Hard day

Today was hard for me from a patient care standpoint. I have to keep reminding myself that I am not practicing medicine in the US right now. I am in Africa.

The day started with a death report on a patient who had been in the hospital for 5 months initially admitted with DKA, but then who was treated twice for Tuberculosis and developed drug-induced hepatitis from the therapy. Then rounds proceeded today as per usual during which time I decided that this 40 year old guy who came in with jaundice likely has pancreatic cancer. He has had a huge weight loss over the last several months and presented with painless jaundice for the last 2 weeks. On exam he has an obvious mass in his epigastrium. His chest x-ray appears to have evidence of multiple circular lesions throughout the lung fields that I first thought might have been an infectious process, but putting the whole story together, I'm fairly certain are metastatic lesions. I still don't have any labs back yet, and the abdominal ultrasound only commented on hepatic cirrhosis. My plan now is to get the labs--hopefully they will be back tomorrow, and wheel him down myself to redo an ultrasound with my own eyes. It may sound crazy, but the ultrasounds are done by techs who read them as well (not done or read by an MD), and they are of very limited diagnostic value. My attending who is an oncologist from Italy agreed with my assessment of him, but because it is a diagnosis that means he will go home to die, I need to make sure of it somehow. I cannot just order a CT scan outright because he will have to pay for it himself and there is no such thing as a tissue diagnosis here at this time because there is no pathologist. There is no CA 19-9 or the like, so I will be relying on my very limited ultrasound skills tomorrow to try and make the diagnosis.

The case the really made my day difficult was a new patient who was admitted the previous afternoon with complaints of anasarca (generalized body swelling). He is a 15 year old previously healthy boy from a remote are in Eritrea and because of this he does not speak Tigrinya, so the usual staff cannot communicate well with him or his family. Just to speak to him today, we had to find another patient's family member who spoke the same language in order to speak with him. The short of the story is that he came in with 3 weeks of anasarca, hematuria (bloody urine), and pulmonary edema (fluid on the lungs). We transferred him to the ICU this morning because when I came in, I checked his pulse ox and found it to be between 20-40%. He was still awake and breathing and the machine was working properly. In the ICU, he had an ABG done which showed he was acidotic and hyperkalmic--both being 7.2 (the first time I've had that happen). He apparently only urinated once overnight, and is clearly in renal failure. I treated what I could medically--treating his hyperkalemia and giving him some lassie to see if he would urinate with that, but the bottom line is that he needed to be dialyzed. The intern in the ICU called the physician in charge of dialysis, but he refused to dialyze without the approval of the ICU attending. So, she called the ICU attending who decided that the patient should not be dialyzed based on the fact that he thinks that the patient's renal failure is chronic. At the time she spoke to the attending, the patient's labs had come back and revealed a BUN in the 200s, Creatinine of 9.9, and a bicarb of 11. His CBC revealed a normocytic anemia with a hemoglobin level of 4. Based on this, he refused to allow the patient to be dialyzed because there is only one dialysis machine at the hospital and they cannot dialyze people who have chronic renal failure due to lack of resources. I understand obviously that because of the severely limited resources here there cannot be chronic dialysis. It is just so difficult to see this young boy and know that there is almost nothing I can do for him, but in the US it would be so easy to treat him appropriately. I did what I could medically for him, but the thing that is hard to accept is that he very well will likely be gone in the morning.

His case is one that more than any other case I have seen since I have been here has made me thankful for all of the medical resources we have in the US.