In the past 2 or so weeks on the wards, I've had the opportunitiy to do/supervise a LOT of procedures. Meningitis is common here, and the diagnostic test of choice is a lumbar puncture. Likewise, I've had the opportunity to do several paracenteses and thoracenteses as well. Today, we did all three. In the US, we have separate kits and needles and whatnot for every procedure. Here in Kenya, we have the trusty "branula," or IV catheter. It's a flexible plastic catheter over a fairly large bore IV needle, about 2 inches long. We use it for essentially every procedure we do on the wards.
Desperation: Today we had a patient with a massive pleural effusion (accumulation of fluid in the cheltst cavity) who was having significant respiratory distress despite oxygen. It was clear that she needed to have the fluid removed, however, her platelet count was only 19,000. (Normally I would want them to be greater than 50,000) In the US, this wouldn't be so problematic, simply transfuse some platelets and do the procedure. Here, however, there were no platelets to be transfused(due to some of the difficulty with the blood supply that I've mentioned previously) So here was the choice - do the procedure with the low platelets (and increased risk of bleeding) or not do the procedure, knowing that the patient would probably not survive the weekend due to her respiratory comprimise.
If you know me very well you can probably guess what happened next.
Determination: After inserting the ubiquitous branula, our choices for draining the fluid were still rather limited - the fancy three-way valves we use in the US just aren't so easy to get here, and there is no such thing as wall suction. However, with a 20 mL syringe, it's pretty impressive how quickly you can remove 800 mL of fluid. I'll probably have a blister on my thumb tomorrow...
18 Gauge Branula: The green guy pictured below. After pulling off the fluid by hand, we taped the branula to the skin and attached it to a Foley bag to let more fluid drain by gravity. It will be interesting to see if it's still there on Monday!
Lesson #2: Calling the ENT clinic at 4pm on a Friday and demanding that they see a patient goes over just as well here as in the US.
We had an elderly lady admitted overnight with nosebleeds, and had nasal packing twice on the ward. Late this afternoon, she started bleeding again, and we had quite a time getting it to stop, and by the time we got it to slow down there was a decent puddle of blood by the bed. I eventually got ahold of the ENT consultant (attending) who told me that the patient should be brought to clnic. I then called the clinic to tell them she was coming, and they informed me they were getting ready to close and wanted her there...NOW. Since we had trouble rounding up anyone to take her, I grabbed a wheelchair and pushed her there myself. Judging by the looks I got, we must have been quite a sight - a Mzungu doctor pusing an old lady in a wheelchair who every few minutes would spit out a mouthful of blood. (hey, I WARNED you, squeamish person!) I kept having to ask for directions, but eventually we made it there, and they packed her nose nicely. However, when we got back to the ward, her family was in a panic, as she was not in her bed and there was a puddle of blood on the floor when they arrived! I tried to nicely explain to them that we had taken her to another part of the hospital to have the problem fixed, and I think they were just relieved to see her.