Ryan

I realize that a great deal has changed over the last three years, especially in the realm of the internet, electronic media, social networking, and online privacy. With that being said, I found that most meaningful and memorable experiences from Kenya v.1 almost all revolved around people, with many of those people being my patients and their families. I would like to continue to try to communicate those experiences, both to help my Faithful Readers understand a little better what my life and work are like here in Kenya, and also to help myself process the disease & suffering that surrounds us here on a daily basis. While HIPPAA (or a similar concept) does not exist in Kenya, I still believe that the children I take care of (& their families) are entitled to their privacy, and for the sake of full disclosure I must mention that I have not explicitly asked their permission to tell their stories on the internet. For that reason, I will not use the real first names of the patients I talk about, nor will I try to include any specific identifying information about them. It's an area of struggle for me, as clearly I could not keep any sort of blog about my patients while working at home, and I don't think that the children here deserve less than we think standard in the US. Thoughts & comments on the above issue much appreciated.

Monday was my first day of rounding on the wards, and as I'm a resident now, I will be spending the entire 8 weeks working with kids only. No adults this time. This makes me very happy. The first day was, pretty much like most first days on the job. It was hectic, chaotic, and I spent most of the day feeling like I didn't know what was going on. My firm (team) had admitted the night before, so there were many new patients for the consultant (staff pediatrician) & registrar (upper level resident) to learn about. For any of you who know about how thorough Kenyan med students' presentations are, you might imagine that rounds took a long time. We rounded on about 15 patients yesterday, most of them two-to-a-bed (or really 4, if you count their mommas), a pretty decent mixture of "bread-and-butter" Kenyan peds: malnutrition, dehydration, vomiting & diarrhea, malaria, pneumonia, and one very sick little boy with a great family who probably has leukemia (more on him in a later post).

Today was actually significantly better. The students had an exam all morning, the consultant didn't come to rounds (unfortunately a common occurrence), and our registrar had a meeting, so it was just the Kenyan intern & me rounding on our patients. It was enjoyable in that I really like the intern on our team, he is thorough & thoughtful, very hard working and does what is best for our patients. It was also a little intimidating, in that the intern asked my opinion on most of his decisions and psuedo-staffed most of the patients with me. While this is not an unusual occurrence in the US (for an intern to get help from an upper level resident), it is a bit unsettling here in that the intern knows far more about the disease processes, available treatments, and how to get things done at MTRH than I do. At any rate, we made it through rounds relatively quickly, I examined all of our kids and got a much better handle on what is going on with them.

Shortly after we were done rounding, the IU resident on the other firm (team), who is admitting patients today, asked me to review a head CT with her. The little boy was a new admission, just rolled onto the wards from casualty (the ER), head CT in tow. We looked at the scan and both had what can best be described as an "oh poo" moment. Per the very brief casualty history (parents spoke Swahili only, so we couldn't ask any more questions initially), Ryan is a 7 y/o boy who parents brought in for a 3 day history of headache, nausea, vomiting, and abdominal pain. They became concerned when he stopped using the right side of his body today (which also happens to be his birthday. Completely unfair). The CT scan from casualty showed a very large mass in the left front side of his brain, most likely an abscess. The most worrisome thing about him was that he was not very responsive during our exam, and his pupils were unequal, with the left pupil being dilated and minimally reactive (non medical people: this is bad!). Our main concern initially was that the abscess was causing an increase in the pressure of his brain, which if left untreated can lead to death. The third worrisome thing was that he was bradycardic (low heart rate) and hypertensive (high blood pressure), which can also be a sign of increased pressure in the brain. Of course we were the only 2 physicians (Kenyan or otherwise) to be found. We decided to give decadron right away, a medicine used to decrease pressure in the brain from a variety of causes. We also wrote for three different antibiotics, after considering what were the most likely causes of his abscess. In the meantime, we were able to get in contact with the intern for the team, who was coming back to the hospital.

This all sounds horrible, but I was really amazed at how quickly everything happened. As soon as we ordered the decadron, we took the order sheet to the pharmacy, who immediately gave us both that and the antibiotics, found his Sister (nurse), who was GREAT and extremely helpful, who gave the decadron right away and the antbiotics quickly after. By the time the intern came back, Ryan had already received his decadron. The intern quickly reviewed the films & examined the patient, then went to call neurosurgery right away. Within 45 minutes of calling them, the neurosurgeon was at the bedside reviewing the film and giving recommendations. From the time we initially looked at the CT scan to the time the neurosurgeon arrived was all within 90 minutes or so, which is really pretty good even by American standards. Initially the plan was for Ryan to get some blood and then go to the Theater (Operating Room) to have his abscess drained immediately after. We went back to check on him this afternoon, and it seems that his procedure won't be until tomorrow morning, but he already looked much better. His vital signs had improved, and he was much more responsive than before. He will stay on the decadron overnight. I hope he will do well.

What really struck me about this case was that it shows how much we underestimate what "resource poor" settings can do sometimes. Though the system for getting things accomplished is very different here (and can often be EXTREMELY frustrating to the Westerners), there really is a great deal available here to help even very sick patients. The other thing I was struck by was the attitude of my Kenyan counterparts. The Kenyan medical students and interns especially are very overworked & largely underappreciated, but in the end we all (Americans, pharmacists, nurse, intern, surgeon) were doing what we knew how to help this particular patient. I realize that it often doesn't come together in such a team effort (in Kenya or America), but today it did, and I hope that it means something good for Ryan & his parents.

It's been a busy first two days, but I am truly enjoying caring for my patients, which is a feeling that can be few & far between during residency. I am grateful.