Only 1 week left

It must seem like I've been spending all my time writing during this week given my volume of blogging but in reality, I've just been hoarding them up and being lazy about writing over the last 3 weeks and now that it's almost time to go, I've realizing I need to actually post them! I'm required to journal for my rotation anyway, so this has been a nice way for me to do that.

Anyway, as I write this, Frank is at this moment having a very serious discussion with the 5 year old twins about the afterlife. The alternatives I have heard so far are:

1. Frank is going to come back as a carrot in his next life.
2. Frank is going to go to his far-away home in the sky after he dies.
3. I am going to marry a good friend after Frank dies (???? What does this have to do with reincarnation???)
4. If Frank comes back as a bunny, will he have enough brains to want to be anything more than a carrot in the next life?

This conversation ends with someone running off in tears….not good….

Anyway, I had a very exhausting week last week, but very good, as my time with the medical students became more defined. I discovered that working with the 3^rd year medical students was a more comfortable place for me and I think they felt comfortable with me, so we had a lot of time together over the last few weeks.

So as I mentioned briefly, the students have quite a few case presentations they have to give, so I spent a lot of time listening to case presentations, which involved standing at the bedside, listening to a very thorough history and physical, and then about 10-15 minutes of me quizzing the student and trying to teach them something they didn’t know about the patient. Sometimes, other students came and listened too and contributed, so these sessions could last up to an hour. The teaching sessions are anything from discussing theoretical treatments for the suspected disease (i.e., if they were in America, which tests could they have done?), going over how to read a chest x-ray systematically, or trying to go over how to do a proper cardiovascular exam. And again, they are so bright, often I had to go home, pour over some book, draw some diagrams, and then come back the next day to tell them whatever it was I had forgotten.

The students also have “tutorial sessions”, where one student had a required topic to teach to the other students, and I precept these sessions. These also last at least one hour. The students also have required teaching sessions with a senior on parts of the physical exam, and then they are required to have me watch them do the physical exam and then critique them. It is so intense, what they have to do! Since the Ugandan doctors are very busy, sometimes it’s really hard for the medical students to find as much teaching time with the doctors as they want. So I was happy to do that for them. I think also that I am a lot softer on them than the Ugandan doctors so they were less afraid to make mistakes around me. (I'm not sure if I'm doing them any favors, though.) Some of the students had never heard a heart murmur or never had anyone watch them do a physical exam so they never knew if they were doing it right or not. And honestly, I remember there were many rotations in medical school where no one ever once saw me interact directly with a patient independently; I could have been the biggest jerk and made up a whole physical exam and I’m not sure anyone would have noticed. So it’s definitely not just in Uganda that this happens. But I’ve never taught as intensely as this before, it’s so exhausting! US doctors are in general not near as thorough in their physical exam skills as Ugandan doctors so I have had to read up very thoroughly on my physical exam. It's very embarrassing.

And every night, I have to go home and do reading as I’m seeing stuff I’ve never really seen before. We see so many patients with meningitis, and these people have true psychosis. Staring off into space in a VERY strange way, rigid in all their limbs, talking nonsensically or not talking at all, unable to bend their necks---I’ve never actually seen this in the US. And even more interesting is trying to figure out the best way to treat these patients, since it’s often done empirically. Meaning, often they can’t afford the lab test we want to do or the lab test was done too late or the patient is deemed too sick to wait for lab tests; therefore, we would do our best to guess what they have and then treat them appropriately. Sometimes, we treated them for the top 3 things. They problem is, if they get better, you have no idea which of the treatments actually helped so you’re left not knowing what diagnosis they actually had.

Today, Sarah, an immunologist from the UK, and I did rounds on my side of the ward (very interesting to try to do rounds without a doctor who spoke the local dialect) and here is an example of some of the patients we saw:

1. Pt with renal failure who had fluid everywhere in her body (and I mean everywhere!). Her lungs are getting flooded and I think it’s only a matter of days till she dies. She really needs dialysis.

2. Pt with a grossly distended belly, so much so that I thought she was 40 weeks pregnant but it turns out it was all fluid in her belly. Her heart filled her chest, crowding out her lungs and she had the loudest heart murmur I ever saw. We wondered if she had a dysfunctional heart valve?

3. 3 patients with meningitis. Most have HIV as well and fortunately, most were improving.

4. Pt with a very large left sided pleural effusion, meaning she had fluid filling her whole left lung. Any attempts to get fluid out of it has failed. She also has a bony chest mass sticking out of her sternum and a very, very large liver. We wonder if she has cancer? Maybe a surgeon can come do a biopsy for us?

5. 2 patients with probably STD’s which look very painful. One of them most likely needs to have an abscess opened but not sure how to contact the gynecologist?

6. Pt with a total body sloughing skin rash of some sort, and nobody knows why. Most likely a drug reaction, but who knows which drug she took?

7. A 14 year old girl who looks 7; she has very, very bad hypothyroidism which has stunted her growth but there is no hormone replacement available to her. She might never go through puberty.

8. 14 year old patient with the largest spleen I have ever felt, filling her whole abdomen, looking very pale and sick and breathing fast. Probably has a cancer and maybe malaria, but can’t afford any labs. Even if we could diagnose cancer, there is no chemotherapy, so the best option she would have is hospice.

9. 3 patients with TB---1 with plain old TB in the lung, but the other have TB everwhere---TB in the kidneys, TB in the brain, TB in the gut. They get transferred to TB ward once they are stable.

It’s amazing to me how long these patients will wait before they come to the doctor. In the US, I hardly ever see these kinds of physical exam findings as people come to the doctor way before it gets that serious. People here often think if they come to the hospital, they die, so they avoid it; but by doing so, it’s a self-fulfilling prophecy as they often come too late for us to help them. I wish there was a way to change this but it’s a cultural as well as a money issue. Thank goodness I’ve been lucky and most people on my side have gotten better.

Probably overall, the hardest thing is to try to keep a balance between being sensitive to the cultural differences and resource limitations here, but also wanting to keep patient care as excellent as possible. It’s easy to fall into either trap: On one hand, foreigners are often indignant and upset that this pt with meningitis didn’t get a lumbar puncture the day of admission, and why didn’t he get this morning’s dose of antibiotics, and why hasn’t he had iv fluids, and why didn’t anyone check his blood pressure more than once in 24 hrs? On the other hand, after a few days, it’s easy to see a very sick patient with chronic renal failure who doesn't make urine, but there is no dialysis, so all you can do is give water pills, hope the potassium is ok, and advise the family the pt will die soon; you move on without attempting to push for that ekg or serum creatinine or albumin to make sure you don’t miss something potentially curable or handle side effects of your treatments properly. I’ve come to the conclusion that though we have to learn to work gracefully with the limited resources that are here, we have to challenge the sometimes lackadaisical attitude of health care workers here to be as attentive as possible despite the limited resources (and of course this is a gross generalization); and that we also can’t forget that it’s unfair to have such incredibly disparate health care in the world; the status quo is not ok. I feel like I'm saying we should try to make sure that people here don't die of potentially curable diseases more often due to factors we might be able to help change such as apathy, drug availability and cost, but it is ok to accept that people die here more often due to many other problems that can't be changed fast or easily and we need to have patience and understanding. I think I'm doing a bad job at trying to understand a complex situation so forgive me if I just confused or offended anyone.