“Doctor, I have trouble breathing when I walk up stairs, and I cannot lie flat in bed, so I have to sleep sitting in a chair. I feel much worse than before I got pregnant.” I recognized the diagnosis at that point, but I continued the appointment to confirm my suspicions and to revel in the art of medicine.
I listened to the young woman’s lungs, full of crackles from fluid backup, and noticed the swelling in her legs. I placed the ultrasound probe on her chest wall, attempting to get a view of her heart as I suspected that she had heart failure since she gave birth three months ago. Postpartum heart failure is a hauntingly common complication of pregnancy in developing countries caused by an unknown toxicity, infection or vitamin deficiency. Science doesn’t search for the answer since health issues that only affect poor women in developing countries don’t receive the research dollars necessary to ascertain their cause or cure.
The ultrasound machine only has an abdominal probe, the wide-angled head designed to examine larger structures like the liver. When directed at the heart, the abdominal probe provides a narrow window, requiring the operator to scan the heart several times to get a complete picture. The U.S. and Canadian emergency room doctors who volunteer at the hospital are trained to use ultrasound as their bedside tool for diagnosis, but it takes a few days to acclimate to the narrow views. After performing hundreds of ultrasounds with the wrong probe, I understand the limitations and can interpret the incomplete images, combining them with the history and physical exam to arrive at a reasonable diagnosis.
While challenging, practicing medicine without modern resources is to rediscover the art of medicine. When I practiced in rural Rwanda, we had virtually nothing. Simple blood tests were often unavailable, straining our diagnostic capabilities to near impossibility. It takes years of practice to diagnose fluid around the lungs or defects in the heart valves solely by listening with a stethoscope, but it is near impossible to determine the level of potassium in the blood without the use of blood tests. Without a CT scan or an x-ray, we thankfully had an ultrasound to diagnose problems from heart or kidney failure to blood clots or appendicitis.
In Haiti, the issue is not that we don’t have access to many of the most useful, high-tech tools that we use in the United States. Haiti has four CT scans, an MRI, and several labs that perform the tumor marker tests and autoimmune disease panels. Unfortunately, the patients often do not have the means to afford these tests.
In U.S. medical schools, we’re taught to only order tests that will change the management of the patient’s care, but many of us fall prey to assigning tests that we deem simple and inexpensive. While in Florida I may order daily blood tests, the patients in Haiti will let me know that they had a blood test the previous month, and, even if it’s not the same test, they will question the necessity of the repeat exam.
The question the doctor in Haiti or Rwanda must ask themselves is not “Will this change management?”, but “Can I treat anything that I’m trying to diagnose with this test?” Why pursue a formal ultrasound of the heart when we can’t surgically replace damaged heart valves? We’ll treat postpartum heart failure with the same medication regimen as damaged heart valves. What difference does it make if the patient has lupus versus rheumatoid arthritis versus giant cell arteritis? In all those cases, we start steroids for autoimmune disease and observe as the rash or joint pain improves.
I originally selected the specialty of internal medicine because of the complexity, the intellectual challenge that came with picking through a range of diseases and ultimately arriving at the conclusion that one diagnosis stands out among the others. Like Sherlock Holmes sifting through clues, internal medicine doctors weigh the physical exam findings against a carefully taken patient history, discerning the true diagnosis from imposters. From the moment the patient walks in the door, I’m observing everything about the patient, hoping to find the shred of information that directs me toward the diagnosis. I know what surgeries they’ve had by each scar on their body; I can tell if they’ve had children, and I can guess at their socioeconomic status by the smell of their clothes. The giveaways are always different: maybe the gait is slightly off, or there’s a hyper-pigmented rash on the elbows or trivial swelling around the eyes. Through years of practice, I can guess a patient’s blood level (hemoglobin) within 10 percent simply by looking at the lower conjunctiva of their eyes.
I’ve even placed ice over a patient’s eyelids in order to determine if the lower temperatures affected the range of contracture of the muscles, possibly suggesting an issue located where the nerves innervate the muscle. In the United States, I would have simply ordered a dozen blood tests that would have offered a similar result, perhaps with more certainty. But in Haiti, as in Rwanda and the majority of countries around the world, I am compelled to practice medicine instead of permitting the test results to decide for me.
Practicing medicine means exactly that: Doctors must try and try again, gaining experience over time, until we arrive at the correct answer, the solution for each individual patient.
I gave the young woman with postpartum heart failure a cocktail of four drugs, each attacking a different problem, hoping she is one of the lucky ones whose heart returns to near normal function over the next six months. People often ask me why I went into global health and I give a range of answers, depending on who I’m talking to: less paperwork, less defensive medicine, fewer patients with unrealistic demands, less waste. Really, though, medicine in developing countries brings me back to being a doctor. I sit with a patient, gather clues, discover a diagnosis, and attempt a treatment. The practice of medicine comes roaring back to life.