BPC blog

Bad mix

admin — Thu, 24 May 2012 00:52:33 +0000

Three consecutive cases of mixed malaria on rapid test yesterday. Confirmed on smear (seeing trophozoites is so reassuring). Ages 17, 22, and 26. BEWARE Timor-Leste!!!

Dr Dan Murphy is the head physician at Bairo Pite Clinic

Lots done, even more to do

admin — Sun, 20 May 2012 23:12:50 +0000

He carried his 3 year old son from somewhere in Ailiu near the border with Manatutu to Bairo Pite Clinic. Why? Two weeks of unrelenting fevers and cough. Desperately ill with T 39 C and RR of 60/m he weighed in at 6 kg. We pull out all the stops and inject ceftriaxone along with the standard TB meds. Next day his breathing eased, looks like there is a chance. Thanks to an extraordinary caring father. So much for fatalism.

Dr Bayley here for 3 days. We disagreed on which valve was causing such advanced CHF in a 17 year old girl. He thought aortic and I mitral… ECHO resolved the Dx… severe tricuspid insufficiency≥the 3rd valve involved in rheumatic heart disease. Learn from a pulsatile liver! But will anyone do a valve replacement? In the meantime we give spironolactone.

One month of multiple granulating draining wounds of the hand following a puncture wound by a thorn. Decent chance of it being Nocardiosis. Already on trimetheprim/sulfa.

Ten years of independence for Timor-Leste. Congratulations. Lots of work being done. Even more yet to be done.

Dr Dan Murphy is the head physician at Bairo Pite Clinic

Another night’s work

admin — Sat, 19 May 2012 11:43:27 +0000

In the night Fernanda walked through the rain on a mountainous path for four hours carrying the tools of her trade. She is 23 years old and trained with us for three months to become a village dayan (lay midwife).

A native of Fatubolu she arrived in Manusai just in time to deliver a healthy baby and remained to be sure both mother and child were safe. Then the trek back to her home base.

Just another day's (night's) work but for those in the know it represents another page in the amazing transformation taking place in the isolated regions of Timor-Leste.

Dr Dan Murphy is the head physician at Bairo Pite Clinic

Dancing frantically

admin — Mon, 14 May 2012 00:33:29 +0000

Palpitations in a 22 year old mother of two… left ventricle dancing frantically under her blouse… irreg V-rate 160 as we admit
beta block
loop diuretic
benzathine penicllin

now ACE-inhib as rate slows to hear her systole
and warfarin to use our new INR capacity.

supplement with depo-medroxyprogesterone… how did she survive the first two?

and keep the faint hope alive for Dr Bayley's arrival in two days.

Dr Dan Murphy is the head physician at Bairo Pite Clinic

Enough is enough… or isn’t it?

admin — Fri, 11 May 2012 01:34:12 +0000

At risk of overloading your “consumption” circuits I am hopelessly overwhelmed and moved by our reality. Just a smattering of yesterday’s pathology parade: 34 year old carried in because she can no longer lift her legs… and oh, just to mention it, she has a 5 year history of a draining fistula near the posterior iliac crest… no clonus though… this cursed malady doesn’t always extend into the spinal canal… just impinge as many nerve roots as possible.

Then a 45 yr old Oicusse native trained in Russia as a Tentara airborne parachute commando (no, I’m not making this up) enters on a stretcher with a subacute chronically inflamed knee… by now we all know the diagnosis of monoarticular arthritis in the tropics… we communicated in a mix of Viqueno, Indonesian, English and Tetun… her Russian is minimal.

And finally a 9 yr old with the most spectacular case of phlectenular conjunctivitis I’ve yet to come across.

Oh, I forgot… a 35 yr old woman presented with 6 months of a 5 cm irregular breast mass punctuated by a draining fistula… any guesses on the etiology? We’ll see what happens in 1 week of Category I national protocol.

This in a single day! When people ask “How’s the war on TB going?” all I can do is shake my head.

Dr Dan Murphy is the head physician at Bairo Pite Clinic

More poison

admin — Mon, 07 May 2012 01:46:14 +0000

Although it's not routine for us yet this case shows how things can work…

22 yr old male failed after 3 courses of TB protocol including 2 months of streptomycin given twice… thin and pale with chronic cough his sputum was positive on smear… chest x-ray showed a hematogenously disseminated pattern…

But now our new twist came into play; state of the art PCR analysis… results… positive for Mycobacterium tuberculosis and more importantly, also positive for rifampin resistance.

Fortunately Dr John, an infectious disease specialist visiting from Colorado will help us design an appropriate MDR protocol and procure the meds as best we can. Every effort must be made to limit the detrimental impact of this condition on our fragile society.

Dr Dan Murphy is the head physician at Bairo Pite Clinic

Narrowing the gap

admin — Sat, 05 May 2012 03:02:41 +0000

Jump onto a plane and in a matter of a few hours you can experience the sharp contrast between the million utterly poverty stricken masses of TimorLeste and the 5 million privileged silver spoon inhabitants of luxurious Sydney.

I visited the the vast complex of Westmead Children's Hospital to link with their state of the art oncology service. How different from us administering chemo in what can appropriately be termed a shed in our ramshackled Bairo Pite worksite. I saw Manly with it's mansions and condominiums overlooking the sparkling bay and thought of Behau teeming with the downtrodden and malnourished in bamboo huts hawking woven baskets to survive.

Our fundraising launch was on the 15th floor of a crystal palace punctuating the already posh downtown skyline. The parking fees alone for our guests would go a long ways towards feeding our 50 in-patiens for a month. It went well and we are on our way to narrowing the gap.

My commitment is enhanced as I returned to a nation where most people wear the same clothes every day and live on a plate of rice and greens. At least access to healthcare delivered by those who know what is possible and are dedicated to moving towards that standard will be solidified.

Dr Dan Murphy is the head physician at Bairo Pite Clinic

TB (what else is there?)

admin — Sat, 28 Apr 2012 03:07:25 +0000

7 in the morning… time to put yourself on full alert because another obviously seriously suffering patient has just been helped into the consultation room…

I see the obvious baseball sized draining mass near the angle of the mandible… it has a bluish hue… she is cachectic… her ipsilateral eye won’t open and doesn’t recognize light… it’s been 5 months… multiple treatments in various facilities all to no avail… the process has eroded into her mouth and she has lost hearing in that ear…

35 years old, this woman has lost all hope and meekly responds in only a word or two when addressed… on rounds an hour later I told the medical students and nurses to look carefully at this case because it may be the condition most often misdiagnosed in the world. She is on high dose penicillin intravenously administered and has a good chance at recovery.

Dr Dan Murphy is the head physician at Bairo Pite Clinic

Hyper reactive knee jerk

admin — Thu, 26 Apr 2012 10:26:44 +0000

Brought by ambulance from Kasnafar… age 29… male… gradual loss of function of the lower extremities over 2 months… tenderness over the spinal processes of T2, 3, and 4… knee jerks hyper reactive…

My response is also a hyper reactive knee jerk… MYCOBACTERIUM TUBERCULOSIS!!

In remembrance of Sir Percival.

Dr Dan Murphy is the head physician at Bairo Pite Clinic

Change of learning strategy

admin — Wed, 25 Apr 2012 02:18:34 +0000

I asked one of our visiting doctors in training for primary care as she was in her last day at the clinic what she had learned from her experience. I was amazed at her response, “Everything I have done in the past has been wrong. I focus almost exclusively on sophisticated lab and imagining analysis and now I realize I know almost nothing about good history taking and how to do an appropriate physical exam. I will immediately change my learning strategy.” Of course it depends on the setting but I still find that something I can see with my own eyes or feel or hear is much more valuable than a report appearing on the chart.

I really enjoy the new textbooks I have received but get frustrated as more and more topics only refer to the website and internet is all but inaccessible.

Never would have thought praziquantel administration could be fatal yet that is what I think happened as we gave a recommended intense dose to the patient suspected of having neurocysticircosis and within 8 hours he appeared to herniate his brain stem dying in respiratory failure.

Fernando is back from NIH and none of the medications recommended are currently available in ET. Primary problem is PNH which to my knowledge has never before been diagnosed in this country. We could alleviate his need for repeated blood transfusions if we could only access Solaris or an unlimited supply of greenbacks.

Dr Dan Murphy is the head physician at Bairo Pite Clinic

Uncharted seas

admin — Fri, 20 Apr 2012 01:48:02 +0000

15 years old but looked more like 10 as she was assisted in a hesitating walk onto the exam room. “Tired” for the last 2 months… no strength to walk… maybe a few fevers and a dull headache to round out the picture. War weary I picked up her leg and rapidly dorsiflexed the foot and held it in the flexed position… the rhythmic response against my palm told me all I needed to know. I added streptomycin to the standard protocol and most likely prednisone in the next day or two. Frequent sequelae make this not infrequently an exercise in futility.

2 teenagers side by side ever more proximate to their ultimate demise… hyperhydrated, allopurinol, Cotrim PCP prophylaxis, promethazine for nausea, then daunarubicin to each drip by drip, and finally cyclophosphamide with 200 cc’s over an hour… may they survive the night! Dare not to hope as driven by desperation we stumble along in previously uncharted seas.

Dr Dan Murphy is the head physician at Bairo Pite Clinic

Reports seeing light

admin — Tue, 17 Apr 2012 00:51:40 +0000

Who would have thought we would be extensively discussing the anatomy of the cavernous sinus on rounds this week. But when you have a 30 year old female patient with 5 months of a 6th cranial nerve palsy coupled with advanced unilateral optic nerve atrophy what else could we do? Probably just a tuberculoma a bit anterior to the optic chiasm. In 3 days of a therapeutic trial of standard TB protocol she already reports seeing light.

Dr Dan Murphy is the head physician at Bairo Pite Clinic

Pathology factory

admin — Thu, 12 Apr 2012 00:54:04 +0000

Rett's syndrome, acute rheumatic fever, advanced TB of the hip in a 12 year old, Gaucher's disease with greatly elevated diagnostic enzyme levels, TB of the tongue, and two teenaged sarcomas all presently admitted…

The ultimate pathology factory.

Dr Dan Murphy is the head physician at Bairo Pite Clinic

A steep curve

admin — Wed, 11 Apr 2012 00:04:54 +0000

“We can’t make a diagnosis because this 2 year old won’t stop crying.”

Well, let’s just take a look… is he cyanotic? No. Now put your hand on the precordium. Is the left ventricle working overtime? Yes. Feel the upper left sternal border. Wow! A thrill. Ummm, I think you have your diagnosis and not even a stethoscope.

It’s a steep curve for the rotating expat students.

Dr Dan Murphy is the head physician at Bairo Pite Clinic

The menacing specter

admin — Tue, 10 Apr 2012 06:05:03 +0000

One month of fevers, aches, and shortness of breath… female age 15, systolic murmur at the laterally displaced apex and prominent S3… C/T=14/24cm… benzathine penicillin, captopril, furosemide, and prednisone… as we know these don't always make it through the acute stage… then there's the menacing specter of mitral stenosis looming down the line.

Dr Dan Murphy is the head physician at Bairo Pite Clinic