Measles Monday!!

We came into the hospital today and found that the gastro ward was turned into the measles quarantine area. A while ago, there were a few confirmed measles cases up north, near the Angola border. This made the news, so now any patient with a cough and a rash gets admitted with "probable measles." None of our cases our confirmed yet, and I don't think any of them will be. We haven't seen any koplick spots or any impressive conjunctivitis. And none of them are from the north; all of the "measles" patients live in Windhoek, most in the slums of Katutura. I am pretty sure all of our patients just have colds with viral exanthums. We have sent out measles IgM on all of the suspected cases, but they take a long time to come back. For the sake of everyone's sanity, the IgMs better come back soon. We are going to run out of beds for the actually sick patients! Both Stacey and I know that people with measles don't need to be admitted unless they have complications, but its hard to get that through to all of the interns and the outside docs. And yes, Mom, we are washing our hands frequently and wearing masks on rounds (even though we should be immune.)

TGIF!!

Stacey and I had quite the clinic afternoon. In under 3 hours, we saw a total of 14 patients (just between the two of us) admitted 3, and sent one patient's blood for measels!! It was exhausting! We have had a long week and are too tired too type much now. I am posting a chest xray of one of the patients I admitted. I'll let you figure out the diagnosis. With that said, both of us are turning our brains off for the weekend and going to the mall.

Thursday

Today, we had an acedmic conference to discuss how to evaluate a blind patient. On 8A, we have a 12 year old girl who has experienced progressive bilateral blindness for one year. She had a previous diagnosis of optic neuritis and was treated with steroids. She is now totally blind bilaterally although she has no other neurologic symptoms. She came to Katutura Hospital for further evaluation. A CT scan of the head suprisingly revealed hydrocephalus and a tumor in the cerebellum. Due to the hydrocephalus and the location of the tumor, the presumed diagnosis of tuberculosis meningitis was made and she was started on treatment. She is now awaiting evaluation by the neurosurgeon for placement of a VP shunt. TB meningitis continues to be one of the most common diagnoses that we see here, one that is very uncommon in the US.
We also experienced another afternoon in the POPD (outpatient clinic). Anna had two interesting patients. A 3 month old male with macrocephaly and signs of increased intracranial pressure who was admitted for evaluation for VP shunt placement by neurosurgery. It is amazing the number of cases of hydrocephalus that we have seen here. Often, the cause is due to TB meningitis. She also saw a 7 month old patient who had been treated repeatedly for chronic constipation. On further examination today, it was felt that she may have an abdominal mass so she was admitted for further work-up. It seems that every afternoon, we see patients with interesting diagnoses. Today, I felt like I was back a Knapper seeing patients with diarrhea, atopic dermatitis and URIs. It is sometimes nice to see that African children can have many of the same illnesses that American children have.
We are looking forward to the radiology conference tomorrow morning where we can view and discuss all of the images of the patients from the week on the wards with the radiologist.

Our patients: the good, the bad, and the adorable!

Tuesday

Today, we continued our daily routine of rounds in our respective wards in the morning and seeing patients in the clinic in the afternoon. On 8B which is the ward for patients older than two years of age, there are a lot of interesting cases that continue to be a work in progress. As we have commented before, many of the patients are waiting for imaging or for a subspeciality service to evaluate them which can sometimes take a long time. There is 2 year old boy who was admitted for evaluation of potential malignancy. He has had an extensive work-up including a lymph node biopsy and an abdominal/chest CT scan. We are still awaiting the biopsy results. His potential diagnosis is Histocytosis X based on the differential given by the radiologist who read the CT scan. He was supposed to have a bone marrow aspiration today however the correct supplies were not available at Katutura (the bone marrows are usually performed at Central Hospital) so the procedure was postponed until tomorrow. We also had a 3 year old female who was admitted with bilateral lower extremity weakness. All of the work-up including the LP was unremarkable therefore the potential diagnosis of Guillan-Barre Syndrome was made. The management here is simply supportive care. The weakness does seem to be improving and she will be discharged home soon.
Outpatient clinic continues to be an exciting place where we are getting to see a variety of illnesses that are not as common in the United States. Anna and I are getting the opportunity to see patients on our own and formulate a management plan. Each day, it gets a little easier trying to navigate through the medical passport that contains each child's medical information. I was very lucky today the the majority of my patients mothers spoke English which makes communication so much easier. Today, we saw a one year old female with varicella who was otherwise healthy. We also saw a patient with newly diagnosed Hepatitis B. We continue to see our share of many of the same diagnoses we see in the US including eczema, diarrhea and otitis media. The challenge here is trying to determine what medications are on the formulary and available to prescribe for treatment. Each day continues to be a tremendous learning experience.

Happy Labor Day!

It may be a nice day off today in the states, but here in Africa, it was just a typical Monday. We rounded on our respective wards again and went to clinic in the afternoon. One of the things that keeps striking us is timing. At Geisinger, we can order lab tests, xrays, even MRIs and they will be done pretty quickly. We can even view the imaging studies minutes after they are completed. This is not the case here in Namibia. Lab tests are ordered on rounds, then the intern draws the blood after rounds and it is sent to the lab. The lab (or Namibian Institute of Pathology) completes the labs within 1-2 days. Usually, we have to call the lab to get them to hurry tests along. Imaging studies take even longer. All of the larger machines (MRI, CT scan, echo, ultrasound) are located at Central Hospital. It is a few miles from Katatura State Hospital. So, anyone who needs any of these tests has to wait until the days that the techs are at Central to do the tests. We have several kids waiting for echocardiograms that will not get them until October. Stacey has a 13 year old patient who came in because she couldn't see. It took over a week to get the CT done and even longer to read it (actually it isn't even officially read yet.) The CT showed a large ring enhancing lesion. So now they are waiting for neurosurgery to come see her and decide what to do next (the neurosurgeon is on vacation.)

All of this waiting can be very frustrating. It is making us rely more on our clinical judgement. We only order tests that are absolutly necessary. In clinic today, we saw a 6 day old infant who was jaundiced. If we had been at Knapper, we would have ordered a stat bilirubin, waited an hour for the results and then either admited her or sent her home on a wallaby. This baby was a preterm infant and she was jaundiced down to her toes, so we knew that she would need phototherapy (and they don't have wallabys here.) Rather than waste 3+ hours waiting for her bilirubin level, we decided to admit her and start the phototherapy right away.

Thursday

This morning, we helped Dr. Kaaya put on a very condensed NRP course for the interns. She took the whole course and shortened it to under 2 hours. After that, we had daily rounds and then set off for the OPD again. Stacey and I were allowed to see patients on our own today, but we had to ask Dr. Kaaya for advice several times. We also needed several interpreters. There are at least 11 languages spoken in Namibia, and most people speak at least 2, so we were always able to find somebody who could translate. My first patient ended up being very interesting (and sad) and I had to admit him. I'm not going to tell the story, because I'll probably use him for a morning report.

The most difficult thing about clinic was not the language barriers, but the yellow passports the kids carried with them. Its basically their medical record from birth. They carry them around and doctors write in them anytime they were seen. They were so confusing! I couldn't read most of the handwriting or understand why they were given certain medicines. An 18 month old boy came in with a cough for 2 days and "oh by the way, he was diagnosed with TB in June but never treated and opps, we lost his passport." I was so confused! I think he just had a cold and not TB, but we did a ppd and a cxr anyway. After today, both of us are very thankful for EPIC.