Another night of obstetrics call is in the books. It began with mother who was admitted with a femur fracture from a traffic accident. She was 31 weeks pregnant, and the baby’s heart tones were not completely normal. I watched her overnight as she was readied for surgery the following day. I imagined that her placenta would separate from the wall of her uterus due to the trauma, and I would have to rapidly take her back for a cesarean section; I wondered if I would need to call the orthopedic team to fix her fractured femur at the same time. Next was a severely ill pre-eclampsia (high blood pressure in pregnancy) patient. Her pregnancy already was complicated by severe growth restriction in the baby and loss of fluid around the baby both of which indicate that the placenta is failing. The estimated weight of the baby was about 2 pounds which indicated she was about a month behind where she should be. As I watched the heart tones of the baby they were minimally reactive indicating a unborn baby at the end of its rope. I took her for cesarean section and pulled out such a small little girl. She is doing well as of now on a ventilator, and I hope she makes it. The call ended with a delivery of twins right at midnight. The first came out normal looking for the exit. The second backed its way out in a breech position. The interesting thing is despite being twins, because of the timing of their birth, they have different birthdays. Cool!?
I spent the last Saturday morning participating in the exams of our Family Medicine residents. They were given 20 minutes with different patients to demonstrate their ability to interview, examine, and diagnose a patient. Overall they did well. I drove to Nairobi in the afternoon to see Avengers with a bunch of high school boys. Almost two hours in each direction makes for a long day, and the movie had better be worth it.
I walked into the ICU and the nurses came to me to tell me how a patient in the far bed was a walking miracle. It turns out he had hurt his neck two weeks previously, yet had continued to walk around Nairobi for a few weeks before he finally showed up in our emergency department. By the time I met him he was flat in bed with two large screws in the side of his head holding his neck in traction. All he complained of was a little weakness on the right side of his body. He was lucky he wasn’t paralyzed! Everyone was telling him how he was a miracle.
The best part of the job is working with residents, medical officer interns, clinical officer interns and other consultants in the hospital. I am feeling especially pleasant this week because I am working on the internal medicine service. Last week I was in the ICU which is definitely intense. There is a definite lightening of the load when one gets to move away from the care of the deathly ill patients. The worst of last week was a young mother who came in at the young age of 32 years. Four weeks ago she delivered a baby premature. Something happened at her delivery, and she ended up needing four units of blood in transfusion. This happened in a hospital a in a different district. She was discharged and slowly became weaker and weaker with more and more trouble breathing. She presented to our hospital, and she was found to have a very weak heart. This is called peripartum cardiomyopathy. Hers was so bad that she had developed multiple organ failure. Her kidneys, lungs, liver, and heart were all failing. On top of that she had a big blood clot in her heart as well as a problem with the ability to clot her bood. We admitted her and began the fight for her life. Initially she responded to our treatment, and I was hopeful that she would get better. However after 3 days she quit improving. On day 4 she began vomiting blood. I had the sinking feeling during morning rounds that although she had improved and was better than when I first met her, that there was nothing more I could do to improve her more. Unfortunately that afternoon her heart stopped during an investigation to determine why she was vomiting blood, and after about 4 hours of trying to rescue her she passed. It will not be easy to get over. This week my patients are less sick, and I find myself almost skipping through the hospital, enjoying the people I work with and enjoying the patients who are getting better.
Again we are back at Kijabe Hospital. And although the kids and Allison get to continue their break, I am back in the hospital. This week I am serving as the consultant in the ICU. There are some very challenging patients, but they are so interesting. And when they get better, you really feel like God is with you because sometimes it seems like a miracle. And as always the biggest responsibility is to teach the residents and interns on the skills it takes to be effective in their care for patient’s when they leave their training.
Two of the doctors from Kijabe Hospital are mentioned in this long article about antibiotic resistance in Kenya. It is a real problem, and it is one that we are fighting against in our hospital under the leadership of Dr. George. I get to work with some amazing people.
A passionate man with wide, expressive eyes, Dr. Otieno, 36, is a driving force behind the hospital’s newly established antimicrobial stewardship program. But he expressed frustration over the lack of progress, describing overworked nurses reluctant to embrace complex hygiene protocols and the hospital’s own pharmacy, which he said continued to overprescribe antibiotics.