First, we had a case of true eclampsia, not pre-eclampsia. Good efforts are made at prenatal care, but there is not 100% penetrance. This 20 year old young lady came into Casualty with seizures, hypertension, and was at ~32 weeks gestation. Fetal heart tones could not be heard. I went down to Casualty to speed up the admission process and tried to identify fetal heart sounds with an ultrasound fetoscope, but could not (and taught one of the Casualty sisters how to use a Doppler ultrasound in the process). She was brought to ICU, put on magnesium, and the OB-GYN tried to induce her with a misoprostol cervical insert. When labor did not occur in the overnight, Dr. XX and I had a discussion in the morning about how a Caesarean was not only about protecting a viable fetus, but protecting the mother as well, which was apparently a new take on the situation. When mom continued to manifest renal insufficiency and hypertension the day after her admission, the doc did a Caesarean and mom stabilized nicely. All's well that ends well.
The other case that was of extraordinary interest is a case of mild to moderate tetanus. Although not rampantly common, it does occur here, perhaps once a year or so. Typically, it is a rural person (this nice fellow is a farmer), and often the offending injury or puncture can't be identified-- life is kinda rough and tumble in the boonies and small cuts, punctures, and scrapes are part of life. I am not sure about tetanus immunization. My anesthesia colleague and I discussed this at some length, and apparently routine DPT immunization and injury-related immunization are not terribly prevalent.
In any event, an extremely astute district doc diagnosed tetanus when this fellow came to the local hospital with painful muscle spasms, and he was transferred to JDWNRH. An equally astute internist here (aside-- Dr. Yangchen is a lovely person, smart as anything, and dedicated. I'd let her take care of me in an instant. Over the past week she's been coming to the ICU regularly and we've had a great time together on these cases.) wrote management orders that could have been lifted from the Treatment section of the UpToDate article on Tetanus. Unfortunately, we did not have tetanus immune globulin.
Having never seen a case, I read up as best as I could. I felt silly offering any input given my lack of experience so I kept my mouth shut. The one aspect where I could weigh in was on whether or not to paralyze and ventilate the patient. Initially, I chose not to do so. He was only having a few spasms per hour, could swallow, and we were able to markedly reduce the severity and painfulness of the events with diazepam and morphine, and I was balancing comfort against having this man ventilated for a couple of weeks. In the end, after a couple of days, when his CPK was 6600 we collectively decided that the risk of renal injury tipped the balance in favor of paralysis. JDWNRH had never done continuous paralytic infusion before, so we worked through continuous sedation, paralysis (complete with infusion calculations) and ancillary issues such as a wakeup every morning, frequent turning, feeding, etc. This was a good experience all the way around, for me learning from my colleagues about this illness, and my giving back a bit in terms of sedation and paralytic management.
I've blocked the man's eyes for privacy, but his mouth shows typical "rictus sardonicus" of tetanus. Happily for him he was not having full blown opisthotonos:
On a far less technical note, I had a lovely dinner at the home of one of the nurses, Damcho. I had seen a couple of her family members for her, and she invited me to her home for dinner. She had two wonderful young kids, who spoke English very well, and the little girl (a real firecracker) flipped back and forth between calling me "Uncle" (appropriate address in this culture) and "Your Majesty" (decidedly not!). Damcho's sister, also present, had married an American grad student; he was there as well so I was able to have some very comfortable conversations as well as interacting with the rest of the family. The meal started with some drinks and snacks, followed by several different dishes including ema datse (chilies with cheese), a mildly spicy chicken dish, a mildly spicy mixed vegetable dish, and mashed potatoes. Everything was delicious. These are solid, middle class folks with some disposable income, yet they live in hospital subsidized housing and do not have central heating. We sat clustered around a wood stove with plates on our laps, happy and comfortable in the radiated heat. Dinner ended with what, unfortunately, I found to be an utterly undrinkable concoction of fermented rice, the liquid containing the alcohol, and butter (hot). It tasted kinda like rice porridge mixed with yeast mixed with vodka mixed with butter. Definitely an acquired taste. Not drinking it was expected on the part of my hosts; they thought my reaction was pretty funny. Damcho's father was also present. He spoke no English, but participated in the meal. He and I exchanged bows/head nods at the beginning and end of the visit, but nothing else. As in other homes and places I've visited, the King's portrait is displayed prominently. In the master bedroom, one wall was essentially a religious shrine with statues of the Buddha, prayer flags, wind socks literally covering the wall. It was actually quite beautiful. My host gave me a ride home to avoid the dogs.
Next: the long awaited entries on food and "La Vie Quotidienne"
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