Tuesday, January 15, 2013

Keeping Busy

Thank you for those that have checked in about the blog. I'm doing well, here in Sagam, though we've been kept busy with a lot of work at the hospital. Since coming back from the States, little Sagam Hospital has been hopping. The patient census has been high, as has the acuity of some of the patients' illnesses. We have helped treat some tough cases, and have been lucky and blessed to see a number of the patients get better and walk out of the hospital.

A few of the cases that have been on my mind:

We recently had a child living with HIV who came in with a severe case of malaria. He was weak when he was admitted, was slow to respond to questions and was not acting like himself. When he wasn't responding to the various medications we were giving him for malaria we also added a strong antibiotic in case we were missing a bacterial infection in his brain.  Due to the swelling caused by infection (malaria or bacterial meningitis or both), the pressure in his brain was building up to dangerous levels.  He started having seizures, and the brain swelling caused him to slip into a coma and begin to hold his body in a rigid posture, called opisthotonus (see photo).  We did all we could, and I was pretty sure he wouldn't make it until morning.  When we checked on him in the little pediatric ward the next day, he was alive but still doing about the same. But still, he was alive, and so there was still some hope. We continued our treatment and later that day, though still comatose, his muscles were a bit more relaxed.  Again, as I went home, I was pretty sure there would be an empty bed the next day. But lo and behold, little by little over the next few days, he came back to us. He emerged from his coma, he began to follow us with his eyes, and eventually could take a little porridge, answer questions, and then the big one - smiled at us. Today the clinician in charge, Benard, signed him out of the hospital, and the little guy walked out. He's still in danger, as he missed several days of his HIV medications, and there is risk that his virus is now resistant to one of the medications. But nonetheless, he has a chance.

Another recent challenging case was that of a young man in a coma who was brought to the hospital on the back of a motorcycle.  He smelled strongly of a chemical that made me think of turpentine, and he was not responsive at all. Thankfully he was breathing on his own, and he had a heart beat; but otherwise he was in a deep coma.  On questioning the family, it turned out that he was in a argument with a family member and purposely ingested a poison called Triatix, which includes the compound known as amitraz.  This chemical agent acts as an alpha-2 agonist (an example of a medicine that is an alpha-2 agonist is the blood pressure medicine known as clonidine). In the US he would have had a breathing tube placed down his windpipe, hooked up to a ventilator machine that would do the work of his lungs for him, and two dozen tests and imaging studies would have been ordered before he had spent 30 minutes in the ER.  Here, we had a very limited number of tests and treatments at our disposal. So we gave him oxygen through a machine and suctioned the oral secretions that he couldn't swallow due to being in a coma. Those worked until the power went out. We were able to start a diesel generator the size of a suitcase and run it intermittently when he needed it, keeping in mind that we needed to ration fuel.  When his pupils remained dilated and unresponsive to bright light, and he showed no other signs of cholinergic poisoning or prior treatment with atropine, we called the family to let them know that he we thought he had brain damage and would likely not recover.  We waited until they arrived and then went home with heavy hearts. But yet again, we were pleasantly surprised to see him in the morning.  He started to grimace when we suctioned his oral secretions. His pupils were no longer dilated. As the day went on he began to become a little more responsive. When I walked into the wards the next day, he was watching the medical team and responded to our greetings. Amazing. Again, we were wowed and humbled. Thankful for his recovery, we are still cognizant that his road ahead to good mental health and well-being will likely be a long one as well.


Steve Albrecht said...

Jeff, the photo immeidately brings to mine the term opisthotonus and protrays the finding so well. My first guess was you were going to discuss a case of neonatal tetanus, the classic setting I think of for this sign. I'm eager to visit and expand my horizons.

sarah said...

I love all of these hopeful stories!!

Jefe said...

Steve. Great thought. I had forgotten about this finding in tetanus, and when reviewing the differential thought for a moment that I had missed tetanus, but what was reassuring that this wasn't the case was that the mental status was very depressed - compared to tetanus, where the patient is awake and in pain from the spasms. Thankfully haven't seen any cases of neonatal tetanus here. We saw one adult with it in Juba, and it was pretty bad to witness, even with treatment available. See you soon!

sarah said...

So you've given up on blogging?