On Call

I have always found the term ‘on call’ slightly misleading in medicine. In most jobs where I have worked the term rarely refers to sitting at home waiting for a call more often it has referred to 24 hours plus hard slog. In St Francis as in any hospital the doctors share out night and weekend on calls. There is no bleep or mobile phones – the security guard comes to find you – but otherwise things run pretty much the same.

Apart from the type of cases seen that is. Call on Saturday started in the paeds ward which is quite compared to busier times of the year. First up ITU only about six children here seriously ill from malaria or pneumonia, unfortunately one child dies during the round despite resuscitation attempts. Most of the others are doing ok, some need blood, transfusions are generally only given if Haemoglobin less than 5, a couple need NG tubes siting as there oral intake is not good and they will develop hypoglycaemia unless they get glucose water.

Next up is the acute malnutrition area. These are mostly children under two though there are some older. When many arrive they are acutely unwell, oedematous and septic. Most are on broad spectrum antibiotics. Feeding is commenced on F75 and then move on to plumpy nut (F100 is currently not available in the hospital). Some of these are very complex cases being HIV positive from maternal transmission or being on TB treatment.

After that the rest of the paeds ward seems like a breeze. Most of the children here are no more unwell than those on paeds wards at home, many are ready for discharge some need a day or two more, some that are not doing so well need changes in treatment or further investigations. From there it is onto the babies room for more of the same.

Paeds done we can move onto the adult wards taking one side each. In the male side St Augustine I start in the ‘ITU’ which isn’t exactly what we are used to at home, this is simply an area near the nurses station where the patients are under closer supervision and the wards two condensers for oxygen are located. Here there is a young man in an unconscious state following an alcohol binge a few days ago with aspiration pneumonia and possibly had a head injury. There is a man who is HIV positive and has a pneumonia occupying pretty much all his right lung, he gets to have one of the oxygen machines.

Next up is a man who has renal failure secondary to diabetes and complicated by pulmonary oedema. His creatinine is higher than what the lab can measure here but renal dialysis is only available in Lusaka. The next patient is extremely unwell. He has advanced HIV, TB and has now presented with abdominal pain and vomiting blood, he is in hypovolaemic shock needs fluids and blood, is to unwell for the surgeons to take to theatre and unfortunately has a very poor prognosis.

Beside him is a teenager who presented with new onset cardiac failure with cardiac failure and valve disease on echo. He is being treated for infective endocarditis. The man across form him is HIV positive and has presented with a 2 week history of severe headache and neck stiffness. He has no neurological signs but is confused and non compliant with attempts to perform a lumbar puncture. After some intravenous diazepam I manage to do the LP, his CSF is clear but comes spurting out under pressure (normally comes out like a tap dripping). Immediately after the LP he has had great relief from his headache, the analysis of the CSF will probably show cryptococcal meningitis an opportunistic fungal infection not uncommon in HIV patients.

From the ITU it is onto the rest of the ward all 30 patients don’t need seeing just the sick ones the new admissions and ones fit for discharge. When I am done there I head to special care baby unit where premature infants are cared for in cockroach infested incubators in an uncomfortably hot room off the maternity ward. A child born a few hours ago has just being brought in. The child has Gastroschisis where most of its intestines and stomach contents are outside its body. At home this would have been picked up on ante-natal ultrasound and the baby delivered in a specialist unit and presented to neonatal surgeons for corrective surgery. Here there is nothing we can really do.

After that a two day old premature baby is brought in. She has not fed, passed urine or opened her bowels since delivery. The family have given her some herbs to see if this will help. She is flat, cold and hypoglycaemic. Despite efforts at treatment she later dies.

I enjoy a short break before beginning the evening round back in paeds. First reviewing the ITU patients and then see the new admissions. Most of the eight new children who have arrived have fever, vomiting, diarrhoea, cough or a combination of these. In a normal GP on call at home I would see very similar children but I am definitely more nervous of a child with a fever here. After seeing these I head back to the adult wards to do the same review the ITU patients and see the new admissions. In St Monica’s I discover one of the patients in ITU has passed away. She again had HIV and had been extremely unwell.

After the evening round in St Augustine I am informed a new patient has arrived and is extremely unwell. He is 28 breathless, sweating, with a slow heart rate and extremely anxiety and restlessness. His brother informs me he has taken some cotton insecticide. A quick search through a useful St Francis hospital guideline booklet informs me he has organophosphatase poisoning and I need to treat him with repeated doses of intravenous atropine.

Between the doses I take out my palm pilot and read about this in the Oxford handbook of A&E medicine. It details a multitude of investigations which I should carry out, none of which are available to me. Thankfully the treatment is the same and it advises me on signs to watch out for when the patient is appropriately atropinised. After he is settled I found out that this young man is single, suffers from epilepsy and has poisoned himself on a previous occasion. After this I retire for some sleep.