Last Call

One more night call before I finish my time here. Charles heads back to Seattle tomorrow PM – he could use a break (but that was the 18 hours of planes flights are for right?). The women’s ward team that he is on is quite busy. Our load of patients is moderate now after a few discharges and the ICU is nearly full (which means there is room for only one baby and that’s it). The best way to summarize what I’m up to is to describe the patients we have now to give you a good snapshot of the problems we have faced this month.

Isolation room:

45 y.o. with disseminated Kaposi’s Sarcoma, PCP pneumonia and TB pneumonia with AIDS

24 y.o with PCP and TB with AIDS

64 y.o. with TB of the right lung (NOT HIV positive – wow)

Regular ward:

58 y.o. with myelodysplasia who we just diagnosed with chronic lymphocytic leukemia

70 y.o. with pneumonia and COPD

67 y.o. with a stroke with facial weakness and confusion

80 y.o. with a stroke with difficulty with swallowing and speech

54 y.o. with TB meningitis, AIDS dementia and profound wasting from AIDS

23 y.o. with severe ulcer disease, improving on treatment

18 y.o. with seizure disorder and labyrinthitis

18 y.o. with AIDS, TB of the spine with paralysis and extensive bedsores (now with his femur and

sacrum exposed).

42 y.o. with a pulmonary embolus after 3 weeks in the hospital for a perforated ulcer

Private ward:

58 y.o. with a AK-47 gunshot wound to the thigh resulting in non-union of a femur fracture

ICU: 59 y.o. with necrotizing fasciitis resulting in disarticulation of the R leg at the hip socket, sepsis (improved…)

33 y.o. with cervical spine subluxation, now repaired and extubated today (Yeah!!)

35 y.o. with acute abdomen, pancreatitis, sepsis

44 y.o. with flail chest from a car accident (2 weeks on the ventilator).

Each patient has a story, a family that visits daily no matter how far away they live it seems, and they are being well cared for by a staff that is stretched for space, sanitation and supplies. We still see many patients sent here by local government hospitals that don’t have the means to care for them well so they send them here for the right medications and surgical care the many of the patients require.

If there is any question whether or not Kijabe Hospital deserves the support of the many western churches that provide missionaries and funding for this place, it only takes about a 15 minute tour to see the profound impact that this dedicated Christian staff is having on their neighbors near and far. The future is brighter as the leadership here has taken hold of the core value of training – creating the next generation of leaders in Kenya’s health system – from nurses, therapists, dieticians, clinical officers, interns to residents – they are training them all. Whatever we can do to support that goal will have long lasting impact. Let’s hope we can rise to the challenge before us.

“Tree fall”

25 July
What happens when you mix alcohol with tree cutting? - Nothing good, especially when the tree falls on you in the process. Charles and I are on call this weekend, covering the ICU, the ED, the two main wards and Pediatrics and the nursery. We do have a intern on call, and a clinical officer staffing the ED. After fairly uneventful rounds this morning, I was called at 3:30 PM by our surgery team to see a patient with them in the ED who was drunk and had volunteered to help some guys cut down a tree. In the process of pulling the tree over, he failed to get out of the way and it landed on his left shoulder and neck.
The patient was lying in the ED on his back with a cervical collar loosely wrapped around his neck to stabilize the spine but with every inspiration, you could hear a very guttural sound emanating from his airway. Clearly his upper airway was being compromised. With gentle traction stabilization of his head and neck, I opened the collar to inspect his neck. There was swelling of the neck laterally on both sides. We replaced the collar and tried to position him better to clear his secretions but he continued to struggle. We had our anesthesia nurse in house so we called her, anticipating this could be a challenging intubation. With heavy sedation and paralytic drugs, we were able to intubate him under traction without disturbing his neck. The rest of his trauma survey was clear so we focused on maintaining his airway.
So now Charles and I rotated bagging him for the next hour as we prepped the ICU for his arrived and got his X-rays done. The X-rays showed a clear C4-C5 subluxation of about 4-5 mm, a small anterior avulsion fracture and a shattered scapula on the left side. His lung was slightly bruised at the apex but otherwise he was remarkably spared more significant injury. Trouble is, his airway is going to be swollen for days, so we’ll need to keep him intubated for days as a result. Once in the ICU, I hooked him up to the ventilator, wrote orders to keep him snowed overnight and started him on steroids for the swelling in his airway. Now it’s time for the waiting game to see how he does.
26 July – We had a completely full house by Sunday PM. The ICU was the only place with an open bed, which I thought I was going to fill at 5 PM on Sunday when a 74 year old man was brought in with signs of a massive stroke. However, he herniated his brain into his brainstem within about 60 minutes of arrival an died in Casualty with Charles and I watching him through his final decline. He arrived with fixed and dilated pupils so we knew he had little chance of any brain function even before we started to treat him.
Our young man with the C-spine injury went off to surgery today. I hope to have him extubated in 2-3 days and he should do very well. He is amazingly fortunate, considering what his outcome could have been.

An Old Enemy

Three days have passed since we performed the cervical node biopsy on our patient in Bed 12. Since then we have turned over nearly the entire service. We discharged a number of patients; we have a heavy load of consults from our surgical teams including 2 patients with acute pulmonary emboli that we are now treating with anticoagulants to prevent further clots from killing them. Both had very low oxygen saturations (45% and 70%) but with no ICU beds available, we have managed them on the overcrowded ward.

Today the biopsy results came back from the node biopsy – adenocarcinoma – moderately differentiated. Thought the node doesn’t tell us where it come from, it is nearly certain it is lung cancer with a very poor prognosis. The patient’s family also paid for him to go to Nairobi for a CT scan that reveal multiple masses in the central chest and neck with bony metastasis. A grim picture. We met with him and his family and discussed his limited treatment options and palliative care. Lung cancer is not very common here – much less than in the US. For an American doctor, it is easy to make the diagnosis based on his presenting story and initial laboratory studies because we see it so often. Lung cancer is the most common cancer diagnosis I have made throughout my career in medicine and it is a formidable enemy. There are some types that are more treatable than others, but many don’t have a great prognosis. As usual, the families were extremely grateful to have the truth of his diagnosis and prognosis. They have been to multiple facilities over the past month with no answer but now were relieved to know what was going on.

Charles had a particularly rough day with a patient of his who died very suddenly and with a very unclear picture which only after the fact could we piece together the likely cause of death. The patient’s sister showed up on the ward an hour after she died and collapsed to the floor, wailing and weeping over the loss of her sister. The patient had AIDS, TB and PCP infection that was being treated but a catastrophe occurred that killed her quickly. It was a real blow for Charles, August (the attending of the service) and for the nursing staff. We’ll save the case details for later as it would be an excellent case conference for teaching when we return.

Every patient we can discharge home healthy means a great deal here. So often, we are sending patient home with bad news, a diagnosis of AIDS or cancer, or they leave by the morgue. I can see why OB is something I have loved doing here in the past as most of the stories are joyous in the end. Yet, in these difficult cases, it seems that God’s grace is most evident in the families and the patients as they move into the uncertainty that requires faith, not facts.

“Triangle of death”

It’s Monday, and the wards are fully packed again, though Casualty was not boarding patients for the night so at least everyone is on the wards. We had our first rain this morning – after a good two weeks of sunny mornings and cloudy afternoons, but no rain. Yesterday we went to the AIC church at Kijabe and had a chance to sing in Swahili (which is a bit challenging with all of the syllables they pack into a phrase). We also took a walk around the grounds of Rift Valley Academy, enjoying the view over the valley and having a restful day.
Our team has grown with more and more surgical consults – today a couple pre-op consults and one post-op patient who had his sigmoid volvulus resected on Saturday AM and had some trouble on Sunday with his fluid status, which was pretty well corrected by this AM.
Both patients with the creatinine levels of 12 on Friday died – one on Friday PM just as he arrived to Kenyatta to try to get dialysis and the other today at about 4 PM. We had just met with one of the patient’s family to recommend comfort measures only due to his profound renal failure coupled with his incurable bone disease. As usual, the families are exceedingly gracious and thankful for the care provided by the staff here. We knew he was going to die soon, especially when we came in to see him this morning and he had the odor of uremia as well as “uremic frost” – crystallized sweat and urea on the skin that signals very high levels of urea in the blood.
John Kuguthi (my R2) and I did a biopsy of a cervical node in a man who almost certainly has a lung cancer. We delved into the “triangle of death” – the area of the neck that contains the jugular vein, the carotid artery and subclavian vessels. After a bit of very careful dissection, we found the node and excised it. We had to tie off several small vessels that tried to flood our field. John has good surgical skills though, so he managed the procedure very well.
I finished off the day doing a rudimentary cardiac echo study. Charles brought his patient to ultrasound so that we could look at her heart to be sure we know what her ejection fraction looked like before he committed further to his treatment plan for her heart failure. With the transducer beaming up under the ribcage to see the ventricles and a view of the left ventricle from the apex of the heart, we could see her large dilated ventricles with a very poor ejection fraction. That was the answer he needed and we were done in about 3 minutes. Simple, but good enough to make a clinical decision.
Many of the missionary MD staff are taking off this next week for vacation. Looks like the newbies (all of us short term people) are going to be staffing a lot of the services for the next 12 days. No wonder we have so much call coming up.

"12"

The past few days have had major ups and downs on our inpatient team. Our census dipped to about 10 for a few hours on Wednesday then Thursday morning I met with Anne and John to start rounding and we had 3 new admissions and 2 new consults. However, the ward now was completely full and one of our sicker patients was still in the emergency room as there was no bed for him as the hallway on the Wairegi Ward was already full with patients. The ICU was full and Salome (Women’s ward) was also full. The ER was packed all day on Thursday with a log jam of patients.

We rounded on our ward patients first then went to the ER to meet Peter. Peter was in his late forties with a history of having “multiple myeloma” diagnosed in Nairobi but treatment was suspended 3 year ago due to a change in diagnosis as his evaluation done here did not reveal any definitive studies that were consistent with myeloma. But, he still had progression of whatever his diagnosis was, which was not clear. Now he was terribly anemic, short of breath and moderate to severe pelvic pain from a fall 3 weeks ago in the bathroom. Three days ago he became acutely short of breath. He was in renal failure with a creatinine of 12 (nl 1.5) and his X-rays were a mess. Compression fracture of the cervical spine, moth-eaten appearance of his skull and pelvis (with many small fractures present)– all consistent with either myeloma (a non-secretory type since his SPEP was normal in ’07) or histiocytosis. He never had a bone biopsy except for an infected area of his leg that just showed inflammation. Not a clear picture but either way, he is in a very bad way. Dialysis in Kenya is only done on those with reversible kidney failure, not chronic kidney failure like he has. Plus it costs about 1,000,000 shillings a year (about $12,000 – a prohibitive price for most everyone here). We tried to improve his status by transfusion him for his profound anemia and to hydrate him and after 24 hours, he still is at a creatinine of 12. He and his family have to decide what they can afford and what he will do next.

Then this AM, we were asked to consult on multiple trauma patient with infected fractures who clearly threw a pulmonary embolus from his badly injured leg last night and was decompensating quickly. No beds in the ICU, very low on oxygen and developing pulmonary edema on top of that. I tried adding Lasix to try to get him to urinate off some of his excess fluid, only to find that he was already in complete renal shutdown (creatinine of 12 too). He was on an antibiotic that can harm the kidney for almost 2 weeks and no one had checked to see how his kidney function was after his massive trauma. We sent him to Nairobi for dialysis as he has a chance of recovery and he also needed an ICU bed if he is to survive this combination of insults. It was a full day affair today to arrange his transfer while his lungs continued to fill up with fluid. A very tragic combination of events.

I need a weekend…

"Billy G"

Monday – The men’s ward, which had a few empty beds on Saturday (a rare event), was completely full again Monday AM when we started rounds. Anne, my intern, and I were the only two on the team today due to our CO being on vacation and our registrar off on other duties. Still the service was quite manageable in size and we had only a couple new patients to add on to our rolls. One gentleman in particular, seems to have a problem that is amazingly prevalent – obstructive nephropathy from an enlarged prostate. Like the 5L liter patient last week, this man had 3L in his bladder but it has been going on a long time and I’m afraid his kidneys are nearly dead at this point. His BUN was 96, his creatinine 9.1 (both 9 times what they should be). Dialysis is not an option in Kenya for chronic renal failure (for the average person, anyway). We catheterized him and hydrated him, hoping that he will recover enough kidney function to live, but he has been minimally arousable for the last 24 hours so I am not sure if we are going to see any improvement. This morning it appears by his bloody urine that he may have acute tubular necrosis (another bad kidney insult).

But, the challenge of the day was coming up – call night and covering the ICU was my main assignment. Charles was to cover the pediatric and adult medical admissions with the intern on call. The night was pretty quiet except for the one call from the newborn nursery. There is was a 1 month old who had been in the nursery since birth due to a very complicated course of airway problems due to a malformed nasal passage (choanal atresia) requiring urgent surgery on day one of life and 3 trips to the ICU due to tracheomalacia (a weak windpipe that collapses with rapid inspiration). A peds surgeon called me to say he thought the baby needed to be intubated and transferred to the ICU. I went down to assess the baby and she was fighting hard to breath past her retracting airway and was using every accessory muscle to breath. She also had a fever (new) and a stent placed in her left nostril that didn’t seem to be improving her breathing (since the problem was below that part of the airway). We made ready for the transfer to the ICU and I called Steve Letchford, the intensivist, for some guidance on how to use the pediatric ventilator and sedation protocols here. Steve said, “Man, wouldn’t it be nice to have one of the ENT docs that is here with a team for another couple days to take a look at this kid tomorrow?”.

I returned back to the nursery to get ready to move the baby. Standing above the baby was a very familiar face – Billy Giles. Ok, Billy is someone that most of my current friends and family don’t know. But Billy and I go way back – 1979-1983 at Wheaton College. Took most of our premed classes together – funny, wisecrack of a guy who was really sharp and a young man with great compassion and faith. Well, here he is at 9 PM at Kijabe Hospital, in the middle of nowhere, Kenya – a pediatric ENT specialist now, right where God (and all of the rest of us trying to sort this out) needed him. Ok, I was just telling Charles the stories of how amazing it was here when specialists with just the right skill set show up just when you need it the most. This little girl has a very rare defect, something that I’ve never seen before but read about.

Billy looks up and grins – we both just laugh at the odds of us being at this place at the same time in this situation. “Yep, I just pushed this stylet past both choanae and they are open so she can breathe fine through her nose but her lower airway is still the problem.” Billy, with his usual wry humor was just sliding this coated heavy wire in and out of this kid’s nose like it was going out of style. “Yeah, you want to be careful not to push too far and go into the brain”. Gulp…

After a lot of deliberation with the baby’s mother and 5 docs standing around this little 2500gm newborn, we decided her only hope was a tracheostomy (with all of the long term complications that entails in a 3^rd world setting). We transferred her to the ICU –which caused her to get into real trouble for a few minutes – nearly had to intubate her but with some ketamine sedation, she calmed and breathed much more effectively. This morning, she is in the good hands of Dr. Billy Giles getting a new airway that will allow her to grow. Without it, a simple cold virus would likely have killed her. At least now, she has a fighting chance.

Kijabe Hill

After rounding on our patients on our respective wards, Charles and I headed out at 12:30 to Kijabe Hill. The sun was peeking out behind the clouds trying to break up the haze across the Rift Valley so we would take a chance at the hike hoping to see the views from this nearby mountain. We wound our way down the road to Old Kijabe Town, passing by monkeys and the wild flowers along the side of the road that are if full bloom right now. We slipped down a few drainages then climbed up to some open range land with better views of the valley below us as we started to climb. It is quite green and lush this year, far more so than other summers in the past. From Old Kijabe Town to the top of the peak is a 2000 ft climb, most of it in the last two miles, and it ends at 8700 ft. with a commanding view of the valley below.

We entered the “Candelabra” forest – a beautiful collection of the native candelabra trees that rests below some of the farms that cover the east side of Kijabe Hill. After 3 hours, we were at the top with a great view of the valley floor, though the haze in the distance shrouded the distant horizon. Knowing that sunset was not far past 6 PM, we headed back the way we came. It is a LONG hike – at least 10 miles, all of it above 7000 ft., so we were pretty tired by the time we made our way back to the hospital compound. Now the feet and joints are tired and achy – nothing a little ibuprofen won’t ease a bit. Tomorrow is a day to rest – I’ll need some energy for the next week with call on Monday PM and a full week ahead of work in the hospital.