More hospital cases from Don

What do you do when somebody doesn't have a measurable blood pressure? That's kind of a problem. A 26 year old woman came into the hospital in the midst of having a miscarriage. That's the first problem. She does have a heart beat, but the blood pressure is so low that it can't be measured. This is considered to be a bad situation. She also had excess fluid in her body, heart failure. Her heart was huge on chest X-ray. The platelet count was low so we initially were concerned that she had HELLP syndrome.  Yes, that is really the name of that syndrome. The platelet count came up quickly so either it reversed quickly or it was a lab error. We don't have any of the intensive monitoring equipment to duplicate monitoring that happens in the US.  We also don't have blood pressure or heart contraction stimulating kinds of medications. We used very small doses of a diuretic to increase urine production.  We can't help the blood pressure, but can carefully reduce the excess water situation. By the next day she is feeling somewhat better and I am barely able to find a blood pressure..  Her echocardiogram showed massive chamber enlargement and mitral valve stenosis and regurgitation; the valve is too tight and leaking at the same time most likely due to rheumatic heart disease which has become fairly rare in the industrialized world, but is still common in the developing world. She survived and we are following her as an outpatient to continue to get the rest of the fluid off and adjust her heart failure medications plus she will see the gynecologist to manage contraception.  She will not likely survive another pregnancy. It pays to be young if you get sick.

Two weeks earlier, another no blood pressure and in heart failure ICU patient came in and we also couldn't hear bowel sounds. You hear your stomach growl every once in a while.  Your doctor can hear bowel sounds ALL the time. Normal hemoglobin is higher than 12 and we think about transfusion at 7.  Hers was 2.8 probably from a bowel perforation and internal bleeding.  We gave her a transfusion which can help the anemia and blood pressure, but contributes more to her heart failure so we also gave her the diuretic.  The next day we also found pneumonia. She won't survive anesthesia or surgery so we treated her multiple problems medically and she did seem to perk up then suddenly died two days later. I don't think she could have survived in a US ICU either.  When you get so many strikes against you, additional organ systems start to fail and survival becomes impossible. Failure is more likely when practicing medicine in a "resource poor" setting. My digital medical textbook recognizes that 80% of the world's population live in resource poor countries and gives different treatment recommendations for resource poor settings.

We do get some straight forward and almost always successfully treated kinds of problems.  High blood pressure because of stopping the pills, new diagnosis of diabetes, malaria. Globally, malaria is the #2 cause of human death behind humans killing other humans. I have not had a patient die from malaria while I have been out here. It is particularly deadly for children and pregnant women so the OB and pediatrics wards have the high risk patients.

We just sent home a patient with a disease I have never seen before.  After seeing my photos, you will be more experienced than 99.99% of doctors in the US. A Maasai women came to the hospital with the right side of her face extremely swollen.  I had to pry her eyelids apart to get a peek at that eye. She also had two funny looking skin ulcers on the back of her neck.  I didn't have a clue as to what those things were.  The intern in casualty (urgent care) suggested a diagnosis. I looked it up in my digital medical text downloaded in my smart phone.   Sure enough.  That is what the patient had.

Raised, swollen edge and black eschar (like a scab) in the center.  Anthrax. There was that anthrax bioterrorism in Congress in 2001 with a bunch of anthrax cases.  However, in the 2 decades prior to that, there had been only 7 known cases.  It is not common among the cattle-herding Maasai, but it isn't rare either since most human infections come from infected animals.  

The humorous puzzle was the intern's history that the patient got the infection from eating a "caccus." I wondered if the intern was misspelling "cactus." When I asked about that, the verbal report was that she had eaten a "cawcus" (my phonetic spelling). That was when I recognized the Tanzanian soft R sound in that word.  She had eaten a dead sheep, a carcass. The intern had written a phonetic spelling of how he pronounced carcass. The Maasai think cooking meat well cures all ills which is partly true, but in the processing of the "caccus," you get exposed to the bacteria and the bacterial spores. Infection follows.

She was a particularly delightful Bibi ("Grandmother" in Swahili which is  a respectful title), waving to us with both hands when we saw her on ward rounds (2 weeks of IV antibiotics). She only spoke Maa, the Maasai language, so I had to talk to her through a series of 2 translators (Maa to Swahili, then Swahili to English). She consented to posing for a photo with me which I appreciated since Maasai are reluctant to be photographed unless you pay them a modeling fee.

Then she decided to be funny and rub my head. She needs 2 months of anti-anthrax pills to protect against repeat infection if the spores start to activate and grow. After 2 weeks of IV therapy, my risk of getting anthrax from her was slight, but that was more exposure than what I was planning on. At least I will recognize it if I get anthrax skin lesions.

Don