Working hard...

So, I know I haven’t written much over the past week. Things have just been that busy. On Easter Sunday, I went to a sunrise service then worked in the hospital so that I could get oriented before I was on-call. Oh yeah, I may not have mentioned it, but here I’m acting as the attending. I have a group of interns who see the patients on call and page me with admissions or questions. So I learned something about the patients that Sunday and then tried to prepare myself for my call night the next night.
The things I’ve seen here are so interesting. Oddly enough a lot of meningitis. I’m not sure why outside poorer hygiene conditions or patients wait so long to seek medical help simple infections get out of control. A lot of the Kipsigis (local people of this area) believe in “herbal medicine”. I was curious about this because some of this medicine seems to cause acute liver damage and really messes with all blood cell lines. So in the past the herbal remedies were passed down in the families and were actually often helpful, or at least not harmful. Over the years as Kenya has moved toward “modernization”, the recipes have been lost and people now get their herbal medicine from, I can’t describe them, I guess the closest would be a bush pharmacist, but that’s not right either. The problem is the newer remedies aren’t tried and true and who knows what’s in them! Either way, the remedies delay other medical treatment and often worsen the course due to these nasty side effects.
On my first call day/night, things went fairly well. The night before my fellow pediatric resident, Susan, admitted a baby who had been born at home, umbilical cord cut with a kitchen knife (hello tetanus…) and had progressive difficulty breathing, so they had come here. As best we can tell, the child had cyanotic heart disease, most likely due to a congenital heart lesion, as we couldn’t get the pulse oximetry (yes we have that here) about 83% on any amount of oxygen. We ordered a chest x-ray, but that didn’t happen, and it wouldn’t have really changed our course of treatment. We would have done an echo, but the one and only machine is broken. The baby continued to grunt (sign of difficulty breathing) and be hypoxic (low oxygen) all day long. That night I was called to the nursery because she had stopped breathing. We attempted to resuscitate the baby, but there was no hope, she never began breathing again. Overall it was sad, but not overwhelmingly so because I know even if I had saved her then, if she had a serious heart defect we couldn’t fix it surgically here and the family wouldn’t be able to afford such a surgery in Nairobi. In a way I could say it was for the best and now she’s in a better place, but at the same time in the US this child would never have died. We would have had a diagnosis and medicines or surgeons who could have saved her.
Since then I haven’t lost any other children, not that none have died, but not while I’ve been on call or called to. I’ve seen all sorts of things, lots of typhoid, malaria, and rheumatic heart disease. The heart disease is interesting because in the US, we’d never see it due to ready use of antibiotics. There are young teenagers or sometimes even younger children with congestive heart disease/failure due to rheumatic heart disease—so I’m managing something in the US only cardiologists would handle.
I had another interesting and sad patient. He presented with classic symptoms of meningitis before I came and was being treated appropriately with antibiotics. When he didn’t respond, we switched him to some antibiotics we don’t readily use in the US, but have decent coverage. When he continued to not respond Susan and I started reading of other causes of meningoencephalitis as his condition had deteriorated. She ended up reading about some of the viral causes and for whatever reason I read on TB meningitis. Now TB is present here in a higher incidence than in the states, but it’s still not hugely prevalent. And this child had no known exposure and although the symptoms and progression fit, it seemed unlikely. Then the day after I read this and while we were rounding, the nurse came up to me and says that two family members are being treated for TB! We had asked previously and the dad had said no. Unfortunately despite started the right TB drugs, he has not improved and I’m not sure if he will. From what I can tell the prognosis is poor based on his symptoms at the time of treatment.
It’s not all doom and gloom though, we send patients home often and in better shape than when they came in. Although sometimes you discharge a patient and they’re here for a while afterward because they can’t leave until they pay their bill. It’s an odd system, but it’s the only way Tenwek can continue to do the work it does. There are funds available to help, but they still need to pay part of it themselves. There are other hospitals who require payment on admission for the presumed diagnosis otherwise you can’t receive treatment. There is some insurance here in Kenya, but it is very rare for our patients to have it. I’m not sure if more Kenyan’s have it in Nairobi or note.
Well, I should head to rounds now, but I promise I will try to be better about writing. Next edition…Safari!