Shop Talk

My roommate, Eric, and Dr. Johnson from Minnesotta

Yes, the nurses really do dress like this.

Selian Lutheran Hospital is a 120 bed hospital just outside of the town of Arusha. As the town of Arusha grows, so does its need for medical services and a new hospital is under construction in town, right next to the current Arusha Town Clinic that is staffed by Selian doctors. The new hospital will serve the city population and the existing Selian hospital will continue to serve those who travel from far. Selian is in Maasai country so many Maasai people come to Selian for their health care and will likely feel more comfortable at the existing hospital than the new one in town.

So far, I have been spending my time on the medicine wards, seeing both male and female patients. I see plenty of malaria, diarrheal illnesses, and complications of HIV/AIDS. We offer HIV testing and counseling to nearly every patient that is admitted and we have many new diagnoses. It is interesting to me how many patients come in saying that they have been unwell for months to years. It makes me wonder why they came in today. Why not a year ago and why not tomorrow? I see the late stages of many conditions that have gone untreated for quite some time. I see patients as young as 45 with severe congestive heart failure due to untreated hypertension for years. We have a 12 year old boy with CHF, likely due to rheumatic heart disease. I see cirrhosis and massive ascites due to chronic hepatitis infections, alcoholism, and schistosomiasis infections. I have never seen so many enlarged livers and spleens because so many tropical diseases can cause hepatosplenomegaly. I see peptic ulcer disease from Helicobacter Pylori infections and plenty of abdominal and chest pain due to gastroesophageal reflux. I see pneumonia, TB, and patients with reactive airway disease. I have seen terrible thrush in an HIV patient and many patients with wasting due to HIV, TB, or malignancies. I’ve seen cerebral malaria and coca-cola urine due to hemoglobinuria from severe hemolysis. I also see the results of untreated or poorly treated diabetes with peripheral neuropathy, retinopathy, and nephropathy. Insulin is not used as commonly in the out patient setting here as in the US as clean needles are more difficult to get and disposal is also a challenge. I have seen some crazy x-rays of fractures from accidents as well. We have a patient who fell off the top of a land rover and has the worst displaced bimalleolar ankle fracture most people here have seen. My roommate is doing orthopedic surgery right now and he’s loving it because he gets to do so much, but he expresses frustration at the lack of resources here. They often don’t have the correct size of screws or wires and they always have broken or missing pieces of equipment. As a result, some people don’t gain full functioning as they might with proper hardware.

It is often difficult to obtain a good history from a patient, even if you do speak the same language. Some people do not keep track of time in weeks, days, and months so some Maasai will talk about bring sick for 3 market days, which basically means 3 weeks. Also, some people are unsure of their age. If you’re born out in the bush, it’s very likely there will be no record of it and so you may not know your birth date. We had a patient who claimed she was 110. She looked really old, but I’m not sure that I believe 110. On the other side, we have a woman who looks close to 40 who claims she’s 21. I already commented on some of the difficulties in diagnosis due to limited labs and imaging. Nearly everyone we admit gets a blood slide for malaria and all else is ordered depending on their presentation. Patients must pay for their x-rays or ultrasound before getting it done and that can delay diagnosis. There is a CT scanner at Kilimanjaro Christian Medical Center (KCMC) in Moshi, about an hour drive from Arusha. We rarely need to refer patients to another hospital, but we are currently without a pediatrician so we sent a sick 9 year old boy to KCMC this week for further evaluation. Some patients would not be able to afford a transfer.

I took overnight call at the hospital for the first time on Wed. night and it was quite an experience. The 3 interns have living quarters next to the hospital and they made a bed for me, but I never saw it that night. We had 17 admissions to keep us busy and some very interesting cases as well. There was a cute 2 year old boy who swallowed a little bit of kerosene and substances like gas and kerosene are worse on the lungs if aspirated than on the bowel so these are the few substances where you don’t want to induce vomiting. He’s doing well. We also had a 13 year old boy come in with a urinary tract infection and I noticed something was off about him. After taking a more detailed history from birth and doing a lengthy neurologic exam, I realized he has cerebral palsy that had been previously undiagnosed. I guess it’s common here to have cerebral palsy and not know it.

There was a woman laboring for about 20 hours with her 4^th child and the baby was found to be presenting with its elbow. There’s no way this kid was coming out elbow first, so we had to take her for a C-section. The intern called the doctor on call to come in and she assisted him. They are short on gowns, so I didn’t scrub. Instead, I held the patients hand and watched the procedure. Most C-sections here are preformed with a vertical skin incision and then a horizontal uterus incision, which I’m not familiar with. Surgical scars aren’t as big of a deal here. I became very scared when they were having trouble getting the baby out and after 3 or so minutes of pushing on the uterus, the baby came out not breathing. 2 nurses alternated bagging and suctioning the meconium from the baby and the mother was looking at me and probably asking me what was wrong, although I couldn’t understand her. All I could do was squeeze her hand and pray that this baby lived. A wave of relief came over both our faces as we heard the baby cry. I kept thinking how this birth wouldn’t have been so scary in the US with all the technology we have, but then I reminded myself that the baby, and likely the mother too, would not have survived if they were out in the bush without medical attention.

The two most interesting cases of the night were of suspected cholera. 2 women came in with what seemed at first glance like gastroenteritis. There are plenty of bugs here to give you diarrhea and neither had fevers or blood in their stool. Hours after admission of the first woman, we got a report that she had 10 liquid bowel movements and that’s a lot of diarrhea for gastroenteritis. Within an hour of this, the second woman started having watery diarrhea without effort and also vomited profusely, about 1.5 liters. We opened 2 IV lines on both patients and attempted to give the recommended 10% of their body weight in the first 4-6 hours. They don’t do central lines here so we used peripheral IVs and other options would be parenteral or interosseous rehydration. These 2 women are isolated in a room together and cholera patients are sent to a government designated site for treatment, but we don’t have the results back from their cultures for confirmation yet. I hope they don’t have cholera because I really don’t want to get that. I’d pick malaria over cholera any day.

Clinic: As I stated previously, I see a more affluent population in clinic and many speak English. I see many of the same problems here in clinic that I would see in the US, only the treatments may vary. I’m having a tough time with medications here because either the drug I use at home is not available here, or the name is different. They use many medications here that are older and no longer used in the US, but they’re often cheaper and they may have an undesired side effect that makes them unpopular in the US, but the benefit often out weighs the risk here. So I’m learning about some new drugs and new ways of treating familiar problems. On Tuesday, I treated a wart on a 4 year olds toe with silver nitrate. I’m used to liquid nitrogen, but we don’t have that in the clinic so we’ll see how the silver nitrate goes.

My spell check really doesn’t like this post and I apologize to those of you who aren’t in the medical field and find this post boring. I promise to write of some more fun things later. I’ll be working with a plastic surgeon from the US this week so I’ll also have a few more medical stories.

Chapel