Dusting off my clinical skills

(OK, this blog is especially for those of you who are doctors or in the health profession.)

One of the things I’ve really enjoyed about my time here is the opportunity for interaction with children and their parents and specifically, the opportunity to use my clinical skills, which I had put on hold while I pursued my public health career. Working with the kids and assisting with some clinical evaluations has made me realize how much I do miss practicing clinical medicine – not enough that I’d go back full time, but enough that a part-time gig would be pretty cool.

At the same time that I enjoy the little actual clinical practice, it can also be frustrating here. On the one hand, I see how relief agencies, NGOs, and other sources have provided a number of resources like antibiotics, antimalarials, and clinic and laboratory equipment, or even just electrical power. On the other hand, there are no doctors in many of the dispensaries and health centers, and very few in the subhospitals, if any, and hospitals. Usually, there might be a nurse and/or a clinical officer, and I often wonder about their level of training and knowledge – of course, I’ve wondered that about some nurses and physicans assistants, and even some doctors, back in the U.S. All the same, it seems like there’s often only the most basic understanding of the how’s or why’s of using whatever resources are available.

For example, they’re so concerned about malaria here that it’s often clinically diagnosed in any child with fever, and antimalarial treatment is begun empirically. At the same time, the child might be treated with an antibiotic. All these meds given in the face of a presentation, for example, that is clearly chicken pox (i.e., viral etiology). OK, here’s where my infectious disease training balks and shudders as I consider how much potential antibiotic and antimalarial resistance may be bred by this kind of practice. The countries here on this continent have enough problems just dealing with the diseases and other challenges here; how much worse would it be with the addition of resistance issues, although one could argue that they already have them here. At any rate, it’s hard to argue against the constant empiric treatment (i.e., giving out meds like water) when they often can’t even do a basic bacterial culture or get a simple complete blood cell count (i.e., CBC or blood cell indices), and likelihood of patient follow-up is often sketchy given the often tough, rural conditions (i.e., lack of transport, lack of money for transport, long distances to travel to clinical facilities, etc.).

All these things make me more aware of how fortunate we are in industrialized countries. While here you often have only your clinical exam to aid you in the management of your patient, in the U.S. and similar places, we’ve grown used to being able to order all sorts of blood tests, imaging studies, and other diagnostics to aid us in getting and even more complete picture of our patients’ problems. Having little else but one’s clinical skills can be very daunting and frustrating.

Today, I saw a 7-year-old Ugandan girl who presented with refusal to bear weight on her legs. I won’t go into detail here, but from her presentation, I doubt we have to worry about polio – the “weakness” in her legs seemed to be more due to pain and some process referred from her distended abdomen. However, I’m stumped as to the real cause of her problems (although a differential diagnoses list springs to mind), and I admit to feeling blind without even a CBC and a few other basic labs or X-ray. Well, I made what recommendations I could given the limitations and urged them to transfer her to the district hospital at least where there would be more resources, especially if her condition progressed and given that her very pregnant mother is about ready to pop with her next child – no one will be able to care properly for the child once her mother delivers (in the health facilities, your family is responsible for taking care of you, including feeding and washing you, your clothes, and your bedsheets, not the very few nurses). However, her mother is very reluctant/resistant to let her child be moved so far away. This is just one of many, I’m sure, similarly tough situations here. I’ll probably check on this girl through my public health/health care contacts in the next few weeks while I’m still here in Kenya. I would really like to know what’s going on with her. Hopefully, her mother won’t decide to just take her home and/or even take her to some traditional healer and then they all disappear into the bush somewhere.