Greetings from the Daktari Cases blog (we've decided to marry the clinical cases with the family life and missions blog, beware medical images and descriptions. Previous cases: www.daktaricases.wordpress.com). One of my goals in writing is to introduce you to and connect you to our work here. And that includes the tragedies, as well as the victories and the comedies. Our patients come to the hospital desperately sick, often on the brink of death; and our inpatient medicine mortality rate averages 10%. Of the 40-50 patients that I see every day, 4-5 of them will die in the hospital. These are a couple of their stories.
Joan was a 37-year-old
woman who came to the hospital after having a septic abortion. All abortion in Kenya is illegal, and
when it is done by the hands of a non-medical practitioner it is called a
“criminal abortion.” When I was
asked to see her in the ICU, she was unable to speak, and I will never know why
this happened. I was asked to see
her in the ICU for multi-organ failure and sepsis.
The source of her infection was a necrotic uterus, an
all-to-common complication of these illegal “procedures.” As we attempted to resuscitate her with
IV fluids and antibiotics, there was an ongoing discussion with the
obstetricians about whether or not she would have to have a hysterectomy to
remove her uterus, her womb, and the source of her overwhelming infection. Through the course of the day, a
repeated CBC showed that her hemoglobin and platelet counts were dropping
precipitously. Her body was
consuming her own blood products (a condition called DIC: disseminated
intravascular coagulation). The
treatment for this condition is with replacement of those blood products;
ideally with FFP (fresh frozen plasma) or cryoprecipitate, neither of which are
available at Tenwek.
What we can
give is fresh blood, straight out of the donor, through the screening process
(to insure against transmission of HIV, hepatitis etc) and into the
patient. And there was no fresh
blood. Her blood was typed:
A-positive. Do you know who else
is A-positive? I am. By this time, it’s getting late in the
day, and I was on-call the night before, and I’m tired. The only chance this woman has to live
is to receive fresh blood during the night and then have surgery to remove her
necrotic uterus after the transfusion.
So we come up with a plan: I go to the blood bank, give my blood for the
transfusion, and then we set-up the OR for the moment the transfusion is
accomplished. After the blood
bank, I go home, pretty well spent.
That night, during her second transfusion, her heart stops beating, the
code team comes to resuscitate her, and is ultimately unsuccessful. And in one week last month 3 pregnant women died: one of AIDS complications, one of status epilepticus, and one of a stroke from a rheumatic mitral valve. Prior to moving here, I had never seen a pregnant woman die in the hospital.
Stanley Rotich was a Good Samaritan. He was 28-years-old and had cared for
his brother dying of AIDS complicated by tuberculosis in their 10x10 foot one-room home.
It only takes one deep breath in the right circumstances to acquire TB,
and when Stanley was brought to our hospital, he was in respiratory failure,
requiring high flow oxygen to keep him alive. This was his chest x-ray, which showed miliary TB, one of
the most aggressive and advanced forms of TB, spread through the
bloodstream. He remained in our
ward for 5 days, and this image is copied from the clinician and chaplain notes
of his last 18 hours of life before he passed. This is one of the cases that are so hard to understand that
challenges my clinical judgment, and my faith. Is this a tragedy?
These are some of the cases of note
from the past few weeks. The
stakes are very high here; the acuity of these patients once they get to the
hospital is almost always a matter of life and death. There are no cases here of indigestion in an 85-year-old
great-grandmother that undergoes a nuclear stress test to insure that it’s not
a subclinical heart attack.
Sometimes I miss those cases.
But this is my dream job- to be living out my true vocation (calling). Thank you for being interested enough
to read these stories, to pray for us, and to support us.