July 15, 2010

Today at the hospital a 17 year old boy named Abraham died.  I had been overseeing Abraham for the past week.  He had previously complained of coughing and severe weakness.  The palms of his hands were white (compared to the pink hands of others), which Dr. Kudoh said indicates anaemia.  Based on these symptoms Dr. Kudoh diagnosed Abraham with severe malaria and secondary anaemia. 

When I arrived in the ward, Abraham was having convulsions and had bloody sputum blocking his airways, likely from a bacterial infection in the airways.  The nurses were trying to aspirate off the sputum and give Abraham oxygen.  Because Abraham was anaemic, oxygen levels in his tissue were already low.  Abraham’s breathing was wheezy, and the nurses believed he likely had fluid in his lungs (acute pulmonary edema).  With the fluid in his lungs, the little oxygen that could be brought to the tissues now had to pass through fluid (as opposed to air) which further decreased his tissue oxygen levels as fluids have a much higher resistance than air.  Consequently Abraham’s tissue oxygen levels were becoming dangerously low. 

Dr. Kudoh had not yet arrived because he was away at another hospital.  The nurses injected Abraham intra-muscularly with 5 mL quinine to reduce any symptoms caused by the malaria parasite.  Amoxicillin, an anti-bacterial, was given to try to clear some of the bacteria that were likely infecting the airways and causing the bloody sputum, which was blocking his airways.  The nurses kept Abraham on a slow-drip, intravenous dextrose saline.

I looked at a chest CT scan of Abraham from earlier in the morning, and saw that the heart was extremely enlarged, just like the previous patient (Thom Johnson) who had died of cardiac failure.   

I checked for pitting edema in the legs, which had also occurred in Thom Johnson, but found none.  A good sign, perhaps? I listened to Abraham’s heart beat, and it sounded very irregular.  The nurses gave Abraham 100 mg of hydrocortisone dissolved in saline I.V., and checked his vitals.  Temperature was 32.7 (very low), blood-pressure was 110/70 (low for this patient), and his pulse was too feeble to count.  The nurses continued to aspirate off sputum and give oxygen.  Two other doctors who I did not know came in, and said to continue aspiration and oxygen delivery, and wait for Dr. Kudoh.

When Dr. Kudoh arrived he confirmed that cardiac failure was occurring using his stethoscope. He also found that acute pulmonary edema was occurring, and showed me how to distinguish between the sounds of a fluid filled lung filling with air (distinctive crackling) and a normal lung filling with air (smooth sound).  Dr. Kudoh said to continue aspiration and oxygen delivery, but told the nurses to remove the I.V. saline immediately, as the added fluids were only increasing the work-load for the already failing heart.  He also told the nurses to prop-up the patient as much as possible, which allows blood to circulate the body more easily.  Dr. Kudoh gave I.V. lasix, a diuretic, to help pass fluids and lower the workload of the heart.  A catheter was inserted to allow excretion of the extra fluids.  Dr. Kudoh said that this was all that could be done for the boy, and we just had to wait.  Two hours later Abraham died.

Abraham’s death hit me a lot harder than any of the other deaths I had seen.  Abraham had been in the male ward since I started 4 days ago.  He spoke English and I had talked to him a few times about soccer, which he loved to play.  He had appeared relatively healthy in those first 3 days, and his sudden cardiac failure came as a large surprise.  After the experience, more than ever do I want to train as a doctor, so if I am ever in a situation like that again I will know what to do to best help the patient survive and recover. 

At BCL, I read a story with the kids and pointed out different grammar things we had learned previously as we went, which the kids seemed to really like.  At the end of class, the kids asked me to do some dictation (like a spelling B), so we did that.  After the difficult day at the hospital, teaching at the afterschool program really cheered me up.  I took a picture of my classes (Figures 18 and 19).  I have now agreed to teach 5 days a week from 4-6 P.M.

Figure 18. BCL class 5 (younger class).

Figure 19. BCL class 6 (older class).