My time here has been spent almost exclusively on the wards and it has been intellectually stimulating, challenging and satisfying.  It has also been frustrating, sad, and just as frequently, diagnostically unsatisfying.  Since I was here 3 years ago I have some metric against which to measure my current experience.  I certainly know more and have experience managing teams.  When someone asks about sickle cell disease I can do a 5 minute impromptu teaching session without a problem.  Nonetheless, I have had to radically change the way in which I think about and manage patients since diagnostic capability is so limited, many therapies are empiric, and the scope of disease is very different.

I am primarily responsible for taking care of many patient populations that I do not routinely manage.  AIDS, Tb, malaria, and malnutrition are probably the most common of these and have fairly extensive WHO management guidelines which help.  And then there are the more exotic problems, like the 3 year old with an 8 month history of abdominal swelling who had a spleen that crossed the midline and extended to her pubic symphisis.  Her only other pertinent was moderate malnutrition and a liver down about 4cm.  We had at our diagnostic disposal some basic lab work (CBC, peripheral smear, AST/ALT, HIV serology), CXR, abd U/S, and echo.  Other than malaria seen on peripheral smear, anemia and thrombocytopenia, and the organomegaly, the labs were normal.  A bone marrow was performed by one of the residents and was dry (though I suspect this was due more to the poor suction generated by the ancient glass syringe than a truly dry marrow).  Our differential included malignancy such as leukemia or lymphoma but the indolent nature of her presentation without any other significant findings (e.g. no blasts on smear, no adenopathy, no masses on U/S) made it less likely.  An indolent lymphoma could do this but without any palpable nodes and the inability of the family to afford a CT there was not much more diagnostically we could do.  Hyperreactive Malarial Splenomegaly Syndrome was also possible though 3 is a very young age of presentation.  Then there are some of the less common disorders such as Gauchers which we have no ability to diagnose much less treat.  The patient was in the hospital for nearly a month and was treated with several courses of antibiotics (for what I was never sure) and quinine for the malaria, with no change in her condition. And so we were left to treat Malarial Splenomegaly Syndrome empirically with weekly chloroquine and have the patient follow up monthly to see if there is any improvement.

As a resident you can really make a difference here.  You are certainly not taking anyone's job.  There are only 5 attendings, 5 residents, and a variable number of interns (1-4) covering wards with a normal census of ~80 and several busy clinics.  The clinics, which are run by the attendings, are usually given staffing priority meaning the wards are often covered by an intern who may only have a week or two of pediatric experience or, even worse, an AMO student (roughly the equivalent of a PA but with far, far less training).  So to have a resident on the wards every day helping with management is a terrific help.  What was nice for me (since even as a resident I often craved someone senior to bounce a few ideas off of) is that Satish Gopal, a med-peds doc here with the Baylor Pediatric AIDS Corp, would come down most afternoons to see if there were any difficult patients I wanted to discuss.  So there was a nice balance of autonomy with some attending level teaching and discussion.

My wife and I are now scheming about ways for us to come back over for a more extended period of time.  We will see what happens!  Hope all is well back in Durham.  See you in a few weeks.

Kevin Watt is a Senior Resident in the Department of Pediatrics. He is currently completing a two month global health rotation at Kilimanjaro Christian Medical Center accompanied by his wife and son.