Mood swings

Oof. This morning was a challenge. It was yet another reminder (as if we needed one) that the limits on providing care at Bugando extend far beyond lack of laboratory tests, diagnostic tools, or therapeutic interventions. Let’s revisit the last 24 hours!

Yesterday morning, ICU rounds
Patient 1: 43 year old male, recently underwent an exploratory laparotomy for a surgical abdomen (which, incidentally, revealed a liter and a half of fluid that had accumulated for no apparent reason, and of course, did not get sent for analysis), with post-operative severe hypertension.
What we would do in the US: use any number of IV anti-hypertensives at our disposal
What we were doing: using hydralazine, the only IV med we had, while hoping that he would be able to take oral medications before he had a stroke
What happened yesterday: He passed gas! Hooray! We started him on 2 oral anti-hypertensives. By the afternoon he had achieved target BP reduction.

Patient 2: 41 year old male, in the ICU for 3 weeks with severe tetanus.
What we would do in the US: probably run frantically to Up To Date because we have no idea how to manage tetanus
What we were doing: effectively controlling his spasms with a combination of sedating medications. He was past the worst and was getting better every day; the only problem is that he hadn’t had a bowel movement since coming in, and was now starting to eat. We had tried a lot of stool softeners and they weren’t working. This day he had started hiccupping (a sure sign that the gas he was making was coming out the top instead of the bottom), so we asked the nurses to do an enema.
What happened yesterday: he had started vomiting bile, and (understandably) refusing to eat food. We asked the nurses, again, to do an enema.

Patient 3: 37 year old female with a recent self-induced partial abortion, who had developed endometritis, likely sepsis, and complete anuric renal failure with encephalopathy.
What we would do in the US: urgent hemodialysis, imaging, and probable hysteroscopy to rule out retained products of conception.
What we were doing: first, trying massive doses of lasix to try to generate urine output (unsuccessful), then attempting to convince the surgeons to place a peritoneal dialysis cathether so we could perform intermittent PD in the ICU. Oh, all this without any way to objectively measure her renal function.
What happened yesterday: The surgeons took her to the OR! Hooray! We planned for PD overnight.

Patient 4: 39 year old female, known diabetic, who recently went to a healer in Arusha who has been telling people that he can cure 5 common diseases (AIDS, TB, asthma, diabetes, and epilepsy), with a plant boiled for 10 minutes. She had stopped her insulin and presented in diabetic ketoacidosis, as well as neck stiffness, fever, and altered mental status.
What we would do in the US: DKA protocol, head CT, LP
What we were doing: actually pretty close. No imaging, but we started the DKA protocol and did the LP
What happened yesterday: CSF was in the lab for analysis, and her blood glucose was improving. We planned to transition her to an outpatient insulin regimen.

Annie, Judith, and I left triumphant. We had made some big steps forward.

This morning (Saturday), ICU: We walk in to a disaster.
Patient 1 (hypertensive emergency): after stopping the hydralazine drip and starting PO medications, the nurses saw that his BP had rebounded somewhat. Instead of giving him a PRN medication to keep him off the drip, they restarted the drip and skipped his AM medications.

Aftermath: This one isn’t so bad: we stopped the drip, added on more oral medications, and left detailed instructions for the nurses).

Patient 2 (tetanus): continued to vomit bile, refused all oral intake, no bowel movements. No enema done.

Aftermath: Even this one is OK: Annie hovered over a nurse until she did the enema. And he had a bowel movement! Yay! Poop!

Patient 3 (complete renal failure): Mubarak (an amazing resident here at Bugando and the man in charge of peritoneal dialysis) shows up at 11pm to start dialysis and finds the patient in a pool of her own blood (hemorrhaging from her cathether site). He orders an urgent blood transfusion, holds pressure for 2 hours before she stabilizes. Labs from 3 days ago return showing that she is in DIC. This morning, she is stable, but unarousable.

Aftermath: peritoneal dialysis is finally started, but she has lost alot of blood, and being in DIC isn't going to help things.

Patient 4 (DKA +/- meningitis): We show up to find her intubated. The flow sheets show that she became hypoglycemic in the evening, but the insulin drip wasn’t stopped. Then at some point, the drip was stopped. In the middle of the night, she inexplicably became hypoxic and was intubated. This morning, she was back in DKA. Oh yeah. They never sent the CSF.

Aftermath: We took the CSF down to the lab ourselves, and re-started the DKA protocol. Unfortunately, patients who get intubated at Bugando have essentially a 100% mortality.

So. It was rough. Now, as usual, onto some happier items!

1) The boat ride happened!!! It was amazing actually; you can sit on top of the boat and have a completely unobstructed view of Lake Victoria and Mwanza. One of the coolest things we’ve done here.
2) Thursday, we went to yoga, then came back to have dinner at a local restaurant that we all like to say goodbye to Jenny, one of the OB residents who was leaving. It was a blast, until a crazy thunderstorm started and the power went out in the city all within about 3 minutes.
3) Friday, we went back up to Dancing Rock and had a picnic for our friends Sonabel and Nora, Cornell med students from Qatar who left today. Then Annie and I came home and watched West Wing, and I started on The Plague (loving it so far).

This weekend’s big plan: possibly a trip to Capri point (apparently the neighborhood where the wealthy Tanzanians live, with lots of scenic viewpoints).

Oh yeah. Annie and I bought some chocolates for the village kids behind one of the houses, and I got to give them out. I felt like Santa. It was AWESOME.

Till next time!