Week 4: Cases of the Week

Two hospital posts in a row--lucky you! Week 4 was very light on the clinical side, especially after week 3. We had to put in a lot of hours to finish the next step in our projects, and we left Wednesday afternoon for our safari, so we only spent two mornings in the clinic. Always great cases though!

***Bug of the week--Leaf bug!
There are always creepy crawlies about the hospital but they're usually gigantor moths and beetles, so it's exciting to see cooler bugs like the praying mantis last week and the leaf bug this week! This not-so-little guy was hanging out on one of the windows in the maternity ward, and after the furtive whispering and poking and pointing between Shalina and I Dr. K paused and asked us if we'd like to get a picture so we could move on with rounds. He knows us so well now!


***Burst Abdomen--Guts on the Outside: This case was as dramatic as it sounds. Remember the two C-sections from the Friday of the previous week, where nothing seemed to go right? Well this case was the second of those Caesars, the woman who was operated on around midnight by a different surgical team.

We rounded on her Monday morning and were pleased to see that she and her baby were alive and recovering well (her baby was very pale after the prolonged labor, so there were several jokes cracked that she had somehow given birth to a mzungu baby). She had developed a cough since the surgery, but since it was likely due to the anesthesia she was prescribed a cough syrup and we moved on.

A while later a sister (nurses=sisters here) discretely came up to us and said that the patient in Bed 6 needed help. When asked what's wrong the sister quietly said that the patient was...bleeding. When pressed for more information she just again quietly said "She is....bleeding....from her....wound," and said she should be seen by the doctor. Though confused, we went with Dr. K back to the front of the ward and had the patient uncover her abdomen. That's when we saw not blood seeping through her dressing, but a large softball-sized amount of bowel coming out of her abdomen! It was pretty shocking for all of us, since it was not what we'd been expecting. The woman was varying between staring at us and staring at her intestines, and Shalina and I could not believe that she wasn't going into shock.

The coughing would have had to rupture through at least three layers of stitches for her guts to come out, which seemed very unlikely for the mild cough the woman had. Dr. K demanded to see her chart again to see what doctor had operated on her, and immediately started calling people for an emergency surgery. Since we'd experienced "emergency surgeries" before I decided to look at my watch and decided to time how long it took to get this woman into the theater. It was 11:18am.

We finished rounds and came back to check on her before we left, around 12:30pm. No progress had been made on readying the OR, though sisters were still trying to track down theater staff while doing their other duties. The patient was trying to keep a gentle but firm hand on the sheet covering her extruded intestines, and trying really hard not to move or cough, but perfect immobility was impossible and more bowel had slipped out since we last saw her. Lots of other women in the ward were stopping by to encourage her and help her and her baby out, and hopefully that helped keep her somewhat calm.

Shalina and I left for lunch and to work on our projects around 2:30pm, and the woman was still nowhere close to getting into surgery. We had hoped to come back later for the surgery, but it wasn't until after 8:30pm --over 9 hours later--that she went into surgery, and Dr. K didn't have a moment to call us once he'd corralled everyone into the theater. Dr. K told us that by the time they started operating almost all of her large and small intestines were outside her body. Completely insane.

He did a thorough wash, sterilization, and repair, and miraculously the woman has not gotten sepsis. It's especially lucky considering her HIV+ status. Unfortunately her cough has gotten worse (don't worry! Dr. K used an extremely tough suture technique so nothing has come out again), and the sisters mistakenly cut her sutures after only 6 days instead of the 10-12 days Dr. K had ordered. Now we're waiting to see if she has tuberculosis (which is super great since she's been coughing around us for two weeks now), and Dr. K re-repaired her outside layer of stitches this past Wednesday.

We never found out if it was a medical error that cause the original 'burst abdomen', but some external sutures have blown on two other patients the same doctor has operated on... We wish Dr. K was available for every surgery!

Me and the most awesome peds nurse, Sister Grace!

***Convulsing Infant: As we were leaving the pediatric ward on Tuesday we were bombarded with several urgent cases. The first one was a day-old infant who had been fine until he was taken to the immunization clinic for his first round of shots. On the way back he started having full-body convulsions, so his mother brought him straight to us. Upon examination we saw that he was having convulsions predominantly on one side, and that they would last for a few minutes and fade away, and then another round would start. Disturbing him too much would set off rounds of convulsions, but they would also start without any stimulus at all. Additionally the baby had a large lesion the size of a quarter on the side of his scalp that was semi-crusty but would ooze fluid if it was poked or squeezed. The mother said he been born with it, and that it didn't seem to bother the baby.

Also, the boy had six digits on each hand! He had extra fingers growing out of the middle of his pinky fingers, so while we were waiting to see if the seizures progressed or abated Dr. K tied off both digits tightly with sutures and said they would fall off in less than a week. He said this was decently common in Kiboga District (which was super surprising to us!), and then asked the mother if she had been born with extra digits. She held up her hands and we saw that she had small bumps of flesh on the outside of both pinkies--the remnants of her extra digits.

During all of this the side having most of the convulsions switched! Most of the diagnoses on our differential diagnosis didn't fit, and we were left with thinking it was a reaction to the immunizations (which had been our first suspicion anyway). The other option left was that the lesion was communicating through to his brain and allowing bacteria to enter. The boy was admitted for observation, but since we didn't return to the hospital this week we never found out what happened to him.

***Two tongues: One last weird case was a six-month old infant who appeared as we were walking out the door. The mother, nurse, and Dr. K got quite excited discussing the case in Luganda, and we could tell Dr. K was teasing the mother. When he finally turned to us he said that the boy was really a snake--he had two tongues! When we pried open his tiny mouth to examine him he did indeed appear to have two tongues. But unlike a snake's split tongue this boy had two tongues on top of each other--very bizarre! The mother said the boy had no problems swallowing or breathing, so while Dr. K wrote a referral to Mulago he told the mother not to take the boy until he was five years old or so, unless he developed problems before then.

With these two cases this week, the boy born with no arms the week before, and a couple other cases we feel like we've been seeing lots of weird birth defects. Dr. K says we've seen only a few, and that there are lots lots more. When we tried to press for more details about what he thinks is causing them he didn't really have an answer for us. More unsolved mysteries in Kiboga!

Safari Palm Tree says, "GO STANFORD!"