Pathology galore

So yesterday was a crazy day.  I think I saw more real pathology than I've seen in a month's time back home.  I started the day on the peds ward making rounds.  We saw a few of the kids who had been admitted for a day or two, but then made our way to a new admission.  You could see the 13-month-old boy was sick at first glance.  He was holding his neck extended and would not move it at all.  He laid still in mom's lap just kinda whimpering.  The story was that he had been irritable and had fever for a couple days.  Rightly so, Serge (one of the housemen on peds who I've been working with) was concerned about meningitis.  I went to examine the boy and tried to flex his neck.  He screamed!  I don't think I've ever seen such a demonstration of meningismus before.  Long story short, the spinal tap did show lots of white blood cells, indicating infection was present, but the more impressive thing was the Gram stain--positive for Gram+ diplococci!  I've had positive cultures back home in the States, but I honestly can't remember having a positive Gram stain.  So we explained the situation to mom and continued him on the high-dose Rocephin.  I pray he does well, but you never know.  Sadly, the pneumococcal vaccine is not a routine immunization here in Cameroon.  I'd like to take a picture of this kid and send it to all those nay-sayers of vaccinations.  This is what happens when you're kid doesn't get his pneumococcal vaccine! 

A little further down the row was a little 5-year-old boy with a distal femur fracture.  Mom reported no trauma, but upon further questioning we learned that the boy has profound developmental delay, is essentially non-verbal, and has what sounds like a seizure disorder.  Ortho and PT are seeing him for his fracture.  I'm not sure what else we can offer besides anticonvulsants.  Next to him was a 10-year-old boy with a large cystic left parotid mass that had apparently been present for years.  The boy had a previous biopsy or excision of some kind (they didn't know and his medical book didn't mention it), but now the mass had recurred.  Dr. Acha, our ENT surgeon, planned to take him to theatre later in the morning. 

Across the aisle was one of the saddest cases.  This was a little 5-year-old boy--they all seemed to be boys yesterday--who had been in a motorcycle accident 5 days previous and had been referred from a hospital in the city of Douala (8 hours away from Mbingo).  They had done a CT scan of his head, as they were worried about intracranial hemorrhage, but it was normal.  They came to Mbingo for further management.  On exam, the young boy could not move either of his legs or his torso, and he could feel nothing below a line drawn between his armpits.  How sad!  The question is when did the injury actually occur.  In his medical book, a medical student had recorded an H&P, and there was not much documentation about his neurologic exam.  All it mentioned was that the boy had not had loss of consciousness but that he had nausea and vomiting and that the abrasions on his head made them concerned for bleed.  My suspicion is that he had to have had some kind of neurologic deficit for them to decide to CT him considering the cost.  Being as he arrived to our facility without any kind of C-spine stabilization, I hope against hope that the transfer process did not cause or worsen his deficits.  Sadly, we really don't have a lot to offer him either, and it was a hard conversation explaining that to the dad.

Right after finishing rounds, Anita, my houseman from maternity, came into the ward looking for me.  "I have to tell you a story," she said.  She went on to explain to me how a young lady with her sixth pregnancy had come in early that morning.  She was 29 weeks along with twins, and shortly after arriving, the midwife went to check her as she was complaining of contraction-like pains.  However, when she did, she realized that the baby was delivering.  A few minutes later a young preemie boy was outside and, considering the situation, was doing quite well.  The baby's placenta delivered a little later, and then the crew waited a bit expecting the second baby to come.  The fetal heart tones were quite reassuring, and after several minutes, the midwife decided to check mom again and see what was the status of the situation.  To her shock, she couldn't feel a presenting part.  The cervix was only a few centimeters dilated, and there was no baby head to be felt!  She listened for the heartbeat again, and it was fine.  By this time, the U/S techs had arrived to work, and so the patient was sent for U/S.  The U/S showed a perfectly healthy 29-week baby sitting in plenty of amniotic fluid.  But to everyone's amazement, the U/S showed what looked like to be a didelphic uterus.  A didelphic uterus is what happens when the two embryologic halves that make up the female organs only partially fuse in the midline.  This lady essentially has two uteri and cervices (I don't even know if that's how you spell those words!).  I couldn't believe it.  So these twins, if we can call them that, were each in their own uterus.  They will certainly have different birthdays, and, if the second one is lucky, different birth years!  The mom's actual due date is in Feb 2011, and now that there is more room in the abdomen, she just might carry the second baby past New Years!  I've never heard of such!

Of course I've seen lots interesting and weird cases since being here at Mbingo, but yesterday just seemed to be especially full!  I can't imagine a day like that back home at Self Regional.  I'll have to email Dr. Gentry with that case report.  I'm sure he would get a kick out of it!

The lone resident

Friday I started rounding on pediatrics as well as maternity.  Emiley, my pediatrician counterpart, headed back to the US on Thursday, and since Dr. Bardin is an internist and geriatrician, he said he would be fine with me taking over Peds instead of him!  Karen left for the States as well yesterday, so I’ll be the only rotating resident for the next couple weeks until I depart.  It was great to have a couple other residents around to hang out with and to ask for second opinions on cases.

Dr. Bardin and his wife Debbie have been such great hosts for us here.  I can’t remember how much I’ve written about them, but they are (most recently) from Michigan where Dr. Bardin practiced in a large multi-specialty group with a large emphasis on medical missions.  They served for 10 years at a mission hospital in Nigeria back in the 1990s.  Debbie is a nurse and works with the HIV/AIDS care and treatment team here at Mbingo.  Dr. Bardin is an internist, but upon return to the States after their stent in Nigeria, he completed a pathology residency, a geriatrics fellowship, and some on-the-job training for endoscopy.  So, this guy does EGDs and c-scopes for patients who need them as well as the biopsies and FNAs (not just on endoscopy) to discover pathologic diagnoses as well.  For example, yesterday, we had a 33-year-old man with a 1-year hx of severe sciatica-like pain and now has developed progressive leg weakness.  He also noticed a large lymph node in his groin and presented to the surgery outpatient department for evaluation.  The resident referred him to Dr. Bardin, who did a modified needle aspiration of the mass, and just a couple hours later, we knew the guy had a rhabdomyosarcoma (muscle cancer).  While that is a horrible diagnosis and we don’t have the exact treatment he needs here at this hospital, we know what he has and we can refer him for proper treatment.  Most patients wouldn’t or couldn’t present to a larger facility for pathology investigations, so the fact that we can do the biopsy and get the read here is amazing.  Those who have diagnoses needing further treatment we can’t provide can know the options and be referred if possible.

Pediatrics has been a mixed bag so far.  Like on maternity, some of the cases are challenging, both diagnostically and emotionally.  My most difficult right now is a nine-year-old boy named Elvis with full-blown AIDS.  He was started on HIV medications only a few months ago, and his last lab work showed his disease was quite advanced.  He has multiple issues going on during this admission, and without cultures and some of the better diagnostic tests, honestly I’m not entirely sure what all we’re treating in him.  He’s still spiking fevers on several antibiotics, including those for most of the opportunistic infections AIDS patients develop.  It’s hard enough seeing any patient suffer with AIDS, but it’s especially difficult seeing kids go through it.  The Cameroonian residents were very surprised when I told them that I had never actually treated a child with HIV.  The rate of HIV infection here is, by some estimates, 50%.  FIFTY PERCENT!  That’s ridiculous!  But spending some time on the adult wards seems to confirm that statistic.  Debbie Bardin, however, was telling us the other day that working in the outpatient treatment area is a bit more encouraging.  While the inpatient cases are mostly complications and advanced disease processes, she reports some pretty exciting success stories for those patients who are following up regularly and taking their medications as prescribed.  I guess it would help me to remember that we are getting a somewhat skewed sample on the inpatient service.

 

Dr. Bardin's office/pathology lab

The staining setup

Needle biopsy in action

We've seen several goiters like this one

This is the CXR of the lady in the previous picture.  See how deviated her trachea is!

A elderly man with an impressive goiter

A young lady with Stevens-Johnson syndrome

Precious and Praise, twins that Emiley took care of on the pediatric ward.  Now the family is hanging out at the hospital until they are able to pay the hospital bill...which is quite common here.

Louisa Faith, one of the preemie success stories.  She was born shortly before I arrived to a mom who had severe pre-eclampsia, and now she is finally discharged home!

There is a deaf school on the hospital campus with ~150 students who attend.  They love snapping photos and grab whatever is nearby to show in the picture.  Emiley posed with them for a picture.

 I hope you enjoyed the picture update.  Thanks for your continued prayer support!  Talk to you all soon.  

Pictures!

Tony, one of the surgical residents, trying on an interesting hat

Shopping in one of the local grocery stores called "Our Parents"--not sure what the name is about???

I told Karen she couldn't buy this soap until she turned 65

The block soap sold in the market

It's amazing how they carry things on their heads so easily...and this is pretty lightweight compared to some bundles

A view down one of the market aisles

The beef vendor...that dark thing in the center of the table is the cow's stomach--a tasty treat, apparently!

This man was proud of his ox tail

Elle wasn't too happy...she told her mom she didn't want to be "squished between the boys!"

Our snack purchase...fresh munguin (grasshoppers)

Frying 'em up in pan

Margaret was kind enough to fix them for us

As a thank you, we shared some with her as well

Tasty!

These were supposed to go with my last post, but I couldn't get them to load that night.  Hope you enjoy!

Bittersweet

This past weekend was kind of bittersweet.  The sweet part was our group outing to Bamenda, the larger town nearby, where we had lunch, did some souvenir shopping, went to the open-air market, and visited a couple grocery stores.  The Bardins and the entire Ritchey family went, as well as the three of us American residents and Tony, a first-year surgical resident.  We had a very nice time, and I enjoyed the fellowship with the others.  Just as we were leaving the market, Karen decided to buy a bag of the grasshoppers for us to try as a snack.  We’d been talking about trying them, and Margaret, the hostel cook, said she would prepare them for us.  When we got back to the hospital, we gave the bag of grasshoppers to her and she sautéed them up nicely.  We were a little nervous, but after the first bite, we could tell they really were quite delicious.  Almost like a good French fry—a little salty and kinda crisp.  We ate most of them and then went to the Ritcheys to share the remainder.  Never thought I would find myself saying I enjoyed eating a grasshopper!

The more bitter part of the weekend was caring for a mom with preterm labor and her baby, which she delivered at 25 weeks gestation (about 15 weeks early) on Friday evening.  The cusp of viability is around 24 weeks, and that’s with modern medicine (surfactant, ventilators, CPAP, etc.).  We talked with mom about how there can be many complications with extreme prematurity, and she seemed to understand and asked us to do whatever we could to give her baby a chance.  On first exam, the little one was actually oxygenating quite well with supplemental O2.  The real adventure was placing a umbilical venous catheter in this boy...without a normal UVC line.  I was really glad Emiley was there, as she’s certainly had more NICU experience than I have, and she had the bright idea to use a peripheral IV catheter.  While it is more rigid, it is shorter and thus should not end up in the liver after placement.  So, she prepped the kid, and I assisted her as she got the line in place.  We tucked the kiddo in for the night on oxygen, IV antibiotics, and glucose.  He was actually surprisingly vigorous for his age, and we both figured this kiddo was gonna be a fighter.  The next morning, we found that the IV had migrated almost all the way out, so we had to replace it.  Emiley let me take a stab at it since she did the one the previous night.  After a little finagling, we got it back in place and sutured it more securely…we were going to make sure it would stay in place until we wanted it to come out.  Still, the baby’s oxygen levels were good on nasal cannula O2, and it was that morning we left for Bamenda with the group.  When we arrived back at the hospital that night, there was no news of complications from the nurses on maternity.   

Sunday morning, I awoke and had breakfast, then made my way to maternity to check on the patients before church.  I walked directly to the room that has become known as our NICU, the room with the incubators, to check on our preemie.  All the incubators were empty.  I turned to the nurse, and she informed me that our patient had died during the night.  This case was another emotional roller coaster for me.  Obviously, it pains me to lose a patient and, especially, to see his mother grieve the loss of her tiny son.  But at the same time, I’m thankful that he is no longer suffering and that he has avoided the horrible complications that can arise from extreme prematurity (e.g. serious gut infections sometimes requiring surgery).  His short life on this earth reminds me of Psalm 39—“each man’s life is but a breath…”  Even though his life was only a very short glimpse into this world, from God’s eternal perspective, all of our lives are a vanishing vapor.  It is so easy at times to become consumed with the things of this world and the busyness of life.  Lord, help us to realize the brevity of this life.  Help us to live for those things that truly matter—coming to know You more, falling more in love with You, making Your name and Your love known to those around us. 

With the new day today came some exciting news.  We were able to discharge Praise home with his mother.  He has been eating well and gaining weight like a champ.  He will definitely be one of the successes I remember most about my time here.  Thanks to everyone for their prayers.  Continue to pray that the Lord’s hand will move both in our lives and through our lives here at Mbingo.  Talk to you all soon.

Fauna and Flora

I thought it would be nice to give you a glimpse of the plants and animals we've encountered around Mbingo.  My little apartment is connected by a breezeway to the Palmer's house.  Dr. Palmer is the IM residency director, and he and his wife are currently back in the U.S.  The Palmers have a helper named Bridget who has been assigned to help take care of me while I'm here.  She has been so gracious during my stay so far, keeping me supplied with filtered water, washing and drying my laundry when needed, and keeping my room spic and span.  Her young son has the responsibility of tending the Palmers flower gardens while they are on leave.  Some of the plants and flowers are from those gardens, others are from around the hospital compound grounds, and some are from the couple of hikes we've been able to take.  Cameroon has some pretty exotic and cool-looking flowers...

Flower growing on the mountainside where we took our first hike

Banana trees grow all over the hillsides.  Not sure what the central hanging part is...or if it's edible.  I'll have to ask.

Such an interesting looking plant.  It almost looks like a colorful pine cone growing on stem.

View from behind Emiley and Karen's place

Eucalyptus trees are pretty ubiquitous here

Huge palm growing right in front of the Palmer's house.  Just the leaf part is almost as tall as me.

What a view!  God's grandeur displayed.  This is the view in back of the Ritchey's house...a little jealous they get this view every day!

Looks like a little pink pineapple growing in the middle of this plant...but it's not.

There are quite a few critters hanging around the hospital compound too.  It's not uncommon to see tons of grasshoppers (which the Cameroonians love to fry and eat!), praying mantises, termites, and ants all around the hospital, both outside and inside at times.

I thought this was a pretty good capture

Ants everywhere!  The Palmers have an outdoor cat that is still living here, and this is her food bowl.  They feed her leftovers, but she wasn't too interested in the rice.  I guess it's not a problem then that the ants are overtaking it.  Don't leave any snacks lying around uncovered--it's an open invitation for ants to attack.

The cat would rather eat the mouse she caught.  She devoured the whole thing in probably less than 2 minutes.

A small gecko outside the Bardin's house

This was my little friend I found as I walked into my bathroom one morning.  Sadly, he is no longer with us on the earth.

Hope you enjoyed.  Will post again soon!

Mayhem on Maternity

Maternity was manic today.  When I walked onto the ward first thing this morning, my houseman Anita informed me, “Dr. Pike, we have a sick baby.  Momma was transferred here this morning, she delivered, and now the baby is not breathing well.”  Long story short, mom’s water had broken 4 days ago, the baby’s APGARs were very low at birth, he was bagged via tube for quite a long time, and once extubated (since we don’t have ventilators) his spontaneous respirations were only 1-2 agonal breaths/minute.  We explained the situation to the parents, who were obviously shaken.  I expect he will pass sometime later today.  Anita and I also had to do a spinal tap on a different newborn today, trying to rule out invasive infection.  We also had to talk with a mom about possibly placing a feeding tube in her baby’s belly.  Other cases on the ward today included a VBAC, another PROM-er, a patient with marked polyhydramnios (AFI of 48!), and a 32-week IUFD (intrauterine fetal demise)—baby was transverse lie but mom happened to progress to labor and ultimately a hand/cord presentation…never seen that before.  It was hard to have to tell that mom she had lost her baby.  Through her tears, however, she said to me, “Thank you for helping me, doctor.  Know that my hands are like this…”  She placed her hands out before her, palms upward—a gesture of openness.  “God is in control.  This was not my will, but God is in control.  He will take care of me.”  What a statement!  What courage!  This young lady in such a tragic situation had the resolve to immediately confess her faith in the Lord.  It reminds of Jesus, praying in the garden, “Not my will…”  I can only hope that kind of faith would be found in my heart.  I prayed with her then, and she thanked me over and over again.  Although it was a tough situation and an outcome for which no one would hope, I feel privileged that the Lord allowed me to be an encouragement to this young lady and her husband at such a dark time in their lives.  Little did she know that she too was an encouragement to me. 

Thankfully, not all on maternity today was sadness.  My little now-9-day-old buddy, Praise, is actually doing quite well.  He was the preemie who had developed such severe respiratory distress.  Over the past several days, he has continued to improve.  He is now off oxygen with no signs of respiratory distress, he is feeding well on breast milk, and he continues to gain weight daily.  Truly, PRAISE the Lord!  His mother is a bright young lady (who sadly lost all three of her previous pregnancies due to various problems) that, appropriately so, is playing the same praise and worship songs everyday on her little cell phone.  Praise’s success thus far certainly helped to lift my spirits today amidst all the other losses.  Below is a picture of Praise and mom.

Mom and Praise

Praise and his incubator roommate, one week ago

Linda, Praise's previous roommate.  Each has their own incubator now, since Louisa graduated from incubator status!

God is good.  Whether tragedy or triumph meets us each day, we have a God that is in control and that is able to sustain His children.  I am thankful that He continues to demonstrate to me His faithfulness.  Even though I may not and often cannot understand His ways, there is peace in knowing that He loves us and that He is sovereign.

Cameroonian trek

Today being Saturday, we had some much needed downtime after AM rounds, and we made use of it by hiking to a nearby waterfall.  We took off after lunch, and Rebecca, wife of the surgeon whose kids I posted earlier in their Halloween costumes, was our tour guide.  It took about 1.5-2 hours one-way, so it was a pretty good trek, but the views were great!  We went over cattle pastures, through thick muddy riverbeds, and climbed slippery rocky slopes.  (Markus, thanks for the Chacos...they came in quite handy!--definitely getting me a pair)  It was a great encouragement to see the beauty of God's creation as we walked along, and the waterfall topped it off.  It may have not been a Niagara, but it sure was beautiful.  We arrived on a hillside opposite the falls, and as you approached you became surrounded with the mist coming up the from the turbulence of the falls hitting the river below.  I hope you enjoy the photos.

Small farm located just beside the falls.  What a view to wake up to everyday!

We had to cross the fence into the pasture to get to the falls.  Please disregard to blindingly white legs...they haven't seen much of the African sun!

I thought this was a great capture of the huge rocky plateau nears the falls

Karen, Rebecca, Emiley

Beautiful!

 Me with Emiley (peds from California) and Karen (internal med from NY)

 This is the farm house.  Next time we'll climb to the top of that plateau and get some good distance photos

Herd of cattle we saw along the way.  I'd hate to be on the wrong side of those horns

 The entrance to the hospital's ranch.  They use the land for grazing cattle (meat consumption and raising capital for the hospital) and the houses on the ranch to house visiting missionaries.

Today's hike was refreshing and a reminder of God's greatness.  Thanks so much for your all's prayers--what an encouragement!  Thanks for following along with me in this adventure.  I'll write again soon and give you some photo updates.  'Til then...