Here is some medicine for those of you interested in the nitty gritty details...some of these cases are interesting because of the medicine, but many are here to illustrate the challenge of resource limitations.
- Case 1: 6 yo M with sickle cell disease admitted with acute chest syndrome. He had multiple episodes of acute chest in the past. Febrile and hypoxic on presentation, he remained febrile after 7 days of antibiotics and was still hypoxic with attempts to wean his oxygen. He wasn't able to get a chest x-ray due to his low oxygen saturation. When we finally convinced the tech to due the XR, he had a large pleural effusion on the right side. He improved after the addition of gentamicin to his antibiotic regimen (ceftriaxone, azithromycin started initially). We attempted US guided thoracentesis, but without lidocaine and with a needle that was too short, so it was unsuccessful. He required multiple blood transfusions for a hemoglobin in the range of 3-4. We considered attempting an exchange transfusion if he was not improving and we were unable to wean his oxygen.
- Case 2: 10 yo M w recurrent seizures who previously had cerebral malaria and was treated, but now is in status epilepticus (multiple back-to-back seizures). We are limited here by the medications we have available to treat certain conditions. We have benzodiazepines (first line) to treat seizures, but our only second line option is phenobarbital, which can cause respiratory depression -- and we do not have the ability to provide ventilatory support for patients beyond an Ambu bag, making this a potentially risky choice. This is the second patient in status epilepticus we have had since I arrived. The first week I was here, we had another child in status who we transferred to the government hospital in Kisumu because his respiratory status was already poor (he tolerated the placement of an oral airway without gagging) and we did not have any other options for treatment here. He had multiple seizures en route to Kisumu and was intubated on arrival to the ICU.
- Case 3: An older gentleman presented with hypertension and altered mental status, reportedly also with a fall from standing. His blood pressure was 200s/120s on arrival and he would not speak to staff or follow commands. His blood pressure was treated emergently in the ER with hydralazine and nifedipine with a resultant drop in his systolic blood pressure to 109 -- which is too much, too quickly! His mental status did not improve with the drop in blood pressure. We were concerned for possible ischemic stroke vs hemorrhagic stroke vs intracranial bleed related to the fall vs hypertensive encephalopathy given his presentation. He had a history of a prior stroke as well with unknown residual effects. We cannot use CT for stroke diagnosis without referral to outside facility, and usually patients with stroke do not present acutely anyway. His mental status improved after about a day, although he demonstrated some signs of dementia/delirium and it was unclear how much of his altered mental status preceded the elevated blood pressure or was a result of the hypertension.
- Case 4: Another older gentleman presented with altered mental status and was found to be hypoxic on initial evaluation. His etiology of hypoxia and altered mental status was unclear (although it is very possible that he was altered because of the hypoxia, we did not know why his oxygen saturation was low), he had a negative urinalysis and unrevealing labs. He was started on empiric antibiotics with meningitis coverage and a CXR was ordered. He would not tolerate oxygen through the nasal cannula due to his altered mental status and kept pulling the cannula off his face. He was not on a cardiac monitor or continuous pulse oximetry. He could not get the CXR done due to his hypoxia. Overnight, his saturations dropped further and he became unresponsive and pulseless. After 3 rounds of epinephrine and chest compressions, he was pronounced.
- Case 5: A young woman in her 20s presented with new renal failure of unknown etiology. She was evaluated at an outside facility and started on dialysis, but discharged from that hospital after a few days. She was not continued on dialysis as an outpatient. She presented here with altered mental status, likely related to uremia. Her GCS was 11 on arrival and precipitously dropped to a GCS of 3 within a few hours. We did not have the ability to do an EKG (out of EKG paper), nor did we have time to do labs and evaluate her potassium/BUN levels. Because of the acute mental status change and need for emergent dialysis, we arranged for transfer to a facility with the capacity to start her on hemodialysis. She died on the ride to the outside hospital.
- Case 6: We checked on a 80 year man in the morning on rounds during the CO's presentation it was noted that the patient was at the hospital for the complaint of dysphagia (difficulty swallowing). As a side note, he mentioned that the patient was also hypoxic despite placing him on 4 liters of oxygen by nasal cannula. Noting the continued low oxygen saturation, the CO increased the patient's oxygen to 5 liters per minute, but he never rechecked the oxygen saturation. When we were at bedside, the patient was altered (unclear baseline), had a gaze deviation to the right, and his oxygen saturation was 92% on 5 lpm oxygen. It seemed likely to us that his dysphagia, which was reported as the chief complaint, was actually due to a stroke and that the hypoxia was presumptively secondary to aspiration. Because his symptoms began more than 5 days prior to arrival to the hospital, and his poor overall prognosis given that he was dependent on oxygen (which he cannot go home with), he was discharged home with his family and referred to hospice care.
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