Fanta-stic

1/21/2010
Day 14

A wise friend once told me that she got through hard times on her medical rotation in Africa by indulging in a cold Fanta soda. I am sitting down to my first Fanta. Call last night was more than a little challenging. I was paged to Casualty around 6 pm to see some patients to be admitted. The chief complaints: “Toes falling off” and “Unresponsive.” Just your garden variety of patients. The first patient was a 50 year old man who had already had one lower leg amputated from diabetic complications. He came in complaining that his other foot was black and his 4th toe had recently fallen off. This patient really redefined the concept of “foul smelling wound” for me. It was beyond putrid. We admitted him to the men’s ward and were teeing him up for surgery. I discovered this morning that he is refusing surgery which is altogether a terrible idea given the alternative is eventual death from septic shock (he’s currently stable).

On to the comatose patient. She is a 39 year old woman who was transferred from an outside hospital after becoming unresponsive 1 day ago. She had been in the hospital for about 1 month with a complaint of progressive bladder and bowel incontinence, inability to walk, and chronic cough. She was recently started on TB medications and arrived with a “referral letter” from the other hospital. These letters are hand written notes from one hospital to another attempting to explain why a patient is being transferred. I have found that these letters hardly ever have a date on them, let alone a diagnosis or any sort of explanation of hospital course or medical care received. Her letter was slightly better than the norm, and informed us that she had a diagnosis of Pott’s disease (TB that has spread to the bone) of the spine (explaining her neurological issues), and a recent diagnosis of HIV with a CD4 count of 27 (very very low). She had been moved to Kijabe hospital so that we could properly care for her in her comatose state (always a good reason). Her husband gave us a history that for the past month ago she had been getting increasingly confused, not recognizing him at times, in addition to her bowel, bladder, and gait problems. The day prior to her transfer, she stopped eating, talking, responding, and hadn’t passed urine in 24 hours.

I came to her bedside (the only person in casualty to have an N95 mask on) and quickly realized this was the sickest patient I have ever seen as the first responder. She was clearly in shock, with unstable vital signs, thready pulse, cool, clammy extremities (she was one of many reminders last night that two of the most useful items to have in Kijabe are a TB mask and the Glascow coma scale). She had one IV in place through which fluids trickled slowly. I attempted to mobilize nurses to help place another line, get more fluids running, and place a foley catheter. 0/3 of these things happened. I had palpated a firm mass in her abdomen which I thought was her bladder and decided to take matters in my own hands. I placed a foley and got back over 1 L of very concentrated urine. This was somewhat reassuring that her kidneys had not completely shut down. Still no second IV. I drew labs, did an LP (champagne, thank you very much), and got a chest xray. I also took note of her painful, swollen L upper arm (she would only move to squeezing of her L biceps) and concluded she has a DVT there. Meanwhile I felt conflicted as to how aggressive we should be with her care. At Kijabe, they won’t admit the sickest people to the ICU since it is seen as futile and a waste of resources. They generally also won’t put end stage HIV patients in the ICU or intubate them. I called the attending to discuss and he confirmed this, but said we should continue her resuscitation (difficult with drops of fluid going into her veins) and admit to the women’s ward. We did so, and as far as I know she is still alive today, though her spinal tap hasn’t shown signs of infection as we thought. And she never did get that second line.

Then we saw a 2 year old who had her hand bitten by a rabid dog followed by a 41 year old with a large, painful, swollen testicle. He had an ultrasound done to see if it was torsed (twisted on itself, cutting off the blood supply = bad = surgery). They did the ultrasound but didn’t comment at all on the blood supply (argh!). Treated him for orchitis/epididymitis and are hoping for the best.

It was then on to an 88 year old woman with dementia who was brought in by her family because she was less responsive than usual. She was mildly hyperglycemic and had missed her insulin dosing that day. The geriatrician inside of me insisted on getting a UA to make sure she didn’t have a UTI. Well, guess who does the in and out caths in casualty? Not the nurses! (You might wonder what they DO do, since it is clearly not put in IV lines or take vitals.) Second foley insertion of the night, this one was even more fun since the patient had wasted, rigid legs, and screamed bloody murder as I did it (But it made her be more responsive!). About an hour later I realized the urine sample that we had painstakingly collected was still sitting on the counter staring me in the face. I had to ask a nurse about 5 times to take it to the lab. She ended up not having a UTI and went home.

Then we decided to divide and conquer since it was about 1 am with a line of people waiting to be seen (and in the middle of it all we missed a page to the delivery room to resuscitate a floppy baby. Oops. They had to call in the attending). My intern admitted an 8 month old girl who had been completely normal up until 1 month ago when she started regressing and losing all her developmental milestones. She can no longer sit without support, hold her head up, and is lethargic and barely responsive. (Enter Glascow coma scale.) It sounds like she had a febrile illness (malaria?) a month ago and might have had a seizure with hypoxic brain injury. She also has newly diagnosed hydrocephalus which may contribute, and/or viral encephalitis (LP number two, champagne).

Meanwhile I was seeing a 61 year old diabetic man with 9 days of massive, painful facial swelling and warmth. He was a sight to see. His eyes were swollen shut with crusty discharge from the eyes, his lips were enormous and with a few pustules on the surface, his nose was also swollen and tender with a few pustules, his L parotid gland was swollen and tender, and he had a huge L submental lymph node. Apparently he had some sort of small wound on his nose which progressed to look as it did last night. He had also been transferred from another hospital where he had been getting “something in an IV” (Note to all: write down your medications!). His family called that hospital a “bush” hospital and brought him here (to the private ward – a more exclusive ward that is of course more expensive. I started broad spectrum antibiotics thinking bacterial parotitis vs facial cellulitis (dental source?). Today he looks about the same. At least he’s not septic. Yet.

I finally headed to the last patient we had in cue, a 29 yr old woman with cough. I first stopped to read the preliminary notes taken on her. Apparently, about 2 hours prior to my reading the notes, the patient had vitals taken that were as follows: pulse 156, bp 90/60, oxygen saturation 78% on room air. It was noted that she was “barely responsive” (Glascow coma scale!). No one had informed us of her state (triage anyone???), and I found her lying on a bed stuporous, without oxygen. I grabbed the nearest nurse to ask for a new set of vital and some oxygen (neither happened). I pieced together a cursory history from the patient’s sister and a referral note. Turns out she has had a cough, night sweats, and weight loss for about 4 months, was seen at a clinic recently and had a positive HIV test (and was not notified). We got labs, a chest x-ray (diffuse infiltrates, small cavitary lesions), an LP (number 3 of the evening, champagne), started fluids, Ceftriaxone, TB meds, PCP meds. I also got a pregnancy test since her abdomen looked a little suspicious. This morning she was also still alive, a bit more responsive, and also with unremarkable CSF results (I am wondering if the lab machine is broken…) and no pregnancy test results (the urine sample is probably still sitting in Casualty).

I stumbled home at 3 am, my mind reeling with the events of the night. The lack of any sense of urgency towards the treatment of these patients is very hard to comprehend. Is it that the local staff here is just so used to seeing this level of acuity? It is also nearly tear-evoking to sense the nurses’ frustration towards me as I try to take good, thorough care of the patients. I know I need to roll with it a little more but it’s tough. Maybe I should just have another glass of Fanta.

Needless to say I was a bit wrecked when my alarm went off at 6 this morning. In the few short hours I attempted to sleep, I dreamt there were no more beds in the hospital (which was actually true last night) and so they had to put a TB patient next to me in my bed. Honestly. Talk about an anxiety dream.

The truth is I learned more and got more hands on experience in one night here than I probably have had in years of my training in the US (ok maybe not quite to that extent, but you get the point). I am grateful for that, and am trying to focus on that instead of all the other things I could be mulling. And I am still having a blast working with the Kenyan interns, who are so kind and unfazed. My intern last night, after all was said and done, said, “Wow, Cabou, you are so persistent.” This is the same intern who said to me on my first call night, after putting in an NG tube, “You are so nice. And you are such a good doctor.” Through all of the chaos we managed to have some laughs last night. My intern was urging me to speak Swahili. I attempted to inquire if a newborn child was breastfeeding well and instead asked, “Does your child see well?” All the Kenyans found this hysterical. Ahhh, cultural exchange. Now I think it’s back to my Fanta.