One week down

So I’ve been asked many times how work is going, what it is like, etc. I think I can best sum up my first week in casualty (the Kenyan form of an emergency department) with one word…different. Different culture, different language, different diseases (although there are many that are the same…they are just often far more advanced), different expectations, different way of thinking/practicing medicine. Thankfully I wasn’t blindsided by this. Through the various people who have been at Tenwek and in casualty I had acquired a pretty good idea of what I was in for. In fact, I was fully expecting most everything that happened throughout the week, but that certainly didn’t make it any easier as events unfolded. I wanted to wait until the end of my first week to make a post so I could ensure that it was a more accurate representation of how things work (but after only one week I am by no means an expert). I apologize for the length of this post but I wanted to really paint a picture of “real life in casualty”.

First, an overview of my role in casualty. I am a consultant (which is interesting because I am in no way an expert…especially when it comes to tropical medicine). A clinical officer, whose level of training is similar to a mid-level provider in the U.S., runs casualty. I can see patients on my own and I also oversee their patients. They are able to perform most minor procedures on their own and I have been amazed at the level of skill with which they perform them. (They perform LPs daily and they are done with both impressive accuracy and speed!)  I also serve as a consultant for the outpatient clinic.  Six rooms are running to churn out a large number of patients.  When complicated patients present they call me to help determine a plan of care.  I’m not sure if I am actually helpful in this regard or not.

This was a patient I was asked to see.  Progressive skin lesions for one year now increasingly painful.  It turns out he is HIV+ and our working diagnosis is a fungal infection.  Hoping to get pathology back soon to see if we are correct.

The casualty department is a very interesting part of the hospital. It has seven beds with additional chairs between each one. (One bed is in a resuscitation room.) Often times the beds and chairs are full so additional patients are packed into whatever space is available. Oxygen and machines to check vitals are limited…two for the department…so patients routinely are being shuffled around to check vitals and to provide supplemental oxygen. The limited supply of machines also means that continuous monitoring is nearly impossible. As with many countries outside the U.S., there are a lot of times when you have to “hurry up and wait and wait and wait”. This can definitely be a frustrating experience when speed can be so important. There is a definite benefit to working in Kenya (well there are a lot but this is definitely a good one)…chai. At 10 am and 4 pm everyday it is teatime and at 1 pm I get an hour for lunch (which means I can walk home and eat with Steph and the kids). This is a big upgrade from potentially not eating/drinking anything for an entire shift!

 

These are two views of casualty.  Patients and staff everywhere.  Because patients aren’t usually gowned until they are admitted, it can be difficult to determine who is the patient and who is family.

As I mentioned earlier, the diseases that we see are different and/or more advanced than what we often see in the states. HIV and TB are very common, which means that the secondary diseases related to these are also common. Because of the lack of access and lack of resources, people will often wait until their illnesses are far more advanced. I have yet to see anyone show up with the sniffles or a stubbed toe. The finances are interesting as well. For some studies, such as CTs, patients/families have to pay up front. The costs are expensive for many families, which means that obtaining the study could be delayed by days.

 

This is a breakdown of the cost for various CT studies.  The conversion is 83 shillings to a dollar so a non-contrast CT of the head is ~$82.

For those of you who want more details of what I have been seeing, here is a day-by-day summary of my first week.

Day 1
Going into work I was informed of a measles outbreak overnight. Four children were brought in and sadly one died.
It became obvious very quickly that normal vital signs in casualty is not a normal occurrence. I lost track of the number of patients with low O2 sats…and I’m not talking about borderline, argue with the admitting team kind of low. There were several people (who walked in) with sats in the 50s-60s.

There was a woman in her 40’s who is one-year s/p MVR who presented in respiratory distress with a RR in the 20s-30s. She was tachycardic in the 170s but shockingly had a relatively “normal” saturation. Her x-ray showed either an unusual pattern of bilateral pneumonia or a very unusual pattern for pulmonary edema. We began treating for both and it was two days before the admitting team finally decided that it was pulmonary edema. She has since improved.

We saw another woman who presented with “an allergic reaction” to an antibiotic. She had one episode of vomiting and developed a diffuse rash. Strangely, the rash did not appear at all allergic. It had a striking resemblance to chickenpox (or even smallpox) although she reports having had chickenpox when she was younger. Her GI upset improved and she didn’t meet criteria for smallpox so we sent her home with a follow-up appointment next week.

We also saw a man in his 20’s with HIV. He c/o headache, fever, and pain throughout his back/neck. An LP confirmed cryptococcal meningitis. Throughout medical school, internship, residency, fellowship, and working as an attending I have never seen this diagnosis. This was the one of two patients with this diagnosis this week.

Day 2
Again we saw numerous patients with abnormal vitals (systolic blood pressures in the 60s-80s and O2 sats in the 60s-70s).

My partner saw an elderly woman with an advanced abdominal tumor. Labs showed severe renal failure (Creat of 1299) with hyperkalemia (her K was 10). A CT confirmed an advanced ovarian tumor with mets. Her family did not want her to die at home so she was admitted with comfort measures.

One of the common patient presentations here is organophosphate poisoning as a suicide attempt. While overdoses are common in the U.S., they are generally due to illicit drugs or various types of pills. Other than alcohol and marijuana, drugs are not readily available and neither are prescription meds. Fertilizers and other organophosphates are so these are the methods of choice for many people.  My patient was in his 20s and was initially seen at another facility. He had an NG tube placed and had gastric lavage. He was also given atropine. On arrival he had a GCS of 3 (for reference for any non-medical people, a rock also has a GCS of 3). Basically he was comatose with a low respiratory rate. Shockingly, despite his respiratory status, when we placed him on a non-rebreather, he had fairly decent oxygen sats. In the states, care of this patient is a no brainer. He gets intubated, 2-PAM, and a call to the ICU for admission. Not as simple here. First, we have no available vents. Second, we have no ICU beds. Because he was maintaining his sats well what we decided was to intubate and place a T-piece on the ETT, which would serve to protect his airway. My residency at Lehigh Valley prides itself on producing experts in airway management and I would like to think that I could handle an airway relatively well. I had everything prepared (no back up airways except for a couple bougies that I brought with me). After passing the tube, a copious amount of secretions blocked the tube and the suction (which had just been working) malfunctioned so I had to pull the tube. After re-preparing and fixing the suction issue I intubated him again. Suctioned everything and began bagging…and his O2 sats dropped. After rechecking everything, I found that the BVM was malfunctioning so it was disconnected and we found one that did work. After several minutes of getting him situated we finally connected the T-piece and his oxygen levels improved. Thankfully after about 90 minutes a bed and vent became available and another hour or so later he was moved out of casualty. I heard that he has since been extubated and will likely make a full recovery.

Day 3
This day brought more extremes in terms of vitals and labs. Apparently it is possible to actually be alive with a Hgb of only 2 (two patients presented with this). The level for transfusion here is <5…they obviously met this criterion and were admitted.

The day before I saw a gentleman in his 30s with metastatic, end-stage gastric cancer. He presented with GI bleeding (probably from his tumor) and a low Hgb (~5), which was causing symptoms of weakness, shortness of breath, and dizziness. After long discussions with both him and his family, it was decided that we would provide a one-time transfusion to give him more time. Blood supplies are limited so his family had to provide the blood (sadly we can’t provide from our supplies to someone who is terminal). It took all day to acquire the blood as the relatives with the appropriate blood type had to be located and transported to the hospital. He was to receive the blood overnight but because of a lack of staffing, it did not begin until late morning. He was discharged home from casualty late in the evening the following day.

A one-year old severely malnourished baby presented in status epilepticus. IV access was impossible and no rectal benzos were available. An EZ-IO would have been awesome but those are significantly cost-prohibitive. One of the interns attempted an IO with an IV needle but that ultimately failed. Eventually IM meds were acquired and the seizures stopped but it was difficult to watch the prolonged duration of the episode.

Day 4
When I walked into casualty this day it resembled a pediatric ward. Apparently three separate motorcycle incidents had provided us with three pediatric patients. (There has been a sharp increase in the number of motorcycles in recent years. This is due in part to the removal of taxes on them in 2008 to promote business…they are commonly used as a means of taxi service [boda bodas]. The influx of cheap motorcycles from China has also contributed to a marked increase in ownership. On any given day in casualty there is easily at least a handful of vicitims due to this mode of travel.)

 

Common sights around Kenya as people and supplies are transported on motorcycles.

I took a five year old and began the process of repairing two moderate-sized scalp lacerations. Again I found myself missing some of the amenities of LVHN. A papoose is a very useful tool when trying to suture head lacs on a child…we instead used three relatives (by the time I was done they were dripping with sweat…that was a strong little girl). Copious amounts of clean or sterile saline are the best way to prevent wound infections. We don’t have unlimited supplies so we use what is available and do the best we can.  Large syringes are useful to provide a means a high-pressure washout. Not available so we just use gloved fingers to hopefully remove all debris. African hair is not ideal when trying to suture an underlying laceration. Hair clippers aren’t an option so they use a #15 blade…and it was the cleanest shaven scalp I think I’ve ever seen. After a bit of a struggle we did manage to hold her still long enough to allow me to suture the wounds and we sent her on her way. Unfortunately one of the other children was in a little worse condition. In addition to a head lac, he also had a pelvic fracture so he was admitted for bed rest and analgesia.

Pelvic fracture after being hit by a motorcycle.
Later that day we received another victim of a motorbike accident. She was five and was struck when crossing the road after school. She was initially seen at a local clinic and was referred to a nearby hospital due to a severe head injury. This hospital started an IV and referred her to Tenwek for a CT scan.  (It was clear from exam what her injuries were but this facility did not have the resources or personnel to care for her injuries.)  Her family transported her the 1-1 ½ hours to Tenwek. Sadly by the time she arrived, she had already died. A cursory exam indicated that she had a skull fracture with underlying brain injury/bleeding. Her family bought a blanket at a local market and carried her body out for the long journey back home.

Day 5
The day started with more significant trauma. This time it was a 47-year old man who had been pushing a car that was stuck in the mud. Somehow his foot/ankle was run over and nearly severed his foot (I won’t post the picture of that…I think the x-ray gives a pretty good idea of his injury.) What was most surprising was the level of pain tolerance he had. He never screamed or cried. In fact, I never saw him do anything more than wince in pain.  He was taken to the theatre for a BKA.

Significant tib/fib fractures.  The overlying tissues were almost non-existant.
Later I saw a 37-year old woman with a hx of metastatic colon cancer who in the last year had under gone resection with a diverting colostomy as well as chemo. Her cancer had recurred and she was now on hospice. Her family brought her in because they became concerned with her respiratory status. She was hypoxemic in the 50s with obvious pulmonary edema, renal failure, and significant hypotension. We placed her on a non-rebreather and I spoke at length with the family. The chaplain prayed with them in Kipsigis and we kept her on oxygen while her family all came in to say their final goodbyes.
There was a little levity that occurred when a man in his 20s came in and threw himself on the ground. He appeared intoxicated (the nursing staff said that he definitely sounded intoxicated as well). He never really complained about anything but he kept flopping around like a fish out of water and would hit himself in the abdomen and chest. Felt kinda like I was back at Sacred Heart dealing with my psych patients.  He eventually just walked out.

The last patient on my shift was pretty impressive as well. He had a tooth extracted a week prior and developed increasing swelling of his face, neck, and chest along with a muffled voice, difficulty swallowing and now with increased work of breathing. He was seen at another hospital, was diagnosed with Ludwig’s angina, received a dose of antibiotics, and was sent to our facility for definitive care. To say he was sick would be an understatement. He had an abscess that started in his jaw and extended down his neck and across the upper half of his chest. He was quickly sent to x-ray while we contacted surgery. His x-ray showed that his condition was even worse than we first thought as he had a massive pre-vertebral abscess as well. The surgical intern worked to get his consultant to come evaluate the patient and an OR was cleared while additional medications were infused. Honestly, I think he had less than an hour before his airway was completely occluded and a surgical airway would not have been a possibility due to the extent of his infection. What I wouldn’t have given for a fiberscope and supplies to nasally intubate!!

   

I have never seen an x-ray like this before.  The large black part on the neck film is all abscess.  His airway was only ~2 mm wide due to the significant amount of swelling that was present.  You can see the density (another large abscess) on his upper chest on the CXR as well.

 

So that is an overview of my first week. From what I hear, every week that follows will probably provide equally challenging patients in terms of the severity of illnesses and unclear diagnoses. I definitely feel out of my league with what I have been seeing and trying to manage.  One thing is clear.  God is alive and is at work at this hospital through all of the doctors, nurses, chaplains, and other staff.  It is clear that lives are being forever impacted and Tenwek is truly living up to it’s motto – We Treat…Jesus Heals.

Prayer requests:

That we will continue to transition to our new lives in Kenya.  Thus far it has been relatively easy but we don’t expect that to always be the case.

That we will all be able to develop deep and meaningful relationships with our fellow missionaries as well as with the local peoples.  One large opportunity for this is the house help that we have hired to work for us 5 days a week.

One of my personal goals is to learn Swahili to be able to better communicate with some of my patients (there are dozens of tribal languages but this is one of the more prominent ones).  I’ve never been gifted in languages so this will be a challenge.

That no matter what happens, that we may seek the Lord’s will and diligently follow his leading on our lives, no matter the cost.