On Doctoring

My first few days on the adult wards have been rather interesting.

I admitted my first adult patient last night. Rebecca, 57, came in florid congestive heart failure, with generalized severe body swelling, difficulty breathing, chest pain, and palpitations; all getting worse over the last 2 months. I actually saw some orderlies wheeling in this woman on a stretcher earlier in the day, and I just thought, "I bet she's coming to our ward." And sure enough, she was my patient. This poor woman could barely breathe, even on an oxygen mask, and her face was so swollen and edematous that she couldn't open her eyes. We got her on some Lasix though, and some cardiac meds, and already this morning she's off of her oxygen and can sit up in bed without huffing and puffing.

The other thing Rebecca told me was that she's had this cough productive of bloody sputum for the past month or so, and her roommate is currently being treated for TB. Great. She told me this AFTER I was all up in her face examining her, without my N-95 mask on. Oh well. Robert says that in the 25 or so years since IU's been here, only 2 people have converted to TB positive after returning to the states. So that's good. Yet one more reason I enjoy peds so much more -- it's very difficult to catch TB from a child.

At any rate, I got Rebecca admitted. Then Priti, who was also admitting last night, asked me to help her with her patient. A 3 month old little girl with diarrhea and vomiting for some time, as well as fevers and decreased feeding. Priti told me she looked bad and I was like "ok, just one sec." I walked over to the peds side and this baby looked bad bad BAD. The first real case of 'severe' dehydration I've seen yet. Her eyes were sunken, fontanelles sunken, very dry mucous membranes, breathing fast, fast heart rate, extremely pale, with a glazed over look in her eyes. I think she was only an hour or two away from coma and death. Seriously, this baby looked terrible. Obviously the first thing she needed was fluids, and they were written for and she had an IV in place, so we couldn't figure out why she hadn't gotten any fluids. We finally found a nurse who would actually talk to us, and she said that actually the IV was not in good position, they had tried fluids, and it had just infiltrated. After expressing the need for a new IV as NOW as possible, the nurses tried for 30 minutes or so to get an IV into the baby. They had no success, which is not surprising considering how small and dehydrated she was. They asked us if we wanted to try, which I was not really jumping at the chance to do. The intern on call last night was busy with crashing babies in the new born unit, so in order to buy some time we put an NG tube in the baby and gave her some fluids that way. Though really not the most efficient way of rehydrating someone, it was a temporary fix until the intern could get to the ward and get an IV in. Today she was doing a little better, but the team is still not quite sure what's wrong with her: malaria vs sepsis vs meningitis -- so she's being treated for everything. She's also HIV positive and severely underweight, which will do her no favors in terms of getting better.

We waited around on the wards until the NG was in and the fluids running, and in the meantime we played with Diana and her new crib-mate Gideon. Gideon is not technically abandoned, but his mom is currently being treated on the psychiatric ward, so he's hanging out on Ward 4 for now. Diana stays up way to late at night (it was about 9 when we were there) and is such a stinker she doesn't let Gideon sleep either. She was obviously very tired, as she was being an absolute terror -- screaming when we played with her and screaming when we put her down -- but there's really no one to put her to bed, so how can she know when it's time for her to sleep? I eventually gave her my pen and a piece of paper, and she calmed down and started drawing, allowing Gideon to fall asleep (he was quite fussy as well) and Blessing, who's in the next crib over. We even helped out the nurses by feeding Blessing and changing all 3 babies, which I think they really appreciated.

I've come to realize over the past few weeks that the hardest thing for me when I leave will be leaving the Sally Test kids, especially the abandoned ones. It's so easy to get attached (#1 rule of pediatrics being not to get attached), but I don't really think of them as patients, as they are for the most part healthy. Every day I look forward to rounds being over, partially because rounds can be extremely painful, but mostly because I can go to Sally Test and see Diana, Kevin, Phillip, and the other babies. If on my last day in Eldoret, someone handed me any of the 3 of them (or all 3 of them) and said "take them with you" I'm pretty sure I would. Especially Diana -- she is an absolutely precious baby. Although we learned today that it is illegal to immigrate to the US if you are HIV+, which applies to HIV+ children being adopted in as well. I was appalled to learn this. I guess I'll just have to sneak in Diana. As hard as it is for me, it's really even worse for the kids, who have already been abandoned by the people who should love them most, and now their time at MTRH and later in an orphanage will see a whole slew of people who come in and out of their lives -- loving them dearly and then leaving them again. It's a hard thing for a little one to understand. It's a hard thing for ME to understand, how someone could ever leave their child.

But, I suppose I should just enjoy the time I do have with them, and hope that some way the love of strangers will be enough for them, though I somehow doubt it.

I went to the Rescue Center again today, with Priti, Hao, Rhonda (4th year med/peds resident from IU who came last week) and Jeremy (pharmacy student). Again, it was so great. Since it FINALLY stopped raining for a few hours, we got a tour of the compound, which was nice. We learned a little bit more about the Center: the funding comes from a collaboration of churches in Eldoret, and though it's not a lot of money, it does pay for some full-time staff including the nurse, as well as the dorms, the meals, and the uniforms for the school-aged kids. When the kids first come in they get 1-2 weeks of counseling and catch-up education (longer if needed) then if they show that they are going to stick around for awhile, the school-aged kids go to primary (elementary) school. While primary school is free, secondary school is not, so the older kids either have to find sponsors in Eldoret or abroad or they have to work odd jobs in order to go to school. As you might imagine, the cost is prohibitive so some, so not a lot of the street kids end up finishing school.

At any rate it was nice to learn about the facilites and the demographics of the kids that live there. There are about 150 kids at the Center at any one time, though they do tend to come and go. Quite a few of the 'older' girls (12 and up) tend to come in with their own babies, though there was only one girl there today with an infant. We talked about the logistics of HIV testing for the kids -- something that is completely necessary, as well as some other nuts and bolts things. It was a great visit. Most of the girls we saw today were quite healthy. There was one little girl about 10 who was hit in the arm with the blunt end of an axe some time ago, and now her arm is very contractured and painful. We tried to see if we could bring her to the hospital today for an XRAY, but a lot of the staff are out sick so there was no one to accompany her. They promised they would take her in tomorrow. There was also a little girl with daily headaches and blurred vision, with difficulty seeing the board in school. She really needs glasses which seems like such a simple thing. But here, nothing is really simple. She needs transportation and a chaparone to the ophthamology clinic. If/when she can get that, she needs to have the money to pay for the visit, which is only about 100 shillings, and any one of us would have paid it, but the really expensive thing is the glasses -- 3,000 shillings and up. And then she'd need yearly exams and new prescriptions, and kids tend to break expensive things anyway... so.... But, we're going to have her go to the clinic and just go from there. Certainly we can't let her go without glasses, as that's no way to live.

Jeremy got a list of the meds that are available at the Center (not very long) and he's going to look into how to get more. I think we'll try to start with the basics: anti-fungals for tinea (which ALL of the kids seem to have), de-worming medicines, some basic antibiotics, things like that. The other thing that the center could really, really use is a car, but I think that's a bigger project that will come some time down the road.

Today was a really good day, despite the continuing rain. Priti and I are currently making plans for a long weekend on the coast in Mombasa, then it's on to Masai Mara next weekend! The weekend after that, I'll be home. It's very hard to believe.