Life on the Wards in Kapsowar

Marta’s New Week

                It hasn’t been so long, so this will be much shorter.

                Today I tried a custard apple for the first time.  The outside is green and it looks like a cross between a pineapple and a pinecone.   Inside, there was a creamy, sweet fruit, with seeds big enough to just pick out.  It was 20 schillings, so about 20 cents.  Katy was excited to find it, and it was a nice treat!

                I have taken over the pediatric ward from Katy this week.  She was collecting patients, and holding on to them!  My last few days have been filled with multiple dismissals per day, and lots, surprisingly that comes with a fair amount of paperwork, even in Africa!   There is a one page form, which is shorter than my usual dictations, that summarizes the diagnoses, hospital course, and discharge meds.  A separate card is for the patient and had the diagnoses and meds.  

                I did have one new admission for severe malaria this morning, and one for ingestion of insecticide yesterday.  Kids don’t usually ingest too much insecticide as it tastes and smells so foul, but this guy got somewhere between 5 and 75 ml!  Yesterday afternoon he seemed pretty stable on admission with clear lungs, reactive pupils, and general fussiness from all the poking and prodding.  This morning he was obtunded, pupils were pin-point, lung sounds were coarse and crackly throughout and he was drooling.  I was amazed how well just one dose of atropine worked, and was expecting to have to give it every 15 minutes, but the first dose held for at least a few hours!

                I was helping out in the outpatient department today, and saw two patients this afternoon.  That is quite a difference from the 12 I was seeing to try to squeeze in all my frequent fliers before being absent for this month!  The first had abdominal pain and knee pain, both were chronic.  He had been treated empirically for H. Pylori on the last visit in September, and his abdominal pain resolved with that.  I simply refilled his omeprazole and offered him a knee replacement for the crepitus and arthritis in his knees.  Just kidding…no such thing.  But, in the end he said he had had the pain for years and didn’t care for any medication for the pain.  What a difference to be on another continent!  No narcotic seeking behavior! 

The second patient had three complaints: chest pain, localized to the left side wall for 24 hours, no change with exertion, position or deep inspiration, this was the second time she’s had the pain, and the last time was a year ago.  There is some associated shortness of breath.  We don’t have an EKG machine that I can tell and given her age and risk factors she would have been a shoe-in for a heart catheterization to rule out/for reassurance.  Instead, I offered her an aspirin a day, which she declined.  She said that her diagnosis was that she was going to get pneumonia, but didn’t have any symptoms yet.  She was afebrile, had no cough, lungs were clear on exam and had no aegophany.  I even offered to write, against my own doubts, a script for amoxicillin in case she did develop symptoms of pneumonia, so as to save her the clinic fees again, but she declined.  (See, no med drug, antibiotic, or narcotic seeking!)  Her second complaint was feeling hot x 2 years, LMP 2 years ago, menopausal for the last 2 years…  I am not aware of any hormone replacement therapy available, so I reassured her she was afebrile and she seemed ok with that.  The third complaint was pain in the knees, ankles and feet.  Again, there was marked crepitus bilaterally.  I looked through the medication formulary and found the only injectable steroid was dexamethasone, and there was some cousin of lidocaine.  I offered her a joint injection, but she declined based on cost.  For the steroids and lidocaine, it would have cost 350 schillings, or about $3.50, but she had only brought 200 schillings with her.   I felt as if the encounter dragged on considerably, and I have much more empathy for anyone who has to use an interpreter on a regular basis (and makes me very thankful for being able to speak directly with my Spanish speaking patients!)  At the end of the visit, the patient asked, if she were to come back the next day, would I be there.  In my mind I’m thinking that she is thinking, “Who is this crazy white girl, maybe doctor?  She wants to give me aspirin and I don’t want it.  She wants to reassure me she doesn’t think my chest pain is because of my heart, but she still insists aspirin may have protective properties.  She is convincing me I don’t have pneumonia, but what if I get it tomorrow?  Why doesn’t she want to take my blood?  She could test for typhoid or malaria, but I have no symptoms, she could check for pneumonia, I’m sure.  Why won’t she take my blood?  Why is this the longest time I’ve ever been in a doctor’s appointment?  I wonder if this girl knows what she is doing?”  In reality, she said she appreciated the way I interacted with her, and she would come back tomorrow afternoon for the joint injection, if she could get the money.  

Katy’s Days

It’s my turn this week to learn obstetric ultrasounds, and today I promptly asked my preceptor to confirm a twin gestation that he said was “straightforward singleton”. Okay, so I need more practice. After that, I did get a real twin gestation and practiced measuring dates on two babies for the price of one!

Cesarean section is very different in Africa in the sense that the field is a little bit more bloody, seeing there are no electrocautery set up, and you only get five lap sponges the whole case. FIVE. Marta and I have been alternating to be the primary with our preceptor. Most of the uncomplicated vaginal deliveries here are done by nurses and nursing students, since there is a nursing college on site. When they get in trouble, as in the case of a retained placenta yesterday, they’d call in the daktari. After manual extraction of the placenta in fragments, IV and IM oxytocin to contract the uterus, and bimanual massage, there was still a lot of vaginal bleeding, so we requested help from the surgeons for a potential hysterectomy to save her life. Thankfully, we established hemostasis enough and examination under generalized anesthesia allowed us to identify and repair several lacerations.

One hospital phenomenon that’s especially worth mentioning is that a patient of mine left this morning (Wednesday), but she was discharged on Monday! Yup, if you can’t pay the bill, you have to stay in the hospital and wait until someone pays your bill, whether it’s family member, or in her case a Children’s Fund. I can’t imagine how this practice would pan out in the States.

Since we’ve been here, we’ve seen many premature births. Kyle attributes some of that to heavy duty manual labor, which makes me wonder about my recommendations to my early second trimester moms who want to start leave of absence (FMLA) right then for belly pain and back pain, since I’d tell them, “In many countries, women work up until the day they deliver, so there is no medical indications for you to start staying at home now.” The youngest estimated about 22 weeks gestation age (5 ½ months), and there was nothing we could do for the baby girl, except to keep her comfortable and let the native nurses ask mom, in their culturally acceptable way, whether she’d want to see the baby before she died.

Yesterday was a bittersweet day (UPSETTING CONTENT, not for the faint of heart). One first time pregnant mom came in for “three days of abdominal pain.” As I asked more questions, the shocking truth came out. She was about 24 weeks pregnant, and right before she got pregnant she was diagnosed and treated for Typhoid fever and amoebiasis. She has also been having nausea, vomiting, and poor appetite, so last week she went to Eldoret for an abortion. She later revealed that she chose abortion because she was a single primary school teacher, and the man became distant when she told him she was expecting. The more horrifying fact is that she went to someone who “gave her some drugs and put something in her uterus,” which is likely to induce abortion. On my ultrasound I didn’t see a foreign body, but I did find twins (really, there were two). At this time my preceptor came in and heard the story. A father of four young children, he was visibly upset by whoever’s performing abortions on twins, not to mention abortion is illegal in Kenya! Kyle spoke rather directly with her, and she expressed remorse, stating this was why she came to the hospital yesterday.  Kyle did the sterile vaginal exam, on which the cervix was visually closed, but there was frank pus and blood in the vault. She was then admitted to get intravenous antibiotics, while the gram stain showed gonorrhea. Thankfully, ferning was negative, so she didn’t break her water, yet, and she has some time to get steroids for maturing babies’ lungs.  A little bit later, Marta went to check on maternity ward while I was in a C-section and found out more to the story, which I’ll put in her own words:

“   A short time later as Katy was finishing a cesarean section, I went down to see that everything was under control on maternity, and a nurse told me, another nurse had felt a syringe in the patients vagina.  I’m not entirely sure she was being checked at such an early time, but I donned my sterile gloves and as I had the patient open her legs for the exam, a 6 cm long piece of plastic was protruding from the introitus!  Her SVE was 4 cm dilated, very thin, and +1 station, but the presenting part was something other than head as both twins are breech.  I was sure the patient would have delivered overnight last night, but she is still currently pregnant tonight, and still receiving steroids to help their lungs mature!  The patient is remorseful, and knows she did the wrong thing so caring for her and the babies is easier.  I’m not sure what we would do if she hadn’t changed her mind. “

So please pray for this mom, who is in such a difficult dilemma and both physical and emotional pain. And pray for the babies, who may have a chance of surviving if we can get the steroids in and mom’s infection under control. I can’t believe what they used to induce abortion, and I’m thankful the mom came when she did, and that the babies are still beating their hearts and going strong. One of the student nurses was so upset by what happened, but I told her this is one of the reasons we’re here, to catch people when they’re in trouble and help them turn around, to reassure them of the forgiveness in Christ, when they realized they’ve done wrong and want to make things right.

Sorry to end things on a sad note… The next one will be more cheerful, I hope. Just an FYI, I’ve killed 3 mosquitoes while writing this note.