Friday, October 24, 2008

Differences

I have been in Kenya now for about three weeks, and I feel like I have almost gotten into a bit of a rhythm at the hospital.  Today is a clinic day, and just like back home, no surgeon wants to be in clinic…we want to be in the OR, but you have to see patients in the office to do surgery…kind of like penance.   So there I was in clinic at about 3pm…it seemed like I had already seen 50 patients, but there was still a crowd in the waiting room, and the worse part was, I had skipped lunch to catch up.  So with my stomach growling, I picked up another chart, walked into the waiting room and announced the name as best I could.  (This had become a joke throughout the day as all the patients would laugh at my attempt to pronounce what seemed to them to be common last names like Mbugwa.)  An 18-year-old Somali girl stood up along with her mother and they began to walk toward me.  As I walked the patient to the exam room, she looked relatively normal, but by this time, I have learned to expect the unusual...

*** 

After three weeks here, I have seen many clinical problems that look identical to pathology I have seen in the US: gallstones, diabetic foot infections, varicose veins, breast lumps, enlarged prostates, and various malignancies, but there is often a subtle, but significant difference in the presentation or problem compared to what I have seen in the US.

For instance, patient expectations are different here.  I had a patient and her son wait 6 hours to see me in clinic for follow up of a below-knee-amputation she had a few months prior.  This patient had already had her left leg amputated secondary to a diabetic infection years before, and now she had recovered from her more recent right leg amputation.  I looked at the right stump, and it had healed as beautifully as the left.  I beamed that all was well, and that the stump could not have looked better.  Then the son explained that he was not concerned about how the stump looked.  He had come in to see if his mother was ready to begin “walking on her knees”.  He did not want prosthetics made for her…he wanted my approval to let her start crawling around on her knees and hands.  He wanted her to be able to go to the bathroom by herself, and “work around the house”.  I tried to persuade him to go to the CURE hospital to have her fitted for prosthetics, but he was convinced this was a waste of time.  He had seen other amputees walking on their knees and stumps, and wanted to know when his mother could start doing so…


Pictures of a woman's hand after an electrical injury: She presented one month after injury

I have seen quite a number of trauma patients, and while gun shot wounds and motor vehicle accidents are the same no matter where you go, the interesting thing is WHEN they present.  For instance, I have a patient who was shot in the face with a high powered automatic rifle, breaking his mandible and ripping a gaping hole in the soft tissue of his cheek.  This injury was not really that unusual, but you would think, a man who was shot in the face with a completely shattered mal-occluded mandible and a hole in his face might present right away…or not.  He showed up more than 24 hours after the injury, which totally blew my mind. 

Sometimes, it’s not that the patient did not seek care…they just went to the wrong place.  For instance, I saw another man with a mandible fracture who had been in a motorcycle accident.  He had gone to a local hospital, and one of the providers there knew how to stabilize mandibular fractures by wiring the teeth.  But in addition to the fracture, the patient had a large avulsion of the mid-portion of his upper lip too, for which they did nothing.  He presented to me about a week after the injury,  essentially with no upper lip (see the picture below).  Apparently, after they wired his jaw, they just admitted him and watched him…waiting for this to granulate in and heal.  Fortunately, his father decided to seek a second opinion (albeit a bit late).

Young man with avulsed lip ~1 week after motorcycle accident

Of course the mechanism of traumatic injury is a little different here.  First of all, people don’t just ride in cars in Kenya…They ride on the roof of cars, hanging out of the side of cars, standing on the bumper, or sometimes on bicycles being pulled by cars.  Public transportation in Kenya falls far short of the need, and that is why you see this type of crowding into and onto cars, vans, and trucks. But when people are not falling off cars, there are still other interesting ways to get injured.  So far, I have seen buffalo and hippo attack injuries.  The hippo bite was impressive.  The gentleman presented with an open femur fracture.  The hippo snapped this guy’s thigh like it was a toothpick.  I was warned, that I might see many such injuries from the herbivores, but I will never see a lion injury.  (Lion attacks are extremely rare, but if they do attack, they finish the job I am told.) 

Traumatic injuries are not the only diseases that present late here.  As you can imagine disease is often very advanced when it presents to Kijabe.  People tend to present in the latest stages of disease with massively disfiguring tumors, crater-sized wounds, disseminated infections, and fungating cancers.  Most recently, I saw a man with a penile cancer that was so advanced, I could not believe he was still able to pass urine out of the thing he was calling his penis.  (I am tempted to post the photo, but I won’t for obvious reasons).   One of the most heart-breaking stories I have heard here (and there are many) was told by my orthopedic colleague.  He told of a 14 year old patient who was seen in a hospital in Nairobi, and had been found to have a small bony tumor in his leg, and was diagnosed with a sarcoma.  The only problem was that his family did not have the money to pay for the operation.  Three months later, they returned to that hospital, but only had enough money to get another film showing the tumor increasing in size.  Seven months after that, his brother brought him to Kijabe hospital when he was sick and malnourished with metastatic disease to his lungs.  He died a few days after his palliative operation on his leg.

In addition to late presentations, there are unusual presentations.  What I have learned in my brief time here is that if you have a mass of unknown etiology, suspect TB.  I have seen TB everywhere in the past 3 weeks.  I saw TB lymphadenitis (scrofula).  I saw TB in the mesentery of the small bowel.  I saw TB orchitis (the testicle).  You name it…TB granulomas can be found there.  In the US, TB is always on the bottom of the list of possible explanations for disease, but here in East Africa, TB is one of your leading diagnoses for any sick patient. 

In three weeks of being a physician in Kenya, I have learned to expect different pathology, different problems, and different patient reactions.  It’s just different here.  I feel much more accustomed to those differences now than I was on day 1, but I expect I will still be adjusting to the differences even when my time is done in June.

*** 

So after my introduction to surgery in Kenya, I sat in clinic and interviewed this 18-year-old girl and her mother, expecting some surprise, but it turned out to be a relatively routine problem.  She had a thyroid goiter, but had normal thyroid functions.  After discussing the options, we settled on a plan, and I was about to escort them out of the room, when I noticed she had a x-ray jacket.  Someone had apparently ordered a chest x-ray.  I decided to take a quick look at it.  The lungs were normal, as was the trachea with no apparent mass effect from the goiter.  I went to put the film back in the jacket, when I noticed what looked like an artifact over her left shoulder, and motioned to it briefly that it appeared to be a foreign body.  The mother then casually said that it was “nothing”…just some shrapnel from a bomb in Mogadishu when she was younger…  To them, bomb shrapnel was common place...but to me, it was just another one of those differences that is slowly changing my perspective here in Africa.


Noting Differences,

chad


The rapprochement of peoples is only possible when differences of culture and outlook are respected and appreciated rather than feared and condemned, when the common bond of human dignity is recognized as the essential bond for a peaceful world. 
~J. William Fulbright

3 Comments:

At Sat Oct 25, 02:49:00 PM, Blogger Cherise said...

This post was quite revelatory. It will be interesting what you encounter as the months go on. I think your experiences will be educational for you and those of us that read your update.

I hear about the burden of TB, but to read you encounter brings this home. Hopefully, we will develop a vaccine!:-)

 
At Sun Oct 26, 03:29:00 PM, Anonymous Anonymous said...

Please tell me you removed the shrapnel?! Did her mom allow you to remove it or did they leave??

Oh my goodness. With all the money in the world. America being the trillon dollar (even with the fall of Wall Street)economy, we have the money and doctors where no one should have to suffer such.

The wisdom and awesome revelation of the LORD that you are using, is such a blessing to the Kingdom of God. He smiles on you. He will continue to meet your evey need, ACCORDING TO HIS RICHES IN GLORY, THROUGH CHRIST JESUS....Mark my words. Chad, my precious Brother in Christ, you will lack NOTHING. No good thing...I assure you.

Please let me know, what specifics you would need me to pray for you and the practice or what ever you need. Let me know and you will receive it.

p.s. Your "Care" package will be arriving soon from all of us...

Evang. Ro*

 
At Wed Nov 05, 09:12:00 AM, Anonymous Jonathan Sprinkles said...

Khaki Chad,
This blog is quite amazing. I find myself reading it as though it's a movie script, not the writings of someone I know. Wow. You seem to be having a life-changing experience. Because you're such a phenomenal writer...so am I!

 

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