Tuesday, July 31, 2007

A late lunch

Post-call day.

I had yesterday's lunch at 0130 this morning.

Elizabeth, my stellar 3rd year resident, was baptized into the Kijabe medical community by sharing call with me and taking on our new service on her first day. As expected the call day was a challenge – it was Monday so all of the weekend travelers from Somolia, Ethiopia and central Kenya arrive in the ED or the Clinic by midday. We started out the morning getting our service rounding going and in the process of getting our team up to speed on all of last week’s admits from my call day and Dave Welch’s call day on Friday. We found one of our young ladies (the 19 y.o. with a belly full of pus that Mary Weirusz admitted right before she left) was in DIC from sepsis, laying in her bed slowing exanguinating from her abdominal wound. We transferred her to the ICU as fast as we could. We were covering the ICU that evening so we knew we’d be caring for her over night. Another patient with pneumonia had a progressive pulmonary effusion so we tapped it but found it was loculated so couldn’t adequately drain it. We had one “normal” patient, as Elizabeth noted. Our 88 y.o. with lobar pneumonia, dementia and an old stoke made us feel right at home and desirous of a geriatric consult from our Geriatric team back home.

After rounding on 15 patients, somewhat incompletely due to calls to the ED for admissions, we settled into OPD (the outpatient clinic) at about 2 PM. OPD consultations included a man with metastatic cancer in his liver and lungs with no known primary, an Ethiopian with an old CVA, a young man with cord compression from his severe scoliosis, etc. Never had a minute to sit down much less eat.

The ED – seizing patients, heart failure, lumbar fracture from a fall, - all ably handled by Elizabeth and tucked into our service and that of the surgeons.

At about 6 PM, I was in the ICU getting signout on the patients :
55 y.o. with a huge aneurysm who had his sentinel bleed yesterday just when a new volunteer vascular surgeon showed up from Texas and saved his life. Not doing terribly well post op and later in the evening hemorrhaged into his stomach from an ulcer that coincidentally was adjacent to what may have been his aorto-duodenal fistula.
19 y.o. with DIC who we knew well – no fresh blood available and her platelets bottomed out. She died around 10 PM from sepsis and DIC.
96 year old with an upper GI bleed – did well.
41 y.o. “Ruth” from my past call night, still struggling with her respiratory status but survived the night.
65 y.o. with end stage heart failure that spiraled down and succumbed at 0120.

To add to the fun, we were now on OB call. I did a D&C with one of the Kenyan interns at about 7 PM, then we tried to find our patients we admitted to the ward. This may sound silly but the politics of getting work done here is delicate at times, especially if the nurses are signing out (with chai time as well). We finally found our last patient at about 11:30 PM!

At about 8 PM, our 55 y.o. in the ICU started his active bleeding and all of the management that ensued. Then we had a young pregnant girl show up at 33 weeks of gestation with a footling breech at 5 cm dilation. Elizabeth and I took her back for an urgent C/S (which Elizabeth did as primary surgeon- way to go!). It’s only fair that her first case be a preterm breech C-section. Mom and babe did well, though the baby is a bit preterm and will need care in the nursery for a couple weeks.
After the C/S, we regrouped to sort through our patients to tied up loose ends then care for our heart failure patient who died quietly very early in the morning. Elizabeth managed our newborn as it developed transient tachypnea of the newborn (TTN) and required transfer to the ICU for management.

So at 1:30 AM, it was finally time to grab lunch…

1 comment:

mary said...

Oh dear friends, how long ago it seems I was just there... I'm very, very saddened to hear about the 19yo--she was in the ICU when I left but I was hopeful she'd have a full recovery--did they ever find out what had caused all that pus? I also know "Ruth" as she was admitted to the ICU my last night on call there and I found it a miracle that she survived that night, let alone a code situation. I am thankful to be home and enjoying friends and family but also oddly miss much about the chaos (and simplicity) of Kijabe. Elizabeth, I was on call my first day as well, but thankfully did not have a call day like this! I was on a "team" by my lonesome that first week... I know you are both making such an important difference to the patients and staff there with your loving, intelligent care.