December 17th, 2019 by Daniel Russo

I am back on the inpatient ward. Elaina is rounding on the female ward and I am on the male ward. Overall I will say I prefer working on the inpatient side here in Kijabe. My team consists of Dr. Caire, Faith (the same MO intern I worked with two weeks ago), and Nancy (a CO intern). Interestingly there are fewer patients on the medical service in the male ward than the female ward. I’ve been told this is usually the case. It may be that males are less likely to seek care here.

Dr. Caire has given me near-free reign of the team. Today I rounded on the patients with the interns and made decisions regarding their care, only later discussing the patients with Dr. Caire. I am certainly getting a feel of what it is to be an attending on this service.

One of our patients on the ward has been deteriorating the last two days. Over the weekend he was talking and joking and now will only open his eyes to pain and does not retract his limbs when stimulated. He has cryptococcal meningitis but confusingly is HIV negative (tested 3x) and has no known cause to be immunocompromised. He has been on appropriate treatment but now has become less responsive and has spiked fevers overnight despite being covered with amphotericin, fluconazole, anti-TB meds, and meningitis-dose ceftriaxone. His last lumbar puncture 1 week ago had a mildly elevated pressure of 20 cm H2O, but not generally high enough that he would need serial taps. With all this in mind we obtained a CT of his head (after a delay of a couple days) which showed ventriculomegaly and was read by the radiologist as concerning for OBSTRUCTIVE hydrocephalus, meaning that something was blocking the flow of the CSF out of the 4^th ventricle. This can be a complication of meningitis as cellular debris can clog off the flow of CSF and effectively create a dam. However, this is usually seen with bacterial and TB meningitis (which we were already covering for anyway) but not usually with cryptococcal meningitis. The importance of this finding is that if true, the patient would need a shunt from the CSF to allow the pressure on the brain to decrease. That would require a neurosurgeon which would mean transfer to Nairobi or Tenewek. This patient’s family has already been struggling with financial issues and this may not be a possibility. After Dr. Caire called the NS in Tenewek and ran the case by him we all decided the best next step was to repeat the lumbar puncture. If the pressure in the spine remained low, this would almost definitely mean that the patient would need transfer and a shunt placed. However, if the pressure was now very high, this could still just be due to high CSF pressure in general from cryptococcal meningitis and all the patient may need to recover is serial LP’s over the next few days. So just before lunch my interns and I placed the patient on his left side and my intern attempted the LP, two tries, unsuccessful. She then offered to let me try. Now this is not a procedure we regularly do in the States. Either the ER doc or the interventional radiologist has done the LP for the few patient’s I have seen that need one. Earlier this week (see another blog post) I had tried unsuccessfully to do one on a patient that then ended up passing out and vomiting. But sure, let’s try again. This time on my first try I felt the soft pop as I entered the dura and as I pulled the stylet out and saw the flow (pretty brisk flow) of CSF drain I definitely felt a sense of pride. Low and behold his pressure had increased to 36 cm of H2O which is quite high. Hopefully now with serial LP’s his mental status will slowly improve and he won’t need transfer or surgery.

Immediately after the LP I had to hustle down to the education room to give my lecture to all the interns on BPH and prostate disease. It was relatively well-received and we had a good discussion about PSA testing and cancer screening. Interestingly, here they seem to jump to ordering a PSA (which is a send out lab and likely not cheap) on any male with urinary obstruction, even before thinking of checking a urinalysis, doing a DRE, or starting on tamsulosin. One of the Kenyan attendings was present at the talk and indicated that this is a management style they are hoping to change.

Last night we went to the weekly dessert night hosted by the long term missionaries. This time it was at Bob and Hope’s home. Bob is a Family Physician who works part time at the hospital on the palliative care team and part time at the local Bible college teaching a course on HIV. It was interesting to hear how the pastors are educated on HIV/AIDS and how to counsel patients and their congregations on the disease. He noted that there is still an entrenched anti-condom sentiment amongst some of the students, even amongst the protestants.

They chose to have their dessert night be themed as a “Love Feast” which is a traditional meal of coffee and sweet bread shared amongst Moravians as a sort of communion. Now no one in attendance was Moravian but Bob and Hope had lived in a Moravian-founded town in North Carolina so they wanted to share this tradition with us. While most of the attendants (from Australia, Somaliland and Nebraska) had never heard of a Love Feast, by pure coincidence I am actually from an originally Moravian town called Lititz and was familiar. Of course there was a bit of a Kenyan twist with the coffee being spiced with cinnamon, nutmeg, and cardamom. We spent the evening singing Christmas carols and they even had candles for us to hold while singing Silent Night.