A night without skype...

I was on call. Yes, in a fancy clinic. No real patients. No headaches. Just rich folks looking for an excuse to sleep out of their homes. Because yes, these rooms were posh. Marble floors. Plasma TVs. Jacuzzis and even maid service. Definitely, an excuse to sleep out of the house. And I was a fresh grad looking to make some quick cash so this was a match made in heaven. During night rounds, I felt like a nuisance. These folks weren't sick; they didn't need me yet I had to smile and ask for complaints. I'd get a polite nod or barely an acknowledgement. "Doctor or housekeeper?" sometimes I doubted my own identity yet managed to keep the pleasantries until my rounds were over.
Then I'd return to my office (yes, I had an office) and skype away...till either a pseudo-complaint came through or my eyes could no longer struggle with gravity. 

The nurse informed me of a new admission so I followed her to the patient's room hoping to make it rather snappy and return to my favorite past-time. I met there a young man on the bed with two adults around him - a man and a woman. Quickly scanned him; stepped out and the nurse followed soon after. One look at her and I wanted to demolish her very existence. How the heck could she admit a patient like this? Unconscious! This was a clinic, not a hospital. Where was the equipment to monitor him? He needed a head CT Scan, an EKG, even X-rays; we didn't have any of that!

After pacing for about a minute, which felt like 20, I went back in there to break the news. "Sorry. We can't keep him because our facility isn't equipped to handle critical cases". Then I caught his wife's eyes...I mean, she was looking at me like I was her only hope. How can you put your hopes in someone like me??? I just wanted to surf the internet; I had no idea what was wrong with him and what to do with him. But till today, I can't explain what happened to me. I suddenly awakened and took control! I told the nurse to start an IV line and while taking his vitals, I took the history. We took his blood sugar, which was very low. We immediately administered hypertonic (high sugar) fluids, and in seconds literally, he came to life. In minutes, he was as good as new, like nothing had ever happened.

The story goes thus: his boys came home before dinner and dragged him out to the bar. He drank on an empty stomach and suffered from alcohol-induced hypoglycemia. Patients have described symptoms such as hypothermia, nervousness, rapid heartbeat and sweating (American Diabetes Society), but coma occurs when the blood sugar level falls very very low, which can happen quickly if fasting or exercise precedes drinking. Why does this happen? Because alcohol blocks the liver from making glucose (gluconeogenesis) so that you run out of energy in no time.

Mayo clinic website

The treatment is giving the individual glucose: 1 teaspoon of sugar or fun sips of coke or (even better) indulging on hard candy- ok, maybe a couple! However, if the person is comatose like in our case, an intravenous infusion with hypertonic fluids (20-30cc of Dextrose 30%) should wake him up. We had a less than ideal concentration, but still flushed it down until he woke up. As long as he got the glucose...
I did retire to my office after my patient was fully up and chatty. But I couldn't skype that night. I began reflecting. What if I hadn't checked his blood sugar? This was Cameroon; I was the patient's 911. What if I wasn't prepared for this? And then I realized that I was my greatest obstacle. And that I had to get out of my comfort zone!!!

References:
American Diabetic Society
uptodate.com
get.smarter.com
cs.stedwards.edu

Cradle of Humanity

Who are you? How old are you? What are your achievements so far? Are you happy with them? Or do you want more? It's that time of our lives, right? We ask these questions and scrutinize our responses more intently than ever. 

I just turned 32. My name is Annie. Or Naariah (child of God), an awesome metaphor! I aspire to change lives. Perhaps I'm doing that already but only God can answer for sure. I am of African descent. Cameroonian. Sometimes, culturally jaded; I moved to the US at 19, lived there for 10 years then moved home for 3 years then moved back to the US again. I wanted to become a flight attendant, then a journalist, then a sales professional. Never a physician...yet that's what I became.

Is it possible for someone to have "so much" yet so little? Think about it; I'm sure it makes sense. You know, like you have a job, a nice circle of fr-amily and a busy social life...yet something's missing. 

The first time I heard about "cradle of civilization" I remember asking myself "how come Africa?" We are the most underdeveloped, needy and most vulnerable. It was quite ironical; how come the place where humankind was nurtured in its earlier stage, is today in several respects, still the baby of the family? It didn't make sense, just as much as that inner hollow people feel despite their palpable success. But I wanted to dig deeper. And then it hit me that perhaps I was going about it the wrong way. It wasn't about being the perfect place, but about a good home, where the right values would be taught and would make us whole. 

 www.goaway.com. Kruger National Park, South Africa.

I was in Cameroon for 3 years. I still don't know if Africa is the cradle of humanity, but that's what she is to me. There's something about that place that does something to you; it's like going back to basics (you've got to experience it for yourself!). And after everything, I can say I found what I was looking for. It was sitting somewhere in the midst of that simplicity and serenity, and found solace there. So... where is your cradle of humanity? 

Tell them to be compassionate...

"Doc, you don't want to go into that room" The nurse was giving me heads up. I was about to do my rounds, and although the comment was welcomed I still had to see my patient. As we walked towards the room I tried putting away any prejudice.
So I put on my mask then walked into the room; after all, this was the isolation ward with numerous TB patients. Soon after my entry, I realized that no amount of cover-up could mask the stench that filled my nostrils. I walked to the patient's bed. Her very massive left leg, oozing foul-smelling pus, immediately caught my attention. She was there, seemingly clueless as to what was happening to her body so for her to keep whatever was left of her dignity I had to act normal (even though my nose was having a heart attack). I inquired about her life and the course of her illness. I turned to her husband who'd been standing there the whole time. I had a mask and was complaining about the smell yet this man hadn't left his wife's bedside.

Characteristic KS lesions: violaceous plaques 

This wasn't TB; it was Kaposi Sarcoma, a common condition in AIDS patients. She was 23-years-old and had four children at home. Uneducated, she could barely keep her story straight. Her husband, a farmer twice her age, filled in the blanks often. I was touched by their humility but saddened by reality. So much that I asked Mr Sam, her husband, to test for HIV. When he declined I realized he too must have been dreading the same thing. After addressing his concerns, he finally took the test and..........was HIV positive as well. Giving him post-test counseling was difficult and emotionally draining, but his wife was very sick and needed our complete focus.
Kaposi Sarcoma is a cancer caused by the human herpes virus 8 (HHV8). There are four different forms of KS, but the AIDS-related variant is most likely what my patient had. KS is an AIDS-defining illness meaning that its diagnosis along with a documented HIV infection is conclusive for AIDS. KS can also affect HIV-negative people (as is the case for other forms of KS), but it tends to be more aggressive lethal even in HIV-positive people especially if their immune system is very compromised (CD4 count below 200).
AIDS-related KS isn't curable but the lesions will regress if the immune system is reconstituted with Anti-retroviral therapy (ART). Chemotherapy could be of additional benefit if the disease is widespread as was the case with my patient.

So the cancer team came in and wrote my patient up for chemotherapy. Mr Sam, with a lot of difficulty, managed to pay the 1st of four rounds of chemo needed for his wife's regimen. Unfortunately, she died before we could even administer it. I felt a deep compassion for Mr Sam and his bereaved children.



References:
1) Image1:"<a href="http://commons.wikimedia.org/wiki/File:Kaposis_Sarcoma_Lesions.jpg#/media/File:Kaposis_Sarcoma_Lesions.jpg">Kaposis Sarcoma Lesions</a>" by OpenStax College - Anatomy &amp; Physiology, Connexions Web site. <a rel="nofollow" class="external free" href="http://cnx.org/content/col11496/1.6/">http://cnx.org/content/col11496/1.6/</a>, Jun 19, 2013.. 
2) Image2:"<a href="http://commons.wikimedia.org/wiki/File:Kaposis_sarcoma_01.jpg#/media/File:Kaposis_sarcoma_01.jpg">Kaposis sarcoma 01</a>" by M. Sand, D. Sand, C. Thrandorf, V. Paech, P. Altmeyer, F. G. Bechara - M. Sand, D. Sand, C. Thrandorf, V. Paech, P. Altmeyer, F. G. Bechara: Cutaneous lesions of the nose. 

Cleaning out the attic...

This man I know gave a testimony in my church. He'd been in a motorbike accident the previous day and had his pinkie finger cut off. Yet he stood there with a huge smile on his face, thanking God. I felt like asking him to shut up. Was it irony or just plain insanity? Well, it turns out after examining his injury, the doctor had told him that the whole hand would be amputated. And since he was a carpenter, that would have been a major disaster. So I can totally understand that he was grateful to keep his hand, but I wasn't over the fact that he'd lost a finger. I realized that this man was in a place, emotionally, that I couldn't access. That he had something that I wanted but wasn't sure how to get it.
So there I was walking through Central Park, New York. Four years ago, in this same city, I had a serious falling out with close friends, which led to a cascade of other events that unmasked personal issues that I've been struggling with. That's when it dawned on me that perhaps all this time, I was the problem. And that I was holding on to things such as unforgiveness and selfishness that had become a hindrance to me.

Then I thought about God. A verse in Psalms says that as high as the sky is above the earth so great is his love for those who seek him. He loves me more than my mind could ever fathom, and this fact challenged me to be better. It challenged me to let go of whatever was holding me back. Maybe this trip to New York wasn't random after all. It was time to clean out the attic. And maybe after doing that, I could finally behold the full measure of joy that the man had experienced. The kind of joy that makes you praise God even when circumstances dictate otherwise. I thank God for opening my eyes to see my faults; I thank God for new beginnings and I definitely thank God for New York City (ah-may-zing)!!!

Who are M E N???

Now with a busy job, I can’t blog as often for the hours are always gone! I can’t even find time to shop (window shopping of course). I’m hardly Carrie from Sex & the city, but lately, there’s been something on my mind: MEN Men Men!!! Perhaps because the year is quickly wrapping up and a look back isn’t inappropriate. I remember my New Year resolution and a bold request for “emotional rollercoaster’s”. Someone said: mind what you ask for you just might get it. Well, I got what I asked for but don’t regret it because what doesn’t kill you makes you stronger. 

So men have been on my mind. Dudes. Guys. Males. Why are men the way they are? I studied the science of human beings. You know, what they’re made of, how they break and how to fix them. Some psychologists think they have them figured out but that’s BS. I wasn’t taught how human beings think, but since I spend so much time talking with them it can only come to me naturally. Yet there’s something about men! These people are bizarre. Have you ever seen a group of people walking around like everything is under control? Even if inside they're a mess? And women have learnt to go along with the charade (the smart ones anyway). I consulted a lady who had a sexually transmitted infection and when I explained to her that her partner had to be treated as well, I was surprised when she stepped out of the room and returned with a bunch of questions. Her partner was waiting in the lobby because he felt that confiding in me would make him look vulnerable (and real men are never vulnerable). That I found fascinating!

Having been involved at a personal level a few times, I realize that men are all different from one another, but just like any other human being made by God, are love creatures too. They will care despite carefully built-in appearances and will expect those feelings to be reciprocated.  They will feel bad after treating you poorly (even if an apology may never surface). And they will fight for the ones they love…because it’s inborn and they simply can’t help it.

I always take my dad as an example. The man hardly shows any sign of life (phone call, email, whatsapp, viber) unless it’s an emergency. He finds no interest in attending life-changing events such as birthdays, graduations and weddings. And talking to him sometimes is like talking to a wall; he’s not listening. 

Yet I don’t need proof of his love; it’s everywhere: he took care of me like a princess; he named me after his mother, the most important person in his life and when we’re in the same room the world stops. Literally and figuratively. I know the man loves me.

Finally, I turned to God; as the Divine Maker I figured He would have answers. But I never gathered enough courage to ask him why. I realized that women aren’t so simple either, and on that note, I chose to proceed with caution. I also realized that men will always be men, and that’s why we love them. Why bother then?

Jean Paul Tedga himself !!!

The Big deal about Tb

Tb (Tuberculosis) was just another disease that I'd learnt about in med school in the US. It was a very bad disease with a very long treatment. And if you had it you were probably an immigrant from India or some African country.
I was surprised back in Cameroon when my first HIV/AIDS patient who presented with a lung infection became a topic for discussion amongst my young colleagues and myself. While it was clear to them that Tb was high on the list, I was thinking of PCP, which is also a bad disease but as I came to realize, is less common than Tb. So we never really found out which one of the two my patient was suffering from, which is often the case so we treated for both. 
Several months later, in a teaching hospital, I was exposed to a wider array and diversity of medical conditions. But I still kept bumping into Tb...in its multiple forms: patient has a  chronic cough-Tb; patient has a big belly-Tb, weight loss-Tb, patient has a big heart-Tb too. Tb was everywhere!!! So I learnt that it could be pulmonary ie in the lung (and which everyone knew of) or it could be extra-pulmonary ie outside the lungs. 

A normal chest Xray. Courtesy of WedMD

Chest Xray of pulmonary Tb (look at right upper lung)

And outside the lungs, Tb could affect any organ ranging anywhere from spacing outside the lung (the pleura) right down to even the genitourinaty tract. Yes, there is such a thing as urogenital Tb as well as Tb meningitis, Tb of the bone (Pott's disease-spine), Tuberculous ulcers and abscesses, Tb pleurisy, and the list goes on and on. But what has marked me the most so far is Tb of the lining outside the heart called Tb pericarditis.
I met a young man who looked really sick. While examining him, his heart sounds weren't loud enough so I got an chest x-ray (below). His heart was huge and globular (water-bottle heart), which is characteristic of a heart with fluid in its pericardium, a space surrounding it. In this case, the fluid resulted from the inflammation that Tb was causing in the pericardium (Tb pericarditis). Sometimes, this fluid can accumulate such that it prevents the heart from filling and pumping blood properly. This condition is called cardiac tamponade and is a medical emergency. Fortunately, our patient didn't have that although he did have a lot of fluid around his heart.

Water bottle heart in pleural effusions

My patient had other symptoms such as profuse sweating especially at night-time (night sweats) and weight loss, but he was also suffering from HIV/AIDS. The plan was to start him on Tb meds, a painful 6 month course of multiple antibiotics all in a special cocktail with varying side effects. With good compliance, most people are completely cured, but that's when they are relatively healthy. The picture can be complicated by co-morbidities such as HIV and diabetes; these can and usually worsen the outcome. 
As for me, my journey continues as I unravel more and more Tb mysteries and discoveries. Wish me luck...

Threat to the health...EBOLA!!!

After practising for almost 3 years as a physician, I've learnt that medicine isn't this sure thing that medical school painted it to be. You know, it's not always getting the history, running the labs and getting a diagnosis with a clear management plan. I've been exposed to cases that were interesting yet challenging and choosing managements that eventually led to positive outcomes was a great learning and fulfilling experience. However, I was also faced with the reality that things don’t always go smoothly as I witnessed tragic deaths despite relentless efforts.
There were times when defined treatment plans couldn’t be executed due to patients’ limited funds. And there were times when I was clueless in front of an unknown disease. These cases were equally engaging and educative as I was expected to provide a solution as well. My greatest satisfaction nevertheless, was to see my patients leave the hospital happy.
And now I realise that there are times when you may have to choose between life and death. I'm practically surrounded by the deadly Ebola virus, and everyday when I wake up in the morning I have to ask myself: what would I do if an Ebola patient was admitted on my ward? Would I scram and never come back or would I put on the armor of courage (the protective gear) and care for my patient? I must be honest and say that I'm still struggling with this decision.

Update (Sep 26th):
Word has it (and from a reliable source too) that ebola has been contained in Nigeria. Nigeria is our next door neighbor so to say that this has been quite a scare is an understatement. Does this call for jubilation then? I don't know. And I don't think so. How can one jubilate when hundreds are still dying in Sierra Leone...in the Democratic Rep of Congo...in Liberia...in Guinea. I'm not a skeptic, and I'm not pessimistic either, but what a grim outlook for the motherland. Africa is still bleeding!!!

Courtesy of the Huffington Post (Seyllou/AFP/Getty Images)