Wednesday, 3 April 2013

A Tale of Three Clinical Vignettes

Clinical Vignette A:
As you can see in the picture to your left, we process our X-rays creatively using what natural resources that are available to us. In this case, it was a skull X-ray of a 19-year-old boy who was thrown off his motorcycle when it hit a dead cow in the road on Saturday. Upon presentation two days later, his GCS was 7 (E1V1M5), he had had minimal to nil oral intake, was non verbal and was obviously not doing too well. Bearing in mind that there is no neurosurgical service - or for that matter, a CT scanner - in the entire country and the nearest centre was in Kampala (Uganda), almost a day's drive away over dirt roads, we admitted him, commenced IV fluids, dressed his wounds and, basically, hoped for the best. Did I mention he's also got a fixed, dilated left pupil? At this stage, we've encouraged his family to find out if he could be transferred to Kampala so we're all waiting for his older brother who is currently in some far-away location to be contacted to make a decision.

Clinical Vignette B:
Last night was my first experience of a Caesarean section in South Sudan. It was a primip who we suspect had cephalopelvic disproportion and had been pushing for over two (or maybe it was three) hours. When I piped up and asked my senior colleague (a GP obstetrician from the States) if he was going to do the spinal, he asked if I was good at it; I answered that I could hardly say so and he replied, I might still be better than him anyway (!). Then, our missionary nurse from New Zealand informs me that we're down to our last vial of bupivacaine. Ok....pressure's on! Thanks be to God, my first spinal after a year away from anaesthetics was a success and the entire operation went smoothly. It's the first C-section I've seen where the surgeon prays with the staff and patient beforehand too :)

Clinical Vignette C:
In contrast, less than 24 hours later was also my first experience in this country of witnessing a patient's demise. It was a middle-aged man who was brought in by his family with acute respiratory distress associated with new-onset productive coughs and a possible one-month history of central chest pain and orthopnoea. Upon presentation, he had a RR of 40, HR of 160 and SpO2 in the 40s! Worse still, he was barely responsive and could not speak at all. We got the oxygen concentrator working pronto, but the sad fact is we can only get a maximal concentration of 5L (the usual maximal concentration on the wards back in Australia is 15L and we can double that by adding 'tusks' to non-rebreather masks or failing that, achieve almost 100% with a bag-mask-valve device). Our working diagnoses at this point were either severe pneumonia and/or acute pulmonary oedema secondary to cardiac failure. Hence, the choice to get a CXR asap and give IV ceftriaxone (an antibiotic) and po frusemide (a diuretic - we didn't have the intravenous form).

Well, 'things don't happen like they do back home' may be the understatement of the day (or year). A man was brought in at the same time suffering from a snakebite and all of my nurses and medical attendants went off to look after him in a different room and I was left scratching my head. Back in Australia, this man would have had a MET called on him, possibly even a Code Blue, and likely taken to ICU, intubated and ventilated. Here, I could not even get anyone to get meds for him for another 10-15 minutes! So frustrating. Anyway, he went into respiratory arrest right before my eyes and then died, just like that. To have resuscitated him at that point would have been an exercise in futility as there isn't an ICU to which we could transport him even if we achieved ROSC (return of spontaneous circulation).

Comparing that with the many sessions that all clinical staff back home are required to attend on recognising a deteriorating patient, I think there's definite room for improvement on this point. That's another difference between our cultures as well, I guess. The family of the deceased patient was totally understanding; one of the other men even threw up his hands and said, "it is God's will". Death is so common here and life so short. What we strive to do - or should - is to ensure that at the same time, life isn't cheap. Remember what God Himself said in Ezekiel 18:32 - "'For I have no pleasure in the death of one who dies,' says the Lord God. 'Therefore turn and live!'"

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