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Monday, 01 May 2006

Volunteering in Lesotho - Page 2

Written by Devon Rossetto
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The early morning sun shines brightly; I hang my wet clothes to dry on the clothesline, hoping it will not rain before I come back for lunch. Ever since the water pump has broken and there has been no running water, simple chores like washing clothes takes infinitely more time. As Tarra, a visiting PhD student said to me, “you haven’t been to Africa until you’ve experienced the joy of bucket showers”. I wonder if my experience is even more enriched since our bucket showers come from our rainwater tank, which was also the home for a colony of small red worms that found their way into the buckets and thus, in our showers.




The patient is in severe respiratory distress; he is breathing at about 60 (normal for an adult is 14-20) and is unable to speak. He is afebrile. I wish for an oxygen saturation monitor that can tell me if his blood is being oxygenated; a useful sign in ruling in certain pulmonary processes like pneumonia or asthma. They are standard of care in every emergency room in the United States. On my third day in Lesotho when I was still adjusting to the limitations here, Dr. Rodriguez, an Argentine supervising doctor at the hospital, told me frankly: “We are in Africa now. Forget what you might do at home with technology and fancy imaging. You can only help your patients by using your head and your hands”.

His lungs sound clear beneath my stethoscope, moving entities like pneumonia or asthma farther down on the list. I stop and listen to his heart. I linger here for several moments longer than I normally would in this emergent situation. That’s odd, I think. I can’t hear his heart beating clearly. The sounds are muffled. I have never heard this before, but muffled heart sounds is a buzz word which every first year medical student learns is associated with pericardial effusion: fluid around the heart. If the fluid collects too quickly, the heart is trapped beneath the pericardium and cardiac tamponade ensues, which can lead to death because the heart is unable to pump against the weight of the fluid. Could this be the cause?

When I reach his abdomen, I have difficulty examining him because he is so short of breath that he can’t lie down. Sitting up, I can feel that his abdomen is soft (a good sign), but his liver is several times the normal size. There are many causes of hepatomegaly, most of which require lab tests to elucidate the cause. If I had been working in Africa for longer than a month, I might be able to put two and two together sooner and come up with the most likely diagnosis. However, the important thing at this point is to stabilize his breathing. At this time, we have drawn blood for labs and a young doctor from Malawi has joined me. We bring out an old portable ultrasound machine from the prenatal clinic to look for fluid around his heart. His heart, a fuzzy beating blob on the small screen, is completely encased in pure blackness, representing the fluid within the pericardium (the sac around the heart). This patient is in cardiac tamponade and the treatment is emergent pericardiocentesis. The fluid has to be removed.

I think about what might have happened at Boston Medical Center, where I trained. Cardiology would be there to perform the procedure. Or maybe interventional radiology would get involved. The state of the art imaging technology would be available. Most likely, he would be in the ICU. He is complaining of getting tired of breathing, a sign of respiratory failure. I hand Dr. Dullie a thirty cc syringe attached to a long needle. Using the ultrasound probe for guidance, he finds the largest fluid collection in the left side of the chest and sticks the needle in. He withdraws pinkish fluid. We wait. Almost instantaneously, the man begins breathing comfortably and starts to talk. I also breathe comfortably at this point and begin to get his paperwork together for admission. We will admit him for observation. I will learn through my reading that the most likely cause of a pericardial effusion and tamponade in Africa is tuberculosis. This is consistent with his large liver; extra pulmonary TB is also very common.

The children's ward at the hospital
Moving on from the men’s ward, I make a mental note to write an order for checking the man’s liver enzymes today. He has developed hepatitis from the TB medications and I am monitoring his liver enzymes for improvement. In the pediatric ward, brightly painted animals decorate the walls, but the floors are the same crumbling tile as in the male wards. Luckily, the smell is not as strong. The windows are open, allowing bugs to fly into the rooms. Steel cribs are lined up against the walls, the bright brown faces staring at me. I pass by Neo, who smiles at me; he is one of the country’s 100,000 orphans and has begun to recognize me as I play with him every day. He is only about 13 months old but is developmentally delayed in motor, speech and interpersonal skills. His mother has died and he was neglected by his foster mother, despite the fact that she collects donations in his name from unsuspecting donors. His eyes follow me across the room and I wonder if I will see him stand up before I leave.


(Page 2 of 4)
Last modified on Sunday, 16 December 2012

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