Archive for February, 2009

Friday, Feb 20th

Trying to set a line in neonate meningitis admission

Trying to set a line in neonate meningitis admission

My ineffectiveness today can only partially be blamed on my massive hang over. To be honest, I almost didn’t come in today, but I couldn’t just skip out simply because I chose to stay up all night drinking and gisting. But, my ineffectiveness can also be blamed on the overall festive atmosphere that surrounded my fellow house officers today. People showed up late and we were all around giddy today. There wasn’t much that needed to be done today. We were discharging a lot of patients, and it was my last day. I had to leave particularly early today because my Uncle F. called a board meeting for NELA and he wanted myself and Tinuke to be inducted as board members at this meeting. So, today was a half day in which nothing was really accomplished.

I met Tinuke at her clinic as she was seeing a man with a wicked leg ulcer that has to be malignant by now. See picture below. He has had his leg like that for two years and didn’t come see a doctor because it only caused him some mild itching. The interesting thing is that it wasn’t the “ulcer” on his leg that brought him in. It was his two week history of hematochezia. Further history revealed weight loss and anorexia. P.E showed massive hepatomegaly and Jaundice. Tinuke and I both agreed that there had to be some kind of malignancy going on here, but the question is, where to refer him to get a more extensive work up? Oddly enough the choice was btw dermatology or plastic surgery, not internal medicine. She explained to me that those two departments would be the ones that have to do the leg work before IM could delve down a more extensive diagnostic rout. So yeah, it was pretty interesting and I will have to ask my cuz/sis what the old man ended up having.

We left for Ibadan latter than we should have and were amazingly late for the board meeting. We were inducted and discussed the future of NELA. My uncle wants to move away from being an HIV NGO entity because of the scam NGOs that are out there, that are turning HIV/AIDS into a profit for themselves and not the people that actually need it. We talked about what our roles will be ( I will most likely be useless for the next three years, but I am hoping only 1.50) and what we could and should bring to the new NELA. Essentially my concern as I walked away was that I fear that if we become concerned with NELA sustaining itself and being less reliant on international funding and grants, then we will be shifting our emphasis from serving the ones that need it most and improving the health system of Nigeria and worrying about sustaining NELA. Money just corrupts. My uncle and I agree that having a foundation would be the best solution, but we are a long way away from having the money that would support it. I know that that is where I will come in, and I am excited because I love raising money for a good cause. I just don’t want to manage it. I want my uncle to have a good trust worthy person to manage the foundation because, well, lets be honest. Money corrupts and Nigerians have a reputation of being easily corruptible.

So yeah, here ends my three week at Ile ife.

Leg Ulcer? Yeah right!

Leg Ulcer? Yeah right!

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Thursday, Feb 19th

My nephrotic twins!

My nephrotic twins!

Nothing much to report today. I missed the first part of morning rounds because of endocrine clinic. I must say, for once I would rather have been at rounds than at clinic as clinic was particularly painful. There were not that many patients at all this morning and the students were there. Students…God bless them but their necessity to learn, makes everything a little bit more painful. So, this morning was pretty much a pimp session for the students who skipped out yesterday, mixed with presentations from a pharm rep, mixed with other business meeting between the Consultant running that clinc and some other ones that kept on popping in. I did get to learn what the specific treatment was for cerebral malaria in this environment (quinine with dextrose)and went further into the development and stages of Burkitt Lymphoma and the relationship between it and malaria. So, it was not a total loss.

I returned to the wards in time to see my nephrotic syndrome kids both of which are doing extremely well, and love getting their picture taken. Brakarat is doing much better, I went back to check in on her, and found out what I needed to do. If her fever stays down tomorrow, we will discharge her early Saturday morning, or even Friday night so that she and the mom can go home for the weekend and gather funds and just enjoy being out of the hospital for just a little. She has to come back on Monday and start another round of chemo. All my patients are actually doing pretty well, and will mostly likely be discharged this weekend, which is pretty good since tomorrow is my last day. I helped out the rest of HOs get their work, but no one really had much to do. We all went to the residents room and just enjoyed a quiet afternoon. I’ll be honest, it was nice to sit, relax and just gist with my friends, who have become a little like family with all the time we spend together. There is one of the HOs who may have had a little crush on me, but I can’t be sure how real it was. He is also the one that feels I am too westernized. Lets face it, he couldn’t handle this much woman, but he is a lot of fun to hang out with.

Late entry: The laxity of the day continued into the night as Deji (my cuz/bro) surprised us by coming into town (after my cuz/sis went to get her scan and SURPRISE she is having TWINS) later in the evening. I was home by myself and he took me out. We met up with my cuz/sis toasted to her twins (no she didn’t do any toasting) but yeah, I may have gotten more than elegantly tipsy, it was a blast though. There is nothing like good Nigeria beer and all types of meats…suya…asun… mmmmmm yeah, it was a good night.

Me with the HO fam!!

Me with the HO fam!!

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Wednesday, Feb 18th

Today started out pretty good. As I was walking to morning lecture this morning, who did I run to outside but the grandmother of my child with congestive heart failure. Not only did she come back, she came back bright and early. She told me that she was having trouble getting admitted and she was unsure of what she should do. I went and got one of the house officers on duty with me yesterday and we were able to assist her. The boy was admitted to Children’s emergency where they will stabilize him and then he will be transferred to the ward. So yeah that was a pretty good start to the day. Unfortunately, things then started to take a turn for the worse.

So, usually in the mornings before we do our morning lectures, we talk about any new admissions and where they were transferred to and all that jazz. This morning we had the sad opportunity to talk about an admission that turned into a mortality. At 11:15pm, a two year old male was brought to children’s emergency. He presented with pallor, fever of 40.0 and chills. He was semi conscious. Parents had taken the child earlier to a smaller community clinic, and when they realized the gravity of the situation, they told the parents to come quickly to Ile-Ife. The community hospital was one hour away. Immediately upon presentation, they attempted to set the line and at the same time tried to secure blood for a transfusion (btw since this was an emergent situation, they attended to these things first before worrying about payment). The resident on call with the two house officers was in the neonatal ward trying to attend to a situation there. One of the house officers was attempting to set the line without success; the other was running to secure blood. By 12:30am the child was dead.

The reality of the situation? Child was most likely suffering from hypoglycemia secondary to malaria. What should have happened, when the child first showed signs of malaria, the child should have been brought to the hospital. Second, they should not have taken the child to the hospital when the child was clearly getting worse. Third, the community hospital (which is maybe half a step up from the traditional healers) should have told the parents to come to the hospital as soon as the child presented to them. Fourth, the truth is, and this doesn’t make it any better, the reason why the parents brought the child to the hospital at all is because they were poor and didn’t feel they could afford a real hospital and they didn’t want the child to die at home.

After we talk about this case, and where the break down occurred, I then asked what the infant mortality rate was in Nigeria. The Consultant who was present, runs the Emergency Department, could not come up with the exact numbers but stated worldwide, Nigeria was 4th for infant mortality, and 2nd for maternal mortality. The main reason? Poverty and lack of education of the people. Not the medical teams. I have stated again and again that they are so well trained, so much better educated than we are in the U.S, but lack of money, and to be honest, lack of good structural management keeps them in the dark ages it was really sad.

We spent about two hours during morning report going round and round, talking about what changes needed to be made, what changes could be made and the reality of what could actually happen under the government as it is right now. I left morning report with mixed emotions. Depression, an immense admiration for the doctors who choose to stay here and fight what seems to be a losing battle, and a fierce determination to be part of the change I dream of.

At morning rounds and Brakart’s temp was still not stabilizing and though she seemed to be otherwise a little clinically better, she still wasn’t herself. I was not in the mood to play the money game. We told the mom that she needed to get parastemol, i.e Tylenol for the fever. She again couldn’t afford it and wept and said enough, that she was going to go home. I couldn’t stand it, when no one was looking I quickly just slipped her the money to buy the medication…and hell, for right or wrong, whatever else she needs I will slip her the money. Enough is enough. It was really a nothing victory in the grand scheme of things, but its one life, and that one life matters.

I spent the afternoon doing ward work then at 2:00, I left for the Ilesha which is another campus for the teaching hospital. Half of the residents stay there, and all the medical students rotate through there as well as through Ile-Ife. My cuz/sis told me that she had enjoyed her pediatric rotation much more while she was at Ilesha, so I was curious to see what the difference was. The real reason for me going (with a couple of my fellow HOs) was to attend a lecture. Of course we get there late, but the real reason we ended up missing the entire lecture was that apparently the presenter was horrible and ill prepared and the whole thing lasted about ten minutes and he was asked to present again next week. So yeah, we missed the lecture, but I still considered the trip an overall success.

The campus was certainly more asthetically pleasing than in Ife, and oh my goodness the wards were more spacious which gave the illusion of being more clean. I actually think that the wards were cleaner. The neonatal ward was certainly better than the one at Ife. Ofcourse my camera ran out of battery by the time I got inside the wards, so I only have outside pictures. Oh well…what are you going to do? I spoke with a couple of the HOs that were there, and they said that the wards are in better order, and that the experience is better for them at Ilesha because the Consultants are more readily available and have more of a presence. My Ife HOs agreed. They have more independence at Ife, but less back up from the consultants. The reason why they have less of a presence in Ife as was explained to me, was that the ones in Ife have more non ward responsibilities, teaching, private clinics, research, running departments ect. So, it seems to be a trade off. Ilesha was the very first campus, then Ife was built and became the main campus where the administration is centered. It was a pretty interesting experience, and helped shake the blues from the earlier morning. Truth be told, I am not really sure why it had that affect. I mean, Ilesha has less diagnostic tools available than Ife does, so most of the more advanced cases have to be transferred to Ife, but I don’t know. I guess, it was just the more serene and clean environment.

Ambulances! Who knew we had thoes here? This was at Ile Sha

Ambulances! Who knew we had thoes here? This was at Ile Sha

Outside of the children's ward at Ile-Sha

Outside of the children's ward at Ile-Sha

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Tuesday, Feb 17th

Busy day. Started at seven this morning with morning rounds. Its funny actually, I was late because my arrival depends on my ride, but I was only ten minutes late, yet I was the second to arrive. The next HO to arrive was twenty minutes late, the next 35 minutes late, one was on call and the last didn’t bother to show up at all. All I can say is that if Dr. Adefeinti was around, none of that would have went down.

Anyways, it was still a pretty interesting day. During rounds, I have to admit had a bit of a scare. My kid with the orbital burkits (Brakarat) is not getting any better and in fact she looks worse today. The only slightly reassuring thing is that though she is still febrile, the fever curve is decreasing, meaning that she is responding to the antibiotic we are giving her. The bad news is that it is taking so long because the mother can’t afford the abx she ought to be on, and furthermore, she is impatient and wants to leave today. She says she doesn’t have any money. That she was supposed to leave on Monday (which was true only if her fever went away and she was clinical ok), and she has just run out of money. The father of the patient one bed over, tells her to stop, and to think of her child. Then other parents come around and encourage her to keep going, they all chip in the little bit they can, and honestly, in a very positive way, shamed her into realizing that if she takes her home, she will die. It was really emotional for me and I had to keep the tears back. It was just so touching how practically all the parents in the ward came to rally around this woman, who is obviously suffering. I kept the tears back, but she couldn’t.

Later I asked why I couldn’t just give the money, and Dr. Hazzan told me that I could not. That with the way I speak Yoruba its obvious that I am not from here, and that I would just get exploited. He said that she could get the money, that she just wants to take her child home. It was scary nonetheless. All my other patients are doing well with current management, and the rest of rounds was otherwise uneventful. The spirit of camaraderie that I witnessed stayed with me all day. That’s the thing about Nigerians, yes, we may try to scam you and take your money, and we beg for everything even if we can afford to get it ourselves, but ultimately we are good people. If we see you in any distress and we can help you, we will. We are truly good people. I could give so many more examples of things I see every day, but I want to talk about my clinics today before my battery runs out.

The first clinic was sickle cell clinic and two notable things occurred. Most notable was a lady who actually meant to bring her child to ENT clinic, but they were full. Quick aside, last Thursday, I also went to endocrine clinic and I forgot to mention it in my anger. It is relevant now because today the lady’s son had cerebral palsy, and I actually saw another patient with cerebral palsy last week during endocrine clinic and taped the examination of it. I will insert it below.

Ok, now, last week as the doctor was consoling the patient, he was telling her to leave the child with a care giver and have more babies. I thought he was saying this because a care giver would be more experienced and thus could give the child better care, but the reality of what he was saying didn’t sink until today when Dr. Hazzan said the same thing. This time, I paid more attention and couldn’t believe (much like last week) what I was hearing.

Dr. Hazzan counseled this patient to leave the child with the grandmother and have other children. He said this child could do nothing for her or her husband other than create stress, take time and resources, and they would not be able to have other children. He told her that if she didn’t do as he adviced, her husband would leave her, and she would be left with a child that could do nothing for her. The grandmother would take care of this child and give him the love he needed. After hearing this conversation my shock died down because I realized ( just has this mother did) that he was absolutely right. With her SES level, that is exactly what would happen. I mean, lets be honest, that would happen in the U.S, only oddly enough I feel as though it would be more likely to happen in higher SES levels. My mind wonders back to my little Benny, whose parent split shortly after he was born. It was mom who lived in the hospital with him. But still, as true as this statement is, its not easy to hear, and for the mom who clearly loves this child, its not easy to do.

The second notable thing that occurred during this clinic was a young lady that presented with the most clear cut case of osteomyeltis I had ever seen. I have placed the picture below as well. It was just impressive. We admitted her right away and wanted to begin aggressive treatment. Guess what the limiting factor was? Money, so we most likely won’t use the antibiotics we should. The second was time. The mother wasn’t prepared to stay for an admission because she had to work. She said that she would come back and have the child admitted once she had someone who could stay with her. The problem with that is…will she actually come back? God I hope so.

Renal clinic. Let me take this moment to talk about the morning report which was about chronic kidney disease. The take away point is that here in Nigeria, the child will die. At Ile Ife teaching hospital, they don’t even perform transplants for children, and actually, they don’t perform transplants for kids in Nigeria at all. Second, though there is a dialysis unit, it is mostly for adults. Most of the patients we see, cannot afford dialysis, and if they can, they can’t afford it for very long. Here is why. From my experience here, 100% of the patients that come in with renal diseases ( CKD and Nephrotic syndrome whatever the cause is) are of extremely low SES who live in the places depicted below. These families have many children, and as was explained to me this morning, the loss of one child at the cost of feeding the rest of the children is worth it. Though they feel the pain, and the loss of their child, it is a sacrifice that they know they have to make. As I hear this, my mind goes to my renal patients, Zenab, Tope, Tussin, I pray to God that none of them progress to the point of needing dialysis, because that is their death warrant. But I already know that Tope is already there. It breaks my heart, as it will break her mother’s heart to know that her child is dying, and will die…needlessly. I think of how she is there every day since admission and has yet to leave her side. Its painful.

But, about the new patient that came…of course at the end of the day. This is my patient, so I go with another HO to Clerk this patient. Just by looking at the child, we are thinking Nephrotic syndrome, secondary to God knows what…only to listen to the history, and perform the exam. This child…this four year old boy has Congestive Heart Failure. I listened to his lungs and heart, and think I must be wrong, or that I am not hearing right. I have Dr. Hazzan listen, and his face confirmed to me that he already knew, this child, this FOUR YEAR OLD BOY is presenting with CONGESTIVE HEART FAILURE!!!!!!! Are you kidding??! With me, and my NO experience of this ever happening, ask what the most likely cause is. Dr. Hazzan first pimped me about heart sounds, then gave me slack cause they here hard to hear in this child. But he said its most likely secondary to severe VSD that was never diagnosed. This kid needed IMMEDIATE admission and treatment, but of course..this could not happen. WHY THE FUCK NOT you ask? Because the father does not think it is his role to stay with the child at the hospital. That is woman’s work he says. The grandma can’t stay cause she is working. The mother who is at home can’t stay with the child because she is a nursing mother and children that young are not allowed on the unit for infection reasons. So, they say they will come back tomorrow and with someone who can stay with the child. ARE YOU KIDDING ME!! The dad didn’t even give the excuse of saying he had to work. No, he is a man, and thus shouldn’t be the one to stay. I wanted to drag him by the ears and show him timitope’s dad, who stays there everyday with his son. Akin’s day who stays with his son. Yinka’s father who is there with his daughter. I wanted to slap him. Crap, I am about to get shut off my own computer. I wish they would hurry up and bring light!!!!

Osteomyelitis

Osteomyelitis

typical housing for 98% of the patients that can afford to come to the hosptial

typical housing for 98% of the patients that can afford to come to the hosptial

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Monday, Feb 16th

So my cuz/sis started work today so we all left the house as a big happy family, though a little later than I would have liked. I don’t like walking into morning report late, hell I don’t like being late for anything at all! But it turned out not to matter much because today is Monday, so we have ground rounds today in Children’s emergency. Talk about a painful waste of time. It was an hour and a half of listening to the residents toss blame around for the four deaths that occurred over the weekend. Three in children’s emergency and one in the neonatal ward. I couldn’t even tell you what happened because I couldn’t hear (it was done at the bed side with all the unit HOs and residents so about 20 or so people in a cramped hot room), I couldn’t see, and I was literally about to pass out. When 9:30 rolled around and they were still bickering, I just left to go to the wards and started seeing my patients before rounds started. Luckily everyone else was not far behind.

My little pneumonia girl went home on Saturday, I knew she would, she was so darn cute and pleasant, it was good to see her getting better, but still I was a little sad to see that she wasn’t there. My little Burkit’s kid was not doing well. Kept on having fever spikes over the weekend and just wasn’t herself. We are already treating her for malaria, blood samples are not back yet, we added antibiotics…she seems to be septic. I hope she can pull out of it. I am really worried about her. Her Burkits is improving so much, it would be heartbreaking for her to die of something as “silly” as infection. Sigh.

My little nephrotic syndrome girl is doing so much better. Below are before and after pictures, and she is still getting treated. We still don’t know the cause. Renal biopsies take at least 3 mos to be returned. Most likely nephrotic syndrome secondary to infection. Most common infections in order are Hep B, Malaria, and HIV. Though, sickle cell nephropathy is more common than HIV as the cause. So far she has tested negative for everything, so we still don’t know the cause. I know what you are thinking, its most likely minimal change. Not so, in this patient population, the most common primary cause of nephrotic syndrome is Membranoproliferative. Even that is less common than Malaria associated nephropathy. Right now, what we are thinking is that she had a case of subclinical malaria and her only manifestation is the nephrotic syndrome. Crazy huh? So, how are we treating her? High protein diet, low salt diet, hydration, diuretics and anti-maliral, and it all seems to be working just great.

The rest of my day included getting samples, setting line and having cute little Zenab following around wanting her picture taking taken. All in all, I must say it has been a pretty great day. Tomorrow, we have to be there an hour and a half early because we have two clinics and still have to get our ward work done. I also may have volunteered to take call…why do I like punishment?

How she was my first week of meeting her.

How she was my first week of meeting her.

After two weeks of diuretics, steriods and a high protein diet!

After two weeks of diuretics, steriods and a high protein diet!

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Sunday, Feb 15th

I have been bracing myself all week and today is here. I am going to the four hour church service. FOUR HOURS!!!

Ok, so it didn’t end up being so bad. Why? Because my family never gets anywhere ontime so we were an hour late which mean we missed Bible study, which I would actually have enjoyed attending. So we arrived for the spirituals and the message, my brother in law (ok, really cousin in law, but he has become like my big brother), who is actually the one who likes going to this four hour church service, falls asleep during the sermon. My cousin/sister and I laugh at him, then later on in the sermon..she falls asleep, he wakes up for the testimonials refreshed, she is still asleep, wakes up half an hour before the service is over, needs to take a dump but can’t do it in the church (secretly I think its because she wanted to go) and we leave. He complains about us leaving early, about how he doesn’t force her to come (which he actually does in a passive way) and now they are leaving early because of her. I bite my tongue, because umm… really, I WAS the only one who was not only awake but also attentive during the whole service. But one shared knowing look at my cuz/sis told me it didn’t need to be said.

All in all, I was only in church for two and a half hours. It wasn’t bad and I actually enjoyed myself. I love the singing, the testimonials were interesting and the serum was interesting, though hard for me to understand the whole thing. My ear is still training itself to understand the thick accent when English is spoke, plus it was so loud it was hard to make out all the words, but I am pretty sure I got the whole message.

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Saturday, Feb 14th

Let me just say that my man rocks and I don’t deserve him, well no, actually I do. Its about time I had a great man like this in my life and I hope it only gets better with us. But yeah, lets just say on a deeply personal level that doesn’t need to be discussed here, he made my day from across the world. As for my family here, we actually went out on a Friday night. It was pretty fun. Not much else to say. Club scene is jamin as one would epect from a country that has 1/5th of all the black population in the world

Biracial love

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