Door Number 1

1/11/2010
Day 6

Today was yet another crazy day. Our team nearly doubled in size as we said “karibu!” (translation: “welcome!”) to two new members. We now have two fourth year US med students, one from a military based med school and one from Wake Forest. I was kind of enjoying our intimate peds team and was a little wary of the new crew, but it is nice to spread the work around a bit. Especially since the work here is endless. Rounds lasted from about 9:30 am to 1 pm. It is very academic and involves a lot of on the spot teaching. We have some fascinating cases (no big surprise there). One is a 12 month old boy with a history of recurrent pneumonias. He presented with cough, fever, diarrhea, and hypokalemia. We’ve been treating him for those things, and just discovered that despite having rickets, his serum calcium is very high at 15. We are now wondering if there is some underlying malignancy or hyperparathyroidism. Needless to say I will be doing a little extra reading tonight on hypercalcemia. My attending (called “consultant” here) asked me to present on the topic tomorrow.

In other patient related news, my 5 yr old paraplegic Paul, who just had spine surgery last week, has quickly become my favorite. He transferred from the IUC yesterday. While in the ICU he would communicate with me by mouthing words and gesturing. I wasn’t actually sure if he could talk normally at baseline. Today I walked into his room and he gave me a huge smile and said “Hi! Do you want to take my picture?” I had taken his picture a few days ago. The sound of his voice and his near-perfect English (rare for most of our patients and especially 5 yr olds!) stopped me in my tracks. We chatted for awhile. He is feeling great and very glad to be out of the ICU, free of his chest tube, foley catheter (bladder catheter), and IV lines. He is getting fitted for a special back brace or cast today and may even get to go home this week. I asked him to give me Swahili lessons. So far he’s taught me “kwaheri” which means “goodbye”. My vocabulary has just about doubled now knowing that word!

My other Paul (the paraplegic with decub ulcers and UTI) was actually discharged today. He’s been in the hospital since September. I nearly fainted thinking I was going to be responsible for the discharge summary and paperwork. The surgeons, however, took care of that for me. Also, discharge summaries around here are merely a list of diagnoses and discharge meds. I hope he does well at home. We are all fearful that he will be neglected and come back with further infections and ulcers. I suppose the proper thing around here would be to pray for him. In my own way, I think I just might.

One of our patients took a turn for the worse today. He is a 2 month old boy named Kennedy who was admitted with meningitis, seizure, renal failure, and hypernatremia. He had been doing better after a short stay in the ICU. Today he became lethargic which progressed to unresponsive. We are not sure it if is secondary to uremia, or to a build up of his anti-seizure medication that hasn’t been able to clear through his damaged kidneys. Before we really had time to think about it, he became hypothermic, bradycardic, and bradypneic (Julie assures me this is a word). It is so different the way near death is approached here. Whereas at Swedish bells and whistles alarm and massive resources get mobilized, things here happen quietly and without pomp and circumstance. Of course, we don’t really have any resources to mobilize. He was transferred to the ICU but honestly that just allows us to know more concretely how poorly he is doing. I am quite sure he will die tonight.

Another fascinating child came through casualty (translation: ER) today. I was in clinic seeing a child with cough when someone burst into the room and said “There is an ill child in casualty, you must come.” So there I went, butterflies all a-dancing in my stomach, to find a 3 year old girl looking miserable, crying, with an oxygen saturation of 70% on 2L of oxygen. She has pitting edema in her feet and legs, and periorbital edema as well, and a very tense belly. I flipped through her chart to find she had been admitted in December with a diagnosis of congestive heart failure (called CCF here) of unknown etiology. She was discharged on Lasix and Enalapril. Now there are two meds that I thought I’d leave behind in adult world. It turns out (after many layers of interpreting as the patient and her family speak Kikuyu, not Swahili) her family ran out of her medications a few days ago and couldn’t afford more. It also seems she contracted a viral respiratory illness that in combination flipped her into failure. Her heart on xray pretty much filled the entire film. Her prognosis is poor. And there are no echo capabilities here. But that would only tell us what we know, that her heart function is extremely low. The etiology of her cardiomyopathy is uncertain. Interestingly she has a twin at home who is well. It is likely post-viral or maybe some sort of infiltrative process. She is getting diuresed now. I hope she feels better tonight.

But on a more positive note, I had some real breakthroughs today. I found a bathroom with actual soap! Now, don’t get excited, there wasn’t toilet paper. But it was the first time I washed my hands with soap and water in the hospital and it felt fabulous. Also, I managed to figure out a bit more of the ways of the hospital. I liken it to some sort of game, the object of which is to find people or things you are looking for. It involves pacing the halls, running all over the hospital until you finally bump into the thing you are looking for. That is how we find consultants. I also devoted about an hour to finding out if a lab had been drawn. No, not finding out the RESULT of a lab. Just merely if it had been drawn. This involved talking to the mom, the nurses, the nursing students, the hematology lab, the pathology lab, and finally back to the hematology lab until I finally got an affirmative. Victory!

I also spent about an hour trying to find a chaplain to speak with the mother of one of my patients. The mother wanted to leave today because she was fearful of her other children’s safety at the Somali refugee camp where they live now. The chaplain was going to help speak to her and get in contact with her family. I paged the chaplain twice to no avail. Then I wandered around the hospital for awhile looking for her. I actually found a door that said “chaplain.” I opened it to find about 15 Kenyan people in a room the size of a phone booth, some of them wailing and thrashing around. Needless to say, I did not find the chaplain I was looking for. Sometimes it seems like a game of “what’s behind door number 1.” There truly is no way to predict. But I actually later bumped into the chaplain on my way to do something else. Victory!

I am starting to learn the ropes a bit. And by learn the ropes I suppose I mean realize that most every second of the day I am out of my comfort zone and can not predict what will be thrown at me next. But I am game for the challenge. Tomorrow is my first day on call and I am certainly wondering what will be behind that door… Better get some sleep!