Friday, July 18, 2008

Shop Talk: Days 1-2 in the hospital

Shop Talk

My first two days in the hospital were good ones, eventful to say the least.

My first clinical experience turned out to be my first major foot in the mouth cultural mistake. Bonehead Lorenz in Africa.

After a short tour Monday morning, there were “special rounds,” equivalent to Grand Rounds where we talk about tough cases from the weekend. Beginning in the male ward, we reviewed the chest x-ray of a 20 something male with a knife wound to the left side. (There goes my “No violence Tanzania” idea). The Tanzanian attending said the xray looked, fine. With 2 US medical students, I decided to take another look and explain how you evaluate a chest xray for pneumothorax (air in the chest cavity), hemothorax (blood), etc. First of all, it was not easy. It’s not like we had PACS or a computer system, where I could zoom in and scrutinize for lung markings or a line. Hell, we didn’t have an xray light to put it on. It was me holding up a crappy xray against weak light from a window. My xray skills are average at best to begin with. In this situation, I was feeling like they were a smidge above dirt poor. But I did my best anyway.

As I was explaining things to them, I realized this guy had a monster pneumo—at least 50%, more like 60-70. The left lung was completely collapsed. I freaked out. The patient was stable (vitals stable, not short of breath) and there was no tracheal deviation to suggest tension pneumothorax, a life threatening emergency that would require putting a needle or chest tube in ASAP, so that was good. But the attending…seemed to have overlooked a pretty significant finding on the xray.

The problem came in the way that I handled this situation. I think it looked like I was a little punk American doctor challenging the experienced (50 year old) Tanzanian physician. I should have said, “What do you think about this, this and this. How would you manage that?” Instead, I declared, “This guy clearly has a major pneumothorax,” implying it was missed, and went on to explain my point. There was some lack of eye contact and then avoidance of the situation. We agreed to repeat the chest xray, (which was unnecessary) and moved on to the female ward.

On the one hand, I was feeling pretty good about myself. I knew what to look for on the xray, I read it correctly and applied it to the clinical situation. Solid work.

On the other hand, have I learned nothing about respecting my teachers, making first impressions and being a gracious international guest? Sheesh. I felt really bad. So I shortly thereafter genuinely tried to give him an opportunity to teach me about this situation with regard to chest tubes. Basically, they put them in for tension pnuemo, and not otherwise. In the US, if the lung is only partially collapsed (<15%) style=""> Anything more gets a needle or tube in the chest. I appreciate their perspective, and now want to review the literature to see if there really is any big difference or not.

As for my attending, he cared much less that I about my little insurgence. Things were nzuri (fine). As I’ll later discuss, he’s become an even better teacher and friend since.

After special rounds, we rounded on the pediatric ward with a different attending, Dr Machuggi, the medical director of the hospital. It’s malaria season, and the peds ward was full with 30 kids. And 90% of them had the same diagnosis: severe anemia secondary to malaria. In Tanzania, malaria is the #1 killer (according to their govt; AIDS claiming 30% of deaths was from WHO), especially of young children. Not gunna lie, it got boring rounding on them. What’s this little guy got? Well, he came it with fevers, vomiting and diarrhea; had a very low blood count (they use PCV: Plasma Cell Volume, 40 is normal, <15 style=""> They got quinine, the treatment for severe malaria, and a transfusion if necessary, and improve in a couple days.

I was initially intimidated by malaria because I’d never seen it before. Would I know how to diagnose it based on a microbiology class I’d taken 4 years ago? Sorry Professor Parmele, but doubtful. But it’s like the flu in Africa. If it’s malaria season and a kid comes in sick, check their blood. Done. I was working in the ER later that day and diagnosed my first malaria case—it was a no brainer. Little guy came in, looked sick, listeless, pale. Had a fever and vomiting for 1 day. Bam, malaria. It can hit them in a day or two, and if they get really anemic, they can die, and fast. Some blood and anti-malarials, and he started to improve.

That’s what makes third world medicine so intoxicating—you can save lives and really help people. That’s the dream, I think, of all of us that went into medicine. That’s real satisfaction.

In the US, the opportunity to do that—dramatically help people or save lives—is less. There are some. But most of what I train in is chronic disease management—of problems that probably wont be cured, like diabetes or high blood pressure—and prevention. Still noble and satisfying, but COME ON. Really comparable?

I chose family medicine largely for the relationships—I wanted to be somebody’s doctor. And whatever their problem was—their weight, their back pain, their anxiety, whatever—I wanted to be the one that they could come to throughout their life to do something about it. I stick with this value in the doctor patient relationship still today. But the satisfaction that comes from saving lives is often with the specialties that are largely void of long term relationships. Surgery for example. The gallbladder gets sick, you go to the surgeon to cut it out. You are saved, you never see them again. Cure, but short relationship.

After long peds rounds, I decided to hang out in the ER with a medical officer, akin to a physicians assistant. They do much of the triage and admitting to the hospital, and function as ER docs. It was great. I’ve been writing down all of the cases I’ve had—I’ve seen over 50 patients in 2 days, including scrubbing in on 3 surgeries. In the ER, there was supposedly an “infertile” woman who hadn’t conceived in 3 ½ years of trying. They were beginning to do a whole workup on her, including ultrasound, hysterosalpingogram (I was impressed they had this), and I said, “Where’s her husband? Has he ever fathered a child? Have we tested him yet?” At this point in the workup, in the US we’d start with a sperm count before the battery of tests on the woman. In Tanzania, I think my suggestion was a little progressive and almost culturally inappropriate. The assumption being that if there’s a problem with conception, it’s her until proven otherwise. Not sure if chauvinism is the right word, but we talked about getting him tested, when to test her and how to maximize baby making during her cycle.

More to write, but I’m tired and must go to bed.


--the little rascal that stole a book from me on the street and made me chase him home.

--the genius orthopedic surgeon, a professor, visiting for 3 days doing surgery.

--cases of tumors, masses, TB (another no brainer diagnosis), and several things I still don’t know what to do with (5 year old girl with right sided hemiparesis and apahsia).

--my host and the sweet meal he made for me, with a juice shake recipe I’ll be bringing home

--the hospital outreach motorcycles I walk by everyday coming and going, and how I’ll be getting the keys tomorrow for 2 weeks!!!

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