I got to work an hour early today. I knew it would take me some extra time to get use to the system, the system of actually finding patients. I'm not too sure how many medical wards there really are, but there are quite a few, and they are scattered about.
I think there are about 10 general medicine wards, each holding 65 patients. As best as I understand it, each general medicine team has 2 wards, a male and a female ward. Teams are on call every 5 days, and take all the admissions for 24 hours. The day of call, some patients from that team will be sent to wards with free beds to make space for the admissions. And then when the new admits have filled all the beds on the ward, the overflow admissions will go to other wards.
The average number of admissions seems to be well above 100 -ONE-HUNDRED, and probably closer to 130+
So, I admitted 3 patients last week. One on Thursday, and two on Friday. And it was my goal to locate them all by 8:30 am, and to have hopefully rounded on at least one, or two of them before meeting the consultant at 8:30. I started with what I thought would be the easy way of finding the patients. I looked in the lab results of the computer, hoping that they had labs done over the weekend, and that the lab results would say which doctor (in which ward) had ordered the recent labs. And, so I randomly picked a medical ward to go use the computer. (I had to fight the urge to go back to the pedi admission ward, or even ward 18 to use the computer). As luck would have it, I ran into a resident there who I knew from my time in pediatrics. (She doing her mandatory community service at Bara). And she was kind enough to inform me that the computer in her ward didn't work. So I did the next logical thing, or so I thought, I headed to the next ward, and searched for the computer. Same story, not working. But, while I was there, I skimmed the book to see if the patient was on the ward.
The bloody books. The manual record of who is on the ward, or who has been transferred to another ward. The is no computer system to indicate where patients move, but rather one relies on multiple log books of patients. And no success in that ward. So I moved on to a third ward, as I looked at my watch and realized that it would be less likely to see 2 patients before 8:30. Strike 3.
Somewhat getting desperate, I decided I would head to pedi land and use the computer there. And as I was walking to pedi, I passed the same resident from earlier, who told me to pop into the medical admission ward and use the computers there. Which I did.
Patient #1- no labs since admission. Not helpful.
Patient #2 and #3-no ward indicated on the lab computer.
Shit. Now I don't know where they are. But at least I have some lab results.
I run into the resident again, and try to figure out how to find these patients. And it's simple. Knowing what day they were admitted, means they were allocated to either the male or the female ward of that team that was on call that day, and then all I need to do is head down there and look in the books to see where they are. And here I've spent the better part of half an hour to learn this.
I head to the male ward (16), to see Patient #3. I saw him in the clinic on Wednesday. Nice guy, 52 y/o male. On HIV treatment for 3 months now, and on TB treatment for 2 months. But he's lost 7Kgs (about 15 pounds) in a month, has a horrible cough, and just has that unwell appearance which made me think that something bad is going on, or something is being missed. So, since I saw him late on Wednesday, and they were done drawing bloods in the clinic, I send him out with a lab form and instructions to come find me in the clinic the following day to review his results. To make a long story short, his results were all out of whack, new kidney failure, worsening liver function tests, and he didn't come find me on Thursday. So I called him back and saw him on Friday and admitted him to the hospital. Since his admission, there really hadn't been much progress in his work-up. I find him in the ward, don't really have time to write a note on him, since I haven't even found the other 2 patients yet, but we chat briefly, and I glance through his notes. It'll be nice to come back and see him later and leave better instructions about which tests I'd like done. He likely has either MAC, or MDR-TB, or Non-Hodgkin's Lymphoma, plus his renal and liver issues.
Patient #2 was admitted the same day as patient #3-so she must be in the female ward (15) of the team that was on call on Friday.
So, on Friday, as I was writing the admission letter for #3, there is a knock at the door, and the sister opens the door.
"Doctor, the next patient is sick, can you see her?"
Of course I think "no" let her see a consultant. But I'm here to learn... "Sure, let her stand outside the door while I finish writing this note."
I send off patient #3, and then patient #2 is wheeled into the room by her aunt and uncle. And she looks like crap. She will have to be admitted. Turns out she's 26, was seen in the HIV clinic back in October, but then never came back for any visits. And today is brought it to our clinic by her aunt and uncle who are worried about her, rightfully so. Her CD4 count is 60. She has a weeks worth of a horrible headache, as well as she can't swallow anymore because of the pain. She also has Kaposi lesions all over the face and her arms. She's unwell. She's going to need a lumbar puncture (spinal tap), lots of labs, and empiric treatment for a bunch of stuff. I check her vitals (I know-it's a universal... I don't even ask ancillary staff anymore to check vitals.. I just do them myself). Heart rate of 160, BP of 82/54, RR of at least 30. (Ok I didn't formally count the RR, it was at least 30, and I didn't want to know if it was 40, or 50). So I ask the consultant to see her when I'm done with my note, and he agrees, book her for admission.
I'm walking into the ward, and I look over her results. Her lumbar puncture is actually bland. Will have to see what grows out on the cultures. I hope they've started her on antibiotics. Her other labs show bad acidosis on admission, which improved a bit as of yesterday. There are blood and urine cultures pending. I'm thinking what my plan will be for her. She's unwell, and needs to get on HIV treatment, fast. But she may need TB treatment for 2 weeks first...
I look in the book, and she's in bed 14. So I walk down the ward. Curtains are closed at pts are getting bathed. And I peek behind curtain 14, and the sheet is pulled up over her head. For a minute I wonder if she's been having chills with fever, but then I realize that it's also tucked in around her body, and she's not really moving.
She's dead. Too little. Too late.
