Call

Last night was my first call shift in what is called the 'adult filter clinic' (AFC) in Zambia. Emergencies basically get sent to either surgery or medicine here, and the AFC deals with the medicine cases.

There were, again, a large number of unusual cases. You would expect lots of HIV / HIV complications + malaria + all those tropical diseases, but but you might not expect (I definitely didn't) was that there are a huge number of patients who come in to the emergency with organophosphate (OP) poisoning from attempted suicide. OPs are a common pesticide that basically act on the body in a similar way nerve gas would. It is unbelievable how many OP overdoses are seen - I would estimate 1/4 to 1/3 of the overnight emergency caseload! I've been told that rarely is the suicide attempt genuine, and that generally speaking the people who OD on OPs are doing so to draw attention to themselves. I really do hope that there is some sort of mental health follow-up for the truly suicideal ones :(

There was also a patient yesterday who came with decreased level of consciousness and a history of DM and HT. When we got the lab results back, we found that the GFR was 2 and his potassium was 8.3, and that the decreased conciousness was from uremic encephalopathy. Apparently, uremic frost is also quite common here... at any rate, my resident basically told me the following in regards to his management:

"In Canada, this fellow might be an ideal candidate for hemodialysis. In Zambia, he will not get hemodialysis - we only have a few machines and reserve them for people with reversible renal failure"

So, we gave him supportive treatment, but his prognosis is quite poor in the long run. Alas, an example of how deficient even the best-equpped hospital in Zambia is.

On that note, in our emergency room the only equipment we have for resuscitation is an oxygen tank. No defibrillator, no ventilator, no monitors, and we often run out of fairly basic medicines. I've been told that there isn't even a working defibrillator in the entire hospital.

unusual cases

As far as I can tell, the three most common (serious) presentations in internal medicine in Canada are myocardial infarction, lung/breast/prostate/colorectal cancer, and COPD. In Lusaka, things are a little different. I get the feeling that the internist's bread-and-butter here is TB pulmonary infection with HIV co-infection. A few of the random things I have seen I list below:

1) Cryptococcal meningitis - fungal infection of the brain that only occurs when cD4 counts drops to a certain level in the presnce of HIV
2) Miliary TB - a pattern of TB on the X-ray that looks like little nodules (millet seeds) everywhere in the chest
3) MDR TB - we went to see a patient, and before I realized it we were in the TB room. Everyone just walked in, no masks or anything. After I left, my doctor told me the patient didn't just have regular TB, but MDR TB. So much about immediate respiratory isolation when TB is suspected!
4) Chloramphenicol - a cheap, powerful antibiotic that isn't used in Canada since it causes aplastic anemia but that is quite common here
5) Peripartum dilated cardiomyopathy - we didn't ever learn about this in class... it is a variant of dilated cardiomyopathy found in pregnant / post-partum women - usually reversible, but can present with cardiogenic shock

There are also quite a few cases of hypertension and diabetes, which I found surprising. Interestingly, it seem that the hypertension here tends to cause heart failure, as opposed to MI, most often...