"To all the esteemed users..."

1/13/2010
Day 8

My call night went out with a real bang. I went to check on my patients only to find two kids with hydrocephalus to be admitted, a woman in casualty needing attention, and most pressingly, my 13 yr old girl with respiratory distress acutely decompensating. The easy parts first: We admitted the two hydrocephalus kids, and then went to evaluate the woman in casualty. She is a 22 yr old woman 2 weeks post vaginal delivery with fever and abdominal pain for about 5 days. Her pain localized exactly in the right lower quadrant, but of course our differential was still pretty broad. Although my money was on some sort of post partum infection, her pelvic exam was completely normal (I told you I shouldn’t be a betting person!). Her labs came back with an elevated white blood cell count. At that point there wasn’t much else to do besides call the surgeons to evaluate. She ended up being admitted, put on antibiotics (Amp, Gent, and Flagyl for all! Even the lactating!), and will likely go to the “theatre” tomorrow. She was supposed to go today, but apparently “she was fed”. Translation: Despite writing the NPO order she ate today. Another oddity: To ask if a patient has been NPO, you say “Has the patient been starved?” So very much to learn around these parts. Oh, but you thought she was just a simple appy, eh? Well, it turns out that she has had L sided weakness and R sided facial droop since 2 weeks prior to delivery. Her neuro exam was quite impressive. We are assuming that she for some reason had a stroke prior to delivery. You know, just your average 22 yr old patient issues.

After getting through that evaluation, my intern and I were paged that Jane, my 13 yr old patient, was having more respiratory distress. But at the same time, we got paged to admit a 4 day old baby with a bilirubin of 35. Yes, you read that correctly. What else to do but divide and conquer? My intern headed to the nursery to start on an exchange transfusion (which are apparently all the rage around here), while I headed to the peds floor. When I arrived at Jane’s bedside she looked terrible. I harkened back to all those lectures where the goal was to stratify kids into categories of sick or not sick. My internal monologue was screaming, “Sick!! SICK!!!” She was satting 84% on 10 L by facemask, sitting up, hunched over, grunting, and breathing at a rate of about 80. She was moaning in pain and pointing to her hips and low back. She had just bought herself a one-way ticket to the ICU. One complicating factor: The ICU was at full capacity after we transferred our 3 yr old with heart failure earlier that day. So, I had to check on the 3 yr old, determine she was stable to be transferred to the floor, and mobilize the troops to swap positions (to add an extra element of confusion, both patients are named Jane. What is it with my patients that come in pairs? Is it some sort of bizarre take on Noah’s Ark?). Then I had to call the ICU attending on call (Dr. Trotter, as fate would have it). He groggily agreed to come in to oversee the transfer.

Once in the ICU and on a non-rebreather mask (which are hard to find on the wards), her sats came up to the mid 90s on about 7 L of oxygen. I gave her some pain meds which helped calm her down a bit too. Dr. Trotter and I discussed treatment options, challenging given we have no idea what her underlying lung process is. We decided to give her steroids, practically our only other option aside from antibiotics which she is already getting. I stayed with her for awhile, expecting her to tire out and get intubated (I had the valium, succinylcholine, ET tube, and blade all ready bedside). Intubation here is a tough fate, though, since more than half those intubated never get extubated. With her history of 4 months of respiratory problems before this acute worsening, her prognosis for extubation is poor.

She surprised me, though, and made it through the night with her facemask. Today she is marginally better (meaning she at times will breathe with a rate in the 50s-60s before going higher). I presented her to the daytime ICU attending this morning and got a lot of questions and head-scratching. Everyone is equal parts fascinated and frustrated by her. Right now our differential includes TB (less likely from her clinical picture and the fact that she has been on TB meds), atypical bacterial pneumonia, fungal pneumonia, PCP (both less likely if she is immunocompetant which she so far appears to be – HIV neg), leukemia, vasculitis, rickettsial infection, sporotrichosis… The list is extensive. And our diagnostic capabilities are so limited here. Complicating all of this is her complaint of hip bone pain, and severe anemia (she was transfused a total of 5 units last month during a hospitalization at another facility). I was pouring over my tropical medicine book and thought I’d found the golden ticket with Brucellosis. Turns out they don’t have that here, per the ID doc (he’s an American adult ID specialist who we drag into the peds world frequently). We are sending a bunch of tests (ESR, peripheral blood smear, cd4 count, elisa confirmatory HIV test, and a lumbar spine film). Expect those all to be back in, say, 48 hours. The ID doc thinks she needs an open lung biopsy (since no CT scan or bronch capabilities) and a bone marrow biopsy. Meanwhile I feel so helpless with the pace of things here. She very likely doesn’t have a lot of time to play with. I will keep you posted.

I am sure my medical jargon babble is getting little tiresome, so I’ll sprinkle you all with some non-medical factoids I’ve picked up. Kenyan people are kind, soft-spoken, and the least direct communicators I’ve experienced. Everything is explained in a round-about fashion. Or not explained at all. Many times I’ve asked a nurse (or a “sister”) a yes or no answer only to be met with “It is ok.” Apparently a lot is ok around here. The informational signs posted all around the hospital are so hilarious to my American self, I can’t help but take photos of them all. I will leave you all with my very favorite sign. It is on the inside of the bathroom door on the peds ward (the one with soap!). I wish I could post a picture of it, but that is definitely not in the realm of possibilities around here.

“To all the esteemed users:
Please note that even though we have a “new cistern” the quality is not the best so before leaving this small but important room make sure that the business you transacted has gone down well. IF NOT please pour water with a bucket to ensure that it goes down. Please use this office well and leave it clean. Enjoy your time here.”

Translation into American terms: FLUSH!!
PS there’s no bucket!