Well, 0ver the past two weeks, I (Scott) have made the transition to work in Casualty, which is the name of the ER at Tenwek. Needless to say, this has been quite the interesting, challenging, and unique experience. In addition to working in Casualty, I continue to round in the ICU and on the medicine service in the mornings, then cover casualty in the afternoons/evenings. This double-duty has made the past few weeks especially busy, but Steve, a fellow Duke resident, is also on the medicine service now, so it has been enjoyable working together and brainstorming solutions to a variety of dilemmas. Below are some of my experiences I’ve had while working the last two weeks.
A tough case:
My first day in casualty was actually rather calm with no trauma cases and no pediatric patients (two types of patients that Internal Medicine physicians like me do not typically provide care for). However, day two was especially hectic with several minor traumas and an overflowing Casualty unit. One particular patient was especially difficult. He was a 17 year old young man who presented with right leg swelling and difficulty breathing. He had been completely active and healthy 5 days prior, and never had any medical problems. When I saw him, he was clearly in distress. His heart rate was very fast, his blood pressure low, rapid breathing, and his oxygen saturations very low at 54% on room air (normal is >90%). With his leg swelling, I presumed that he had a blood clot in his leg that migrated to his lungs causing a pulmonary embolism (PE), which is a blood clot in the vessels that supply the lungs. I gave him a shot of Lovenox, which is a blood thinner used to treat the clot. Ultrasound was done which confirmed the clot in his leg, but we are unable to do a CT angiogram or VQ scan, which are the tests to confirm PE. Nonetheless, based on his history, it was clear that this was the diagnosis.
Unfortunately, over the next few hours in Casualty, his condition deteriorated. He became more hypoxic, restless, and developed more labored breathing. He was still able to saturate ok with an oxygen facemask, but I anticipated we would have to intubate him if he worsened. I grabbed an ultrasound machine, and did a bedside echocardiogram on his heart. What I discovered was a massive clot in his pulmonary artery and that the right side of his heart was in complete failure due to the clot. In the U.S., this would be someone that would be a candidate for thrombolytics, which are potent “clot busters”, however, we do not have that here. A few minutes after the ultrasound, he suddenly coded, stopped breathing, and his heart stopped beating. We immediately started CPR, and shocked his heart several times due to an abnormal rhythm. During the code, his labs came back that he was also in renal failure with a high potassium, which may have contributed to the code. We continued the resuscitation attempt for about 30 minutes giving him continuous CPR, shocks, multiple drugs, and intubation, but we never regained a pulse. I was devastated…probably more than any other death I have had in a long time. I don’t know whether it was that he was so young, or that the cumulative effects of all of the mortalities I have witnessed here, finally taking its toll, but whatever the cause, this death was especially difficult. After talking with the family, I came home, and was fortunate to have Whitney to help process my emotions, as I was struggling. That night was a near sleepless night. I replayed the events of that day over and over again, trying to determine what we could have done to save this boy. Through prayer and reflection, I eventually realized that no matter what we do for patients, whether in Kenya, or even in the resource rich United States, we cannot always save everyone, which is a hard truth, but the reality. Although I was able to re-compose myself in order to continuing taking care of patients the next day, I will never forget this patient, and his memory will always be with me.
Fortunately, despite having several patients pass away, we are able to help the vast majority of patients. We had a number of patients come into casualty this week that made dramatic recoveries as well. One such patient, was a 20 year old college student. She presented with acute lower right abdominal pain that had just occurred 2 hours prior to arrival. She was previously healthy. On arrival, she had a very low blood pressure, and severe lower abdominal pain. We gave her several liters of fluid while awaiting her lab work to return, but her pressures continued to be low. She denied the possibility that she could be pregnant, but we checked a pregnancy test anyways given her age and presentation. While waiting for the results, she was found to be very anemic with a hemoglobin of 5.7 (very low). We ordered emergency blood products to transfuse her, as she was becoming drowsy, and more hypotensive. We continued infusing fluids rapidly, and eventually her pregnancy test returned positive. Immediately, based on that result, I suspected a ruptured ectopic pregnancy, which occurs if the fertilized egg implants in the tubes instead of the uterus, and then ruptures. A quick ultrasound confirmed that there was no embryo in the uterus but a large amount of fluid (likely blood) in the pelvis. We rushed her to the OR where the OB team operated and confirmed the ruptured ectopic. She also had >2L of blood in her pelvis, which is why she was so hypotensive. She is now doing great after getting transfused, and the proper operation. Praise God that she presented when she did, and that we could help!
There are numerous cases such as these of patients who present likely hours from dying, but after stabilization, a careful physical exam, and focused diagnostic workup, we are able to help many patients. We also have continued to have patients give their lives to Christ while in the casualty bay. Yesterday morning, casualty was slower than usual with only a few patients in the unit. Moses, one of the young Clinical Officer’s (equivalent to a PA in the U.S.) who was with me in casualty was very excited about the hour or so with casualty not being busy. Instead of just sitting around, he excitingly proclaimed to me, “Scott, this is a great chance for us to really talk to our patients about the love of Jesus.” We walked around spending extra time with every patient and there family about God’s love, the gospel, answering spiritual questions, and praying for patients. It was awesome to see Moses’ excitement to do this, as if he could not contain the love of God within himself, but just had to share it!
A few days ago was an especially interesting day in casualty. First off, we were crazy busy. Our casualty unit has 7 beds, however, that day we had at one time 15 patients in casualty, most sitting in chairs or where-ever they could find room to sit. By 6:15 pm, we still had 12 patients in Casualty, most of them had been admitted, but were waiting to be taken to the various wards. However, since we were so busy, our two casualty nurses did not have time to wheel the patients to the wards. At 6:20, we received a phone call that there had been a serious, multi-car accident, and that 8 patients were being taken by ambulance to Tenwek, and would be arriving in 20 minutes!
Over the next twenty minutes, myself and Steve, took matters into our hands and were wheeling patients all over the hospital trying to clear out the unit for the victims of the car accident. We quickly wheeled patients to the ICU, medical wards, surgical wards, pediatric wards, and for the ones not yet admitted, we moved them into the hallway to wait. Before we knew it, we had completely emptied casualty. This left a few minutes to inform the on call surgery residents, and additional clinical officers, and any other personnel that was around. We set up eight stations with IV lines, oxygen tubing, IV fluids, and other essentials.
Next came the victims. Initially, the first two patients walked in and aside for some scrapes and bruises, looked not too bad. It seemed that maybe this wouldn’t be so bad after all. However, a minute later 6 patients were brought in, all bleeding, hurting, or even unconscious. Each consultant and resident assigned themselves to a particular patient. Since we didn’t know their names, patient were assigned a number based on the severity of their injuries with #1 being the sickest. The patient I was working on was patient #2. My patient had a massive laceration of his head with a large hematoma. He also dislocated his right hip and had a severe fracture of his left arm. Fortunately he was conscious. After getting him stabilized and determining the extent of the injuries, he was taken to the OR where he was fixed up. Patient #1 ended up dying, although everyone else has now been discharged from the hospital. It was a unique experience for me, since I have little experience working in an ER, and during those previous experiences, never had a mass casualty like this. It was cool to see the efficiency and teamwork displayed during that chaotic, but effective two hour period.
A few images:
Once again, I could go on and on with countless stories about the interesting cases we encounter on a daily basis, but again I have become more long-winded than I intended. I am on call this weekend, our last weekend at Tenwek. I cannot believe our time here is coming to an end. It has gone so fast, and been life changing! Please pray that our last week here will be fruitful and cherished, as we say goodbye to friends, patients, staff, etc. I hope to post once more before leaving. Anyways, I thought I would end with a few xray and CT scan images from some of the cases I have seen that may be of interest. Thanks for reading.
This is a young woman that had a large brain abscess (the white ring you see) with severe edema. She came in with multiple seizures, and could not move the left side of her body. We were fortunate to have a visiting neurosurgeon to drain the abscess, and she was recently discharged with continued antibiotics. Pray for her recovery!
This woman presented to Casualty a few days ago after falling off a motorcycle taxi and smashing her head. At the top of the image, there is a large, depressed skull fracture. The fracture caused intracerebral bleeding and edema. Additionally, some of her brain was visible outside the skull. She received emergency surgery, and left the ICU yesterday. She is doing amazingly well with only mild neurologic deficits.
This was the mass casualty patient that I saw (trauma patient #2 as discussed above). Here you can see his humerous (left arm) is fractured in multiple pieces.
This patient was admitted for “asthma”. However, when I met him, I heard what sounded like stridor (a high whistling breathing noise caused by airway obstruction). On examination, he had a massively enlarged thyroid gland that can be seen extending into the chest above. CXR showed his trachea was displaced and extremely narrowed with as little as 1-2 mm left for air to pass through. He was likely only hours from completely obstructing his airway which would cause him to suffocate. Fortunately, we had his thyroid removed, and he did great!
This xray is extremely abnormal. This is an unfortunate woman who came in with severe anemia. She received a unit of blood from a relative on arrival, and within hours of her transfusion, she developed severe respiratory distress, requiring intubation. Her xray revealed that she likely had TRALI (transfusion related acute lung injury) which is a rare reaction to a blood transfusion. Unfortunately, despite our best efforts, she later developed kidney failure and passed away.
This is what disseminated, or miliary TB looks like on CXR. We see this often, and patients tend to do poorly with this, especially if they also have HIV. This woman recovered well and has been discharged home.
Until next time,