Pressure

This week has been one of the busiest weeks of my life! At the end of Wednesday, the other doctor (a recently-employed Ugandan-trained South Sudanese PGY2 - who has done 200 Caesarean sections during her internship!!) and I looked at each other and mumbled that if the rest of the year was like that day, we would totally break down in exhaustion. Well, ironically enough, Thursday was worse than Wednesday and Friday was even more terrible! I heard yesterday was très horrible too, hopefully things have settled down by today.

We had another bub who died on Friday. She was born via vaccum-assisted vaginal delivery two days prior. Her mother had a previous C-section but did report one successful VBAC (vaginal birth after C-section). In retrospect, I thought it would have been reasonable to take her to theatre for repeat C-section; she had prolonged rupture of membranes (over 24 hours) and there were multiple decelerations on monitoring as well as a persistent anterior cervical lip on examination. Anyway, that didn't eventuate and it mightn't have changed the outcome either (hard to predict since we had no way of telling how long the foetal distress had been present). We try to avoid C-sections if at all possible since contraception's unheard of here and it'd be disastrous for a woman with two or more scars to deliver at home.

Anyway, on delivery, there were large amounts of meconium in the liquor as well as in the baby's airway, she had low Apgar scores and took quite a bit of resuscitation. She seemed to do well over the next few hours and was even weaned off oxygen. Right around midnight, I was called back to the ward since she started developing respiratory distress and became febrile despite already being treated with IV ampicillin and gentamicin. The next 36 hours was chaotic as we battled with temps over 41 degrees, seizures presumably due to the high fever, and ongoing laboured breathing even with oxygen and CPAP support. Poor baby, it was all too much for her and she just gave up after around midday. The first hint I got of it (since I was on clinic duty) was when I saw the large group of people congregated around her bed, all of them standing stock still and solemnly listening to someone inside the room speaking. It was quite touching as they then sang a song (a requiem, if you like) before leaving with the body, the women weeping as they did so.

Could we have done anything differently? I honestly don't know. Meconium aspiration syndrome +/- peripartum foetal asphyxia +/- ?occult subgaleal/intracranial bleed (no way of excluding it but no pupillary or limb movement asymmetry) = ultimately futile efforts. Of course, it's no reason to stop trying; in the end, God is the decider of our fates. Because, really, we all die one day. The question is when, where and how. Will we be ready when the time comes? Am I prepared to meet my Maker? At times, I can confidently say 'yes, Jesus, take me home'! However, I've to confess that my heart has also sought greener pastures that inevitably turn out to be gateways into the wilderness instead.

Jeremiah 2:13 "For My people have committed two evils: they have forsaken Me, the fountain of living waters, and hewn themselves cisterns - broken cisterns that can hold no water."

P.S. Regarding the pic, we had an unexpected appendicectomy a few weeks ago. A German missionary from another NGO developed appendicitis (in first trimester pregnancy, no less!) and we had the opportunity to host a visiting general surgeon for the procedure.

Complexity

The pic is a preop X-ray of a little boy's left foot (yes, left - I had unwittingly flipped the film over when I took the photo). He presented two weeks after accidentally kicking a fence while playing football (such a dangerous sport!), a week after his mother had found and removed a wooden splinter sticking out of his great toe just adjacent to the toenail, and a few days after he developed three sinus tracts over the dorsum of his foot that subsequently discharged frank pus. As you can (hopefully) clearly see, there is a transverse fracture running through the epiphysis of his proximal phalanx. What was worse was that when we took him to theatre for washout and debridement, it was an open fracture; the proximal edge of the toenail had lifted off, revealing the bony structures underneath. The little box at the corner of the pic shows the epiphysis of the proximal phalanx on the left and the entire distal phalanx on the right (looks rather similar to a tooth, right?); these bone fragments were found to be completely detached from the neighbouring soft tissue once the nail was removed. At any rate, he's probably headed for a partial amputation, poor kid.

Two days ago, we had two deaths, both boys under the age of five years. The first was dead on arrival; he had been admitted at our facility for over two weeks back in June with developmental delay, stunted growth, pectus carinatum (pigeon chest), and an incidental finding of malaria, which was treated but never really made a complete recovery. At any rate, he represented with respiratory distress, was seen at another clinic that morning and got referred to us. However, due to it being Saturday, he was left sitting outside the clinic (which is closed on weekends) for around half an hour before I was notified of his presence and by the time he was brought to the ward, had already passed on, presumably from a primary respiratory arrest.

And neither's even the complex case I wanted to discuss. The second boy, aged 2 years and 8 months, has got to be one of the most complicated cases I've encountered in my brief career and, in my humble opinion, would have warranted ICU admission posthaste as well as a postmortem back home (but unfortunately, such resources are unavailable here). He presented in a pre-terminal state - obtunded with minimal response to external stimuli, bradypnoeic (RR 8/min) with a Kussmaul's respiratory pattern, as well as generalised oedema. In fact, he was so puffy that none of us could obtain intravenous access and we had to rapidly make the decision to insert an intraosseous line. On the (correct) hunch that hypoglycaemia could have contributed to his moribund state, we gave a bolus of 50% dextrose with immediate improvement in his respiratory effort.

Over the course of the afternoon, more history was elicited; the oedema was first noticed a MONTH prior to presentation, which in turn was preceded by (non-bloody) diarrhoea, some oral as well as buttock sores and possibly a sore throat. On the other hand, his respiratory distress was an acute event, having only started that morning after breakfast. A CXR and quick ultrasound scan did not reveal any drastic effusions (pericardial, pleural or otherwise), consolidation, cardiomegaly, cardiac valvular pathology, hepatic/splenic lesions or ascites. We don't have biochemistry so we were unable to exclude renal or hepatic impairment but his urine output was borderline adequate and there was no obvious hepatosplenomegaly, jaundice or coagulopathy; urinalysis did reveal a mild degree of haematuria and proteinuria with white cell casts seen on microscopy. No paediatric sized blood pressure cuff either so his BP remains unknown.

At this stage, my top differentials were glomerulonephritis of some form (likely post-streptococcal) +/- malaria (smear proven two weeks ago with likely suboptimal treatment elsewhere). As you could probably tell, that wasn't the end of the story. As a matter of fact, it only got curioser and curioser (as Alice would put it). He then developed seemingly refractory hypoglycaemia; it was persistently low despite numerous boluses of dextrose. Was it due to leakage of the dextrose solution from the intraosseous line? A false reading since the samples were capillary in source and there was gross oedema giving a dilutional effect? Or something occult like central adrenal insufficiency? Not having any hydrocortisone, we trialled a stat dose of dexamethasone. Either way, despite our throwing everything we have at him, it was a case of too little, too late. Spontaneous respirations ceased eight hours later; throughout the whole admission, he had been (almost malignantly) tachycardic with laboured breathing and a decreased conscious state.

If it had in fact been GN, why was his respiratory distress so acute one month after the precipitating cause? If it was malaria causing severe hypoglycaemia, why was the smear at our lab negative when it should have shown at least some degree of parasitaemia? If it was APO secondary to some other cause (cardiac, hepatic or otherwise), why was it not shown on CXR? Why did the hypoglycaemia not respond to treatment? Could it have been HUS secondary to enterohaemorrhagic E.coli; if so, why was bloody diarrhoea absent? There were just so many points that didn't add up and it's left us confounded. Worse still, it's left his family with one less member. His mother wasn't even present to say goodbye as she was at home with a newborn. At least, he died surrounded by his father, grandmother and a cohort of aunts and uncles.

It reminded me of how finite our knowledge is, how limited our skills and talents are, how powerless we are in the face of death. The good news, thankfully, is that through the love of God incarnated in the body of Christ, we can transcend this mortality and know that this is not the end.

1 Corinthians 1:20-25 Where is the wise? Where is the scribe? Where is the disputer of this age? Has not God made foolish the wisdom of this world? For since, in the wisdom of God, the world through wisdom did not know God, it pleased God through the foolishness of the message preached to save those who believe. For Jews request a sign, and Greeks seek after wisdom; but we preach Christ crucified, to the Jews a stumbling block and to the Greeks foolishness, but to those who are called, both Jews and Greeks, Christ the power of God and the wisdom of God. Because the foolishness of God is wiser than men, and the weakness of God is stronger than men.

Let the little children come

This picture is of a precious little girl who can be seen most days running around the hospital compound as her mother is one of our cleaners. She is such a cutie! And very bright too. She now associates me with my iPad mini, which I carry everywhere with me (since it contains most of my medical references such as UpToDate) and always asks to see the photos on it and has already learned to swipe to get to the next pic! Mind you, this is on the background of most people here having never seen a computer or a camera.

Kids can be found in abundance here. In fact, I recently met a patient who was surprisingly distraught over the revelation that she was 17 weeks pregnant. She kept repeating, 'No, I'm not pregnant. I cannot be pregnant!' in spite of my showing her on ultrasound that there was clearly a baby in her womb and his or her heart was beating along at a happy pace. With further probing, it appeared that she was so upset because she was currently breastfeeding her second child (a nine-month-old girl who, incidentally, I later found out was an inpatient in our ward suffering from malaria) who was also conceived while she was breastfeeding her first one! So much for lactation as a form (really, the only version here) of contraception.

But Jesus said, "Let the little children come to Me, and do not forbid them; for of such is the kingdom of heaven." (Matthew 19:14). Expanding in Mark 10:15 that "whoever does not receive the kingdom of God as a little child will by no means enter it" and in Luke 9:48 that "whoever receives this little child in My name receives Me, and whoever receives Me receives Him who sent Me. For he who is least among you all will be great."

It has often puzzled me what He meant by "receiving the kingdom of God as a little child". Did He mean in innocent wonder? Open acceptance? Trusting credulity? All of these and more? I haven't been a child for a while now (although my parents still treat me as one!) and I don't have one of my own so feel free to leave any thoughts or comments on this point. For now, I guess I will have to study these little ones and attempt to discern the difference between childlike and childish faith :)

P.S. To my amazement, I discovered that the little girl's hair was NOT held up with any hair tie or band; apparently, the hair fibres of the Africans here are stiff enough that when braided, will hold together of their own volition! Pretty crazy, hey?

The socioeconomics of health (or the lack of it)

View from the front of the hospital

My nose is running (leaking?) like a tap. Probably an after-effect of almost 25 hours of work yesterday; got woken up at 4.30am to attend to an increasingly tachycardic pre-eclamptic primigravida lady post vacuum-assisted vaginal delivery. She turned out to have postpartum haemorrhage (with an acute drop in haemoglobin level from 113 to 53 in less than 12 hours) requiring manual evacuation of clots under sedation. And didn't get to bed until 5.30am the NEXT morning. "You have got to be kidding me" was my apt reply when informed by the nurse on duty at 10.30pm that the heavily pregnant mother of one of our long-stay patients (a malnourished pre-school boy) had gone into labour. I've been awake for much longer before but haven't needed to be "switched on" (seeing patients and having to navigate the intricacies of their management) nearly that entire time.

Anyway, that brings me to another of our long-stay patients, also incidentally a malnourished boy who's just under 3 years old. He's been with us for 2.5 weeks (which is very very long by the standards of a mid-level rural African hospital where the average turnaround time is just a couple of days). Poor kid's severely wasted and we've been trying to get his weight up to little avail despite successfully treating his malaria and diarrhoea (secondary to ascariasis, which I previously didn't know existed). We think it's most likely attributable to his HIV-positive status. We've been trying for over two weeks now to get him to the local public hospital's antiretroviral treatment centre (the only clinic in town with UN-funded HIV meds), which has to be one of the most trying endeavours I've ever embarked on.

First time, his mum 'forgot' the referral letter we had given her. Second time, she said that the centre had told her that there were no meds available. Third time, we sent our own VCT counsellor (voluntary counselling and testing for HIV prevention) to go along WITH her to firstly, act as an advocate on the patient's behalf and secondly, because we were suspicious that the mother had never actually reached the centre. You see, due to the stigma associated with the disease, most patients are (understandably) very reluctant to be seen anywhere near that centre. It doesn't help that it's located prominently right smack in the centre of the hospital compound with the sign "ART Centre" (antiretroviral treatment) written in large letters; not very subtle, indeed. Anyway, they were sent back to us the third time without any mention of further management for the kid's HIV, whether his CD4 count or viral load were tested and when and how ART should be commenced, etc etc. Just some desultory notes (which were basically copied from our own notes) about his intercurrent infections and starting cotrimoxazole (which we've already done). Gah! Felt like screaming at them.

And against all this was the backdrop of the mum's insistence on being discharged home in spite of the kid weighing less than on admission (hovering betwen 6.4kg and 6.8kg from 7.3kg for a 2 years and 7 month old boy on a maximal therapeutic feeding regime)! So so frustrating. Upon further questioning, the socioeconomic factors behind that bizarre request were elucidated. Firstly, she was concerned over how to pay for the boy's admission as she, being his full-time carer, was obviously out of work (just as a fyi, we never force our patients to pay and there have been many a patient who has defaulted). Secondly, she was worried about her husband and what he was up to; he had been MIA the whole time, which is pretty unusual as I've seen most African dads showing up every now and then to check on their family. Thirdly (and this I found most strange) she wanted to go buy soap and her boy's favourite food items since he didn't like what we offered (and I don't blame him - it consists mainly of beans and rice BUT it's probably more than what he would have gotten at home; when I suggested that she could leave the boy on the ward during the daytime to get the food, she actually confessed that she didn't have the money for the purchases so I thought this a moot point and just another excuse to leave).

Anyway, tomorrow's our fourth attempt at trying to procure these ridiculously elusive drugs. God willing, we will be able to start him on the meds he needs and that would prove to be the solution (since we've already exhausted all other options). The harrowing likelihood (and what's most depressing) is that the boy is going to return to his baseline state and possibly die in the next few weeks or months as soon as he goes home unless his social situation dramatically improves.

Why fight so hard for what seems to be doomed for defeat?
James 2:14-18 What does it profit, my brethren, if someone says he has faith but does not have works? Can faith save him? If a brother or sister is naked and destitute of daily food, and one of you says to them, "Depart in peace, be warmed and filled," but you do not give them the things which are needed for the body, what does it profit? Thus also faith by itself, if it does not have works, is dead. But someone will say, "You have faith, and I have works." Show me your faith without your works, and I will show you my faith by my works.

As the Apostle James so poignantly puts it. This passage has been one of my life's driving forces over the past few years. A Christian who does not lift a finger to help his or her brethren is no Christian. When would the church wake up and realise that there is so much need outside her doors? That God put us on this earth not just to eat, drink and be merry, but to use what we have been given for the greater good and for the glory of His name?

11-Aug-2013 Update:
Bah! The public hospital straight out refused to give him the meds without his attending a supposedly obligatory three-session education course which takes place only once a week, i.e. we've to wait a further three weeks to start him on ARV meds! This is despite our giving the hospital's medical director a call, who promised to give us what aid he could but then backtracked and gave in to the clinical officer (not even a doctor for crying out loud!), who persists in being obstinate over a stupid protocol! Dear God, give us patience...