December 9th, 2017 by georginagreen

(They have cats here, too. This one was on the roof. Saw him through the window as I was writing a patient note.)

*A ten-year-old boy recently admitted, has a three month history of fatigue, fevers, and increasing shortness of breath. He is stable in the ICU on oxygen. A chest x-ray shows a large effusion on the right side. An echocardiogram shows a VSD (ventricular septal defect, a hole between the bottom chambers of his heart) with “vegetations,” infection in his heart, infective endocarditis. His hemoglobin was very low. His kidneys are showing signs of stress. And he seems scared. We have him on antibiotics and have been talking to surgery about possibly trying again to drain the fluid in his lung. There’s also a cardiothoracic surgical team visiting here in three weeks who may be able to help. Antibiotics, oxygen, labs, watching carefully for now.

In the US, as a family medicine resident, especially if I had been rotating on a pediatric ward, we would have consulted pulmonology, infectious disease, cardiothoracic surgery and possibly nephrology. Here we usually discuss management options with colleagues at the hospital. And there are daily Phone-a-friends to the US. But ultimately it’s our patient. It’s so very different here.

*A five-year-old boy has been sickly for several years, is sweating, underweight, has increased work of breathing. Has nodules on his back and a new one on his chest. He has pulmonary TB which is now in his bones. We’re trying to pull the records together, get him stable so that he can follow up with his pulmonologist in Nairobi. It’s not clear why he doesn’t seem to be getting well with current treatment.

*Another girl on her way here by ambulance from another hospital, is four hours away. Pulmonary TB, on treatment, continuing to decline, may need to be intubated. I will go to Casualty (ER) for the little girl with TB and anyone else who comes in.

*In the nursery/NICU, the babies are well today. Another baby is off the vent, and I (we, but I…I’m mentally checking off all of these firsts, so I…and PS I think I’m more brave here, so I) extubated her this morning, put her on bubble CPAP. I just checked on her, and she is doing well. We don’t have a chest x-ray (baby gram), because the portable x-ray isn’t working, hasn’t worked for the past few days. It would be nice to see what her lungs look like. The 25 weeker is still on the vent, also stable. And I had time to cuddle a baby who was upset after getting an IV placed.

*On the OB floor: Tonight several women are in labor. I asked the midwives to call me when people are in labor so that I can get more experience. A woman’s water broke at home this morning, and shortly thereafter the umbilical cord came out, and a foot, and the cord stopped pulsing. She has lost her baby, and I will get to do a breech delivery. The male midwives on call tonight will teach me. Through the curtains next to her, she will hear other mothers delivering their live babies, hear their loud heartbeats on the monitors while she waits until her ordeal is over. There are no epidurals here. But this woman, she received pain meds.

*Almost 10pm. The little girl has not yet arrived at the ER. The breech delivery was done by a midwife, a different one after change of shift. I think he was a bit less enthusiastic about teaching. Nice, though. The baby appeared to have died some time ago. The mum had tremendous pain, is resting now. Before that baby was born, another full term IUFD (intrauterine fetal demise) arrived. That mum had no idea. Was there for a labor check. So the first mum delivered without having to hear the joy of another mum, but possibly, if she was listening, she heard the similarly tragic situation of another mum.

In the nursery, I cuddled a few babies who were crying before feeding time. Because I can. And I talked to the mum of the baby who was extubated this morning. She hadn’t realized her baby was breathing on her own and stable, said she was beginning to give up hope. The tubes and machines can be confusing, so we talked through what each reading meant, what CPAP was doing. She gave her daughter a middle name in Swahili which is apparently a really good name. It means something like “many people coming together to help the child be born” (?). That mama is reassured tonight. I hope the baby continues to improve.

Again, I must learn Swahili. It is isolating to not speak the language. Rounds are in English. Notes on the computer are in English. Life is in Swahili.