9/11/12

To day was day two back at work.  It was nice to get back at it again, after so long away.

 

My first day back I was also on call!  Which is a long way to start a day.  I rounded on a few of Lisa's patients in the morning, and then had a small rest before late morning, and again before afternoon clinic.  I was back in the under 5 year old clinic, PMI, and admitted patient after patient.  Definitely more than I sent home!  But, that is the way the system is designed.  The first stop is to gather pertinent information including weight and temperature, as nearly every medication is based on weight in kids, and so many kids with malaria have fever!  Then, two other well trained guys (I'm not sure of their title, but perhaps they are "screeners" see the patients.)  The recognize and can treatment many common complaints according to the protocol.  The ones that need admission, or the derm cases, or the complicated cases get a little note that says, "see dr."  And then they become the admission, or the baffling derm case or the next severely malnourished kid, or the nephrotic syndrome...

 

For the first time, I had a patient I walked up to the wards to try to hasten the process.  I listened to a faint heart beat in the clinic, and even fainter heartbeat over in the hospital, and the third time I listened, silence.  There was no wailing.  Tears and strain were obvious on mom's face, dad made a phone call and they picked up their child, slung him on mom's back, and they were out the door.  The child had severe anemia from malaria, and the conjunctiva were the whitest I'd yet seen.  Even with a transfusion stat, I'm not sure it would have been enough.  As it was, nothing was enough.  We were too late.

 

There were some borderline sick kids I sent to get labs before making a final determination on whether or not they needed to be admitted (mostly based on whether or not they would need a blood transfusion.)  After the lab closed, they were all sent back to clinic.  Most of those needed admission, just to get the labs drawn and the blood donation and transfusion process started.

 

While we still had probably 30 kids to see in clinic, I was sent up to the ER to handle the emergencies, since I was on call.  I admitted patient after patient after patient.  At 9:30, the coast was finally clear, and I made my way home to gather my laundry off the line, and find something to eat!  Good think I had practiced not eating for so most of the past two weeks!  (Joking, kind of…)

 

Throughout the night, about every 2 hours, I had another phone call.  One was a 60 year old with hematemesis (vomiting blood).  I questioned whether or not it was hemoptysis (spitting blood) because I only ever saw her spitting, and no blood.  After asking her to breathe deeply to listen to her lungs, the vomiting blood began, and within a few minutes she had produced about  500 ml of bright red blood.  I wrote for a hematocrit, but that wouldn't be done until morning.  There are no IV H2 or PPIs, and not even the oral meds would be available till the morning when the pharmacy opened.  I couldn't give her blood, or a PPI drip, or octreotide or vasopressin.  I could give her IV fluids, keep her NPO, and try to control her vomiting and cough with metoclopramide and phenergan.  When I checked on her this morning, she was resting, and had no further vomiting.  Part of the difficulty is knowing the diagnosis and source.  Was it a ulcer that eroded a blood vessel, a pulmonary process, cancer?  We may never know.  100% of the population here has H. pylori by the age of 5, likely by the age of 2.  It is a bacteria that protects itself from the acidity of the stomach with a clever lining, and goes about its business of eroding through the stomach wall, sometimes into blood vessels that lay beyond.  Most likely this was the source.  We treat these patients who are bleeding for H. pylori.  The treatment with four medications is too costly to treat everyone who has H. pylori present (which is everyone) and would need to be repeated frequently.

 

After that urgent call I wasn't even able to fall asleep before the next came in - a baby with pneumonia.  The baby was using every muscle possible to help get air in, and the lungs sounded horrible.  After covering the bases with antibiotics and malaria treatment, and increasing the oxygen by nasal cannula to 5 L/minute, I knew I had done what I could for the night.  The baby was working way to hard, but was holding his own.   This  morning, the oxygen requirements were down minimally, but still tremendous effort was being exerted just to breathe.  This afternoon, I went by and the oxygen was at 2.5 Liters.  I should not have taken that as a reassuring sign and should have rechecked the saturation.  The next time I came by, the bed was empty and the chart was in the pile of death certificates to sign.