Week 3: Cases of the Week

Yes, yes, I know it's now week five, but such is life in Africa. Here's the long update from week 3!

This week was a doozy. We did four full clinical days, which lasted 10-12hrs each (with an hour break to escape and eat something...anything!) and included a trip to the OR every day. It was amazing, and soo exhausting. We also had meetings crammed in here and there and everywhere for our projects, but with long hospital days and no electricity at night, we didn’t get very far on actually writing our next assignment…oops! Luckily it got finished the next week so we didn’t have to feel guilty about our clinic time!

The post is long but hopefully not as graphic as the last one, though with medical cases and surgeries there will be some details that may make some squeamish, so again feel free to skip to the next post.

***Praying Mantis: Okay, so this more of a hospital story than a medical case, but there was a praying mantis on the door to the labor suite on Wednesday! It was giant! Shalina and I were shocked and amazed! The locals thought we were bananas, as usual, and found it hilarious that Americans bother to round up bugs and put them on display at zoos (we told the staff that’s the only place we’d seen them before). Later we learned that not only do mantises roam free here, they FLY, and it can be quite distracting when a giant green bug zooms past your head as you’re trying to focus on a woman in labor.

***Surgeries: This week we saw four surgeries—a hernia repair, a circumcision, and two Caesars.

The hernia repair was on a 20yr old man who’d had an indirect scrotal hernia for over 5 years. The man had spent 400,000 Ugandan Shillings on traditional herbal methods of healing with no luck (obviously—I’m not sure how herbs could push bowel back up inside your abdominal wall…) and so finally scheduled the surgery during his school break. Shalina and I thought the hernia was pretty big to leave unattended for so long as it was 6-7” long, but Dr. K said he’s seen indirect hernias the size of basketballs—insane! The hernia was completely manually reducible—you could push all of it back up into his abdominal cavity though his external inguinal ring, but it would all just slip back out again (this is all under his skin of course) after you removed your finger. Pretty crazy. The surgery was awesome to watch since the whole anatomy of the abdominal wall, inguinal canal, and spermatic cord was integral, and Shalina and I were sweating getting ‘pimped’ with all of the questions Dr. K threw our way.

I was also really not feeling well this day, and at one point I had to bolt out of the theater, strip off my sterile layers and galoshes, find my shoes, and rush/stumble to the toilet to puke. When I was finished I chugged some water and wondered if it would be a poor medical decision to return, but I could hear Dr. K calling for me so I got back into all my layers of gear and entered the OR to find everyone staring at me silently. Dr. K calmly called me over to the patient’s side and asked me to describe and identify the different pieces of the spermatic cord he’d just un-entangled from the intestine. The surgery continued on like nothing had happened…

The circumcision on another 20-something year old man was also very interesting. Typically only Muslim men are circumcised in Uganda, and men in a few tribes in Eastern Uganda (in a crazy, painful, un-sterile, HIV-spreading ritual---yeesh), but with the advent of HIV and the studies proving efficacy more men are choosing to have elective circumcision to reduce their risk of contracting and spreading HIV. Though all the men in the room teased the patient that he was “Hadj” now (the Ugandan nickname for all Muslims, whether they’ve made the pilgrimage or not), the patient stood up to it and recovered well.

The first C-section we saw was a sad case. A woman came to the hospital early in the morning  after laboring for 48hrs under the care of a traditional birth attendant in her village. Upon examination it was discovered that the baby was lying obliquely in the abdomen, and so the forearm was being delivered first out of the cervix, wrapped and tangled in the umbilical cord (which was what was causing the obstruction). When Dr. K examined her at 9am there was no umbilical pulse; the baby had already died. He told us it was a "forearm prolapse" but when we saw her in the OR at 1pm (the quickest the OR could be prepped and the staff recruited) the entire arm was out of the woman's body, along with a foot or so of umbilical cord. It was very disturbing-looking and much more extreme than we'd expected. The surgery went well considering the murky state of things inside the uterus, and miraculously the woman recovered without developing sepsis (several women in the maternity ward did not receive their prescribed antibiotics this week, and two did develop sepsis likely because of it, but this woman at least had some small good fortune).

The second C-section we saw was one of two women who needed Caesars on Friday. Both women had arrived early in the morning after laboring for several days in their villages—the woman we operated on had been in labor since Monday! Horrible. Both women were spiking very high blood pressures (understandably—their bodies were not handling the stress of labor well after so many days) and so could not be operated on until they were lowered. Many doses of bp-lowering drugs were given before the anesthesiologist would accept either woman, and by the time our first woman’s came down and the OR was prepped her baby had died. The woman had developed a very high fever and she was heading for septicemia and a coma or death, so she was operated on first around 6pm. Her surgery did not go well; the woman bled too much and petocin, a drug to stop peri- and post-partum hemorrhage was mistakenly not given until the very end of the surgery when the bleeding could not be stopped (it should have been given as soon as the baby was delivered). Additionally the scrub nurse assisting Dr. K was sick, and she couldn’t even stand to complete the surgery. Tempers were running very high in the room.

After the surgery, even though the second obstructed labor patient was waiting, the electricity was cut, it was now completely dark, and the scrub nurse refused to do another surgery. Then the anesthesiologist left to get dinner and would only return if all of the problems were resolved. Dr. K was in a very dark mood, and after ranting about how screwed up the system at the hospital was (totally understandable) he tried to convince me to scrub in on the next surgery and assist so the woman could be delivered as soon as possible. There were a million reasons why this was a bad idea, and luckily Shalina and I had already discussed them during the previous surgery. I was torn--what if I agreed to help on the surgery but made a mistake or acted too slowly and the woman died on the table? Or worse, what if I refused to help and just let the woman and her baby die downstairs while waiting for surgery? The woman was also HIV+ and the OR was short on protective equipment; another factor to consider. Additionally the woman's family was too poor to afford a transfer to another hospital, so it was here or nowhere. I was basically ready to cave in despite all the arguments against it, but since there was no electricity, not enough sterile equipment, and no anesthesiologist Shalina and I just went home. We later learned that Dr. K spent several more hours fighting the system to get this woman her operation, and she was finally operated on by another doctor and team around midnight. She and her baby both survived, but she became a case of the week the following week, so stay tuned…

Don't fret! We're still cheerful at the hospital!

***87yr old mystery man: It’s extremely rare to see someone over the age of 60 in Uganda (the mean age of the population is 14yrs, and the life expectancy is around 50), so when we were called into the male ward to see an 87yr old we had to ask if we heard the age correctly. The man came in with his granddaughters who explained he’d been feeling poorly for a while but had staunchly refused medical care all his life. Now he was too weak to resist, though he still had some fire in his eyes even has he remained silent in protest during the whole exam. There were very cool physical exam findings, so we got to use all our new skills! There was crepitus across his right rib cage—air bubbles trapped under the skin that feel totally crazy, kind of like popping tiny bubble wrap. There was also fluid in his belly that was only present right below his rib cage (our mad percussing skills narrowed down the area). His lungs sounded funny as well, but we knew he had emphysema among other problems there. Lots more positives were found throughout the exam, as would be expected in an elderly man (it was much more exciting than doing full exams on healthy medical students!)

So the debate began: is this a lung problem or a liver problem? Pneumothorax? Liver abcess that had ruptured? Obstructed/perforated bowel? Without more certainty Dr. K didn’t want to push a needle into the man’s side to see what came out, and with no imaging options available we had to transfer him to Mulago, the national hospital in Kampala. It was so frustrating not to be able to just send this guy down for a chest and abdominal CT scan and get the answer within a few hours. The radiologist had gotten married the previous weekend so there weren’t even ultrasound or chest x-rays available. Now we’ll never know what was wrong with this man (sigh).

***Pediatrics: Though we only spent one day in peds this week there were still too many notable cases to talk about. Cerebral palsy, severe malnutrition, a possible thalidomide case in a boy born with no arms… One case in particular though stands out in my mind.

There were two adorable toddlers who seemed well recovered from their bouts of malaria and kept escaping from their moms to come play with us as we progressed around the ward doing rounds. We saw them eventually, and both were due to be discharged later that day. One of the moms came back to us half an hour or so later and said her boy was convulsing. We went to go look at him and indeed he was having small tremors all over his body. The staff didn’t seem too concerned, and Dr. K suggested an anti-seizure drug. Half an hour later Shalina and I wanted to check on him on our way out since we felt uneasy with the previous visit; the boy had come in for malaria, which can cause both high fevers and hypoglycemia, both of which cause convulsions in toddlers. We saw he was still convulsing--more severely now--and he hadn't even received the previously stat-ordered meds. So we bullied and nagged Dr. K until he spent time to re-examine him and ordered more appropriate treatment, which quickly stopped the convulsions. Though the case was minor Shalina and I both felt like the boy may never had received correct meds and wouldn’t have stopped convulsing for hours unless we’d intervened. This case made me apprehensive of how many other cases on the busy, overcrowded ward were being overlooked due to harried staff and soft-spoken young mothers…If this kid hadn’t been totally adorable and charming before I might not even have noticed his rapid decline and fought for him to receive appropriate treatment, and who knows what damage would have been done.

***Mulluscum contagiosum or Varicella?: A women in her second trimester of pregnancy was in an isolated room off the labor suite when we stopped by to visit her with no inkling of why she’d been admitted. We walked in the door and saw a women covered from head to toe in pox. Shalina and I have both had chicken pox, but we’re in the middle of nowhere in Africa, and we both took three steps backwards to flatten ourselves against the wall as soon as we saw her. Not super proud of that, but the pox looked extensive and weird. We were laughed at by the staff who assured us it was probably chicken pox. We crept a little closer to examine the woman and noticed that many of the pox were umbillicated (look like cheerios) across her abdomen, so we threw out Mulluscum contagiosum for the differential diagnosis, and asked about her HIV status. Dr. K was pretty sure it was chicken pox, despite the weird presentation, and was pretty unconcerned with any dangers to the fetus, though we were told in detail about the dangers of varicella to the fetus in microbiology class. She was treated with calamine lotion and antibiotics and while she remained the only person in her room she wasn’t in isolation and wandered out around the other pregnant women quite frequently. We haven’t seen an epidemic break out since then, but we still were uneasy with this whole pox case….

***Leprosy: We didn’t see this in the hospital, but like the mycetoma foot the week before we saw a man with very advanced lepromatous leprosy begging in Kampala. It didn’t look like he’d been receiving treatment, so we were glad we were just passing by in a mutatu (though you need a lot of contact to catch the bacteria). It was pretty crazy to see such an advanced case--it looked just like the textbooks!

You made it to the end! Giraffes say thanks!