I hadn't had the best impression of this consultant given our protracted conversation about my religious beliefs on rounds in front of the patient the day before but I have to admit I enjoyed seeing clinic patients with him. Of course, while in clinic, there were several gossiping interludes. However, we did some good work and he was very receptive and curious about my observations and feedback. He even admitted that increased resident supervision would be beneficial and that sometimes he will round on his own on the non consultant rounding days to make sure nothing was being missed.
We saw a 70 year old patient presenting with signs of right heart failure likely due to longstanding emphysema. Here is this man's chest xray. He was a smoker, had TB in the past (MDs - can you tell by the CXR?) and had engorged veins in his neck and swelling of his legs. We talked about optimal therapy and it no longer surprised me that first line medications we use are not necessarily prescribed up front (due to cost), spirometry to evaluate lung function wasn't available in the clinic (in fact the full PFT lab had been closed for a couple of months because the equipment was broken) and that in order for the patient to receive oxygen (which has been proven to extend the life of those with emphysema) he would have to be admitted. There was no such thing as home oxygen.
We also saw a middle aged woman with presented with recurrent hemopytsis (= coughing up blood). She had an episode many years back and now recently had it. It had since resolved.
This was her chest xray 5 years prior.
Here is her chest xray currently.
What we see here are cavitary lesions in both lungs. However, in time, she had developed a fungus ball in her right lung whereas before she only had it in her left lung! Aspergilloma! She had prior history of treated tuberculosis and this type of fungus loves the cavities that TB creates in the lung. I had seen this type of lesion before on CT scan but not so clear and prounounced on a chest xray. This patient we referred to a cardiothoracic surgery to see if she would be a candidate to have the fungus balls resected. We all knew that a major limiting factor would be (as you know by now) - money.
We had another patient that had complete opacification of the right lung, suspicious for fluid and/or mass. We attempted to sample some pleural fluid from the lung (= thoracentesis) with the current supplies that were available. Alcohol to clean the area from a metal bowl. Cotton balls to apply the alcohol. The clinic had a few needles and syringes that were free of cost to the patient. This patient had a bit of adipose (fat) in her back and we needed a longer needle to access the pleural space to get some fluid. We had to write a prescription for this needle; the patient's family member when to go purchase it and then we tried again. This delayed the procedure by about 1 hour. Unfortunately for the patient, the physician had no free lidocaine and he had said that families often balk at buying lidocaine to numb up the area where the needle was going in because of cost. Thus, we had attempted this thoracentesis without lidocaine and I could see that she was in a good deal of discomfort. The consultant said he might go buy some lidocaine himself and use it on patients in the future. This procedure wasn't successful (we didn't get any fluid) and the consultant was suspicious for a mass. We ordered a CT chest for her; hopefully, her family can afford it.
Later in the day, we had an abbreviated ward rounds for one of the visiting professors from where I work in Chicago. The residents presented three of our patients and I very much sensed a high level of deference the residents and consultant had for the visiting professor. This visiting professor is known for his teaching, physical exam and clinical diagnosis and he didn't disappoint. I think it was nice for the residents to see a consultant teach at the bedside in a nurturing, non-adverserial approach. The last patient we saw was basically comatose with a severe neurological lesion - very brisk reflexes and upgoing Babinskis on exam. She had no lumbar puncture and CT head and looked as it death was not far away. The visiting professor and I discussed this case in private later and we were both amazed that this patient had deteriorate to such a clinical condition with such clinical findings. We both knew what was going on and why it was going on.
Following another lecture by the visiting professor on clinical reasoning, there was an outdoor reception for the visiting professors and UCH medical students, residents and consultants. There was free food and drinks so you can be sure the hungry trainees were all around! There were fried donuts, finger sandwiches, pieces of chicken ( a little bit random) and pieces on beef on a toothpick (also a bit random). I was hungry and had some food - no diarrhea illness I'm happy to report!
There was a photographer going around to take pictures. I had noticed a few photographers at a variety of events I had been to over the last few days, esp with the professors from Chicago visiting. I assumed they were part of the university. However, I later learned that they are freelance photographers that take your picture and then ask you for 100 to 200 Naira. Shady, eh?
Here are some pictures from the reception with Dr. Oluwatosi, a surgeon and a friend of Dr. Sola. Dr. Oluwatosi has called on me periodically to make sure I've been doing well.
Here are a couple of the women medicine residents. There are a total of 8 women in a program of 30+.
Most of the residents and medical students that spoke to the visiting professors asked the number 1 question - how can I rotate/work in the US? One medical student even brought out one of our major medical textbooks to have one of the visiting professors autograph it (she wrote a chapter in it). In addition to having someone from "home" to chat with, the arrival of the two visiting professors from Chicago raised the oyibo contingency at UCH by 200%!
Later at night, I received a call from Dr. Sola. The Lagos hospital strike had resolved. Since I was planning on going to play in Lagos for the long weekend (Friday is Good Friday, Monday for Easter and Tuesday is election day), we decided on the fly that it might be a good opportunity for me to rotate next week at the Lagos teaching hospital, provided we could arrange for the clinical experience and accommodations. Plus, Dr. Sola wanted me to see a Nigerian hospital where things were running smoother without as many of the struggles of UCH and tests were available and ordered for patients (not sure how this happens with all the cost issues) so that I could leave with a more complete picture of health care in Nigeria. Thus, tomorrow, Day 21, would be my last day at UCH and we would be off for Lagos on Friday.
Stay tuned!
No comments:
Post a Comment