Three more days have passed here at Zimba and I'm still loving it. I've completed my last day in OPD today and on Monday I will begin doing rounds in the women's ward. Today was a half day and I was thankful for it, not because it's unbearably difficult but because I have a lot to learn for the more critical inpatient cases.
Side note: in the out-patient clinic, a part of the hospital, I see the patients after getting vitals and if needed send them out for tests, which are done in a different area of the hospital, and have them carry their results back to me when they are finished and I explain the significance of the results and decide further treatment from there,
This week I saw a lot of expectant mothers, some who did not know they were pregnant to which I was able to give the good news and others who didn't know they were miscarrying to which I had the responsibility of letting down gently and scheduling them for a D&C... fortunately for me, my patients remained relatively stoic although you could see the distance and disappointment in their eyes. I can't help but hurt with them but I also have to keep it together, and so far thats been possible but not without some serious teeth clenching and pleading with myself.
I would like to say that everything went smoothly in OPD and that I had no regrets, but I did send a 13 year old boy away without proper treatment. The rule here is not to order a test unless you think it will change your overall treatment which makes plenty of sense but this is a whole new take for me on the mindset of "treating the patient" (where one focuses on treating the patient by finding the underlying cause and basically doing whatever you need to in order to make sure your doing everything in your power to treat them effectively). Instead of being only concerned with treating your current patient, here, you have to also be concerned with having the resources to treat your next patient which may be a more critical case. So sometimes effective treatment may be forfeited at the cost of being efficient especially in the case of the newbe (me).
Anyway, this sick appearing boy came in with bilateral crackles and somehow had no fever (maybe it broke earlier that day) and knowing he had a history of asthma I knew an albuterol inhaler was probably a good option for him even though I didn't hear any wheezing, asthmatics don't have inhalers on hand here like we do in the U.S. So, on conferring with Dr. Dan, he said if I wanted to keep him in-patient (aka if I thought the kid had TB) then I could by all means get an X-ray. However, the patient didn't look bad enough for in-patient care to me. He even said he was feeling a little bit better that day. So instead I gave him some medicine for his cough and some albuterol and sent him on his way. Later, talking about the boy with Dr. Joan, she enlightened me that here in Zambia we empirically treat for pneumonia without a chest X-ray as some patients travel hours to days for treatment at the mission hospital. I don't know why that didn't pass through my head, frustrating to think about it. Anyway, before the boy left that day I urged him to return if his cough were not to get any better and he started to develop a fever, I can only hope the boy lives close by and will be back this coming week if he hasn't already returned. If so, you better believe I'm putting him on antibiotics stat and more than likely splurging for a chest X-ray.
I saw several other cases such as what I believe was a facial lipoma, a large non-reducible indirect hernia, musculoskeletal injuries, a domestic violence case complete with bite marks on the cheek and scrotal trauma (would you believe he had two wives? I wanted to tell him his obvious offense but decided I would conquer that issue another day), STI cases where so far I've had the pleasure of telling patients their HIV status is negative, thank you Jesus! (dreading the day when its positive, because often it is here in Zambia), plenty of viral infections with nausea, vomiting, diarrhea, cough, low grade fevers etc. Even these viral infections require more clinical judgement with more differentials of TB, malaria, parasitic infections being a possible culprit.
Today I got a sneak peak at next week in the ward and met 2 ladies I will be treating and went over their files. Its going to take a lot more detective work and know-how to care for these ladies and again I'm both excited and slightly overwhelmed seeing 6+ working diagnoses for each patient including both TB and HIV, opening up a world of possible infectious agents and complications. Prayers for my patients please and prayers for a sharp mind would be much appreciated.
Thanks friends! Hope you're having an incredible week.