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...