Sick Rounds.

There was a huge thunder and lightning storm last night, but still no rain. The thunder was so loud, it sounded like an airplane was driving through the house, I kept waiting to smell smoke. Today the sky is ominous, everyone is hoping for rain.

We went on a hike yesterday evening and scaled our way to the pinnacle of a rocky cliff. It was scary, but made for a good adrenaline rush. You could see for miles despite the dry dustiness and the pre-rain fires that are set purposefully for the new crop season. I kept my eyes out for snakes, but all we ran into was lots and lots of longhorns.

This weekend I was consulted on a 2 wk baby with a 1kg weight loss (2kgà1kg) since birth, poor feeding, and lethargy. The baby’s blood sugar was so high that it was unreadable on our machines, but after many many boluses the blood sugar finally read as 900. It was the first time I’ve ever started insulin on a newborn, so I had to consult the NICU back home for some Neofax guidelines. My guess is that it is all secondary to sepsis, but I was reading that there is an entity of neonatal diabetes but it is exceedingly rare. I wrote out step by step instructions for the deer-eyed overnight resident, but I didn’t expect the baby to survive through the night. Also, Na 171, K 8.5, Cl139, BUN 281, Cr 4.4. Surprisingly not the worst electrolytes I’ve seen since coming here, but pretty darn close. Imagine my surprise when the baby was looking better in the morning and even able to eat by mouth! Today the baby’s blood sugar is around ~100, but the electrolytes are still pretty abysmal. We started somewhat of a manufactured insulin drip with comes to ~0.1u/h, which we have weaned this morning. I am hoping that it is all due to sepsis and will eventually self-resolve because it will be a nightmare trying to manage neonatal diabetes in this setting.

There was another 3 day old baby girl who came in yesterday, floppy and lethargic, who died before we could even get an IV in her. She had been born at home and hadn’t been well since birth. You can start to understand why mothers are hesitant to name their babies until they are a couple weeks old.

It was nice to be back in the community today. There was a lot of “Good morning Dokitah Britt-anee, You are welcome back”. Rudolf is still here, has some osteomyelitis of the hip and the family is working on raising money for his huge bills. It is nice to see his smile. I called my grandfather over the weekend and his home attendant who is from Ghana answered the phone. He said “how do you like Africa?” I told him that it is beautiful and the people are really nice and welcoming. He said that he was glad to finally hear someone say some positive things about Africa, as it often gets so much bad press about being dangerous and poor and scary.

While there are obviously some very dangerous parts of Africa, the Africa that I have experienced here in Mbingo is filled with good morning smiles, invitations to family homes, welcomings into churches, shared meals with strangers, parades of children on hikes, and music in every corner of the countryside. Of course the hospital is filled with death and despair, but outside of its walls is a beautiful place. The people here are so grateful for the existence of a hospital in their midst, there is no one that takes that fact for granted. They will thank you for doing a spinal tap or bone marrow biopsy at the bedside, just as soon as they will invite you into their family home.

They said that the children ward was not so busy last week, but sure enough I walked in today and every bed was filled. And the kids are VERY SICK.

Bed 1: 1.5yoF with vomiting and abdominal pain x2 days, mass in LUQ. ? Intussusception

Plan: Repeat abdominal ultrasound- Go to OR

Bed 2: 4mosM with cough, fever, increased work of breathing x3 days. Transfused x1 at OSH (Hgb5.9), + hepatosplenomegaly. ?Lipoma over left rib cage?

Plan: Supportive care for bronchiolitis. Chem10, coags, sickling test. Abdominal US for HSM and rib mass. Start Fe.

Bed 3: 13yoF with AIDS, CD4 count 4, severe HA and vomiting x1 week. LP shows cryptococcal meningitis. On ARVs x1 mos, Bactrim PPX

Plan: Continue Amphotericin, therapeutic LPs when complains of HA, monitor fever curve, other symptoms

Bed 4: 1yoM with vomiting, diarrhea, lethargy, s/p transfusion x1 for Hgb 4.0. Sickle neg. Likely AGE. Why such anemia?

Plan: Repeat Hgb, ORS, continue supportive care for viral AGE. Start Fe.

Bed 5: 10yoM with fever, cough, tachycardia x4 days, also recurrent epistaxis. CXR with R upper and L upper consolidations

Plan: Continue O2. Ceftriaxone and erythro for CAP, will send aspirate for AFB and place PPD. Follow up Code Status.

Bed 6: 2yoF with persistent fever and FTT. Has been treated by multiple antibiotics in past, as well as antimalarials. Currently on Clinda and Bactrim and Day #2 of TB treatment. Suspect immunodeficiency disorder.

Plan: Will continue TB treatment x1 wk. We are not providing anything new for this child and parents have very large bill. Consider discharge after trial of TB meds.

Bed 7: 3yoF with R leg pyomyositis, s/p I&D. Now afebrile on Clox and Clinda.

Plan: D/c home with continued dressing changes and antibiotics.

Bed 8: 14yo with fevers, huge splenomegaly, pancytopenia. Failed antibiotics, Antimalarials, TB treatment. Bone marrow biopsy inconclusive, Hgb persistently 4.0 following transfusions. Is leaving AMA today.

Bed 9: 14yoF with anemia, bone pain, generalized weakness x3 mos. Has had 4 transfusions in the past, Pancytopenia with CBC last night showing WBC 2.5, Hgb 2.2, Plts 1. Now s/p transfusion x2.

Plan: Bone marrow biopsy once platelets >15k. Send peripheral blood smear and aspirate.

Bed 10: Chemotherapy

Bed 12: 15yoM with abdominal pain and post-prandial vomiting x2 days. ? scleral icterus. AlkPh 646, bili 6.6. AGE versus gastritis, ?superimposed liver injury secondary to traditional medicine?

Plan: Ranitidine. Send LFTs. Abdominal ultrasound

Bed 14: 10yoM with neurodevelopmental delay and full body contractures, present since age 7 after child had seizures x3 days and did not seek medical care (previously normal). Here for PT, also with fever and seizures. Loaded with phenytoin and continued on home phenobarb. Treating also for UTI. Now with cough and concern for aspirations PNA despite CXR WNL

Plan: Continue PT, Flagyl, Cefixime. Follow up antiepileptic dosing.

Bed 15: 8yoF with abdominal pain, fever, and cough x 3 weeks. Febrile with loud holosystolic murmur (new?). + Hepatosplenomegaly with tenderness over liver. Crackles at lung bases bilaterally, 2+ pitting edema of lower extremities bilaterally. Electrolytes ok. Abd ultrasound shows severely congested liver. ECHO show all chambers dilated with severe mitral and tricuspid regurg and significant calcification of the aortic valve. EKG LVH. EF 69%

Plan: ASA, IV Lasix. Start Digoxin? Need to research this more. Talk to Sinai Cards?

Bed 16: 2 wk F with choanal atresia- seen by ENT, can’t determine membranous vs bony.

Plan: Send to Bamenda today for CT scan.

Bed 17: 2 wk F with suspected sepsis and severe hyperglycemia, s/p insulin drip. Still with significant electrolyte derrangements, though better appearing today. Na 183, K 6.4, BUN 245, Cr 3.6, Gluc 109

Plan: Switch fluids to D5 ½ NS and continue to monitor FS q3h. Need to think more about this one. Repeat Chem10.

Bed 18: Rudolf. Has been discharged but parents working on paying bill. Continue PT while here.

Bed 19: 11 day old male with irritability x1 wk, here with dehydrations and electrolyte derrangements. Na 161, K 5.5 BUN 98, Cr 0.7. CSF WNL. Baby improved-appearing. Continue amp/gent, repeat Chem10

Bed 20: 3mosF with suspected HIV, being treated here for CAP, PCP. Persistently hypoxic despite treatment with Bactrim and steroids. WHY?????

Bed 5-2: 11yoF with severe mitral valve regurgitation in severe decompensated heart failure. Needs surgery but family can’t afford it. On Captopril, Lasix, ASA. +HSM, b/l pitting edema. Very ill-appearing.

Plan: IV Lasix stat, continue home meds. Follow up CMP.