Cynicism=Death

So there I was minding my own business and that of the MO whom I was mentoring in a local clinic, when yet another woman (they often are women to the extent that if a man comes through the door he is met with a quizzical look) enters the exam room. In any case, in walks a woman with “a cough” as in “yet another patient, a woman, with a cough”. This cynicism is of course dangerous as something can be easily missed. So I always insist on listening to the patient's chest if the history is compelling. And, in short, it was.

I continually emphasize to the MOs when we lead discussions that “the second question out of your mouth after: “How can I help you?” should always be: “What is your HIV status?” So she was asked and she was indeed positive. The incidence of Tb with HIV here can be 60% or greater. In other words if one lives long enough with HIV one will have a positive skin test at the very least, if not active pulmonary or extra-pulmonary Tb.

So, stethoscope to chest, we noted that the breath sounds were uneven. I took her blood pressure again (figuratively rolling my eyes) and lo and behold she had a pulsus paradoxus; a bit of a long winded explanation to the non medical types that deign to read this rag. The first thing you think about here in Bots is pericardial effusion and tamponade. So off she went for a chest x-ray at PMH where she was met by ambivalent techs in a crowded waiting area, coughing all over the place and exposing other patients, I’m sure, to Tb! We have a terrible track record at PMH of segregating the Tb positive, or suspected Tb positive, people away from the rest of the patients. It truly is scandalous.

Because it was early in the day and because she had transport (the clinic ambulance) she arrived back with the x-ray in hand. We read it and saw a huge cardiac shadow, boot shaped, indicative of a monstrous pericardial effusion that was constricting her heart just as if a hand was squeezing it. No doubt from Tb! Bleep, and to think our collective cynicism nearly missed this.

So back she went to the A&E (read E.D.) at PMH for evaluation and pericardiocentesis (wherein a needle is place under the xyphoid, that little bone thingy at bottom of the sternum, aimed at the left shoulder) and a massive amount of fluid was drained from the sack surrounding her heart (we’re talking liters here). She immediately started to perfuse her body more efficiently, and we saved her! All because we listened to her chest when what we truly wanted to do was send her out with assurance that she would be fine. Jeez and whew!

We head to the Okavango this next week for some R&R. This is one of the true and unique gems of Botswana where an entire river empties onto a plain that was an ancient lake. The watershed that is created has all matter of wild life including some big crocs. It should be a memorable experience to be sure.