Week 2 Recap

So another week in casualty has meant another week of almost unbelievable cases. I spent slightly less time in casualty this week as there were several meetings that I was attending but this definitely didn’t mean there was a shortage of interesting cases! First, updates on patients from last week.

The woman with questionable pneumonia vs. pulmonary edema finally did turn around after several tenuous days. It would appear that it was pulmonary edema but the x-ray remained highly unusual for this.

The woman with the allergic reaction and unusual skin rash resembling chicken pox recovered fully.

The young man that I intubated after ingesting organophosphates has made almost a full recovery. He was extubated, was doing remarkable well, and should have returned home by now.

My last patient of the week (the one with the prevertebral and anterior neck/chest abscesses) was taken to theatre and was successfully intubated. The extent of the abscesses was pretty impressive but they were drained and, the last I heard, he was making an impressive recovery.

Now onto some of my patients from week 2. Again it seems that “normal” vitals are a rarity when working in casualty. We saw many more people (of all ages) with respiratory infections, organophosphate ingestions, and trauma…lots of trauma. As usual, the predominance of motorcycles created a lot of work for the ortho department.

 

Sadly many of the patients that present, do so too long after their injuries have occurred.  We had a 45 year old man who presented from a district hospital.  After being there for a week his family felt he could receive better care at our facility.  He had fallen ~20 feet and complained of back pain and bilateral lower extremity paralysis.  His exam confirmed his paralysis along with loss of sensation starting at the T9 dermatome.  He brought his x-rays with him which helped to explain his condition.

So I have grown accustomed to treating patients with psychiatric disorders, especially with the time I spent at the Muhlenberg campus and Sacred Heart.  I still wasn’t ready for seeing psych patients here though…

I had two patients come in that were tied up by concerned family/friends.  I’ll be honest, this form of restraint is more effective than the soft restraints that we generally use.  Another benefit is that we don’t have to place an order for the restraints every couple hours.  In both cases we medicated them (sadly we don’t get to IM HAC them).  When they awoke and were behaving, we sent them home.  Tenwek does not have any robust psych services.

 

We also saw a patient with known metastatic cancer.  Her primary tumor was a soft tissue tumor of her right elbow.  It had advanced to the point where it was degrading her bones and had also spread to her lungs and other organs.  She presented because the lesion began bleeding and she couldn’t get it to stop.  Here are her x-rays.

Probably the saddest case of the week involved a 14 year old girl.  When I arrived to casualty on Wednesday I heard her crying out in pain.  I found out that she had presented to have a CT of her head.  She was seen one month ago with complaint of headache.  An LP was not performed because she had an abnormal eye exam (if it had been done she probably would have herniated).  A CT was not done immediately and I’m not sure why (it was likely due to lack of funds).  The scan was already done so I pulled up the film and this is what I saw…

 

After seeing the scan we called the chaplain so he could be present when we discussed the results.  It turns out that the people at the bedside were the child’s aunt and uncle (her mother passed away years ago and her father was not yet present).  Basically, with the size, location, and extent of the tumor, she was terminal.  A referral to a neurologist in Nairobi was offerred but they understood that it was unlikely to change anything.  We discussed setting up hospice and then we prayed over her with her family.  When we were done praying the chaplain pulled me aside and told me that during the prayer he noticed that she had stopped moving.  I went back and reassessed her and he was right.  She died as we were praying over her.  I have been present for the death of many patients but it never gets any easier.  I am just thankful that she is no longer hurting.

 

There were many other interesting (and generally sad) cases.

 

Some other cases (sorry, no pictures) included a woman in her 70s who presented to the outpatient department.  The CO thought she may have breast cancer as she had ulcerated lesions across her breast.  It turns out that she had a severe case of shingles.  Can’t say I’ve seen a case that bad in a long time.

On another day I came in to find a two year old who had just been intubated.  He was HIV+ and had three weeks of left sided facial swelling.  He presented in respiratory failure and was hypothermic.  We thought initially that the swelling may be Burkitt’s lymphoma.  Pathology found that it was likely a case of TB.

I had another patient that I was sure had meningitis.  She presented with complaint of severe headache, photophobia, fever, and neck stiffness.  LP was done and was completely negative.  After a liter of fluids she felt better and went home.  I have no idea what was wrong with her.  (Go figure…just when I thought I was starting to figure some things out.)

So that is basically what my second week of work consisted of.  Overall, I am starting to settle in to work here.  In some ways, I find that it is easier working here compared to working at LVHN and yet in other ways it is much more difficult.  As for family life, the kids are absolutely loving Kenya.  They are constantly outside playing and exploring and getting into trouble.

 

As I’ve been thinking about the cases I have seen over the past couple weeks it made me think of a song by Andrew Peterson.  It is called After the Last Tear Falls and it pretty much sums up the hope that exists despite all of the pain and suffering we experience in this world.  Here is a link to it http://www.youtube.com/watch?v=8GiPb6gwuPQ (I can’t really vouch for the video as our internet is slow and I couldn’t get it to play).

 

Thank you for your prayers, kind words, and expressions of love.  I doubt we would be here or doing as well as we are without them.  Additional prayer requests would include:

-improved health for Hannah as she as been fighting a stomach bug
-peace for Kenya…elections are quickly approaching and there is the potential for violence to erupt (although many believe that things will go smoother this time than they did during the last election)
-that we will continue to acclimate to our new home/surroundings
-that we will find meaningful ways to engage  and connect with those with whom we come in contact