Chai and Porridge

1/17/2010
Day 12

Seven more hours to go. For my call weekend, that is. It has been quite an adventure. This morning I arrived at the hospital at 7:30 am after not getting paged from midnight on. Instead of being reassuring, this actually frightens me just as much as getting paged. You can be sure there is always something happening at the hospital. The quiet pager is merely someone taking pity on you and letting you sleep. I woke up every few hours with a jolt of terror that I missed a page. I also had a dream I was in respiratory failure and had to be intubated in the ICU here.

There were a few cases last night from which I was spared, mainly ortho trauma. Motor vehicle accidents are as common as chai tea around here. The intern I have been working with this weekend is on call for medical, pediatric, and surgery patients (meaning BUSY!). I am technically on call for peds and medicine, though I get called for all the surgery patients anyway. I am relieved I got to sleep through that one last night.

I rounded on my peds patients by myself this morning. The team is generally off on Sundays except for the call person. It is challenging to feel confident in my management decisions about issues that are so foreign to me. Hyperglycemia in a 3 day old 1 day post op from a spina bifida repair? Hmm… Recheck the glucose. It’s a little better? Ok. Seems fine to me. Or, resolving hypernatremia in a 3 week old with recent VP shunt placement? Sodium a little better today? Hmm… Let’s stop the fluids and see how it goes. No IV access in a 2 yr old post op from kyphosis repair? Was getting ceftriaxone and now needs a PO option? Hmmm… Augmentin for you! Thus went my internal monologue.

After rounding on the wards I was sucked into the vortex known as casualty. Today was an orthopedic potpourri. Have I mentioned that I’m not even technically on surgery call? Ok, just checking. Today’s roster:

1. 44 yr old male beaten with sticks and rocks last night after being accused of thievery. The chief complaint from the intake nurse was otorrhea and rhinorrhea (fluid from the ears and nose). This gave me a bit of tachycardia. A shout out to Feigenbaum: Thanks for the otoscope. More handy these days in trauma then in peds! Turns out he just had a lot of dried blood from superficial abrasions all over his face that had run into his nose and ears. He hadn’t been able to clean himself off because his hands and arms were so swollen and painful. He ended up having a R 4th digit fracture (closed, transverse, volar apex, through the proximal phalynx for all those wondering. The orthopod insisted upon proper characterization of the fracture, and I was quite relieved that he decided to grill the intern instead of myself), and a L forearm fracture (closed, ulnar, comminuted). He left with 2 casts and we were wondering how he was going to be able to herd his cattle. He thought the cattle might be frightened by his casts and therefore more motivated to move along.

2. 41 yr old male with comminuted tibial plateau fracture (aka knee) sustained from a fall. He works as a golf caddy and slipped on the course in the rain. We splinted him and admitted him. He will likely have surgery in a few days (not a big surprise that the ortho case load is a little heavy this week). We chatted about golf. His handicap is 2 (He said the courses in Kenya are much easier and the ball travels better… Altitude?), and when I asked him what he thought about Tiger Woods, he said, “He has big problems.” Kenyans are quite up to date.

3. 19 yr old male with respiratory distress, pleuritic chest pain, and recent diagnosis of pulmonary TB (which doesn’t necessarily means he has TB, but it is of course possible). Chest x-ray showed a huge pleural effusion (fluid on the lungs). I rounded up my intern and prepared for a thoracentesis. And I thought the Swedish thoracentesis supplies were meager. We had to jimmy rig a foley catheter bag to collect fluid, and use a needle that was too wide and too short. In the end, I didn’t get any fluid, much to my disappointment. And just when I was really starting to feel capable around here. I sent the patient for a lateral decubitus x-ray (meaning it is taken while he is on his side to see if the fluid is free flowing. If it is chunky and thick then that explains why we couldn’t get any out). Well, wouldn’t you know, the fluid didn’t budge. We called the surgeon to assist us with a chest tube. The possibility of logging that procedure was really getting me excited. The surgeon, though, said we couldn’t put the tube in blindly because there were likely pockets of fluid. He wants the patient to get a chest CT (meaning a trip to Nairobi and about 15,000 Kenyan shillings) before we place the tube. I am not sure this will be feasible for the family. When I ordered the second x-ray, the family took about 2 hours to scrounge up enough money to pay for it. We’ll see what happens tomorrow.

4. 59 yr old male with angiodedema (swelling of the lips). My intern had taken a long history and then pulled me into the room. I saw a pile of his medications on the bed, asked how long he had been taking the ACE inhibitor (2 weeks), told him to throw them in the trash, gave him an antihistamine (they have one here, and I’ve never heard of it), and sent him on his way. (Don’t worry, he wasn’t having any respiratory compromise, surprisingly!)

This brought us well past dinner time, and we were on our way out when we got paged to the nursery to admit a new baby. The mother of this baby had been transferred from a smaller hospital today and spent most of the day in casualty. I had heard her tragic story peripherally. A week ago she had given birth to twins (vaginally!), had a retained placenta, had an unsuccessful manual extraction followed by a hysterotomy (surgical opening of the uterus to take the placenta out). She failed to wake up post op and has been in a coma ever since. She was admitted to our ICU today and is going to get a head CT somehow tomorrow. Meanwhile, one twin weighed 2.7 kilos and died, and the other twin, weighing in at 1.7 kilos, was our new admission. He actually, despite being quite small, is doing ok. His mother, however, is another story. Her prognosis is grim.

At this point it was about 9:30 pm and my stomach and bladder were calling out to me. One of the interns, Pauline, insisted that I join her and my intern on call, Janet, for some chai at her house. Chai is a big deal in Kenya and it puts Starbucks to shame. We have been told repeatedly that in Kenya, fostering personal relationships is paramount. This explains why nothing starts on time and no one is ever rushing to do anything. It is completely acceptable and even expected to stop and chat with anyone you see along your way. You ask how they are, their family, their goats, cows, sheep, children. Seriously. The bare minimum is to give a hello and a handshake to someone you pass. Our American “avert your eyes and keep walking” really doesn’t fly here.

So, I of course gladly accepted my invitation to have chai and porridge (another Kenyan staple, made with water and millet flour or maize flour. The patients who are fed via NG tubes get a regimen of porridge feeds via the tubes. No premixed tube feeds here!). We had a fascinating conversation about Kenyan medical school (it is basically their undergrad – there is no concept of undergrad before med school), gender ratios (now over half women in med schools, a big change from a few years ago), if they get called nurses (yes, and they don’t like it!), and Kenyan marriage traditions (the man pays a dowry of traditionally goats, cows, and money). They were shocked to find out I am in my 30s (with no undergrad before med school, they are all in their early 20s) and married (none of them are married). I tried to explain the American health care system (very cursory as I can’t say I even understand it myself): How patients have no idea how much medical interventions will cost, have all of them done anyway, get a bill later that they can’t pay, acquire massive debt, and lose their homes. In a nutshell. Blank stares from the Kenyan interns. I told them that one of the most shocking things I’ve seen in casualty is the sign listing the cost for body bags (depends on the size), body removal, and burial. Their faces when I tell them these things make it seem as though they’ve spotted a unicorn. One of the most enriching parts of this experience has been getting to know the interns. They are a good crew.

I came home around 10:30 pm to find Julie had made a delicious carrot soup. And now I lay me down to sleep with a belly full of soup, chai, and porridge.

PS: Jane update: Kidneys still working better, respiratory status unchanged. Tomorrow will be a telling day for possible withdrawl of care.