Today I was able to
find an interpreter from clinic to help me with rounds. I only had a few patients that I had admitted
from the outpatient clinic (age greater than 5), so rounds were not too long. I was able to send one kid home who had
recovered well, and the elderly gentleman who was carried into clinic by his
family, whose oxygen saturation was 36 % (normal 98-100%, but acceptable
greater than 92%) was sitting up in bed and chatting/answering questions! He checked some labs, and his goal for the
day was to eat and drink better, which he did!
I filled the rest of
rounds seeing some other patients, and then it was time for clinic at
10:30. I saw a few patients in the
outpatient ward - patients who had been seen the day before, but came back with
lab results today. After that Lisa had
finished an LP (lumbar puncture) and took over.
We are switching between the adult and pediatric clinics because so many
kids are admitted because they are that sick.
Lisa admitted at least 12 kids between the pediatric clinic and being on
call, so it was my turn to get my census up!
My greatest fear in
going to the pediatric clinic was only in part how sick the kids have been, but
even more so, not being able to speak French or Hausa. A nice young man was discovered(!) working in
the repair shop who speaks very good English, and Hausa (although no
French!) He was great! We helped me all day in clinic, and helped me
check on a few patients after clinic as well!
He will help me round tomorrow, as well.
So, the language
piece aside, thankfully there were not as many kids as the day before, and we
only rarely had to think that a kid may take his/her last breath as we
listened. Again, most were malaria, and
of those, most were cerebral malaria at that.
And several required blood transfusions. There were also a few kids with
the grand spectrum of malnutrition. Some
were scrawny and wasted, some were swollen in their bellies and feet from lack
of protein. One girl's black hair was a
light red color from malnutrition.
Needless to say, I admitted most of the kids I saw.
One child came in
for convulsions. The kid is what we
would say to ourselves, or at the dinner table where medical folk tend to share
their experiences, a FLK (this is a largely inappropriate term, and definitely
not diagnostic, but more of an observation - Funny Looking Kid.) This baby was 2 months old and weighed 3.3
kg. All of his sutures were prominent
and his fontanels were sunken - a sign of dehydration. His body and head were small, but the back of
his head was still elongated, like right after delivery of a kid who has been
in the birth canal for too long. His jaw
was small, his first toes bilaterally were widely spaced from the other toes, a
so-called "sandal gap" deformity, on one foot he had six toes, he had
poor tone and poor skin turgor. Unfortunately,
I didn't do a more thorough exam to test for reflexes, test for hip laxity,
look for palmar creases, etc. I did want
to admit for rehydration and malnutrition, but the family was unable to do so. I hope to see them in one week to follow
up. Given that there was another child
born who looked like this one, but died, and a second child was stillborn, we
have a high degree of suspicion for a genetic abnormality. I know there is some association between the
sandal toes and Down's, but this kid didn't have that appearance… If you have any ideas, let me know!
I was wondering how
many patients I would round on tomorrow, and then I was called in at about 9
pm. There was admission after admission,
and there were 7 or 8 admissions before we were able to go home about 11:30 or
so. Most were patients with vomiting
and/or diarrhea, and most would not have required even IV fluids if routine
monitoring could be done, and admission likely would not have been required if
the patient had presented to the clinic during the day time.
One 30 year old
woman may have cholera - profuse, watery diarrhea that can be quickly fatal due
to dehydration, and another 30 year old woman was carried in by her family, and
who had abdominal pain that I could not localize. On my differential was anything from
pregnancy to her gallbladder to her appendix.
Thankfully she had no vaginal bleeding.
In the States I would have gotten a CT of her abdomen, and here I would
have liked to get - haha, by that I mean personally perform and interpret! - an
ultrasound, but ours was locked safely in the outpatient clinic. Her breathing was fast, but her heart rate
was strong and normal. Both myself and
my supervising doctor did suspect there may be a psychiatric component, but
without even an ultrasound, that was premature.
We treated her with some Tylenol, and some antibiotics until we can get
a closer look, and maybe a surgeon's opinion in the morning. I was relieved to see that she was resting
well at 4am.
At 4 am I was called
in for another admission. It was another
kid who looked relatively well, but we will keep an eye on for the remainder of
the night. These admissions here are
impressive in their brevity. If I were
to ask about medical history, I would get a blank stare, or perhaps be pointed
in the direction of the patient's outpatient record that they carry with them. More often than not, there is none, or none
available. When I ask about medications,
I am told how many pills are taken, but without any recollection of the name. That makes the history much shorter, and
limited to why are you here, and for how long have you had those symptoms. After a quick exam, deciphering the spelling
of the patient's name from their intake sheet as well as their village, writing
a week of dates on both sides of the admission card - one side for vitals, the
other for medications, and filling out the treatment, I am finished!
In the States, most
of our patients end up with 10 problems on admission, and by the time they go
home, at least 20 problems we have acknowledged and treated! That makes the admission and the discharge
time consuming, and an average patient with all the paperwork, dictations and
orders takes 45 minutes to over an hour to admit (ICU of course, often taking
longer). Here - if the history is right,
and the exam confirms, an admission can be done in about 5-10 minutes,
including the required use of an interpreter!
I'd hope to impress
my family medicine attendings and the KIS attendings (the hospitalist group we
worked with in Wichita) with the sheer number of admissions and how proficient
and efficient I've become on only my second day, but I can't. The reality is that a lot of these patients
would be in the ICU in the States, and some may die before I round
tomorrow. I am grateful for the long
termers advice, suggestions and help in managing these very sick patients.
I haven't gotten any
more calls yet, so will try to sleep for another hour before rounds!
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