More Medicine Again

We've had an interesting few days medically in old Thimphu. My young woman with peritoneal sepsis went into cardiac arrest and died over the last weekend. Really a shame. She was treated well,but had waited so long at home that we were really behind the eight ball before we even started.

A 30 year old fellow was admitted with Ludwig's angina:

This brought up the interesting question of antibiotics in a resource poor country. According to UpToDate, the treatment of choice is ampicillin/sulbactam. The closest place to get this drug quickly was Bangkok, as this is not on the Bhutan formulary. He was under treatment with ceftriaxone (for some reason, they have lots of ceftriaxone) and metronidazole. UTD said that PCN and metronidazole would be a very acceptable alternative, and I recommended that because they have both PCN and MTZ. This man is a friend of the king, so a physician associated with the royal court requested that we continue ceftriaxone because he was already on it and it was working. So, my young friend is on PCN/MTZ/CTX. He is doing quite well. I did manage to convince the surgeons to obtain a CT scan of the neck before "exploring", as it showed there was no drainable collection.

My quadriplegic is doing poorly, and is uncontrollably septic. He developed purpura, almost purpura fulminans, over the course of a night, and is now having episodes of bradycardia. He hasn't been responsive for days.

The tragedy is that it may almost be better that he succumbs. There are no nursing homes, and no home mechanical ventilation. His family would be responsible for providing attendants for the rest of his life.He'd likely never leave the hospital.  We shall see what happens.

An old man was admitted with aspiration pneumonia and profound dehydration. He was really sick, and it was gratifying to see that my pep talks about fluid resuscitation were starting to gain some traction. The old fellow got six liters over the course of a night, and it probably saved his life. Unfortunately, he went into rapid atrial fibrillation from the stress of the events. I broke it with IV amiodarone; the anesthesiologist working with me was quite impressed and there was clearly a lesson learned. His weaning from mechanical ventilation was an opportunity to demonstrate a pressure support assisted spontaneous breathing trial with subsequent extubation. As I was getting ready to remove the tube, one of the nursing sisters came up to me frantically wanting to know why I hadn't done any T-piece trial. I showed her how we could use the vent to not only simulate the T-piece trial but get better monitoring while we did it, and I had another convert.

I gave a talk today on mechanical ventilation and a preliminary report of my needs assessment. Despite the fact that it was pointing out lots of areas where improvement was possible, the audience appeared appreciative and motivated.

My apartment mate leaves tomorrow, and I will inhabit this place alone.She is a good soul, and I have enjoyed spending time with her and learning about being a first generation Indian in North America. She's also been great to eat with. Much of Bhutanese cuisine is bastardized Indian, and she's shown me the ropes.

I'll get to that food posting one of these days. Tomorrow is national day, which is a big holiday. Hopefully I'll have some good stuff to show and tell.