The other reg and I went to one of the wards this afternoon to do a cardiology consult. Our normal fashion has been to get as little information as possible from the referring reg, and just go see the kid, examine them, then look at the chest xray (if there is one) and the EKG (if there is one) and the labs, and come up with a diagnosis.
So today we went to evaluate S, a 5 year old. Part of the diagnosis was easy. He's a malnourished, sickly looking 5 year old. Who doesn't smile-at all. He had clubbing (the shape of the nail beds changes) and was anemic looking. He had swollen nodes, enlarged parotids, as well as oral thrush. He liver was 5 cm enlarged, and his spleen was sticking out by a cm. Not only was it evident that he was HIV positive, but also that his immune system was faltering. The only piece of the puzzle was which lung condition was causing the clubbing-was it TB or LIP?
Examining his cardiovascular system, which is what we were to focus on, was rather unimpressive. Slightly displaced apex indicating a generous heart size, slight parasternal heave (enlarged right ventricle), but normal auscultation. We examined the rest of the data. The EKG showed some a slight right axis, but more of an enlarged left ventricle, than the right we were expecting.. The CXR showed significant lung disease, likely TB, likely LIP. And the reason for the consult was cardiomegaly, based on the chest xray, which when reviewed carefully was not enlarged.
This boy is unwell. He's not on HIV treatment having missed his intake appointment at the pedi HIV clinic. He has had a partial work up for TB, but is not on treatment.
And it was clear to me exactly what needed to be done. He needs to be immediately started on steroids (for the impressive adenopathy surrounding his bronchi) and TB treatment (3 or 4 drug, it's debatable an abdominal ultrasounds to rule out TB in his abdominal cavity (which will change his treatment course for TB). What he really needs is to get on HIV treatment as soon as possible, which won't happen for 2 or more weeks (the time he needs to be on TB treatment before starting HIV treatment). There isn't an isolated cardiac issue. We'll do an echo tomorrow, but we'll have no recommendations for his care, other than to fix his medical issues.
And sitting there in ward 33, writing up his note, I realized that things had finally clicked. It no longer bothered me that I don't have "proof" that he has TB. I was no longer naive to think that maybe his malnourished state was because he didn't get enough to eat, but knew it was related to his HIV.
I have acquired a fund of knowledge which I didn't have before coming here 5 months ago. If (or rather, when) I find myself being the sole pediatrician in an environment that is rife with malnutrition, TB, HIV, I'll know what to do, or at least where to start.
In the past five months I have not treated an asthma attack. I have not treated eczema. I have not treated "reflux" (which I am beginning to think is a diagnosis created by the pharmaceutical industry). I have not treated constipation. If I really thought about it, I'm sure I could come up with a list of 10 more "common" things that I have not seen here. Not to say that they don't exist, as common outpatient stuff is dealt with in the clinics..
In the past five months, I have written more prescriptions for ampicillin/amoxicillin, gentamycin, vitamins/iron/zinc (ps-every child with diarrhea back in America should also get zinc) than I have written in my 3 previous years. I have not written a SINGLE prescription for azithro, clindamycin, cimetidine...
What I'm realizing, is that I am developing two skill sets. One set of skills for the practice of medicine in resource rich environments (like back in the US), and one in resource poor environments And what I'm finding is a misconception about how my knowledge is changing... I don't expect to return to my program in the US being any "smarter" than when I left, and in fact, I suspect I'll be a bit rusty on things that I use to know off the top of my heard. I expect to return to the US, having a fund of knowledge which I won't use, and I already find myself dreading questions of "well, what would you have done in South Africa?" It's apples and oranges. Different bugs, different drugs, different standards of care...
