Some of you may be aware of my dislike for the Intensive Care Unit (ICU) in the States. I am not a big fan of the high intensity with multiple patients on the brink of death. I have discovered that I probably wouldn't mind the ICU here - it is NOT high intensity.
I had my first real encounter with the ICU team this week when I wanted them to come see a patient on our team. The patient arrived on our team around 10 AM as we were going about our morning rounds. We stopped to assess the new patient because he looked quite sick. After a quick examination we found that his extremities were cold, he had no peripheral pulses, and we were unable to get a blood pressure or oxygen saturation. He was on oxygen and was clearly having difficulty with his breathing.
It was clear that this patient was not adequately perfusing his organs and he would quickly die if we did not get him to the ICU with some type of pressor support. On rounds we discussed this and the plan was to call the ICU and cardiology to come see him. After we saw the patient I noticed that no one was calling the ICU or cardiology. I asked my intern and he said he would call after rounds (rounds are an average of 3 hours long). I told him the patient wouldn't survive that long, so I called both consults myself.
I was pleasantly surprised when cardiology showed up 20 minutes later to see the patient. They agreed that he needed to be transfered but thought it might be too late to help him. I continued to wait for the ICU team to arrive. The patient died at 1pm and the ICU team showed up to see him around 3pm.
I was extremely frustrated with this but I learned that the ICU works a bit differently here. They take all the consults they recieve and go around seeing the patients. They may have 1-2 beds available so they try to find the patients they feel might have a chance at surviving. The others they turn down and the patients remain on the wards to be managed.
I guess my patient did not fit into their "possible recovery" category as he was unable to survive long enough for them to come see him. There is absolutely no urgency here in patient care.
Tuesday, May 31, 2011
Saturday, May 28, 2011
The Street Children of Eldoret
There is a large population of street children living in Eldoret. The total number is unknown because they are very difficult to track, but the estimation is over 2,000 children. Some of the children live on the streets during the day and go home at night but many live completely on the street with no home to return to at night. These children are often forced to leave their homes because of lack of food or violence toward them in the home. On the streets they can make their own money and have freedom from those who may harm them at home. They form communities on the streets with the older children assuming leadership over the younger children. The age range is broad with some of the younger children being 4-5 years old. Many of the older children living the streets are killed by police.
On Saturday morning several of us went to an outreach for the street children. The outreach is put on by Tumanini House (with means Hope in Swahilli). This home is a day center for the street children where they can come and shower, eat, and participate in different types of education. The people at Tumanini are working hard to help the children find a way to get off the streets by teaching them a trade and getting them back into schools.
There is a huge problem with substance abuse among the street children. Nearly all of the children are addicted to sniffing glue. It was hard to watch as we played soccer with them on Saturday because as they played they would have the glue bottle in their mouth sniffing.
It was a neat experience but overwhelming to see the needs of these children. Tumanini is definetly a place that is trying to make a difference in their lives. If you want to read more about the Tumanini center check out their website: www.tumaninicenter.org.
On Saturday morning several of us went to an outreach for the street children. The outreach is put on by Tumanini House (with means Hope in Swahilli). This home is a day center for the street children where they can come and shower, eat, and participate in different types of education. The people at Tumanini are working hard to help the children find a way to get off the streets by teaching them a trade and getting them back into schools.
There is a huge problem with substance abuse among the street children. Nearly all of the children are addicted to sniffing glue. It was hard to watch as we played soccer with them on Saturday because as they played they would have the glue bottle in their mouth sniffing.
It was a neat experience but overwhelming to see the needs of these children. Tumanini is definetly a place that is trying to make a difference in their lives. If you want to read more about the Tumanini center check out their website: www.tumaninicenter.org.
Thursday, May 26, 2011
Neema House
Neema house is a home for children located in Eldoret, only a five minute drive from where I am living. Yesterday afternoon I had the opportunity to spend several hours playing with the children. It was so much fun!
Neema house is home to 39 children at this time, 29 of them are HIV positive. It was started by an amazing couple who wanted to provide a home for abandoned children. They have also built a primary school on their property for the children to attend. It is a amazing place and I am eager to go back and play with the kids some more. I think I will stop by on Saturday for a few hours! I am sure to have more adorable pictures :)
Wednesday, May 25, 2011
Pellagra
Sorry if my pictures gross you out, but I wanted to share this amazing case with you. This man has a disease called Pellagra. Pellagra is caused by a deficiency in Vitamin B3 (Niacin). Patients with pellagra usually have a diet that is rich in unprocessed corn. It can also occur in alcoholics due to malnutrition. The treatment is very simple, you just have to give the patients a vitamin. Ofcourse we ran out of oral Vitamin B Complex today in the hospital so my patient has not been recieving his mediations.
If Pellagra is left untreated it will result in progressive dementia and ultimately death. Pellagra is a very preventable and treatable disease.
Lack of Supervision
The day to day routine at the hospital is alway different depending on who shows up. Some days we have a huge crowd with 10 medical students, two interns, 1 registrar, 1 attending, and myself. Other days it has been only me and the intern rounding on 50 patients. It is actually more fun and interesting the fewer number of people because it allows me to be more involved in patient care.
Today I was a little more involved in patient care than I prefered. Last month the intern I worked with was awesome. She knew what she was doing and just asked me for my opinion on certain issues. We have two new interns this week, one who is very strong and one who is extremely weak. Somehow today about half way through the rounds the registrar and good intern had to go to a meeting and I was instructed to "take over rounds." It was me, the weak intern, and 2 third year medical students. Talk about overhwelming. We had at least 40 patients on our service, about 10 of them were new admissions from the night before.
In the first 15 minutes of being the "attending" on my rounds today we had 4 patient that were completely unresponsive and one man with an acute abdomen. One unresponsive patient has cryptococcal meningitis and was actively seizing during rounds. Another man was in clear respiratory distress with an oxygen saturation of 68% (normal is 98%). Another patient I am concerned has TB meningitis (which I have seen twice in my life). The guy with the acute abdomen had severe rebound tenderness, guarding, and peritoneal signs.
I felt very helpless and overwhelmed today, but I was definately participating in patient care. None of the patients died during rounds or before I left for the day, which I thought was an accomplishment. I know I am getting use to the wards but I would prefer a little more supervision.
Today I was a little more involved in patient care than I prefered. Last month the intern I worked with was awesome. She knew what she was doing and just asked me for my opinion on certain issues. We have two new interns this week, one who is very strong and one who is extremely weak. Somehow today about half way through the rounds the registrar and good intern had to go to a meeting and I was instructed to "take over rounds." It was me, the weak intern, and 2 third year medical students. Talk about overhwelming. We had at least 40 patients on our service, about 10 of them were new admissions from the night before.
In the first 15 minutes of being the "attending" on my rounds today we had 4 patient that were completely unresponsive and one man with an acute abdomen. One unresponsive patient has cryptococcal meningitis and was actively seizing during rounds. Another man was in clear respiratory distress with an oxygen saturation of 68% (normal is 98%). Another patient I am concerned has TB meningitis (which I have seen twice in my life). The guy with the acute abdomen had severe rebound tenderness, guarding, and peritoneal signs.
I felt very helpless and overwhelmed today, but I was definately participating in patient care. None of the patients died during rounds or before I left for the day, which I thought was an accomplishment. I know I am getting use to the wards but I would prefer a little more supervision.
Monday, May 23, 2011
Giraffes, The Rift Valley, and The Rainforest
Our rainforest guide taking a break on the river.
Gillian and I enjoying the view of the rainforest.
Beth, Jaime, Sarah, and I overlooking the Great Rift Valley.
My buddy giraffe at Kruger Farms.
Sorry for the lack of blog posts, the internet has not been working ver well at the IU house. It has been working on and off for the past hour so I am trying to get some pictures and stories up for you to read. There is so much to write about it is hard to put these experiences into words on a blog. I am trying the best I can and hope you enjoy it. Hopefully, the internet will cooperate better with me and I can write more.
This past weekend we took two day trips which were both a lot of fun. On Saturday we went to a place called Kruger farm. This is a large farm owned by a South African family. When Eldoret was expanding the giraffes in the area were being killed for their meat and hides. They transported a family of giraffes over to Kruger farm to protect them from poachers. So you can walk the farm and look for family of giraffes. We found them after about an hour hike. There was a family of about 15 and they let us get within 10-15 feet and take lots of pictures.
After our visit to Kruger farms we drove to The Great Rift Valley where we ate at an awesome restaurant that overlooked the valley. We had a wonderful dinner and enjoyed the view.
On Sunday we took a group for a hike in the Rainforest. Kakamega forest is the only remaining rainforest in Kenya. We hired a guide who took us on a four hour hike through the rainforest. It was beautiful! We were very glad to have the guide because we would have been lost in about 5 minutes. Plus he pointed out all the cool birds, monkeys, butterflies, and plant life.
Another weekend full of adventure. My plan was to just stay at IU house and relax but I couldn't pass it up when people asked me if I wanted to join them. I hope you enjoy the pictures!!
Avoidance
For all of you who know me you know I have an interest and passion for end of life/palliative care. It is something I feel very strongly about and work hard to make sure my patients and families are comfortable at the end of life.
Due to my interest in end of life care I have had many frustration on the wards. I have discovered that as a patient dies here very little attention is given to the patient. There is one patient on our team who was admitted last Monday with altered mental status. He quickly declined and now is completely unresponsive, has bed sores from being unable to move, and started having seizures. On Wed, Thurs, and Fri of last week I was the only person to see this patient. The rest of the team skipped over him during rounds despite my reminding them. This patient is still alive, which is truly amazing, and recieves very little attention if any at all. Nothing is being done to make him comfortable.
A similar situation occured last week. We had a patient that presented with an intestinal obstruction and was found to have a large mass in his abdomen. We were planning on doing a CT scan of his abdomen but he quickly went downhill, we were not sure why. On our morning rounds the patient had agonal respirations (a sign of immiment death) and there was nothing else for us to do. The attending physican (head doctor) and I had the following conversation....
"Dr. Lupov, do you think there is anything else we can do for this patient?" Attending
"No. I think our focus should be to keep him comfortable." Me
"I agree. Our plan should be to keep him comfortable." Attending. After saying this he walks away and moves on to the next patient.
"Wait...do you have IV Morphine or Ativan? What can we give this patient to make him comfortable? He clearly looks like he is in pain and has a lot of air hunger." Me
"Giving those drugs is euthanasia and that is illegal in Kenya." Attending
"I disagree. We can keep patients comfortable without expediating there death." Me
"If you give that man Morphine and he dies, the family will say you killed him." Attending. At this point he stopped talking to me and moved on to the next patient.
How incredibly frustrating and sad. It has been so hard for me to watch numerous people on the wards die with absolutley no effort to keep them comfortable. I have not given morphine to a single patient since I have been here (and I have seen a lot of people die).
After talk about this with several people I have calmed down a little (not all the way) and realized that the Kenyan doctors' attitudes is likely a defense mechanism. Due to limited resources there is little to nothing to do for these patients. It is easier to avoid the patient then face the reality that the patient is dying and there is nothing you can do.
I hope palliative care/hospice can take hold here in Kenyan and change this attitude. Every person deserves dignity at the end of life and I believe it the physicans duty to make sure that happens. It has been hard to me to keep my mouth shut, because I don't think it is something I can change now. It will take time and many people to implement this changes. Maybe I can be a part of it in the future.
Due to my interest in end of life care I have had many frustration on the wards. I have discovered that as a patient dies here very little attention is given to the patient. There is one patient on our team who was admitted last Monday with altered mental status. He quickly declined and now is completely unresponsive, has bed sores from being unable to move, and started having seizures. On Wed, Thurs, and Fri of last week I was the only person to see this patient. The rest of the team skipped over him during rounds despite my reminding them. This patient is still alive, which is truly amazing, and recieves very little attention if any at all. Nothing is being done to make him comfortable.
A similar situation occured last week. We had a patient that presented with an intestinal obstruction and was found to have a large mass in his abdomen. We were planning on doing a CT scan of his abdomen but he quickly went downhill, we were not sure why. On our morning rounds the patient had agonal respirations (a sign of immiment death) and there was nothing else for us to do. The attending physican (head doctor) and I had the following conversation....
"Dr. Lupov, do you think there is anything else we can do for this patient?" Attending
"No. I think our focus should be to keep him comfortable." Me
"I agree. Our plan should be to keep him comfortable." Attending. After saying this he walks away and moves on to the next patient.
"Wait...do you have IV Morphine or Ativan? What can we give this patient to make him comfortable? He clearly looks like he is in pain and has a lot of air hunger." Me
"Giving those drugs is euthanasia and that is illegal in Kenya." Attending
"I disagree. We can keep patients comfortable without expediating there death." Me
"If you give that man Morphine and he dies, the family will say you killed him." Attending. At this point he stopped talking to me and moved on to the next patient.
How incredibly frustrating and sad. It has been so hard for me to watch numerous people on the wards die with absolutley no effort to keep them comfortable. I have not given morphine to a single patient since I have been here (and I have seen a lot of people die).
After talk about this with several people I have calmed down a little (not all the way) and realized that the Kenyan doctors' attitudes is likely a defense mechanism. Due to limited resources there is little to nothing to do for these patients. It is easier to avoid the patient then face the reality that the patient is dying and there is nothing you can do.
I hope palliative care/hospice can take hold here in Kenyan and change this attitude. Every person deserves dignity at the end of life and I believe it the physicans duty to make sure that happens. It has been hard to me to keep my mouth shut, because I don't think it is something I can change now. It will take time and many people to implement this changes. Maybe I can be a part of it in the future.
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