During one of our first meetings with Dr. Thuma upon arriving in Macha, he described to us how delivering medical care in this area as a physician is based upon bedside clinical diagnoses, rather than the confirmatory tests, studies, and lab work that we are used to back home. I think yesterday I had my first glimpse of this when we stopped at a village house where a man of around 20 years was potentially suffering from malaria. Prior to meeting him, I learned that he had been ill for around a week and was deteriorating as time went on. He had lost his appetite since he became ill, he was feverish, having difficulty breathing, suffering from headaches, and he was so weak that he wasn’t able to move around a lot on his own. I asked his family member to take me into his hut to see him. He was lying on his side in his bed and was wheezing. I had also been warned that he was diagnosed with asthma as a child but had stopped taking his medication. I felt his pulse and I could immediately tell he was tachycardic. I also felt his forehead and thought he felt slightly feverish. We wanted to do a rapid malaria test on him, but it was completely dark by that time and the field box was tied to the top of the vehicle roof. When his family members said that he was too weak to move, I realized we should take him to the hospital. I could tell that something was not right with his health and that he should be seen. The research compound that we drop off our equipment at is adjacent to the hospital, so it wasn’t too difficult to take him with us. He was so weak that it took him several minutes to get dressed and I had to help him button his shirt and coat as he couldn’t manage the buttons on his own.
At the hospital, his rapid malaria test was negative, however he had a low-grade fever and a heart rate of 135. He was also very tachypneic while sitting upright, although his wheezing had stopped once he got out of bed. His brother came to the hospital separately and had to help him move around the hospital ward, as he was so weak. When he and his brother went into the consultation room with the nurse and ‘clinic officer’ (PA-equivalent here), I stayed out in the waiting room. I was surprised that the visit didn’t take too long though, and when he came back out (supported by his brother) the nurse was already giving him a discharge summary with medications. She said he was having asthma problems from not taking his asthma medications. He was prescribed salmeterol tablets and an NSAID pain medication. We were the only ones in the ward and the family member was responsible for trying to find a ride home for him as he was too weak to walk. However Macha is extremely rural and when I looked outside into the night, I didn’t see any cars driving on the roads in the distance. After a few phone calls that didn’t pan out, I realized how idiotic it was that we were trying to send the young man home in his condition. I asked the nurse if he could just stay in the ward for the night until they were able to find a ride for him in the morning. Thankfully, she agreed. I felt that while asthma exacerbation could be on his differential, it didn’t explain everything that was going on with him. Something just didn’t feel right. Belinda and I went to grab Dr. Freiberg at his hostel for a ‘consultation.’ He accompanied us back to the hospital with my stethoscope and we listened to his lungs. Immediately we heard crackles in his left lower lobe. He also had egophony in the same lobe. I asked the family member if the clinical officer had listened to the patient’s lungs in the room and he said that he had not. I wondered if it had been pure laziness that would have potentially sent an ill man home with the wrong medications and false sense of security. We instructed the family member to have the patient stay put until the morning when we rounded with Dr. Thuma and could bring him by for a second opinion.
At 8 am the following morning we met Dr. Thuma at the hospital for Saturday morning pediatric rounds. We asked him to first accompany us to the OPD ward, explaining the previous night’s case as we walked. After listening to the young man’s lungs, Dr. Thuma was equally confused why he had not been immediately admitted. He wrote up orders to admit him and have him screened for the new differential: pneumonia, TB, and PCP. We thanked him profusely for his help in ‘navigating’ the Zambian healthcare system for the young man. After rounds (around 11:30) Belinda and I stopped by the men’s ward to check-in on him and saw Alyssa rounding on him at that very moment with another Zambian physician. His chest x-ray was already back and it showed a very large consolidation in his left lower lobe. Belinda and I had felt that something just wasn’t right with the patient and that asthma exacerbation had not fit all of his symptoms. And our persistence and determination with the Zambian healthcare system may have saved the young man’s life. The case helped drive home Dr. Thuma’s introductory message to us and it will always serve as a reminder to me to trust my gut instincts. The young man is on gentamicin now and will have a TB sputum sample performed on Tuesday. Fingers crossed that it is negative, for his sake and ours.
During pediatric rounds today, our second patient was a one-month old female who was admitted in the night for “right-sided swelling”. However the nurses hadn’t called a physician to see her in the night and so Dr. Thuma was the first one to perform an exam on her. The baby was on oxygen via nasal cannula and didn’t seem to stir very much when he examined her. After listening to her heart and lungs, he asked us to do the same. She had a heart murmur that was initially hard to discern whether it was a lung sound or a heart sound because she was breathing so fast. Dr. Thuma said she likely had a congenital heart defect and in Zambia there are no bypass machines to perform open heart surgery to fix such a defect. He said while it was difficult, he had to move on to the other patients in the ward who needed him because there was nothing he could do for the little girl. As he moved onto the next child, Becky pointed out to the nurse that the little girl was starting to bleed out of her nose. I had never seen heart failure before so I didn’t know it at the time but the baby was dying before our eyes. Her little heart stopped while we were rounding on the fourth patient in the ward. The nurse called out, “doctor, is this baby okay?” And Dr. Thuma replied, “no, she is not okay.” He went back to her and auscultated her chest again but we could see her tiny fist in the air was already pale-colored. The nurse turned off the oxygen and removed the nasal cannula from the baby’s nose. The mother’s affect didn’t change at first and so I wondered if she understood that her baby had just died. She calmly covered the baby with its blanket and walked out of the ward. She later came back in with an older woman, perhaps her mother. Together they quietly mourned at the bedside. Dr. Thuma explained that mourning is different here than we are used to back home. While outwardly the mother initially appeared unaffected by the child’s death, she would likely go mourn the death at home with relatives. I found myself more shocked by the mother’s response than the death of the baby. Perhaps it would have been easier for me to grieve alongside the mother had she displayed the emotions I was expecting, or would experience, had we been in the US. According to Dr. Thuma there were 22 patients in the peds ward and she made the 7th death in the ward this month.