I climbed the 8 flights today--catching the cool breeze of the rainy season through the open windows in the stairwell. The hospital seemed exceptionally more crowded today than yesterday, or perhaps the haziness of jetlag has let up. My first task today was to give a lecture on treating pain, agitation and delirium in the ICU. I got a brief look yesterday on how this is done, and usually with intermittent dosing of pain regimens while in the US our teams are accustomed to starting continuous infusions. Cost is a real issue here and all decisions are made with that in mind. My lecture went well but many of the limitations I discussed were based on availability of certain types of medications.
Following the 8a-9a lecture were rounds in the ICU. I led rounds today which was such an interesting experience. The ventilators are different the make-up of the teams is widely variable. The residents from yesterday are not the ones who presented today. The presentations are full and complete and often data is a few days behind and empiric decisions are being made--and often correctly as the practice of medicine is so artful here. To give an example, one particular patient who was improving the day prior started to have increased tracheal secretions (sputum production), he was not tolerating being weaned from the ventilator and had exam findings consistent with a new pneumonia. The CXR would take some time to obtain and the wbc count was from two days prior. However, our clinical gestalt was the deciding factor between just monitoring and starting antibiotics, we went with the latter.
The next patient was a 45 yo female who was admitted with a hemorrhagic stroke. The likely cause was uncontrolled hypertension or high blood pressure. One of the most important primary care campaigns in Ethiopia and arguably the world is the importance of recognizing hypertension. It is called the silent killer and with good reason. This woman did not even know she had high blood pressure until her stroke. Her stroke was quite large and she was treated with an osmotic agent to reduce swelling in her brain. Her mental status was a little better today and her blood pressure is now controlled. She is being fed via a feeding tube through her nose and neurosurgery has declined any surgical intervention. In a patient like this, with such a severe stroke she may have been kept in the ICU for a day or two longer but the truth is there are no further ICU interventions and she will be transferred to the general ward.
With the knowledge of a bed opening in the ICU we took 6 flights down to the ER to evaluate the potential candidates for ICU admission. Often if there is no room in the ICU we are at least able to provide our consultant services. We made a similar trek to the Emergency Room yesterday. It is on the 2nd floor and PACKED. There are just hoards of people everywhere and a feeling of helplessness as a medical professional is more than overwhelming. We entered the critical unit of the Emergency Room, similar to the "resuscitation bay" in most US Emergency Rooms. We attended to a woman just yesterday with likely a clot on her mechanical mitral valve in acute heart failure who I thought may still be there but she had unfortunately died and her place was taken by an equally sick patient. Today's patient was a young woman from a malaria endemic part of Ethiopia. She came in with fevers, mental status changes, a high heart rate and high respiratory rate and a borderline low blood pressure. Her kidneys were acutely injured and she was barely making any urine. She was in great distress, breathing over 40 breaths a minute, using all available muscles to breathe--an act most of us perform without any effort. Her blood smear was positive for Plasmodium Falciparium--the major cause of severe malaria. The patient had many features, such as evidence of shock, impaired consciousness and renal impairment but she was missing other features such as severe anemia and the parasite load on the blood smear was not available. A key piece of her history is that she just recently was admitted for cleft palate surgery--this presentation happened only a few days after her surgery. Now sepsis was on the differential diagnosis. She was only being treated for malaria and we suggested antibacterial coverage as well and asked that she promptly be moved to the ICU. The unfortunate issue was that there were physically no more ventilators and she would likely require intubation and a respirator, almost certainly. I was not shocked by the limitation of available ventilators because this is not uncommon in a resource limited center. Just earlier today a patient on the ventilator was requiring bag-mask-valve ventilation while the oxygen tanks were being exchanged--a problem we do not ever see in a resource rich setting.
Every patient and all decisions made towards treating a patient, even down to the medications ordered has to come with a great deal of thought. The patient's families are responsible for obtaining and purchasing the medications needed if the hospital cannot provide it. This requires understanding the cost with each type of medication and the burden it places on the patient and their family. In truth we should be more mindful of this in the US but most hospital culture does not allow for that--at least not as readily as it probably should.
Following the 8a-9a lecture were rounds in the ICU. I led rounds today which was such an interesting experience. The ventilators are different the make-up of the teams is widely variable. The residents from yesterday are not the ones who presented today. The presentations are full and complete and often data is a few days behind and empiric decisions are being made--and often correctly as the practice of medicine is so artful here. To give an example, one particular patient who was improving the day prior started to have increased tracheal secretions (sputum production), he was not tolerating being weaned from the ventilator and had exam findings consistent with a new pneumonia. The CXR would take some time to obtain and the wbc count was from two days prior. However, our clinical gestalt was the deciding factor between just monitoring and starting antibiotics, we went with the latter.
The next patient was a 45 yo female who was admitted with a hemorrhagic stroke. The likely cause was uncontrolled hypertension or high blood pressure. One of the most important primary care campaigns in Ethiopia and arguably the world is the importance of recognizing hypertension. It is called the silent killer and with good reason. This woman did not even know she had high blood pressure until her stroke. Her stroke was quite large and she was treated with an osmotic agent to reduce swelling in her brain. Her mental status was a little better today and her blood pressure is now controlled. She is being fed via a feeding tube through her nose and neurosurgery has declined any surgical intervention. In a patient like this, with such a severe stroke she may have been kept in the ICU for a day or two longer but the truth is there are no further ICU interventions and she will be transferred to the general ward.
With the knowledge of a bed opening in the ICU we took 6 flights down to the ER to evaluate the potential candidates for ICU admission. Often if there is no room in the ICU we are at least able to provide our consultant services. We made a similar trek to the Emergency Room yesterday. It is on the 2nd floor and PACKED. There are just hoards of people everywhere and a feeling of helplessness as a medical professional is more than overwhelming. We entered the critical unit of the Emergency Room, similar to the "resuscitation bay" in most US Emergency Rooms. We attended to a woman just yesterday with likely a clot on her mechanical mitral valve in acute heart failure who I thought may still be there but she had unfortunately died and her place was taken by an equally sick patient. Today's patient was a young woman from a malaria endemic part of Ethiopia. She came in with fevers, mental status changes, a high heart rate and high respiratory rate and a borderline low blood pressure. Her kidneys were acutely injured and she was barely making any urine. She was in great distress, breathing over 40 breaths a minute, using all available muscles to breathe--an act most of us perform without any effort. Her blood smear was positive for Plasmodium Falciparium--the major cause of severe malaria. The patient had many features, such as evidence of shock, impaired consciousness and renal impairment but she was missing other features such as severe anemia and the parasite load on the blood smear was not available. A key piece of her history is that she just recently was admitted for cleft palate surgery--this presentation happened only a few days after her surgery. Now sepsis was on the differential diagnosis. She was only being treated for malaria and we suggested antibacterial coverage as well and asked that she promptly be moved to the ICU. The unfortunate issue was that there were physically no more ventilators and she would likely require intubation and a respirator, almost certainly. I was not shocked by the limitation of available ventilators because this is not uncommon in a resource limited center. Just earlier today a patient on the ventilator was requiring bag-mask-valve ventilation while the oxygen tanks were being exchanged--a problem we do not ever see in a resource rich setting.
Every patient and all decisions made towards treating a patient, even down to the medications ordered has to come with a great deal of thought. The patient's families are responsible for obtaining and purchasing the medications needed if the hospital cannot provide it. This requires understanding the cost with each type of medication and the burden it places on the patient and their family. In truth we should be more mindful of this in the US but most hospital culture does not allow for that--at least not as readily as it probably should.
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