Well another week is almost done and the more time I spend in hospital the more things slowly start to make sense. I had a very nice morning this morning, attending a lecture on rheumatic fever given to the medical students by the paediatric consultant, then a bit of bedside teaching for the students on malnutrition, something which in just three weeks has become bread and butter. The initial dread of being put on the spot doing bedside teaching on patients I know nothing about with the wildest pathology I have ever seen is beginning to subside a bit and I am well aware that teaching this stuff is making me learn huge amounts too. I can’t help but feel that in the UK we have become over reliant on investigations instead of clinical skills. Here there is no option to send any murmur that sounds vaguely pathological to a cardiologist for assessment /ECHO. There is no cardiologist, and no ECHOcardiography. Just my ears trying to decide whether this patient just has mitral regurgitation or whether there is a mitral stenosis murmur too (trucks on cobble stones anyone?) and 22 eager medical students awaiting the verdict.
There is still wild pathology. This week I have seen a three day old baby who was born at home with a huge spina bifida lesion, present with fever and almost certain meningitis. He is currently better from his meningitis although there is absolutely nothing we can do for his spina bifida, and it may have been better not to treat him at all. Along the same line I have also see a 14 month old present with on lump on the back of his head present since birth. Sounds innocuous enough until you realise he has severe developmental delay(no head control, can’t sit), macrocephaly (abnormally big head) and the lump is almost certainly an encephalocele of some variety ( ie spina bifida of the head rather than lower back for want of a better description). Again absolutely nothing we can do – not sure why they waited 14 months to see a doctor but then there wouldn’t have been anything that could be done 14 months ago either.
So what is available in terms of diagnosis? Well I’ll give you a list. The investigations are so few and far between that listing them is possible: Haematocrit (but no Hb), WCC and differential, platelet count (not done routinely), blood film, ESR, urea, creatinine, bilirubin, SGOT/SGPT (transaminases I’ve never heard of before), alk phos, blood glucose, wider test(typhoid) wiflex test (typhus), Hepatitis serology,HIV antibody test, urinalysis, microscopy of most fluids, xray, ultrasound.
That’s it.
No electrolytes, no blood gases, no albumin or bone profiles, no clotting studies, no cultures (of anything), no ECG, no EEG, No CT or MRI (not that I was expecting those really).
No nebuliser or spacers (subcut adrenaline for acute asthma anyone?)
No neonatal resus equipment, or any equipment for resus at all. (But there wouldn’t be much point in the latter when there is no ITU either)
No phototherapy units. No incubators (well one, but it’s broken and no one knows how to fix it)
No water.
There. I’ve managed to thoroughly depress myself with that, but it’s really not all that bad. We have a few small triumphs – in fact I’m amazed at how resilient some of the children are. Two in particular cheered me up today: A girl who came in with high grade fever, diarrhoea, purpura everywhere, bleeding nose, bleeding gums, unwell but alert. Haematocrit 17%, Platelet count 9. She was treated as ITP+infection with antibiotics, steroids and blood transfusion. She looked a million times better today. I still think she probably has leukaemia but it was nice to see her looking better. Secondarily, a boy with acute hepatitis B who had been to see a traditional healer which is common practice here. He had been given a herbal remedy which turns out to be pretty toxic to the liver and came in with jaundice, massive ascites looking decidedly encephalopathic (ie bad for the non medics reading this). Transplant not being an option he was managed with iv fluids and multivitamins and was wide awake again and looking much better today. Hooray! The herbal remedy seems to be really bad stuff. I haven’t seen so much ascites since I worked on the alcoholic liver disease ward in Glasgow Royal Infirmary as house officer!
Anyway. I think that is all for now. Apologies for the very medical content of this post – not so interesting for everyone. I’m off to Dire Dawa this week end so the next post will almost certainly be full of touristy stuff and photos.
Jo x
No comments:
Post a Comment