A Day's Work

It is 9AM.  I am walking down a shaded path between the buildings of Princess Marina Hospital, accompanied by one of the chiefs of the pediatric service.  It is at least 70 degrees and I have rolled up my sleeves to avoid sweating.  “Unfortunately, winter has come early this year,” she remarks to me.  I note that she is wearing a dress shirt with a light sweater over it, and get an acutely heightened sense of self-awareness.

That morning started the same as all others thus far: morning report.  We briefly review all the previous day’s admissions and discuss their management.  This is a familiar experience, although the inclusion of HIV status alongside age, gender, and chief complaint is unique.  With each case, the accompanying radiology films are passed through the crowd to be reviewed, as electronic radiology is unavailable.  I feel out-of-place attempting to position the light optimally behind the lung infiltrate.

This morning was unique.  The residents have had essentially one new neurologic patient per day, so my ability to contribute has always been there.  However, this morning was the first time they had a head CT to review.  The presenting resident commented on their frustration that the head CT was read as normal despite the child appearing quite ill, and was discussing the possibility of starting the several day-long process of getting this child an MRI.  Their head of pediatrics calls me to review the films, and miraculously I catch something that was missed: a subarachnoid hemorrhage.  I discuss in detail where it is, why it fits with the story, and how we can test for it without MRI.  Later, a spinal tap would confirm the diagnosis.

Up until that point, it was always on my mind that I was an outsider.  I come from a place that historically considers their people and their work as not only in a different continent, but in a different, “third” world.  Anything that could be perceived as arrogant likely would be, and that would be a wall that would likely undermine my whole purpose in coming.  So I held to silence until asked, finally, that day for help.  And, mercifully, it was one of the few times I could be of practical help.

In waiting, though, came significant appreciation.  Here I was not immediately needed to handle problems that would typically be out of the scope of practice of a more skilled internal medicine or pediatric physician.  Overall their comfort in navigating multiple anti-seizure drugs surpasses even some neurologists.  And for many of them, they are able to do so without having ever trained under a neurologist.  It is a humbling realization, particularly since these young doctors are doing their complex management without the infrastructure of pharmacists, computer checks, and insurance cross-checks.  Plus their world is one far more fraught with death and despair.

This lesson is one that proves particularly poignant in the management of the child I first mentioned.  After all, at home, I never manage subarachnoid hemorrhage.  They are typically handled by neurosurgery or neuro-ICU.  However, neither I nor these Batswana physicians have those resources available.  So it becomes incumbent upon me to take a lesson from them, and step up to the plate.

That is, of course, unless I get eaten by one of these
gigantic fricking spiders I pass everyday to work.

For today, I can take solace in a small victory.  Earning legitimacy is the first step to making change, and in the next few days, I am able to build on it.  It starts by being asked to demonstrate a neurologic exam.  It follows by being asked urgently to see someone they feel is very ill.  And hopefully it will finish with lasting change in the way they perceive and manage these neurologic patients.