DISCLAIMER: The following post is quite lengthy and filled with
medical jargon. It was written more for my own remembrance and mental cleansing
after a long weekend. However, if you want the important point, Scott tells me
you can just skip to the final paragraph and get all you would ever need. (Although, I find the rest pretty interesting too...J )Thanks for reading!
As I mentioned in my last blog, this weekend I was charged with
the responsibility of rounding on the internal medicine services and overseeing
the admissions by the interns. Being not far from their training myself and not
knowing the girls I was privileged to work with, that meant that I came in to
see each of their admissions with them as we worked collaboratively through
their presenting symptoms. Since in Kenya healthcare is only available to those
that can afford to pay up front, many people present very late in their illness,
and many only when they are on the brink of death. Needless to say, the
admissions were fairly complicated. However, I was excited to tackle the
weekend and see everything from falciparum malaria to classic ST elevation MI
(massive heart attack).
Since I have already relayed to you most of Saturday’s
events, I would like to walk you through my last 24 hours: The morning began
with rounds by myself on our critically ill patients. One patient who had been
admitted overnight on Friday was not faring well, as her pulse was in the 160’s,
her blood pressure was in the 200’s and her breathing had become labored. She
was admitted with known HIV, a diagnosis treated much like stage 4 cancer here.
Therefore, a collaborative physician decision was made that she was a DNR, as
the likelihood of her surviving was slim. She was being treated for liver
failure of unknown origin (suspected to be from either her AIDS medications or
some herbal concoction she had received from a traditional healer).
Hepatic encephalopathy is not a diagnosis we are unfamiliar with
in the US, but she was not responding in the way I would have liked. Therefore,
I did what any confused resident is likely to do…I went back to the drawing
board and attempted to make a differential for altered mental status in an HIV
patient. I did not have the benefit of any prior health history or a CD4 count.
I’ll spare you the details of my varied list, but I systematically tried to
rule each in or out, and decide how, or if I could treat them. Unfortunately,
lab tests on the weekend are hard to come by and basic at most. Imaging is
limited to ultrasound or x-rays unless a patient is stable enough and wealthy
enough to make a trip for a CT or MRI to Nairobi about 2 hours drive one way
(not an option in an unresponsive patient without an airway). Therefore, I
started antibiotics empirically to treat any of the possible infectious causes
we were not treating, and prayed for the best.
I realize as I’m typing
this you probably thought that after reading 2 paragraphs about one patient, I
would have revealed to you her mystery diagnosis, but alas even today she
remains a mystery on the brink of heaven. I write this only to demonstrate the
mental anguish of watching a patient deteriorate in front of you without the benefit
of knowing what is ravishing her body, and the frustration of limited resources
(AND lack of knowledge on my part…I was thankful that our senior attending
returned today to add her own clinical expertise!).
While attempting to seek other physician opinions about the
lady above yesterday, I came upon a pediatric code in the ICU. It was so much
calmer than any I have seen in the states (no code stat junior called overhead,
and no pharmacy, chaplain, or scores of scared residents to crowd the room).
Since there was only the nurse and one pediatrician present (one bagging and
one doing compressions), I quickly offered my services. They requested that I
run to the blood bank to seek the blood they had ordered to transfuse him. It
occurred to me as I ran through the hospital that this is a situation I have
only seen in movies. When I arrived and urgently requested the blood, the lab
tech sluggishly checked the progress and told me that it would be 30 more
minutes. To this I replied, “It’s an emergency…the baby is dying right now!” He
finally agreed to let me have what was available for an emergency protocol but
only if I could go back to the ICU and get the blood carrier. I felt much like
a ping pong ball, but the baby survived the code. Unfortunately this morning I
curiously passed his room to find it empty. I don’t know the details since I’m
not currently on the pediatric service, but I know he is frolicking in heaven
unbound by tubes and lines today.
After my adrenaline calmed down from running through the
hospital, I made my way toward the gate to go home for lunch. However, I
stopped by the ER to see if any interesting admissions were coming our way. The
clinical officer (PA) was so happy to see me and showed me an EKG of a patient
who had presented with chest pain. He had classic tombstoning ST elevation in
the anterior leads (massive heart attack for my non-medical friends). These
patients are usually whisked away to heart cath in the US before we ever have a
chance to see them. Unfortunately, a cath is not available in our hospital
where a cardiologist is only here once a week for clinic. We initiated typical
therapy for a heart attack and I was excited to be able to teach the clinical
officer. I learned later than thombolytics are sometimes available to treat
these patients, but unfortunately, our hospital was out yesterday. He was
admitted to the ICU team and I moved on to the next patient.
A 50 year old lady with known HIV had presented with altered
mental status, vomiting, and left sided weakness. On her exam, she was quite
stiff and unable to move her left side at all. With her right arm she was
persistently performing repetitive motions which made me concerned for partial
seizures. We were highly suspicious of a space-occupying lesion, stroke, or
infection. Her family was unable to afford a head CT, so we decided to treat
for meningitis empirically, knowing that a lumbar puncture would be very risky
in her. They planned to consult with family members and attempt the head CT the
following day.
After getting her settled, we were called about a patient
with a likely bowel obstruction and a sodium level of 103. Next, was a patient
with chest pain after previous history of a heart attack. Following him, our
team was asked to see a 16 year old girl with known focal segmental glomerulonephritis
and pyelonephritis (kidney infection) on immunosuppressants. Then, we admitted
a lady with seizures and hypertensive emergency.
After finally getting each of the above settled it was about
1:30am and the clinical officer quietly asked for my opinion about 2 other
patients in the unit “since I was there.” He briefly told me their stories
concluding that they likely both had pulmonary TB (number 1, 2 and 3 on the
differential here for any patient). I asked to see their x-rays and I examined
both.
The first gentleman had the largest, most nodular liver I
had ever felt. He had an ultrasound that showed 2 focal masses and a x-ray that
looked like diffuse metastatic lung cancer (although to the credit of the
intern, it also looked like military TB, ARDS, or PCP …all very likely causes
of his symptoms). He was hypotensive and had signs of infection on his labs. We
concluded that he likely had metastatic lung cancer and potentially ARDS as the
result of an infection he may have acquired while in and out of the hospital. I
attempted to stabilize his shock and moved to the second patient.
The second gentleman was very thin and frail, with a blood
pressure of 86/50 and saturating 75% on 15L of oxygen. On his admission vitals,
it was recorded he had a sat of 32% on room air. He had clubbing (signs that he
always had low oxygen levels) and was in mild distress. The intern described
his x-ray as “unusual” but he wasn’t sure what was going on. Taking it to the
light box, it became quickly apparent that he had a moderate pneumothorax with
a white out of the right lung and diffuse patchy infiltrates in the left (one
must learn to become a radiologist here, because that is another subspecialty
we are lacking).
Because of the hypotension, I was concerned that he was
developing a tension pneumothorax and potentially had a lung full of blood
since that’s what he had been coughing up for the last week. I called the
surgical resident to place a chest tube and then the intern and I prepared to
do a needle decompression (something I’ve only read about but never actually
done). It was slightly anti-climactic, but it did buy us time until the other
physicians arrived. The ICU covering attending came and performed a bedside
ultrasound to look for signs of cardiac compromise from the collapsed lung
(thankfully there were none). After that, the ICU team took over. Unfortunately
when I went to find the patient this morning to follow up, he was nowhere to be
found. Another soul with the Lord after a long night.
After about an hour of long awaited rest, I went back to
round on my patients for the day. I walked into our unit to find the nurses
coding the lady I had admitted with HIV, seizures, and left sided weakness.
Again, it was actually a bit calmer and more organized than those in the US. I
took over the lead from the intern who was bagging and we tried to think
through what might be going on. Unfortunately after about 20 minutes, she too left
this world to be with the Savior.
I sat down with her family when they came to visit this
morning, and it was odd how at peace they were with her passing. They knew she
had been suffering with AIDS for nearly 10 years and calmly acknowledged every
word without so much as a question about what happened. Given that her acute diagnosis
was still unknown, I was amazed at their acceptance that God is in control.
I keep seeing over and over again this contrast between
American and Kenyan culture: Kenyans believe in a spiritual universe. Whether
people know Jesus or not, they still realize that there are powers greater than
us at play. They understand that as physicians we are entrusted with knowledge
and expected to use that as the gift that it is, but they do not blame us or
question when bad things happen. They know that we do our best, but sometimes
it is time for the suffering in this world to be done.
After the conversation with the family, my call shift was
finally over and it was time to begin the day with traditional rounds. As is
customary on our team, we prayed to begin the day. I shared with them this
verse that the Lord has been impressing upon me this weekend: “That is why we
never give up. Though our bodies are dying, our spirits are being renewed every
day. For our present troubles are quite small and won’t last very long. Yet they
produce for us an immeasurably great glory that will last forever. So we don’t
look at the troubles we can see right now; rather we look forward to what we
have not yet seen. For the troubles we see will soon be over, but the joys to
come will last forever.” – 2 Corinthians 4:16-18. I realize that medicine and
physical things are only temporary. I’m not going to lie, I was pretty beat down
this morning after feeling futile for so many patients. However, the Lord
reminded me that we work for eternal things. We touch patient’s hearts and
souls, and the love that we show them will last far longer than any medicine I
could ever give. With that I am encouraged, and the journey continues!
👍🙏👍
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