We have safely returned to New Orleans & started on the all of the paperwork for graduation & residency that has been patiently awaiting us. I do, however, have a small list of thoughts and topics on which I wanted to comment from our time working in Swaziland.
To start, just some general information about HIV in Swaziland gleaned from conversations with the doctors. One interesting part of the epidemic in Swaziland, and in many ways Sub-Saharan Africa overall, is that it does not have the same drivers as some of the other infamous HIV epidemics. As I studied for public health coursework, the HIV in Thailand is driven by commercial sex workers while much of the HIV in Vietnam is a result of intravenous drug use. Those are two common drivers of HIV epidemics everywhere. In Swaziland, though, there is not such a clear cause for the extensive spread of HIV. The major contributors to the epidemic in Swaziland seem to be two things: to start, working way from home. Many men travel for their employment - go to South Africa to work in the mines or drive trucks. The time they spend away from their homes and their wives does not mean that they're not sexually active at that time, however, and whether from infidelity or using prostitutes, these men subsequently expose their wives to a whole host of sexually-transmitted infections, potentially including HIV. A second thing in Swaziland that perhaps has historically (or currently) expanded upon this aspect of the epidemic is polygamy, which is legal & in many cases a cultural norm in Swaziland (where the King has several wives). Although polygamy itself will not likely send HIV rampant through a population, there will be more spread of infections when a husband comes back from being away & unfaithful to not just one wife but several. The second major apparent driver in the Swaziland epidemic is vertical transmission, from mother-to-child. We learned that 42% of women seeking antenatal care in Swaziland are HIV positive....and one must consider who that percentage may be missing. It does not take into account all the women who may not seek antenatal care (and one could perhaps argue that a higher percentage of those women may be infected) or women who choose not to test themselves for HIV, whether before or during pregnancy. It is the general opinion of many of the physicians and other healthcare workers that the only way to make a strong and successful impact on the prevalence & incidence of HIV in Swaziland is by reducing/preventing the mother-to-child-transmission of HIV.
In any part of medicine, there are always old-wives tales & other lore surrounding diseases, treatments, medicines, & so forth. I always find it interesting to hear the questions that arise in regards to such topics.....and the concerns seem to be most off-the-wall (to someone who is scientifically trained to any extent) when they are in regards to HIV, sexually-transmitted infections, & pregnancy (perhaps because the topics are somewhat taboo and go un-discussed in many households). During one of our weeks in Swaziland, Carter & I sat in on a nurses' training designed to teach about HIV and providing anti-retroviral drugs to the patients at the non-Baylor clinic sites. At the end of the first day when the floor was opened up for questions, one of the nurses asked about the truth behind or explanation for the lore (which apparently circulates in some circles in Swaziland) that the ARVs to treat HIV increase sexual appetite/desire. The matter-of-factness with which the nurse asked the question almost made the whole thing funnier (though in a sad way I suppose) to me on some level....the physicians who were leading the training session, however, gave a very reasonable explanation without belittling the nurse for expressing concern for this view that her patients (and/or patients' parents) often hold. The doctor explained that the antiretrovirals make patients feel better & less sickly, and thus it's not entirely unreasonable that the would then have more energy to do things that otherwise healthy individuals would also be doing.
Hopefully from the things that Carter & I have posted on the blog, you will have gotten the impression that we had a great experience& really did get to work in a great environment that Baylor has been able to create in its clinics. There were, however, little things that affected the clinics if not the entire country that to those of us practicing in healthcare in a Western nation would find more than a little crazy. For instance, we often hear about their being blood shortages in the States....and many of us have probably gotten the phone calls or mailings requesting that we make blood donations to help replenish the supplies. Earlier this year (before Carter & I arrived) there was NO blood for transfusions in Swaziland....none at all, even for emergencies and children with hemoglobin values less than 5 or 6 (or lower). We heard of a couple very sick patients that the doctors worried so much about that they started to take stock of which physicians had what blood-types in case they felt like the only way to get blood was to donate it themselves. Similarly to the blood shortage (which was somewhat resolved when we arrived as there was blood available), there were essentially no urine dipsticks available in Swaziland when we arrived. Eventually by the time we left, one of the doctors was able to find some at a private pharmacy/medical supply warehouse - but the government facilities as well as the private facilities had been without the simple test strips to analyze urine. Instead, if they suspected someone had a reasonably straight-forward urinary tract infection, they simply treated to cover for it & hoped that the symptoms resolved. The only real study they could do to that extent in the clinic was to look at the urine sample under the microscope, in case there were obviously bacteria or blood cells therein.
Thursday, April 29, 2010
Tuesday, April 27, 2010
Abducens Palsy & Superinfected Zoster
As a future Neurologist, there were two cases that I found particularly interesting over the past month. Pictures were taken of these patients with their permission. Their names, gender, clinic locations and other details will not be mentioned in order to protect their privacy.
The first case is of a young child who came to the hospital with overt meningeal signs and fever that had progressively gotten worse over 2-3 weeks, according to the family. The patient presented with a stiff neck and positive Brudzinski's sign (hips flexed when chin was tilted toward chest). The child was treated empirically for meningitis with the available antibiotics, an antiviral (acyclovir) and anti-tubercular treatment (rifampin, isoniazid, pyrazinamide plus pyridoxine). No ethambutol was given as the child is less than 5 years old and resistant TB was not suspected. The child was also given a dose of steroids. The presumptive diagnosis was TB meningitis given the indolent course, low-grade fever and rapid response to treatment. However, a viral meningitis is also a possibility. The patient recovered within a few days and the only sequela was a cranial nerve 6 (abducens nerve) palsy of her left eye. As a result of the CN VI palsy she was unable to abduct her left eye. This apparently is a fairly common sequela of meningitis as CN VI has the longest subarachnoid tract of any of the cranial nerves. Inflammation from the meningitis presumably damages or alters the function of CN VI itself. Most cases resolved spontaneously within 6 months, although alternate side patching may be an option if the palsy does not resolve on its own. Since the child cannot move her left eye out laterally it appears positioned toward the midline when the right eye is moved laterally to the left.
The second case was of an adult who presented with a very painful, burning sensation of the left side of the face and lateral/posterior scalp. The patient had pustules in that region that had recently burst and had left open sores. The patient had been treated by another physician with acyclovir for varicella zoster virus (shingles). The patient was still having intense pain and it appeared that there may have been a superimposed bacterial infection. The photos below clearly demonstrate the dermatomal distribution of zoster and how it does not cross the midline. The patient was treated with oral chloramphenicol for bacterial infection (it was the only antibiotic available) and amitriptyline for pain.
Wednesday, April 21, 2010
Animals, part II
Here are the last few of the select-shots from Kruger. I got the first handful uploaded okay, but the last few were pokey. This is attempt number two, so there are just a few pictures.
The animals....
This was the second chameleon we came across of the day - this one on our way out. He curled his tail (just like you see in advertisements & stuffed animals & such) right after we finished snapping pictures, but his bright colors are still pretty amazing. I'd expect it in the rain forest, but not in Africa - it was crazy! Also, you can kind of see it with this guy - the way he has his feet positioned - but when the road is hot, the chameleons basically dance (think of Michael Jackson as a reptile - going forward, not backward) across the road. Once we have faster internet, I'll get up some pictures in sequence so you can better imagine the dance - it makes me think of beer commercials.
And last, but not least, of the major animal sightings of the day was our last lucky stumble-upon sighting. We were on our way toward the gate, not in a crazed hurry but in a reasonable rush, when we noticed that a bunch of cars were stopped along both sides of the road ahead of us. That of course means that there is something to see. As we pulled up we all tried to figure out which side they were looking toward so we could see the animal as efficiently as possible without making ourselves late for the gate. Turns out it was a lion - 2 lions in fact, a mating pair. The lioness was just hanging out in the middle of the road, biding her time, facing the male lion, who was sitting down on the side of the road, just watching her (waiting for her go-ahead signal). We got really close to them, especially the lioness, as we drove by, snapping pictures as we went (unfortunately we couldn't stay very long at all on account of the gate closing tiem). It was amazing! It was also probably the closest we got to "being the wildlife" though contained in the backseat of the car. They were on Carter's side as we pulled up, but she couldn't stop shaking, so all of the sudden she excitedly whisper-yells at me to switch sides. So all of the sudden, as Mac & Nancy just looked on and chuckled, Carter & I crawled over/under one another & switched sides of the car so I could take some more pictures. It was an incredible thing to see - - - another part of the reason to go back one day, so I can just sit & watch without having to rush off. It was a great end to the day - we saw a few more animals & birds as we pulled away toward the gate (at which we arrived with 10 minutes to spare).
(Note - these pictures upload WAY faster on real internet - currently in the airport in Johannesburg finishing this post. That bodes well for getting a good number of my pictures from the trip onto the web once I'm back in the States in approximately 24 hours.)
The animals....
This was the second chameleon we came across of the day - this one on our way out. He curled his tail (just like you see in advertisements & stuffed animals & such) right after we finished snapping pictures, but his bright colors are still pretty amazing. I'd expect it in the rain forest, but not in Africa - it was crazy! Also, you can kind of see it with this guy - the way he has his feet positioned - but when the road is hot, the chameleons basically dance (think of Michael Jackson as a reptile - going forward, not backward) across the road. Once we have faster internet, I'll get up some pictures in sequence so you can better imagine the dance - it makes me think of beer commercials.
Monday, April 19, 2010
Getting ready for the last hoorah
Good morning everyone.
We have had one or two emails recently, missing our blog and/or worried because no one had posted. Rest assured, we are fine & safe.....we just had a busy last week along with slow internet connection & other work to do on the computer.
A brief update to tide you over. We have now moved out of the cottage at Baylor in Mbabane & have been staying at Mac & Nancy's house since Friday night. Mac picked us up, as usual, late Friday afternoon & then we all headed off to get Nancy from work. They both teased us that it's kind of like getting the kids from boarding school - only this weekend they don't have to return us - they have to ship us off instead!
In any case, we've had a lovely weekend so far. Nancy made us delicious chocolate mousse from Toblerone bars (it's very simple & delicious - not too sweet - and we will be sure to make it when we're back in the States). We had it for dessert on Friday, and I've eaten it at least once a day since then.
On Saturday, we drove to the northern part of Swaziland & did a little bit of shopping before driving out to an old mining town to look at the cable-lines that were used to take ore over the mountains to South Africa. The lines are still standing but not in use - it makes Mac a bit sad as it's all on its way to a rusty-ruin (though it's apparently the longest running cable line in the world). The drive out there was bumpy, but it was interesting to see - and we also got to see a bit of the timber industry in progress as we passed through the mountains. After that little trip, we went to Malalotja - another nature/animal reserve in Swaziland. It is more known for its hiking trails & nature than big animals, though we did see a few wildebeest, warthogs, & some other impala/antelope family animals. We did/attempted a hike to the waterfalls. It was supposed to be a loop though about halfway in we heard the thunder moving in & found the trail poorly marked, so we saw the falls from that point & reversed back to the car. We got back, tired & sweaty, rested on the benches for a bit, & were back in the car just as the first few drops fell. It didn't turn out to be much of a storm, but it wasn't worth taking a chance of getting caught out in the park on the trails.
After the hike we headed home for hot showers (possibly one of the best showers of my life-helped by the fact that Mac & Nancy have a huge, beautiful shower). We cleaned up & then met Dr Stephanie (our supervisor at the clinic) as well as the new visiting scholar (a family med resident from New Mexico) for dinner at a traditional Swazi restaurant just outside of Mbabane. Mac & Nancy were a bit nervous about exactly what that might mean, but it turned out to be delicious (no green tripe - which is essentially uncleaned tripe, to Nancy's relief). The woman who owns & runs the restaurant was great, & we had a lovely time.
Yesterday (Sunday), we took our time in the morning & then headed out for the last round of souvenir & gift gathering. We returned to a few places for a few more gifts, had lunch, & then stopped back in Mbabane to see Sibebe Rock - a huge granite face just outside of the city. It's apparently the second largest such rock face in the world (after Ayer's Rock in Australia) - it was quite impressive. I will try to post pictures a bit later (sorry, this will be a words-only update). Then we walked along a little stream & falls to stretch our legs before coming back home for a braii (the Swazi term for grilling-out).
This morning finds us having a particularly relaxed day - doing laundry & cleaning up. This afternoon Nancy will drop Carter & I off at Mkhaya game reserve, an animal/nature reserve here in Swaziland. We will spend 24 hours there - going on 2 game drives & 1 game walk. We are hoping to see more rhinos, elephants, and such. We're not positive they have lions though they are supposed to have leopards (the latter of which we did not see at Kruger). In any case, it's going to be amazing. They feed us (apparently) delicious meals after each game drive/walk, & we will spend the night in traditional-style stone huts (that are somewhat open on the sides - I'm secretly hoping a giraffe sticks its head in though Carter would not be so pleased!).
We'll let you know how it all goes soon - the next update may be while we are still in Swaziland (or it may be en route home). We're not anticipating any travel difficulties due to the Icelandic volcano ash as we will fly directly from Jo-burg to Atlanta, thus staying south.
Also, for those of you who remain curious about the medical-side of things, I have a list of thoughts & comments to make, so I will post those soon as well.
Have a good week, we will see/talk to you soon!
We have had one or two emails recently, missing our blog and/or worried because no one had posted. Rest assured, we are fine & safe.....we just had a busy last week along with slow internet connection & other work to do on the computer.
A brief update to tide you over. We have now moved out of the cottage at Baylor in Mbabane & have been staying at Mac & Nancy's house since Friday night. Mac picked us up, as usual, late Friday afternoon & then we all headed off to get Nancy from work. They both teased us that it's kind of like getting the kids from boarding school - only this weekend they don't have to return us - they have to ship us off instead!
In any case, we've had a lovely weekend so far. Nancy made us delicious chocolate mousse from Toblerone bars (it's very simple & delicious - not too sweet - and we will be sure to make it when we're back in the States). We had it for dessert on Friday, and I've eaten it at least once a day since then.
On Saturday, we drove to the northern part of Swaziland & did a little bit of shopping before driving out to an old mining town to look at the cable-lines that were used to take ore over the mountains to South Africa. The lines are still standing but not in use - it makes Mac a bit sad as it's all on its way to a rusty-ruin (though it's apparently the longest running cable line in the world). The drive out there was bumpy, but it was interesting to see - and we also got to see a bit of the timber industry in progress as we passed through the mountains. After that little trip, we went to Malalotja - another nature/animal reserve in Swaziland. It is more known for its hiking trails & nature than big animals, though we did see a few wildebeest, warthogs, & some other impala/antelope family animals. We did/attempted a hike to the waterfalls. It was supposed to be a loop though about halfway in we heard the thunder moving in & found the trail poorly marked, so we saw the falls from that point & reversed back to the car. We got back, tired & sweaty, rested on the benches for a bit, & were back in the car just as the first few drops fell. It didn't turn out to be much of a storm, but it wasn't worth taking a chance of getting caught out in the park on the trails.
After the hike we headed home for hot showers (possibly one of the best showers of my life-helped by the fact that Mac & Nancy have a huge, beautiful shower). We cleaned up & then met Dr Stephanie (our supervisor at the clinic) as well as the new visiting scholar (a family med resident from New Mexico) for dinner at a traditional Swazi restaurant just outside of Mbabane. Mac & Nancy were a bit nervous about exactly what that might mean, but it turned out to be delicious (no green tripe - which is essentially uncleaned tripe, to Nancy's relief). The woman who owns & runs the restaurant was great, & we had a lovely time.
Yesterday (Sunday), we took our time in the morning & then headed out for the last round of souvenir & gift gathering. We returned to a few places for a few more gifts, had lunch, & then stopped back in Mbabane to see Sibebe Rock - a huge granite face just outside of the city. It's apparently the second largest such rock face in the world (after Ayer's Rock in Australia) - it was quite impressive. I will try to post pictures a bit later (sorry, this will be a words-only update). Then we walked along a little stream & falls to stretch our legs before coming back home for a braii (the Swazi term for grilling-out).
This morning finds us having a particularly relaxed day - doing laundry & cleaning up. This afternoon Nancy will drop Carter & I off at Mkhaya game reserve, an animal/nature reserve here in Swaziland. We will spend 24 hours there - going on 2 game drives & 1 game walk. We are hoping to see more rhinos, elephants, and such. We're not positive they have lions though they are supposed to have leopards (the latter of which we did not see at Kruger). In any case, it's going to be amazing. They feed us (apparently) delicious meals after each game drive/walk, & we will spend the night in traditional-style stone huts (that are somewhat open on the sides - I'm secretly hoping a giraffe sticks its head in though Carter would not be so pleased!).
We'll let you know how it all goes soon - the next update may be while we are still in Swaziland (or it may be en route home). We're not anticipating any travel difficulties due to the Icelandic volcano ash as we will fly directly from Jo-burg to Atlanta, thus staying south.
Also, for those of you who remain curious about the medical-side of things, I have a list of thoughts & comments to make, so I will post those soon as well.
Have a good week, we will see/talk to you soon!
Saturday, April 17, 2010
Don't be the wildlife, South African version
The animals at Kruger National Park in South Africa, just a few hours away from Swaziland, were amazing! If you ever have the chance to go, take it.....or let me know, & I'll keep a list of people to take with me when I come back someday. In any case, here are some of our favorite pictures & brief stories to go along with them. To start the day, we actually got flooded out of our desired-entry gate. The river was too high & had flooded the road, closing the entrance gate we had intended to use. So, we drove back out to the highway & down a little ways further to the Malalane entrance gate. At first it seemed an annoyance, but we had a pretty incredible day that would have turned out far differently if we had come in a different gate - - so it all worked out for the best.
The first animal sighting was, of course, impala - because there are thousands of them (by far the most animals in the park - I don't remember the last census numbers exactly but it was huge). For the time being, we're going to skip further impala pictures. Instead, large mammal sighting number one at Kruger was the elephant. We came upon this guy along the side of one of the main roads in the park. He was apparently quite hungry - at first he just ate from the shrubbery and shoulder-level leaves. Then, he got greedy - or extra hungry - or something.....so he pulled down the entire tree to be able to eat the leaves from the top (they are apparently the best - - - the giraffe must know something). As astounding as it was to watch him pull down the tree with his trunk, the sound of the trunk (yes the trunk, not a branch - - mind you, it wasn't a huge tree) snapping was pretty cool too.
After a little while, the elephant disappeared into the bush (probably looking for more appropriate trees - or maybe some of his friends as it is apparently not particularly common to see just one elephant on his own). Our next major animal sighting was a herd (a few herds, really) of animals: zebras & impala & rhinos (yes, rhinos!) - we believe they were white rhinos (the more common of the two) though we're obviously not experts (yet). We watched those groups of animals for quite a while & then moved on. Not far down the road was another up-close-and-personal animal group for us - more rhinos! The second set may have been black rhinos (we need to go back and look to compare the jawliens), which are much more rare at Kruger. There were 2 of them, just hanging out on the side of the road - one or two car-lengths away - chomping on the brush & leaves lining the road. We sat and watched them for 15-20 minutes, snapping pictures & talking about it. Again, hearing the sounds of the heavy animals moving around & doing their thing was cool. As we sat, Mac & Nancy were telling us a little about rhinos (apparently they are responsible for a surprisingly high number of human deaths - not very many, but high relative to what people would expect). They are very docile until provoked, at which point they fiercely charge. All the talk of charging rhinos started to put Carter a little on edge and after a little while she thought she was ready to go....Nancy turned around to look at us & just started laughing because Carter was taking pictures with an apple core in her mouth. It doesn't all make for a great story (at least as I tell it), but one thing led to another & Carter bust out laughing by the window & the rhinos finally moved. Luckily for Carter, it was not to charge but just deeper into the shrubbery for more food - they did give us a very good audience for a while though!
I know I said no impala pictures - but I had forgotten these young bucks we came across, trying to grow into their manhood. Among the many groups of impala we saw, this one had many bucks together (male-bonding time apparently). This pair of young guys was feeling playful....they went back and forth mock-fighting several times....until the senior buck bossman came along & scooted everyone on their way. He didn't have time for the foolish games....either that or he was just sick of us watching them all.
Among my favorite animals of the day were the giraffes - they're quite impressive. I'm not sure if it's the spots or the height or what, but they were amazing to watch pick at the leaves off of the very tops of the trees. Carter had the first spotting, one guy by himself eating by a bunch of impala. Then later I finally got my first big animal spotting when we came across 2 giraffes by the side of the road. Initially there was one on each side - we seemed to interrupt their crossing the road (there must be an old elementary school joke there somewhere..."why did the giraffe cross the road?). So we waited a little while & sure enough, the guy on the left moved over & both of them started eating from the trees on the right. It's kind of silly I suppose, that we would get such a kick out of watching a giraffe cross the road, but we did. If only Mac & Nancy had secretly recorded the conversations & comments in the car, you would all find some amusement in them, I'm sure!
We stopped at one of the "camps" where you can either visit for the day or stay for the night to have lunch & stretch our legs a bit. We heard the hippos more than we saw them, but we did get to watch a pair of elephants in the river have their playtime. Carter & I had actually spied the elephants earlier in the riverbed as we were driving up to the camp though Mac thought we were crazy because we couldn't see them again in the riverbed until just before we pulled off to the camp. At the point of this pic, the elephants had already hydrated on the other bank/sandbar & then walked across towards the tree for playtime. After this shot, one of the elephants intentionally just plopped himself into the river - unfortunately, I didn't have the right angle for a picture of that.
We had a slight disaster with lunch - first they didn't bring Nancy's food, & then they brought the wrong food for Carter. In the end, though, everyone ate (some faster than others) & we hit the road again. After lunch (which we didn't really stop for until 2 or so), we were on a tighter schedule as the rules of Kruger are that you have to be either out of the park or in a camp (with a reserved spot) by 6pm. If you're not, there are large fines. So, based on where we were at that time in the park, we only had a few options for getting ourselves out in time to avoid the fines. We did, though, still manage to see a number of animals on our pseudo-race to the gate. We finally managed to spy a few monkeys in the trees & a baboon mother with 4 or 5 babies (Mac said they probably weren't all hers) playing on a low branch. Unfortunately, I couldn't get any great shots of them. Turns out, that was okay, as the next 5km or so we came across several large groups (herds? packs?) of baboons.
Mac told us a story of a baboon who used to hitchhike up and down the road in Kruger - hop on the hood or trunk of a car & ride a while, then hop off & head back the other direction. The first group of baboons we saw didn't look that mischievous - though there was a little one cart-wheeling his way down the road. Mac was telling us how they're known to jump into a car window every now and again as we watched & snapped pictures. Then - out of no where - papa baboon comes racing up, chasing after someone - roaring and baring his fangs/teeth. Carter insisted that we roll the windows back up at that point! We went along, seeing a few more episodes of arguing papa baboons - not sure if it was a territory thing or a food thing - and several mom/baby pairs in various situations - cleaning one another, eating, playing. Here are a few sample pics of these wildy human-like creatures.
More pictures to come later....just building the anticipation ;)
The first animal sighting was, of course, impala - because there are thousands of them (by far the most animals in the park - I don't remember the last census numbers exactly but it was huge). For the time being, we're going to skip further impala pictures. Instead, large mammal sighting number one at Kruger was the elephant. We came upon this guy along the side of one of the main roads in the park. He was apparently quite hungry - at first he just ate from the shrubbery and shoulder-level leaves. Then, he got greedy - or extra hungry - or something.....so he pulled down the entire tree to be able to eat the leaves from the top (they are apparently the best - - - the giraffe must know something). As astounding as it was to watch him pull down the tree with his trunk, the sound of the trunk (yes the trunk, not a branch - - mind you, it wasn't a huge tree) snapping was pretty cool too.
Mac told us a story of a baboon who used to hitchhike up and down the road in Kruger - hop on the hood or trunk of a car & ride a while, then hop off & head back the other direction. The first group of baboons we saw didn't look that mischievous - though there was a little one cart-wheeling his way down the road. Mac was telling us how they're known to jump into a car window every now and again as we watched & snapped pictures. Then - out of no where - papa baboon comes racing up, chasing after someone - roaring and baring his fangs/teeth. Carter insisted that we roll the windows back up at that point! We went along, seeing a few more episodes of arguing papa baboons - not sure if it was a territory thing or a food thing - and several mom/baby pairs in various situations - cleaning one another, eating, playing. Here are a few sample pics of these wildy human-like creatures.
Friday, April 9, 2010
End of clinic week 3
I walked over to clinic 15 or 20 minutes early this morning, intending to check my email & make sure the slides for my afternoon journal club presentation were ready.....I suppose the "intending" part of that phrase makes it somewhat obvious that didn't happen.
Fridays are a slower day at the clinic, something like a half day because they start and end with weekly meetings (of the doctors in the morning and of all clinic staff in the afternoon, followed by journal club)....so the time to see patients really ends up being something like 4 hours. This Friday, however, didn't start with a meeting for me....I was the first "doctor" to the clinic this morning and as I walked in a few of the other clinic workers (nurses, social workers, etc) who were already there came up & asked "doctor, can you come look at this patient in emergency?" Though it will soon change, I pointed out that I wasn't a doctor who could write prescriptions (expecting it to be an early patient who needed to make it to school or work early). They assured me that was fine - they just wanted someone to look at the baby that had been brought in to be sure she was somewhat stable.
In the "emergency room" (the urgent care/procedure room normally) there was a 6 month old who was coughing & having trouble breathing normally (for at least 1 week and maybe up to 3 weeks). She also was losing a little weight and not eating well. It doesn't sound good - and it wasn't - but she really didn't look that bad overall, which was surprising. The baby girl was not really fussing a whole lot - not quite lethargic but on her way there. She was not overly dehydrated or malnourished, as are many of the sick little kids. Signs of the trouble started with her nose (nostrils flaring a bit with each breath)....then she would cough a few small, weak coughs, take a few normal-ish breaths, & then almost seem to stop breathing/hold her breath for a few seconds. When I tried to listen to her lungs, it was much of the same - listening for/finding lung sounds was difficult to impossible because she was breathing so irregularly. Her heart rate wasn't astronomical for a sick infant, in the 150s perhaps, but once we got some oxygen on her so her breathing evened out a little, she had a respiration rate of 70+ (and oxygen sats that came up nicely from low 80s to 100%). Luckily as my initial exam was finishing, one of the Baylor physicians was walking in to help make a plan & the emergency nurse arrived soon thereafter. We will not know for a few days what the diagnosis will turn out to be, but we sent her to the hospital after a shot of rocephin. HIV positve with an unknown CD4 count - they will get an x-ray and treat her empirically at the hospital, but PCP and TB are both very feasible options.....and they may well be accompanied by a run of the mill pneumonia. It will be interesting to see what they find in the hospital - hopefully when the Baylor docs go for rounds on Monday, she will be doing much better.
So, that was my adventure in "doctoring" today. It really won't be so long now before it's the real thing (though not with kiddos), and to that end, this trip has been great experience for thinking "outside the book" even though oftentimes I don't totally agree with the approach that may be taken in the limited resource setting here.
The rest of the clinic day went pretty smoothly & the patients were of the typical nature (a few tb, a few med refills, and so forth). I gave the journal club presentation on dehydration, fluids, & gastroenteritis associated mortality.....and now it's just a little downtime to catch up & organize for the weekend. Mac will soon be by to whisk Carter & I off for another weekend adventure.....I believe Nancy has chocolate mousse (made with Toblerone) in store for dessert tonight. Tomorrow morning, first thing, we will head for South Africa again to make a trip through Kruger park to see more animals and big game (crossing our fingers for elephants and giraffes and lions and leopards and everything else!) No promises on getting those pictures up this week (it took hours for the last batch from my camera)....but maybe we'll try to pick a few winners & get those up.
I hope everyone has had a good week back home - have a great weekend!
Fridays are a slower day at the clinic, something like a half day because they start and end with weekly meetings (of the doctors in the morning and of all clinic staff in the afternoon, followed by journal club)....so the time to see patients really ends up being something like 4 hours. This Friday, however, didn't start with a meeting for me....I was the first "doctor" to the clinic this morning and as I walked in a few of the other clinic workers (nurses, social workers, etc) who were already there came up & asked "doctor, can you come look at this patient in emergency?" Though it will soon change, I pointed out that I wasn't a doctor who could write prescriptions (expecting it to be an early patient who needed to make it to school or work early). They assured me that was fine - they just wanted someone to look at the baby that had been brought in to be sure she was somewhat stable.
In the "emergency room" (the urgent care/procedure room normally) there was a 6 month old who was coughing & having trouble breathing normally (for at least 1 week and maybe up to 3 weeks). She also was losing a little weight and not eating well. It doesn't sound good - and it wasn't - but she really didn't look that bad overall, which was surprising. The baby girl was not really fussing a whole lot - not quite lethargic but on her way there. She was not overly dehydrated or malnourished, as are many of the sick little kids. Signs of the trouble started with her nose (nostrils flaring a bit with each breath)....then she would cough a few small, weak coughs, take a few normal-ish breaths, & then almost seem to stop breathing/hold her breath for a few seconds. When I tried to listen to her lungs, it was much of the same - listening for/finding lung sounds was difficult to impossible because she was breathing so irregularly. Her heart rate wasn't astronomical for a sick infant, in the 150s perhaps, but once we got some oxygen on her so her breathing evened out a little, she had a respiration rate of 70+ (and oxygen sats that came up nicely from low 80s to 100%). Luckily as my initial exam was finishing, one of the Baylor physicians was walking in to help make a plan & the emergency nurse arrived soon thereafter. We will not know for a few days what the diagnosis will turn out to be, but we sent her to the hospital after a shot of rocephin. HIV positve with an unknown CD4 count - they will get an x-ray and treat her empirically at the hospital, but PCP and TB are both very feasible options.....and they may well be accompanied by a run of the mill pneumonia. It will be interesting to see what they find in the hospital - hopefully when the Baylor docs go for rounds on Monday, she will be doing much better.
So, that was my adventure in "doctoring" today. It really won't be so long now before it's the real thing (though not with kiddos), and to that end, this trip has been great experience for thinking "outside the book" even though oftentimes I don't totally agree with the approach that may be taken in the limited resource setting here.
The rest of the clinic day went pretty smoothly & the patients were of the typical nature (a few tb, a few med refills, and so forth). I gave the journal club presentation on dehydration, fluids, & gastroenteritis associated mortality.....and now it's just a little downtime to catch up & organize for the weekend. Mac will soon be by to whisk Carter & I off for another weekend adventure.....I believe Nancy has chocolate mousse (made with Toblerone) in store for dessert tonight. Tomorrow morning, first thing, we will head for South Africa again to make a trip through Kruger park to see more animals and big game (crossing our fingers for elephants and giraffes and lions and leopards and everything else!) No promises on getting those pictures up this week (it took hours for the last batch from my camera)....but maybe we'll try to pick a few winners & get those up.
I hope everyone has had a good week back home - have a great weekend!
Wednesday, April 7, 2010
Back to medicine
Now that we've got a menagerie of animals posted in pictures, I'm going to get back to a little medicine in my posting (after all, that is why we're here).
Each day I've been trying to write down some of the more interesting diseases and conditions we see (though I have not been as good about it lately). Overall, probably 98% of our patients are HIV positive (the clinic offers screening & they will follow a HIV negative patient until any other acute issues present at screening are resolved....often this involves malnutrition and/or TB), so pretty much all of the disease we see is automatically in the setting of HIV & some degree of immunosuppression). That said, the following are among the things we see in a "typical" day over the last 2 weeks: tuberculosis (and more tuberculosis - both pulmonary and extrapulmonary), pneumonia, diarrhea, malnutrition, measles, STIs, rashes. It seems that almost everyday there are also one or two patients with extremely unique diagnoses as well. I have seen two patients (both girls in their early teens) with Kaposi's sarcoma, a form of cancer that is seen most often (in this era of medicine) in HIV/AIDS patients though endemic forms do exist in Africa. (Both girls are improving on chemotherapy regimens currently.)
Yesterday we had a man who has not only HIV and TB but also leprosy. Leprosy is a pretty uncommon diagnosis in Swaziland, from what I understand; however, the patient lives near the Swazi-Mozambique border, and there is apparently a reasonable amount of leprosy still in Mozambique. His leprosy lesions are on both hands such that it almost seems as if he's had amputations of each & every finger (as the fingertips are somewhat squared off). The peripheral nerves are damaged in leprosy which can lead to contractures (shortening) of the joints as well as increased susceptibility to infections...any combination of these things may have led to our patients fingers changing the way they have. Here is a picture from the web that is somewhat similar to the patient I saw (especially the hand on the left side of the picture) though these fingers are more shortened.
We have also seen children who are very sick (or recovering from having been so). One of the patient's who is still something of a mystery to the doctors here is a 13 year-old who was recently in the hospital with severe dehydration (secondary to diarrhea and vomiting). While in the hospital, they discovered that her kidney was acutely failing (for an unknown reason) in addition to a few other seemingly unrelated problems. In medicine everything ties together somehow though the missing link in her case remains to be found....in medical school we joke about unknown diagnoses being autoimmune disease, cancer, syphilis, or tuberculosis (as they can all present in a huge variety of ways). In her case, though, those have all been checked and are so far negative (which is good for her). The best hope (because it is an answer) is that her kidneys were strained with her recent illness and are failing because of underlying kidney disease secondary to her HIV infection. (one more little mystery, for the medical folk reading this, is that despite having a CD4 count qualifying for ARVs - around 200, I believe - and potentially HIV nephropathy, she is still producing enough white cells to get a WBC count of 17)
Not all of the patients are sad stories or mysteries, however. For instance, today we had a 7 month old baby girl who is robust & happy. Although her HIV results are still pending, all clinical signs point towards her being uninfected. Even many of the children we do see, who are HIV positive, are happy and healthy - eager to play outside, go to school, & do all the same things other kids do. It's nice to see the positive patients to help balance out both the more trying cases (for instance, how to handle patients who just aren't taking their ARVs as they need to and are getting sick because of it) as well as the "fact of life" parts of the high HIV prevalence in Swaziland (like the multiple billboards for funeral homes and funeral packages or all of the young faces that peer out from the obituary sections of the papers).
In any case, I will leave those thoughts short & simple so as not to make the great wildlife photos too bittersweet (so many different realities here in Africa). We are still enjoying our time here & learning a lot. This week has flown by - it's hard to believe we have just 7 more days of clinic work remaining (and we'll be starting our second massive travel day in just two weeks).
I hope everyone had a lovely Easter and is having a smooth and easy week.
Each day I've been trying to write down some of the more interesting diseases and conditions we see (though I have not been as good about it lately). Overall, probably 98% of our patients are HIV positive (the clinic offers screening & they will follow a HIV negative patient until any other acute issues present at screening are resolved....often this involves malnutrition and/or TB), so pretty much all of the disease we see is automatically in the setting of HIV & some degree of immunosuppression). That said, the following are among the things we see in a "typical" day over the last 2 weeks: tuberculosis (and more tuberculosis - both pulmonary and extrapulmonary), pneumonia, diarrhea, malnutrition, measles, STIs, rashes. It seems that almost everyday there are also one or two patients with extremely unique diagnoses as well. I have seen two patients (both girls in their early teens) with Kaposi's sarcoma, a form of cancer that is seen most often (in this era of medicine) in HIV/AIDS patients though endemic forms do exist in Africa. (Both girls are improving on chemotherapy regimens currently.)
Yesterday we had a man who has not only HIV and TB but also leprosy. Leprosy is a pretty uncommon diagnosis in Swaziland, from what I understand; however, the patient lives near the Swazi-Mozambique border, and there is apparently a reasonable amount of leprosy still in Mozambique. His leprosy lesions are on both hands such that it almost seems as if he's had amputations of each & every finger (as the fingertips are somewhat squared off). The peripheral nerves are damaged in leprosy which can lead to contractures (shortening) of the joints as well as increased susceptibility to infections...any combination of these things may have led to our patients fingers changing the way they have. Here is a picture from the web that is somewhat similar to the patient I saw (especially the hand on the left side of the picture) though these fingers are more shortened.
We have also seen children who are very sick (or recovering from having been so). One of the patient's who is still something of a mystery to the doctors here is a 13 year-old who was recently in the hospital with severe dehydration (secondary to diarrhea and vomiting). While in the hospital, they discovered that her kidney was acutely failing (for an unknown reason) in addition to a few other seemingly unrelated problems. In medicine everything ties together somehow though the missing link in her case remains to be found....in medical school we joke about unknown diagnoses being autoimmune disease, cancer, syphilis, or tuberculosis (as they can all present in a huge variety of ways). In her case, though, those have all been checked and are so far negative (which is good for her). The best hope (because it is an answer) is that her kidneys were strained with her recent illness and are failing because of underlying kidney disease secondary to her HIV infection. (one more little mystery, for the medical folk reading this, is that despite having a CD4 count qualifying for ARVs - around 200, I believe - and potentially HIV nephropathy, she is still producing enough white cells to get a WBC count of 17)
Not all of the patients are sad stories or mysteries, however. For instance, today we had a 7 month old baby girl who is robust & happy. Although her HIV results are still pending, all clinical signs point towards her being uninfected. Even many of the children we do see, who are HIV positive, are happy and healthy - eager to play outside, go to school, & do all the same things other kids do. It's nice to see the positive patients to help balance out both the more trying cases (for instance, how to handle patients who just aren't taking their ARVs as they need to and are getting sick because of it) as well as the "fact of life" parts of the high HIV prevalence in Swaziland (like the multiple billboards for funeral homes and funeral packages or all of the young faces that peer out from the obituary sections of the papers).
In any case, I will leave those thoughts short & simple so as not to make the great wildlife photos too bittersweet (so many different realities here in Africa). We are still enjoying our time here & learning a lot. This week has flown by - it's hard to believe we have just 7 more days of clinic work remaining (and we'll be starting our second massive travel day in just two weeks).
I hope everyone had a lovely Easter and is having a smooth and easy week.
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