Jessica’s Blog

Friday, April 23, 2010

I was on call on Friday, which is why this blog is a little late.  We rounded like usual, then when everyone else went to clinic, I stayed in the wards to check in new admissions, help with procedures, and tour the pharmacy and lab.

I did two or three I&Ds in the theater and Drew walked me through a D&C.  It seems like any tropical medicine doctor should be trained in obstetrics and gynecology, because pregnancy and it’s complications lead to so much of the morbidity and mortality here.  I also did an LP on a woman who was pregnant and was recently discharged after completing treatment for meningitis.  Her mental status has not yet returned to baseline.  The tap was clean, but she was admitted for observation overnight because the family felt more comfortable that way. 

After clinic, the procedure room was flooded with women needing ultrasounds, mostly for abnormal menstrual bleeding or concern about losing a pregnancy.  I did two and watched many others. 

Once all the patients in the theater had been seen, I walked through the wards again.  During clinic, about eight new pediatric patients had been admitted.  I checked their labs, looked at the sick kids, and adjusted medications and doses.  There were a few very sick children admitted, including a three year old boy who suddenly lost consciousness during the day.  His CSF was clear, but he was positive for malaria.  A five year old boy was the weight of a 2 year old.  His parents said he had been sick for a week, but he looked like he had been severely malnourished all of his life.  I discussed fluid resuscitation and refeeding with the nurses.   When the options for fluid rate include slow, medium, good, and fast, it is difficult to prevent flooding the patient’s lungs or inducing dehydration.   We do not check electrolytes, which in some ways makes it simpler.  In my opinion, as soon as the patient can drink, it is safest to stop the IV fluids.  There were two girls who were swollen, possibly due to kwashiorkor, but urinalysis results had not returned and renal dysfunction was also a possibility.  We don’t do BUNs or creatinines, either.  They had been started on milk feeds for protein replacement.

In the adult ward, I saw a young woman with an acute abdomen concerning for appendicitis.  A girl with sickle cell came in with severe abdominal pain, likely a sickle cell crisis, but I could not rule out a typhoid perforation versus other cause of an acute abdomen.  There were snake bite patients who needed their bleeding time results checked, and young and old women with abnormal vaginal bleeding. 

It grew dark outside and Terry drove the truck back up to the hospital to pick me up since I didn’t have my flash light with me.  I put him to work on some of the adults, then we headed back to the houses.  We stopped by Dr. Dickens’ house to tell him about the appendicitis and sickle cell patients, and he said he would head up after a bit.  Susana and Zion had saved some goat burger pizza for me and we all gathered at the Wichita house to watch reruns of the Office.  I hadn’t seen it before and it was pretty stupid, but funny in a way.

Zion and Susana wanted to come back to the hospital with me for night rounds.  The only patient who needed attention was a 20 year old woman who was 32 weeks pregnant.  She had taken a local medicine today to induce labor and it was working.  She was already dilating and having frequent contractions.  We started dexamethasone to mature the baby’s lungs, and antibiotics.  The nurse midwife sat with her for the rest of the night.  I didn’t get any more calls until the next morning.

At 5am, Jill woke me up because I had not heard the knock on the door.  The nurses wanted me to come to the hospital to see the woman who was in labor.  She had been uncooperative all night, was on the floor crawling around, and was refusing to have cervix checks.  The nurse midwife seemed frazzled and wanted me to call someone to do a C-section and get it over with.  I talked with John, who decided to wait so that she could complete the steroid doses prior to delivering the premature baby.  I was pleased since it would be better for the baby to have as much time as possible provided it continued to have good heart tones.

Dr. Dickens went during the night to do the appendectomy.  The woman’s appendix had ruptured and she had an abscess that was drained.   She will hopefully do very well.