Hey, What’s Back There
All the following patients were first encountered within a single week.
A visiting doctor asked me to see a 10-year-old boy. His emaciated frame barely cast a shadow, save the right leg swollen from a presumed blood clot. A nice breeze would have carried the child away like an autumn leaf. He had been ailing a long time. How long? Months claimed the father. Time is relative, indistinct. A long time. Zamani, in Swahili. Kanthawi, in Chichewa. A visit to the government hospital yielded a prescription for laxatives, which after two months had remarkably provided no improvement.
I examined. Perhaps I am old fashioned. A dinosaur. A Luddite. Maybe you will find me in the woods subsisting on wild mushrooms, unkempt beard, off the grid, forswearing modern technology, holding fast to an ancient prejudice: the history and exam are more important than any lab test.
On the boy’s back — visualized by lifting his shirt, a procedure for which an internist charges nothing — were several confluent, superficial, glistening ulcers. What are these? I asked the father. Oh, every once in a while pus comes out. Pus? For how long? At least two years, maybe three.
Stop. I turn to the team. What pus-producing infection in Kenya goes on for years without killing you? “TB,” ventures a physician assistant. (My monomaniacal reputation preceded me.)
Yes, we did some tests, but in this case I would have been perfectly happy in those woods, the ones with the wild mushrooms, and no tests. My decision was already made.
The chest x-ray revealed a pneumonia on the left side. We waited to swab pus from the wound, to search under the microscope for bacteria and the little tuberculous “red snappers,” but none appeared.
An ultrasound illuminated an enormous inflammatory mass, enveloping the back muscles, brushing against the kidney, nearing the spleen. It was dense and bright, suggesting the intruder had settled in for the long haul and had partially calcified. The scan also confirmed an ominous blood clot sitting in the vein of the upper right leg, just ready to break off, speed to his lung, clam up his heart, and snuff out his life.
We began tuberculosis treatment. The blood clot represented a bigger challenge. The TB drugs make blood thinning tablets hard to use. The family couldn’t even afford the necessary lab measurement once, much less weekly or more. We used heparin, a blood-thinning injection, for a time, in a manner which didn’t require testing.
When I returned two weeks later the child had gained 14 pounds and was walking on his own again. The team — against my advice — had started the blood-thinning warfarin, which in his case became un-monitored rat poison. We finally managed to send a sample to the lab. Still too thick. Hopefully with TB treatment, and youth on his side, the clot will resolve itself. Favorably.
On my very first day ever in Kenya, in 2002, the missionary I was replacing, Dr. Nate Smith, took me around the hospital. He pointed down the corridor. “That way is maternity. If you are called there, it’s not good.” We are internists. We avoid maternity. Like the plague. Well, actually, Nate and I run to the plague. We run away from maternity. Nate is even married to an obstetrician and still maternity scared him.
Present day: I am consulted regarded a HIV-negative pregnant woman, third trimester, with a history of paraplegia (she cannot move her lower legs) for one year, now admitted with a pneumonia not responding to antibiotics after four days. We find her sweating, struggling, panting hard.
What was she told about her paralysis? She didn’t know. It had happened slowly.
I examined the patient. It was difficult to lean her forward. A bump, a discontinuity in the mid-spine. A chest x-ray shows pneumonia. By the next day she is worse, pain now coursing down her neck and the outside of her left arm. The left side of her face is drooping.
A theorem, not a hypothesis, based on long years of observation in this setting where medical care is still so limited: All chronic diseases, ignored long enough, ultimately become acute. Her vertebral tuberculosis (known as Pott’s disease) had simmered for a year, felling her. Now she had it in her lung, and in her brain. We began TB treatment and she improved. But she will never walk again.
A 65-year-old woman finds herself on the ward for a cough of four months. She is not acutely ill. She has gone to many hospitals, received courses of antibiotics. Of all the cases, this one was the easiest.
The back exam, lowest of low-tech, continues to surprise: a protruding Gibbus deformity of Pott’s disease could not be missed (see photo). Unless a patient is never examined. In four months. Obviously never examined.
A decade and a half in Africa, and my most common command remains, “Treat for tuberculosis.” That is, right after, “Hey, buddy, stay on your side of the road!”
A 30-year-old HIV-negative woman, markedly malnourished, presents with very low oxygen concentration in her blood. Chest x-ray looks like a pneumonia, which improved with a single dose of antibiotics. But whatever else is distressing her did not begin recently, and wouldn’t improve with just a single injection. I ask the team: Did bacterial pneumonia give her a body mass index of 15 in a couple days?
She has severe, localized back pain. What makes someone dangerously frail over several months and produces discrete back pain in Kenya? “TB?” comes the hesitant reply. Yes, tuberculosis of the spine. Or cancer. But we cannot treat metastatic cancer in very poor rural Kenyans, especially during a national strike. So we treat for tuberculosis.
“The essential keys to disciplined Bayesian reasoning can be simply summarized: Anchor your judgement of the probability of an outcome on a plausible base rate. Question the diagnosticity of your evidence”
— Daniel Kahneman, Thinking Fast and Slow
In other words, common things are common, what is common depends on where you are, and unless it’s a very good test it won’t change your diagnosis much.
She improves. The back pain resolves. She begins eating, gaining weight. After two weeks she stands on her own. Every day she smiles gratefully, is optimistic. A success, we crow! Then she begins walking. We prepare for discharge home.
She collapses and dies. We suspect a blood clot to the lung, formed after months of immobilization. Something which has taken many of my very sick TB patients even as they recover. Something which robbed her of decades of life. Something which threatens the boy who cannot afford a basic blood test, or a doctor, or — by the looks of his family — a change of clothes.
Yours in struggle,
Jon Fielder, MD
Dr Fielder. a medical missionary who has served in Kenya and Malawi since 2002, is President of African Mission Healthcare Foundation, which he directs from Kenya.