Sun vs Clouds

1/14/2010
Day 9

And another day flies by. This one happened to be a bit calmer than the norm since we were able to discharge a few of our patients. It certainly wasn't without excitement and frustration, though. Jane continues to be tenuous with high oxygen requirements on the ventilator. We are still no closer to having an answer. Some labs came back today that essentially told us what we already know: she's sick (for those medically inclined, her peripheral blood smear, or "film" here, showed neutrophilia suggestive of infection and hypochromatic RBCs suggestive of iron deficiency anemia, and her ESR is 111). We added some more big gun antimicrobials to bring her medication regimen to INH, Rifampin, Ceftriaxone, Azithromycin, Amphotericin, Dexamethasone, and a boat load of Morphine and Valium for sedation. She has been very difficult to sedate, requiring large adult size doses (which we think is due to the Rifampin which in addition to turning her urine into orange cool-aid, increases the metabolism of a lot of sedatives and analgesics). Sedation on ventilators here is done by q2 hour IV pushes of Morphine and Valium. To me that sounds like q2 hour moments of terror as the meds are wearing off. It is hard to watch her when she starts to wake up. We wanted to get a tracheal aspirate today but she wasn't sedated enough. We figured out that you can make a ketamine drip, though it takes about 6 MDs to be able to calculate the proper concentration and the proper hourly rate. Infusion pumps are another rare item in these parts. Yet another reminder of how flush with resources we are in the states, and how little we stop to ponder that fact.

So Jane now is getting whopping doses of ketamine in addition to the other sedatives. We were finally able to get a small sputum sample that I personally carried down to the micro lab (butcher gloves on and all. I keep meaning to take a picture of the plastic baggie-like Mickey Mouse-sized gloves they have around here. The first time I put on a pair of those gloves I asked one of my patients if he knew who Mickey Mouse is and got a big ol' blank stare.).

The ID doc wants to do a bone marrow biopsy and thinks the tracheal aspirate will be low yield. The ICU doc doesn't want to do anything more invasive right now. There is certainly no lack of opinions around here. Me? Well, I want to do the biopsy (mostly so I can log it into new innovations and make Tuggy proud) and get a more definitive answer for the family. But it is costly, and the family is already struggling to pay the bill they have run up thus far. I had a family meeting today (go go gadget family medicine skills!) with Jane's mom and her older brother. They are all very concerned about the cost of this hospitalization. These past 2 days have cost 27,000 Kenyan shillings, which is probably more than her family makes in 6 months. They wanted me to give them an estimation of how long she will be in the ICU and need ventillatory support. I wish I had an answer for them. The truth is that if she shows no signs of improving over the next 48 hours or so, our team likely will withdraw care. This makes me think of a patient we had at Swedish last summer who had a prolonged intubation (H1N1 followed by pneumonia and multiple other complications) and was still in the hospital when I was there last month (Her medical bill is well over a million dollars. Wonder who will pay that one... Rod Hochman?). That is definitely not in the cards here at Kijabe.

There is an ICU price list posted on the wall in the unit. Everything is itemized (bipap, cpap, intubation, resuscitation. Simply one night in the ICU without those interventions is about $90). Of course coming from our extremely efficient system (to be read with thick sarcasm) of blind costs and escalating prices, this at first seems crude and inappropriate. But it doesn't take long to realize with limited funds and resources, there is no other way. Perhaps Obama should take a few lessons from his homeland?

On a lighter note, Paul, my 5 yr old paraplegic who had a spine surgery about a week ago, is going home today. He was so excited to be going home. We chatted today about his brother and sister, his parents, and his dog. I showed him a picture of Linus on my iphone and his eyes widened into saucers, he covered his mouth with his hand, and let out a big gasp and giggle. I don't think he's ever seen the likes of a designer labradoodle. Those haven't quite made it to Kenya it seems. Taking care of and getting to know him has been a highlight of my first week here. It is nice to have a ray of sunshine in the sometimes cloud-filled atmosphere that can be the hospital.

And now, it is time for our first social engagement of the week. We were invited to our neighbors' house for dinner. Phil is a medicine resident from Mayo working here in the ICU and his wife, Kerry, is a Mayo nurse. It's nice to have some camraderie after a long day on the wards.