Major Rounds Cancelled- Time for Work Rounds

8/2/12

Posted by Amanda Thornton, MD (a third year Internal Medicine resident from Kaiser Permanente, Oakland while on a global health elective in Lusaka, Zambia with University Teaching Hospital).

The internal medicine department head has been called away briefly to help organize for the the Ebola outbreak in Uganda- and the medical students still have their exams today. So major rounds were cancelled, and I went on work rounds with the interns.

As a resident, you always have to deal with work-arounds. You know, the shortest distance between point A and point B is a straight line, but somehow you are thwarted and end up doing spirals before you can make it to point B. These aren’t even worth telling your attending about- it’s just the things you do to work with what you have.

And what we have here is completely different than what I’m used to.

There haven’t been test strips for the glucometers for the past 2 days. We’re waiting for a shipment. In the meantime, the poorly controlled diabetic in the low-cost ward for whom we’ve been adjusting her insulin for the past two days wakes up with a head ache and feeling shaky. Her blood sugar hasn’t been tested in the past two days since we increased her insulin (for blood sugars in the 300s). Do we want to tell her to eat to insure that her symptoms aren’t hypoglycemia and hold her insulin until lunch? The intern asks how frequently she’s urinating overnight- 5 times- then starts her on intravenous fluids and increases her insulin again.

Then, another patient, this time a 17 year old male, presented with a wasting disease which the team had initially assumed was new onset RVD (the shorthand for retroviral disease or AIDS that we use in the chart to prevent immediate identification by nursing and nosy family members) but was diagnosed with adult protein-calorie malnutrition. I had come in early to pre-round and talked to him about what foods he was and should be eating, only to discover that he had only been eating bread. I suggested chicken or eggs. He said his family had them, but he didn’t eat them. I suggested beef, beans and nuts- and he shrugged.

Frustrated, as he has the puffy cheeks, and cadaverous frame I’ve only seen on female anorexics in the U.S., I waited until we came around with a medical student who spoke the teen’s tribal language. The resident questioned his sister, who had come in for the formal rounds. Apparently when he was younger, he had a few “fits.” They had taken him to a traditional healer who had told him to avoid eggs and chickens- which besides maize were the family’s major source of protein. The fits had never returned, so this was seen as a sensible solution by all involved. When the problem was explained and the importance of alternative protein sources emphasized, the patient agreed to peanut butter and multivitamins and was discharged that day.

Another patient, a pretty unnaturally pale-brown skinned woman in her late 30s, who I first met last week on the last major rounds, has been diagnosed with CLL  for more than a week. Her family had been raising money for the chemotherapy- but the pharmacy only had half of the necessary drugs, no matter the money available, and the rest were only orderable from South Africa and have not arrived. In the meantime, her lymph node biopsy site still had stitches in place. When I saw her in the morning, she told me that they were supposed to have taken out the stitches 6 days ago, but no one has come by. I had watched the intern make the surgical consult for suture removal during the last rounds- but I have also never seen a surgeon in the internal medicine low-cost wards, likely because they are simply overloaded with surgeries.

I feel entirely comfortable with both my simple suturing and suture removal skills, so I asked the nursing for a suture removal kit- only to discover there were none, but that they might be able to get a surgical blade from surgery. They dispatched one of their precious few nurses to attempt to get one, and I tried to loosen the stitches, which were now all infected. One of the medical students said she knew where to get surgical blades, and arrived back with one precious sterile blade (handle-less). Using gloved fingers and the tiny blade, I took out the stitches. Firm pressure around the site yielded pus, which I removed as much as possible… and told the family to wash the wound in a diluted hydrogen peroxide solution which I had learned was cheap and easily available from the pharmacy.

Following up on the wound for the next 2 days, I was pleased to discover her face healing well- and her chemotherapy will progress without delay with the available medications. It’s easy to get discouraged in the face of the number of deaths of young patients with treatable and preventable diseases from the filter clinic, but from following the lead of the attendings and the residents, I’m learning a lot about operating with the minimal amount of waste, allocation of resource, and triumphing in the successes of every patient discharged healthier than when they came in.

And I bought a stash of 50 glucose test strips from the pharmacy after one of our adult male diabetics stridently refused to have his blood drawn for a serum glucose measurement- $26 is a relatively small cost if it means we can properly titrate insulin and get someone out of the hospital a few days sooner. Between that, my personal blood pressure cuff, forehead thermometer, pulse-oximeter, and stash of non-latex purple gloves, everyone is beginning to get used to my ever-present bag and my bulging white coat pockets (containing my notes and references to look up relatively rarely seen conditions and convert nearly every medication and lab test they talk about to an American equivalence that I know how to interpret).