Good medical outcomes. Bad shoes.

The recent days at the hospital have contained a fair amount of joy.  A young adult with multiple abscesses within the abdomen who has been sick in the hospital for weeks was able to go home.  A young child with problems including meningitis and a brain abscess who has been admitted for over a month has finally had the fever go down and is eating some.  A newly-admitted young child with a badly-infected leg, distended abdomen, and pneumonia has turned the corner and is starting to improve after a very worrisome couple of days.  All these patient and more have recently done far better than could possibly have been expected.  These are the times, when you can not explain the good things which are happening to the patients on the basis of the medical care available, that you understand what it means to have others praying for the patients and the work here.

I was walking back up the long hill from the marketplace a couple of weeks ago when I got caught in the rain (it is hard to blame anyone but yourself when you get "caught" in the rain during monsoon season in Cameroon).  I was wearing my regular street shoes and was having great difficulty negotiating the steep muddy hill.  As I stood there motionless, contemplating my next step, a young man came striding down the hill wearing his sandals.  I pointed to my shoes and he smiled.  He continued on his way down the hill but stopped after a few steps, turned to me and said only, "This is Africa."  He then continued on his way confidently down the hill.  I have taken his implied advice.  Now, when I am cleaning my sandals and washing the mud from between my toes, I think, "At least I do not have a broken wrist.".  Yet.

Singing by the Morgue. Tetanus.

A toddler was brought to the clinic yesterday with severely labored breathing.  The child was critically ill with pneumonia. We had to act quickly to start oxygen and other treatments.   Within a few hours, the child looked much better and the child's oxygen  levels were rising.  The day began early today with a call to see a surgery ward patient who needed medical care before going to the operating room for a badly-broken leg.  Walking past the hospital morgue after seeing the surgical patient, a young woman could be seen in the early morning light, sitting by herself in front of  the morgue, rocking back and forth, and singing softly.   It was not until we went to make rounds on the pediatric ward and saw the clean, freshly-made bed where the ill toddler had been the evening before, that we realized the young woman  was that child's mother.   The woman was not at the morgue when we passed again. I spent the rest of the day thinking about the mother and about a missed opportunity for us to console her.

Dr. Eugene and I were at the hospital a few nights ago to see a young adult who had been admitted earlier in the day with difficulty opening the mouth.  As the evening wore on, it became evident that the diagnosis was tetanus.  We started such appropriate treatments as were available, but it will be a long and hard road for this young person.   Mission medicine often reminds us of the blessing of resources to treat illnesses.  It is less often that I think of the equal blessing of vaccinations, public health measures, clean water, etc.,  which help us to not become ill in the first place. 

The Law of Parsimony. Slight-of-Foot.

There is a truism which, when applied in medicine, says that a collection of symptoms (such as cough, fever, and shortness of breath) is usually caused by a single diagnosis (e.g. pneumonia).  The opposite has been true recently at the hospital.  The young child with fever and headache who, on performing a spinal tap to rule out malaria meningitis, has meningitis caused by a bacteria in addition to his malaria.  The young woman with weakness who has typhoid but is also found to have severe anemia.  The many people with HIV or tuberculosis who are subsequently found to suffer from both illnesses.  Your diagnostic efforts are not so much a matter of finding that one illness which explains the person's symptoms, but a matter of continuing your search after each diagnosis is arrived at until you are certain that all serious illnesses which are present have been identified and addressed.  The fortitude of the ill patients we serve is always an inspiration.

I was seeing a young child (about 5 or so) this morning who was admitted a few days ago with severe tuberculosis which had spread throughout his body.  He was placed on medications for his TB.  This morning I was examining him as he did not seem to be getting better as quickly as I would like and happened to notice a blue coloration of his foot.  On closer inspection, he had taken his tuberculosis medication and hidden the tablet between his first and second toe.  I was quite impressed with his ingenuity but still showed his mother who will certainly "encourage" him to take his medication from now on.

80 and Creechies

In the middle of rounds yesterday we reached the bed of a middle-aged person with newly-diagnosed HIV and complications of the illness.  One of the nurses presented me with the person's initial "CD4" count, which is an important lab indicator of the strength of  the immune system with HIV.  The value was 80, which is quite low and much below where HIV medications would usually be started.  As we wrote the orders to start new medications for the HIV, one of the nurses on rounds commented that this was the highest CD4 value we had seen all day.  We all continued on rounds in a fairly somber mood after reflecting on the truth of the statement.

Things changed two patients later when we saw a person in their 40s recovering from typhoid.  This person had developed a row of very tiny blisters across the cheek and the side of the face.  Maria and I were in the process of formulating a list of what this strange new lesion could be when I looked over and saw two nurses quietly looking at each other.  This is a universal sign in mission medicine that the nurses know something important that you do not know.  Upon asking, we were told that these were the tracks of a "creechie" (no one knew how to spell it.  I guess it is not a word which needs to be written often).  The creature leaves such tiny blisters on the skin when walking across it.  There is  no pain or irritation, and the blisters can be treated or prevented by wiping the skin with a little alcohol.  We took the advice of our nursing consultants and ordered the appropriate treatment.

Of course, you can't just hear about this bug without seeing one, so the busy rounds ground to a halt while everyone searched the walls of the ward building until we found one.  It looks like a little winged ant (we tried to take pictures but they just turned out as little "bug blobs").   We were happy to see what this amazing creature looked like and the patients in the ward were all smiling at the sight of a bunch of their doctors and nurses searching the walls of the ward for a bug.

I now feel a bit more self-confident knowing what to do if a creechie ever walks across my arm.   And,  just for the record,  the little creature was not harmed and was allowed to continue on his way and do whatever creechies do during the day.