A typical day in the clinic

Today was clinic day.  I had a few short cases in the OR in the morning but the majority of the day was spent in the clinic.  compared to state side clinics this one is a very basic space separated by curtains on three sides.  I bring my instruments and headlight so that I can do some sort of exam of the patients.  The language barrier is a difficult situation.  Although the national language is english most people speak their tribal language.  Some communicate in swahili.  I have a physician's assistant who speaks several tribal languages and swahili but his english is difficult to understand.  So the history is often taken by him and then translated into broken english.  I am finding out that the history is usually inaccurate and misleading.  This in combination with the cultural differences makes practicing medicine a whole different ball game.  I generally have a good sense of judgment but in this circumstance I find myself making constant mistakes.  Thank heavens for the Lord who one way or another gets me to where he needs me.

This patient is a 40 year old female who presented in fairly significant respiratory distress.  she was in a wheel chair with inspiratory stridor.  She has been evaluated at another institution and comes with some reports that she pulls out of a black trash bag that are worn and difficult to read.  she has a cancer of the upper esophagus.  she reports she has had this for multiple months but over the last week has had increased difficulty swallowing and breathing.  she can drink some milk but has lost 16lbs.  She is 2 months pregnant.  The family offers no xrays for evaluation.  Physical exam reveals a thin cachectic female having difficulty breathing and spitting her saliva into a second trash bag.  Evaluation of her voice box reveals no visible mass.  I rush her to xray for a STAT chest xray and neck films to try to figure out where the airway obstruction is coming from.  The findings actually aren't that bad and there is evidence of airflow in the trachea although maybe a slight narrowing in the upper chest.  We decide that the esophageal tumor is probably narrowing the trachea or eroding through the trachea.  This would be end stage terminal disease.  But do I trust the reports from the previous hospital and is the history that has been translated really adequate?  A CT scan could be really helpful but the cost of the scan is high and would probably prevent one of their many children from going to school.  After much debate and anguish I decide she is a young pregnant 40 year old female with terminal cancer.  Her husband should take her home and make her comfortable with morphine.  I have recommended hospice care.  Then the family pulls out of the black trash bag the morphine that was prescribed at the other hospital.  yes they had already been referred to hospice care.  They just came here to see if we would come up with anything better.  This ordeal has been exhausting and I have multiple other patients waiting with similar life threatening disease.  Every patient is prayed for and put in the hands of Jesus.  You definitely can't carry all this on your own.

I hope tomorrow is a better day!!!

thanks for all the prayers,

chase miller