Hospital Updates

Recently, I spent a couple of weeks rounding in the pediatric ward. There is a pediatrician from Brown University here now (Marisa), so I was able to round with her, and I learned a lot. We learned about pediatrics in school, but I don’t feel too familiar with the medication regimens, as they are very different from adult medications. Marisa was able to teach me a great deal about the medical conditions and special considerations in children.

Since she just arrived in Eldoret, I also was able to learn about how to integrate yourself into a new situation. When I first arrived here, I really had no idea how to do this; I did my best, but I found it very difficult to gain trust and respect from the Kenyan physicians. Marisa was excellent at this, and I think it’s because she did a lot of listening during her first two weeks. There are so many times when you want to chime in and make suggestions, going off of how things are done in the US. Marisa refrained from doing this and just listened and learned about how the Kenyan system works. She eventually started asking questions and speaking up more, and after less than a month she is an integral part of her rounding team.

Some of the things I saw in the wards were heartbreaking, but as much sadness as there is, there is just as much hope. There is one child who looks about 8 years old, and she also looks about 9 months pregnant. She has severe malnutrition and possibly a malignancy in her abdomen, but she is extremely skinny and wasted other than her belly. It is very sad because it is even difficult for her to walk. There is another patient in the oncology unit that has a malignancy that has misshapen her face so badly that she hardly looks human. She has masses on/above both of her eyes and on the rest of her head/face. I want to go sit with her sometimes, but she is very shy and scared, and I can understand why. There are not many good treatment options for this type of cancer, and the prognosis is not good. Today, I went into the pediatric oncology ward to say hello to all my friends, and this girl was sitting up and smiling at me. She has the most beautiful smile I’ve seen. Her teeth are literally perfect, and her face lit up when I offered her candy and talked to her. She then was able to go home, and I hope for the best for her-I will always have a special place for her in my heart. Another similar case has a malignancy of the eye and had to have one of his eyes removed. He still walks around smiling and takes my lollipops, and at that I am amazed. I am starting to believe that these children are angels. They have endured so much, yet they bring hope to others, when they could so easily lose hope for themselves.

It is also inspiring to see the parents. The parents may not be able to provide food every day for their children, but they will recruit friends and family to pay for hospital bills or a chest x-ray that goes for about $10. Many of the children have acquired HIV through mother transmission, and these children display some very serious disease states and are at an extremely high risk of infection. The hospital is pretty much a second home for them. One good thing is that children under 6 cannot transmit tuberculosis due to their physiology and sputum production; this at least prevents the spread of one more disease in young children.

During my time in peds, I learned a lot regarding drug therapy, but I also learned and grew emotionally and personally. There is a lot to be learned from children, and they are very good at helping you put some perspective into your life.

After a couple weeks in pediatrics, I decided I would return to the adult wards to finish up the rotation. I initially had some challenges with my rounding team as they doubt the impacct that pharmacy can have, but I have learned a lot about the Kenyan systems and culture, so I am looking forward to working for a couple more weeks with my original team and trying to help as much as possible.

Just like the first day of this rotation, on my first day back in the adult wards, one of our patients passed away. It is always sad, but when the patients are so ill, I am almost grateful that they are in a better place and out of pain. That said, it also hurts and frustrates me when so many of these deaths are preventable (or would be in the US, anyway).

The biggest challenge this week has been making sure that patients are receiving medications from the nurses. The nurses are responsible for administration, and it seems like it does not always get done, or it at least does not always get documented that it was done. Many of these drugs are critical to life, and for some reason that seems difficult for nurses to grasp. No one has been able to figure out what the attitude or mental outlook of the nurses is. When I talk to them, I try to get them to see the impact that they can have- if they give the medication, they can save this patient’s life.

On Wednesday, we had a patient who was bleeding out of the mouth. He was not really vomiting, but he was losing a lot of blood, and we think he had a severe GI bleed. IV omeprazole was ordered, but that was not in stock, so we ordered IV ranitidine. I knew that this would probably not completely stop the problem, but it may help with the vomiting. I asked the nurse if they would give it soon, and she said she would when we finished rounding. I came back after lunch, and the medication was still not given. How can you not give a patient medication when he is bleeding profusely out of the mouth? I found the treatment sheet where documentation occurs, and started to look for the nurse in that area when I heard a women screaming and people holding her and trying to walk her out of the hospital. I looked over, and this very patient had just passed away. There was a knot so big in my stomach that I wanted to vomit. I’m not saying that his medication would have saved him, but there is no excuse to not give a medication. I was so upset by the lack of urgency regarding this patient.

I walked into rounds the next morning, and the curtains were closed around yet another patient, indicating that he had just passed away. This week was very difficult, and I saw a lot of death. This increased my motivation (to say the least) to make sure that medications were being given. We started an antibiotic for one patient with possible cellulitis, and I noticed that it wasn’t given. I asked the nurse and she said the pharmacy didn’t have any. That was interesting considering that a few other patients showed documentation from the same nurse of receiving the same antibiotic that day. I went to the pharmacy and brought the medication to her myself and she promised to give it. Thankfully, when I checked this afternoon, the patient had received the medication.

Will has experienced similar challenges and has ended up giving medications to patients himself. It is a lot of work, but it is comforting when you know for a fact that patients are receiving medications as opposed to feeling like it’s always a guessing game.

Messai had a patient with an INR of 8 (this means that she was at a very high risk of internal bleeding because her blood was essentially “too thin”). To treat this, we can administer Vitamin K to increase the clotting factors. We were trying to avoid giving this vitamin K IV because it can cause an anaphylactic allergic reaction if given too quickly. Luckily, the IV formulation can also be given by mouth. We administered the vitamin K to the patient orally, but it must have tasted awful because within 30 seconds she had vomited it up. We discussed with the nurse and decided that it should be given IV very slowly, but for some reason we had a lot of difficulty. The nurse resisted administering the medication, and it took so many tries to place an IV line in this patient that she began crying. I don’t think anyone would like to be poked 7 times with needles in your hands to try and place an IV. When Messai returned to rounds the next morning, the vitamin K was never given. This patient went an entire day and night with a huge risk of bleeding.

These are a few of the challenges that we have faced recently. It is easy to lose hope and get frustrated, but you have to keep a vision of the future in your head and heart. By helping one patient, you are making steps to helping more. Together, Will, Messai, and I are learning how to overcome many challenges to patient care and taking on a lot of responsibilities ourselves instead of always trusting others to do it. We are not trying to step on nurses toes or anything, but we are doing what is necessary to save lives. Patient care has come a long way, and I know it will continue to improve as long as people persist and put their heart into patient care.