“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.