On the male medical ward

It’s been a very tough week this week. I don’t know if it’s anything to do with the rain which has been bucketing down most of the time, but we have been very busy with admissions, mainly of very sick young men. They come so late in their illness, by which time there is not much that can be done. On Thursday a man in his 40’s came in unconscious. The history was of five days of severe headache, neck stiffness, and fever. We were dealing with meningitis, and severe sepsis. His respiratory rate was through the roof, and his tongue was obstructing his airway, making his breathing very noisy. They don’t do anything about obstructed airways in unconscious patients, apart from occasionally some suction. I managed to find a functioning suction machine in the high-dependency unit (quite an achievement) and tried to clear out his airway. The suction isn’t very powerful, but it made a little bit of difference. After ensuring he was receiving plenty of intravenous (IV) fluid, I supervised one of the clinical officers while he did a lumbar puncture (LP). I’ve only been doing LP’s for two weeks, but in general the clinical officers knowledge of a sterile field is pretty much zero, so I’ve been trying to get them to understand the importance of a sterile LP technique. Their ability to actually do the LP is fine (as in it is usually successful), they just do them without being sterile, which worries me (Me: “now put on your sterile gloves. Good. No, you can’t touch the bed or move the patient or scratch your head with sterile gloves on. Go and change them”. I don’t know how much they take this in. Usually they just giggle at me and one of them told me to “chill out”!). Anyway, pus came out of this patient’s spinal canal, mixed with the cerebrospinal fluid (CSF). This is not a good sign. Charles (the registrar) told me he has only ever seen one patient with purulent bacterial meningitis survive. We started the patient on an antibiotic (they use IV ceftriaxone for bacterial meningitis here too, or sometimes IV cefotaxime because the nurses don’t like drawing up ceftriaxone as apparently its too much effort). The patient was moved from the admissions room to the ‘meningitis room’, and we carried about our business of seeing the rest of the very sick people, and reviewing others on the ward. I happened to be in the meningitis room, and noticed the patient we had just moved had run out of IV fluids. I set more up, then one of the interns decided to come to the ward (it is as haphazard as that!), and was asking me about the patient. We discussed him, and talked about what electrolyte imbalances he may have, as his urine output wasn’t great he was probably in acute renal failure. This intern is very good when he is on the ward, a lot of knowledge and for some reason he decided we might be able to do something for this patient. We decided to get urgent renal function tests (U&Es), so I spent the next couple of hours rushing around between labs, trying to find a signature (the KCH lab machine is still broken, so if we want U&E we have to take samples to the UNC lab, which is a 15 minute round trip from the ward, and only two people in the whole hospital can sign their lab forms, both of these people are difficult to find!), and collecting results. The patient did have renal impairment but his electrolytes were OK. The intern added a different antibiotic, as he said it might help, and I made sure his fluids kept running for the rest of the day. They probably wouldn’t be kept up overnight however, even though the intern said he would hand over the patient to the doctor on night duty.
The day before (Wednesday) I had done an LP on a 54-year-old patient who presented last week with loss of sensory and motor function of both legs. He also had urinary incontinence and constipation. The symptoms had started in his feet and moved up his legs. He was HIV positive and on antiretroviral therapy (ARVs). Guillian Barre Syndrome (GBS) was considered a differential diagnosis, and we needed a CSF protein analysis to confirm this. The KCH or UNC labs don’t do this test, so Dan (the consultant physician) had told me to send the sample with the patient’s guardian to a private clinic in town which would do the test. The patient would have to pay for the test. I wrote a letter to go with the sample, explaining that we only needed protein analysis. I had sent another sample to our own lab for other CSF analysis which would cost the patient nothing. The guardian came back at the end of the day with the results: CSF protein: test not available. They had analysed the CSF for everything else instead, and charged the patient for something we could have done at KCH. I was so cross. The patient’s guardian kept chasing me around the ward asking me what the result had shown and what was going to happened and would her husband ever walk again. The doctors who were supposed to be in charge of him hadn’t really explained everything and because I talk to the guardian, she has decided to follow me everywhere. I had to do a pleural tap (drained 2L off each side of a TB patient’s chest much to his relief) and couple of paracentesis (draining fluid from the abdomen) that afternoon (drained 5L off one poor chap because I just left him in the treatment room while I was dealing with another sick patient, gave him a litre of fluid quickly and made sure his blood pressure was OK before he went home), so this was not helpful being followed and pestered, but I understand why she was doing so. Dan was going to be away on Thursday (district hospital visit), and so had asked me to go down to the radiology department with the ?GBS patient to do the LP for a myelogram investigation. This investigation is no longer used in the UK, we use MRI instead, but it involves injecting contrast into the spinal canal and then uses x-rays to visualise any filling defects that might indicate that the spinal cord is being squashed my something (tumour, bone, etc). Another differential diagnosis for this patient was spinal cord/cauda equina compression, probably caused by TB, or schistosomiasis. I went down to the department in advance, and discovered I was to be the radiologist, and not only do the LP, but also inject contrast into the spinal canal. I was by myself, and decided this was not a good plan. A clinical officer came to supervise me, but after taking plain films of the lumbar spine (we had previous x-rays that were very poor quality), we decided there might be an abnormality, and he then said we should do the myelogram. I didn’t know if this was the right decision or not, but felt relived that I didn’t have to be a radiologist for a day. That would not be right. I have organised for this patient to have an MRI scan in Blantyre (the second biggest city in Malawi with better equipped hospitals) next week.
So, after not doing the myelogram, I remembered about patient with purulent meningitis, and decided to go and check on him. His fluids had run out again, and he was still obviously very unwell, with a high respiratory rate and needed suctioning again. I asked Cosmos, the amazing male nurse (really, the only one who does any work, and will do anything you ask him to) to suction him for me because he is better at it than me and I had to do something else.
I can’t remember how Thursday ended, but it was late and I was shattered. Wednesday was pretty much like that too, I seemed to be going procedure crazy with the pleural tap, paracentesis and a couple more LPs.
I came in on Friday morning, and was surprised to learn that my meningitis patient was still alive, I noticed his breathing was becoming more eratic though. I asked Cosmos to suction him again, but he didn’t get round to it. While making sure his fluids were running another unconscious man (about 30 years old) came in, very similar to the one I was in the process of looking after. Exact same story, exact same late presentation. I did the LP, and viscous cloudy CSF came out. He got left in the admissions room as there was no space anywhere else. I was then called by one of the clinical officer students to see a patient out on the balcony area who has frank haematuria in his catheter bag. Turns out he hadn’t really had a proper work up, so I struggled for about half an hour working out the patient’s history and examining him. He had a mass in his pelvis that hadn’t been documented anywhere, and with Charles advice, I sent him for urgent ultrasound and x-rays, and took blood, and re-sited his venous cannula. This was a bit of a set back to the morning. I was then called by another clinical officer student to see the first meningitis patient. He had stopped breathing. I examined him, explained to the wife with the student as a translator, and informed the nurses about the death. Shortly after that, while chasing Dan around the hospital trying to get him to make a decision about the management plan for the patient with ?GBS ?spinal cord pathology, I walked past through the admissions room and noticed that the second meningitis patient had also stopped breathing. Again I did the examination and explained to the young wife (using a student as translator) who was sitting next to the bed with a baby strapped to her back and probably at least another couple at home. She looked at me with disbelieve and shook her head. The guardians never look worried when they bring in their half-dead husbands, and don’t seem to notice when they stop breathing. There was no wailing for this death, I don’t know why. But what will she do now? With several mouths to feed and limited ability to earn an income.
I was beginning to think the day couldn’t get much worse, and it was only about 11am. I admitted a patient last week, an 18 year-old boy with generalised enlarge lymph nodes, and splenomegaly. It looked like a case of advanced lymphoma, and the plan was to give him chemotherapy. He was severely anaemic though, and this needed to be corrected first. I hadn’t been following him up, but found out a few days ago he had only had one pint of red cells in the week he had been admitted, and was still awaiting further transfusion. In that time, his haemoglobin had dropped further. I was standing in the corridor when I heard his mother wailing. Just because the lab didn’t have any blood. I couldn’t really deal with much more, and after a few tears went to have a break for an hour.
Late on Friday afternoon Charles asked me to do an LP on an inpatient who now had a headache and had become confused. He was at the far end of the balcony, not sure if he’d been missed out on ward rounds (which happens quite a bit). Again, cloudy CSF. We quickly started antibiotics and moved the patient to the meningitis room. I went to work on Saturday this week. Charles asked me to come in to help him, and I sort of couldn’t leave sick patients I had seen on Friday all weekend. I found out near the end of my stint on Saturday that this new meningitis patient had pulled out his drip the night before, and no one had re-sited it. Even though he was prescribed IV antibiotics, the nurses just gave him them intramuscularly, which would do nothing for him (at least he was getting some antibiotics, other patients I have been managing for some reason don’t get them at all, even if they are prescribed). I asked a nurse to cannulate the patient as I needed to do something else, and she started at me blankly from under the coat she was curled up in sitting in a chair in the office (torrential downpour makes the hospital quite cold), and said, “I am resting”. Resting from what I don’t know, because she had done diddly squat all morning. I got cross and told her the patient was dying (because he is and he will) and needed a cannula now. “After I have finished resting”. I give up. Cosmos says they never do anything, and he is lucky if they come to work at all. He says sometimes they are sick (HIV) and need time off, but other times it’s because they just don’t come, or they are attending a funeral. Cosmos will cannulate my patient. Thank you Cosmos.