Surgery and Healing in the Developing World - Dartmouth-Hitchcock

Medicine Writ Large in the Raw, without Power or Plumbing
Fiberoptic Scopes, Image Intensifiers and Video-Enhanced
Endoscopy
No way.
What Tools Work Rather Well and Even Get Better with
Repeated Use?
Eyes. Fingers, ears—and the acumen between them.
This is the golden opportunity for clinical skills to flourish. There are two reasons
for this. Almost no one presents with early stage disease, and the classic full-blown
textbook picture (almost exclusively reserved in historic textbooks in the western
world now) surround the healthcare worker daily. Some diagnoses are so obvious
that they are apparent at a glance, in a living museum of physical findings. Far from
being a “no-brainer” in terms of diagnostic challenge, the typical patient might cause
you to scramble for your camera to record your own atlas of advanced pathology.
When two-thirds of the gut is in the scrotum, the diagnosis of hernia is not very
difficult, but the concepts such a hernia may recall to mind include the “loss of
domain” and concern that the patient might not be able to breathe with the diaphragm
when such a hernia is reduced. Now is the time to reach back into the hard
disc memory banks for the names of entities that are recognizable at an informed
glance: “sabre shins,” “Charcot joints”, “Argylle-Robertson pupils”, “mulberry incisors”
were just names to be memorized for test-taking until I encountered them all
in a single day in a Nigerian outpatient clinic. Here one will encounter the throwback
to the prepharmaceutical era of “organizing pneumonia”, measles pneumonia,
post-meningitic deafness or blindness, and the classic signs of vitamin deficiencies
and protein/calorie malnutrition. In a later chapter, the exotic diseases rarely encountered
outside the tropics can be sampled. But here it should be pointed out that
the clinician should know the standard diseases encountered in the western world,
but here encountered in much later from as they have run most of the natural history
of the disease by the time they are first seen by a western-trained physician.
That is also true for the clinical skills that are needed. There will not be as much
need for some special stain or recognition of which kind of trypanosomiasis or schistosomiasis
species is causing the disease, as the careful use of the clinical skills in
physical examination already in the possession of most of the healthcare workers
who will come to this introduction already equipped. Know the western disease
patterns well and be prepared to be surprised on how amazingly obvious many of
the problems are simply on the basis of their late presentation. Record keeping is
minimal, but significant, with most clinics using the equivalent of a 3 by 5 card as
the patient’s “chart”. The life expectancy of a paper record is not more than two
rainy seasons, though, so for personal interest, I have always carried a hand held tape
recorder and some small personal electronic record keeping system as well as photography
and a notepad. Many times in clinic, the “history” is taken through translators,
but often it is as unnecessary as the lifting of an involved extremity with a self
evident problem.
And these clinical skills improve while on the field and do not have a tendency to
break down. Furthermore, they are quite capable of being transmitted, and passing
them along to others gives a multiplier effect. The most useful clinical tools in the
field hospital are the same ones that are longest lived and regenerative, as skill is
synergistically passed along and communicated—-in each direction.
31
5