Last 24 hour updates

I just checked into my flight home, meaning I have less than 24 hours left here. Can't believe how time flew! And sadly, there has been an influx of people over the past 2 weeks so now there are a lot of new friends I've made that I have to leave :? At least one lives in Providence though and another will still be in Kenya when I'm back here in the fall!

Anyways, I haven't written much about my time on pediatrics. Basically it is crazy busy but also rounds have been a bit disorganized or at least difficult to integrate myself into. But we have seen some interesting patients. One in particular is a mystery...a 9 month old baby with massive splenomegaly (into his pelvis) and hepatomegaly, with thrombocytopenia and anemia who we can't figure out. He keeps spiking fevers and is sat'ing 60% off oxygen but his lungs sound clear. He doesn't have leukemia, and we have even starting thinking about things like leishmaniasis (too young and not really exposed here), HLH, and Gaucher. Nothing quite fits. And as I have seen a lot here, once the doctors realize someone has something that is not straight forward, they tend to lose interest and the patient gets less and less attention (sort of the opposite as in the US).

This afternoon I went in to check on the patient above and was called over by the clinical officer to see a discharged patient (has been sitting there for 2 weeks) with respiratory distress. Now, this baby is 3 months old BUT was a 29-weeker so is super vulnerable. She has been sharing a bed for the past 2 weeks with an 8 year old boy with a huge parapneumonic effusion who almost definitely has staph pneumonia. Great set up. So this tiny little baby was just put on oxygen and is in clear distress, RR of 80, nasal flaring, subcostal retractions, the whole shebang. Also happens to be jaundice. So I geet nervous because clearly he is sick and also is so so young, and there are no doctors around and the CO is asking me what we should do. So I call the attending and chat with her about him. Basically he needs some labs, a culture, and a line for fluids/antibiotics which are all things that the CO can do better than me. But I am scared to leave the poor baby because I'm not confident everything will get done for him. But I also can't actually sit around the hospital all night making sure he is still alive. I have to trust in this system, but the problem is, I really don't trust the system. So, i had to make myself leave because honestly, there wasn't anything defined that I could do to help and I didn't want to make myself crazy. but I really hope he is still alive in the morning.

Today I also went to the pediatric diabetes clinic. All the patients (260 of them) have type 1 diabetes. And the clinic was great! Dr. Apondi spent at least 30 minutes with every patient and did a ton of counseling. They also have a great system, in which someone calls the patient every week and has them read of their twice daily sugar readings. Then Apondi looks over the sheet later and makes dose adjustments which are called back to the patient. it's really neat. The issue is, almost everyone is so poorly controlled despite this great system. So some of the reasons I pieced together from today are: 1) the very high carbohydrate diet in Kenya, 2) the difficulty in keeping insulin cool with refrigeration (they have neat clay pots that supposedly work well but I didn't get to see), 3) the out od date insulin regimens -- almost everyone is on NPH/regular 70/30 ("Mixtard"), with a few on NPH/humalog (and whom happened to be even less controlled), 4) the lack of flexibility given to patients regarding changing their own insulin dose based on meals. Also, I saw Dr. Apondi explain to a couple patients about food groups and apparently this is how they break it down here: carbs, proteins, vitamins, and sugars. There is no fat group, vitamins means fruits and vegetables, and protein includes milk and sometimes chai. So basically, they are told to eat a lot of vitamins and proteins but this also means a LOT of milk and fruits which are high in sugar. And never was it explained about trying to eat carbs with fats to slow digestion, in fact, the doctor recommended eating dry bread for breakfast rather than bread with butter or "Blue Band." So I thought this could use some work.

At the end of clinic we got into a discussion about being a doctor with a patient's dad and he was surprised when Dr. Apondi said that all it takes to be a doctor is discipline and hard work. She said it takes no skill and no talent and the father was a bit dissapointed and was like, But doesn't it require a lot of caring about people and wanting to help people. And Dr. Apondi was like, No, it really doesn't. She thought that you start to care about people as a result of becoming a doctor but that caring is not a reason people become doctors. I had to disagree. lol.

Oh yea, yesterday I went to hematology clinic. It was billed to me as sickle cell clinic and it mostly was kids with sickle cell, but we also saw a woman who we diagnosed with pancreatic cancer, a 21 year old girl on treatment for colon cancer, a women with a cystic adenoid carcinoma of her cheek that was eroding through her cheek, and a boy with craniopharyngioma in which the medical officer injected bleomycin into a port in his scalp right in his office. We also saw so many patients over the course of 7 hours (there is no break for lunch here). Seeing the sickle cell patients was great! They have hydroxyurea available here now for free (except that the pharmacy has been out for a couple months) and they have a great system for starting it and following them up. Clinic began strangely though because there were 10 Kenyan med students there who were supposed to see a patient first, present them to the attending in the patient's room with the patient/family member and all 10 med students there. Then the attending just talked to the med students and taught while totally ignoring the patient. One of the patient's father actually spoke up and was like, "Okay all you have been doing is talking to your med students but you have explained nothing to me. Tell me what these labs are in lay person's words." It was a fantastic moment. But then that attending left and the med students drifted away and it was just the medical officer and me and it got much more like a clinic a home. Except that each patient got about 5 minutes and not much counseling. But that's a systems issue and has nothing to do with the medical officer himself, who was great.

So yea, peds is fun :)

Day trip to the heart of the Rift Valley

More peds

Today is a Saturday, meaning none of the med students or residents were there so I came and helped my CO (clinical officer, like a PA in the states) with her rounds. We have at least 25 patients so despite our efficiency it took a while. It was a bit disconcerting how much she left up to me -- I did all the physical exams while she took the histories -- and then she asked me a lot of management questions. That being said if I wasn't there this would all be up to her and CO's don't have that much training. Regardless, it is scary knowing that no one else will be doing exams on these patients today, unless they become obviously sick and the intern for the entire ward gets called over. We have one patient who is very complicated and very sick. He is 1 year old but only weighs about 5kg or something like that and he originally came in with anemia and possible meningitis. He later developed severe dehydration and overnight got fluids to rehydrate him and he went into congestive heart failure. Turns out he has pulmonary hypertension (again, like everyone here -- although his is in unique given his age). Anyways, this was a week ago and he has been on Lasix since, however today, both the CO and I thought he tooked very dehydrated again. But we didn't want to put him in heart failure given his heart problems plus his baseline malnutrition. I ended up calling the attending because this was definitely something I felt uncomfortable making a decision about and feeling responsible for. I think that is one thing that makes working here sometimes tricky -- I can often have a lot of responsibility in terms of doing procedures and making management decisions, but I also don't have responsibility in terms of the fact that I'm visiting and a student -- if anything goes wrong it won't be on me. So it's definitely been a lesson in learning the limits of what I feel comfortable with and honestly, I think I have done really well with this. I don't think I have gone beyond what I am capable of and should be doing in terms of patient care and I also think (or at least hope) that there is more (invisible) oversight and checks and balances than it seems.

The tiny little baby with severe malnutrition I mentioned yesterday died overnight. We don't know exactly what happened but she was so malnourished and so sick that it really could have been anything. It's so sad that she survived in that state for so long only to die in the hospital. It makes me wonder what went wrong along the way, why wasn't she brought tot he hospital sooner? She went to the HIV clinic in April and her mom also goes to that clinic. It seems obvious to me (but I'm also new to seeing severe malnutrition) that she needed to be admitted and there is no way given the state she was in yesterday that she wasn't also really sick and malnourished 2 weeks ago. But then again, what do I know about severe acute malnutrition and HIV in a 1 year old?

The nice thing about doing rounds this morning was that I got to examine every patient on our team and there were some interesting exam findings. Also, I always take my own vitals whereas many of the other doctors and students don't, and so I caught the fact that this one toddler with pneumonia had a PO2 of 75% and we got him on oxygen. That was one win. Turns out his xray was impressive too, he has one lung that is basically all whited out. The most impressive exam I saw was this 9 year old boy who has pulmonary TB and is on treatment, who came in with generalized lymphadenopathy. But this is no run of the mill enlarged lymph nodes. His cervical nodes are protruding from his neck to the point of sticking out past his chin. And his inguinal nodes are like 1 golf ball and 1 tennis ball on each side. It was one of the wildest things I've seen. He also has a rash all over his body which his dad says has been there for a year. His xray shows apical cavities -- classic for TB -- and he needs a lymph node biopsy. I'm curious to know what it is but sadly it is most like cancer.

I also saw plenty of healthy, chubby babies today, by the way. And it is great when they are chubby and happy even when I'm the one examining them because more often than not I elicit remarkable fear and crying from many of the younger kids. Presumably because I;m white. So maybe I'm not the best one to be doing all the chest exams...

Pediatrics

I just switched to peds yesterday and we were admitting. We admitted 24 patients yesterday. 24!!! That's nuts. I was there most of the day yesterday and clerked 5 patients. And we only had one patient die overnight (I mean "only" just because I'm coming from the adult ward where the death rate is so much higher) and he had obstructive jaundice. I didn't get to present any of the patients I clerked because it took 3 hours to see 4 patients this morning during rounds before I had to do my sally test talk. This is a talk we give to mothers and fathers of the children on the ward. It's informal and so much fun. I talked about stroke and people had a lot of questions which was awesome. I also mentioned sickle cell and there happened to be a woman whose 12 year old son has sickle cell and also a mother whose 9 month old was just diagnosed on this admission. Not only did they have a bunch of questions so I got to talk to them after the main talk and discuss what sickle cell disease is and everything about, but they were also able to meet and the older woman helped support and counsel the younger one. It was great to see.

A sampling of the patients that I saw today included a lot of patients with meningitis, including one that had a very impressive bulging fontanelle and very high pressure when we did the tap. I did my first LP today! All they use here is a basic needle and then reusable little glass jars. We wore sterile gloves but besides that there was no kit or anything. And it was so easy! I also saw a child with not just a stiff neck, but episodes where he would arch his back and his eyes would roll back and it was unclear if he was having seizures and/or meningitis or what was happening. Regardless he looked a lot better this morning. I also saw a lot of kids with pneumonia and with sickle cell pain crises. But the most common thing was malnutrition. The first patient I saw was a 1 year old who weighs 4.7kg, so 10 lbs. She has classic marasmus-kwashiorkor -- her face looks like an old person's face with sunken eyes, prominent zygomatic arches, a very distressing look in her eyes, and a very weak cry. She has pitting edema in both of her feet (which automatically qualifies her as having severe acute malnutrition) plus she weighs 47% of her ideal body weight. She was diagnosed with HIV in April and started HAART then. The mom is from Sudan and is separated from the father and is sick herself but before this didn't know she had HIV. She has no money and so is not able to get enough food for the baby, plus the baby has oral thrush and probably a number of infections that causes her to refuse food. The whole situation is really sad but it was also very helpful to evaluated a patient with severe malnutrition and to learn the protocol for treating it here. The thing that kills them most often and fastest is hypoglycemia, often related to hypothermia, and her random blood sugar this morning was 30. But we got her glucose quickly. Getting an IV in her  tiny little veins was a different story. She is holding steady for now though.

I also saw a lot of babies with severe dehydration due to diarrhea. It was helpful to see the classic signs of severe dehydration -- reduced skin turgor, sunken eyes, decreased capillary refill. And also good to see how good the care is in terms of nurses following the protocol for these common ailments.

All in all peds is super busy. The clinical officer asked me to come in and round with her the next 2 days because she will be alone. I wanted to take a day off finally but oh well! It's hard to complain when she was there was 7:30am until 5 today without eating lunch...

Rural health clinic

Today I went with Dr. Gardner to a rural health clinic in Mosoriot; it was maybe the best experience I've had so far here. I clinic is really nicely set up and it originally was only for HIV/AIDS patients but now is for the management of chronic disease in general. Hence, the closest thing to primary care I've seen here so far. All the patients we saw today had HIV but I got to see such a wide range of severity. I saw a man in his 30s who has been on the same first line regimen for HIV since 2003, with an undetectable viral load since around that time. He was so healthy, has never been hospitalized, and has always been compliant with his meds. On the other end of the spectrum I saw a 16 year old girl who weighed 28.5 kg (had lost 15 kg since January), giving her a BMI of around 11. She had also had fevers for 2 months and was just overall extremely sick-looking. So we gave her some IV fluids and then took her to the ED at MTRH on our way back. We saw a patient that Dr. Gardner knows well who was hospitalized for 3 months last year with TB meningitis and has been homeless for a while. She was really sick but he has worked really closely with her and she has been staying at the shelter that AMPATH helps fund that is near the Mosoriot health clinic. The photo below is of all her meds, at least 9 meds and she has to take up to 4 tabs for each of the medications. It's crazy! But at least there is someone at the shelter who helps her with all of this and she is doing so much better. I also saw a woman who was just diagnosed with HIV at the end of April after coming in for a family planning visit. She is 29 and she told her husband (of 10 years) and he refused to get tested. She said he didn't looked shocked by the news and so she seemed to imply that he might know he is positive. He is also 20 years older than her. Dr. Gardner was great and gave her an little empowerment pep talk. She seemed very well adjusted to learning she has HIV and when her CD4 came back today at 141, meaning she had to start ARVs today, she was determined to do this and was about as positive about the whole situation as one can be. She was such an inspiring woman -- if only she could get out of her relationship with her scummy husband (in my humble opinion).

Weird thing i've noticed, there are a LOT of DVTs here. 2 of the 10 or so patients we saw today at clinic we diagnosed with acute DVTs. Including the really wasted 16 year old I mentioned above. why is this?

I also learned a few things about AMPATH and HIV in Kenya, including the fact that the AMPATH clinic in Eldoret is (or at least was recently) the biggest HIV clinic in Kenya and cares for 20,000 patients! That seems like so many! Also, according to Adrian, almost everyone in this area has been tested for HIV because of the home counseling visits they did in the past. This is pretty unbelievable.

 one of the clinic rooms. the clinical officers see patients her daily, while an attending (usually Joe Mamlin) comes once a week to see the more difficult cases, read xrays, etc

so many pills!

Cardiology clinic

Today I went to the cardiology clinic -- in the brand new chronic disease building (photo below) -- and went to rounds in the CCU. This CCU is really, really nice compared to the general wards. The patients have their own beds, the nurses have a much, much smaller census, and they have a couple continuous EKG, heart rate, SpO2 monitors. There is also a pretty well established (though not always carried out) protocol for much of what goes on the in the CCU, including admission orders. For example, everyone is supposed to get an EKG upon arrival into the CCU. They have many of the drugs we have at home like dobutamine drips, norepinephrine drips, etc. The main thing they do not have is a cath lab. The other main difference is the pathophysiology you see her compared to the CCU at home. Almost everyone has rheumatic heart disease. With some really crazy pathology. There is this one boy I saw you is 17 years old and has really severe aortic and mitral regurgitation. His AR is so bad that he basically doesn't have an aortic valve -- he has no S2 on exam. His heart is so hyperdynamic that you easily see his chest heave with each beat and you can almost see the thrill from his mitral valve. It was both fascinating to see and also devastating.

The cardiology clinic was also interesting for much of the same reasons. It is very efficient compared to the wards here -- they see usually 80 patients in a morning between 4-5 providers. Patients don't have set times but instead queue up in the morning. Against most of the patients have rheumatic heart disease, while many also have hypertension and ischemic heart disease like what we see at home. I saw a couple patients with severe mitral stenosis and they had very good exams -- the classic diastolic rumble and palpable thrill. Most were my age or younger, but one was 60 or 65 which is unusual. He had a mitral valve area less than 0.5 which is very, very severe, plus very  severe pulmonary hypertension and a left atrial thrombus. It is crazy to see how well he looked given all those numbers. On the other hand, I saw a patient with dilated and ischemic cardiomyopathy and a low ejection fraction who had gone to the US last year to get an ICD placed! That blew my mind. Talk about disparity of resources around here. He was doing really well though, so good for him!

Overall, again it was great to see another outpatient clinic and to see how organized they are compared to inpatient here and also how well people are when they are outside of the hospital!

Clinic

Just wanted to mention that I finally got to attend a clinic here -- the HIV resistance clinic -- and was really impressed with how well it was run. Only a couple patients showed up (much like in the RIH clinic at home), however, there were many phone calls placed to track down the patients and make sure they either come in another time or make it to one of the outreach clinics. The AMPATH clinic even has an EMR (although everything is written in paper and then someone types it into the record) and it makes all the patients' info easily accessible which is super crucial to those patients with drug-resistant HIV and those with poor adherence. The clinic became a sort of catch all of conditions when I was there and so we treated a young man with hepatitis B and counseled him and his girlfriend on the contagious-ness of this infection. He was really mature and told her right away that he had hep B and she did a bunch of research on it and started her vaccination series and everything. It was great to see. We also had a young man with HIV since he was 11 who had struggled with the diagnosis and treatment thoughout adolescence and had become a peer counselor in the pediatrics AMPATH clinic. He still struggled with taking his meds because they made him feel weak and nauseous and effectively wasn't taking them at all until 1 month ago when he was switched to a once a day treatment and this was a major game changer. Hopefully he hasn't developed resistance to those drugs in the meantime! He was very eloquent about the problems with having to take daily meds and his friends constantly asking him why he was doing that and the fear of stigma if he told people. Now he tells those he is close to and his roommates so that it is not a barrier to him taking his meds and everyone seems to be fine with it.

Tomorrow I get to go to cardiology clinic and the day after to an HIV outreach clinic. Should be nice to see something different from the wards which is starting to tire me out with the many inefficiencies and the many deaths. I had another one overnight who was just admitted Saturday night. He had HIV and diarrhea for 3 weeks -- at first we thought it was just gastro like cryptosporidium or something, but he was also pretty hypothermic, 33 degrees celcius (like 91.5 F), and was talking very slowly and seemed confused. I am learning the hard way that HIV patients often look much better than they are and can crash very, very quickly.