The second in a series. Last year I published Part 1, sharing some of the more unusual cases we see at Tansen. As with that and Part 3 (coming soon, with pictures), this entry is geared for you medical folks out there, so apologies in advance for all the jargon…
At Tansen Mission Hospital, much of what we routinely treat includes diseases with a high prevalence worldwide: viral gastroenteritis; pneumonia, iron deficiency anemia; UTI and pyelonephritis; atrial fibrillation; supraventricular tachycardia; rheumatoid arthritis; hyper- and hypo-thyroidism.
There are also a number of diseases gaining popularity here as our dietary and exercise habits continue to evolve, diseases that often seem to attend “development” – hypertension, diabetes, stroke, myocardial infarctions and ischemic cardiomyopathy. Additionally, in Nepal as in the rest of the developing world, we often diagnose disease, especially malignancy, at very advanced stages. (Stage IV ovarian, cervical, lung, gastric and pharyngeal cancers are among those diagnosed in the past year.)
And then there are those “usual” diseases with very unusual presentations. Severe systolic heart failure and a massive MCA-territory ischemic stroke with hemiparesis in the setting of a-fib may not seem so rare on your hospital’s medical ward, until you discover that it’s how an 18 year old female presented – the tragic, preventable sequelae of longstanding rheumatic heart disease.
In the past year, I’ve also helped manage…
- Three more cases of cardiac tamponade, including the return of that same woman I’d mentioned last year – bringing my total count of “urgent pericardiocentesis” procedures to four;
- Suspected Crohn’s disease – terminal ileitis/ duodenitis on an abdominal CT scan, in the setting of chronic diarrhea, abdominal pain, and a 20-kg (yes, 44 pound!) unintentional weight loss over the preceding 4 years. This gentleman had been seen at countless hospitals all over South Asian, each time given the diagnosis of irritable bowel syndrome…
- A 30% pneumothorax incidentally found on a screening chest X-ray for a 26 year old male’s pre-employment physical;
- A newly-diagnosed 3-cm atrial septal defect, mitral-valve rheumatic heart disease, massive atrial enlargement (9 cm x 7 cm!) and afib/RVR in a 58 year old female whose initial presentation was palpitations
- End-stage liver disease with portal hypertension and severe tricuspid regurgitation due to pulmonary hypertension (PASP’s in the 70’s) in a 28 year old female with no prior history of alcohol or tobacco use. We suspected alpha-1 antitrypsin deficiency – a “hoofbeat” diagnosis, maybe, but this is after all a land of zebras. We weren’t able to send off any confirmatory tests for it, though.
Every one of these “interesting” cases, of course, represents the suffering of an individual human being. Each has their own story, their own family and friendships, their own loves and fears, their own unique personality quirks. They come seeking relief from their symptoms, answers to their questions, names for their problems, cures for their ailments. Yet here, all too often, the diseases are far advanced and the treatments limited by cost or availability.
Yet sometimes we are able to help, and it’s immensely gratifying to see. I think of Mr. Kumar,* a man with severe asthma who returned to our ER only a few hours after his discharge earlier that morning, back with yet another huge flare of bronchospasm. His chest was profoundly, ominously silent. Saturating in the low 50’s, his lips were a dusky blue. He lay on the gurney, barely conscious, laboring to breathe with the desperation of a dying man. None of the usual treatments – oxygen, IV hydrocortisone, stacked albuterol nebs, a theophylline drip – made any difference. (With just one ventilator and no way to check a blood gas or bicarb level, mechanical ventilation is unfortunately not an option for the vast majority of our patients.)
He finally began to show signs of improvement with a slow bolus of IV magnesium, buying enough time for the steroids to kick in. Against all odds, this gentleman survived the night and walked out of the hospital ten days later. It was truly a miracle – a beautiful answer to prayer, when all too often it feels like those prayers for healing are answered with a “no.”
*name changed for patient confidentiality