MCI at Tenwek…almost

Now that I have your attention, I can tell you about what I have been doing recently. And I’ll get to the MCI part in a bit. So this has been another interesting week that, among other things, has made me increasingly grateful for the life and health that I have been blessed with. I wish I could give a detailed outline of everything that I see but unfortunately there is just so much that it isn’t possible. Maybe I should hire a scribe to document everything for my memoirs…

As usual, lab studies, vital signs, and images are anything but normal. We have continued to see so many cases of meningitis, HIV, TB, and plenty more trauma victims. One patient that stood out was a 28 year old (I honestly thought she was in her 50s when I saw her). She was HIV+ and was on the standard regime of HIV meds and TB meds. She was incredibly tachypnic and tachycardic and she also had a fever. Her kidneys were failing (I’m still getting used to the difference in scale. Her creatinine was 367…the conversion factor is 88 but my simple mind just rounds that up to 100) and she was also anemic. Here is her CXR.

We didn’t have a recent CD4 count for her so our presumptive diagnosis (there is no way to confirm this) was PCP. One of the difficult things about these patients is trying to determine what the underlying disease process is. I’ll spare the medical details but TB, pneumonia, and PCP can all resemble each other quite closely so many times we treat what seems to be the most likely (sometimes we treat for several) and hope they get better. Such is medicine in this setting.

On another day I came in to see a patient that was already being evaluated by the admitting physician. She had the worst hemoptysis and hematemesis that I have ever witnessed. She was in her 40’s and presented with two weeks of progressive shortness of breath. Her prognosis was not good so she initially was made DNR/DNI. After discussing the case with the endoscopist, however, it was decided that we should intubate her so that she could have endoscopy (which was really her only chance of survival). We prayed over her prior to intubation and she was later taken to the ICU. As she was wheeled out of casualty, we knew that her chances were likely not good. In early evening she coded and was successfully resuscitated. Unfortunately, overnight she succumbed to her illness. I was told by the admitting physician that she was a believer.

The degree of pathology continues to amaze me. There was a patient that had been seen several months ago and had a frontal tumor removed. He presented with progressive left sided weakness and had a repeat CT done which revealed the cause of his symptoms.

I also saw several interesting patients in the outpatient department. I was asked to consult on a patient in her 30’s or 40’s (I can’t remember). She presented with marked jaundice along with mild abdominal distention. Her labs confirmed that her liver was not working properly. An ultrasound had been done that showed a dilated common bile duct but no gallstones or mass. I discussed with the CO the need to get a CT and the potential for cancer. Unfortunately it was an extensive tumor involving the biliary tree. She is to be evaluated by surgery but likely any therapies will only be palliative in nature.

I saw another patient that I’m still not exactly sure about. She had been seen earlier in the week by my partner with complaint of headache. She was having some visual disturbances as well and after being evaluated by opthalmology, it was found that she had bilateral papilledema. A CT scan was ordered and upon my evaluation, this had been completed and was normal (one of the few normal head CTs I have seen since arriving). We spent some time discussing her symptoms and one of the leading diagnoses was idiopathic intracranial hypertension. We decided to perform an LP (spinal tap) which confirmed increased pressures (we don’t have the extra tubing to actually measure…it’s more of an estimate based on the speed of outflow of CSF). After performing this, her pain began to improve. We started her on appropriate meds (I think) and she will return next week for re-evaluation.

On a much lighter note…I again had the opportunity to wrestle a patient (unfortunately this was the day after I resumed a workout routine…after a six month hiatus…ouch). Lets just say that it’s never good when you hear the screams of a patient from the time they are about 50 yards away. As the jumbled Swahili got louder (I had to confirm the fact that it was jumbled with someone who actually speaks Swahili. I didn’t recognize any of the 20 or so words that I actually know.) Thankfully this person was brought in by several friends who aided in the process of restraining him…on the ground…as he kicked, screamed, and cried. (I was kind of wishing that his friends had hog tied him like the other patients I’ve seen recently.) A combination of judo, pressure points, and overall manpower allowed us to obtain IV access and administer medications. We later found out that he had presented in an identical manner last year when he had meningitis. Needless to say, there was another wrestling match to allow a repeat LP to be performed. Sure enough…at least part of his problem again was meningitis. I saw part of his problem because while he was being seen by the admitting resident/consultant his friends divulged the fact that he also had a bleed in his brain at that time which was confirmed by the CT report that they had. (I’m not sure why they didn’t feel that this was pertinent information for us.) At this point his friends/family have not yet raised the funds to have a repeat scan so we are not sure if this is again the case or not.

For those of you who enjoy looking at imaging studies, here are a couple. I didn’t get quite as many pictures this week.

So I guess I should get back to the almost MCI. So Friday was an unusually slow day in casualty. At one point in the afternoon, a patient was brought back after being involved in an RTA (road traffic accident). The person who brought hime in told us that he was on a bus (of about 50-60 people) that had rolled over and people were trying to extricate other victims. This would not be the first time that something like this has occurred at Tenwek, although often there is NO warning until a large number of victims arrive at the front door. Numerous phone calls where then made to alert all interns, residents and consultants of the potential for a huge influx of patients. We cleared out casualty and relocated all of the patients in the outpatient department to prepare for the soon to arrive patients. One of the clinics located at the front of the hospital was also partially cleared so that it could serve as a temporary morgue in case there was a large number of fatalities. The cohesive manner in which everyone worked to prepare was actually quite impressive! So myself, the other casualty consultant, and a surgeon were then waiting at the front of the hospital. Looking around, we saw ~12-15 people standing around with gloves on ready for what was sure to be a lot of badly injured patients. A district officer was located and he contacted his supervisor who was on scene and confirmed the rumors that a roll-over bus accident had occurred. So there we were waiting…and waiting…and waiting…and waiting. There is no organized prehospital transport system so we can’t wait for a row of ambulances with sirens blaring to indicate the arrival of our patients. So with ever vehicle that pulled in we anxiously peered inside to see if our first victims were arriving. Every time was saw one of our chaplains pass by we asked them to be praying for us and the victims. I’m not going to pretend to be an expert in prayer and how God chooses to answer them but I’m pretty sure that a major bus accident should produce a lot of badly injured victims. I guess our chaplains really know how to pray because no such victims ever arrived. We heard a rumor that some may have been taken to a district hospital but the last I heard we never received another patient (and if any were badly injured the district hospital would be quick to send them to us instead). So our almost MCI did work well as a drill to assess how quickly we can organize for such an event. It also proved that it is possible to have an empty casualty department on a Friday evening. I kinda doubt we’ll be seeing that again any time soon.

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Aaron Kelley

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