January 16, 2013

A Kenyan medical student asked me to describe egophony today.  We were amidst a student-delivered lecture on pneumonia, and I had interrupted with a long laborious diatribe about typical vs. atypical pneumonia and how the pulmonary exam would be different between the two.  At first I intended to just add some brief context to the ongoing presentation, but then I realized the students were taking notes from what I was saying, so I kept talking.  And talking.  And probably talked way too long, but I couldn't stop.  It was an utterly surreal feeling, a sea of foreign medical students looking up at me from their hasty scribbling, listening intently to every word.  That level of attention, and interest, and focus I had never seen before when I’ve taught at home on the wards.  These students truly were sponges, soaking up every teaching point.

And then I was asked to describe egophony.  This was a 6^th-year medical student, with nearly as many years of medical training under his belt as me, asking me to describe one of the most basic pulmonary exam findings we have in pneumonia.  The same med student who had earlier in the day rattled off all of the numerous adverse effects of amphotericin (a commonly used antifungal medication with many side effects), of which I knew very few, like he was reciting the alphabet.  At first I thought it was a trick question, and he was checking my knowledge.  But the wave of subsequent scribbling suggested otherwise.

On rounds, Kenyan medical students are treated like books.  They are expected to contain vast quantities of information and to be able to recite that information on the spot, in front of upwards of 30 people surrounding a patient bed.  Often it is clinically useless information, like aneurysm scoring systems, encephalopathy scoring systems, and the max allowed dosage of amphotericin.  Rather than be asked to think, and to put the puzzle together, they are asked to meticulously memorize and regurgitate on command the fine details of every individual puzzle piece without knowing how they fit together.  By the book, they are brilliant.  By the bedside, they are bewildered.  We have much to offer each other this month.

We are also fortunate to be starting this week with brand new teams of freshly minted 4^th and 6^th year medical students.  This week is like our July, when those in the know in the hospital tell you to stay away if at all possible.  The bananas are very, very green this week, and that leaves the door wide open for lots of teaching.  4^th year Kenyan med students are essentially equivalent in training to 3^rd-year American med students, and 6^th years to American MS4’s.  I have no idea where the 5^th years are.  Apparently they are on safari.

Although the med students left an indelible impression today, it was one of many.  Many words would be appropriate for my experience today.  Some might use words like overwhelming, or helpless, or devastating.  Others may say pungent.  I found myself using the word fun.  Despite the many, many systematic difficulties and patient care challenges, I truly enjoyed myself today. 

The wards here are organized in one long hallway, separated in the middle by the entry foyer and nursing station, separating male from female patients.  Each hallway then has two sides, "Firm I" and “Firm II.”  Each Firm contains recessed areas perhaps 30 feet deep, called “Cubes.”  There are 4 cubes to a Firm, for a total of 16 cubes.  Each cube contains four beds on each side, and two patients are assigned to each bed.  There are four separate teams assigned to each Firm.  Today I was in the men’s side, assigned to Firm II.  For the remainder of the month I will be on the women’s side.

I could spend thousands of words further describing the wards, the patients, the differences from the U.S. system, the surprising lack of any intervention designed to accomplish disease control (that is a laughable concept here – on the wards there is no control) – but as an independent description I don’t think that is very interesting.  I’ll try to incorporate those details along the way.

I do want to talk about a gentleman we’ll call Samuel.  He was a 26 year-old male patient on the wards who I met today on rounds.  Whereas we spent upwards of 20-30 minutes on each patient, Samuel received very brief attention.  He had been in and out of the wards for many weeks.  His initial presentation three weeks prior was for tuberculous pericarditis – an inflammation of the sac surrounding the heart, caused by infection with tuberculosis.  That inflammation was not only dangerous because it was caused by tuberculosis, it also produced a lot of fluid in that sac surrounding the heart, consequently constricting the heart and making it difficult for it to fill.  We call this tamponade, and at its worst, this is a medical emergency.

Today Samuel had returned to the wards after a stay in the cardiac intensive care unit, where he had undergone drainage of this sac to relieve the pressure, and had also required special medications to raise his blood pressure.  He needed those medications because he also had heart failure – not the typical heart failure we see most often in the U.S., where the left side of the heart cannot adequately pump blood to the rest of the body, but right-sided heart failure, where the right side of the heart cannot adequately pump blood through the lungs.  His blood pressure had improved to the degree that he no longer required those medications, and his reward was to be transferred back to Cube 2 Firm II on the wards.

As we approached, he was lying in bed on his side, a blank expression on his face.  He was breathing very shallowly and very quickly, upwards of 40 times per minute.  He was not wearing any form of oxygen.  He glanced up briefly and knowingly as we surrounded his bed, and then turned his gaze back to the floor, concentrating on his breathing.  He had seen this routine many times before.  And by surrounded, I mean we completely engulfed every crevice of space around him.  Our rounding team today had 27 members – registrars (the Kenyan equivalent of residents), intern, 6^th and 4^th year medical students, dental students, pharmacy resident and students, and three of us Americans (two residents and one medical student).  As a medical team, you might say we rolled deep. 

Today he was breathing fast and his blood pressure was low – 80/40.  He had been receiving Lasix to decrease the amount of fluid in his body, which had accumulated because of his right heart failure.  A decision was made to hold the Lasix today and hope his blood pressure improved.  He was already on therapy for his tuberculosis, and a cursory check of that was made with the pharmacist.  No further treatment decisions to be made, we were about to move on when one of the students commented on his rapid respiratory rate.  A rate like that in the U.S. would prompt immediate action and likely intubation and mechanical ventilation.  At the least an arterial blood gas would be drawn and evaluated.  Neither of those two interventions are even available here.  The best we had was a portable pulse oximeter, which would measure the oxygen levels in his blood.  The head registrar turned to me, as my cheap Walgreen’s model had been popular thus far on rounds.  We placed it on Samuel’s finger as he looked on, and it read 76%. 

Now 76% with a respiratory rate in the 40’s in the U.S., especially in a 26 year-old, would incite utter chaos.  There would be much yelling and scrambling, and because of the gigantic space suits we would be wearing to protect ourselves from TB, there would be extra chaos.  People may use words that they make up on the spot as their panicked brains sputtered and revved into overdrive.  There may be a code blue called.  We would prepare for intubation and clear an ICU bed for this gentleman immediately.  We would call his family and urge them to come in as soon as possible.  Thousands of dollars of workup would be ordered in the first ten minutes.    

The registrar saw the 76%.  On the flimsy thin sheet of paper with three lines on it that served as a progress note for the day, he wrote “give O2.”  It was again agreed we should hold his Lasix.  We moved on to Cube 3