Call Night

Internal medicine/ICU call has been fun because it has often brought me back to what I learned in medical school--making diagnoses based on chest x-rays and physical exam findings.  No $1000 scans or blood markers.  Chest x-ray, ultrasound probe and a stethoscope--it might not be the most sensitive practice in the emergency room but it does make you think, rather than rely on technology.  One of the pediatric anesthesiologists at UNC loves to say, "There are three possible diagnoses for every patient: the one that ties all of the symptoms together, the one that you (or the patient) can't afford to miss, and the one that it actually is."  So true.  When patients here are paying for their own medical care or for the care of their parents, they want to be sure that they are not going to recover spontaneously before coming to the hospital.  Now, they only pay the actual cost of their care (common to see the price tag on a minor surgery to come out to a sum of 20,000 Kenyan Shillings [~$250], whereas that same surgery might cost 10-15x that in America (at cost, not even considering institutional/regional inflation) but that's $250 dollars of a very small annual income.  So they want to be sure that the hospital is needed. 

In the emergency room there are interns and nurses and then an internal medicine physician who acts as a consultant for the adults and a pediatrician for the children.  Even though I'm in anesthesiology, they still ask us to fill this role as internal medicine consultant.  I've already alluded to the fact that seeing patients in the ER is different here because of a relatively low level of malingering (compared to the US).  It is also different because the pathology and presentation is a lot different than what I was used to as a medical student.  I just admitted a young woman last night with a hemoglobin of 3, low platelets and white count--probably a myeloproliferative disorder but I'll leave that for the hematologists.  She had just been 'dealing with it' for a few months.  Her aunt finally brought her in when she could no longer stand because of the anemia.

I was seeing so much great pathology that I started taking pictures on my last night of call:

Erythema Multiforme - when the intern called me on this one he described angioedema and sores in the mouth and I thought for sure it was going to be Stevens Johnson Syndrome/TENS but ended up just having target lesions and a history of recent, new antibioitic use.

Cardiac tamponade physiology - I didn't know what was causing it.  

Enlarged mediastinum with mass effect on trachea to right.  Diastolic murmur evident.  Chest x-ray from outside hospital 5 days prior showing no mass effect.  Altered mental status and incontinence.  Couldn't rule out granuloma but looked like an evolving aortic arch aneurysm.