1-a 35 year old woman comes in complaining of nausea vomiting and abdominal pain for the past few weeks. X-rays show high grade small bowel obstruction. Surgery finds multiple small abscesses; congealed material and small bowel adhered together, requiring side to side re-anastomosis. After seeing her in the ED I reconnect with her in the ICU where she is a few days post-op and I am on call for the weekend. Her breathing worsens over the weekend requiring intubation and her CXR shows evidence of ARDS; not good. I am unable to save her in spite of pressors and respiratory support. I won’t know what she had but I bet it was likely reactivation TB in her abdomen. My Kenyan colleagues tell me that they are seeing more TB in places other than the lung with no history of a prior known TB infection in the lung. Lots of TB around here, without all the isolation paranoia that we have; I won’t be surprised if I turn PPD positive by the time I’m done around here.
2-a 33 year old known diabetic with a history of pneumonia one month ago comes in complaining of increasing shortness of breath. The resident calls and tells me that the patient has pneumonia on the CXR and should do well on oxygen and antibiotics; but maybe a good idea to keep an eye on him in the ICU. I come in to check on him in the Unit and he is breathing 50 times per minute with a believable pulse ox of 66% on mask oxygen. Clearly he’s not talking much and his sugar is high-say around 600. His BP is around 220 systolic which I am glad about since it’s always nice to have more blood pressure than less; that goes for sugar too. But the CXR looks more like CHF than pneumonia and besides the patient is a little puffy. Another intubation and this time out comes pink tinged frothy sputum like a small soda fountain; just like the textbooks said ( I think that’s what they said, at least the lecturer must have said something like that). A little suction, a little lasix, and the sat’s perk right up to 88% which I consider a cure. 4 days later he’s out on the general ward. If you had seen the general wards here at Kijabe that would mean something to you. You’d better basically be ready to go home if you want to survive out on the general ward. Think of the hospital scenes from the English Patient and you have a good mental image; except throw in a little more grime and smell.
A few medical thoughts:
-Try managing ventilated sick patients with no ability to order ABG’s; it’s possible to do.
-Remember my sick newborn that I ventilated and bagged for an hour and never could figure out the old German ventilator? Well a pediatrician came this week for a month and we have two preemies on ventilators, so I got a bit of an in-service on them and now feel confident that I can set up a tiny little baby on a ventilator should I need to.
-Can patients survive without the ability to order vicodin? Yes they can, and they don’t die. I guess they just feel miserable.
-Little sticky electrodes that we use for hooking people up on telemetry monitors are really good things and when you don’t have them it is a problem. I guess they are a donated item; must be expensive.