"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…