First real day in the hospital

Thursday the 16^th

Thursday was my first full day in the hospital.  I rounded first with the pediatric team and then with the nursery team.  Although all the residents, interns, students and hospital workers speak English, it is difficult at first to understand the accent and some of the variations of medical jargon that they use.  I had to listen closely as we rounded, and even then I missed some of what was said.  Thankfully, the pediatric team is run by a 3^rd year family medicine resident who knows his stuff.  I did not have a whole lot to add to the patient management that first day. 

Medically speaking, there were a number of interesting cases that we dealt with that day.  Among other patients, we had one child with a bullous rash that the dermatopathologist though was consistent with staph scalded skin syndrome.  Bullous impetigo was also high on the differential above other less likely disorders like pemphigus vulgaris, bullous pemphigoid, and epidermolysis bullosa.  The child had a rash about a month prior to admission which improved when she was on Augmentin for 2 weeks, then worsened shortly after stopping Augmentin.  In the hospital, we placed her on cloxacillin and her rash improved again.

Also on that first day, I was introduced to several patients with myelomeningocele (spina bifida) and one with encephalocele.  Since these disorders are generally a product of insufficient folate during pregnancy, I began to wonder if there is any significant community education on the importance of prenatal folate.  Later I would learn that most of the these kids are of the Maasai tribe, who have diets high in meat and milk (and sometimes blood), but few vegetables.  Most pregnant Maasai women do not seek medical care early in their pregnancies, either.  When they are discharged from the hospital after giving birth, they are sent home with folate and told to take it for the rest of their lives, but most stop taking it as soon as the first prescription runs out.  Kijabe also sees many cases of MMC and encephalocele because they have the only neurosurgical program in East Africa that deals with these kids.  Patients travel from surrounding countries to come to Kijabe for treatment.

We also had a patient with adenoidal hypertrophy so severe that he had congestive heart failure.  ENT does not want to intervene surgically until cardiology says it is o.k., so the child will continue to have CHF until cardiology says he can have surgery.  Orthopedics consulted us that day to see a girl with severe rickets (bone disease due to vitamin D deficiency).  She was a very sweet little girl with severe bowing of her legs, widened wrists, and a rachitic rosary.  These are the classic signs of rickets that we are taught about in medical school, but never actually see in the U.S., although vitamin D deficiency is becoming more common as our culture consumes less and less dairy.  Several patients that day had pneumonia, TB, and/or malaria.  Although I did study malaria quite a bit before coming here, the treatment is actually quite different than what I had read, mostly due to limited medicine choices because of expense.

After pediatric rounds, I was attended nursery rounds with Dr. Jaster, the family medicine physician who has been running their nursery (read NICU).  The diversity and depth of his knowledge in pediatrics and in neonatology are quite impressive.  Patients in the nursery included a less than 1 kg baby on a ventilator.  This baby was not doing well and needed a femoral stick to obtain blood since the lab was unable to get any.  Dr. Jaster asked me if I wanted to do the stick, which I agreed (with some trepidation) to do.  I recalled the mnemonic for femoral vessel position “VAN” for “vein, artery, nerve” but couldn’t recall if that was medial to lateral or lateral to medial.  The distinction is quite important.  Dr. Jaster reminded me of the NAVEL mnemonic (nerve, artery, vein, empty space, lymphatic) and that the order was lateral to medial.   This is the first femoral stick I have done since residency, now at least 6 years ago, but Dr. Jaster reassured me that if I hit the artery instead of the vein, I could just hold pressure for a while.   The stick turned out to be semi-successful in that blood was obtained from the site after I removed the needle (rather than me drawing blood through the needle).  This baby ultimately had severe intraventricular hemorrhage (a bleed in the fluid spaces of the brain which carries a poor prognosis) and renal failure and did not make it.

Later that day I was back on pediatrics and was grabbed by a clinical officer (a mid-level practitioner in Kenya) to “confirm something”.  Not knowing what I would find, I followed him to the clinic area for neurosurgery.  He led me to an exam room to find a small child with truly massive hydrocephalus.  A shunt had been place about a month prior for the purpose of draining excess fluid from the brain to the abdominal cavity so it could be reabsorbed.  The child had been brought by mom to the clinic that day because he was sick.  The shunt that had been place had eroded through the skin of his neck and was exposed to the open air, which is not a good thing.  The child was apparently dead on arrival, which I had been called in to confirm.  I confirmed that the child had no respiratory effort, no heart rate, no pulses, and fixed pupils.  The C.O. proceeded to tearfully comfort the mother, who apparently did not realize yet that her child had passed away, and I was asked to complete the death certificate.

I was then called back to the nursery to evaluate a baby who had just been born.  The baby had respiratory distress, hypoxia, and generalized edema.    He also had an unusually shaped chest and low-set ears.  Chest x-ray showed no cardiomegaly, but a possible lung infiltrate.  Ultrasound was performed and showed no abnormality of the liver, spleen, or kidneys, but did show a small pleural effusion (fluid around the lung) and a little free fluid in the abdomen.  The differential diagnosis for these findings includes renal disease, hypoalbuminemia, hydrops fetalis, Noonan syndrome, and Turner syndrome.  Labs were ordered to try to discern what the actual cause may be, though some studies that would be helpful are just not available here.

Having so many new and severe disorders present in the same day made it quite an overwhelming day and made it difficult to fight feelings of being inadequate for the task at hand.  I would truly have to depend on God to provide for me the wisdom and skill to choose the right things and perform them adequately.  The day definitely increased my anxiety about the upcoming Friday night call, despite constantly reminding myself that we are to be anxious for nothing and that we are to cast our anxieties on Him, because He cares for us.  Ready or not, Friday was on the way.