Alexandra’s Blog

Complicated patients galore!

This morning, Vahe, Aaron (the med students from New Zealand) and I pre-rounded and rounded on the male medical and surgical wards.

The patients are ridiculously confusing. 

Example:

33 yo male presents with spiking fevers and rigors for the past 2 days.  Hx of weight loss (17kg in the last 2 months)  No PMH. No HIV. KQ or rapid malaria test was negative. Vitals are not the greatest and he has a picture of septic shock without a focus.  We have almost ruled out everybody system (CXR clear, urine clean, blood cx negative). He is on ABX, but no target yet.

1 bed over:

+/- 50 yo male with a PMH of HIV (CD4 = 171, not on ARVs), and pulmonary TB on tx, presents with general weakness, fatigue.  In clinic, blood was sent and he was found to have a Hb of 5.6 and plt of 10. Also found to have LFT derrangments.  US of liver revealed abscess. ?amebic vs TB vs staph. Pt was placed on ABX but Hb continues to drop and this AM he is at 3.5 with plts of 5.  (Btw we still have no blood).  Malaria neg. And this AM he developed acute SOA….

next bed over:

60 yo male with TB Meningitis and confusion.  Getting better with tx. We don’t know if hes blind or just really confused.

Next bed over:

50 yo male with MDR-TB, in resp. distress with a GCS around 8. No intubation done here as there is only 1 ventilator.

Side note: We give empiric tx for Schistosoma hematobium as it is endemic here and almost everybody has it.  Also, when a patient is anemic here they are treated for worms with abendazole or mebendazole empirically as that is also endemic.

Week 3

Update! The patient I wrote about in the last post just returned to us this AM.  She was transfused and monitored at the referal hospital and improved.  I was so excited that she was doing well.

Over the weekend, India (the eingineer from Scotland staying at the Fredlund’s) and I went to Koisi Bay.  It was an amazingly pristine beach on the border of Mozambique.  It was by far the most beautfiul beach I have ever been to.  We applied sunscreen every 1 hour.  But, we stayed out for nearly 6.  By the end of the day, I was a roasty toasty critter.  The African sun is sooo hot.  There is no comparision between it and the sun back home.  Needless to say, I got the worse sun burn of my life.  When I got back to the Fredlunds, Dr. Fredlund commented that I was a brilliant shade of red.  For the rest of the weekend, India and I lotioned up and layed underneath some fans in mortal agony.

Dr. Fredlund told me that pain cleans the soul (or something to that effect) when he was pulling a thorn out of my foot on Sunday night… after this weekend my soul is feeling squeaky clean.

Yesterday, all the med students went to a circumcision camp.  We loaded up on an outdated looking bus in the extreme heat and bumped along a dirt road until we got to the camp.  We got a lot of expierence in circumcisions and were able to perform them alone with supervision.  Toward the end of the day, tribal leaders came to watch.  For some reason they decided to watch the bed the I was working at with a nurse.  The heat, lack of AC, supervision by tribal elders and my excruciating burn left me a sweaty mess.  I was dripping sweat down my legs while performing the procedure.  It turned out fine, but it was just an uncomfortable expierence.  I look forward to the bitter cold of home

PPH

Today, we were sitting in the doctor’s office waiting for teaching rounds to begin when Dr. Dowds (an Irish doc who runs the maternity ward) stuck her head in the door and said, “We have no blood and there is a woman in labor ward with a hemorrhage.”

 Apparently, there was supposed to be a shipment of blood to Mseleni for transfusion but it did not make it yesterday. Dr. Dowds had me palce calls to surrounding hospitals to find more blood, but to no avail.

 The patient’s prelabor Hb was 5.0, we didn’t have blood to give her before she delivered and presumed to be much less now. Several other doctors were assisting Dr. Dowds as the patient was moved to the OR for closer monitoring. She was given 3 L of NS with pitocin added and 1 u. of FFP and continued to bleed. Dr. Dowds filled a sterile glove with NS and placed it inside her uterus to tamanode some of the bleeding. The patient looked terrible, her pulse was in the 170s and BP was 90s/60s.  And her BP became undetectable my the monitor intermittently.  I do not think that I have ever seen anyone look so bad (not even on trauma surgery). Her lips, mucous membranes and tongue went white. The color was drained from her face.  (Note: I offered to donate my blood to her then and there (I am O+ which is a common blood type in Africa), but I was informed that walking donors are ILLEGAL in South Africa.  Blood screening is crucial here esp with the HIV epidemic. But, I was hoping to give her blood on the sly and if she got worse I am not sure if they would have let me do it or not..)

All the meanwhile, we were trying to arrange for an ambulance or helicopter or something to transport her to a hospital that was more equipped to handle this type of emergency (ie a hospital with blood!).

After waiting an hour, which felt like an eternity, the helicopter finally showed. Our patient was loaded up and flown away. I hope she made it.

Preventing HIV transmission, all in a days work

Thursday (12/9/10), I accompanied Dr. Inglis to a clinic that refers to Mseleni called Mxdoko.  We saw a lot of patient for refills of their ARVs with some changes for side effects (severe lipodystrophy with stavudine) and some kids with rashes on ARVs.  Then, we performed 6 circumscions on 15 and 16 yo males.

The purpose of adolescent and adult circumsicion is to reduce the risk of HIV transmission.  On study showed reduction by 60%!  I acted as Dr. Inglis’s assisent and sutured the first 5 after he cut, and I completed the last circumsicion by myself.  It was a quick and relatively simple procedure, I was definitely glad that I got the opportunity to learn that.

Frustrations

There is a common occurance around the hospital, when working with Western healthcare professionals, someone will often say, “Well if you were in the {insert UK, USA or New Zealand here}, we would be doing this…”

This morning I saw a patient with Stage 4 Cervical CA. The only reason that we know it is Stage 4 is because she has a pathological fracture of here pelvis bilaterally.  We do not have a CT Abdomen and Pelvis. But, she does have renal failure and hydronephrosis from obstruction. 

She is in pain.  What we have here is morphine, at most 5 mg. She cannot have a drip, she cannot get dilaudid, and her oncology appointment at the District referal hospital with a medical (not gyn) oncologist is not until Aug of next year.

This morning she had coffee ground emesis.  So, she got Omeprazole PO. Why? There is no IV PPI here!  I feel like screaming that its not fair.  Theres nothing I can do. I can only do the best I can when I see her and be grateful that I live in America.

“THIS is Africa!”

Tembe ElephantOver the weekend, the other students and I went to a game preserve.  We got a last minute sweet deal for R800 (aka 50 US dollars) for the entire weekend, including: lodging, dinner Friday, 4 meals on Saturday, and 1 meal and snack on Sunday, and 3 game drives.  So, we drove to Tembe Elephant Park on the border of Mozambique.I had no idea what to expect. The lodging and food were incredible.  They somehow managed to decrease the amount of bugs in the rooms which was a great relief to me.  The rooms were little bungalows set off in the woods with a toilet and shower inside.  I stayed with India, an eingineer from Scotland.  We ate Impala on our first night and surprisingly it was awesome.We woke up early Saturday morning (4:45) to go on an game drive.  In South Africa, the animals do not just roam freely like I had imagined.  They are in game preserves and kept realtivly safe. So, we hoped into a 4×4 bus with no windows and canvas doors to go spot the animals.There is something known as the BIG 5 around here.  That includes: lion, leopard, water buffalo, rhino, and elephant.  We saw everything but the leopard, but we did see fresh leopard prints.  We asked the tracker and he said that they only see the leopard once a year.  The elephants walked up within 10 feet of us.  It was an incredible expierence.  I got great pictures, which I will be sharing when I get back to the US and have cable internet instead of dial up. My favorite animal was definitely the warthog. He had the most personality out of all the animals.But, during one game drive a student from New Zealand made the comment, “THIS is Africa,” upon seeing a giraff standing next to a zebra standing next to a wildebeast.  I had to think, No. This is NOT Africa.  Africa is what we experienced this week.  Incredibily sick patients, nice people but some very large and complex problems.  Africa isn’t just the picturesque safari of Nat. Geo.

Zulu

So, English was not as widespread as I had anticipated.  All of the patients are Zulu and speak Zulu, naturally.  I am starting to pick up a few words and the patients get a good laugh out of my attempts.  Some of the attendings (consultants in UK code talk) here speak Zulu fluently.

A lot of the words are hard to pronounce as they include clicks and side clicks.  Here are some examples: (the spelling is totally interperative)

-Sowabona = Hello

-Yeybo = an appropriate answer to sowabona, if you do not want to continue the conversation, but it is polite. Also the word for yes

-Injonne = how are you

-Gillapilla = doing fine

-Geyabunga = Thanks

-Nx (pronounced as side click of mouth)Geyabunga = no thanks

Last week, we went to a Christmas party for the OR staff (known as the “Theatre” here).  We started off with some music and soon awkward dancing insued.  I think that the Zulu thought that they were dancing like us and we thought that we were dancing like them.  In the end, we ended up with a Macarana and some jumping, according to Dr. Fredlund nothing he saw there was traditional dance.

The food was crazy good and I am afraid that instead of losing weight on this trip, I will quickly be gaining.  No GI upset yet. Doing well.

Mseleni Hospital

The hospital sits up on the hill surronded by gates.  It is more like a compound than a traditional hospital, with housing for nurses and residents. 

HIV and TB are so prevalant that when presenting a patient you say, ” This is {nsert name here} she is a 57 yo female who is E tic (which is code for HIV pos) with a last CD4 of {insert very small number here},” before even getting to the cheif complaint. 

Patients are seriously ill here.  In one day, I saw three AIDS patients with Cryptococcal Meningitis, 4-5 with pulmonary TB, 1 with resistent TB, 1 questionable hemorrhagic fever (I didn’t stand very close), an HIV positive woman who was pregnant with breech twins, and a 18 wk pregnant HIV pos women who had poisoned herself with “rat poison” but clinically looked like organophosphate poisoning.  And technically speaking almost every pregnancy here is high risk since almost all patients are HIV positive…

Rounds are very casual which is conflicting with the severity of illness here.  Attendings and residents are extremely friendly and laid back.  I am learning a lot, but it is almost overwhelming espically because the lab values and abbreviations are in the UK style.  I still do not understand how to interpret a glucose.  Here normal is like 5.7.  I don’t even know how to convert that into anything.

 It is so exciting to see the things that we get to see here. 

First 2 days..

So, after 4 days of travel I arrived @ Mseleni Hospital.  The drive up from Durban was just about 5 hours.  I knew we were getting close when I saw the Hippo crossing signs.

I am staying with Dr. Fredlund and his wife @ their house.  3 other medical students and an engineering student are staying there as well.  Everyone else is from either the UK or New Zealand.  Actually, I am the only American in the province I think.  The Fredlunds have chickens and ducks, from which we eat eggs.  They have tons of rabbits that are fattening for eating.  There is also a fish pond with tilapia.  They do not throw away all of their trash, but intead compost it and give the scraps to the rabbits. 

The house is really nice, with large open windows and it overlooks hills all the way to the coast.  There is no airconditioning here, but you get used to that quickly.   The one thing that I am still not used to is the Jurassic park sized insects. The cockroaches and beetles here are otherworldly (pictures to follow).   But, the other students seem not to mind them anymore, so maybe I will become immune soon as well.

 The hospital is just a quick walk on the dirt path through the woods.  It is absolutely beautiful here.

Still traveling.

My flight out of St. Louis had mechanical problems, which caused me to miss my flight out of Atlanta to Johannesburg.  I stayed in Atlanta 1 night and then got the exact flight I missed, just 1 night later.  Currently, I am waiting for my flight to Durban.  It is night here, and it is Monday the 29th.  The time change in combination with the long flight made orienting myself very difficult.My first impressions of South Africa (so far) are good.  Everybody has been nice and smiles. It is already hot here, I can feel it from inside the airport. Hopefully, the rest of the night is uneventful.