In this post I wanted to write about some of the interesting cases I've seen thus far at JFK. I have am taking a ton of photos of interesting pathology (with permission) but these are mainly for teaching as apposed to "show and tell." I have a few, however, with no patient identifiers that I can share. The majority of the sick patients I see have severe or cerebral malaria. Their management is largely the same: IV quinine, broad spectrum antibiotics, IV fluids, glucose supplementation, gastric decompression and evacuation, airway positioning, and seizure control as needed. These patients typically either perk up quickly, or die. Many people have a misconception that the locals live with malaria and thus don't get sick from it. Give me 2 seconds of your time at JFK and I'll prove you wrong. They get very very sick, and often don't survive bad cases of it. I won't bore my healthcare colleagues with stories about malaria as they are often the same. Instead, I'll talk about some interesting diagnoses throughout my time here and the good saves.
Case 1: A 32 y/o man comes to the ED for right upper abdomen pain. He has a history of being Hep B SAg + (he has hepatitis B) and now has this mass in his abdomen. Other docs have looked at this, and assumed it was a tumor in his liver as a complication of his hepatitis. He was given some tylenol, and sent home. Several weeks later he comes to see me for more tylenol. His liver function tests are mildly elevated, but he is having blood in his urine. I'm able to convince the "radiology department" to let me use the ultrasound machine, and find that this guy has a largely unremarkable liver being pushed up on into his chest by a large tumor on his kidney! It has large vascular flow, and multiple smaller nodules as seen in this ultrasound. This could be a renal cell carcinoma, or other malignancy. There is very limited cancer care here in Liberia, but this tumor would likely be amiable to surgical resection. We don't have radiation therapy. I consulted a "surgeon" who looked at my scans and agreed that he would take out the kidney. He was to be seen in clinic on Thursday. I discharged the patient home to follow up in clinic with some pain medication. Unfortunately, he never left the ED because he could not pay his bill (approx $1.5o US). He missed his surgery clinic appointment, even though it was down the hall, and eventually was discharged home. I don't know if he ever made it to clinic.
Case 2: 2 patients are brought in by taxi after a high speed head on collision around 5:30 AM after drinking and driving. One patient was ejected from the vehicle. He had obvious skull trauma, GCS of 5, grunting and difficulty breathing, not responding to anything but pain, and posturing (an ominous neuro exam finding). He was essentially left for observation. I asked for medications to sedate him to intubate him. From the looks I got, you would have through I ordered a STAT sex-change operation in the ED. Instead, I intubated him through his nose while he was awake so I could take over breathing. This worked... and I'm glad, because once to took over breathing for him, he tired out and would have died on the spot. In the US we would never intubated a head trauma patient through the nose out of fear for causing further injury - but in this case I had no choice. We placed him in a cervical collar, elevated the head of his bed, and gave him some mannitol given by Stanford pharmacy. I made up a hypertonic saline gtt from sodium bicarb from my resuscitation bag I made and gave him 3% NS boluses. Given his history and likely prognosis - I was concerned that without decompression he would not survive. I asked if there was a surgeon who could perform burr holes, and offered to do so if nobody else could. A prominent local physician was called in, agreed with the assessment, and took the patient to the OR. In the OR, a basal skull fracture was noted, no burr holes were performed, and the patient was taken to the ICU. When I went to see him in the ICU, his nasotracheal tube was pulled way back, to the point I knew it was no longer in his throat and residing somewhere in the back of his mouth causing nothing but an airway obstruction. The nurse seemingly not concerned about this stated, "another doctor saw it and through it was too deep, so he pulled it back." I had to plug the end of the tube with my thumb and demonstrate he was breathing around it to prove it was dislodged. I was told that the surgeon on the service was not in control of the patient, and that the respiratory therapist saw the patient and through everything was OK. I advocated and tried my best to raise awareness, documented my concerns in the chart, found the on call MD and showed him, and recommended that he be re-intubated and offered to do so. This was refused, so I left my phone number in case there were any problems or if they wanted help. A few hours later the patient died of a respiratory arrest.
Case 3: A 1 and 1/2 year old child was brought to the ED and admitted by my HEARTT doctor colleague with fever and vomiting. The on call resident at the time diagnosed the patient with stomach infection, gave antibiotics and was about to sent the kid home. The HEARTT peds doc listened to the chest, pounded on it with her finger, and quickly became concerned about a chest infection. She got the XR noted below which showed a large accumulation of fluid taking over the entire side of her lung. We needed to drain the lung, because in the absence of heart failure, and in this setting, it was most likely a bacterial infection or tuberculosis as the cause. Both required drainage of the pus and analysis of the fluid to help guide further treatment. In the US, the child would receive sedation medication and likely have no memory of the event. This child had 2 people holding him down. After injecting local numbing medication, a plastic catheter was placed in the chest over a needle and 200ml (almost a can of coke) of yellow / green pus was drained out of his chest. He began coughing, a sign of a re-expanding lung. The next day his fever went away, his oxygen saturation improved, and his breathing quickly got better. After a course of antibiotics, he was able to be sent home playful and smiling. There was no sign of tuberculosis.
I'll post other interesting cases in the future. I'm seeing the full rang of tropical disease here! It has been a very educational experience thus far. While there are no formal learning opportunities here, I'm spending about 2 hours a day reading up on topics trying to educate myself on these conditions that prior I had only seen in text books.
We attended the orientation meeting, and after a 3 hour discussion about the logistics and contingency plans, several people raised their hands all with the same question, "what on earth is a marathon anyway?" Suddenly I realized that many of the people in attendance have never seen or heard of a marathon!
Last night we rounded in the ED before going to bed, just to make sure everything was alright. To our sorrow we discovered one of the sick children was not breathing. She was still warm, but didn't have a pulse. Nobody knew how long she had been dead - not even the mother or nurse who was sitting less than 2 feet away. There are no monitors like in the US - just chest rise and skin color. We coded the 1 year old baby for about 30 minutes before pronouncing her dead. It was time to go home.
