Pediatric Mortality Meeting

It's pretty much as gruesome and disturbing as it sounds.

Today was my first day of pretending to be a doctor again (yay?) and using my stethoscope and otoscope for the first time in over a year. Apparently, using a stethoscope is just like riding a bike, but using an otoscope requires a little bit more thought to figure out. It's kinda sad how much better at this stuff I was as a second-year medical student than I am now as a third-year preventive medicine resident.

Anyway, I was in the pediatric ward today, and after the initial "so what year of medical school are you in?" and "let me tell you what pneumonia is", I got back in the groove of doing things. The woman I was with is a clinical officer intern, which is pretty much the same amount of training as an entry-level PA (physician assistant). She had three years of post-high school school, and now needs to complete her internship before she'll be certified to practice independently. For the most part, she was pretty good at what she does, but there are some things she did that were just blatantly wrong, like trying to count the respiratory rate of a crying toddler and attributing upper respiratory noises as lung noises (when the patient is breathing through his/her nose and you listen to the chest with a stethoscope, you can hear the sounds from the nose), which she interpreted as pneumonia. The most common diagnoses in the pediatric ward, at least based on what I saw today, were "pneumonia" (blanket term for any respiratory tract infection, it seemed), dehydration from diarrhea, and malnutrition. There was usually an overlap with two or all three of those.

I caught one of the clinical officers sneaking out of the ward (he wasn't really sneaking and in fact announced where he was going) on his way to the mortality meeting, so I decided to join him, because it sounds fun and cheery, right? Mortality meeting here is what we call Morbidity and Mortality in the States; it's a chance to look at things that didn't have the outcome we were looking for (I think we can all agree that death in a kid is not the ideal outcome), examine them closely, and figure out if there's a way that the system could be changed to prevent a similar death from happening in the future.

This mortality meeting was specially for the newborn unit, which is the closest thing Malindi District Hospital has to a NICU. There were 97 admissions to the NBU in June and nine deaths, each of which was discussed (the deaths, not the admissions, or we'd still be in the meeting). One was very clearly not anyone's fault; it was a baby with a laundry list of congenital abnormalities, including a small head, small ears, abdominal distention, and polydactyly (extra fingers), which I'm guessing was Trisomy 13 (three copies of the 13th chromosome), which is fatal within the first month of life in most cases in any country. There was also a case of hydrocephalus (swelling of the brain) which requires neurosurgical intervention to place a shunt. Three babies were premature at less than 30 weeks of gestation and would be NICU babies if they were born here. The other four were neonatal sepsis and the only four that I would consider to be preventable deaths in this setting. By that I mean that if everyone was on top of things--the parents brought the kid in early enough, the diagnosis was caught right away, the right antibiotics were given right away--the kids might have pulled through. Those are the cases these mortality meetings are made for, because it let them see where things went wrong and how they can fix it in the future to keep it from happening again.

Mortality meeting ended up going through the usual lunch hour, so I had a late lunch of Kenyan food (it seems to be Kenyan food for lunch, European food for dinner), which was much better than yesterday's Kenyan food. Nothing terribly exciting--fried chicken with rice. I think every culture has some sort of fried chicken as a dish.

Since there's not much happening in the afternoons, I swung by the safari office and shelled out the money for a two-day safari (either this weekend or next, depending on availability). I'm still suffering from sticker shock, and I'm still pretty sure the combination of the safari coordinator and my driver overcharged me. For some reason, I had to pay an extra $56 because I paid in Kenyan shillings instead of American dollars. Does that make sense to anyone else? I'm sure I'll have a great time on the safari and forget about the money, but until then, I need to get to my bank's website to move some money around.

Tomorrow: more pediatrics wards (but not more mortality meetings).

Pediatrics Clinic

I actually started in the peds clinic at NNMC (Bethesda) on Friday, after returning from C4 on Thursday (and I'll start posting entries from C4 as soon as I'm done with this one), but nothing really exciting happened then, and I didn't think anyone would want to read about the kid with the scraped nose or the other kid with the flu.

Anyway, the way peds clinic works for transition year interns is that we aren't assigned patients (as the pediatrics interns/residents are), but choose an attending and work with them. Today I tagged along with a pulmonologist, because the idea of doing well-baby checks was really boring to me. The morning was mostly asthma patients (not that exciting), but we did CF (cystic fibrosis) clinic in the afternoon.

Depending on the patient's age and how he or she is doing clinically, patients are seen either quarterly (every three months), semi-annually, or annually. Overall, it's a pretty simple appointment--ask them (or parents) how they're doing, if they get short of breath, energy level, any GI symptoms, and what kinds of medications they're taking.

The first two patients were siblings, a 22-month-old boy and his eight-month-old sister. Both of them were doing really well, so that was good. Like I said, pretty simple appointment, and we ended up just telling the father to keep doing what they're doing and come back in three months. The third patient, on the other hand, is not doing so well. She's seven and has been pretty sick (pneumonia, diarrhea, etc) for about five weeks. At some point in there, she had the flu (don't know if it was seasonal flu or H1N1) and had a course of Tamiflu, which definitely didn't help the nausea and such. Then her cultures came back as a bacteria in the Mycobacterium family (same family as TB), which automatically buys her at least a year of four more antibiotics, in addition to the other medications she was already taking.

All sorts of fun. Really.