Chapter Six- A Day in the Life

Since I know you are all DYING to find out what its like to be in a South African hospital, here is a glimpse from one day out of my medical journal. We do take extensive notes so its kind of long and for that I apologize. If you find yourself reading it and being confused by the rapid progression and heavy use of medical jargon, then I have done my job. Now please sit back, relax, and try not to get TB from simply reading it:

Monday, June 20

This morning we missed ICU rounds with Dr. Colene because he showed up half an hour early. So we don’t know the meeting topic on Friday or what was discussed but we will find out then. We made our way to C-mix where we saw quite a few patients because Dr. Matika wasn’t there and Dr. Camps had to cover the whole floor.
The first patient had COPD as a result of smoking. He was a very typical smoking patient, having claimed to have quit “about two weeks ago” which is code for “about the time I realized I couldn’t breathe and needed to go to the hospital”. His x-ray showed that he had large lungs with a flat diaphragm which is typical of COPD. Rhonchi were heard in both lungs upon auscultation. We discussed lung sounds a bit according to the way Dr. Camps explained them. “Rales” is the name for all abnormal lung sounds collectively. Crackles/crepitation indicates alveolar problems and sounds like sandpaper being rubbed. Wheezing is usually a problem with the small bronchi, and rhoncus is large bronchi. There was a patient with a herpetic infection on his lips so he was given Aciclovir. He also had streptococcal pneumonia which is very often concurrent with herpes infection.

There was another room which had two recovering stroke patients, one young and one old. The younger one was beginning to regain some speaking ability and was ready to start physiotherapy to learn to walk. His ECG showed a left bundle branch block (LBBB). The outcome for young stroke patients is much better as far as regaining functionality. The older man was conscious and able to sign to us but in worse condition overall. He appeared to be embolizing which was causing his left foot to develop early stages of gangrene. It will likely be amputated but they wait for demarcation to show up so that they can determine where to cut it off. In addition to that he was demonstrating Cheyne-Stokes breathing pattern (deep, heightened rate alternating with periods of shallow or normal breathing). This is a sign of cardiac failure in addition to the peripheral circulation issues and likely embolism. An ECG was ordered to confirm and a D-dimer test for blood thickness. He was currently receiving aspirin but it didn’t appear to be enough so he switched it to Clexane.

The next large room began with a 21 year old man who was fitting and suspected to have organophosphate poisoning, but he turned out to be an epileptic. He was given a toxic screen and a Cholinesterase test, which was high (would have been low for poisoning). He exhibited no signs of meningitis, which is more common to develop in epileptics. He also had a cough and slight indications of TB on his x-ray. All seizure cases are given x-rays in case they aspirated vomit which could get into the lung, usually the right. He also had slight leukocytosis, but fitting can cause that in addition to infection and he had no fever. A sputum will be done to check, otherwise he will just be stabilized and discharged. The next patient was possibly a case of acute Parkinson’s, but was likely the result of a drug reaction. He had been experiencing tremors for three days and then began being confused. He now had “cog-wheel rigidity” which was stiffness in the joints that caused them to move in jumps. However, he had psychosis as an underlying condition and was taking Etamine and Haloperidol (anti-psychotics). Haloperidol was the likely culprit and can cause extrapyramidal reactions which would lead to the tremors. The next man was a possible new diabetic. He was admitted with hypoglycemia which was now under control, but was also HIV-positive and hypertensive. He was on ARV’s (3TC, D4T, EFV) and pharmapress (for hypertension). Dr. Camps said that ARV’s can cause pancreatitis and lead to diabetes. The patient also had severe peripheral neuropathy which can progress to numbness in the legs, so the patient had an ulcer on his leg but it didn’t seem to bother him. As he often does as a quick inquiry to nutrition, Dr. Camps asked the man questions like, “are you working?” or “how are you eating?” This man was not working and so the hypoglycemia could have been a result of malnutrition. Because he had no money he also had stopped taking Diflucan for cryptococcal meningitis which he had. It was very important to check his CD4 and do an India ink test to see if the infection was gone or not.

We then went to the ARV clinic and afterwards came back to C-mix as Dr. Camps was finishing rounds. The second time we saw a man with right upper lobe pneumonia, which could be TB because it usually attacks the upper lobes. He also had a chronic cough, night sweats, and cavitations on his x-ray which are all classic TB symptoms. In addition he had high neutrophils (indicative of bacterial infection) and high CRP. CRP is an acute phase reactant which binds to phagocytotic cells and aids in fighting infections so when it is high it indicates likely infection. There was a CCF patient with high BP, which is unusual because usually once the heart starts to fail it is unable to circulate blood well enough to remain hypertensive. He had a lot of distention-abdominal, scrotal, lower limb, and face, so he was given a high dose of Lasix. Normally it is given 40 or 80 mg bd but since he was so swollen he was given 120 mg bd. Another man had empyema (pus in the pleural cavity) in the left lung. On the x-ray, a meniscus of fluid was visible even with the chest tube, and the lung was shrunk and did not entirely fill the pleural cavity. The last patient was the most severe case of Stevens-Johnson Syndrome we have seen here. SJS is a drug reaction that occurs with TB treatment and affects the skin, causing systemic rash and epithelial necrosis (cell death). It covered his entire body, with the appearance of a burn and his skin was just drying out so he was beginning to recover. Once the drugs are removed, SJS is treated just like a burn with fluids and blankets to keep them warm and hydrated. I was surprised he was not in the burn unit or a more sterile environment because he had no first line defense against infection and was more or less a burn patient.

In the ARV clinic, we saw about fifteen patients today. We were in our own room without even Dr. Makhakhe supervising us, but we had almost no troubles (besides language). The first woman was on HAART since this March so she was not suppressed but was showing signs of TB (cough, night sweats) but was only on INH as prophylaxis. We did not change or do anything but sent her for a chest x-ray and she will come back tomorrow with that. There was a man with resistance to first line, shown by suppression with his first two and a half years on ARV’s and recent increase in viral load even with compliance. He was on 3TC, AZT, and EFV. We moved him to 3TC (always keep it), TDF, and Aluvia after checking his lipid profile. One woman had already had an initial consultation and all we had to do was look at her blood results and decide which ARV’s to place her on. She was slated to get 3TC, TDF, and NVP but she had Hep B and her ALT was high so we used NVP instead. There was a patient who, after exactly 6 months of treatment, was not suppressed. Since that is the borderline for determining resistance, we referred him for a checkup in 3 months to reassess then. There was a man who was supposed to be taking 3TC, D4T, and NVP but he was mistakenly taking 2 doses of D4T rather than 3TC. Stavudine is fairly toxic with lots of side effects in a single dose so of all the ARV’s it is the worst to make that mistake with, and the noncompliance makes resistance likelihood greater. Four or five more patients were routine checkups and doing well on their treatment and others had minor non-ARV related complaints which we referred to the clinics. It was good practice being fully on our own. After the patients were gone at the clinic, we went to D ward to look at patient charts and then went home.

This is half of one of the rooms in the wards. There are 8 patients and about 4 rooms per wardThis is the foot of the man with Stevens-Johnson Syndrome