Ward D

I apologize for the lack of posts this past week. I have finally established an internet connection in the apartment I am staying in – but it is not the most reliable connection I have ever had. Needless to say, I have been experiencing technical difficulties once again.

At any rate, I switched to Ward D this week. This is the ward for children ages 3 years and up. It looks much like the infant’s ward (Ward B), only larger. But I have been much happier on Ward D for several reasons.

One big difference is the variety of pathology. On the infant’s ward the vast majority of patients have respiratory or diarrhea illnesses. And most of them will get better in time, whether we do anything for them or not. On Ward D there is no majority. We have patients with type I diabetes, pneumonia and asthma (although they are slow to diagnose asthma here – often treating for pneumonia instead). There are children with congenital heart disease who underwent repair when they were younger, but are in need of surgery again. One child has chronic nephrotic syndrome – presumed to be minimal change disease, but undiagnosed without a kidney biopsy. One child has a kidney mass, likely Wilm’s tumor, awaiting surgery. There is a child with pemphigous vulgaris and one with severe cellulitis in her finger. There are children with HIV and children with failure to thrive. And the list goes on.

I have been forced to become my own consultant, relying on my own knowledge and text books when I would prefer to rely on the sub-specialists at Rady Children's Hospital. I am finally honing my physical diagnosis skills and making alternate decisions without access to all the diagnostic and treatment modalities I have come to know so well. I don’t have any misconceptions that this medicine is any better or more satisfying than the medicine we practice in the U.S. But it feels good to stretch my brain in new directions. And it feels even better when doing so helps some of these children get better.

Another reason I am enjoying this ward is the staff. The doctor who covers most of these children has not had any official training beyond medical school (i.e. no pediatric residency). But he has been working on this ward for years, so his practical knowledge is extensive. He is willing to learn from me, but also capable of teaching me at the same time. We have a good rapport, with an open exchange of information. He does not always do things my way, but at least acknowledges that my points may be valid. And he is openly appreciative when I teach him things he thinks are useful and valuable.

The charge nurse is also an asset to this ward. He is organized and knowledgeable. He is helpful. And his English is much better than average here. He can actually understand what I say and works quite well as a translator when I need it. He also respects my knowledge and experience. He does not question my every action or decision.

But yesterday I ran into the invisible wall I have been banging my head against since I got here.

I have a patient with bilateral cervical lymphadenopathy that I presume is scrofula (an infection caused by tuberculosis), but I can’t be certain. I decided that given my options the safest thing for this child would be to treat presumptively for TB and see how the child responded.

I pulled out my handy Nelson’s Pocket Book of Pediatric Antimicrobial Therapy – a favorite among pediatrics residents in San Diego. (Thank you to Dr. Bradley and Dr. Leake). And I wrote for the appropriate doses of Isoniazid, Rifampin and Pyrazinamide. The charge nurse balked. The doses I wrote for were well above any dose he had ever seen before. I went to my e-pocrates and my Johns Hopkins Antibiotics Guide to double check. My dosing was correct. The nurse decided to call the medical director. He agreed that my dosing seemed high and said that he would come to the ward to help resolve the issue.

Because the director had not arrived by lunch time I went by his office after I finished eating. Of course he was not there. And the entire place was locked up so I could not consult the Red Book, the American Academy of Pediatrics guide to infectious diseases that I brought with me as a gift for the hospital. So I went to the medical library located on the hospital campus. There I found a Red Book from 1997. Not the most up-to-date, but reliable none-the-less. Indeed the dosing listed in this book was the dosing I wanted to use. But alas, I could not check the book out of the library. All books are for use on the premises only.

I went back to Ward D and tried to figure out what to do next. The medical director never showed up, big surprise there. So I finally consulted Hospital Care For Children – Guidelines for Management of Common Illnesses with Limited Resources – the handbook produced by the World Health Organization. Lo and behold here was the dosing the Eritreans were using. The doses listed were half of the lower limit my resources indicated.

The WHO guidelines suggest antibiotics for known viral illnesses. They indicate that tachypnea (fast breathing) should be considered pneumonia first and foremost. And they under-dose medications for TB, one of the top three infectious causes of morbidity and mortality in the developing world. My initial reaction is to think that maybe these lower doses are safe and effective and save limited resources in the third world. But then I think about Paul Farmer and Mountains Beyond Mountains. And I realize that the WHO is actually doing these people a disservice.

I wonder if I have the strength, the determination, the status and the ability to effect the changes that Paul Farmer has. Can I convince anyone in Eritrea to use the appropriate dose of medication to treat TB? Can I convince the WHO that they need to change their guidelines? Maybe. Eventually. But for now I conceded to the lower doses. Because this child needs some treatment. And if I spend too much time arguing about it he won’t get any medication at all.