04-JUL-B-5
A FULL DAY OF TWO CLINIC SESSIONS AT THE
HOSPITAL IN JIMANI, FOR AN IMPROVEMENT IN THE PROCESS
AND ONE MAJOR EXPLOSION FROM A SOURCE
WHO IS NOT GETTING ADEQUATE RESPECT AND
ATTENTION
Today, we
had a full day at the Hopital General Melenciano: a full day, that is, if you discount the hour
and a half it took to reinvent the wheel in the morning, after setting up the
system and having it taken down twice for the local staff who had encouraged
the crowd to rush the doors in attempt to get to the promised shopping bag load
of free medicines to be given to them all through the largesse of the local
staff from the manna that fell from heaven.
We saw large number of patients through the morning, and then broke for
lunch with the usual “end of the day” that occurs in
Suzie
Zieger who had described herself to me as a
When I cam in she had said that I should stand aside since she had someone who needed to be examined, but not by me, and that she would be carrying her over to a private room for the examination to, as she said “Have her ass checked.” Since I am responsible for each interaction here, I did not think there should be some private patients off the side I did not know about, and she said she had already taken care of it and I did not need to know about it. I saw the boy with the Stage II hypospadias, and the small preputial flap that would be possible to correct this was explained. Suzie was irate, I believe, because this boy was having his privates examined by several students, and had gone over to the room where I had been working with two teams, and taken over the corner of it with a screen to examine the patient whose story was that she had swallowed glass and now had a painful fissure in ano—probably unrelated.
She was busily shooing people out of the way when I got to be part of that general process and she had raised her voice to tell me to get out. I then informed her that one of us would be giving orders and one of us would be taking orders and perhaps she had been confused about who was who. She exploded and said I was not to disrespect her, and she had been working very hard and was not being appreciated by me. I told her that I certainly did not appreciate her disrupting the clinic and causing this scene in front of a lot of patients who were the ones who have the problems that we are focused on, and that whatever problem she has could best be handled by absenting her from the team. I would be responsible for the care of the patients, the first priority, and also the medical education component, the second. The composition of the team and its harmonious working was a third, and if that was best accomplished by sending any disruptive member out, that would be done immediately.
We reassembled the patient groups into the teams as she sulked, and after we had seen the remaining patients we had a little talk which was resolved around the problem she had, “not enough attention is being paid to me, and I am working hard, and I get very emotional about these patients.” Well “as the one responsible ultimately for both patients and team, this will not happen again, or else we will be missing your translation services.” So, she is still on the team, but chastised, and as Huda said “Rather high maintenance.” With the rest of the team struggling to understand how the group can help people they cannot understand through a medicine they have a very tenuous introductory grasp of, to have another person whose demanding personality is an issue would not be a plus. So, we have had our “Doctor Bill Norton” leadership crisis already in this team, and so far, again, the leader of the team, who is supposed to show as much attention to the privates and sergeants as to the colonels and majors is supposed to do the stroking on a mercurial woman who is loud and demanding in requiring attention and stroking that others should better have of what seems to be a limited supply.
I will list the series of patient
case presentations that the team members are presenting to each of us, and show
that we have the full panoply of congenital, traumatic, inflammatory,
neoplastic, and infectious problems in a tropical environment. The cases lend themselves well to good
discussions of the pathophysiology of disease, and that is causing a lot of “Ah
Hah reactions” in the group some of whom have not realized before what it is
that they have been seeing in a textbook kind of way. The senior students particularly can put more
of it together than the freshmen and behind them come the MPH students, but
they have each found it rewarding to review the patients and to go over the
reasons for our treating some problems the way we have and with whatever
resources we still have left after rather profligate use of some of the
resources. We will append the list of some
cases and their various team presenters. .
DIDACTIC SESSION AROUND CASE
PRESENTATIONS:
A Vista 29 year old with weight loss, night sweats, cough, no blood tinge—rub on physical diagnosis—Diagnosis, to be proven with a sputum AFB=TB; almost ALL the patients I saw with a diagnosis like this were made afresh, and none had known of any prior diagnosis, be it TB, HIV, diabetes, hypertension of early pregnancy—we were seeing virgin pathology.
B Laurie: a 6-year-old with sigmoid colitis and diarrhea with no change for months; the diagnosis? Endameba histolytica, and I differentiated those with colitis, from the invasive forms that give pyelephlebitis and amebic liver abscess that dissects to the tissues around it through he diaphragm and pericardium and pleura; I described the “zymogenes” that could distinguish them, and gave her long term metronidazole.
C Anthony presented the type II hypospadias, and we stressed the importance of not having him circumcised so that a repair could be done in about a year with a preputial flap—diagrammed for their understanding.
D Vesta: a patient with thalassemia—a hereditary hemoglobinopathy, compared to and differentiated from sickle cell anemia and sickle trait, with both thalassemia and sickling being found where malaria is endemic (“Thalassa” =”sea” doe Mediterranean kind of conserved hemoglobinopathy compared to equatorial African sickling.) The importance of the trait being passed along, with the nasty complication of Sickle/Thal combination being thromboembolus.
Second Round from our abundant hospital patient clinics:
A Siayavash: presented a kid with Ascariasis, with worms visibly confirmed by parents. WE differentiated the three round worms and used the Albendazole treatment—which Siayavash himself was eager to start on himself as soon as possible!
B Zeb: a fat faced little girl: we differentiated the Cushing’s Syndrome (look at nose and earlobes would be invisible) from the edematous face of nephritic syndrome, here most likely secondary to malaria and Blackwater Fever.
C Sanbol: a woman with a big belly, and a noncompressible
mass of fluid filled cyst. We discussed
the first law of hydraulics: liquid is not compressible, so diagnosis was made
of ovarian cyst. This is not as big as
the one I removed in
D Adam; a blind child; we went over the reasons for blindness in a child, and ruled out cataracts, and she did not have meningitis consequences: this was corneal opacity from trachoma—the Chlamydia trachomatis, and the Five F’s: Fingers, Flies, Feces, Families Fomites
Again—the
freshman medical students do not yet know how much they are learning and can
take the next two years off in medical school if the rate continues at this
pace. The MPH students are a bit out of
it, even if we encompass the bigger issues of hygiene, clean water, latrine
service, nutrition and economic support--over against the advice of one
enthusiast: “We should simply be
distributing truckloads of condoms!” As
a Global Health Consultant, perhaps not knowing enough to treat any single
patient would be the qualification for taking on the globe’s population with
advice that should be sought out!