4 Brief Cases from a Surprisingly Encouraging Clinic

 (from Eric)

(Note: These windows into my life and work are undeniably medical.  My experience is that the non-medical folks divide pretty quickly into the camps of "Boring!" and "So fascinating!"  I offer this in hopes that it will be helpful to medical readers as well and those non-medical folks who find such things interesting.)

For many years, Wednesdays have been my day for offering Internal Medicine specialty consults.  It started as a small clinic, and has steadily gained steam to the point that it's quite a long, busy day every week.  I have (somewhat) jokingly also called it my "bricks without straw" clinic, or alternatively my "everyone gets amitriptyline" clinic.  Suffice to say that managing complex chronic medical diseases in our context is often really hard.  Some days are quite exasperating, but there are usually some people that I feel that I've been able to really help.  Aside from that, I always have a post-graduate intern doctor with me and a couple medical students, so there are also unique educational opportunities.

This past Wednesday was a public holiday in Burundi (commemorating the death of President Ntaryamira in 1994, who was shot down in a plane with then Rwandan President Habyarimana).  Technically, this would mean I wasn't seeing consults like normal, but I figured I might as well be there.  It turned out to be a pretty busy day, and most of the people who came had been given a follow-up appointment for that day after past visits or past hospitalizations (because we forgot it was a holiday).  In the end, there were a number of really encouraging moments, and I thought I'd share 4 of them, both for the purposes of encouragement and interest.

1. Leonidas is a 35 year old man who was hospitalized on our service a couple weeks ago.  He came in with whole-body swelling (imagine an enormously swollen person and then double that) along with trouble breathing that needed oxygen therapy.  His swelling seemed to be from a severe kidney disease (mixed nephrotic/nephritic for medical folks), but his lungs were super wheezy, which

 seemed weird (though not impossible) for the expected "water on the lungs" that seemed most likely for him.  We were giving him huge doses of IV Lasix (to try to help him pee off the excess fluid) with absolutely no effect.  We had a thought that he could have a rare inflammatory vasculitic syndrome that was causing his lungs and kidneys to both fail together.  In absence of any tests to confirm that, and with his life obviously threatened, we started him on steroids.  His lungs were getting better, and he got off oxygen, but given our failure to get his swelling down at all, we recommended he go to Buja to see a kidney specialist, and he agreed.

    Fast forward to clinic, a man walks in, smiling at me, and I don't recognize him in the slightest.  It's Leonidas, whose kidneys started working, and our medicines caused him to lose OVER 25% of his body weight in fluid.  He's walking around and feels quite good.  I'm shocked, and we laugh together at the surprising goodness of it all.  Turns out he didn't have any money to go to Buja, so he's been haunting the hospital grounds for a couple weeks, waiting to see me in clinic.  I was afraid all our medicines could have hurt his kidneys more with such a dramatic response, but they are almost back to normal.  We adjusted his meds, and set him up to come back in a month.

2. Gloria is a 48 year old woman hospitalized last month with new onset diabetes who came in in a coma from diabetic ketoacidosis (DKA).  Despite the low mortality rate of this problem in the US, most of these patients used to die here.  Starting around 3-4 years ago, we found a way to reduce the cost of blood sugar testing at the bedside, which enabled us to test more frequently, and patients generally do much better.  Gloria had the added blessing of showing up when Carlan was in the ER, which meant a quick diagnosis and initial treatment.  She went home after about 5 days.  We stopped her injectable insulin (super hard to maintain in a village home with no electricity), and hoped her metformin pills would do the trick.  They're working beautifully.

3. Esperance is a similar lady, but she's only 16.  She also came in with new diabetes and a coma with DKA.  We hemmed and hawed about stopping her insulin to try pills.  It shouldn't work.  She should be dependent on injectable insulin.  But here's the funny thing.  Here in Burundi, I see numerous young skinny patients with diabetes who can be well treated with pills for years.  Given how huge of a difference that makes in their lives in this context, we usually try and usually succeed.  But 16 years old?

    As it turns out, I wasn't around the day she came back, and our Burundian doctors tried the pills.  Their gamble paid off, and she is doing great.

4. Charlotte is a 52 year old lady that I diagnosed with severe heart failure (ejection fraction of 15%) in 2017.  She easily would have died around that time without intervention.  She has been incredibly faithful in taking her medicines and coming back every 6 months to see me, even though she feels totally fine and is able to farm in her fields like everyone else.  We rescanned her heart, and it's still obviously sick, but significantly better than 5 years ago.  She'll continue a half-pill twice a day and we'll see her again in October.  We thanked God together for the past 5 years of health that she has received.

A view of my consult room.  I didn't see this lady last week, but she's been seeing me for years and always comes at the end of the day full of smiles and joking.  She's my biggest fan.