The Wards

Where do I even start?  I guess to warn you that this entry is not for those who are hoping to brighten their day and to apologize for all the medical words (I will try to explain as much as possible)....

See last blog for a partial description of the hospital.  I forgot to mention that it is unbearably hot most days on the wards (of course there is no air conditioning or even fans and it has been around 35-40 Celsius (95-104 F) these days).  As a result, all the windows are open and so there are always tons of flies, it's a losing battle to try to swat at them...) Here are some stories about a few of the patients I've tried to take care of over the last week and 2 days. 

O.N was a 5 yr old diagnosed with osteosarcoma (bone cancer) in July and started on chemotherapy for 2 doses.  Then he never came back for chemo as scheduled.  He finally returned the day after Christmas with a now humongous arm (the cancer is in his left humerus) and respiratory distress.  A chest x-ray showed that his entire left lung was full of fluid, most likely from the cancer spreading.  The only pediatric oncologist in the country is a fellow PAC doctor and he was back in the States for the holidays.  So our team was covering all the oncology patients.  We tried to find a surgeon who would help us to place a chest tube to drain the fluid, but the one pediatric surgeon was not returning our calls and we could not find any other surgeons.  So Gelane and I decided to do a thoracentesis (procedure where you drain fluid from around the lung with a needle).  I did one thoracentesis in medical school, but it has been awhile.  So we read up on the procedure.  Then I acted as anesthesiologist (we actually had ketamine and versed!) and Gelane as surgeon.  We were able to drain a little bit of the fluid, but not enough to provide the symptomatic relief we had hoped.  O.N. tolerated the procedure well, sleeping through the whole thing. He managed to do okay on oxygen for the next 30 hrs until the pediatric oncologist returned.  Upon looking at the chest x-ray (CXR), the oncologist was sure that it was a spread of his malignancy and that the reason we were unable to drain more fluid was because what we were seeing on the CXR was spreading tumor.  After explaining all of this to the family, he worked out a palliative care plan for the patient.  Two days later, just 2 days before the new year, O.N. passed.  

T.M. is a 12 yr old with the greatest smile I have ever seen!  He was diagnosed with HIV 2 months ago when he was first admitted to the hospital for bad headaches and severe malnutrition (he now weighs what an average 8 year old would weigh).  It was discovered that he had crytptococcal meningitis (an AIDS defining illness in that it is pretty much never seen in patients with normal immune function).  At the time he was started on treatment for the meningitis and for HIV, he improved and was sent home on a prolonged treatment course.  He returned in early December and was discovered to still have residual crytptococcus surrounding his brain.  He was begun on an extended course of Amphotericin B (which we are lucky enough to have in Botswana) and after two weeks we did a repeat lumbar puncture.  Seven days later it is still not growing crytptococcus, but is not considered to be truly negative until day 10.  He, his incredibly devoted parents, and I are all keeping our fingers and toes crossed that it will stay negative and we will have finally rid his body of crypto.  He will still need to take medications for cypto for a long time, but at least he will be able to leave the hospital and do what he so desperately wants: to start the new school year on time on January 11!  Every day I give him several stickers and his huge smile in response, despite everything he has been through, makes my day.

My first ever call, before tonight, was on New Year's eve.  I was in the middle of skyping with my family when the pager went off.  When I called back, the voice on the other end said "we need you in the NNU (neonatal unit) there is a baby that won't stop bleeding."  In 10 mins I was at the hospital walking as fast as I could from one end to the other (of course the NNU is on the opposite end from the parking lot and in a country where land was not at a premium, the hospital is flat and the distances far.)  The bleeding had stopped but the baby had lost a lot of blood.  The blood bank was having trouble finding blood that the baby did not react to, but at last they managed.  The medical officer (MO) and I talked about the plan and I was getting ready to go home when the pediatric ward called to say that a child in severe respiratory distress had just been admitted.  Leaving the MO to finish with the baby, I went over to investigate. 

The admission was a 9 mth old baby.  His mother had tested HIV negative during her pregnancy, but had not been tested since until 2 weeks prior when the patient had been admitted for failure to thrive.  On that admission it was noted that the baby who had initially been normal weight for age, was dropping percentiles at each check.  As part of the work up they had retested the mother and found her to be positive.  This meant that the baby was at high risk of being infected with HIV, as the mother had gotten it late in her pregnancy and the baby had not gotten any prophylaxis.  The test for the baby (a PCR) takes 4-6 weeks and was still pending, so we were unsure whether the baby actually had HIV - however given all the signs I am 99% sure he did.  The baby had been discharged and was doing well at home until the 29th when he got a high fever.  The mother brought the baby to the local clinic 4 times in 2 days and each time the baby was sent home with Tylenol and some antibiotics. Finally the mother had enough and brought him to the hospital, but by then it was too late.  When I saw the baby he was working very hard to breathe, had signs of meningitis and was very tired.  We did some blood tests and a lumbar puncture, started antibiotics and oxygen, but it was not enough.  It would have been nice to be able to intubate him, but there is no pediatric ICU here and the adult ICU does not take children very often. The baby died 1 hr before the new year.  I can not even begin to imagine what it must be like for that mother and I have thought about her a lot over the last week.

There are many more patient stories....There is the 3 month old with a heart murmur and beginnings of heart failure who will have to wait at least 2 weeks for an ECHO since the one person who does them is not available until then.  The 6 mth old with focal seizures who cannot get an EEG because the one person who will do them is at the private hospital and the government has not paid him for the patients he has seen for the last year, so he is not seeing any more public patients for the time being. The 2 month old who had not gained weight since birth because there are 11 children at home and no one working, so there is not money to buy food.  The numerous children with measles (a disease I had never seen before coming here) as the country is in the midst of a measles outbreak.  And the list goes on and on.  There are more deaths than I have ever witnessed on a pediatric unit in the States.  And yet many patients do get better.  I am trying my best to channel T.M.'s happiness.  If he can do it, I can too!