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 :)
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