A month? Already?

As this is my last day on the wards here at Kagando, I thought perhaps some reflection on clinical medicine was in order. This my first exposure to really being involved (and occasionally completely responsible) for the care of others has been exciting, sometimes frightening, sometimes frustrating and mostly rewarding.

It's been the work on paediatrics that I've enjoyed most here, not necessarily because of the paeds patients, but because you get to really be involved there. I'm not quite sure how the doctors do it when there are no students to help out, but at any given time there are probably 130 kids on paeds (many two to a bed or on mattresses on the floor) and seeing every one of them every day is a challenge when there are two or three groups with translators going at it.

Although I certainly don't have any real confidence in my clinical skills at this point, I have learned most of the patterns you see on paeds here. Everyone has malaria. Or is at least being treated for it. That means 7 days of quinine. Everyone has either a respiratory tract infection or acute gastroenteritis. That justifies the antibiotic they're on. Most likely they came in with a fever or some pain. Therefore they're on acetaminophen (or paracetamol as they know it on this side of the ocean). From there, most histories go about the same. You ask if they're improving. Everyone is, with rare exception, and you sit up and take notice when that's the case. The tricky part is ascertaining when that improvement started. Timescales seem to be a difficult thing for some people here, and I imagine it has something to do with the local language, but the repeated question "are they improved since yesterday?" is usually met with the answer "there is improvement." Sooner or later you learn to give in and just take it as that and ask about their symptoms and use the previous day's history to see if you think there really is improvement.

One of the main frustrations centers around the meagre battery of tests that are available here. On paeds especially you don't order many, since kids tend to get better and so burdening the parents with extra charges for tests doesn't usually make sense unless you can't figure out what's going on with a particular kid. But the frustration comes from the tests that you do order that aren't done. I've spent many an hour running down to the lab to see if a sample for a particular test was ever received. Almost without exception, they've been fruitless. I think it's just a way of life in Africa that sometimes things just don't get done. But the third time you see a child and the test that you ordered, reordered and rereordered still hasn't had a sample taken, you start to get a bit frustrated. Often by that point the kid has gotten better and you just end up discharging them, unless the test is such that you don't feel you can justifiably let them leave without knowing the result. Then you end up with a patient sitting in hospital who doesn't need to be there simply because things couldn't get done in a timely manner.

The problem with falling into patterns when so many of the kids do is the ones that don't. There was one child - a little older than most on the ward, say 10 or 12 - who I'd seen two days in a row with a couple other students, and had some complaints that should have tipped us off but didn't. He was just really weak, we were told again and again, can't sit up on his own. We all assumed that was due to malaria or other sickness and we'd see improvement over the next couple days. What we really should have done was quantified the weakness, because we probably would have realized that it wasn't symmetrical. His left side was much weaker than his right. Suddenly our differential diagnosis gets a lot longer and probably a lot scarier. The symptoms got worse over the next day when I didn't see him, but one of the staff doctors did. He came and found us after seeing the patient and pointed out the things we had missed, all very nicely and with the intention to teach us to be thorough, not to get us in trouble or tear a strip off for missing what should have been a reasonably easy diagnosis of stroke. The problem is, stroke didn't fit the pattern at all. Kids don't have strokes, at least not with any regularity, so it wasn't on our radar when we saw him. It took a while to get over that one, though I'm not sure there's much we could have done for him anyway had we caught it earlier.

That leads to the other frustration - things you can't treat. We've had several kids go into renal failure - the best we can offer is diuretics, steroids and hope. A couple cases of congenital heart disease. Those at least we refer to a big hospital in Kampala, but I'm not sure what treatment is available there either. Kids with asthma and adults with asthma are woefully undertreated - long acting bronchodilators and inhalable steroids just aren't available. The list could go on.

But all of this has to be remembered by the huge numbers of people who come to hospital, get their IV "X-pen and Gent" (benzylpenicillin and gentamycin.... "gent" is another story for anyone who's interested in pharmacology, I won't get into it), their quinine and get better in a week and get sent on their merry way. The healed up kids are fun to play with and run around the extension while their parents wait to assemble the money for their discharge.

It's been good to learn how to think on your feet and have the pressure of making decisions. I'm sure I'll be terrified all over again on a ward in Canada where everyone speaks the same language as me and expectations are so much higher, but it's been a good learning experience and I am glad to have been a part of it.