Anita has primary pulmonary tuberculosis and is finally well enough to go from the inpatient ward to the TB house. This is backwards - folks with TB start in the hospital and when they're no longer desperately ill, they go to the TB house until they're done with the daily medications, since the PNG requirement is directly observed therapy for at least the first month to 2 months. She's feeling great and full of beans, and tolerating her streptomycin regimen quite well. It's just a little too far for her to come to the hospital to get her medicine every day.
Anita's mother tried to have a conversation with me in tok pisin, and I sort of stumbled through it. We managed the basics, like 'where are you from' and 'I'm a doctor for moms and babies in America'. It was fun, and she was such a nice woman. I printed a copy of this picture out for her and brought it to the TB ward, and she hugged me.
Like most days here, it went sort of uphill and downhill from there. There were less kids on the floor, but it was still 11 before we finished rounding on the ward, and then one of Susan's little ones decided to try to die. Successfully, unfortunately, despite suction and CPR and 2 rounds of adrenaline. He'd been working on it all morning, with sats in the 50-75% range and some kind of illness we couldn't beat - platelet counts of 1 and 2, white counts not much higher. Maybe TB. Maybe something else entirely. We'll never know.
We took lunch after that; it was close enough to noon that nobody minded. Came back and saw patients from 1 to 5:30 PM.
I sent my first five or six patients to Xray for chest films; one of them was a man with no cough but shortness of breath for the last few months. He also had back pain. He'd been treated with prednisone and amoxicillin (they spell it amoxycillin here) and salbutamol, but hadn't really improved, and I didn't think the air on his right side was moving very well at all, so I wasn't really surprised when he came back with a big right-sided lobar consolidation. Off we went to ultrasound, with Steph's assistance, and produced some very nice images of a loculated pleural effusion that looked a whole lot like it might be TB.
At home, this is when I might have called the pulmonologist. Here, we sent him over to the ER and got out the thoracocentesis kit, and I pulled off 180 mL's of straw-colored pulmonary fluid with a big syringe. Then he got dizzy, so we stopped. Follow up Xray looked good, and lab confirmed a probable TB effusion, so he'll be starting TB medications tomorrow.
While we were in the ER, one of Becky's patients apparently rapidly metabolized his Valium. We use ketamine and valium for our conscious sedation procedures (I&D, minor surgery, D&C, that sort of thing) - it's a fast-acting dissociative anesthetic (related to PCP) that doesn't suppress respirations. The downside is that when it wears off, it induces hallucinations. Vivid hallucinations. Most of the time, this can be avoided by co-administering a benzodiazepine such as Valium with it - our usual practice is to always co-administer these in adults. Apparently, this particular patient didn't get enough Valium, because he was lying on his ER table with five men holding him down - one on each limb - thrashing and screaming in the midst of some kind of religious ecstasy. "JESUS! JEEEEEESUS!" He nearly thrashed himself and his handlers off the table, almost kicked out a window, and then calmed down a bit after a few more milligrams of Valium IV (two men on the arm, Becky with the needle ready). After that, there was no more thrashing, just the preaching. "Do YOU! Have a Heavenly Passport?!" Finally, one of the security guards answered one of his questions: "Do you know JESUS?!" "Yes." "That's the right answer, praise JEEEESUS!" And he settled down.
Mental note: Never skimp on the Valium.
My note is sketchy; just-the-facts. 100% on room air, respiratory rate 60-70 breaths/minute, liver margin palpable at 1 cm below costal margin; very large spleen. It doesn't adequately portray my request for Susan-the-pediatrician to "please come check this baby out" or her frowning face as she palpated the firm mass on little Jesicka's left side. Feels rounded. Start with a chest X-ray.
I didn't have the heart to charge 12 more kina for something that I was sure was going to be bad news. Furthermore, they were longwe patients who I was going to have to refer back to Mount Hagen for management, so I just called it a followup ultrasound on the chest X-ray and went for it without billing.
I laid the probe on her belly and scanned what I expected to find: liver, right kidney, bowel gas, and then awholebunchoffluid where no fluid should be. I tried to make sense of it, but couldn't; big cystic things full of fluid and debris without reference point, and Susan wasn't in her room. So I asked Scott to come in - showed him the X-ray, told him the story, and he frowned. A few minutes later, ultrasound probe in hand, he was staring at the screen with the same solemn expression. That's not a spleen. Did you find a left kidney? I shook my head. I think this is it. We found her spleen, tucked up under her ribs, but half or more of her belly was occupied by what, under his guidance, revealed itself to be a multicystic structure with solid components. Maybe a nephroblastoma? I don't know. I thought they were solid. Neither did Jim, or Susan, but we all agreed on one thing: that has to come out. And then I had to explain it to Jesicka's mother, who thought maybe her little one just had pneumonia before we laid hands on her. I told her that sometimes this is cancer, and that I needed her to see a surgeon in Mount Hagen, that Dr. Jim thought there was someone there who would do the surgery. She nodded. "Jesus." It was an invocation. We prayed - for strength, for guidance, for the right surgeon's hands to be guided to the right place. Wednesday is surgery clinic day in Mount Hagen, so I wrote my referral note and gave it to her, told her to be there early in the morning. And I pray that someone there will look at it and understand.
Wilms' Tumor, or nephroblastoma, is the most common abdominal tumor in early childhood. A little research indicates to me that there is, in fact, a cystic variant (multilocular cystic nephroma) which looks on CT scan sort of what I imagine this kidney would look like, if there were a CT scanner in range. In the US, with nephrectomy and radiation therapy and chemotherapy, it has an 85-90% survival rate in Stage IV disease (assuming those really are lung metastases). I don't know here; I'll have to look at the Cancer Treatment in PNG book tomorrow. It's associated with several genetic syndromes, none of which quite exactly match Jesicka's abnormalities.
It frustrates me that I won't know the outcome; but I'm going to choose to believe that God does great and wonderful things, and that someday Jesicka will be just another PNG woman who only happens to have one kidney. What else can you do?
I will call to mind the deeds of the Lord;
I will remember your wonders of old.
12I will meditate on all your work,
and muse on your mighty deeds.
13Your way, O God, is holy.
What god is so great as our God?
14You are the God who works wonders;
you have displayed your might among the peoples.
15With your strong arm you redeemed your people,
the descendants of Jacob and Joseph.
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