My last week on the male medical ward (written in retrospect)

Although a long time ago now, I just wanted to write a note about my last week on the male medical ward as I remember it being packed full of interesting cases.
Following a trip to Nkotakota hospital (2.5 hours drive north of Lilongwe) the week before, Dan and I had seen a diabetic patient with a serious eye infection. His glycaemic control was erratic because of the infection, and he needed to have his eye surgically removed (enucleation). We arranged for him to come to Lilongwe, and he turned up this week (I love it when things actually happen as planned!). I took him under my wing, and with the help of Dr. Roland (a German physician here for a long time, at least 2 years I think, he’s been on holiday since we arrived and I’ve only just started working with him, but he’s fantastic. Cuts lots of corners but an impressive doctor and does a lot in a short space of time) managed to get him seen by the ophthalmology department by chasing clinical officers around the hospital. Most ophthalmology is carried out here by clinical officers, not doctors, including the surgery this patient needed. As well as poor diabetic control and a serious eye infection, this patient also had a swollen abdomen full of fluid. The patient was complaining that the distension was uncomfortable so I drained it following Dr. Roland’s instruction (he said we would wait until after the eye operation to investigate the cause of the abdominal fluid). The patient was very pleased with his now comfortable tummy, but not so happy when he came back from theatre without pain relief. The surgeons hadn’t seemed to consider his post-operative care. While I was organising some intramuscular pethidine (a drug like morphine, no morphine in this hospital) for this poor chap, Dan (who isn’t supposed to work on the male medical ward but had heard about this interesting patient and come to get involved, as he often does) and I were dealing with a 40-odd-year old man who had presented earlier that morning with loss of consciousness. He had no previous history of illness, and there was no further history available. The physical examination had revealed hypertension (high blood pressure) and bradycardia (slow heart rate). His pupils were fixed and dilated. This patient had raised intracranial pressure, that had already caused herniation of the temporal lobes through the tentorium (demonstrated by the fixed and dilated pupils) and demonstrated the cushings reflex (raised blood pressure with a slow heart rate). In a developed setting, this patient would have headed straight for the CT scanner to search for the cause of the raised intracranial pressure. But as I have mentioned before, there is no CT here in Lilongwe. The short history of loss of consciousness in a previously well patient made an acute intracranial bleed high on our list of differential diagnoses. Dan decided to do a lumbar puncture (LP) to see if this was the case. The most important contraindication to performing an LP is raised intracranial pressure, because if you remove CSF from a high pressure system, this can cause the brain to herniated through the hole in the base of the skull (foramen magnum) and cause death. Because of this patients certain poor prognosis, and because we had no other means of reaching a diagnosis, Dan decided to do an LP. Actually, he asked me to do it, but I refused because I knew what the consequence would be and thought it would be better if Dan did it. So, we were doing the LP while relieving the pain of the patient who had just had his eye removed. We had a diagnosis within seconds: bright red blood flowed into the needle chamber, we didn’t even need to take a sample. The patient had suffered a sub-arachnoid haemorrhage. While Dan explained to the family the diagnosis and poor prognosis, I catheterised the patient. The doctors who had clerked him in earlier that day hadn’t thought to do so and his bladder was distended up to his tummy button. It felt good to be able to explain to the family what the diagnosis was, rather than just shrug our shoulders and wait for him to die.
I chased the ophthalmology clinical officers around the hospital for another reason this week: while I was away for Christmas holidays and doing the audit last week, a patient was admitted with Stephen Johnson syndrome, a severe reaction to medication suffered by some patients. In this case it was a reaction to antiretroviral therapy for HIV infection. Stephen Johnson syndrome is a severe blistering disorder, involving the skin and mucous membranes such as the mouth and eyes. This guy was covered from head to toe in blisters and raw skin, and was being treated like a burns patient, underneath a cage covered in blankets. Ophthalmology input was needed because his eyes had bee sealed shut by the healing blisters. They came on several occasions to cut the adhesions that had been formed, and dress the wounds. This patient was well known in that ward because he had been an inpatient for about a month, and everyone was very happy with how improved his condition was. He walked out of the ward at the end of this week with a smile and wave. How lovely.
On my last day in medicine I was the first to see a condemned man, brought in by prison officers. My initial assessment revealed he was in shock (fast pulse and low blood pressure), probably caused by sepsis because he had a high temperature. I worked him up, pumped him full of fluid and made sure he received IV antibiotics, did an LP which turned out to be negative. Anyway, several hours after I had admitted him he died, not much of a surprise considering the state he was admitted in. Whilst confirming the death, I noticed the prison officers had handcuffed the patient to the bed, as if he was in a fit state to run away. Not only had they done that but they had left the hospital, so I can to call various people to organise unlocking of the handcuffs before the patient could be wrapped and sent to the mortuary. This country gets weirder and weirder.
In addition to these patients, this week I also saw a patient with severe mitral stenosis (narrowing of one of the heart valves), who had a thrill (you could feel the vibration of the stenosis when you put your hand on the patient’s chest) and a fascinating chest x-ray. I saw a patient with a huge (7cm) pericardial effusion (fluid in the sack covering the heart) who was on TB treatment but when Dr. Roland did a pericariocentesis (drainage of the fluid) it looked more like a purulent bacterial infection so we started treatment with antibiotics injected directly into the pericardial sack. I did a couple of therapeutic lumbar punctures in patients with cryptococcal meningitis to relieve symptoms of severe headache, and I did a pleural tap on a patient with shortness of breath and a large pleural effusion. I was reminded about the difference between the internal and external jugular veins in the neck through watching a central venous catheter insertion into the internal jugular, and inserting a venous cannular into the external jugular of a patient with a sickle-cell crisis who needed intravenous fluid therapy.
Its was a full and busy last week, and in general very positive with several learning opportunities. I am worried that I have become desensitised to all the suffering and death however, I don’t seem to react emotionally to sad things that happen on the ward.