Cases of the Week….from Week 1!

I’m dreadfully behind on sharing my hospital experiences. This is mostly because every day is so eventful I could write a novel about it, and I barely take time to jot bullet points down in a word file before falling asleep in bed each night. So my new hope is that I can do a cases of the week post and share the weirdest/rarest/most troubling cases of the past week, or at least from Monday-Wednesday, when we do most of our clinical hours. If I’m a good girl I can get Week 1 done today, Week 2 done tomorrow, and do this week’s post on schedule!

As a reminder, most of the cases we see are in maternity or peds, where we do rounds with Dr. K (by the way, he’s the only doctor who does rounds at Kiboga, and getting them done is often like pulling teeth from the staff). He does get pulled to look at mysterious or urgent cases in the men’s and women’s wards (since there never seem to be ANY other doctors around outside of the outpatient department) so we get to see those cases too.

Most cases we see are already becoming weirdly too common—severe malaria, anemia, upper and lower respiratory infections (pneumonia, bronchitis), and dehydration or malnutrition cases in peds; severe malaria, anemia, obstructed labor and other complications, and patients waiting to deliver or be operated on in maternity. While the severity of these cases were staggering at first I’ve quickly learned they’re the norm at the hospital, so unless one of those kinds of cases has extra complications or is more compelling, I’m leaving them as the background filler that make the days long and the hospitals overflow.

Here's a couple of pretty butterflies in case things get too real :)

Week 1: Cases of the Week

   • Full Blown Tetanus: Even after studying the biochemistry and physiology of tetanus this year I never expected to see such an extreme case of tetanus, and especially not on my first day at Kiboga. The patient was a 13 year old boy who had deeply cut his foot one week before (the wound still looked horrible—the cut between two of his toes was so deep you could see through the subcutaneous tissue to fat pad and bone). He had all of the classic signs: trismus (lockjaw), risus sardonicus (grimacy facial spasms), and opisthotonous (full body rigor with the backbend into a U-shape). Spasms were triggered by any minor stimulation. It was painful to watch. Tears quietly leaked down his face the whole time we were in the room. He was given some antibiotics and transferred to Mulago for IVIG to counteract the toxin, but since his case was so advanced and had progressed so quickly, his prognosis was poor.

   • Boda Boda Accident: We have been avoiding boda bodas (the motorcycles/dirt bikes so ubiquitous here) since we arrived, and this case highlighted why. This man had been “knocked” by a boda boda while walking down the road, and had been brought to the hospital the day before in a coma. Kiboga is not well equipped for emergencies, but Dr. K had tried to piece him back together. When we saw him his coma had improved, but he still looked horrible to us. Besides the many abrasions and cuts that had been neatly stitched back together, he had multiple depressed skull fractures that had just been superficially repaired, and they were now oozing pus. I mean oozing. Dripping off the mattress onto the floor oozing. Dr. K reopened, drained, and repacked the head wound (all with minimal equipment), and Shalina almost lost her breakfast. It was bad. The man also had not been cathetered as requested so he and his bed were a mess, and as his bed was in the sun all the smells were extra pungent. Dr. K explained that a lack of nursing care would be what prevents this man from recovering—at the hospital there is only one nurse per ward (maybe two), and so most nursing responsibilities like cleaning, dressing, feeding, and checking on the patient regularly are the family’s responsibility. It works well for most patients, but when a patient comes in alone they do not receive adequate care, and so become septic and die. You can’t even transfer the patient to Mulago for surgery when he’s alone; he needs attendants to watch him in the ambulance. Dr. K was still optimistic about getting his family to come and getting him transferred to Mulago once he was conscious, but we learned today (6/27) that he died that weekend still waiting for care.

   • Sickle Cell Pregnancy: Sickle cell was another disease we studied the minutia of this year, but I’ve never seen such an advanced case. The woman, who was in labor, and on her way to obstruction, had bossing (big square forehead), very long long-bones, and widely different lengths of fingers—all consequences of her blood cells forming weird shapes. The woman had been told the day before to go to another hospital to deliver since Kiboga didn’t have any blood in her type (a common, almost daily problem) and she would likely need some on hand for her high-risk delivery. She didn’t go, and showed up in advanced labor at Kiboga instead. She labored for another day before being transferred to Hoima with another delivering woman, where there was blood and staff available.

   • Septic infections: The two saddest cases of the week (which is a hard prize to claim) were two women who had long, obstructed labors and didn’t make it to the OR in time to save their babies. We saw them on the wards during rounds, and they both had developed sepsis around their surgical wounds. The wounds looked awful—deep, raw, and so full of pus—and the only way to drain them is open back up the top layer of stitches and squeeze these poor women’s sore, cut up abdomens. It was extremely painful to watch. These women were just heartbroken, and so sick. They had really long labors, and then C-sections, and then had not been eating or drinking properly (if at all) in the days since then; all of these factors lead to increased risk of septic infections. The women slowly got better, and went home after another week or so of staying on the ward with all the excited expectant mothers and just-delivered happy moms and babies—not the most restful place for women who had lost their pregnancies.

Those were the most notable cases of week one--I tried to walk the line of being honest without being too graphic, so let me know how I did. Week 2 cases soon!