So, as I mentioned in my last post, I was on call my second day at the hospital. Talk about jumping right in! I only missed rounding on one patient and went to the wrong place for one overnight delivery- which considering how lost I was the first day, I thought was pretty good. At the start of the day, I found out that two NICU patients had died the night before. One full term infant born with HIE and Apgars of 0 and 3 who was coded for a while at birth. Unfortunately the NICU is like a sauna with all the heating lamps for the premies, so there was no chance of keeping him room temperature, much less attempting to cool him. And the other baby was a premie in the 26-28 week range with RDS; since there is no surfactant here, he remained tachypneic over the first two days and died of respiratory distress. These babies could have at least received some kind of treatment in the states, so it's hard to watch them die here.
The patients admitted in the evening were sick - there was a 17yr old with known pulmonary TB on treatment who also had pericardial and pleural effusions, DVT on warfarin, and was coming in for pitting edema, ascites, orthopnea, and hypoxia. I felt like I was on a medicine ward! Thankfully one of the medicine attendings assisted the intern with the pleural tap since I can't say that I've done one on a peds patient ever. A 7 year old came from another hospital with suspected meningitis, high fevers, neck stiffness, irritability, meningeal signs. She had 2 LPs attempted unsuccessfully, so we just empirically treated with ceftriaxone and antimalarial meds. Apparently even if we had been successful with the LP, the cultures here are not reliable and so typically they don't even bother collecting blood, urine, or CSF cultures on patients. Just start treatment and hope you are covering the right bugs! We did do an LP on a patient earlier in the day who likely has post-varicella transverse myelitis but we felt like an LP could help rule out Guillain-Barre. There were no masks or gowns, and they only have size 7.5 sterile gloves (way too big). The spinal needles were in individual packages, but the collections tubes are reused and sterilized. The patients do not get local anesthesia or sedation and the parents often stay in the room to help hold the child down. Despite all that, the medical student got the tap on his first attempt (only 2nd tap ever) and it wasn't even traumatic!
We admitted another patient, age 7, with hemoglobin of 4 who was 'paperwhite' and had massive hepatosplenomegaly and had recently had varicella. Supposedly he has sickle cell disease, but the parents could not tell us when or how that was diagnosed. Sickle cell is pretty uncommon around here, and his spleen was massive at age 7. We started ceftriaxone on him too (without culturing) and sent a smear. Since I didn't have to round today, I'm not sure what the results are. Trying to be thorough and efficient is challenging here because labs and xrays do not come back for hours, sometimes days. In the nursery, we often get bilirubin results back the following day. And xray results - like for a kid I was concerned had NEC- took over 3 hours. So there was no way I could followup on important labs that were ordered overnight on call because they might not have even been drawn until the following morning.
The most concerning patient we admitted was a 10 month old boy with 3 days of respiratory distress and fevers, suspected pneumonia like many of the other peds patients on the wards with bilateral crackles. He was satting 75% on 15L facemask and tachypneic to 80's. I considered intubating him but apparently that is extremely challening to accomplish. There are 3 ventilators in the ICU and one ventilator specifically designated for NICU. Thankfully there was one ventilator available and after moving patients around, there was a bed space available in ICU (combo MICU/SICU/PICU). These are old school machines and since we have great RTs at Duke, I rarely have to set the vent myself. But thankfully, there is a visiting RT from Canada here for 6 months who very graciously came in from home at 11pm to help me set everything up. As we were setting up the vent and getting the intubation supplies ready, the electricity went out at the hospital for ~ 1 minute! The monitors stopped working, the ventilator stopped working and I was trying to figure out if I was going to have to stand at the bedside and bag the patient all night! It took about an hour to get everything set up and the patient moved to ICU where there was a continuous pulse oximeter available (as opposed to the portable machine that is used to take vitals twice a day on the floor). Thankfully at this point he was satting 90% so I opted not to intubate and just keep a close eye on him in ICU where vitals are obtained every hour. Apparently vented patients do not do well, often getting Pneumonia, ARDS, and other complications. And if it's predicted that a patient will require ventilation for a prolonged period of time, they are not even initiated on the vent since they don't want to tie up one of the three ventilators in case someone else needs it during that time.
These patient cases describe the challenges that the doctors here face - there are a lot of physical demands on them to carry large patient loads and be on call often, emtional demands when patients die, and medical challenges to diagnose and treat patients without always having the available diagnostic test or desired treatment. But the doctors here are fantastic and have developed ways of working within the system to optimize patient care. The interns learn quickly how to diagnose and treat the most common illnesses and are able to teach me a lot about how to treat malaria, TB, malnutrition, etc. I'm feeling quite stretched in my medical knowledge and clinical skills and hope that I, too, will quickly adapt to the new system and learn how to recognize the more common illnesses and conditions.
It felt like a typical busy call night at Duke, although with a completely different list of patient complaints. Despite little sleep, I opted to go for a post-call run with two visiting radiologists. We ran for ~5 miles to the top of Motigo, a mountain/hill near Tenwek. I'm told that the elevation increase is ~300 feet per mile, so total ~800 feet from base to top and the top is ~7200 feet above sea level? I tried to create a google satellite map of the run and elevation change, see below; click on satellite for cool images. From the top, we could see the hospital grounds, the city of Bomet 3 miles from the hospital, another small town, and the surrounding country side. It was gorgeous- God's beautiful creation displayed everywhere!! I didn't take my camera so if I get another chance to run up there, I will definitely plan to take pictures. We did pass some motorbikes, cows, chickens, school children, tea fields, and lots of lush green farmland.
http://maps.google.com/maps/ms?ie=UTF8&hl=en&msa=0&msid=210125535873030939362.00049ca7c4862dacfda75&ll=-0.734862,35.363402&spn=0.022743,0.038495&t=p&z=15
I did take some pictures around the guesthouse and hospital compound. I'll try to take actual hospital pictures later. It was a very relaxing post-call day, sitting on the porch, drinking juice and visiting with the other short term doctors and eating lunch with some of the long term missionaries. It's been great getting to know everyone and making new friends.
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| Guesthouse where short term visitors stay. I didn't know to bring a Duke Blue Devils flag, so I'll have to pass the suggestion along to Walker. |
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| view from guesthouse |
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| back of guesthouse with rain collection barrel for water, gardens, and clothes line |
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| beautiful plants around guesthouse |
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| poinsettia bush? or tree? |
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| banana tree- smaller bananas that taste a little different, maybe sweeter? |
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| area around Tenwek |
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| Tenwek falls (natural) and dam built by missions groups, hospital staff, and Kenyan government in 1980's to supply electricity for the hospital and grounds |
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| Kenyan woman carrying not only a small baby tied to her back, but also a large pail of maize for selling at market. And walking up steep inclines near the falls. Later in the day, I saw a 3-4 year old girl with a babydoll wrapped around her front- I guess they start practicing early! |
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| cows chewing grass in the cool shade by the falls |
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| Emergency Room (casualty) entrance |
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| Entrance to Tenwek hospital grounds |
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| Entrance to Tenwek- the smaller sign warns people to slow down (pole, pole), although I don't think it's always effective. It also advises people not to 'hoot' since it is a hospital zone. |
