The rest of Monday passed peacefully. I said goodbye to Izzy
in the afternoon as she was heading back to the States. And in the evening the
bulk of the folks staying at IU House returned from the Maasai Mara, where they
had spent the weekend. So dinner was a lively affair and I met some of the
people I would be working with in the coming weeks. After dinner, I rested and
fiddled on the Internet until bed. Then more “Les Miserables” at 3am as I
struggled to sleep.
In the morning I woke up at around 7am for my first day on
the hospital service. I breakfasted and
then walked the 10minute walk from IU House to the Hospital for “Morning
Report.” Morning Report is a tradition on Internal Medicine services where one
person prepares an interesting case to discuss with the group. The presenter
will start by presenting the patient’s age, gender, and chief complaint. For
instance, “I have an 8 year old boy with a chief complaint of vomiting and
lethargy for 3 days.” The group will then ask questions of the presenter as if
they were the examining physicians, trying to tease out clues about what could
be causing the patient’s complaint. After the patient’s history is discussed,
the presenter will usually stop the discussion and ask the group to develop a differential
diagnosis for the patient’s complaint. Here in Kenya, many of the diagnoses
will have a local flavor. For instance, the actual case we had on Tuesday was
of a child with organophosphate poisoning (OPP). Organophosphates are
pesticides that the farmers use on their fields. Often lacking money for
devoted containers to store them, they will use empty coca-cola bottles.
Children will sometimes mistake the liquid for soda, and thus OPP is far more
common here than in the US, and must be considered whenever a young child comes
in with vomiting and lethargy. After a differential diagnosis is developed, the
presenter will give their findings from their physical examination of the
patient, as well as any lab findings they obtained. The differential diagnosis
will then be narrowed and/or the final diagnosis will be reached. The presenter
will then discuss the disease in question and will usually give a brief summary
of what ended up being done for the patient.
I love the Morning Report style of learning. It really gets
the brain thinking carefully about the diagnostic possibilities in play, but
does so without too much pressure being placed on any one individual. It’s a
fabulous way to grow your understanding of the art and science of medicine.
After Morning Report, we went down to the wards to be placed
onto one of the medicine teams. I was placed with one of the teams on the men’s
ward. They had already started rounding when I showed up. While I had already
seen the wards on my tour with Izzy, I was not fully prepared for the chaos of
the wards on a weekday morning. There are multiple medical teams working
simultaneously. Each team consists of a consultant (or attending/head) doctor,
a registrar (which is the equivalent of an upper-level resident in the US), an
intern, several sixth year Kenyan Students (these folks are at a similar place
in their education to where I am as a fourth year US student), several fourth
year Kenyan medical students (these are just starting their clinical training,
and are roughly the equivalent of a third year US student), as well as nursing
students, pharmacy students, and nutrition students. In all, on a busy day, I
have 17 people on my team. Now imagine this group gathered around the bed of
two patients, already cramped with family members. Then imagine other patients
and their family members, as well as the other medical teams all talking at the
same time nearby. The noise makes it nearly impossible to hear what is being
said all of the time. It is overwhelming. Finally, I am used to an inpatient
service that has about 10-15 patients. Here, our team can be covering anywhere
from 30-40 patients.
Rounds lasted for about 4 hours on the first day. After they
were over, I introduced myself to the Kenyan registrar, intern, and sixth year
medical students. These last would be the people I would rely on to interpret
for me, as almost none of the patients in Moi speak English. That done, I
stepped out into the sun and hurried back to IU House to eat lunch and reflect
on the morning. That I was overwhelmed is an understatement. I found my mind
wandering over the little details I had noticed on rounds – the almost offhand
way that the doctors would move the body of a patient’s bed-mate when needing
to examine him; the cockroaches moving along the walls; the empty looks of the
patients; the constant need to step aside as family members or patients
squeezed by me in the tight spaces.
The next day I decided to follow one of the patients myself.
He was a 17 year old boy who had been having an increasing feeling of numbness
and tingling in his lower legs for about 2 weeks. He had been hospitalized in a
smaller community hospital before being transferred to Moi. In the meantime,
his numbness and tingling had proceeded to become a partial motor paralysis of
all of his limbs. He could talk and understand, but his speech was so garbled
that at first I didn’t realize that he was actually speaking English to me. This was my first time ever seeing a serious
case of Guillian-Barre Syndrome (GBS) – a frightening syndrome in which, in
some cases following a simple viral illness, the body’s immune system forms
antibodies that cross-react to proteins on the myelin sheathing of the nerve
fibers. It begins as a numbness and tingling sensation in the lower limbs
and/or paralysis of the lower limbs, and then it begins ascending up the body
over a course of several weeks. In serious cases it even begins to paralyze the
diaphragm and chest wall muscles involved in respiration. In these cases, if
the patient cannot be placed on assisted ventilation, they will suffocate. If
the person makes it past this point, the prognosis is generally favorable, with
most people eventually recovering full strength. Luckily, my young man seemed
to have a mild case. Or at least his respiratory muscles did not seem to be
affected. Even so, this meant a several weeklong hospital stay with a prolonged
recovery afterward – a terrible drain on the family in terms of necessary
caregiving and money. After managing his case for several days, I suggested
something I would never have done in the US – that we discharge him home to the
care of his family with instructions to bring him back to the hospital if his
breathing at all started to worsen. My reasoning was that the care required for
GBS is generally supportive care, only definitively requiring a hospital
setting if the patient’s breathing is involved. And since this kind of care
could be supplied at home, the family had no immediate need for a doctor’s
care. Therefore, to save them money, it might make sense. However, in the US there
would be no way that a patient would be discharged home until they seemed to be
adequately recovered, or at least improving.
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