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| Surgical linen drying behind the OR |
I don’t know if I’m less optimistic than my last trip, or more educated and can recognize what goes wrong more, or if I feel like I am able to do more medicine myself at home and so really feel the discrepancies while working here, but I haven’t felt like posting the day-to-day stuff at the hospital. For all the patients that do well, there are enough that die despite our best efforts that I didn’t feel like blogging about the losses. It’s been great having other UW people here to talk things through with as we go through similar struggles, but the stories that stick with me the most are not the happy ones.
Despite many
rough days, I loved the overall experience and learned a ton. I got to learn
about tropical diseases, see advanced disease states we don't often see, operate a ton, and see how a
mass casualty event is handled here (answer: not well. It was a very difficult
night that had me yearning for Harborview). I feel much more comfortable running codes now too heading into intern year--not an experience I expected or had ever led before, but one that was repeatedly thrust upon me, and its good to know I can at least attempt resuscitation with what supplies we had and teach Kenyan doctors about effective CPR, ventilation, and emergency drugs (we lost almost every patient we coded without an ICU-level care to transfer them to). I am not scared away from doing global health work, and am excited to move ahead in my career.
To get a small
taste of daily life at the hospital, here are three patients that I chose as ‘case
reports’ to write up as assignments while I was here. I found them to be both
interesting and complicated, especially in our location at a district hospital
in Kenya.
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Case 1: Medicine Wards
This was a 29
year old man admitted late one afternoon with severe shortness of breath, who
was billed as an asthma exacerbation. The UW resident and I were planning to
leave for the day, but the Kenyan intern doctor on call that night was nowhere
to be found. The patient looked sick, was breathing very fast, and was holding
himself in a weird position to try to improve his breathing—all bad signs. We
quickly determined he was NOT having an asthma attack (he had only been
diagnosed with asthma in the past month, and we think that was an incorrect
diagnosis for his shortness of breath). Fast forward a few hours and we are
still trying to diagnose this patient with the limited methods we have—a chest
x-ray, and a bedside ultrasound of his lungs and heart with the help of the
chief resident.
We soon learned that his heart was abnormally large, and his
lungs were full of fluid. It was too late in the day to get labs beyond a blood
count, the hospital was out of reagent for some of the labs we wanted, and the
labs we really wanted you have to send out for at a different lab and it would
take days to get back (at which point they would likely be useless). We had to
start treating him with the presumptive diagnosis of heart failure and volume
overload, despite not having a good reason why he was in heart failure. And
while we had oral diuretics to try to get some of his extra volume off, they
wouldn’t work quickly enough. The chief resident taught us how to do a crazy
system of sequential tourniquets to try to offload the stress on his heart, and
while he didn't seem to improve too much we got a liter of fluid off before we
left for the night.
The next morning he looked just as awful and uncomfortable,
trying to breathe with his lungs full of fluid and becoming delirious and
uncooperative. He became focused on getting food to eat, and despite our best
efforts to prevent him from eating or drinking (as he was breathing 50 times a
minute and required high flow oxygen to keep his levels anywhere near normal)
he stole food from his neighbor and aspirated it into his lungs. We decided he
would likely require intubation soon, and we are unable to put people on
ventilators here outside of the OR. He was set to be transferred to Kenyatta
National Hospital in Nairobi late in the afternoon when we finally got some
labs back and learned that he was in acute kidney failure. His kidneys had
likely shut down a while ago (his numbers were bad), causing him to retain too
much fluid, which led to his heart working too hard, leading to fluid backing
up into his lungs… We were now worried about his electrolyte levels (which can
go wacky in kidney failure), and we could not check them due to the lack of reagent.
We did an EKG which suggested he had high potassium levels, which can be fatal.
We gave him a short-term medication to stabilize him as he left for Kenyatta,
warning the ambulance staff about his potassium, his constant attempts to
remove his oxygen, and his inability to lie flat. We learned later that night
that he died during transit of unknown causes.
This case was
very frustrating, as this guy who was my age would have been diagnosed and
started treatment within 30 minutes at a US emergency room. We were unable to
diagnose him quickly, unable to give him the treatment he deserved, and he died.
Case 2: Ob-Gyn
This next
patient was a 20 year old woman who was pregnant for the first time. She was a
healthy, young primary school teacher excited to be having a baby with her
husband. Only one problem: she had rheumatic heart disease. As a child she had
likely had a case of strep throat, but instead of being treated with
antibiotics like she would have in the states she just got better on her own.
The reason we treat (and perhaps over-treat) with antibiotics despite strep
throat being a minor illness is because of the potential complications, including
bad kidney and heart disease.
This young woman developed a leaky heart valve,
mitral valve regurgitation. While this only slightly affected her exercise
tolerance in daily life, when she became pregnant her cardiovascular system
undergoes some crazy changes. Most women can compensate for higher blood volume,
faster heart rate, and lower blood pressure, but women with cardiac disease can’t
always compensate enough. In the US women with significant heart disease like
this are discouraged from getting pregnant due to the high risk of
complications, and if they are they are monitored very, very closely by the
cardiologists and obstetricians.
This woman
came into the hospital during her second trimester after developing a severe
headache followed by severe left-sided chest pain and then losing consciousness
for over an hour. By the time we saw her on rounds the next day she looked like
a million bucks, but we didn’t have an explanation for what happened. She’d had
her heart evaluated with an echo the week before and everything looked close to
normal for her. Our hospital was out of EKG paper so we couldn’t see if this
was caused by an abnormal heart rhythm that may be causing her symptoms. She
was taking her heart medications as prescribed, and hadn’t missed any doses.
The fetus appeared to be healthy and growing normally. We couldn’t find anything
wrong!
The Ob-Gyn residents
from UW and from Nairobi elected to keep her hospitalized until the period of
greatest stress on her heart had passed, as she was right in the middle of
those weeks of pregnancy. We rounded on her daily and she and her fetus
continued to look great.
Then a week
later we were called to see her early in the morning, as she’d developed severe
chest pain and trouble breathing again overnight. We again couldn’t find a
cause, and nothing we had to offer her seemed to improve her condition. She
didn’t seem to be in acute heart failure, but she was at high risk for it. We
consulted the medicine team at our hospital to see if they had any other ideas,
but they did not feel comfortable caring for her and wanted her transferred to
Kenyatta to be taken care of by a cardiologist. We got labs and an x-ray back
before she left, but still did not have a good explanation for what was
happening, and have not heard anything since transfer.
This case was
interesting because rheumatic heart disease affects millions of children
worldwide, and probably half of these kids will grow up and want to get
pregnant, if their heart disease doesn’t limit them too much in daily life.
There are very few opportunities for heart surgery to fix the faulty valves
here in Africa, and even fewer for children to get valve replacements. I felt
like this was a case that is probably playing out in hundreds of hospitals in
developing countries, and wondering if women were getting better or worse care,
or surviving their pregnancies and post-partum period.
Case 3: Pediatrics
My first day
on peds we rounded on a 21 day old baby who had been admitted to the peds ward
with fever and abdominal distension. He was being treated for pneumonia and
neonatal sepsis. I thought this was an odd presentation for pneumonia, and
perhaps it was the surgeon in me but I wanted to know more about his belly.
With a lot of translation help, I soon learned that this little guy was only
passing stool every 3-5 days, and had not passed his first stool for over 48
hours after birth. He had been having abdominal distension for the past two
weeks, and his mom had taken him to a clinic near their house and tried various
treatments that hadn’t helped. When he developed a fever, fast breathing, and
refused to breastfeed she brought him to the hospital.
He had
initially gotten better with antibiotics for his non-existent pneumonia, but
was still distended and not passing stool. The weekend intern had ordered an
x-ray for his pneumonia, and we could see a massively dilated colon with no air
visible in his rectum. All of these red flags from his history plus this x-ray had
me thinking of congenital causes of neonatal bowel obstruction, and at the top
of my differential was Hirschsprung disease. Hirschsprung is a relatively
common disease you’ve probably never heard about, where the nerves don’t finish
migrating to the very end of your colon during development so you are left with
a segment that can contract but not relax. This causes a big blockage of stool,
and for the normal colon to dilate and get huge to accommodate the extra air
and stool. Depending on how long the segment missing nerves is patients can
present very young (most are identified in the first month of life in the US),
or if it’s only a short segment missing nerves kids may not get diagnosed until
they are older and dealing with chronic, horrible constipation.
This patient was
such a good case for Hirschsprung we got the surgeons to refer him to Kenyatta
for a biopsy and then likely surgery to remove the dysfunctional segment of
colon. I ended up presenting this case with the hour long lecture I gave this
past week, so I did a lot of research on how patients are identified and
treated here in Kenya. Unlike in the US where >90% of patients are diagnosed
as neonates, only 20-40% of cases present as infants here. Biopsy is not
available at most hospitals, and even diagnosis with history and x-rays is not
excellent (as we learned from this case). Once diagnosed, babies in the US
quickly undergo a resection of their diseased colon and have everything
re-hooked-up during the same operation, and kids do really well. In Kenya (and
most developing countries) patients usually require more stabilization as they
present once already sick with an infection (like our patient). They don’t have
as many skilled surgeons who are comfortable with the procedure, and kids will
usually end up with a colostomy bag for a few months before getting 1-2 more
operations to reconnect everything. Unfortunately there are many more
complications with this approach, and they have much higher rates of both continued
constipation and problems with incontinence if the sphincters are not carefully
preserved.
I hope the
best for our little guy in his surgeries, and it definitely reminded me how
little expertise there is for complex pediatric procedures on this continent.
It was also fun to play the pseudo-expert on the team, and to give a lecture on
causes of neonatal intestinal obstruction, how to identify these patients, how
to stabilize and refer them for surgeries, and how to recognize a surgical
emergency (bowel obstruction is the most common surgical emergency in the
neonatal period). Great learning case to end on!
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Like I said, I had a great experience but was feeling a bit worn by the end of it. I am super excited to be starting some vacation time! My friend from med school (and public health school, we expanded together) who has been doing a similar rotation in Uganda arrives today. We are having some fun around Naivasha, then go to safari in the Masai Mara next Tuesday to Thursday. Then late Thursday I fly to Paris to meet Paul! Very much looking forward to the next 2.5 weeks!
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