A better week

I visited Kanye today and saw the little guy with ANUG, who was looking much better! His cheek had gone down and while his mouth was still a fetid hole he is indeed better, but a long way from "good". No x-rays had yet been taken so I encouraged that idea and we'll see.

There has been an outbreak of Rift Valley Fever in all of the countries with which we have a border, not us. Which makes me wonder if we aren't looking hard enough or if the disease just isn't recognized here yet. It is one of the hemorrhagic fevers but is typically transmitted via handling of infected beef. It isn't Ebola or Marburg thankfully, but gives one pause to consider the situation over in this part of the world. Typically it behaves itself and looks like the flu. On rare occasion the disease can become quite virulent nasty and difficult. Rare meaning <1%.

The week has been full and rewarding. We had a chance to teach 4 students at Kanye (KSADH), two from Loma Linda in CA and two from Zambia. There were some unexpected cases of malnutrition that we discovered by actually looking for it. It made for some interesting conversation as I have been harping on this for quite some time to wit: if we don't ask the question we won't detect it early enough to interrupt it.

And Sunday Forrest and Shannon arrive! Should be a great week next. We are all due for one. Now if I can just stay away from the dreaded "BUFFET BEAST" and peck away at something only a bird would eat I can stay in training form. Like THAT'S gonna happen. Here's to you in gluttony.

Opisthotonus and ANUG

The week began in Lobatse where I saw a child, one of several times in the peds ward, that had been horribly attacked by HIV and Tb. She had Tb meningitis and had an opisthotonic posture; back arched in a painful ark and unable to easily breathe or eat. She was not yet on anti-AIDS medication (HAART) as, while she was born here, her mother was from SA and therefore needed documentation that her daughter was born in Botswana, and therefore eligible. Never mind that she was born at that same hospital and this was one of many admissions. She was mal/undernourished and couldn't swallow, so afflicted was her brain and musculature by the combination of these two diseases. I placed an NG tube to start feeds while we waited for documentation that she could get HAART. I know, I didn't understand it either. And in the long run it wouldn't have made a difference.

That afternoon her father showed up to see her. The same that had dropped her off at the police station so THEY could take to the hospital. We informed him of her condition and his ambivalence was deafening. I had to leave. She died that night. Shit.

Acute Necrotizing Ulcerative Gingivostomatitis, a name that sounds as ugly as the disease. Factor in HIV and it is a true bastard. I was in Kanye yesterday and a 2y/o child was presented at morning report. We usually try to attend this before we give our presentation for the week at each outlying hospital. During the report a child was presented that had "an abscess" of the right cheek and was HIV unknown. His mother however was "late" (dead) most probably due to HIV. He, the patient, had been tested for HIV and was found to be "positive" only to have it whited out in his chart, or "card" (who the hell has white out around here other than Lynne?). In its place was "negative". Right....

In any case he looked like he was one year old, malnourished, and deathly ill. He had a right cheek that was immensely swollen and he appeared toxic as could be imagined. The culprit? Looking in his mouth I recognized the cardinal signs of ANUG; erythematous and exudative gingivae, blunting of the papillae, necrotic matter on the margin of the teeth (picture a kid who has just eaten pancakes and hasn't brushed his teeth), and teeth that are carioius to a fair-thee-well. Oh, and an odor of sewage.

I have yet to find a disease that isn't made worse by HIV and this unfortunately was no exception. I gloved up and palpated his right maxillary teeth only to have one float off in my finger. God I almost lost it. My voice cracked and I found myself tearing up as a wave of dismay, empathy, revulsion, and rage washed over me. I palpated his cheek and was greeted by the "ulcerative" component of the name, and things just got worse. He had eroded into his maxillary sinus and was a tissue paper thin bone away from his brain. All of his deciduous teeth on that side were loose, eroded or gone and I could see bone under them.

I have seen much worse but, perhaps to my credit, the immensity of that situation, now years ago, has dimmed and I wasn't prepared for how much I was affected by this child. By that morning he had been tested for HIV and to no one's surprise he was indeed positive. He was on the appropriate antibiotics and needed some x-rays to investigate whether he had infection of the bones of his face (an easy call) and how long to give him IV antibiotics (months). Not a good Friday.

And today I find myself a touch the worse for wear. So how did I handle it? I went to the pool (weird how it feels to say that we have one here), warmed up and swam a 400IM. Now I'm so baked that all I need is fork to finish me. Off for a big fat nap.

Some Vignettes

Yesterday I was in Lobatse where I usually round on the pediatric ward. I feel I have something to teach and the kids are sometimes not seen for several days as the MOs are swamped. As I was seeing a particularly sick child I heard some kid-chirping from the ward next door. I turned around and saw three toddler boys, in for malnutrition and recovering well, who had all discovered their reflection in the glass that separates the two wards. Well....wasn't this just more fun than a two year old should be allowed to have! They were all giggling and laughing that infectious toddler laugh that immediately had the rest of the adults howling. Soon we were all a puddle of laughter and tears. What made in more fun is that I could see it from the "other side" of the mirror/window. The look of absolute joy that was shared between these guys was priceless.

After I rounded, I connected with my friend Roger and we worked the "casualty" (ER) together. Soon after we arrived we were alerted by a nurse that a child was "looking poorly" and could we take a look. Out into the hallway (isn't there always one in every ER, in every country?) we ventured only to find what turned out to be another in what is becoming a long line of septic kids. This one apparently had a seizure disorder and had been doing so more frequently the last three days, probably leading to aspiration pneumonia. He looked the usual for this disease; pallid, sunken eyes, temp of 35C (!), very irregular respirations, in short circling the drain.

It is always tough to get a line in these kids but after too much poking, including two IOs we (well Roger) finally got in an e.j. and I poured in fluids, gave him some antibiotics, and was reassured when his breathing became more regular. Then he fell asleep.

Today I returned to Lobatse. It is a national holiday and I really enjoy teaching/working along side of the MOs without all of the background buzz that is any hospital on a common work day. I rounded with another close friend of mine, Asumani. We first saw a horribly affected man with HIV and Tb. He had started anit-Tb (ATT) meds and had had a terrible reaction to one. The medical term for it is Toxic Epidermal Necrolysis, a term that sounds as bad as it is. Picture a man who is loosing his skin to the depth of a partial-full thickness burn all over his body including the mouth and esophagus and you get the picture. The nurses wanted to transfer to Gaborone. I assured them that the care he was receiving in Lobatse was on a par or better than in Gabs and we started to address his needs. I put in a feeding tube as he is profoundly protein calorie malnourished and simply can't eat the 3500 cal he needs per day. We changed the ointment to be applied to his skin and eyes and now hope for the best.

I went back to peds to find the child from the day before walking around and acting the willful two year old! Whew....

Another guy who was admitted with chest pain yesterday was all over the ward, with, as it turned out, nothing other than malingering. Something seen frequently surrounding a holiday.

Then a five week old with gastroenteritis and dehydration: iv-fluid-meds-ward.

I bid Lobatse farewell and went to Kanye where we had a hugely busy afternoon with a great MO there, Samuel. In came a guy with his head split open, BY HIS SON. The son had been beaten about the head and both were still yelling at each other. One of the med students asked in horror if they had been drinking to which a knowing nurse replied, "Of course they have been drinking!"

The local "beer" is a very irregular swill that is made from fermented sorghum; lumpy, and tastes like the after taste when one roops! Yes, I can say I've tried it. You can smell it from across town and on the breath (if your are brave/stupid enough).

Then off to home.

One of the true delights as I drive home from Kanye is the rural areas on the way to Gabs. I try to pick up as many hitch hikers as is prudent (the roads are full of them on a holiday weekend) and take them to their door, to their great surprise and pleasure. This of course happens only in our vehicle, not UP's ( insert insipid smiley face here). It's a fantastic way to embrace the people and culture.

I stay fortunate in all these roles; with Lynne, our kids, and here.