East Timor Medical Elective - Week 2 (Part 2 / 5)

"OVER-PROTOCOLIZATION" + DOING THINGS OUT OF CONTEXT

I intellectually knew that Clinical Medicine in East Timor had to be different from Australia due to a different case-mix, and vastly less diagnostic and treatment modalities, along with worse under-staffing than even in a rural Australian Hospital. But in my 2^nd week, I made several blunders that demonstrated my rigidity at the time, and obsession with following protocols/algorithms, as I rely on for social interactions with NTs. It also doesn't help that the Australian medical environment is now very rules-obsessed secondary to an increasingly litigious culture, thanks to following America.

"Carlos"
Carlos was a patient in the TB Ward who just commenced TB medications. When clerking him, I immediately focused on his first presenting complaint which was a headache that started about 1 month ago. I became very anal and tried to systematically rule out the dangerous causes of Headaches (eg Bacterial Meningitis, and Subarachnoid Haemorrhage), instead of asking about other more recent medical issues, ie his collapse in bed a few hours ago.

I should've realized that Carlos' headache was unlikely to be something urgent if it started 1 month ago, and should've inquired at the start if he had any other medical issues that needed investigation and/or treatment.

"Josefina"
I clerked Josefina on the same day soon after Carlos, but forgot to address the immediate circumstances by being too focused on history taking and physical exam. She was in respiratory difficulty, but I just skipped the history taking bit due to her shortness of breath, and proceeded to physical exam of her lungs, without realizing that she needed urgent treatment for relief. 

When I presented her to one of the two visiting Specialists (“Julie”), she immediately asked Josefina if she has Asthma, in which she said “no”. Nevertheless, she was commenced on nebulized Salbutamol and Oxygen with immediate relief. 

I felt really guilty that night, and apologized to Julie the next morning as I had partially delayed Josefina's immediate treatment. 

From then on I decided to update my internal algorithm, to do a quick “ABC” (Airways / Breathing / Circulation) scan if patient is in distress before they're able to continue talking etc.

I feel like I'm so dependent on Algorithms to the point where I'm just a human “robot / computer program”. At least if I place ABC at the very start of my clerking algorithm, it'll somehow resemble the “common sense” and “1^st Principles” that NTs talk about.

"Jacinto"

Jacinto was the 3rd patient that I nearly “hurt” that week, who got admitted to the wards for polyuria and polydipsia (drinking lots of water), along with some weight loss. We all thought he had untreated Diabetes Mellitus (esp. Type 1), so did fasting sugars which were all normal. 

Our next differential was Diabetes Insipidus, which is basically a problem due to impaired functioning of a hormone called ADH (Anti-Diuretic Hormone), which helps concentrate urine. I was told by the other visiting Specialist (“Karl”) to help prepare and explain the diagnostic text to him, which according to my OHCM (Oxford Handbook of Clinical Medicine) was the “WATER DEPRIVATION TEST”. Essentially, this test involves not drinking any fluids for 24 hrs and measuring the patient's urine output during that period, to see if the Patient's still producing lots of dilute urine in the face of relative dehydration. I told the patient he wasn't allowed to drink any water for 24 hrs and documented this in the chart. 
 

About 30 minutes later, when Anjali was physically examining Jacinto, she noted my notes and told Karl. Karl then went to Jacinto's bed and corrected it to being ALLOWED to drink fluids during this 24 hr period, and then comparing fluid intake vs urine output, ie ***NOT*** water deprivation. Karl told me later that afternoon that it wasn't necessary to do the Water Deprivation Test immediately, but to do this “intermediate” test as a screen. I apologized to the 3 of them, and most especially to Jacinto, coz had that error not been checked, he would've been in even more unnecessary discomfort.

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From the above blunders, I hope that I'll eventually be able to more rapidly understand the context in which things are done, and also how to possibly be more flexible in a developing country setting. 

I think it'll take a few more days for me to drop my medico-legal "shackles" and just focus on Clinical Medicine in the purest, traditional sense, with minimal red-tape and litigation fears...