RAKCOK

1 May 2021  “Say it ain’t so, Joe!”  An 8 yo girl was admitted with diarrhea, but as I examined her, I was convinced she had malaria (large spleen), pericarditis (cardiac rub), probable Rheumatic carditis, and clearly heart failure.  Her ultrasound showed by far the largest pericardial effusion I had seen with strands of fibrin.  Her ASO was 800, confirming Rheumatic carditis.  I started her on Enalapril, diuretics, and the following day started RHZE and Prednisone.  When we got back the ASO, I was going to start her on aspirin, but she was gone.  No one seemed to know anything.

She is a horribly sick child, but she was not wasted and there was every reason to expect her to do well, but she may have something worse than any of the others—an arrogant, stupid father.  I cannot count the number of children or mothers who have died because some dumba__ father exerted his authority and took her to the local doctor, or whatever other reason he may have had to take her—there may have a real emergency like someone stealing one of his cows.  Worse than the frustration of knowing what a patient needs and not having it available is knowing we could help this child and being prevented by a stupid father (it is almost never the mother).

2 May 2021  Makuac is a 24 yo admitted with Covid-19.  He was not cooperative initially, but over time I realized he had CCF (congestive cardiac failure), TB adenitis and probably in the lungs, and I suspected Rheumatic carditis because he had a high pitched murmur at the cardiac apex.  He had accentuated breath sounds in the R mid back, but diminished sounds lower.  His liver was 15 cm below the ribs.  My desires to get a CXR and ultrasound were frustrated by his Covid, but today I finally took him and did the ultrasound.  He had a huge pleural effusion, and I had not percussed him.  When I did, it was so obvious.  I am the one complaining to the CO’s and nurses about not doing an adequate clinical exam, and I was caught with my hands in the cookie jar.  We drained out over 2 liters from his pleura and he is much more comfortable.  He also does have a thicken Mitral valve and his ASO titer is 400.

3 May 2021  Majur is a 60 yo male with paralysis of the legs and no control of his bladder function.  I suspected TB vertebritis, and we started him on RHZE and steroids.  Over the next several weeks, he started having some pain in the legs, which I hope means the spine is not dead.  His wife has been doing virtually all the care, which is the way it happens in Mapuordit.  Yesterday I realized he has developed a large decubitis ulcer on his R hip and some denuding around the anus.  I talked at length about trying to get a “donut” to help keep those tissues off the bed, and putting cotton (we do not have enough gauze) between the folds of the buttocks with some anti-fungal cream, but none of that was done today.  Now it is a race.  Will he regain function in the legs before he dies of sepsis from his bedsores?  I could scream.

4 May 2021  IRIS—immune reconstitution inflammatory syndrome.  HIV works by attacking the CD4 cells, the most critical cells in the immune response.  When the CD4 cells get low enough, the body cannot protect itself against invading pathogens, even weak ones that most people can handle.  That is AIDS.  When we start ART—anti-retroviral therapy—we start reconstituting the immune response.  If TB or some other opportunistic organism is in the lungs or brain, the inflammatory response can become too vigorous and cause problems—edema.  In the lungs, there is difficulty breathing—worse than it was.  In the brain, swelling results in cerebral edema.  Both can be fatal.  When I was in Mapuordit before, we were careful about IRIS.  We have gotten slacker, and we have lost a couple of patients, though in both cases, we started RHZE for 2 weeks before starting IC (our current triple drug ART).  One case, we readmitted him to restart the ART and he seemed to do well.  He started having some mild problems, so I started Prednisone and he seemed better and went home, but came in a week later and died.  Usually this is just in patients who have never been on the treatment, but I have started being cautious about patients who were taking and have stayed treatment for a long time.  We have a young woman on the ward who was confused when she went to Juba Teaching Hospital and quit taking her meds 1.5 years ago.  She came in with TB and severe cachexia (wasting—her mid-upper arm circumference would be normal for a 2 year old).  Her TB was in the RUL only (or mainly) and she responded well to the RHZE for 2 weeks, but after 2 days on IC, she was struggling.  I started Prednisone, but she is not better, so I stopped the IC.  Maybe in a month we will try again.

5 May 2021  My stepmother has a bulletin board item requesting, “Lord, put your arm around my shoulders and your hand over my mouth.”  I needed that today.  I was making rounds, including maternity, and one patient was admitted with “Placenta previa.”  She bled the day before.  I told the nurse, “We can’t just admit the patient with that diagnosis.  We need to do an ultrasound to confirm or deny and make plans accordingly.”  We did the ultrasound and the mother has a complete placenta previa (the placenta is implanted over the cervix, so if the cervix opens, the mother will bleed, potentially to death).  The baby was term and alive.  Every sign said this patient needs a C-section as soon as possible.  I sent word to our surgeon, who said the child was 34 weeks and he was giving Dexamethasone, and he was waiting for the mother to go into labor.  I assured him that by ultrasound criteria as well as clinical, the child was term.  Prematurity was not a concern, but exsanguination was, but he told me to mind my own business, so I said some regrettable things.

6 May 2021 We had an unfortunate slice of Americana today.  Gramedik is a Darfurian man who came to us a week earlier.  He had a pleural effusion that we drained and he was discharged on TB meds, but he had not left Mapuordit.  He collapsed today and was brought back to the ward.  He had clammy sweat and complained of epigastric pain.  His BP was slightly elevated (156/84) and he had some reaccumulation of pleural fluid, so I did another thoracentesis.  Later, he felt better and went to the latrine and died suddenly.  I think he had a myocardial infarction (MI) and cardiac dysrhythmia.  We have no possibility of checking cardiac enzyme or taking normal steps of stabilizing after an MI, but it is discouraging to lose someone, especially someone who was so reasonable and grateful for the help he had received.
7 May 2021  A young man approached me two days ago with pain in his R knee from a motorcycle accident.  He said he had “dislocated” his knee.  I felt the knee and it was strange, but it did not feel as though the patella (knee cap) had been displaced, so I ordered an x-ray.  He had a fracture in the lower femur through the condyles (the two heads of the lower end of the femur).  I had never seen such a fracture.  I admitted him to surgery, but I think this will require intra-operative management.  I expect Derek to refer him.

8 May 2021  After a fairly busy call, I got a most unusual call.  There was a young woman going through the market who was “struck by lightening.”  I have never had a patient struck by lightening, nor have I read about it in medical texts, but I have read James Herriot and his struggles with cattle determining if a dead cow was struck.  The history was that this girl was struck, fell, and then was hysterical.  She walked to the hospital with the help of her parents, but upon reaching the hospital, she became unresponsive and started an unusual respiration.  She took deep, full breaths, then held her breath as long as she could, then repeated the process.  Her BP was 141/84 and pulse was 100/min.  The good news to me was there was no irregularity of her heart.  She was mildly tachycardic, but no irregularity.  Her eyelids revealed movement behind, but when I opened her lids, her eyes were rolled back.

I am convinced this is hysteria, which I feel is fairly appropriate after lightening strike.  Even though there was no cutaneous evidence of a strike (that was what James looked for in the cattle), I am not convinced the whole thing was fabricated.  I gave her Promethazine 50 mg IV.  That should really put her to sleep, but Promethazine does not suppress respirations, so I am hopeful she will go into a nice normal sleep and wake up fully recovered.

9 May 2021  It had not been a stellar week.  My conflicts with our surgeon adumbrated everything.  The day had been unusually busy, and I was being called in again when I looked to the east and saw a complete double rainbow.  The lower bow was so distinct.  I could not help but remember the origin of the rainbow and its significance.  It was such a quiet, kind reassurance.  I had to laugh at myself as I trekked into the hospital.

10 May 2021  I like playing cutting up with children.  I think I always have, and unless some maturity forces its way into my being against my will, I think I always will.  One of the cute little girls hanging around surgery ward usually cut up with me, but she ran away, holding her neck.  I was able to get her and felt her mandibular nodes, which were large and tender.  Her pharynx was red.  She had Strept pharyngitis.  Though she had been around the hospital for weeks, she did not even have a book (our medical records).  I gave her some Amoxicillin and Panadol, and she responded.  What surprised me, though, was how much her willingness to interact and play increased after that episode.

 

11 May 2021  Bronchiectasis is a condition where the bronchi are badly damaged.  The airways lose their integrity and can no longer clear the mucous that accumulates.  Typically the airways continue with chronic infections, but periodically the infection gets much worse and the patient has difficulty breathing.  It is a typical consequence of TB, particularly if there was a long delay in making the diagnosis.  One of the difficulties here is distinguishes between bronchiectasis and relapse of TB.  Mading was diagnosed with TB in 2014 and treated.  In 2019, he was diagnosed with relapse of TB and again received TB treatment.  When he came to me he sounded horrible.  I got a CXR that showed diffuse lung damage, much worse on the right.  And his ESR (sed rate) was 135.  I was ready to diagnosis another relapse, but 3 days after starting Salbutamol and Amoxicillin and he greatly improved.  Clearly he has bronchiectasis, a condition that cannot be cured, but that is much easier to treat than relapsed TB.

12 May 2021  A middle aged woman was admitted with schizophrenia.  I am not a psychiatrist, but I tend to keep the diagnosis of schizophrenia for those who develop psychosis in their second or third decade of life.  This lady’s problems came on much later.  As I looked into her old record, I found that we saw this same woman in Oct and diagnosed her with Bipolar disease and she had responded well to Amitriptyline and was supposed to come back in November.  So I fussed at her sons.  First of all, any patient with psychiatric problems needs others to help care for her.  Second, women have little opportunity to do anything without the men’s assistance.  I could tell I infuriated her sons, but that is of little consequence.  If they do not help their mother, there is little likelihood she can do well.

13 May 2021  A small woman was admitted with some bizarre diagnosis that did not fit her clinical presentation at all.  She had crackles in the chest that suggested TB, but she also had a huge liver, but she did not have a cardiac murmur or any other signs of cardiac failure.  Moreover, she had a hard, tender area at the lateral, inferior pole.  I did an ultrasound that showed the liver somewhat pale, but there was nothing else.  Sometimes liver cancer just has a large, amorphous “empty” area (no vessels), and I thought she might have that, but it was not as clear as usual.  She also had a CXR that showed clear Pulm TB, and she was smear (+), so she was started on RHZE.  She has done well, but the most remarkable response has been in the liver.  About a week into therapy—she has to stay 10 days because she is sputum (+)—the liver is half the size it was.  I am convinced she had TB infiltration of the liver.  Perhaps it came from the lungs, for they are the more damaged, but the liver may be infected from Bovine TB, as there is no screening of the local cattle.

14 May 2021  A 2 yo boy was brought in with a deep laceration to the 4th finger, right hand.  The digit was 2/3’s amputated.  However, I sutured it back into place.  When I saw the finger tip today, it looked good.  There is still a possibility the distal digit may die, but I think it will survive.  Certainly it is worth the risk, for the worst outcome will be that the child needs amputation of the distal finger at a later date.

15 May 2021  Speaking of visceral TB (see entry 13 May), a woman had been coming for some time with TSS (tropical splenomegaly syndrome).  The spleen was not terribly big, but it would not shrink with treatment and was painful, so I did an ultrasound.  Her ESR was 150.  She had a “starry night” pattern on the ultrasound, one of the recognized patterns of TB of the spleen.  After 2 days on RHZE, the spleen was no longer palpable.  I am fairly certain that this is TB.

18 May 2021  A woman came to me because she was not feeling fetal movement.  She said she was 4 months pregnant, and you should not feel fetal movement that early, but I did the ultrasound anyway.  There was an unrecognizable mass in the uterus, though with fluid above and below it.  The mass did not reflect the sound ways like a fetus, even a dead one.  When I did the pelvic exam, the cervix was open and I felt something like a twig.  I thought at first that someone had tried to induce an abortion, but when I pulled it out, it was a tiny bone, probably a humerus, though about the size of a quail or dove wing.  She had developed a rash on her vulva and torso.  I am sure the child had died and had advanced maceration so that there was not any skin or even muscle remaining, and I think she was becoming septic, though her blood pressure was stable.  I admitted her to maternity.  She will need a D&C, but preferably after some IV antibiotics.

20 May 2021  This has been a strange year regarding the rains, and therefore, the malaria.  Typically, we quit having rains in September and by December we have the tailing off of malaria.  However, this year we had rains until mid-December and the malaria season never really ended.  The other trend I have noticed over the years is the tail-end cases of malaria are different, and many times more severe.  We have two women on the ward who fit the tail end description.  Both have been treated as cerebral malaria, and both are finally recovering.  Neither was RDT (+), but both had big spleens.  Both had convulsions early, but I did not think either had Meningococcal meningitis.  One is HIV (+), but I do not think she has Cryptococcal meningitis.  Both of them required multiple days of IV Quinine, but I remain hopeful both will survive.

21 May 2021  I hate death.  Two women died this week, both hard to take for different reasons.  One was an older woman.  She was wasted and weak.  In my first exam, I knew she had TB, and her sputum was positive.  We started the RHZE, but she died that night.  It has long been my observation that when starting the appropriate medications, the patient often gets sicker before improving.  She did not have that cushion.  There has also been a lot of rain lately, adding some cold stress to her challenges, and it was just too much.  The other was a young woman with HIV who had been non-compliant for 1.5 years (its sounds to me that she got some poor medical advice in Juba, but that may not be true).  She seemed to be improving, so after 2 weeks on RHZE I started her on 1C, the triple drug preparation we are using for HIV.  Two days later she was sicker, so I stopped the IC and started her on Prednisone, but she kept getting worse, though her exam suggested that her TB was getting worse.  Twice we looked for evidence of drug resistant TB, but we never found it.

A few months ago, I would have started her on Streptomycin, but the MoH has stopped its use in South Sudan (??).  She stayed on steroids.  She also had some diarrhea (as did her neighbors), but I cannot help but think, if our hands had not been tied, she might have made it.

23 May 2021  A man was admitted to our hospital with some asthma findings, but also some issues that sounded like TB.  We were in the midst of working him up when he had to leave.  He was the target of revenge.  He might be killed if he stayed.  Revenge killings are common in South Sudan, but they are also strange.  Usually the target is not the one who has caused the trouble.  When something happens to one member of a clan or family, anyone in the offending family can be a target, and most of the time they target the most highly educated in the family.  He thought if he hid for a week he would be safe, so  we have discharged him for a week.

25 May 2021  A man with chronic asthma came in distress, but he made me mad.  I find myself in an ironic position in Mapuordit.  For years I have been the one pushing inhalers, for they are much better at delivering medication to the airways than nebulizers.  I still use them when someone is admitted in distress, but I do not like to prescribe them for home use because they are usually abused despite showing them the correct manner of use.  Also because inhaled short-acting beta agonists are associated with increased asthma death.  I am still convinced that inhaled steroids, particularly combined with long-acting beta agonists, are the best medications, but they are not available to me.  This man pushed me to prescribe a Salbutamol inhaler, but then a week later he came to me in distress with an empty inhaler, so I was furious with him.

The next day, he was complaining of back pain, so I felt down his spine.  He had a gibbous—that is there was a step off of the spinal processes.  He attributed it to an old injury, and it may have been because the sed rate was only 8, but I am going to treat him for TB of the spine.  I may be wrong, but ignoring TB of the spine may result in paralysis.

27 May 2021  A small child was admitted to our ward.  When I was in Gidel, we took patients up to 14 on Pediatrics, but here the cut-off is five (or at least it seems that way).  This child was reportedly 13, though I question that age.  There were two younger children, one nursing and the other around 5, so I think this child is around 8.  Her weight was 14 kg (less than my 2.5 yo grandson) and her MUAC (mid-upper arm circumference) was 10.4, low for a 6 month old.  She has HIV, though her mother does not, so it is probable she got infected by using contaminated needles, probably getting a Penicillin or Ceftriaxone injection.  She has TB.  I am hoping we are early enough to intervene successfully, but I have my doubts.

29 May 2021  Another small child, probably around 9 years, was admitted.  He had a pericardial effusion and large liver and spleen.  We have started some TB therapy and he looks better.  I also started him on steroids.  He was not complaining of chest pain, and studies say steroids make no difference in the outcome, but they do help during the therapy, and we need every advantage for him.

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