RAKCOK

2 April 2021  I was on call and a young girl returned.  I am uncertain as to some intermediary steps since the last time I saw her.  She has Rheumatic carditis and TB pericarditis.  She had obviously been out of her meds for some time, for she returned in distress and her liver was significantly below her umbilicus.  The father had an old record that said something about malaria, but none of the really pertinent issues in this girl.  He lost the other record.  I admitted her and put her back on the critical medications and she responded well.  We got a CXR that showed a huge heart in the shape of a water bottle (the sack kind).  This is such a sweet girl, but the father really worries me because he seems to understand nothing, but he thinks he does.

4 April 2021  We have had 2 men come in almost dead because of their stupidity.  Both had HIV and TB, though in the second, the TB was suspected, but not confirmed before he escaped.  The first one had just quit taking his meds.  In both cases, women family members were hovering around them, babying them.  I took the opposite approach.  I told them both that they were too stupid to live and we would dig a hole for them out back.  I believe they have to be confronted.  If the women make them feel too pampered, they will do the same thing when they start feeling better, but they are playing with fire.  If they will just get mad at me and determine to prove me wrong, they just might do that.

5 April 2021  A three yo girl was brought in with high fever.  In our new arrangements, we typically see the emergency patients outside and it was dusk, so my perception of the child was a bit blurry, but she looked like a child with Down Syndrome.  Though she did not have the wide space between the first and second toes, she did have the stubby finger and the flat bridge of the nose as well as the typical eyes.  I asked whether or not the child was speaking; the mother answered in the negative.  The child had a big spleen, so I was fairly certain she had malaria and treated her as such.

Recently I taught the green students about chronic diseases.  Down Syndrome is not really a disease, but there are many medical problems they face.  Acute diseases often cause perturbations in patients with chronic illnesses, but it is the chronic issues that are the more challenging.  I asked to have this child follow-up with me, but that probably will not happen.  I would like to guide the mother in what she can expect and help where it is needed.  Down children often do not live long in Sudan.

7 April 2021  I was called to get meds for a man admitted in the morning.  He was in the hospital recently and has HIV and TB and was referred to Mvolo hospital for further management, but he did not go.  He came in with itching.  It appears that the admitting doctor did not bother to read the record, but in fact the man was doing well except that he had scabies he contracted a week earlier.  He had never gone back to Mvolo because of insecurity, but he had been taking his medications.  He still had diminished breath sounds in the LLL, but he was doing well overall.  I gave him medications for the scabies and sent him out.  He had a place to stay in Mapuordit, and I do not want scabies coming into our hospital if I can prevent it.

9 April 2021  When on call, a young man was carried into the room by his parents.  It is my conviction that Dinka males love to overreact and be the center of attention by their medical complaints, but this was a 9 yo, and he looked wasted.  He had been seen in our hospital earlier and correctly diagnosed as arthritis, though the clinician failed to go deeper.  He was ineffectively treated and the parents sought aid in the local doctor (the witch doctor) who cut into his ankle and set up a cellulitis to confuse the issue.  Initially I thought this was osteomyelitis because of the drainage from the ankles, but then I noted his L knee.  Though he did not have a murmur, I was pretty sure this was Rheumatic fever.  His ASO titer was > 400, confirming (as far as we can) that this is Rheumatic arthritis.  The cellulitis is responding well to Cloxacillin.  Both his involved joints are better on aspirin and Prednisone.  I am hoping this one “kisses the heart and bites the joints.”  The joints will eventually recover.

10 April 2021  Though there are many things about the Dinkas that discourage me, there are also traits, particularly among the women, that draw my admiration.  One is their patience.  I was struck again by their patient acceptance of what would make me furious.  I rise disgustingly early, as I have done for years.  After a devotion, I walk to the hospital campus where I get on the internet.  As I walked up this morning at about 5 AM, I saw two young women sitting on the walkway, patiently awaiting for the gate to the hospital to be opened.  I came and gave my usual signal (I drop the lock 3 times and it clangs out).  The watchman unlocked the gate and let me in, and also let the women out.  Had I not been there, it would have been at least another hour before the gate would have been unlocked, but the women did not expect better treatment.  They were pleased to get out, but they would have raised no protest if they had to wait another hour or so.

13 April 2021  A woman who returned to us almost dead from Yirol was stable and ready to go home.  She has CCF (congested cardiac failure), atrial fibrillation, and TB pericarditis, and she has recurrent pleural effusion on the R.  She still had some fluid on the R and wanted to get it removed before traveling back to Yirol.  I saw no reason to admit her for that procedure, but we brought her to the ward to do the procedure.  She had her meds and was ready to travel as soon as the drainage ended.  When I came in, there was another patient I had not previously seen.  It was a little boy with CCF from Rheumatic carditis.  He had a to-fro murmur at the apex, suggesting mitral insufficiency and stenosis.  His liver was about 7 cm.  It was interesting to me to have two patients next to each other on the ward with Rheumatic fever—one with joint involvement and one with carditis.

14 April 2021  I was called to the theatre.  There were conjoined twins.  They were joined at the pelvis.  Indeed, it might be interesting to see which organs were shared between the two.  Amazingly, they were delivered through a low transverse cut in a C-section.  As I looked at these two, I was faced with my own inconsistency.  Did I consider the twins alive?  Of course I did.  Did I consider their lives precious?  I did, but the reality of South Sudan came into play.  To try to spare these children’s lives would cost far more than our annual budget.  I am not against such heroic interventions in the first world, but the reality is that these children will die, condemned by the fact that they were born with great needs in South Sudan.

15 April 2021  A man feel from a tree was on surgical ward, but discharged the morning he came to me with pain and bloody urine.  His ultrasound showed free fluid in the abdomen, so I made the diagnosis of ruptured viscus (internal organ) and re-admitted him to surgical ward.  I instructed the ward to tell the surgeon.  I saw him later and told him about the patient.  I assumed he would go that evening or the next morning.  However, I was on call the next day and found the patient on surgical ward, in more distress and vomiting.  His abdomen was substantially more distended.  I again told the surgeon about the patient.  He was operated upon, but the diagnosis of “spontaneous peritonitis” was made.  I am skeptical.  The patient died that night.

17 April 2021  A 26 yo man with HIV and TB was brought to me.  He was in moderate distress.  He had crackles in the bases, far more than I had described when he was started on the TB meds.  I sent him for a Covid-19 test, and it was (+).  His oxygen saturations were 94%.  I continued him on the same TB meds, but I started him on oxygen and Dexamethasone.  The next day, he was significantly more comfortable.  Within three days, we were able to switch to oral Prednisone.

He is probably our 4th or 5th patient with the deadly triumvirate of HIV, TB, and Covid-19.  Surprisingly, all of them have done well.  Our numbers of Covid patients is still fairly low, but given the realities in the US, we have probably had a comparatively high number with the triumvirate.

19 April 2021  I was making rounds when I noticed a lovely pair of breast bared for all to see.  A lot of women spend significant time “topless,” but most of them are elderly women and there is no thought in their minds of attracting attention  I was surprised when we got to the bedside and I realized that the breasts belonged to a young man (early twenties) who presented with combative behavior and convulsions.  When I discussed this with the family, they informed us the gynecomastia (women’s breasts on a man) started about a year ago and the convulsions started about 3 months ago.  I think this is a prolactinoma, a usually benign tumor that can be “malignant by position” because of the pressure it can cause with the expanding pituitary.  We are in a kind of bind.  The family are Jur, a tribe from south of us who are typically hard-working and honest, but dirt poor.  They cannot really travel to Juba.  We have had some Bromocryptine in the past, but we are currently out, though we hope to get some in two months from now.  We’ll have to treat the symptoms until the Bromocryptine arrives.

21 April 2021  My calls seem to be busier than others, though probably everyone thinks that is true.  I had just finished my exercises when I was called to see a patient.  When I got to the gate, there was another book.  By the time I reached the ward, there were eight waiting to see me.  Five of them needed to go to Medical Ward, but the MoH in their amazing foresight had closed the medical ward converted it to a Covid ward, though we have only been averaging about 2 patients with coronavirus.  There was no place to put the patients that needed to come in, and several did, so I overrode the MoH and put our the patients on the Covid ward.  I thought one patient had it (she did), but I was fairly sure the others did not.  Both the patients on Covid ward were more than a week since diagnosis and therefore no longer at risk of transmitting disease according to both Lancet and NEJM.  We are going to set up a couple of rooms in the isolation area for Covid and reopen the Medical Ward.  It’s nice when you are pushed to do what you really want to do anyway.

22 April 2021  A 9 yo girl came to me for splenomegaly.  She did have a big spleen, crossing the midline, but what struck me on her exam was how active her precordium was.  She was a bit anemic, but her heart was racing.  There was no murmur or gallop, but her heart was not right.  I got an ASO as well as a CBC.  Treating the splenomegaly with antimalarial drugs and prednisone has reduced the size and improved the anemia.  The ASO was elevated, so I put her on aspirin (she was already on Amoxicillin).  Intangibles are always dangerous in medicine, but I was impressed how much less active her precordium was on aspirin.  I think she does have Rheumatic fever with heart involvement, but not so severe to result in valvular insufficiency or stenosis.  I think we will treat her for at least two years until we are clear as to whether or not her heart is involved.

24 April 2021  One of the frustrations in Mapuordit is the spotty lab support.  We have had three patients for whom I suspected Cryptococcal meningitis.  Cryptococcus is a fungus that essentially only invades the meninges in patients with severe immuno-suppression, and virtually only in HIV, but we have a lot of that here.  The symptoms are quite different from usual meningitis and the treatment is long and involved, but the diagnosis should be simple.  A drop of India ink is added to CSF (cerebrospinal fluid) and clear spots show up, reflecting the coat of the fungus.  But we have no India ink, so we have to guess about a treatment that lasts for 3 months.  We do not have Amphotericin, the treatment of choice, but we do have IV Fluconazole.  One patient died when we switched her to oral drugs after 1 week.  Another patient awoke from coma and eventually went home.  He received 2 weeks of IV Fluconazole and will receive another 10 weeks at home.  A third patient is coming out of a coma and starting to take some fluids orally.  We are hopeful.

26 April 2021  O horrors!  South Sudan seems to be adhering to the path of her own destruction.  There are a number of great personalities in the Catholic Church’s mission to Sudan/South Sudan.  One that I never met was Bishop Caesar Mazzolari.  He was the bishop of DOR, the diocese of Rumbek, for years during Anyanya, the Sudanese civil war.  He died a week after the independence of South Sudan.  That was almost a decade ago.  There have been some men acting in his place, but no official replacement until recently when Father Christian was appointed to that position, but he had not even been officially installed when thugs broke into his compound, shot off the lock to his door, shot him twice in the legs and struck him in the head with butt of the gun.  This was obviously a conspiracy and almost as clearly involved the guards who were quite tardy in their response.

But this horrible episode also points to why I work in a Catholic hospital.  Sorry, my fellow Protestants, but if this had occurred to a Protestant mission, everyone would have been evacuated to safety, but Bishop Christian is already making plans for his return as he recovers in Nairobi.  Our hospital continues as before.  My hat is off to you, my Catholic brothers.

27 April 2021  I was lecturing the Green students on the GI tract and we were discussing Hepatitis A, B, and C.  One of the students asked me if there was any treatment for Hep C.  “It depends on where you live.”  That is a sad, but true statement.  How many times have I told families that their child had ALL (acute lymphocytic leukemia) and was destined to die, when I knew that in the US the same child had a > 95% chance of long term cure.  We can treat Hep B disease that is causing problems with some drugs originally was for HIV, but we have nothing for Hep C.  We have a man on the ward with ascites and edema that appears to be from liver dysfunction secondary to Hep C.  Recently he started vomiting blood.  He probably has esophageal varices and will probably die soon.  I remember hearing frequent advertisements about Hep C treatments in the US, but I doubt they will make it here in my life time.

28 April 2021  Pneumococcal pneumonia is what we think about when we say pneumonia.  The patient comes in with high fever, chest pain, often vomiting.  The patient’s WBC is almost always high.  We have had at least two patients recently who came in with typical findings of Pneumococcal pneumonia and responded well as would be expected to IV X-pen.  They gave a history of a recent worsening, but also previous chest problems with fever and cough.  They have subsequently been found to have TB.  TB can cause high fevers, but the response to X-pen makes it unlikely TB was the only organism.  In both those cases, there seemed to be Pneumococcal pneumonia superimposed on TB.

29 April 2021  A young girl was admitted to us with abdominal pain, but when I listened to her chest, she had a clear pericardial rub and possibly a MR murmur.  Her liver was 5 cm below the ribs.  When I did the ultrasound, she had a huge pericardial effusion with some fibrin strands.  She almost undoubtedly has TB pericarditis.  I am also wondering about Rheumatic carditis.

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