Back to work

I am finally starting to figure out how I can be useful on the medicine wards here in Eritrea. The first week (actually just 3 days) were a bit overwhelming simply because of the mass of patients, the lack of checkout from other residents, the difference in pathology, the difference in the whole system of record-keeping, and the lack of investigations here. Because of the feeling of being completely overwhelmed the first week, I felt like the students including the interns really had it all figured out. I also wasn't sure what my role here was and how I could be useful. Really, I felt sort of in the way both for the nurses and the intern. I knew that the patient cases were very complicated, but I felt that they were doing as good of a job as they could with the resources that they have, and in a lot of ways I still feel that way. But today after rounding today and realizing that I knew every patient on my ward, and after finally being able to sit down and go over every chart with a fine-tooth comb, I am realizing that I will be, in fact, quite useful.

I may have said this previously, or maybe I journaled about it, but the way that the interns and even some of the attendings work up a patient is very different from how we are taught in the US. There, we are taught that when a patient comes in with a chief complaint, in order to figure out what is going on with the patient and so as to not miss anything, the first thing you do is delineate a differential diagnosis. I will admit as much as anyone that at home I think we become complacent in doing this sometimes simply because we have the tools that allow us to. We know with near certainty about the status of a patients heart because we can get an echo immediately, for example, so it is much easier to rule things out on a systematic basis. Here, however, the importance of a differential diagnosis is not emphasized nearly as much, but here it is even more important simply because we don't have the diagnostic tools at our finger tips to be able to say for sure that patient doesn't have one thing or another. The physicians here take the "common things being common" statement to the extreme and sometimes have a difficulty thinking outside of their box. If a patient comes in with a particular complaint, for example hepatosplenomegaly (large liver and spleen), then they jump directly to infectious causes without considering other simple things like alcoholic liver disease in the differential. Hannah actually has a case that she figured out today on a patient who had been sitting on the service for a month, and all he has is alcoholic liver disease. Now they can move forward in treating this man to actually get him out of the hospital. My point here is that, I am hoping that I can help the intern and other medical students with learning the importance of forming a differential diagnosis to help in cases where the case may not be the thing they see all the time on the wards.

So, in an effort to help myself and hopefully some of the patients, I went through every patient's chart on my side, many of whom have been in the hospital for a month or more and wrote down their initial history, vitals, labs, radiological studies, and what had been done for them so far. This is a much easier feat in the US--here sifting through the chart and gathering all of the information is much more difficult and time-consuming. The reason for this is that progress notes are not written on a daily basis because of the way that rounds are done only on one-half of the patient at a time. Also, the radiological studies are best looked at rather than just taking the radiologists read at face value. One echo that I looked at today, for example, just said LV (left ventricle) and LA (left atrial) dilation. That was it. So, I looked at the pictures. Now, I am what I would consider to be inept when it comes to reading echos, but I could tell just by looking at the 4 chamber view of the heart that the LA was absolutely HUGE, especially when compared to the rest of the heart. The same goes for chest x-rays--it is much more useful to look at the study myself rather than just taking the radiological read's word for it.

I am hoping that after gathering all of the information that I will be more aware of exactly what needs to be done on rounds tomorrow. Additionally, there are several patients where I don't have a good grasp (no one does) on what is going on, so maybe I can brood over the information at hand to come up with a solid plan. That is something else, in the charts here, there is very little mention of what the plan is and why something is being done. Most of the notes simply say "continue same treatment", but if a new medication is started, there is no mention as to what they are thinking and why it is started. Of course, all of my notes are the usual SOAP (subjective, objective, assessment, and plan) format, and I try to get complete histories and physicals. They do not typically do a full H &P with ordinarily should include the past medical history, the medications taken at home with doses, the allergies, the social history, the family history and the review of systems. Not having all of that information in chart has made me realize just how very important that information is. Maybe that is something else that I can pass along to the medical students and interns.

I realize that all of these things I am talking about are not going to change how things are done after I leave or likely how medicine is practiced here. But, at least maybe I can have an impact on some of the medical students to help them become better doctors. And maybe I can help with the care of a handful of patients.

On a different note, Hannah and I finally went to the Pizza house last night and I tried another round at pizza in Africa. It was ok, but probably about what one would expect from African pizza--a bit bland. Otherwise, Hannah and I had a relatively boring day with respect to exploring this place because we both came back to the hotel to frantically read about various things we have been seeing on the wards here. Now, it is time for me to go and figure out what is wrong with some of these people.