a difference of only millimeters. Poking a needle into the lung would cause pneumothorax, lung collapse, and in this situation, probably death. Unfortunately, Tamiru was pretty near death already. The pleural effusion was crushing his lung. Edwin decided to do an emergency thoracentisis.
Tamiru’s relatives carried his now gaunt frame to the treatment room. We had Tamiru sit on the side of the exam bed, leaning his chest forward onto the bedside table to expose his back. I carefully cleaned Tamiru’s right ribcage with iodine and placed a sterile drape over his back. Edwin climbed onto the exam bed behind Tamiru, donned sterile gloves, and carefully inserted a simple IV cathter into the patient’s back. Not quite the right equipment, not the most sterile technique, but it was the best we could do. Edwin’s hands were steady. If the patient moved, or if Edwin inserted the needle to deeply, the lung would collapse completely. Edwin’s syringe filled with red-yellow fluid. He was in the right place! Using a 50ml syringe, Edwin drained 1500ml of fluid from Tamiru’s pleural space. “How are you,” we asked Tamiru intermittenly to make sure he was ok. “Toruno,” he replied in Amharic. “Excellent.” He didn’t look “toruno” to me, but his respiratory distress quickly improved as the fluid was removed. Tamiru was able to walk back to the hospital instead of being carried. He was by no means out of the woods, but at least he was alive.
Edwin was talkative and lighthearted after the procedure, but the nonchalance could not hide his overwhelming relief. As we cleaned up, Edwin’s steady hands trembled.
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