Call nights in Africa

Sorry its been a while since my last “blog” but I’ve been trying to stay as busy as possible to keep from missing Ray and everyone else at home. But, don’t worry, I have plenty of friends here that are really nice. Dolly and her husband Vince even found the British Open on the satellite TV so I could watch Tiger after they heard I was sad I was missing it! Dolly even made a huge thing of popcorn for everyone. (The TV is a projection screen that is set up in the basement floor of the new addition on the guesthouse. It usually is used for movies only, but they bought a two month TV deal so that everyone could watch the World Cup). Hon, you will appreciate this……I wasn’t sure if I mentioned it last time, but a new couple came in last week and the husband will be the Resident with me for the next month. His name is Doug Johnson, and he is a resident in Internal Medicine at Duke. His wife, Sarah, is with him and is a physical therapist. Its interesting b/c he went to Med School at UAB and his parents live down the street from us in Bluff Park! His Dad is a Pulmonologist at UAB. He also is good friends with Tim Heacock from our yearly NC beach trip. Its crazy to go all the way across the world and be working with someone who lives less than 5 minutes from where I grew up (and now live) in Bluff Park. Anyway, since my last blog, I have taken call a few more times and had several new patients admitted to me on the ward. On Friday, my call started with a comatose 31-week pregnant patient who came in after apparent seizure activity. Since she was not HTN, didn’t have protein in her urine, and had normal platelets and Liver Function Tests, the OB team didn’t believe she had Eclampsia or HELLP syndrome and so they admitted her to us?? By the time I got there they were already admitting her to the ICU b/c her pupils were blows. According to the OB team, first priority was the mother b/c nobody knew how long she had been seizing and the baby’s prognosis was already extremely poor. Anyway, right when she arrived in the ICU she stopped breathing! The worst part was, that she stopped breathing right in front of me and none of my upper levels had arrived yet. Luckily there were two nurses there to help me, as I started chest compressions and they began to bag her. A few minutes later the Kenyan intern, Damaris, came in and we intubated the patient and got ready for the defibrillator. She initially regained her pulse and was stable for about 30 minutes until crashing again. This time the CPR code lasted for about 45 minutes (I was completely soaked with sweat by the end of the code from doing chest compressions…..and Rachel knows that I don’t sweat that much normally!) before my Attending said that we had done all we could do…..she and her baby had passed. It’s very hard not to get discouraged and frustrated having these kinds of results so often here, and I’m quickly learning how fortunate we are in the States to have the kind of care we have. In Kenya, most patients do not seek any kind of medical care until the last unbearable moment. In this patient’s case, she didn’t seek care until her family found her comatose and her baby had most probably already passed. But I guess, if we had to walk 3 hours on dirt roads to receive medical care, similar results would occur in the U.S.. Another sad tradition in Kenya is to never bury a deceased baby and mom together. Thus, the morgue had to remove the baby so the two could be buried next to each other. I’m just glad I didn’t have to be there for that part…too sad. But fortunately, even though I have experienced a lot of deaths, there are far more stories where patient’s have been saved and sent home! On Monday, I had a previously healthy 25 year old guy come in who was fine the week before but during a hospitalization at another hospital he developed seizures, tremors, confusion, multiple lower extremity joint pain, and ascending weakness. They didn’t know what to do, so they sent him to Tenwek. Even though his wife said he was walking normally last week, by the time I was examining him he was paralyzed from his toes to his hips. He also had a severe intentional tremor and was so confused all he could stutter was, “I think I should be fine soon.” With no past medical records (or any records at all) a lot of the time we have to treat empirically w/o having the exact diagnosis. In this patients case, his differential consisted of Guillan-Barre (classic for ascending weakness), Transverse Myelitis (usually seen in MS and needs MRI to dx), Lupus (need ANA or anti-smith antibody titers to dx, which we don’t have), Lyme disease, TB meningitis, cerebral malaria, polio, typhoid fever, and bacterial meningitis. Since diagnostic and treatment resources are limited, we had to really have faith that the treatment we choose is most likely to cover the disease at hand. The first thing we started him on was IV steroids to hopefully stop any autoimmune/inflammatory/infectious process causing his weakness. Then we began daily IV ceftriaxone (to cover deadly meningitis), RHZE (TB treatment), and a dose of quinine. He was so nice and scared, which made me want to help him so much more. Luckily, two days later I finally got him to move his big toe!! Then later that day he was using his Plantar Flexor muscles (like stepping on the accelerator). Yesterday, he was able to pick both legs off of his bed! With his LE strength improvements, also came improvements in his tremor and confusion. Today he stood up for the first time in 2 weeks and was speaking almost back to normal. The exact diagnosis is unknown, but I believe the most likely dx was Transverse myelitis, which can be caused by a host of viruses.
Another success story included a woman who came in the other day after being gored by a cow’s horn! It was a very serious puncture and so she was rushed to surgery. A fellow resident in the Guesthouse, Vince from NY, was the Surgeon on call who opened her up and reported that the cow’s horn had punctured her intestines in an “accordion-like” distribution, producing 5 holes in need of closure. During the procedure, Vince pulled out a tapeworm that was over 50 feet long! Talk about an incidental finding!
Other than that I’ve had a few more interesting cases, which include an extremely nice 50 year old male with osteomylitis, a 20 year old boy with (what we think is..) Osler-Weber Rendu disease (a rare Autosomal dominant disease where some of your blood vessels don’t form correctly and you have recurrent nose bleeds, AVMs, and other bleeds). This kid had a hemoglobin of 3.0 (normal is >13.5) and was walking around w/o complaining. In U.S. we freak out if Hgb is <7. I also had a case of Infective Endocarditis, which is an infection that spreads to the valves of the heart, and requires 4-6 weeks of antibiotics to cure (the patient even had the classic splinter hemorrhages of his fingernails). Another patient had a spontaneous pneumothorax that we believe was caused by TB. His CXR and physical exam were crazy. The collapsed lung had pulled his entire mediastinum (which contains the heart) over to the right side of his chest. Thus, to listen to his heart, you have to place the stethoscope over the right chest. Very cool! My last patient was a 70 year old man who presented with several weeks of “severe sickness” and anuria (no urine output). On lab check, his Creatinine was elevated to over 35 (normal is 1.0). Again, in US we freak if it is over 5. It turns out he had such a large prostate he couldn’t pass any urine and so he got bilateral hydronephrosis and damage to both kidneys. We finally got a catheter through the obstruction and drained a ton of urine. He immediately looked at us like we had just cured cancer and hopped out of bed feeling like a new man! He was so thankful, but he didn’t realize that all we did was catheterize him and drain his urine. We sent him home later with some BPH meds.
Saturday afternoon was nice because most of the young people (including myself) were off and we had a chance to hang out. We played a lot of ping pong and a new game called Walley-Ball, which is volleyball played inside a racket-ball court. It was a lot of fun. Then we watched the british open, and I crashed around 9:30 since I only got 3-4 hours of sleep the night before (call=night). I went to Church this morning and got home and had 9 missed calls from Rachel! I was so worried. I finally got through and discovered that our House Alarm had gone off around 4:15 in the AM while she was asleep. She called my house and my Dad ran over to check everything out and convinced her it was safe to leave the room. Probably a false alarm….but of course something like that happens while I’m over here in Africa. Anyway, I’m glad she’s o.k. Well, my computer is about to die so I will end this ever-long “Blog”. Hon, I hope your happy because I just realized this dad-gum blog is like 2.5 pages! Well, I miss everyone and look forward to seeing you soon. Anna, tell Janie-Bird I said hello.