April 20th, 2018 by jamiefelzer

Today was a great day! It was how I had hoped more days would be here, where I felt proud of what I had accomplished and had made a difference. The day started at 8 when Daniel (med student also rotating here) and I started our rounds. We checked in at men’s ward and found that there were 3 new admissions overnight; one was a teenager we had seen in clinic with recurrent, severe malaria (likely cerebral), another was an organophosphate poisoning and a third we were told was just a respiratory tract infection with anal sores who was stable. We went around checking on our other patients, who were a TB patient who was just now starting in improve; a bounce-back with heart failure who also had pneumonia this time, but was doing significantly better; an HIV positive young adult who was doing quite poorly and since he hadn’t responded to any other treatments and all of our tests had come back negative, we started him on anti-tuberculous drugs a few days ago for extra-pulmonary TB.

Then we went to check on the guy who we were told was just a respiratory virus, but was in fact very ill. We proceeded to ask the family a multitude of questions and found out that he was HIV positive, had been treated for TB three times in the past, had a history of being positive for syphilis but unsure if was treated. His HIV meds had also recently been changed and they knew his CD4 count was low (tells us how advanced his HIV is). He came in because a week ago he had paralysis of his right side which then progressed to his left. A rural clinic said that he likely had a stroke because he had also been found to have high blood pressure a week ago. Concomitantly he also had a minor cough and a recent history of diarrhea. His anal sores the nurse was trying to tell me he should’ve been admitted to the surgical ward for, were actually condyloma lata which is a sign of syphilis. His son told me that prior to this he had still been sexually active with his two wives, and added that he had divorced three already. So many red flags went up after hearing his story. There had been no diagnostic work-up ordered upon admission, so I immediately ordered some STAT labs and told the nurse and family he was going to need an lumbar puncture because I was concerned about meningitis vs neurosyphilis. Since he received much of his care at an outside facility, they gave us his Care Card so that we could plug it into the computer and see all of his records. On the way to the HIV clinic, we luckily ran into the head of the hospital and told him about this patient and that he needed an LP. He agreed with everything I had already ordered and said he would be by shortly for the LP.

Before seeing that patient, we stopped by the female ward to see two of the sickest patients. One of them was a lady I admitted a few days ago who has had a GCS of 3-6 on a good day (completely unconscious for the nonmedical folk) for 4 days now, and I’ve been suggesting that we do an LP on her, but the nurses and family were concerned she was took sick for this. Finally the head doctor agreed that we should just do it since she wasn’t improving despite being on medications that should’ve treated all the usual suspects. I was happy to see that the nurses had been diligently recording her turnings every 2 hours to prevent bed sores, the feedings through her NG (mostly porridge and protein shakes). Luckily, I was easily able to get a clean tap on the first try for the LP and we sent it off for studies. Since I did that one, I let Dan do the other guy so he could do his first ever LP! We then went back to round on the sick patients in women’s ward before going to outpatient clinic.

One of my first patients in clinic was a guy who had a motorcycle accident  a few weeks ago and was coming to follow up with the orthopedic doctor who was supposed to come today. However, there was no fracture and a very large effusion so they asked me if I could just tap it. So in the middle of the clinic where there were 3 providers simultaneously seeing patients, I tapped his knee and was surprised to encounter a lot of blood that was in his knee joint. I pulled out about 25ml of blood from his knee and had to ask someone to come over and help hold a container so I could keep dumping my syringe and refill it, since they only had 5cc syringes in clinic. Already today, I was busting out procedures well on my own and was hopefully making a difference in getting these people feeling better. Early in the day, one of the house mothers from the orphanage came to check in with me about her health and showed me her log of how well she had been doing exercising. I was so very proud of her!!

We worked in clinic for a while longer before breaking for a late lunch. One of the doctors calmly dealt with a lady that came in on a stretcher for severe hypotension due to an incomplete abortion. He promptly took her to surgery and stabilized her we learned as we were leaving for lunch. Ester had prepared a delicious meal for us, and had just finished serving lunch for visitors from the CDC Zambia who were here doing some work.

Everyone told us they would be back at clinic at 1430, but alas we got there and there was not a soul to be found. Without a nurse or clerk to translate for us, we sadly couldn’t see patients. I felt bad for the bunches of people all sitting in the waiting room to be seen, but without speaking the language there was no feasible way to see them, regardless of the fact that there were no Zambian doctors there. One of them later arrived and told me that, “white people in America are too punctual and that’s why blacks don’t do well there; because black people are lazier and always arrive a bit late, while whites arrive before the stated start time.” He told us this as we were all walking to theatre for an emergency laparotomy for a sigmoid volvulus.

Now, I don’t see many surgeries any more, but I think that was definitely near the top of my most impressive surgeries. Three of the docs were there, two as the surgeons and one as the anesthesiologist (spinal block and then ketamine). The guy had come in from a rural clinic for apparently 2 days of abdominal pain, but we later learned we think he was probably taking some herbal remedies for this for longer. He already had an NG tube in and foley catheter and his stomach looked like a balloon. They opened him up and then instead of nicely colored pink/red there was black. They pulled it out and the black colon that was blown up the width of my thigh (pretty big) looked like it was about to pop open. I was so very glad that yet again I had my eye shields on and a thick face mask! The dead balloon bowels just kept going and going! They eventually were able to clamp it and cut it off and oh boy, did it smell! Right about the time of removal, the patient started hemorrhaging. His vitals quickly showed this so we bloused fluids, started more IVs and gave him Ketamine at that point to actually sedate him. Luckily, a shipment of 3U of blood had been delivered (we had to transfer two patients to another hospital earlier today because we had no blood), and one was reserved for him. Things were taken control of somewhat quickly and the surgeons masterfully stopped the bleeding and sewed his bowel and abdomen back together. We all had some laughs as they were trying to figure out how the new drain bag worked, and when the patient was trying to remove his restraints and grab the surgeon from behind (he wasn’t intubated or paralyzed because they use Ketamine for general anesthesia, although I tried to encourage usage of at least an oral airway). These docs here do deserve a lot of respect, even if they do tend to show up late. They can manage almost any aspect of medicine in a snap!

All in all, this was the kind of day I hoped every day could been; full of interesting diagnostic dilemmas and actually making a big difference by seeing very sick patients that may not otherwise have been seen for quite some time and adding to the treatment decisions.  And it’s also quite exciting that this weekend I get to go on safari! Not many times can one do that during a rotation!