Cylinders of Death

1/26/2010
Day 19

Today has been a day of celestial dicharges. I say that to attempt to lighten the mood. It is almost routine now to see people die, which disturbs me even as I am typing this. One of our sickest kids, a 6 week old with an infected VP shunt, died last night. To be honest, we didn't expect him to survive the weekend. We have seen a number of kids like this: they come in infected and never recover, no matter how many big gun antibiotics we throw at them. We even give antibiotics intrathecally (directly into the ventricles of the brain) as a last ditch effort that has yet to work. He passed, though another child named Angel (red flag name from the get-go, much like the American favorite Nevaeh, or "heaven" spelled backwards), is similarly close to death with a shunt infection right now. These kids usually start to have trouble breathing, require a lot of oxygen, become hypothermic, and then have kidney failure. They usually last a day or so after the kidneys go. It is so odd to me that I know this progression. It is definitely not a formula I memorized in med school.

One of our kids is in the ICU for sepsis but is actually doing much better. As we were rounding on him this morning, his neighbor passed away. She was a 22 year old woman with an incomplete miscarriage, had a D and C (procedure where you remove retained contents of the uterus) at an outside hospital. She came in septic, was taken to surgery and was found to have a necrotic uterus and bowel. Clearly her procedure at the other hospital went terribly wrong. It looked like she had a perforated uterus and large bowel and there was not much to do to salvage her organs. In retrospect, our docs think she might have had a choriocarcinoma (which can apparently metastasize to the vocal cords) because when they attempted to intubate her they found her cords to be bizarre looking: swollen, bright yellow, misshapen.

Later in the day I was admitting a child in casualty for respiratory distress (obviously). My attending found me and said, "There's a 34 year old woman here with cardiogenic shock, large pericardial effusion, tamponade (fluid around the heart restricting heart pumping = bad). She needs to go to surgery stat but we can't get a hold of the surgeons. Can you take care of this?" @^#%$%&??? It turns out her story is (of course) more complicated. From what I pieced together she was previously healthy but developed abdominal pain and shortness of breath over the past few days. She had been in casulaty for most of the day being worked up for an acute abdomen (turned out to be a big ol' red herring). When we finally figured out her major process was cardiac, it was practically too late. I walked back to the theatre (the surgeons miraculously arrived right as I was having an inner monologue freak out about how to orchestrate action for this woman) and watched the surgeon stick a huge needle into her pericardium to attempt to drain the fluid. She didn't survive the procedure. Her terrified face before she was sedated for the procedure is playing like a skipped record in my head right now.

Also, a young woman who was admitted on my call night last week died tonight as well. She came to us after giving birth to twins (one of the twins died before arriving at Kijabe and the other I admitted to the nursery that night - a little 1.7 kg boy named Cornelius). She suffered an anoxic brain injury after having a surgical extraction to remove a retained placenta. She had been in the ICU for over a week and the decision was made to withdraw care. The most horrific part of it (as if that wasn't bad enough) is that she was transfered from the ICU to the maternity ward and she actually died amongst people giving birth. Seems inappropriate for all involved parties.

So here is what happens after you die at Kijabe hospital: a man arrives to the bedside pushing a long (body-length) cart that is covered by a half cylinder. The body is placed in the half cylinder and then rolled away. It took Julie and I a good week or so to figure out the purpose for these mysterious demi-cylindrical carts that are quietly rolled through the corridors. The cylinders of death have been working overtime this week.

In the middle of those tragedies, we admitted a gaggle of new respiratory kids tonight. One is a 5 year old boy with respiratory distress, pneumonia, possible HIV. We got two conflicting histories about the patient's HIV status from each parent (never a good sign). To complicate matters and to highlight the lack of patient privacy here, a lab worker who happens to be the child's aunt came to us with the lab request form saying we needn't do the test since she knows the child already has HIV. The father denied this immediately. Needless to say, we are getting the blood test.

Another new child is a 3 month old boy (size of a newborn, though) with the most impressive cough I've ever heard in such a small child. His siblings were sick with fever and cough a week ago, making us worry for influenza with a possible overlying bacterial pneumonia. He is getting the kitchen sink of antibiotics as well as Tamiflu (very expensive, very limited supply here, and no liquid formulations). The use of Tamiflu has driven the nurses into a tizzy with concern for isolation (which is not possible given the max capacity of the peds ward). No one bats an eye or reaches for an N95 mask around here when TB comes a-walkin', but use of Tamiflu initiates nursing staff mutiny.

And finally, to round out the respiratory illness for the evening, we admitted a 2 year old with cough, fever, hypoxia and recent diagnosis of TB (had stopped meds after 1 month because they ran out). He of course has rickets, malnutrition, and delayed milestones. Per usual.

I probably should just stop at this point and fail to mention the major trauma that rolled in as I was admitting one of my many kids tonight. But as this is my last call night, and my insane med/ped/surg tales will soon be exhausted, I will continue. A young boy (looked about 7 yrs old) was hit tonight by an oncoming vehicle as a pedestrian. He arrived in casualty altered, with a GCS (always handy!) of about 7/15 (translation: barely conscious). His head x-rays showed a number of fractures, his eyes were fixed to one side with sluggish pupils, and he was moving only one side of his body in response to painful stimuli. He was taken back to theatre where they did a quick FAST scan (ultrasound the abdomen for signs of internal bleeding), determined he didn't have an intraabdominal bleed, and decided to take him for burr hole placement (drill a hole in the skull to drain intracranial bleeding that is likely pushing into his brain and causing all his problems). It is looking grim.

I feel like I am taking my clinical skills test again (an annoying exam that all med students must take that costs $$$ and involves evaluating standardized patients - ie actors - in different medical scenarios). Except this time each scenario is plucked straight from ACLS or trauma guide 101. I never thought as a family doc I'd witness pericardial evauation and burr hole placement at all, let alone the same night.

I must change the subject now. It is 2 am and I believe in my sleep-deprived state I am allowed to make such an abrupt change of direction. Wednesday night (this coming night) we are having the entire Kenyan intern class (8 people) and a few other stragglers (my clinical officer and med student, as well as Julie's OB registrar) over for a Mexican fiesta. We are making a variety of different taco types. When Julie described a taco to her registrar he said, "I believe it is a jumbo sandwich." And when I described the menu to an intern she said, "You are mexican?" and also "I can't wait for tequila!" She meant tacos - alcohol is prohibited on the mission, and after further investigation it was revealed that she has no idea of the true meaning of tequila. Ben and Matt are pushing for intro to margaritas to be part of the soiree. It is safe to say that would not be well-received here in Kijabe. We'll stick to water, Fanta, and mango juice. We are really looking forward to spending more time with the interns. They are a hoot, and have made this experience for both Julie and me.

Now I believe it is time to sign off and scrounge together a few hours of sleep. If the stars align, casualty and the wards will fall silent for the remainder of my call. And we might just hear a word or two from Ben, guest blogger, on day 2 of his amazing and eye-opening community service project.