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.

Waiting

There are so many patients on the wards who either have been discharged but can't pay, or whom are not sick enough to get much attention, that they just sit around literally for weeks. There is one elderly man with HIV who has been discharged for a least 3 weeks but has no relatives and no money so he both can't pay his bill and also has no where to go. So he just lies there day after day. Theoretically he would still be served food (I think) but he has no relatives to feed him (he is too weak to do that himself) so he is basically starving to death. He never even gets to go outside. I want to try to start feeding him Ensure so that at least he gets some nutrition. Although what is the end point with him?

The boy with chronic diarrhea and an A1c of >15% is an example of someone that is relatively well and so he has sat in the wards for at least 6 days just to get stool studies. Which the lab has lost at least once. He is probably getting worse food here than at home and thus is probably becoming even more malnourished (nevermind the risk of infection) while in the hospital. Plus he has literally shared the bed with, or at least been in the bed next to, 4 people who have died during his stay. One was his age. I just feel so bad for him; it is so pointless for him to sit there day after day but I have no idea how to help except to constantly remind people that his labs need to be followed up.

Look what happened to be in the local paper today...

...speaking of having a "renal service"

http://www.the-star.co.ke/news/dialysis-crisis-eldoret-9-machines-fail#sthash.BzJi61U3.dpbs

Death on the wards

Ok, so as I’ve mentioned, I have seen a lot of deaths on the wards. And it has been really hard to deal with, especially those patients that I have gotten to know, because it is hard to convince yourself that you have really done all you can. I know that what we have done for these patients here is severely lacking in terms of the care they would get in the states. But at the same time they are much sicker than the patients I see in the states. I want someone from home to tell me what they think the chances are of these patients living if they were at Rhode Island Hospital, for example. The question of whether we did all we could for these people is really difficult to answer because I have no idea what “all we can do” here truly is. I don’t know the upper limit. So I just feel like it is always inadequate and that is very difficult to deal with.

I also have been struck multiple times with the lack of tenderness towards the patients here on the part of the medical staff. I think part of this might come from the number of patients, stress, and chaos in the wards, but also because of the high mortality rate. It is really hard to get to know patients well and really care for them when such a high number end up dying. And those who die are not even just those who come in really sick. There are so many people who are a surprise. Who turn out to be so much sicker than they look. There have been several patients and relatives that I have tried to develop some sort of relationship with and several of those have passed and it is really disheartening. It is also so hard to say sorry and give consolation to families when there is such a language barrier.

It is also extremely frustrating when you keep seeing patients die and not knowing why they die. For example, Victor, my patient who may have died from flash pulmonary edema (that's just a guess) but whom we still don't even have an idea why he had kidney failure and needed dialysis in the first place. Or this other patient, a 14 year old girl who had aplastic anemia and whom we just realized today maybe has Fanconi Anemia (she is also very short and is deaf) and Bob and I rushed over to the wards this morning to re-evaluate her and discuss this possibility with the resident, only to find out she died last night. She complained of back pain last night but it was vague and she seemed otherwise well. If we only knew what happened to her we could at least learn from the experience. Without this knowledge it just seems like so many people die, not only from such simple things to treat, but also without being able to at least advance our knowledge so that we could maybe prevent it in the future. It just makes the deaths seem even more senseless. And makes me feel all the more helpless in the face of so much sickness.

Post-admitting day

This morning I show up early and my registrar is there early too, so we walk around and try to see all the new patients (11 of them) and start to make management plans before she goes to give a presentation. Turns out the intern has to go to the same presentation so they both leave and tell me I’m in charge. Meanwhile, one of the new patients has a BP of 210/120 with headaches, so I try to get him IV labetolol (which they are out of) or PO (also out), and end up just doubling the dosages of the meds he was on. I got to do this all on my own though which was cool.

To start off on a depressing note, I found out this morning that Victor, the first patient I admitted o the men’s ward, died last night. I mentioned him before because he was in acute renal failure and was an interesting diagnostic dilemma that I ended up presenting for my morning report yesterday. He came in looking terrible but had been doing much better over the past 5 days or so and even started dialysis on Sunday. From what the nurse from last night reported, it sounds like he might have gone into flash pulmonary edema but I have no idea. This was a totoal surprise though because even though I knew he was very sick, he was looking so, so much better. I never would have expected him to die at this point.

Once the labs started coming back we discovered that no less than 4 of our patients have creatinines above 880 (which is equivalent of 10 in the states), in other words raging renal failure. One also has a BUN of 173.6. One of these patients is the one I mentioned last night, the newly diagnosed HIV patient which the not bad sounding lungs (however his CD4 is 66 so he could have PCP and everything else additionally). I pushed and pushed for an ABG (they kept saying they were out of reagant) and we finally got it and his pH was 7.09 and his potassium was originally 8.4!!! We thought it could be tenofovir toxicity or maybe HIV nephropathy. Regardless, we got him quickly on K+ binding therapy and started giving him bicarb while arranging to start dialysis. I left for lunch at 2 and by the time I came back at 3 he had passed. And this was the patient whose sister I had really liked and had started to get to know and had been explaining the plan to and everything. I felt so bad.

There is another patient in renal failure who has not passed urine in ?days, and who we have failed to insert a Foley catheter in 3 times because of obstruction and who has a suprapubic mass (um…most likely a very distended bladder) and who we are aggressively rehydrating; I was like we NEED to geet urine out of him because I really thought we might explode his bladder (not sure if this actually happens) but finally the registrar put in a needle suprapubic catheter temporarily and guess what – a ton of urine came out! So that was one win.

I have another young man – 17 year old – with type 1 diabetes here with chronic diarrhea and weight loss. I had orginigally been impressed with his insulin regimen (NPH in am and pm with hunalog at meals) because everyone else I’ve seen is only on insulin twice a day. Turns out his A1c is >15%...i.e. so high they can’t even calculate it! So much for what I thought was a good regimen. It is unclear if he just doesn’t understand how to give himself this regimen or how to adjust it for what he eats or if the diabetes clinic is failing him or what. One thing I have certainly learned while being here is that type 1 diabetes here are very bad off.

Admitting night

I went into the hospital at 4 pm expecting there to be few admissions at this time and planning to leave and come back at 8. Of course that is not what happened. I got there and only my intern was there (none of the other 7 med students) and we had 9 new patients! So I clerked 4 and didn’t leave til 9 and didn’t get any dinner :/ But admitting patients is fun! Except that the Kenyan med students end up just repeating what I did (and often with better information because they actually speak Kiswahili) and they are the ones to present them on rounds. My role has basically become helping the intern and resident, especially the resident because she seems to think I know what I’m talking about. Which is very questionable. This role is actually pretty fun because they ask me a bunch of questions and I get to actually make a lot of management decisions.

What was not fun about tonight was the 3 different guys who aggressively hit on me. They were each relatives of patients. As it turns out, evenings are when there are a ton of family members around the wards. I have been sort been hit on in a hospital setting before in the States but I have certainly never had relatives of my patients ask for my number… so that was interesting.

Now on to the patients:

40 yo male with ESRD from HIV nephropathy who presents with 3 days of difficulty breathing, chest pain, and cough. He had the most awful sounding lungs I’ve ever heard. Basically the lower 2/3 of his lungs sounded like there was no air but just pure junk. And he was sat’ing 73% on 15 liters of 02.

I have another patient who was newly diagnosed with HIV who also came in with respiratory distress, but with much better sounding lungs. He could have PCP or pulmonary TB, or immune reconstitution syndrome, which is something I have yet to see. His sister was there and spoke really good English and was the first relative of a patient I’ve had who acted like the relatives I’ve seen at home. Meaning that she asked me a bunch of hard questions, tried to get me to move the patient to a single bed (doesn’t exist), and was just generally very vocal about getting him care and making sure we were on top of things. The only other relative interaction I’ve seen like this was young guy today who was asking me a bunch of hard questions about his brother who is being treated for alcohol withdrawal and may have an underlying psychotic disorder – however, he was speaking very close to me and would not let me do my other work and ended the conversation by asking for my number. So I don’t think his intentions were purely to fight for the rights of his brother…

One frustrating thing that kept happening to me was my intern would tell me to go clerk a patient and I would see them and they wouldn’t speak great English and so I would struggle through the interview with the help of some relatives and then the intern would ask for the whole story from me. Then he would go see the patient and get either an entirely different story or at least new crucial pieces of the story, and make the work I did fairly pointless. Like this guy tonight who I correctly determined was in hypertensive urgency with possible AKI, but the part he failed to mention was the seizure he had last night. Great.

As an aside, I had another patient die yesterday. This was a 67 yo man who had type 2 diabetes and hypertension and came in with general weakness and inability to talk or walk for a week. His vitals were: BP 80/60, temp 38.2, RR 48, PR 145, SpO2 85%. He needed an ICU. And I fought to get him there as best I could. He had severe sepsis (likely from pneumonia) and we can’t really tell if he was in shock because in reality you can’t aggressive hydrate someone enough here on the general wards to be able to tell if they are respond adequately. However, he was clearly sick, sick, sick. But other people kept taking his BP (with automatic cuffs or by just looking at the BP tick mark thing and not actually listening) and getting higher numbers. I was basically like, regardless, the fact that this guy is tachycardic to 145 for 3 days means something is clearly wrong! But the ICU and step down wouldn’t take him and so he passed away yesterday evening. Ugh.

Updates

Well I walked into the hospital this morning to discover that patient #1 from yesterday died about an hour before I got there. No one told me when I showed up and he was still in his bed so I was shocked when I went to examine him and realized he was dead. About 3 hours later I saw the people come by to put (more like drag) him into this strange coffin-like thing on wheels. It was really quite disturbing and shook me up a lot.

Meanwhile, the other kid who had herbicide poisoning looked much better this morning. He was awake and a bit confused still but able to walk around. He had an EKG which showed a really prolonged QTc (560) most likely do to his hypocalcemia and hypokalemia and we struggled all morning to acquire him some calcium which ultimately we had to take from the private wing of the hospital (they had plenty). We also couldn't exactly follow his EKG despite his significantly irregular pulse because his relatives refused (or were unable) to pay for the EKGs. He also complained of severe epigastric pain and throat pain likely due to the caustic nature of the herbicide. After looking up 2,4-D amine, it appears that many survivors have neurologic deficits and given his significant neuro abnormalities (hypertonia and abnormal reflexes and ataxia), I'm concerned for him in this regard.

New patients

Forewarning, this is a fairly medically nerdy post...

Last night we were the admitting team and so we rounded this morning even though it is a Saturday…and it lasted about 6 hours. Being in the wards on the weekend was actually great (for me) because there was no intern and the Kenyan med students either didn’t come or left early so I was actually really helpful. Especially since we got 11 new patients overnight, two of whom were (are) really sick.

The first is a 14 year old boy who ingested an unknown herbicide yesterday afternoon. We later discovered it was D-amine 72% after telling the family they needed to go home to retrieve the bottle. When I first saw him he was breathing very fast, completely confused and not responsive, exhibited a mix of hypertonia and posturing, clearly in great distress. When we discovered what the chemical was we realized there was no antidote so all we could do was supportive care (which is true with most chemical ingestions). We got an arterial blood gas on him and discovered (unsurprisingly) that he had a bunch of metabolic derangements (see photo of his ABG below) including an extremely low calcium level. He actually had a positive Chvostek’s sign, which is the first time I’ve ever seen that. Apparently patients who ingest this chemical die of either severe hypotension or ventricular tachycardia so we basically need give him the closest thing to ICU level of care that we can.

The second sick patient was a 17 year old boy with known type 1 diabetes who was transferred from another hospital after having been treated for diabetic ketoacidosis and developed acute kidney injury requiring dialysis. He was the patient I picked up this morning and as soon as I saw him I knew something was clearly wrong. At home in the states he would immediately be intubated and sent to the ICU (as would many of these patients). He also was breathing very fast but had an okay oxygen saturation and was completely unresponsive. He had a fast heart rate and very low blood pressure (about 75/60 but it was so hard to measure because his breathing was so fast and labored that it made the BP dial jump all around). We later got a blood gas back on him (also see below) which showed a severe acidosis (pH 7.09), severe hypernatremia (163), and many other derangements. His blood gas is actually pretty interesting to try to puzzle out. He had a CXR which shows a possible pneumonia and he was quite hypothermic so we are basically resuscitating him and covering him for a variety of possible infections while we also arrange for dialysis. I have no idea what is ultimately wrong with him and he cannot speak for himself and we have not been able to talk to his relative so his story is still very unclear.

Patient 1's ABG

patient 2's ABG

inspiring people

One of the interns here, Dr. Shah, just finished his intern year yesterday. He is a super interesting guy. He was mostly raised in Kenya but went to medical school for 7 years in Russia. He spent the first year learning Russian and then did all of med school in Russian. Then came back to Kenya to do internship and is planning on taking an exam to get a license in Australia and later do his residency there. And he speaks 6 languages…no big deal. Imagine doing med school in a totally new language in a completely different country!

I spent many hours with Mildred, one of the med students on my current team, last night as we were admitting new patients until 11pm. Turns out she has 6 kids! Aged 10 to 24. Nothing quite like that fact to make me realize how easy my life is.

Difficult thoughts

I'm sitting here waiting out the torrential downpour after a fireside chat that got me inspired to write about a few things I've noticed about the hospital and health care system here. Initially our discussion was to be on "culture" and medicine, specifically about representations of illness in Kenya. We read a couple articles about specific and general representations of HIV and as always with these types of articles, they made me shudder a little bit. I realized the reason why is because so often culture (especially "indigenous cultures") are represented as static. For example, some of the ideas about the centrality of procreation to "African culture" (first of all don't get me started on the absurdity of the classification and generalization of an "African" culture); I think much of this is conflated with poverty. Throughout the world, poorer people have more children and as wealth increases, birth rate tends to plummet. I think much of the emphasis on procreation is a reaction to high infant mortality and a way of rationalizing or at least dealing with this hard fact (see one of my favorite books, Death Without Weeping). Starting from here we began to discuss some of the examples of "traditional beliefs" seen on the wards and really the main thing I (and others) have seen is patients and their relatives wanting to leave the hospital to pursue traditional medicine. And I think this has to do far more with distrust of biomedicine, poor experiences while in the hospital, and cost, than it does any sort of "cultural" belief system. I mean imagine being on a ward that has a 30% death rate. A totally open, communal ward with two people per bed and no doors that allows you to see people die right next to you daily. I think it must create an obvious association between going to the hospital and dying that would without question give me pause to want to go to the hospital when I'm sick. I can completely understand why people wait so long to come and why they are so sick when they get here. Which is obviously a perpetual cycle. We talked a bit about how the complete lack of privacy on the wards can be a bad thing (with the visibility of death but also in terms of their being no concept of anything like HIPAA here) but also how this type of ward set-up can foster a sense of community among patients, whom are able to look out for one another at times. This may be helpful, but I notice a lot more downsides -- infection control (lack there of) and the issue of death, especially for the children on the peds ward (which also has a similarly high death rate). Imagine being exposed to that as a young (and sick) child.

Another thing that immediately struck me on the wards was the constant feeling that we (as health professionals within the Kenyan health system) are putting a price on a life here. Everything here is pay as you go (meaning, go buy your catheter and dialysate and bring it here and pay for your treatment and then we can dialyze you). And because so many people can't afford things, you constantly come up against the problem of "Oh, you need this medicine or this test to survive" and if you can't afford it you basically die. And so your life is worth whatever price that is. Case in point: a 30 something year old woman with CML who needs to have a philadelphia chromosome test in order to be enrolled in a clinical trial that will provide her free imatinib for life (which can essentially be a cure). It costs 24,000 shillings or about 300 dollars. She can't afford it and therefore she cannot get treatment. So in a very real sense, her life is worth less than $300 dollars. This is never something I have had to think about in the states. In fact, I've struggled with sort of the opposite moral conundrum in terms of how much money we spend for patients like 22 week infants in order to keep them alive with incredibly intensive care for months on end (and many of them ultimately don't survive but they cost millions of dollars in the interim). It is just such a stark contrast between the monetary value we directly or indirectly place on different lives in different places that has really hit me hard. It is also one thing to see a patient with end stage lung disease who cannot afford oxygen die in the hospital (his lifespan and quality of life even with home oxygen was poor) but it is another to see a 30 year old woman with a cancer that could expect a long life with this one drug, be discharged with very little time to live because she doesn't have $300 for one test. Sometimes it is frustrating when patients cannot pay for diagnostic tests because you as their provider want to know the pathology so you can give them the best treatment, but its another thing to not even be able to provide treatment. 

Updates

...The patient with the really bad bullous lung disease from TB passed away last night. He was really, really struggling to breath on oxygen, with a PO2 of 70% the day before so it wasn't too surprising. What a terrible way to die.

...I found out today just how difficult it is to have type 1 diabetes here. At least if you are poor. The 17 year old boy with anasarca and hyperkalemia most likely has end stage renal disease from uncontrolled diabetes. Meaning that there isn't much that can be done for him except lifelong dialysis and maybe a renal transplant. But he can't get a transplant if he has been non-compliant. But even if he had been compliant, he can only get twice daily insulin here which provides suboptimal control. The craziest thing is that to get dialysis his mother needs to pay $8000 shillings (about $100 dollars) every time he goes, so $24,000 shillings per week. That is an incredible amount of money here and she definitely cannot afford that! And because she can't pay this amount into the near future they won't get him a one-time urgent dialysis treatment now.

...also the above patient, also has pulmonary hypertension! why does everyone what pulmonary hypertension here!? People say it has to do with indoor cooking and indoor air pollution exposure from infancy on. However, recent literature has focused on the role of schistosomiasis in development of pulmonary hypertension, especially S. mansoni. High altitude can also increase susceptibility to pulmonary hypertension. Both of these risk factors are present here. As is rheumatic heart disease.

Some thoughts

I got to the wards this morning early since I was on the admitting team and discovered a new patient, a 17 year old boy with a very puffy face. Turns out he was transferred from another hospital after being treated for several weeks for "generalized body swelling" and then suddenly lost consciousness yesterday and was sent to our hospital. He clearly had nephrotic syndrome from the look of him, plus he had a potassium of 7.1, sodium of 116, and creatinine of 12. He urgently needed dialysis. Remember that photo I posted yesterday of the consult form with the varying degrees of urgency -- very urgent being "within 1 week." Well that appears to sometimes be true, but luckily for this fellow our registrar was on top of it and did all she could to arrange for dialysis by this afternoon. Cross my fingers he gets it. There are many roadblocks, the first being that the hospital does not have catheters, instead the relatives have to go to town to buy them and bring them back so that he can get the dialysis. My registrar said she had a similar case in the past except that the boy came in on a Sunday and since the shops in town were closed, he could't get a catheter and he passed. Wow.

Also, as I mentioned before we see a lot of interesting diagnostic cases, many of which we can't work up fully like in the states. For example, I think one of my patients now has a protein-losing enteropathy but the stool test that we would do at home they can't do here, not to mention all the specific tests to figure out which type. In fact, they can't even do PFTs. Which makes me wonder how many patients they call COPD who in fact have something completely different, but because they have a smoking history are labeled COPD. This means they may be treated incorrectly, but it also means that we may have little idea what the actual diseases that are common here are. We say that things like inflammatory bowel disease, Whipple disease, alpha anti-trypsin deficiency, for example, are more common in northern Europeans (and in developed countries), however, how much of this is just because these are the people (and the places) that we are more likely and able to look for these diseases in. If we looked here I bet we would find much more than we think!

Today was the first day I encountered a consultant (aka attending) on our team (they usually come twice a week but for some reason mine didn't come last week). He was pretty great!

A sampling of patients from today

A 63 year old male who originally came in with significant hepatomegaly, ascites, bilateral peripheral edema, also with cough and dyspnea. He had an echo which showed significant right atrial and ventricular enlargement, severe right sided heart failure, tricuspid regurgitation and severe pulmonary hypertension (75mmHg). However his ejection fraction was 55% with very mild diastolic dysfunction, meaning he did not have left sided heart failure. The conclusion was he had cor pulmonale and the team determined it was COPD-related. But he had only smoked for 10 or so years, did not have a productive cough or increased A-P diameter, and his PO2 was 58%. Also, the team only noticed this today and hence today was the first time he was started on oxygen. Now can this really be caused by COPD?? Do we not see this significant cor pulmonale with moderate smoking in the US because we diagnose and treat COPD earlier? Or is this more likely a restrictive process like interstitial lung disease that we probably won’t diagnose because we won’t (or can’t?) do PFTs?

A 22 year old man who comes with a history of pleural and pericardial effusions who comes in with dyspnea. He has no edema elsewhere but has persistently low albumin of 1.9. He has actually had a fairly extensive workup including intestinal biopsy for protein-losing enteropathy (but no stool tests…), a liver biopsy (that was lost), and a bunch of labs including normal LFTs, normal urinalyses, sputum negative for TB, and a negative ANA. We know he is hypoalbuminemic, and has no history or signs of liver disease and is not malnourished. Plus, he only gets pleural and pericardial effusions, otherwise no other edema, which is strange. He will be discharged tomorrow without an answer but feeling better after pleural drainage (and may need to get another liver biopsy because the clinic who did it lost it).

A 34 year old man with pulmonary hypertension and recurrent pleural effusions who is in the hospital because he needs oxygen but can’t afford home oxygen. Again, the doctors attributed his pulmonary hypertension to COPD (but he’s ONLY 34 and smoked for 10 years!). However, he also has hemoptysis. And bilateral opacities on CXR. Oh, and when we checked his pulse it happened to be 205. WHAT?! He probably has paroxysmal SVT or something, but while an EKG, cardiac consult, and adenosine were theoretically ordered, none happened all too quickly. We’ll see what his pulse is in the morning.

Now for some positive news. We also have a boy on our service, 15 year old, who has sickle cell disease and came in with a pain crisis. My (amazing) registrar made sure to counsel the mother on what sickle cell disease is, what signs to look out for and what precipitants to avoid. She made sure he got an appointment at the MRTH hematology clinic, where he can get hydroxyurea (new here) and get all the vaccines he needs but never got. This kind of attention to detail and coordination of care was wonderful to see!

And here are some pictures from the day:

 classic miliary TB on CXR

 cube 1 in the women's ward

 terrible bullous lung disease from TB -- chest CT

 2 things of note here: 1) this is a note from a patient (not of mine) that has some psych disorder but has taken a liking to me and continuously warns me about Saudi Arabia... and 2) note the levels of "urgency" in the bottom left

Photos

 back entry to the hospital

 AMPATH building

 hospital grounds

 main entrance to MTRH

 entering downtown Eldoret

where in the world I am..

"Doing" global health

People have been asking me a lot lately about if I want to do global health as part of my career and how I want to do it. That is something I have yet to be able to answer and part of being here and also coming back to Kenya in the fall to do research is in an effort to answer that question. Initially when I became interested in global health in high school, my dream was to do Doctors Without Borders. While that is still extremely enticing, as I’ve gotten older I’ve recognized how extreme of a life that is and how much you have to sacrifice to do it. The fact that it is all clinical care oriented and the mission and goals of the organization really appeal to me. One of the fears I have about working clinically abroad is the concern about becoming one of those western doctors that comes in and treats patients for a few weeks or months and then leaves without making any lasting (good) impact. This sort of situation can undermine local doctors and medical education and so it is critical for me to be able to work clinically in a way that helps to train and foster local medical students and doctors. But this is something I had yet to see done well until here. Because of my misgivings about working clinically abroad, I starting thinking that the best way to do global health was through research. In part this stemmed from working with Jen Friedman’s group in the Philippines – in the case she had helped develop a longstanding research project in Leyte that did clinical (and lab) research that seemed to have a direct benefit to the people who lived in this region. She studies schistosomiasis and specifically its impact on mother and child health. Her latest study was testing whether praziquantel was safe and effective in pregnancy. She spends a few weeks to years on site but in between she works very closely with the Filipinos running the study. Her research grants and funding through the hospital/university also allowed her to have an exchange program whereby students and researchers from Leyte could come to the US to get degrees and/or do research. This seemed like a great set-up to me so I started thinking I would do research abroad as the global health portion of my career.

But then Chandler went to Uganda and had a different experience regarding research there. It seems like oftentimes the researchers who work at the hospital that he works at are much more focused on research than on clinical care. The research is also less integrated with the hospital, and so the clinical care suffers. There are many great research groups, but there seems to also be a troubling amount of politics involved in getting things done in collaboration with the public hospital. The research process can be slow and prevent the output from feeding back to the patients themselves. It seems like some of the researchers are focused too much on their outcomes and papers published. Given, there are benefits of research, for example in his study his patients receive US standard of care (for free) rather than what may be available in a low resource setting. But this also throws into stark relief the difference in clinical care between the patients enrolled in studies versus those who aren’t. Not to mention the corruption involved in getting research approved and done in Uganda. Bribes are expected and often required to get things done in a timely fashion. That said, his mentor works incredibly hard to get things done the right way and he always has the patient’s best interest at heart. Unfortunately, the same cannot be said for many parties involved in the research process in Uganda, and this can result in effort and money spent in ways that do not directly benefit the patient’s themselves. And some disheartened peers.

In contrast, the partnership between Brown and Moi University/AMPATH is very clinically focused. The US physicians and students who come here work on the wards, they see patients in clinic, they teach the medical students both Kenyan and American. There is some research being done – all clinical as far as I know – but this is much less emphasized than actually working in the hospital. For example, the pediatrics team liaison here wants to start an adolescent HIV clinic, and as part of this she will do a research project to assess the outcomes of this program. So at its heart it is a clinical and organization project. I love being able to work on the wards here and feel like part of my team – it feels similar to being a medical student back at Rhode Island Hospital in many ways. And I get to learn from and teach the fellow students and residents. Some of the physicians who work here come for a few weeks to work and teach while others live here for years. And I could see myself as one of them. 

Culture of med school in Kenya

In many ways, the culture of the medical school here feels like what I imagine med school was like in the 1950s in the US. The consultants (attendings) often laugh at or berate students who get things wrong and the byproduct is that the students very rarely speak up. They don’t ask questions in morning report or on rounds and they often don’t answer questions even when they know the right answer. One consultant is particularly mean and one of the residents here actually wanted to yell at him to stop. She didn’t. But it is tempting. It is so clear to see from the outside why the med students act so timidly, and it also can obviously feed back to worse patient care because students and residents become afraid to speak up. As I mentioned before, the interns work 365 days per year – not a single day off – and the registrars (residents, like fellows in the states) rarely help them out when they are overburdened. There seems to be a perpetual idea that “I had to do this when I was an intern, so you must suffer too.” But that can clearly be a dangerous (not just sadistic) mentality because overburdened doctors provide worse care. This makes me appreciate the culture of medicine back home at Brown. Interns and residents (and med students) work really hard but there is generally a more helpful and collaborative environment. I appreciate the willingness of students to ask questions and attendings to listen and teach, rather than speak down to all of us.

Innovation

Innovation rarely occurs in the academic medical centers here, in contrast to the US. For example, there are CT surgeons at MRTH, however they do mainly pericardial windows and biopsies, or so I hear, but they do not do valve replacements or cardiac surgeries. More invasive, skilled, and even new procedures occur at private hospitals. According to Chandler, this same situation occurs in Uganda, however, the reason there is because many of the US trained doctors return to Ugnada and work exclusively at private hospitals. I am not sure if this is the case here but it could be. There is such a great need for valve replacement surgery in Kenya, even just in Eldoret, that clearly if these surgeries were offered (and could be afforded) there would be no lack of patients. We just had a 15 year old girl die a couple days ago from rheumatic heart disease who could have lived if she had a valve replacement (or two).

One thing I have been struck by is how smart and up to date all the doctors at MRTH are. Clearly it is not an issue of skill or love of teaching that stops innovation from occurring here. It must be an issue of money. Whereas in the states doctors take pay cuts when they work in academics rather than private practice, there is a significant amount of prestige that comes with academic centers and research grants provide the money needed to conduct innovative research. That is what is lacking here. There are research projects going on, for example studies on cryptococcal meningitis, but there don’t seem to be any surgical or procedural studies.

Positivity

Today I saw a very ill but very sweet patient who, lucky for me, happened to speak fantastic English. She had AIDS and was failing 2nd line therapy, was having trouble feeding and losing a significant amount of weight. She looked very, very thin but at the same time she looked different from many of the other severely wasted patients with AIDS that crowd the wards. The reason was her attitude. Despite her weakness she was friendly, always smiling, even chipper. She was incredibly patient and cooperative despite the many people poking and prodding her. She mentioned that she had not pooped in days because of pain and after she mentioned that she had "ulcers down there." We examined her and found extensive, significantly denuded ulcers across her vagina and anus. They looked so painful everyone in the room cringed. Yet she put a smile on her face despite the pain, and gave us more of her story so that all the medical students and residents in the room could learn from her case. I've seen so much depression and defeat among patients with AIDS so far, that it was both heartwarming to see her positivity, but also heartbreaking to realize that despite her attitude her prognosis was so bad.

CKD

Chronic kidney disease (CKD) is a very common medical problem on the wards in the US. Today I saw my first patient in at MRTH with CKD and this is how she looked: sick-appearing and unresponsive (GCS of 8), severe anasarca on a background of significant wasting giving the eerie appearance of a collection of stark, protruding bones surrounded by puffing, bloated tissue, and labs clearly demonstrating kidney failure (GFR of 7 and a BUN of 80). She was also severely hypertensive (BP 188/130). Now this is just one example of how sick patients often become before they end up in the hospital. And what could we do for her? Give her medications to lower her blood pressure (we did discuss the JNC 8 guidelines before doing this) and recheck her labs. Despite her likely uremic encephalopathy, urgent dialysis was not an option. Now contrast that to the many sometimes ill but generally well-appearing CKD patients we see every day in the US.

Nurses

The interns here work 365 days a year -- not a single day off! So its hard to blame them when things don't get done efficiently. Especially because one of the most striking faults about the clinical care here is the lack of nursing care. Take one patient admitted last night -- she is 28 years old, is failing second line HAART for AIDS, is severely, severely wasted, refuses to speak or feed, and her temperature was 33.4 and BP 65/45. Her initial IV line infiltrated and despite attempts by the medical students and frequent reminders to the night intern, a new line was never established overnight. It was not until 1pm this afternoon that she was finally able to receive her fluids and medications to treat presumed septic shock. There is no one person to blame for this inadequate patient care -- it is an overburdened system with many intelligent, well-trained personnel but not enough time and support to provide the needed care.

Being on the wards here has shown me how enormously important nurses are to the functioning of hospitals and to patient outcomes. While doctors may examine, diagnose, and prescribe medications for patients, it is through the nurses that the medications, fluids, monitoring of vitals, food, and hygiene actually get to the patients in order to make them well.

Ethical dilemma

We have a 15 year old girl who was transferred to our hospital after being diagnosed with AML M2 subtype. She was febrile to 40.6C and her most recent CBC had a WBC of 1.0, hemoglobin of 8.6, and platelets of 21. Her family had no insurance and no money for a private hospital or transfer to Nairobi. She was at such high risk of infection if given chemotherapy on the standard female wards that the resident thought it was more ethical and better for her survival to give her palliative care rather than began induction chemotherapy. 

Musings on daily confusions

Some surprising discoveries here at MRTH: the frequent use and availability of meropenem and cefepime, routine prophylaxis with heparin, and the Coumadin clinic. At the same time, the hospital was out of ciprofloxacin for 3 weeks, the xray machine was out of service a couple days ago, and there was no buffer to run rapid HIV tests.

Intellectual curiosity

Tropical medicine is fascinating because of the scope of illnesses you see in the wards, the broad differential for many patients, and the interesting physical exam findings and work-up (when the work-up is available). However, the treatment possibilities are often limited, the same no matter the specific diagnosis, or frustratingly not feasible given lack of resources. This discrepancy between interesting cases and frustrating inability to care for patients has stood out to me the most, even from the first day on the wards. For example, we have a 31 year old female patient, initially unresponsive who came in with abdominal pain, found to have 2 large liver masses on ultrasound, no risk factors for hepatocellular carcinoma. Labs revealed a very high LDH, elevated uric acid and potassium. Physical exam and history was not revealing for a primary malignancy and she had no lymphadenopathy. Our leading diagnosis became lymphoma, however, the patient needed a biopsy. It has been 5 days and still the patient has not come up with the money for one, once she does it will take several days for the biopsy to occur, and once it is done it routinely takes 2-4 weeks for the pathology to return. So while the patient’s case is interesting and the differential originally very broad, the actual inability to diagnose her and then to treat her is incredibly frustrating. 

My first day

I am currently sitting in the dining room at the IU House in Eldoret, Kenya on my first day on the wards on my medicine rotation. While the diseases that are common here are much different than in the US, there is even more that is different in terms of clinical care, training expectations, etc. Take one of my patients from today, a 20 year old patient with severe mitral and aortic regurgitation from endocarditis superimposed on rheumatic heart disease, and he urgently needs a double valve replacement. There is no one in Kenya who does valve replacements. And apparently, no one else nearby except for a visiting expat surgeon currently at Tenwek Hospital in southeastern Kenya who leaves next week.