The past few days I've been working on the pediatric infectious disease ward.  Not surprisingly, I've seen a lot of things that I suspect are pretty rare in the States.  And the senior house officers (ie residents) are great at teaching, just like the peds ID service back home.  It must be something about the peds ID culture.

On my first day, I got a tour of the facility.  It's a one floor unit with two larger wings and a couple of smaller rooms for very ill neonates and one for patients with tetanus.  The room for the tetanus patients is dimly lit to minimize stimuli that might precipitate spasms.  I've only been in their briefly, but from talking with the residents, they are mostly managed with anti-toxin and benzodiazepines.  During rounds on my first day I was in the neonate room when I started hearing the deeply pained cries of a mother who had just lost her son to tetanus.  The body, wrapped in sheets, was carried past us into another room.  We heard the mother's cries for the next few hours and one of the residents told us of a few other cases of kids that died because from tetanus and pointed out how awful it is that kids die from a disease that's preventable with just a 'jab' as she put it.

The main things I've seen here are septicemia, malaria, meningitis.  The main test that is done early on in the workup of most patients is a blood smear (B/S) to rule out malaria and evaluate for sickle cell anemia when appropriate.  Another test that gets ordered often is a hemoglobin level.  It's not uncommon to see hemoglobin levels of 2.0 to 5.0.  The liver function and renal function panel interestingly (to me) has gamma-glutamyl transferase instead of alkaline phosphatase, which I'm guessing is due to the better specificity of the GGT but maybe it's a cost thing.  I'll have to ask or look that up when I get a chance.  Then the complete bood count is done pretty commonly followed by hemoglobin electrophoresis (which costs about $7-8 US).

Many kids are on antibiotics for septicemia (ceftriaxone mostly) and quinine (for 3 days and then 3 days of artemisin combination therapy) for malaria.  The artemether (an antimalarial) is often given intramuscularly in a childs gluteus muscles.  One kid today was having some right leg weakness that was likely due to administration of the artermether dose too close to the sciatic or other nerve in that area.  The resident said that it's not uncommon for this to happen and that he's seen many cases of patients that have long term neuropathies (like a foot drop).

Today I saw a child with a diagnosis of post-measles encephalitis who presented with fevers and convulsions about 1 week after recovering from measles (a vaccine-preventable disease). 

Yesterday I saw a patient with hepatitis B (another vaccine-preventable disease) who presented with fever, vomiting and diarrhea (no tender hepatomegaly).  The patient's sister was in the bed next to him and might also have hep B though the differential currently includes abdominal tuberculosis and typhoid fever.

Today we saw a patient who has had jaundice for several months that we suspect is hepatitis A (again, vaccine-preventable).  For the patient with hep A, we ordered a PT (prothrombin time to assess the liver's ability to synthesize proteins) to get an idea of whether the patient was at risk for hepatic failure.  Because the patient doesn't have the means to pay, we took the order to the appropriate office to get the 20,000 USH ($8 US dollars) for the test.  Unfortunately the secretary in charge of distributing the funds was out sick so the team decided to front the money.  We went to the lab to place the order and get the appropriate tube, but apparently the lab is out of the reagents necessary to perform the test.  Tomorrow we're going to decide whether it's necessary for one of the patient's family to go to another lab in town to get the test.

After finishing on the ID ward on Monday, I headed to the pediatric acute care service.  This is where parents bring their kids where they are initially triaged.  There was a kid having a sickle cell crisis who was having decreased movement/strength of his right arm, likely due to a stroke.  He was getting transfused and hopefully his right arm weakness improves. 

For another patient who needed an urgent transfusion, the resident took a sample of the patient's blood for ABO typing and did the agglutination tests on a broken tile.  

I also helped one of the residents do a lumbar puncture for a patient with suspected meningitis.  It's actually fairly common for patients' parents to decline a lumbar puncture so often the kids are empirically treated with antimalarials and antibiotics.

In other news, my camera was stolen from my room so my posts are going to be lighter on the pictures.