Seizure On The Playground

May 22nd, 2015 by Garrett Hooker

Yesterday my 45 day old male with respiratory failure was still only able to tolerate bringing his oxygen down to 1/2 a liter, so he’s been admitted about 6 days.

 

At the start of clinic, Vance came and found me.  There was a 27 yo G1P0 at 33-36 weeks with IUGR and poor dates.  He said she was about to deliver, so I went over and sat around with her while she tried to push.  She wouldn’t really listen to any instructions and just kept trying to give these half-hearted pushes.  Vance finally ended up asking me to do a vacuum on her because she just wasn’t moving the baby down and he wanted to get started on his surgeries for the day…not really an indication for a vacuum in the states, but good enough here.

 

As penance for unnecessarily doing this vacuum, I got splattered with all kinds of goop as the baby came out.  It was all over my arms and chest and even looked like I had peed my pants.  Before somebody mentioned there were extra scrubs around, I saw a few patients and must have looked disgusting…at least it’s nice and hot here to make normally unpleasant smells especially offensive.

 

My clinic patients yesterday were as follows:

 

– 21 yo G3P2 at 37.2 wga for routine prenatal visit
– 5 month old M with reactive airway disease; O2 sat initially 82%, improved to normal with neb in the ED
– 20 d old female here for newborn check
– 32 yo G2P0 at 6 wga here for second opinion regarding need for a fertility workup due to prior SAB
– 32 yo G4P3 at 9.3 wga here for ultrasound to confirm intrauterine pregnancy
– 46 yo with cholelithiasis- sent to surgeon for removal
– 15 yo G1P0 at 25 weeks here for her first prenatal visit
– 36 yo F with missed abortion

 

Here’s another pic of one of the platos. This one was from yesterday. Ensalada, arroz, platano, pollo. This delicious feast costs about 40 lempiras, the equivalent of $2.

 

After work I went back over to the children’s center because they’re usually playing soccer or something and there’s not really anything to do at my apartment. Here’s a finished pic of that hut I mentioned from earlier on in the trip. All ready to go now!

 

You can see how they criss-cross all the leaves to improve the roof’s ability to wick off moisture. Another key feature is orienting the leaves so the concave side is facing out.

 

While I was over at the children’s center, I saw a bunch of kids standing next to this guy. I talked to the school mom about him and she said they were planning on cooking him for dinner…and she wasn’t joking. She told me these bad boys taste sort of like a cross between chicken and fish.

 

I initially picked him up by the stomach and luckily, before he had a chance to do it, one of the kids warned me these things bite if you don’t grab them by the neck. A lot of people sell these alongside the road for the purpose of eating. I think they cost around $10. I was really tempted to stay around and try some. About ten minutes after this pic was taken, I heard one of the kids yelling that the school mom was down on the ground. I ran over and realized she was having a seizure. There were a number of other people there just standing around, and one told me she did in fact have a seizure disorder. I asked if she had any injectable medicine around the house, and was told she had some Valium. I told them to run and get it, but by this time her husband showed up with the injection in his hand. He said these seizures usually only last five to ten minutes and usually stop on their own. This one seemed relatively mild to him, despite the fact that she was lying on the ground shaking all of her limbs. He said he doesn’t really like to give her the medicine because it makes her really anxious after it wears off. Back at Research if this happened, there would be no question what the course of action would be, and in fact on many occasions I have ordered an immediate dose of Ativan to abort seizures just like this….but here we just sort of sat there and watched for what felt like a few hours. Eventually, she stopped seizing and actually regained her lucidity pretty rapidly. I saw her husband today and apparently she’s back to normal…

 

After the seizure episode, a few of us took a walk down to the beach. It was getting pretty late in the day by this point, but just about the perfect time for a sunset shot.

 

Today that 46 d old male was still here trying to wean off O2.  I was finally able to get him onto room air and ended up sending him home this afternoon.  He’s supposed to come back in a week for follow up, but he and his family live clear up in the mountains so I’ll be surprised if they come back unless something seems seriously wrong.

 

I’m on call today, and received a wake up call this am just about 5 minutes before my alarm was going to go off that there was a 7 month on in the ED who had vomited a number of times since his arrival and according to mom had abdominal pain and had not been eating.  After evaluating him, I think his vomiting was just post-tussive secondary to the viral URI all the kids around here seem to have.  I gave him some Tylenol and Zofran and he went to sleep for a few hours.  I sent him home but I’m going to have him come back tomorrow just to make sure he’s not getting dehydrated.

 

Today clinic was a madhouse right from the start.  Pts were as follows:

 

– 9 day old female I delivered for a newborn check
– 1 yo M here for a follow up from last week on a viral URI, hypertonic RUE, and anemia; now nothing acute going on and URI sx completely resolved
– 5 month old M with diarrhea, tos, gripe x 3 days.  Tmax 100.7F at home.  Currently afebrile.  WBC 20K with lymphcytic predominance.  Gave him an rx for Albendazole.  I’ll have him come back tomorrow to repeat QBC, and get stool studies and sangre oculta.
– 20 month old M, previously healthy, now with dramatic weight loss.  He was previously at about the 50th percentile for his age and is now well below the 1st percentile.  Treating empirically for intestinal parasites and will arrange for close follow up with our pediatrician.
– Another 9 day old female I delivered here for a newborn check.  Mom also concerned about eye discharge.  Exam normal today, nothing to suggest gonococcal conjunctivitis given mom’s negative history, but from what I read gonococcal disease can affect up to 15% of babies of endemic populations
– 65 yo M with reducible umbilical hernia who wants it surgerized; also had GERD and viral pharyngitis
– 2 yo M named Fernando who I admitted about 2 weeks ago with a concussion.  He still has headache, so probably has post-concussive syndrome.  I’m sending him for a CT Head to rule out a bleed though, and restarted him on steroids.
– 51 yo F with GERD
– 24 yo F with LLQ abd pain mostly associated with ovulation.  Has also had some difficulty conceiving since SAB about 1.5 years ago.

 

Here’s another one of my clinic pts from today. 7 yo F with viral URI.  Also has had a weird rash for 6 years that somebody told her was due to “allergy in her blood”.  I have no idea what that means, but some of the native doctors down here come up with all kinds of crazy stuff to tell people.  It basically looked like a bunch of erythematous, scaling plaques mostly on the extensor aspects of her MCPs, PIPs, and DIPs.  She also had similar lesions on her elbows and lateral malleoli.  She had some other lesions on her palms and plantar aspects of her feet that looked like dyshidrotic eczema. I really don’t know what this is, but it’s responded to steroid cream in the past so that’s what I gave her.

 

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This guy had been bit by a “barba amarilla”, or “yellow bearded” snake, which is basically one of the most venomous pit vipers in the area and a cause for some pretty nasty bite wounds. The way he treated it was sort of a folk remedy where you pour scalding hot water to the area after applying a series of three tourniquets all the way up your arm to prevent the spread of the venom. I’m pretty sure this thing would look a little less gnarly had he not dumped a bunch of boiling water all over everything, but I guess it’s working out okay for him.

 

barba amarilla

Here’s a pic of one of these nasty SOBs I found during a google image search. Apparently they’re really territorial and aggressive, so I figured I should probably familiarize myself with what they look like. I don’t know how well you can see from the picture, but the pattern on their sides forms a letter “A”, which is one of their distinct features…along with a yellow beard.

 

Today a bunch of us went up to Peter’s house for Mary’s 21st birthday party. We had some cake and they were going to watch Pitch Perfect, but apparently there was some concern that it might be a little too racy for some of the audience members. Anyway, I wasn’t really planning on staying around for the movie since I’m on call and those radios are notoriously unreliable at distances far away from the hospital. As I was walking back down to the hospital, I saw this lurking alongside the road at the edge of the jungle abyss.

 

Turns out it was just this little guy….and luckily not a barba amarillla.