I’ll admit that I was having a great time working at Butaro district hospital. So many of my projects have taken on a more educational flavor that I don’t get to do loads of patient care, which made this a far more enjoyable experience. I was a real attending for the first time, and getting to see patients as a group, develop plans, and teach the residents was the best thing ever. Watching the clerks grow through our two weeks together was tremendously rewarding. On my second last day with the group, they demonstrated that impressive growth.

I was walking through the ward without much to do some time around 4:30 in the early evening when I saw four of the students huddled around one bed. From a distance I took notice and watched. They sat the patient up and examined him as a group, then after some muted conversation one of them got the blood pressure cuff and they ran it on his right arm, and then his left. They took a full set of vitals and then discussed among themselves. One of the lady clerks went and grabbed oxygen tubing and then Francis, tall with a clean haircut, came up to me.

‘Doc I think something is happening with this patient,’ he said.

‘Walk me through your thoughts,’ I said as I walked with him to the foot of the bed.

‘This is our 16 year old patient admitted with sickle cell crisis,’ he began. It was a patient I knew already as we had rounded on him previously. ‘He was feeling okay and then suddenly complained of feeling short of breath. I see he is now tachycardic, with an initial blood pressure that was low and then appeared normal when checked again. His oxygen levels are also low and we started him on oxygen.’

‘Okay,’ I said. ‘Walk me through your differential diagnosis for hypoxia in a patient with sickle cell crisis.’

I couldn’t just give it to him, you know?

Sickle cell crisis is a horrible disease. I have treated a lot of it by virtue of a large and health-care necessitating population of sickle cell disease patients in urban Philadelphia. It has many interesting nuances that I will reserve for another entry, but in brief, a congenital mutation causes defective red blood cells to change shape when stressed, like in sickness or sharp changes in weather. When these cells change shape, they clump together and start to block off the small blood vessels where tissues exchange oxygen with the bloodstream. These blockages can cause intense pain and simultaneously lead the red cells to explode, and as the body gets more stressed from the pain it triggers worsening clumping leading to a vicious cycle of pain and red cell lysis. If cells start to explode at an accelerated rate, things can spiral out of control quickly as the body struggles to provide oxygen to its vital tissues. Not every crisis does this, with a wide range of symptoms that depend on severity, ranging from just pain to multi-organ failure and death.

I watched Francis fumble for a bit before I threw him a line. This region of Africa didn’t have loads of sickle cell disease, so these were patients that he wouldn’t have much experience in managing. Even Adeline, local superhero, was the one asking me for guidance on how to manage the patient.

‘Let’s talk about general reasons for new hypoxia in a hospitalized patient and then talk about sickle cell specific pathologies, how about that?’ I said.

‘Right,’ he said. Cogs churned in his mind. ‘Pneumonia is one.’

‘Sure, what else?’ I said.

He gave me a few more. Once I got him going we were off to the races.

‘So let’s break down the clinical features here that could point us more to one of these versus some of the other ones,’ I said. ‘In terms of pneumonia, what might I expect him to have and see on his exam?’

‘Fevers, cough with sputum production, probably some crepitations on exam,’ he said.

‘Any of that present?’ I asked.

‘No sir.’

One by one we picked his list apart. We also reviewed his labwork from the day and got a rapid blood sample for gas analysis. As we discussed, the other clerks tended to our patient at the bedside, hanging fluids and gathering nurses. It was just around 5 o’clock now, and the bus was set to leave for campus.

‘The bus can wait or we can walk,’ I heard one of them say.

Nearly brought a tear to my eye.

In the end we settled on two diagnoses of concern, both of which were related to his sickle cell disease. One was the potential of something we call acute chest syndrome, which is a complication of red cell clumping in the lungs causing fluid in the air sacs that can precipitate respiratory failure. The other was a blood clot, which his sickle cell disease also placed him at risk for. Our resource limitations meant that we couldn’t really confirm a diagnosis. Acute chest would need an X-ray to definitively diagnose, and a blood clot would need a CT scan—in truth his lungs sounded clear, so my money was on a blood clot. What we could do was cover both for now and gather more information later, so we ironed out a plan: start blood thinners for a clot now and get the scan when able, and give one unit of blood to help with his sickle crisis acute chest and get an X-ray to review in the morning.

In the end the bus did wait for us, and everyone left the hospital late. One of the clerks that was coming back overnight even offered to re-examine the patient in case of any worsening clinical status. The patient would end up doing okay and was discharged some time later with a provisional diagnosis of acute blood clot and would remain on treatment for a few months before being seen in the clinic (we were never able to get the scan).

Watching the clerks step up to take action on a sick patient during an inconvenient time filled my heart with pride. Adeline and I reflected on the case later and took great satisfaction from their growth during our two weeks together.

This is what I do this for. I have learned by now that I alone will never fix the many problems that lead to healthcare inequality; it’s an impossible task. Ultimately, the onus for change must come from within, and the biggest role that I can play is providing inspiration for others to join the cause and support the real gladiators that stay behind when I get on a plane heading for the next site. This is why I so much admire the mission statement of the University of Global Health Equity. The investment starts now, fostering the development of future leaders who give a shit about their patients and want to make the system better. Train them to hold themselves and their system accountable, and once they branch out into the world they will find themselves capable and equipped to propagate the same inspiration that I try to bring to all of these places that I go. 

Not a bad target right?