Today was actually
a pretty frustrating day… Well, at least the morning was.
The plan from
yesterday was that we would try to switch off to different departments, to see
different parts of the hospital and get a more rounded experience. To be honest,
for as much as I hate rounding, I was hoping to do internal medicine rounds,
because I feel like there’s more opportunity for teaching during rounds than
while seeing clinic with the same triage doctor, who doesn’t seem to understand
that he’s doing things wrong. Unfortunately, they weren’t prepared for that, so
we decided to continue with the plan for today, and our logistics support would
talk to the hospital commander about us seeing different things tomorrow.
We shall see.
So I went to
triage with the same doctor, and the first thing we did was see a patient on
the wards who came in the night before. Her eyes were very yellow (from
jaundice) and her belly was very extended (from ascites). However, the doctor
said that it was from a perforation in the intestines, and the air from the
intestines was making her belly big. I tried to explain that we see that
finding in patients with liver failure, and that the yellow eyes and extended
belly are both probably from the liver. I was about to suggest that they look
for different causes of liver failure—viral hepatitis, yellow fever, liver
parasites—but he remained sure that the belly extension was from a perforated
intestine.
Sigh.
We went back down
to triage and continued seeing patients. One had a very swollen neck, which
started about five days ago as an earache. If it had been slower than that, I
would have thought it was TB in the lymph nodes (more common in the Pacific
Islands than Africa, but still happens in Africa), but with such a quick onset,
I narrowed my differential to mumps, an ear infection that infected the bones,
or a dental abscess. I had my otoscope (to look in the ears), and there was no
sign of an ear infection, but when I looked in his mouth, the back teeth looked
a bit suspect. This led me toward dental abscess, which apparently the doctor
agreed with, because we walked the patient to dental. The dentist decided that
he should be put on antibiotics until the swelling went down, and then he would
remove the tooth. That made sense, because I don’t think the dental clinic has
general anesthesia, and it would have been too painful for him to open his
mouth all the way for the surgery under local anesthesia. However, what I don’t
agree with was that the doctor discharged him home with oral antibiotics. With
his mouth so swollen, I don’t know that he can swallow pills, and his throat
was swollen that he was struggling to breath. When you have to work so hard to
breath, you can’t always keep it up forever, and eventually you’ll stop. I hope
that doesn’t happen.
There was another
patient with fever and a negative malaria blood smear, so I tried using that as
a teaching point about infections that aren’t malaria, but also cause fever. I
might as well have been talking to a brick wall. Both the military doctor and
the junior doctor in the room insisted that fever is always malaria. When I
tried pointing out that mild dengue looks like malaria, they said that dengue
looks like ebola. I agreed that severe dengue looks like ebola, but mild dengue
looks like malaria, and they said that dengue is not nearby. I informed them
that Cabinda (the piece of Angola north of the Congo River) has dengue, and
that that’s very close to Bas-Congo (the region of DRC we’re in), but they said
no, that dengue was in Sudan and malaria was in DRC.
Clearly I wasn’t
going to get through to them.
Lunch break was at
noon, and then we had academics in the afternoon. The topic today was malaria,
so I wanted the DRC physicians from Kinshasa to give their presentations on malaria,
followed by COL Lesho, one of our teammembers, to present infections other than
malaria (dengue, chikungunya, typhoid) last. However, they’re so eager to have
us talk that they had him go first, and he was a bit awkward with the
translator, taking almost an hour. That only left an hour for the DRC
physicians to talk about their malaria programs, which wasn’t enough time.
We’ll have to finish that tomorrow.
 |
| COL Lesho's lecture |
What we did learn
about malaria in DRC was interesting, though. There are no parts in DRC that
are not endemic for malaria, and everywhere accepts it as a fact of life. DRC
accounts for 11% of all malaria infections in the world, and is one of five
countries that makes up more than 50% of all world-wide infections. Forty
percent of childhood (<5 50="" all="" and="" are="" big="" doctor="" during="" for="" malaria.="" malaria="" numbers.="" of="" old="" p="" pregnancy="" so="" those="" visits="" years="">
Nationally, the
country has programs for treatment and prevention; sadly, I can tell you from
working in clinic that the treatment programs are not followed. All clinical
malaria (fever + any other symptom) is supposed to be confirmed by blood smear
before treatment, but all “clinical malaria” (any fever) is treated as malaria,
regardless of what the blood smear says. So everyone is getting medication that
they probably don’t need, and everyone is ignoring other causes of fever. I
also asked what percentage of the population is using bed nets (one of their
interventions), and was told “everyone”. Everyone in DRC gets free bed nets—insecticide-treated
bed nets are distributed free of charge—but as far as usage? Nobody knows,
because nobody asks.
 |
| Mosquito net sign |
It’s very
frustrating for me, a physician who was trained in evidence-based medicine and
in tropical medicine, to go to a place where evidence is disregarded, where
national and WHO guidelines are ignored, and where the physicians on the ground
aren’t interested in learning from outside physicians. It makes me wonder why
we’re here at all, working side-by-side with physicians who ignore our “helpful
hints” and are only giving lectures to the upper-level policy makers, all of
whom already know what we’re teaching.
I’m probably not
going to give this experience a high rating.
No comments:
Post a Comment