La Guardia/On Call

I've been on call twice so far here and they are definitely a different experience. Call starts right after lunch which is at about 3pm. You are responsible for seeing patients that come in for consults and the hospitalized patients. People are supposed to come in only for emergencies, but the definition of an emergency is pretty liberal.

The first patient that came in on my first call was a little 3 year old boy that came in with severe abdominal cramps. He had had a fever the day before, had pain localized around his belly button, no appetite and his belly was distended and pretty painful on exam. So, thinking in emergency mode, I thought, I have to rule out appendicitis. Fine, except that from 2pm - 6pm there is no electricity, so that meant no blood or urine exams until 6pm and then there is no CT to rule in or out the diagnosis, just a purely clinical diagnosis. And then I didn't really want to think about what we'd do if he actually had appendicitis. Padre Jack is in Iquitos right now, so no one here that can do an appendectomy. Anyway, I kept him NPO (no food), started him on triple antibiotics (for the worst case scenario..a ruptured appendix), and started serial abdominal exams while I waited for the electricity and at least some lab results.

At about 10:30pm that evening when I went to check on the little boy the nurse asked me to check on one of the patients that had been there for a blood transfusion. This is a 42 year old woman who had a kidney transplant about 5 years ago and is again having chronic kidney failure. So, as part of her kidney disease she has chronic anemia and her blood count had dropped enough that she was symptomatic from the anemia. A decision was made to give her 1 unit of blood. The plan had been for her to go home after the transfusion, but the nurse noticed she was breathing with difficulty. I went to evaluate her and she was in fact feeling very short of breath, when I listened to her lungs she was clearly fluid overloaded and the swelling in her legs confirmed this diagnosis. We checked her oxygen saturation and it was 87%, which is not good. Normal is 100%. So we decided to go ahead and admit her and get her some oxygen, which had to be rolled in from who knows where....and we needed to get the fluid off of her. So I started by asking for 20 mg of Furosemide - a diuretic medication that helps you pee out excess fluid- IF your kidneys are working. It usually works pretty fast, so we waited to see if she would pee. Meanwhile at 11pm sharp the electricity turns off and we are doing the rest of our work by lanterns. If I didn't have a sick patient, I'd say the whole look is very quaint, but when your patients 02 saturation won't go up...not so fun to be sitting there in the dark with your lantern and flashlight. Anyway after another 40mg of IV Furosemide and much worried waiting and increasing levels of oxygen the patient finally pee'd and felt started to breathe more easily. Deep breath...the rest of the night was calm, but we were then left with what to do with this patient. We can check her Creatinine (a level that tells us how her kidney is functioning) and so we know she needs dialysis, but we can't check any other electrolytes, so we can't monitor anything else that could potentially go wrong, which is a lot and there is no nephrologist or hemodialysis here. Luckily she's continued to be stable as the doctors have pressed for her to get accepted for a consultation with a nephrologist in Iquitos and she'll be going tomorrow.

The little boy with the abdominal pain eventually had a bowel movement and was tested for parasites and had both giardia and ascariasis and when treated had quick resolution of his symptoms. Good time to remember the saying in medicine, "common things are common."

I was on call again last night and it was quiet. We have only one other potentially unstable patient. He is a young man who has cirrhosis and has esophageal varices (swelling of veins in his esophagus that are prone to bleeding). He has surgery for this about a year ago, but he has presented twice since the surgery vomiting blood. And he did again yesterday....luckily it wasn't much and he hasn't vomited since he got here. We transfused him and are just trying to keep him on his medications, there's really no other way to treat him. We did find a medicine that is used in the US for esophageal variceal bleeding, but it's only supposed to be used with an IV infusion pump, which we can't do here, so not as helpful as you'd think to actually have the medicine. Anyway, hopefully he won't bleed anymore. I'm more than a little relieved when my calls are done....I have a great deal of respect for the work that the physicians do out here with what they have and I love that I have consultants to work with back home.