Manuel Lewis, Class of 2018—The impact of regaining two senses

Patient was a 53-year-old male with no known history of present illness who presented to us with worsening near-sighted vision, bilateral hearing loss of one-year duration, left heel pain of years’duration, and a small non-growing mass in his right popliteal fossa.  On physical exam, the patient had vitals within normal limits, intact long-distance vision, inability to recognize letters within an arm's length, bilateral cerumen impaction, a tender-to-palpation callus on his left heel, and a popliteal mass evident on right knee extension. The patient was diagnosed with presbyopia, treated with prescription glasses, bilateral cerumen impaction softened with water/peroxide irrigation and removed with a curette, a left heel plantar wart treated with excision and cauterization, and a Baker's cyst that was left untreated.

I chose this case because it was one of the most impactful cases I had.  After we provided the patient with glasses, cleared his ears, and treated his plantar wart, he expressed immense gratitude to the attending and myself.  He repeatedly told the translator to thank us for helping him regain his vision and hearing. I felt strong emotions after this encounter recognizing the minimal time and effort it took to treat his conditions, while realizing the impact that could come from regaining two senses. 


Benjamin Bosen, Class of 2017—Twins without the energy to cry

I had the opportunity to see two eight-month-old twins and their 25-year-old mother as patients.  The children had fevers and were less active the past week.  They had a normal birth and did not have any problems prior.  They were exclusively breastfed but had not been eating as much the last week.  They were still urinating and having bowel movements, but the mom was not sure whether they were decreased or not. The mother also had a very tender right breast for the past week and had a hard time nursing on that side.

Their exams were very similar with one of the twins more severe than the other.  Both had tachypnea with respirations in the 5Os and 60s, heart rates in the 140s and oxygen saturation percentages in the mid 90’s.  They had low-grade fevers at 99.5 degrees.  They were awake and aware of me but did not react to any of the exam, never crying or showing discomfort.  They both had decreased muscle tone with the sicker-looking twin especially floppy.  On auscultation of the lungs, both kids had wheezing, with the sicker looking twin having basilar crackles, more on the right.  Anterior fontanels were sunken in, and dry mucous membranes.  Abdomens were soft non-tender with no ascites or organomegaly. The right breast on the mother was enlarged, swollen, and erythematous.

After the doctor came and looked at them, we decided to treat the twins for pneumonia and dehydration and the mom for infective mastitis.  We gave each twin a shot of rocephin along with 10 days’ worth of amoxicillin and strongly advised that they go to the clinic in town a few hours away.  We gave the mom amoxicillin as well and advised her to keep nursing on that side and try to empty it as often as possible.

I chose these cases because they have taught me very important lessons when it comes to pediatric presentations.  The first thing that stands out is how I now view crying and a child not wanting to be examined.  Now when I hear a pediatric patient cry, I get a quick initial reassurance that at least they are healthy and aware enough to cry.  Those twins did not have the energy or awareness to cry.  The other thing that stands out is working with limited resources. Had we been in a hospital in the U.S., these babies would have had more testing to rule out other infections and problems such as bacteremia and meningitis.  We were also very limited on what antibiotics to choose from out there in the village.  Getting stronger IV antibiotics on board would have been a nice option.


Yasmine Mourad, Class of 2018—Coco’s knee pain, necklace & smile

I will never forget when I was seeing “Coco,” which respectfully means "elderly lady" in Swahili/Maa, for chronic knee pain. She knew she could not communicate with me but spoke to me in her language and looked me in the eyes with great concentration.

My translator told me what she was saying—she has had this knee pain for years, and it is making carrying water difficult for her. She held my hand and put her arms around me and told me that I had a look of "care" in my eyes, and that it made her feel so happy--as though I will be able to help her that day after all those years of suffering. She continued to talk to me in her language very urgently. My translator started laughing, and once he caught his breath, told me that Coco was saying that she loved me like a daughter, and she appreciated the love that I was giving her. She then proceeded to remove one of what seemed to be hundreds of beaded necklaces from around her neck and placed one on mine.

I gave her steroid injections into both her knees, and told her that she should be pain-free for at least two months. I will never forget her beautiful smile.


Rebekka Lee, Class of 2018—Warts a boy wanted off to look normal

History of Present Illness: The patient was a 12-year-old male who presented complaining of multiple skin growths on his face and hands that he wished to have removed. He had a history of being chronically ill and small for his age.

Physical Exam: The patient appeared younger than stated age, thin, small stature. Patient appeared tired with rhinorrhea and bilateral eye discharge. On skin exam, patient was found to have multiple dry raised nummular lesions on his scalp.  He also had multiple hyperkeratotic exophytic papular lesions on his forehead, lower cheeks, and bilateral hands. On his left anterior scalp, patient had a dark maculopapular lesion approximately 1.5 cm in diameter with irregular borders.

LABS: HIV test was positive.

Diagnosis: Verruca vulgaris of the bilateral hands and face, tinea capitus, Kaposi sarcoma, AIDS

 Treatment: children's multivitamins

Commentary:  This case will stick with me forever. It showed me how unfair life can be. This boy was most likely born with HIV. He got the short end of the stick. The effects of HIV/AIDS on this boy were pronounced. All he wanted was to have his warts burned off so that he could look normal;  because he was immunocompromised as evidenced by the multiple opportunistic infections, we couldn't even do that for him. There wasn't anything we could do to help him in that environment. The ways to treat HIV in the USA have extended life and increased quality of life, but in Africa there simply aren't resources to pay for the medication. The people we were treating couldn't even afford food. It really showed me that despite the advances in medicine, in many parts of the world, these advances are meaningless due to lack of resources.


Clementine Stowe-Daniel, Class of 2018—Resilient Maasai, unperturbed by pain

One case that I found particularly moving was a 30-year-old female complaining of multiple injuries. I inquired as to what had caused these injuries, and she responded that her husband caused them. She had a well-healed circular bite scar on her right shoulder that she said was one month old, a small hematoma on her left temporal/parietal skull from being struck with a stick (she stated it had been much larger when she first got it), recurrent headaches from her head trauma, and bruising and pain in her right leg and foot from being kicked.

After assessing her injuries and determining that each was on the mend with no red flags or signs of infection, I asked the patient whether she still lived in the same house as her husband (no, she was back with her family), whether she felt safe where she was staying (yes), and whether she had good social support to help her (yes). I expressed my sadness regarding her situation, told her that she did the right thing and that her husband never has any excuse to abuse her—physically, emotionally, or psychologically.

When she left my tent, I thought about what I had said to her. She comes from a culture very different than my own where spousal abuse is very common and normalized. As much as I was glad that she had gotten away from her husband for the time being, I couldn't help but think that she'll probably end up back with him soon and in much the same situation. I also wondered, while I didn't regret my actions, whether it was appropriate for me to foist my cultural norms and personal beliefs upon her by condemning the abuse from her husband. I know I was the medical professional in this instance and it is our duty to keep our patients' best interests at heart, but who am I to question or try to force a change of a culture that is not my own?  It was an internal struggle for me.

My next unique case took place on one of our last days of work.  A 10-year-old female was brought in by her mother for an ankle burn caused by spilling boiling water on the ankle 3 days prior. The little girl could hardly walk on that foot because it was so painful, and while the wound had mostly scabbed over, it was still weeping fluid and covered in flies.

I realized after treating her that I had never asked her or her mother whether that wound was accidental or purposeful, although given the amount of concern her mother showed over her wound and the debridement process, I doubt it was intentional. On assessment, she was feverish and tachycardic with evidence around the wound of infection, so after quickly finishing my assessment, I found a preceptor, presented her case, and asked help to debride the wound.

We set up for the procedure in the pharmacy, and while we worked, a non-medical volunteer distracted our patient by singing and playing games with her. Quite honestly, though, she didn't need it; despite using only topical anesthesia to numb the area, she barely moved throughout the entire procedure, giving no evidence of pain on her face. Instead, she actually looked curiously around the volunteer to watch the latter part of the procedure. We cleaned and debrided as much of the wound as possible. After initially soaking it to help sterilize the area, we found that the wound was more extensive than was originally apparent—leaving a small scabbed area in the center of the wound that, if we had tried to remove it, likely would have done more damage and caused more bleeding than was necessary. We made sure the area was clean and free of flies, then applied burn ointment and thoroughly dressed the wound, instructing the patient’s mother on the procedure and giving her enough supplies to continue dressing the wound over a month.

The mother was overwhelmed and extremely grateful, shaking our hands and thanking us profusely in Swahili. The little girl seemed quite pleased with her bandages, though she still walked with a pronounced limp. She gave me a big smile and let me hug her for being so brave, and then all of those gathered invited the medical personnel into the church building for a prayer. The pastor prayed for the people of Olasiti (the village we were working in), for the medical staff, for our medical contact in Kenya (Dr. Amos) and for them to be blessed one day with a hospital close by to serve their medical needs.

As we departed, I waved from the bus window to my patient and her mother, and I realized that while the medical mission trip may not offer sustainable care to the people who utilize it, and while we can’t always do as much as we’d like for our patients, sometimes we truly do make a huge difference in their lives.

I also reflected on how incredibly resilient and unperturbed by pain the Maasai people are. I don't think I'll ever meet another little girl that stoic during a wound debridement, let alone an adult, yet that's how the Maasai. Culturally they are taught not to show a response to pain lest it lower their station in society. I'm in awe of the toughness and strength of will of the Maasai people.


Robert Nieland, Class of 2018—Burkett's lymphoma & aspects outside medicine

Leprosy/Epileptic/Burns/Ulcer. 58-year old male presents with three-week history of shallow 5-6 centimeter ulcerated draining wound on posterior lateral left lower extremity 2 inches proximal to lateral malleolus. History of epilepsy and thus throughout his life has fallen into several open fires leading to diffuse burn scars in various places on his limbs and face. Distant history of leprosy. Absent digits on left foot, missing second digit on right foot, deformed nose secondary to leprosy versus burn injury. Has had various open wounds on his lower extremities intermittently for years. No sensation below knees. Right eye malformed secondary to burn injury.

Treatment: cleaned, applied antibiotic ointment, and wrapped wound.  Supplied patient with sterile supplies to re-wrap 2-3 more times throughout the next week.

I chose this case because the patient's physical appearance was so memorable, and he was also in incredibly good spirits despite all of  his injuries and medical history. We discussed several of his burn stories and how lucky he was to still be alive and mobile/able to care for himself. He was an inspiring example of resiliency.

Neck Mass/Burkett's Lymphoma. 12-year-old male presents with four-month history of left neck swelling with intermittent neck/jaw pain, dysphagia, and difficulty breathing. He had been to two local hospitals that were unable to provide any treatment, as well as for second opinions. Left neck mass at angle of jaw, firm, non-mobile, roughly fist sized. Trachea slightly deviated to the right. Multiple hard, non-mobile peri-auricular lymph nodes on left side. Deformation/mass visible in left ear canal. We performed HIV testing which was negative.

Treatment: Intramuscular dexamethasone injection to help with some of the swelling and thus the dysphagia and difficulty breathing. Recommended referral/travel to Nairobi where he could be seen at a facility that might have the ability to provide therapeutic/comfort services.

I chose this case because of how unique the local diagnosis was compared to the United States. Everything about his presentation was textbook classic for a Burkett's lymphoma. This prompted our team to have to address many aspects of his condition outside of just the medical facts. We gathered a local leader, one of our best translators, and the boy's father to discuss the consequences of his likely diagnosis and the possibility of transport/services, as well as the economic feasibility of treatment and his prognosis. It was a very sobering moment on our last day of clinic to have this young man as one of my last patients. It prompted me to reflect about medical infrastructure and access during our off/travel days back to the States.