Day 36: 1st day in Pediatric Nursery

Went to the Pediatric Nursery this week, which is where children under 1 year go. Chatinka is the other nursery and that is where the newborns go after birth.

Saw many little ones with bronchiolitis (respiratory infection), pneumonia and gastroenteritis (vomiting and diarrhea), along with the usual hydrocephalus, etc. Many come through and only stay for a few days, but others are in the more intensive care unit. Rounds are relatively short here and we got out early.

I've been reading a lot more books since being here. So far have finished:
"The Girl who Played with Fire" (interesting, although frustrating because the book leaves you hanging. I don't have book 3 with me)
"House of God" (a must read for future doctors, albeit scary to think about),
"Darkfall" (a good old fashioned mystery).

Right now I'm in the middle of "To Kill a Mockingbird," which is an interesting read considering the cultural dynamics here.

If anyone has any book recommendations for when I get back, let me know :)



Day 37: Asthma, a formidable foe

Morning rounds went as usual. Learned a bit about murmurs, as we have a child with a loud VSD. The hole in his heart is actually quite small, but the smaller the hole, the louder the murmur.

Got out early again so went down to A&E. I was in the triage admission room working up patients best I could with my limited number of Chichewa words. I worked with a 3rd year med student, who helped translate as I helped him take a complete history and come up with differential diagnoses.

One child came in profusely bleeding from his lip. He had been born with a hemangioma (blood vessel malformation), which had recently been treated with sclerotherapy. It had gotten infected so he had come back in. HIV status was unknown and he was covered with blood. We kept having to change his dressings because any time he would cry, the clot would bust open and he would soak through the gauze.

Meanwhile, the intern had placed an 11-year old girl with a nebulizer in the corner, as she had come in with difficulty breathing. Asthma is actually not that common here, but if the patient has it, it is usually severe because it is rarely controlled. In the middle of working up a patient with pneumonia, the nurse called me over to the girl. The nebs weren't working. The 3rd year grabbed the intern while I listened to her chest. She had wheezes bilaterally, but a lot of her chest was silent (not a good sign). The intern and I hauled her over to the resuscitation room. I went back to the triage room.

After about 15 minutes, I realized that the 3rd year and intern had disappeared and I couldn't do anymore without getting a proper history. No other medical people were in the room. I went to the resuscitation room, and there were 2 registrars, a Scottish 5th year, the 3rd year and the intern holding the girl down while they were sticking a NG tube and IV lines in her. She was screaming, and I don't blame her. I switched with the intern and held down her legs so he could go back to the triage room and move patients along. Additionally, a younger boy had passed away on the bed next to us and his mom was keening. There was a lot going on at once.

I found out that the girl had gone severely hypoxic (no oxygen) and had become agitated. She "shat" all over herself and every human bodily fluid was on the floor. While the attending was putting in the NG tube, gastric juices and blood sprayed out and covered the registrar's arm and white shirt. They then gave the girl Ketamine, bag-valve-masked her and intubated her. The Scottish student took over the breathing and we all stopped holding her down, as she was sedated.

I remember several discussions about asthma that I had back in the States. Intubation is always the last resort. Also, what most pediatricians fear is an acute asthma attack, because those kids can go down quickly. Now, I see why.

The girl was sent to the HDU (ICU) and was to be ventilated for 48hours. Last I heard they were able to give her nebulizers through the tube and she was looking better.



Day 38: Failure to thrive

A 5th year medical student and I were seeing patients together. The one patient that stuck out was a small, wrinkly-looking child. She wasn't dehydrated (good skin turgor, moist mucous membranes, capillary refill <2seconds, no sunken eyes, alert), but something wasn't right. The diagnosis was gastroenteritis, but there seemed to be more. We found out that she had been losing weight and when the attending came over, we learned that she was a twin. She weighed 2.9kg and her sister weighed 4.1kg. At birth they weighed 2.5kg and 2.6kg respectively. We ordered a chest x-ray and an HIV test and were doing a full work-up on failure to thrive.

The other one I remember was a 5-month old with pneumonia, but who also had Down syndrome. I was told it isn't very common in the hospital to see Down's, but that you do see individuals out in the villages with Down's. I wonder how common it actually is here versus the incidence in the States.

Other children we saw that day had hydrocephalus, hemangiomas, and cleft palates.



Day 39: Figuring out what's wrong

I walked into the ward and saw a 5-month old gasping for breath with her eyes rolling in back of her head. I grabbed the registrar and while she got the bag-valve mask, I extended the neck and thrust her jaw forward. After she gave her breaths for a couple of minutes, the girl came back and was breathing on her own. She was placed on ceftriaxone and that was it. I still don't know why she had an episode of apnea.

I also saw the child with the VSD and checked up on him. He was more active and alert, but still appeared frail looking. He was on TB, PCP and pneumonia treatment due to some lung findings and questionable sepsis, but his HIV test was negative. Since he looked more stable, he was sent to get a chest x-ray. It showed an enlarged heart and some hilar adenopathy (white stuff in the middle). We didn't know what is causing him to be so sick.



Day 40: Where did the LA go?

On morning handover it was announced that the whole hospital is out of LA (a medicine used to treat malaria). So they were going to have to use a more complicated malaria regime using 2 different medications. There are many rumors circulating around the hospital about a lost shipment, but no one really knows what happened.

I checked in on my VSD patient. The attending was out of ideas as to why he was not improving, so he consulted another attending. She recommended re-testing for HIV as he is now over 6months and infants can seroconvert to being HIV positive. They were going to place him back on Cotrimazole and anti-virals were discussed. The epinephrine didn't do anything. Although he was on day 4 of a fever, they are going to give him steroids and see if that will open up his airways.

The other patient I rounded on was less responsive than the day before. She had had no new episodes of apnea, but she had lost interest in anything, including eating. We placed her on IV fluids and stuck a NG tube to keep her fed. The skin on her stomach felt like dough and the attending thought that she may be in hypernatremic dehydration (too much salt because of losing so much water from her vomiting and diarrhea). Not that we have any way to check sodium here. I'm just going to have to wait and see what happens to these two over the weekend and hope for the best.