Made it to 2800m!

The week began with yet another case of sepsis and, well, you've already heard way too much about this.

Tuesday we flew to Hukuntsi, worked in the OPD and saw some cool peds cases.

Wednesday we went on outreach to a remote clinic in the Mochudi area and, thankfully, it was slow. I had a chance to discuss the future with our boss, Harvey.

Thursday was Lobatse where I transfered a child with what had to be a brain abscess to PMH. I round on peds there as they are so understaffed. Some of the kids aren't seen for three days.

Today was outreach with one of the residents I mentor who is also an MO so I can serve two masters at once. It was great fun as it was, of course, off the beaten track.

Then today I took on a swim set written by my old (well not "old"old) lane buddy at CGMS, the marquis de swimming, Bill. Kicked my sorry arse into next week. I think I just now have a pulse under 100.

Gotta eat some apple cake, I deserve it. I think I'll eat it out of the pan with a fork, less effort.

Cheers

Scratching that creative itch..

One of the fun things about outreach is that I get to be more creative than in the US. We were unable to open the top of the antibiotic so out comes the mini-Leatherman and off goes the top. No scissors to cut the tape (there never are) so the Leatherman again. When the ambulance didn't have an IV hook (they never do as they are generally stripped of all equipment) out comes the Gerber tool. I cut off a strip of metal fence and a minute later there was the hook.

Fun and (it's not really an over statement) life saving. And a hoot!

Batting 1.000! Well make that .750 if we include Lorolwane

Three up, three still up! Let’s begin from the end.

Just so I’m clear; there is nothing as fun and rewarding in my profession as pulling a child back from the ragged edge. Today, Friday, I had a little time on my hands to explore some clinics that I might visit in the Kanye District. On the way out to Kanye I always pass a cool little town named Nthlanthle, pronounced with clicks. Kinda like your tongue is disarticulated at both ends. It has a clinic outpost staffed by a nurse. I found it and parked outside the now empty clinic and walked in, saying the Setswana greeting for “hello”, and no one was around. This is usual on a Friday afternoon as the nurse who works at these outposts generally sees patients in the morning and they thin out by 1:00pm. I showed up at 1:30 to an empty clinic and nosed around into various rooms seeing what they had to offer and how I might help them.

After the tour I walked outside to see a grandfather cradling a young child who looked big sick. Now I always emphasize to the staffs at the various places I visit that “sick kids look sick” and this child was going to the light. I thought ‘how the bleep am I going to do a resuscitation on this little guy here if I have no idea of where things are kept?’

The nurse came along (they usually live on site), I introduced myself, and we got busy. Let’s see, two day temp of 40, respiratory rate of 60 with paroxysmal movement, pulse of 130…Now I’m definitely not the brightest bulb in the box but even I know this represents sepsis.

So we weighed him and found him to be 1.2kg less than last week, presumably from the diarrhea and vomiting he had had for that time. As we were doing this he coughed a deep cough and the problem became clearer. Just from the vital signs he had pneumonia, but this cinched it. We took him back to an exam room and Diziro, the nurse, got things ready as I prayed to find a vein. This kid was precisely the wrong age and race; a chubby African, 7mos of age, dehydrated and septic, with no veins. We must have stuck him 15 times. I was thinking if an intra-osseous but thought I’d give it another shot. I said a quiet prayer (I’ll cut back on the swearing, see “bleep” above, if only I could get the Big Guy on the side of this child and his aged doc) and slipped in a line into a scalp vein as sweet as you please. In went fluid (LR, it was the only thing we had Amber, sorry) at 20cc/kg x3. At this point the child fell into a deep sleep but not without me checking his vitals every five minutes. By now my back was up and if Death wanted this child he’d have to go through me.

Next was an antibiotic (Ceftriaxone) at 100mg/kg. Then I wound this kid’s head with anything I could find to secure the IV, looked like he had a turban. He awoke about half an hour later and started to coo and chat! Man this stuff works great. The ambulance came from Kanye, about 40km from Ntlanthle. and we loaded him on to send him to Lobatse. I called my friend Roger there who got things set up at the hospital. He should make it. I was able to congratulate Diziro about the clean save and shed a little mist. Man that was three hours of intense work but what a thrill. If I had been in Sudan I would have had no time to reflect on it as it would be on to the next patient. Here it was driving home to the Gypsy Kings.

Wednesday we were in Malwane, a clinic in the Mochudi district, way out there. In other words, my kind of place. I was discussing with the MO there how taking time to treat patients with four types of pain (literally) was a waste of his time, and was at some level co-dependent, and that the “sickest patient is always in the queue” Sure enough half an hour later and many somatising and malingering patients later, in walks (barely) an HIV+ woman with a BP of 80/palp, pulse of 170, and R’s of 32. Sepsis, it hits you over the head sometimes. In went an IV, three liters of saline, some antibiotics, and she was transferred to Mochudi. The receiving doc was unimpressed with her sepsis (that because we already gave her FOUR LITERS) and treated her as a simple case of pneumonia in an HIV+ woman, like THAT is ever simple.
Never the less, it was clean save number two. This time I was able to congratulate the med student accompanying me as he rode in the back of the ambulance securing the IV’s. Sweet save!

In Tsabong (we fly there as it is WAY out there, I know--cool) on Tuesday I was rounding on the wards with Julien, a doc from DRC who was confused about an obtunded HIV+ woman with low blood pressure. “That’s because she’s septic” says I. We got busy, he started an external jugular and five liters and some antibiotics later she was back from the brink. Save numero uno.

These were all great teaching case especially because they lived (!). It DOES happen in threes just not always this good….

They say that these things occur in threes...

It's been a week. I know, I say that a lot.

On Tuesday we flew to the NW part of Bots and I went to New Xade (pronounced with a click), a San village 100 km out on a dirt road, incredible. The health care is episodic and interestingly full of HIV, but performed with great expertise by the MO who visits there once a month.

On Thursday we were in Lobatse where we work in the secondary hospital and clinics; first leading a discussion with the medical staff in the hospital then, while one of us stays and completes rounds, the other ventures out to the clinics and mentors there. Since the hospital is so understaffed due to people on leave and reassignment, we routinely take on a much bigger treating role there than in at any other facility.

During our discussion of thrombosis and HIV, an exhausted doc who was just coming off night call received a phone call and motioned to me to come with him. One of his patients was decompensating (read dying). We went to the ward and found a 45 yr old man, HIV negative which becomes important later, with massive hematemesis (vomiting up blood) and with a huge amount of blood in his stool. It turned out that he had liver failure and as a result had varicose veins of his esophagus and stomach, which were briskly bleeding. He was encephalopathic (read comatose) and we, Matt and I, got busy. Normally we try to stand back and use the opportunity to mentor but this guy was "heading for the light" and the doc coming off call had that "what should I do?" look.

Long story short, I have a tendency to concentrate with my mouth open. This has resulted in infant boys peeing into the back of my throat as I attempt to circumcise them, tasting engine oil if I can't get out of the way fast enough while I change it, etc. So there I was attempting intubation on this guy with of course an open mouth when he roops up some more blood, which unknowingly (I know, I know already) apparently splashed into the back of my mouth. I wondered why I suddenly had a salty taste in the back of my mouth and dismissed it to the meds I am taking (moth eaten brain and all...). We were unsuccessful in the attempt so, what with a prostate the size if an apple and a small bladder, I excused myself to "the toilet" as we say here. I glanced in a window for some reason on the way to the loo and there it was, some blood on my lip. At first I actually asked myself "how the hell did that happen" then it dawned on me....bleep, so THAT was the salty taste (definitely NOT the brightest bulb in the box).

I pee'd (not quickly, see reference to prostate) and hustled back to to check the guy's HIV status, which was negative within the last two days. He was close to buying the farm. And had had a recent (-)HIV test, which is not particularly reassuring as he could have acute HIV disease and not yet converted to positive. I theoretically could have been in a touch of deep doo-doo.

I called Michelle, our third new partner who is fortunately an Infectious Disease specialist, and she was very understanding if not a little bit amused. "Intubating with your mouth open, huh?" She told me what I already suspected, that my risk was infinitesimal, so I'm not on post exposure prophylaxsis as the risk of me auguring in on the drive home was much higher that the risk of HIV. Any other annoying thing I would have been exposed to was something against which I was either immunized or wherein any self respecting virus would retreat to infect another day.

I wisely, to my credit, called Lynne who got a good laugh out of it at my expense and then promptly informed the kids (cue the collective eye roll and gut laugh)for which I'm sure I will suffer mightily.

Matt and I disagreed about transfer, he for it and me against it, and we held this discussion in front of the nurses. It was a great teaching moment as they had a chance to see two docs who admire and respect each other have a conversation about which would be best; transfer or allow the guy to die in Lobatse as his prognosis was in negative numbers. He ultimately was transfered as the doc coming off call finally got to point where he just wanted to go home and rest and had had enough. We acknowledged his wishes and transferred. I then rounded on peds and had a much needed series of hugs, and laughter.

Yesterday we were out in Lorolwane, a VERY remote, and therefore way cool village I have described before. The first patient of the day was a woman in distress who was carried off a donkey cart. She had "collapsed" at home... Now I can't count the number of times I have seen this type of attention seeking behavior so my cynicism was in the red zone; heavy sigh... We examined her only to find that she had nystagmus (quick uncoordinated movement of her eyes) and since this can't be done voluntarily she was indeed in deep yogurt. She was HIV positive and our resident expert on ID, Michelle, thought it represented pneumoccocal sepsis. So there we were; 85km from the nearest paved road (I've been in tighter jams), with no ambulance(all of these outposts have one but they typically have been stripped of equipment and in any case there is no pre-hospital care as the nurse traditionally rides up front), no cell service (most these little villages have a cell tower, a good thing, but they are rarely maintained, an extremely frustrating thing. Don't get me started), no running water (sinks with pipes to them but no water, an all too common thing. See above about frustration,) an outstanding MO (Cathy), with Matt, Michelle and a dumb family doc.

We valiantly tried everything we could think of and Cathy made some tough decisions with an expertise that belies her level of training. And as the patient was loaded into the district truck that brought Cathy to the site, she breathed her last and died. It was at some level a privilege to witness that and realize her release and, again, teach Cathy about the diagnosis and dismal prognosis of sepsis. But we all felt empty.

The evening was finished with watching Matt play sax with an outstanding African jazz band (that guy amazes me) and then passing out in bed. It's rare anymore that I sleep and awake without being aware I'm in bed but it's been a week. This has been a touch longer than the average screed but it has been therapeutic to externalize it. And at some level I always finish the week feeling most fortunate and loving it.

The Big Five

Ho-ly cow, or water buffalo, or lion. The "Big Five" in two weeks. Incredible! Here are some of the pics:

http://picasaweb.google.com/pendletonmd/MoremiOkavangoDelta#

Cynicism=Death II

Another episode: A woman came into the OPD in Mochudi and complained of nausea and vomiting. We were stealing glances at each and rolling our eyes when her husband produced a jar full of what came up and it looked like wide white spaghetti, only it was segmented. Oh reeeaaaly. So we took a closer look and were surprised to see the segmented remnants of a tape worm! We put her on meds, and the pharmacy had them which was surprising and a relief.

Today I swam again. The pool is dirty, a little like swimming in a pond, but it’s all that I have. I did a 4-4-4 warm up then 4x200 on the 3:20, then 4x100 on 1:40. Slow intervals I know but the best I can hold for the moment. I might get better although it’s raining tonight and the pool, like all pools in the area, is unheated. It always takes a 50-75 to get used to the water. But tomorrow it might be impossible to swim because of the temperature.

Love the rain. Things might green up around here. The trees are in full bloom but the grasses and shrubs will stay brown until after Christmas. Very different from last year.

Best to all…

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.