Peasant

What does the word "peasant" bring to mind? Castles, kings and moats.... Just wrote the word over the occupation line of a death certificate.

Sometime this morning a 50 year old man found himself under an overturned oxcart. He was transported to the nearest hospital where note was made of decreased breath sounds in the left chest and air in the skin(it feels crackly for lack of a better descriptive term). Transport was then arranged to BMC. An official stamped referral letter accompanied the patient.

On a stretcher in casualty with two 14 gauge angiocaths in his chest wall and a blood filled endotracheal tube in his trachea, he died.

It is the 21st century and we still write peasant on a death certificate. The life and death for a peasant has probably varied little between the centuries.

In the twenty first century it means your baby dies of malaria and your dad dies in the afternoon when the oxcart falls on him in the morning. It was probably much like that inside and outside the castles in the middle ages. It is still happening outside the castles today.

Blood Warmer

One of the many functions of the human body is to warm the blood. A couple times in casualty my body has warmed someone else's blood.

The first patient was too weak to stand from the wheel chair and his friend could speak enough English to tell me that he had vomited blood. The bottoms of feet are not supposed to be the color of the sheets and when they are it is a bad sign. Not having a blood pressure is another bad sign. Yet anotherbad sign for a system is that this man had waited to be seen long enough for his old record to be on his stretcher. In that old record was evidence that this man had esophageal varices(enlarged veins lining the wall of the esophagus, prone to bleed because they are close to the surface and not designed to carry large volumes of blood). He had schistosomiasis which is a parasitic infection caught from exposure to water(fishermen on Lake Victoria and children who play in infected water) and a subset of people with this infection get scarred livers and abnormal circulation in vessels outside the liver.

I ordered O negative blood immediately for emergent transfusion along with two large bore intravenous lines with saline running wide open. The casualty nursing director worked on this patient along side me and ran to the blood bank for the blood. We transferred him to intensive care where his low blood pressure was causing confusion and he had to be restrained with sheets tieing his limbs to the bed. I stood beside him squeezing the cold blood bag with my warm hands. He is still alive.

The second patient came in today and was too weak to sit or stand. She was on a stretcher between the 4 beds in the women's ward of casualty. Her feet were pointed in the other direction but her eyelid linings were white, her pulse was thready and the nurse had written "unrecordable" where blood pressure numbers are placed on the chart. Her abdomen was tender in the lower half and up the left side. She told us her last period was August 20th. But there are not too many things that present like this in young women. I told the gynecology intern in the department that I thought this patient had an ectopic pregnancy and ordered O negative blood and 2 lines of saline wide open. For the second shift in a row I found myself at a patient bedside squeezing a cool bag of blood. This time the lab had no O negative blood so I had walked to the lab to explain that I needed a rushed blood typing and 2 units of type specific blood along with 4 units of cross matched blood. In the meantime there was some discussion about sending the husband to the pharmacy to purchase a pregnancy test. The second on-call gynecologic surgeon wanted to see the results of this test. I posed the hypothetical question that in a woman who had no bloody vomitus or bloody stool, had a tender abdomen and no blood pressure, what would they do if the pregancy test was negative. I didn't get an answer to my question. A few minutes later the pregancy test came back positive and two and a half hours later this woman was taken to the operating theatre. The intern told me afterwards that there was about three and a half liters of blood in the woman's abdominal cavity.

Both of these patients survived their time in casualty. Each is an example of the lifeboat approach to care to which I have alluded in a previous post. A whole host of questions arise about systems, culture, training and case management as a result of these two cases. Some of these questions I am ill fitted to ask, much less answer. I share these experiences and have not entirely succeeded in withholding judgment in their telling but withhold judgment I must. A greater understanding is required. For now I am a blood warmer.

Responsibility

Captain of the Ship....that pretense is gone. Captain of the Lifeboat is almost gone. The concept that requires rethinking is this whole captain thing. Living in a wealthy country, born of supportive middle class parents, I have had an intellectual appreciation of God's providence. Mostly there has been the illusion that I was in control. Granted there have been profound failures as when my nephew Charlie died after liver transplant surgery. That wasn't supposed to happen. I have seen more death here in three weeks than I saw in a year working back home. What exactly is supposed to happen?

A 3 year old the second day with large, sad eyes strapped on his Mother's back in colorful cloth had swollen lymph nodes all over, a facial mass and diffuse facial and leg swelling. I thought he had Kaposi's sarcoma, an HIV related malignancy. Sure enough, his rapid HIV test was positive but his biopsy was an inadequate specimen. He died before it could be repeated. Yesterday an older woman with abdominal pain transferred to Weill Bugando after being in a referral hospital for 3 days. She was cold, clammy in obvious pain with a firm, tender abdomen. She was tachycardic with a blood pressure of 120 over 90. I ordered IV fluids and x rays and consulted surgery. Today the intern tells me that she" collapsed" on return from x ray and died. The thin man with a swollen neck described in my first post died in the hospital within a day. A tiny 1 month old grunting in his Mother's wrap, another transfer from the same referral hospital died after a few days in the ICU. A 53 year old woman who collapsed complaining of abdominal pain. I could palpate a pulsating mass in her abdomen that was slightly tender. An ultrasound confirmed a large aortic aneurysm. Her family could not afford the cost to transfer her to Nairobi. As far as I know she awaits her fate on a medical ward in the hospital as I write. I could go on....

I have a selection bias in that I am intentionally gravitating toward the patients who appear to me to be the sickest. Amongst these, there have been some remarkable success'....the woman with a tension hydro-pneumo thorax (fluid and air in the chest cavity where there should not be)
presumably from a bronchial fistula secondary to tuberculosis. She got a chest tube and when food particles were noted in the drainage, she was taken to the operating theatre by 2 surgical registrars and a tear in her esophagus was repaired. She is currently alert and walking around the ICU.

It is actually a good thing to relinquish captaincy. I must admit that I knew enough before I arrived to expect a relinquishment. How to relinquish captaincy without relinquishing responsibility is one of the many unanswered questions at this moment in time.

Sounds and Cold Fury

It's the end of week two. Coming as I do from North Carolina, I have slid down Bust Your Fanny Rock into a mountain stream. The shock of that cold water takes your breath away and you find yourself in beyond your depth. You the readers must forgive my first week's thrashing efforts as I attempted coming up for air. The water is still deep and cold but I have begun to tread and my head's occasionally above the surface.

The door bell is on the outside of casualty. People push the bell when they need help moving someone into the casualty area. When this bell is pushed a medley consisting of "Jingle Bells", Rudolph the Red Nosed Reindeer" and "Joy to the World" plays repeatedly.

There are birds here whose call sounds like a cross between the crow's caw and a donkey braying.

Islamic prayers over loud speakers on one side of the hill and Christian hymns on the other side.

"Karibu" "Habari dakta" "Hujambo" "Shikamoo" are some of the ways of being acknowledged or greeted. It is odd however that these greetings generally come after I am 5 yards past the oncoming person. Occasionally these greetings are in English. "Good Morning" no matter the time of day. Some "Give me money" The always popular "How are you" At other times the greeting is Swahili but the words I don't recognize. These are often followed by cackles of laughter. I'll let you know in a few months perhaps, how I've probably been serving as the butt of jokes.

Today at 4 the Jingle Bells medley signalled a 7 year old girl in a car requiring a stretcher. She arrives in the crowded women's and childrens casualty room with blood coming from her left ear and a swollen, deformed left thigh. She had been struck by a vehicle. She is sleepy but talking. Her Mom comes in and quietly takes her hand. The last sound of my work day is the Mother's whispered voice as she leans over her daughter's battered body.