Last day

Today was a bittersweet last day. We found out one patient we'd admitted earlier this week had died, another was HIV positive, and a third (the subject of yesterday's post) still hadn't gone to surgery.

But I was also greeted this morning by three kids who ran over and hugged me enthusiastically, as they have every morning this week; they held my hands through most of rounds, taking turns tickling me and playing other games. Two kids politely asked me if they could use my camera. They used to demand "Give me your camera!" Now it's "Give me your camera, please!" (We taught them that they're nice kids, and should aim to sound that way.) The interns and medical officers wished us safe travels, and the Sisters in clinic said they'd miss us. We'll miss them too.

This has been an amazing month. We've learned so much, not just about the diseases that are prevalent here, but about the practice of medicine as a whole and the role we play in it. Even the saddest and most frustrating parts of the month have led to discussions about the ideal way to practice medicine vs. how it's done here. Dr. Brown has been doing this for longer than we have, and was able to share his thoughts about how things are, how things should be, and maybe how we can play a role in getting them from the former to the latter.

Namibians have a different perspective on healthcare, and it has been an honor and a privilege to be let in on their experience for the short time we've had here. The parents and patients have been very open, very welcoming, and very patient with their American visitors, and I know I'll really miss some of them. How lucky we are to have learned a bit about their world.

Anger

I've experienced a large variety of emotions here in Namibia. Sadness, discouragement, happiness, gratefulness, and sorrow. But today, I experienced anger. In fact, I was furious. I entered rounds today, to find the team discussing a 1 month-old infant who was lying crying in his crib. The first thing that caught my eye was the WBC of 49k with a left shift. The child had been admitted the night before by the on-call intern. The same intern rotating on the ward with me these past two weeks. The infant had been admitted for pneumonia, a diagnosis often used by the interns when they are unsure of the diagnosis but think the child may be sick.

The medical officer was busy saying that we should get a urine culture and lumbar puncture to be complete. I decided to examine the infant at that time, who had continued crying throughout this conversation. Fontanelle soft and flat, lungs clear, heart mildy tachycardic but no murmur, abdomen rigid. No bowel sounds. Distended. Hard. Had anyone examined this child?? I mentioned my exam findings to the medical officer who said, "Yes, we're going to obtain an abdominal series". I pointed out that I think we had our source of infection.

We finally agreed on a plan. Abdominal films as soon as possible. Addition of metronidazole. Follow up. I mentioned that the baby seemed to be in quite a bit of pain. Could we add morphine? I was told morphine is a strong drug. I said this baby needs a strong drug. A one-time dose was written at the lowest starting dose recommended. I asked for Q 1-2 hour dosing. I got QID. Luckily, the decided-on dose was too small to measure, so we gave the higher dose I requested. Unfortunately, we all know the half-life of morphine is a tad bit less than 6 hours.

We continued to round in the room the baby was in. During that entire time, roughly an hour, the baby continued to whimper with periods of intense crying out. No one seemed concerned. No one seemed to be in a hurry to get the morphine. It took 3 reminders and almost 2 hours to get the infant his medicine. I suspect the baby cried out like this the entire night without anyone showing a hint of worry.

The ridiculousness of the situation continued when after about 3 hours the films finally came back and clearly showed stacks of small bowel loops and air-fluid levels as well as questionable free-air. When the medical officer called the surgeon, he said, "we suspect obstruction". Suspect?? It looked pretty clear to me! He continued on, "the baby has bowel sounds and the belly is somewhat firm but soft". Bowel sounds? Soft?? Fortunately, the bile-stained NG outs were enough to convince the surgeon to come by. A pleasant surprise. Unfortunately, he wouldn't be by until after his next surgery.

I'm not sure what will happen to this baby. I'm just so incredibly angry about the entire situation. Starting with, and especially with, the intern who very clearly missed the diagnosis. With the nightly nursing staff who allowed that infant to cry out in pain all night long without questioning or calling a physician. With the medical officer who didn't seem to identify the diagnosis either and who did not grasp the severity of the situation. With the day-shift nursing staff who did not seem to notice or care that the infant was crying out in pain and took hours to get the baby pain medication. With the medical officer, again, for not conveying to the surgeon the critical nature of the infant or even the correct physical exam findings. This infant may die because of everyone's negligence and apparent lack of caring. So much of the death I've seen here is preventible, and that's enough to make anyone angry.

Mild, Moderate, Severe

Another interesting day - we were eating lunch in the conference room when a Sister (nurse) came by and asked whether Dr. Brown was still in the hospital. We replied that he wasn't, and asked why. She replied "I just wanted him to have a look at a baby in the Gastro unit." and walked away. We both thought for a second, then got up and decided to go see what was going on.

As it turns out, there was a very dehydrated baby there who had acutely decompensated. As we worked on helping the intern with assessment, resuscitation, and reassessment, it was hard not to notice that he was the picture of severe dehydration - it was as though he'd read the textbook. He was obtunded - lying with eyes half-open and not responding even to multiple IV attempts, with skin that stayed in an unnatural ridge long after you pinched it. His hands and feet were cold, and his nailbeds took 4-5 seconds to return to their usual pink color after we'd pressed on them. He was grunting, and had thready pulses which were initially only palpable very centrally. His heart rate had gotten as low as 60 when we first arrived.

The amazing and somewhat scary part was that this child had been doing reasonably well just a few hours prior, when he was seen by the team on morning rounds. Then his diarrhea had increased in frequency and volume, he began vomiting, and the volume loss exceeded his capacity for compensation. As we've heard time and time again - kids are resilient. They'll keep on compensating until they absolutely can't. He had reached that point.

I can't tell you for certain if the diarrhea and vomiting had given him electrolyte imbalances or an acidosis; there was no blood gas or istat to help us assess his situation acutely. We sent off labs once he had stabilized a bit, but we'll be lucky to see the results even tomorrow; when I called for his admission labs, which had been drawn two days prior, I was informed that there were never any labs drawn on that patient. Were they drawn but not sent? Lost at the lab? Mislabeled? We'll never know. I had the lab lady search for his results 4 different ways, none of which proved fruitful.

The baby got transferred to the High-Care unit, where he will get closer monitoring. We'll see how he does. He might pull through, or he might be one of the kids who "just dies" overnight. Yesterday we'd seen a child nearly as sick who looked quite a bit better today - it's amazing what proper hydration can do. Maybe today's baby will be as lucky.

Code Captain

Today, I was the official code captain for a real code for the first time in my life. I wasn't the person standing at the door trying to learn how to manage a critical patient yet stay out of everyone's way. I wasn't the person placing orders for the medications that were administered and the portable films that were performed. I wasn't even the person at the bedside bagging the patient while following the orders of an attending. I was the person who entered the scene to find inappropriate bagging and lack of coordinated resuscitation who subtly took charge, took over performing chest compressions, and began directing my very limited team on how to manage this patient. I even decided when to stop after 20 minutes of CPR with no resultant pulse. There was no attending, no back-up to call, no one more knowledgeable than I on whom I could rely.

It's difficult to explain how I feel following such an experience. It was exciting to take charge, because despite my quiet personality, I am a leader at heart and was able to make sure things got done as well as they were able to be. But I'm also incredibly sad. She didn't make it. I was the one who decided when to stop. That's an enormous responsibility... to say we've done what we can but this is the end. It's a very painful decision to make, especially on a child who had seemed relatively well just two hours ago on rounds.

The experience has given me a lot to think about and is one that I'll not soon forget...

Novelty

Today, I saw a healthy patient. A little eczema, some lacrimal duct stenosis, and a classic case of colic, but an otherwise happy, healthy, six-week-old infant. In addition, she was accompanied by two loving, doting parents. Why write about something so ordinary? Well, in a country filled with poverty, malnutrition, extreme sickness, and a general feeling of apathy, it was both delightful and refreshing to see a chubby, healthy, thriving infant with two parents who clearly loved her...

Erindi

Sara and I went to the Erindi Game Reserve this weekend and had an absolutely fabulous time! We saw all sorts of animals including lions, elephants, a leopard, giraffes, various antelope, zebra, ostriches, and crocodiles. Take a look at just a few of the pictures we took (I managed 449 and Sara a whopping 700). It was a much-needed break that we thoroughly enjoyed. :)

Doctor, look!

Yesterday ended on a worrisome note for me. A mom brought in her baby with two days of fever and diarrhea. The baby was lying there like a dishrag and not very responsive - he was (just barely) conscious, but didn't cry even when we stuck his finger to check his glucose, and his tone was very low. I was worried that he had sepsis on top of dehydration, so I admitted him. Night time at the hospital is a scary time for patients, not that any of them know it -- by which I mean that they're in the hands of one intern who is responsible for kids in the ER, all the peds floors, and resuscitation of any babies who get in trouble perinatally at the hospital down the road. There is no sign-out process, so I had no way of letting the night intern know to look out for this baby. I left the hospital satisfied that we'd put together a solid plan, but worried that the baby would worsen unnoticed overnight.

The Browns' church has a women's group, and they went to the hospital today to hand out packages of toothbrushes/soap/washcloths/etc. and to just offer some support to the moms and the kids. The visit was a success on many levels, but I started the afternoon feeling frustrated and more than a little worried - I couldn't find "my" baby anywhere on 8B - the service where he belonged. I feared the worst but couldn't let myself think that that baby had really died, so I waited to see how the day would unfold.

Next thing I knew, a mom walked by the conference room with a perky and very much alive baby in her arms. She stopped me -- "Doctor, look!" It was my baby from last night, doing a thousand percent better than yesterday. "I was so worried yesterday -- I thought my baby was going to die! But he looks so much better today. Thank you, doctor!" I was amazed and gratified to see the child make such an amazing turn-around, and had the good sense not to spoil the moment by admitting that I'd feared he might die too.

The thing is, we have minimal supervision in the clinic - that baby got better because I made good decisions and did the right thing for that child. I didn't have lab results at my disposal, no readily available imaging. The night intern wasn't there to back me up - she probably didn't even know the patient existed. So we made a plan, used good clinical judgment, and made a difference. That's amazing, and as much as I'll gripe about the broken system here in Namibia and the many frustrating things about it, it is teaching me so much. I'm so grateful to be able to have made this trip, and I'm looking forward to another two weeks of it.