Monday September 13

Made ED Rounds with Adamah and others this morning. Saw a woman with probable Stevens-Johnson syndrome probably the result of an allergic reaction to a drug, but since show doesn't know the names of the antibiotics she has taken. Another man who apparently collapsed at home last night, but his wife had no means to get him to the hospital so she waited till morning when a relative with a car was available. He is febrile, comatose, and having seizures; there is no good way to make a diagnosis other than to treat him for the major possibilities, and then see what transpires over time. It really is medicine by the seat of your pants !

We then attended Grand Rounds on glaucoma presented by the ophthalmologist. It was quite interesting, and reminded me that I need an eye appointment when I get home !

Our cases today included 3 hernias, and an appendectomy. It is difficult to criticize surgical technique given the equipment they and, the conditions under which they work ( dim lighting), and without knowing their results over time. I think that follow-up is an issue, as the system works against it. Moses says that when he tells patients to come to the outpatient clinic following discharge after surgery, he tells them not to register, as it is tedious, time-consuming, and costly. They just come to his clinic office directly to have their sutures removed etc. Of course that means there is no documentation in the chart, but so it goes.

They have had us bouncing between 2 rooms today, which has clearly made everything go faster. They also use MAD ( Minimal Anesthesia Dosing) as a standard technique. I don't think it has been written up, but clearly having the patient awake halfway through the operation allows them to get the patient off the table faster at the end of the case ! It is pretty much routine to have patients bucking and moving a lot; it is not something I tolerate well at home, but there isn't much I can say here. I really do think it is their way of minimizing the expense of anesthesia !

Now we are waiting on a 16 year old girl in the ED with an acute abdomen. Moses thinks it is a typhoid perforation. We are waiting for her relatives to collect the money required for her to have surgery. Konneh was saying that he thinks there has been a decrease in the number of typhoid perforations they see because of better sanitation and earlier treatment of typhoid.

Moses, Konneh and I had an interesting discussion about different aspects of surgery. They feel sort of left out because they have no access to laparoscopic surgery, nor do they expect it will happen any time soon. Even if visitors came and brought equipment, they wouldn't get enough experience to feel comfortable doing it. Moses has only done 2 cholecystectomies in his 15-20 year career !! They also understand the the expense of laparoscopic surgery is a major problem in terms of bringing it here.

We just finished surgery on the 16 year old girl who had a belly full of pus but no perforation that we could identify. We looked at everything, then washed her out and put in drains. I'm not sure what will happen with her, but I worry that she will not survive. Apparently she has been ill for a month at home; the failure of so many to seek medical attention early is a huge problem here.