What antibiotics do we have?

My first lesson on the Wards at MOI hospital in Eldoret is that resources are limited.  As the title of this post indicates, we do not have the luxury here of tossing broad spectrum antibiotics to all of the 'really sick' patients (which make up a great number of the ward patients).  Instead, we are forced to determine what antibiotics are available at the hospital on that day.  Currently, we are limited mainly to penicillin and gentamycin.  I've been told that there is a small stash of Vancomycin, but I've only seen it used once thus far.  If the patient really needs something other than what's on hand, the patient is instructed to have family members go to the local pharmacy and purchase the other antibiotics.  If the funds are unavailable, then things get really difficult…

These limited resources extend beyond medications too.  'Urgent' echos can sometimes take several days and certain lab tests (ABGs in particular) are quite dependent on the operational status of the related machines.  The hospital is out of IV contrast for CTs and even simple items like lubricating jelly for NG tubes are a scarcity (it took me 4 different stations to find a tube).  For many patients, diagnosis of treatable disease does not necessarily equate to treatment/survival.  The ICU is nearly always full and resuscitation necessities like central lines and AEDs (Acute External Defibrillator) are unavailable on the floor.  Even the most crucial of treatments, Oxygen, is difficult to come by as there aren't nearly enough tanks or condensers in the hospital to support all those in need.

To say that things are different here than in the States would be a gross understatement.  The mortality rate on the WARDS here is roughly that of the US Intensive Care Units and losing patients overnight is an occurrence so common that, after only 1 week, I have unfortunately come to expect it.

We do everything we can for the patients, and there are many success stories on the Wards as well.  Even some extremely sick patients come back to health and are discharged from the hospital.  Unfortunately, even once 'discharged', they must stay at the hospital until they can pay their bill.  This often leads to a new infection or disease (pneumonia, Tuberculosis, Deep Venous Thrombosis) that requires readmission and new treatment.  It's a sad merry-go-round that can sometimes swallow a patient whole, turning a happy 1 week recovery into a sad 6 week hospital stay, bankrupting a family and leaving them to try and pick up the pieces.

But for every sad story, there almost always seems to be one to re-boost morale.  For every deadly meningitis I see, there seems to be another case that we successfully treat.  For every heart I watch fail, I see another that is helped.  It can be a sad experience being surrounded by disease and death, but being able to help even the occational patient makes all the difference in the world…

Quote of the Post

How wonderful it is that nobody need wait a single moment before starting to improve the world. 

~Anne Frank

Posted at 12:24

If You Hear Hoofbeats

In medical school, there is an overused saying that paraphrases to "if you hear hoofbeats behind you, think Horse, not Zebra".  The idea is a good one.  If a patient presents with a headache, for instance, you should think migraine before thinking of something like a brain cyst secondary to echinococcus.

Many medical students struggle with this concept early on during their training.  After learning about all the different pathologies of the human body, it can sometimes be difficult to not let your imagination run wild.  Chest pain suddenly means miliary tuberculosis.  Abdominal pain equates to a parasitic infection.  Back pain can be nothing other than Ankylosing Spondylitis.  Instead of thinking heart attack, gastroenteritis, and lumbar strain, students are eager to dig for the 'Zebras' instead of the 'Horses'.

In Kenya though, this saying doesn't quite carry the same weight.  American 'Zebras' are suddenly horses, and things like Malaria, Leishmania, Typhoid, Tuberculosis, and HIV quickly jump to the top of any differential diagnosis.  Similarly, many of the 'Horses' I've come to look for in the US are no longer guaranteed regulars on my ward rounds.  Rampant American diseases, like type-2 diabetes and coronary artery disease, play second fiddle on the Kenyan Wards.

This saying popped into my head recently for two reasons, both of which can best be summed up with photos.  The first photo shows a disease process that truly is a 'Zebra' in the US:  Hydatid Cysts secondary to Echinococcosis.  Simply put, this is a disease caused by tapeworm that harbor in farm animals and dogs before settling into humans, causing cysts in the lung, liver, brain, heart, or kidney.  Unfortunately, there is a patient in the wards with exactly this.  He is a farmer, who (from my understanding) presented with gradual worsening neurologic symptoms.  His actual head CT is shown below.

Scan.jpg

The second reason this saying popped into my head is because, quite frankly, I spent this past weekend surrounded by actual Zebras while at Crescent Island, off of Lake Naivasha.

You didn't think this Kenya Rotation would be ALL work, did you…?

Zebras.jpg

Quote of the Post:

In a gentle way, you can shake the world.

-Ghandi

 

 

Posted at 12:19

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