Another look at medical practice here in Ruhengeri

June 11

Another week has flown by very quickly. We spent two days at the hospital and two days at the clinics. We actually got to see some continuity in our patients as some of the patients we saw with Dr. Nathalie at Shingiro clinic were later transferred to the hospital for more care.

Interesting cases have included a 12 year old boy who presented jaundiced with epigastric pain. The history we could elicit was that he was having diarrhea and took traditional medications for it, and then turned yellow. He was later also found to have renal failure, with a creatinine six times that of the normal cut-off, but this can also be caused by toxicity from herbal preparations. He was given some fluids with glucose and lasix for his renal failure and now we wait to see if his liver recovers.

It has been a challenge for us to adjust to practicing medicine here with limited diagnostic tools. The lab can only run a few tests, and they often come back days after admission. We can check liver enzymes but not albumin or INR. There is a basic blood count, electrolytes, renal function, stool exam and culture and UA, and a malaria thick and thin smear. And that’s pretty much it. As I mentioned before, the x-ray machine broke several months ago and there’s no paper for the ECG machine, so those tests are also unavailable.

In addition, the doctors here do not seem to trust the patients’ histories very much (they are often positive for many ailments as these are stoic people who tend to come in only after many things go wrong) and so very little history is ever taken. We saw a patient in the “ICU” yesterday, a ward where post-surgical patients are usually supervised for a day and where other patients may be put if they need oxygen. The patient had been brought to Urgent Care by his family from a traditional healer’s. He was unresponsive but breathing spontaneously. There was no other history. No one had asked the wife what had brought the patient to the healers or what had been ailing him before he became unresponsive. Without a history, the differential for his presentation was very broad. When we saw him, he was getting sicker and did not look like he was going to make it through the night. No significant treatment had been initiated because no one really knew what he had.

Due to the lack of diagnostic tests and limited histories, many people are treated empirically, based on their presenting signs and symptoms (even if some of those physical exam findings are old). It’s frustrating to me, and difficult to negotiate as an outsider, but I also realize that I’m in no place to judge whether it is right or wrong. Many of the patients get better, and often, the diseases that we default to without much history or diagnosis are the most common diseases to affect people in the region. And given that the hospital wards are busy and that there is 1 doctor for every 50,000-100,000 people in Rwanda, I’m not sure they could spent more time or energy per patient. It is a different system, with different strengths and weaknesses, and so far, there is a lot I think we can learn from it.