Every morning, one of us rounds in the ICU and the other starts seeing patients in the ER. Monday was our first official day at work. I started in the ER and was waiting for Kelsey to return from the ICU so that I could hear an update on our dialysis patient. It was only the first hour and a little slow. I had seen a couple of fractured wrists and nasty nasal abscess when a man ran into the room with a pile of blankets in his arms -- "Please, emergency, I need oxygen." I looked into the bundle of bloody blankets and there was a newborn baby...a blue newborn baby. I grabbed the baby and began to dry him off with the blankets. The nurse told me he was born across the street at the health center immediately before arriving at the ER across. I asked for oxygen and a bulb suction. "We don't have here for him" was the response (in other words: we don't have baby stuff in this room). The baby began to look a little less blue with the vigorous drying and let out a whimper, the first noise he had made since he came through the door. Luckily Jeremy was nearby and suggested that we go to the L+D ward where there is an incubator. I wrapped the baby up and ran across the hospital grounds in the rain. Once we were in the delivery room, we got him under the warmer and I was able to suction him. With oxygen he started to pink up and became a little more responsive. The baby's father stood with us with tears in his eyes, his first baby. It was only then that I heard screaming. They had brought another woman into the delivery room and she was giving birth about two feet away from us. As I looked up, the new baby was crowning. Now that my baby was looking better, I left to write for dextrose (the glucometer is not working so we just treat), fluids, and antibiotics. Jeremy called the pediatrician who would come see the baby once he was done with his clinic. Welcome to the ER.
The ER at Soddo has four small beds and two nurses who translate for us and complete all medication administration. We see one or two patients at a time in chairs (sound familiar?) and then move them to a bed for examination. Some patients are walked back and placed directly on beds without a card (chart) and are called "emergencies" but the triage system is unclear. Long bone fractures are the only things that are reliably walked back to a bed. And people who cannot stand on their own. We write lab and radiology orders on slips of paper that are handed to the patient. The patient then takes the slip of paper to either lab or x-ray, where they pay for each service, have their blood drawn or films taken, and then wait for the results. Sometimes x-rays (on actual film) are brought back to us by the patient, sometimes by a porter who carries both the lab and radiology results. The only patients that don't go to the lab themselves are the ones that are too sick to walk. In this case, the family is responsible for carrying or wheeling in a stretcher or wheelchair the patient to lab/X-ray. Sometimes our nurses will draw labs and have a family member walk the specimen to the lab. Needless to say, sometimes the blood or other specimens don't actually make it to the lab. It is shocking who we send out of the ER by foot to lab or x-ray. Kelsey had a hypoxic patient with saturations of 76% who actually looked clinically well (walking and talking without problems) who we sent to radiology and didn't see for 4 hours. She, like many of our patients, will leave the hospital grounds for breakfast, lunch, church, etc. Some will even leave completely and return the next day for results (a 24 hour ER stay without actually staying in the ER building).
We have learned so much in this first week. We each had a patient with large painful knee effusions. Both knee taps came back as septic arthritis and tested positive for tuberculosis. We have come to realize that anything here can be (and often is) tuberculosis (as Jeremy said, we "are starting to get the hang of it!"). We've seen things here that we rarely even think about in the US. Kelsey saw a 14 year old girl with right lower quadrant abdominal pain. She had never had a period. Her belly looked big when she stood up to walk to an examination bed. Pregnant? We took a look at her abdomen with our ultrasound and she had a large fluid collection in her right lower quadrant and her uterus was huge. It didn't look like a pregnancy, but it didn't make sense. Kelsey did a pelvic exam and the girl had an imperforate hymen. Thankfully Jeremy was around to even suggest this diagnosis as it is not uncommon here. We sent her to gyn clinic for a curative operation. A toxic looking four year old came in with a high fever. He had been vomiting for one day. He was seen the day before in the ER and his family took him home to wait for results. He looked terrible when he returned. His malaria test had been positive a week before. Chest x-ray and urine were negative for infection. His WBC count was 28. One of the Ethiopian residents asked if we had performed a lumbar puncture. She agreed he didn't have meningeal signs (a stiff neck) but she said sometimes they have outbreaks and his parents told her that the child was having a severe headache. They performed the LP and we started him on steroids and antibiotics and admitted him to the hospital. While he was waiting for his bed, his LP results returned -- gram negative diplococci on the gram stain, likely Neisseria meningitidis. We wrote prescriptions for our nurses/staff for ciprofloxacin meningitis prophylaxis and took our own cipro at home. Jeremy called the zone medical board to report it and informed us that he has never had a patient survive bacterial Neisseria meningitis. Hopefully, our patient will be the exception.
There have been a lot of ups and downs this first week. The first afternoon was overwhelming and I needed a break. I ran to the house to refill my water bottle and on the way back I went to check on our dialysis patient. There was wailing in the ICU. I walked in and told the nurse that I was working with Dr. Kelsey and Dr. Jeremy on the sick patient. She responded "Oh, he has died." The wailing was the family. I must've looked shocked and asked her when it happened. "I don't know" she replied. I asked if she needed anything and she said no. I didn't say much else--we all knew that even if he was in the US he probably would've died. I walked back to the ER and told Kelsey. We both didn't say much...and then we got back to work. Some things are the same no matter where you are.
Auna and the blue baby
Our Thanksgiving table
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