12 August 2009

Weird Stuff
Clinically, this place is a tropical medicine gold mine.
In the last two days I have been working pretty intensively with the Consultants. When you are faced with a dearth of diagnostic tools (no lab tests other than a rapid test for malaria), you develop really great physical exam skills and you work with protocols. MSF is crazy about protocols and the organization is determined that everyone follow them exactly.
What's a protocol? Basically, it is an algorithm or flow-chart (boxes and arrows) that is used to diagnose and treat someone with a specific complaint. These protocols have been designed for lots of very common complaints here: pneumonia (first you try one antibiotic, then another, then you get a diagnostic test for tuberculosis); sexually transmitted diseases (broken down by sex of patient and their chief complaint into separate algorithms for: women with vaginal discharge, men with urethral discharge, genital ulcers, swelling of the lymph nodes in the genital region, or lower abdominal pain in a sexually active woman); malaria treatment (child versus adult, pregnant woman, patient appears relatively well versus patient appears gravely ill). Honestly, it takes a bit of the fun out of medicine but make treating common compaints a lot easier.
Of course, lots of patients fall out of the algorithms because they come in with Weird Stuff.
I saw a 10 year old boy today with a chief complaint of restriction of spinal movement that had been gradually getting worse for the last year. It wasn't painful but he was now at the point where he could not bend over at the waist at all. There was a bony hump slightly to the side of one of the normal spinous processes in the middle of his back. What was this? I hadn't a clue, but one of my experienced consultants let me know it was almost certainly "Maladie de Pott" (Pott's Disease) or tuberculosis of the spine.
A six year old girl came in with a 3 day history of painful edema of both legs along with swelling of the lymph nodes in the groin. She had no fever nor any other signs of illness. What was this? This time it was my turn to shine as I had seen a similar case a couple of years ago. It was likely lymphatic filariasis, a parasitic disease transmitted by mosquito bites. It is diagnosed by doing a blood smear to look for the organism, but you must draw the patient's blood between 10 p.m. and 2 a.m., when the worms are making their way around the bloodstream.
Malaria is a constant presence. Any child under 5 years with a fever and any adult with fever and one other symptom (chills, headache, acute back pain, anorexia, vomiting, or abdominal pain) gets a malaria blood test before they even see the Consultant. Even with this pre-screening we end up sending patients back out to be tested—it is usually positive.
Yesterday the pediatric neurologist in me got to shine. I arrived at the more distant Centre de Santé. Waiting for me was a worried Consultant. A 9 year old had been seen the day before with headache but no other symptoms. Her malaria test was negative. The child had had a rough night with little sleep; in the morning the girl had begun to talk nonsense so the family returned to the Centre de Santé. When I saw her, the child was very uncomfortable and the translator told me she was speaking correctly (she knew her name and mother, etc.) but was making strange grammatical errors. This likely encephalitis was way out of my league to treat in a Centre de Santé, so we made plans to bring her back to the hospital with us a few hours later. I continued seeing patients with the Consultant and we peeked in on the child and her mother; things were stable. Two hours later she had a seizure. As she almost certainly had encephalitis and was now seizing, I radioed the hospital in Lubutu for them to send out an ambulance. Fortunately, her seizure stopped after a couple of minutes and didn't require treatment. The ambulance arrived 25 minutes later and whisked her off. What did she end up having? Why schistosomiasis, of course, with eggs travelling up to her brain! Not the first organism that came to my mind, as in the US this is almost certainly viral and not treatable. Here there is a treatment (praziquantel) as long as you think of this parasite as a possible cause.
My job description is all about teaching these Consultants how to diagnose and treat common diseases in the Centres de Santé. Four of the six people I am charged with helping actually need the training, but the other two are teaching me! It is wonderful.