successes and failures

So, on match day, I had 2 very interesting experiences at Bugando. Annie and I encountered the first when we came home for lunch and found one of our housekeepers asleep on the floor of one of the bedrooms. When we woke her, she said she was sick, was visibly sweating, and had a nasty cough. Annie listened to her lungs and heard some wheezing, so at lunch, our group made the executive decision to take her to the hospital (more so because we wanted someone who can speak Swahili to take an accurate history than because we thought she had anything dangerous.) Within about an hour and a half, Judy, Jess (2 of the other med students here) and myself had somehow managed to get her a chest X-ray, blood work, antibiotics, cough suppressants, and an actual face-to-face encounter with an ER doc…mostly by being pushy. It was kind of like a ‘day in the life’ of a Bugando patient, except that in this case the Bugando patient had 3 english-speaking, somewhat medically savvy, highly impatient helpers. We figured it was good karma for match day (turns out, it was!)

The other experience concerned a patient recently admitted to the ICU; a 20 year old woman who presented with shortness of breath, cough, decreased urine output, and a blood pressure in the 200s/100s. It turns out that she had been diagnosed with hypertension at age 16, but was not on medication and a secondary evaluation was not done; she now presented with end-stage renal disease.

People talk about how a uremic death is a peaceful one; that may ultimately be true, but the lead up is anything but. These are some of the unique experiences we’ve had at Bugando – watching the slow inevitable march of uremia in a patient with chronic glomerulonephritis, which you cannot definitively diagnose (because renal biopsies aren’t available), which you cannot cure (as neither are renal transplants), and whose symptoms you cannot even alleviate (because dialysis reagents are sparse and reserved for patients who have reversible acute kidney injury). On admission, she had headaches and signs of cardiac failure (shortness of breath, cough, lower extremity swelling). Yesterday morning she began to develop uremic pericarditis with the loudest and most unforgettable pericardial rub I’ll ever hear. Later in the day, intractable nausea and vomiting began, some blood tinged, no doubt the markings of uremic platelet dysfunction. Today, pruritis set in, causing her to itch as if she had been rolled in poison ivy. It’s true; eventually encephalopathy will set in and she’ll drift into a peaceful sleep. But I wouldn’t call her last 3 days in any way peaceful.

One wonderful thing is that Annie and I are learning to make decisions based on what limited resources we have; we successfully advocated for a trial of pulse steroids in the unlikely hope that she has a reversible inflammatory glomerulonephritis. I doubt either of us has ever advocated for so much steroids with such little evidence, but it’s either that or standing idly by. There are many limitations that are tough to cope with, for sure, but Bugando is an amazing place, with resources that are probably only available in the capital city of Tanzania. Which means that, even in the face of diminishing odds, we've chosen to look around at what weapons we have, gear up, and go down fighting. I should say that we've already had 2 patients (one cardiac arrest, one worsening septic shock) where our efforts haven't achieved much, but I think Gandhi was the one who said "you may never know what results come of your action, but if you do nothing, there will be no result." (Yay, pretentious ending!)