Diagnostic dilemmas are constant here. This comes from the fact that to diagnose different diseases there are a limited number of tests available, and even those are made more limited by patients refusing to do the ones we desire. Most often they want tablets but not tests. The Nigerian patients that come here want both. They are a select few who have some money, are unsatisfied with their own medical system and come here because there is a foreign doctor. They frequently request ultrasound and x-rays because they feel that that is where their pain (“worry” as they describe it in Pidgin English) will be diagnosed. They often want to see where the wound is that hurts them inside.

So an old, very thin (likely between 80 and 90 lbs) sees me in the office. She is deaf and mute. Her son talks to her with gestures, which make no sense to me at all. He somehow has deduced that she has pain in her chest. He says that she has had this for about three months. She has not had a cough but just pain. I listen to her chest and hear breath sounds on the left but very muffled ones on the right. I tap and hear a dull sound, she is full of fluid. I request an x-ray, and they agree and go to pay the $7 to get it. She is lucky because this day we happen to have electricity. It has been out every day for 1-10 hours for the past 5 days. The chest shows a complete white out on one side. I do a tap with a needle and find dark yellow fluid that the lab says has some gram + cocci in it. Infection? Contamination of specimen? It is unclear. But the fluid needs to be drained.

When I first arrived at Koza there were no chest tubes here and I used a urine catheter for my first one. Today we have two sizes so the student missionary and I select the smaller size and numb up the area of insertion. We prep her side and hold her hands out of the way as she is contaminating the field demonstrating where her pain is again. Her son and another nurse hold her arms. We put the tube into her chest and get 1300ml of fluid. She coughs and appears worse for a little while. Maybe I should have let off the fluid a little more slowly.

Over the next few days she drains about 800ml a day. She is getting thinner by loosing all the protein every day in the fluid. Or I assume that’s what’s happening. So if I take out the tube all the fluid will reaccumulate and I don’t have anything for plurodesis (making the lung inflamed and stick to the chest wall, effectively stopping the fluid collection). So eventually I talk out the tube. She reaccumulates the fluid and I let her go home. I’ve treated her with broad spectrum of antibiotics; we are currently out of TB medications. The government supplies these for free but when we ordered them they said they had run out in the far north. So free TB meds doesn’t help when there are none. And since they are free none can be bought either, because there is no black market desire for them. So she reaccumulates her fluid and goes home in a day or two. Another dilemma unsolved.

The same thing happens in the room next to hers. There is a man with huge ascites. I drained off about 15 liters the other day. He had a tense belly for a month. I drained a lot off and he lost 9kg with the fluid extraction. His abdomen was large but then not tense. The peritoneal tap showed no bacteria. I treated him for schistosomiasis, TB, abd peritonitis, other worms, and a loop diuretic (water pill). He does not appear to be improving either. Is it cirrhosis from his long time millet wine usage? Possibly, but I can’t treat that other than, encouraging him not to drink. So another dilemma unsolved. I know these same dilemmas can happen in the US, but it is so much more frequent here. This is the frustrating reality of third world medicine. Greg

Shanksteps #158

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