Emily Hall (PL3) shares 3 memorable cases

 Posted on behalf of Emily Hall, DO (PL3)

To be truthful, I have no sense of who reads these blog posts. Perhaps you're

• a fellow resident or medical student thinking "Should I do my International Rotation in Tanzania?" 
• or a faculty member thinking "Emily, you should be spending more time talking about your experience at the hospital" 
• or my distant relative motivated by guilt, worrying about my well-being and thinking "how am I related to you, I would never associate with such impulsive travel plans and decision making." 

Regardless, I hope you've found my ramblings both interesting and of some value. 

I have packed my bag with the anticipated return to (the frigid) Minnesota and find myself with a few moments for reflection prior to catching a taxi to the airport. I have had incredible opportunities to see the country, develop relationships, and further my knowledge of medicine. I'll highlight some of the memorable patients that have taught me most about the art of medicine and the unique challenges of medicine in low-resource settings. I should note: the following pictures were obtained with parent permission and an understanding the photos would be shared with others who were interested in tropical medicine.  

CASE ONE: 9 year old with unilateral eye swelling. 

Clinical Course. Febrile, sick appearing child (39.7) presents with 4-day history of fever and unilateral eye swelling. Temporal relationship to fever and initiation of eye swelling was unknown. Eye swelling progressed with bilateral involvement the day of admission with associated active serious drainage from the superior eyelid. No obvious skin lesion. Child reports eating cooked meat from a deceased calf approximately 1 week ago, the calf was notably sick prior to dying. No one else in the family or village has been ill; other individuals ate the same meat and did not develop illness or facial swelling.

On admission, the intern overnight believed this was a case of cutaneous anthrax (despite there being no classic eschar lesion). Child was started on high dose Penicillin.  Two days later, child's fever and facial swelling was persistent. Differential diagnosis was considered including H. flu or staph pre-septal vs orbital cellulitis. Antibiotics were empirically broadened. Within 1 week she developed a classic eschar involving the superior eyelid and her fever curve normalized. She was discharged home on mono therapy with high dose Penicillin. She was instructed to follow up within 2 weeks; she was lost to follow-up, presumed continued resolution of her bilateral eye swelling. 

 

Lesson Learned: Trust your colleagues, regardless of their 'rank' in medicine. The intern overnight reported seeing a similar presentation of cutaneous anthrax. Despite this, many (including myself) thought broadly about the differential and given the sick-appearance of the child promptly advocated for empiric antibiotic coverage. In the end, the intern made the astute and correct diagnosis. In retrospect, he had much more to say regarding how he came to this conclusion and demonstrated a sound thought process that was initially overlooked. 

CASE TWO: 4 year old with chronic constipation

Clinical Course: Child with developmental delay presents for repeat admission for withholding stool and abdominal mass. On presentation he last passed stool 14 days ago. No history of vomiting, anorexia, or weight loss. Review of systems notable for gross hematuria. Abdominal ultrasound obtained to rule out mass was normal. Abdominal x-ray with dilated bowel loops filled with stool, no bezoars noted. 

Despite aggressive attempts at a bowel clean out (NG placement, repeated enemas, etc). A bowel regimen was established, but would be required for many months duration. A referral to pediatric surgery was obtained to rule out low-lying Hirshprungs disease. Decision was made for colectomy--which came as quite a surprise to me. 

Lesson Learned: Accept clinical management differences. Though a colectomy seems like an incredibly invasive treatment approach for a child with chronic constipation, it prompted investigation into management options and approaches in Tanzania. Turns out, a colectomy is not an uncommon treatment modality in this area. Instead of trying to be understood--I found in this instance and many others the value of seeking first to understand...and then if prompted invite further discussion. There are many ways of 'solving' problems in medicine. It's refreshing and interesting to see new approaches even if at times they are counter to previous ideas.

CASE THREE: 26 month old with bilateral lower extremity pitting edema

Clinical Course: Well appearing child was brought to the hospital from a rural by family after a medical worker had seen and strictly advised the family to seek medical evaluation for the child. Mother reports personal history of bilateral lower extremity pitting edema as well as siblings (child's aunts & uncles) with similar presentation since birth. No facial swelling. No change since birth. Does not bother the infant. On exam the child has 3+ bilateral pitting edema from the toes extending past the patella. 

Within 20 seconds of seeing the patient, the Australian pediatrician looked at all the trainees and said "there is only one diagnosis possible, I know what it is--and so should you." I looked at her blankly as if to say, "Please don't call on me." None of us came to the correct diagnosis--but after she stated the obvious, my love for physiology resurfaced. Congenital lymphedema. 

Lesson Learned: Hold dear in your heart the knowledge of physiology--and take time to think through problems for yourself. Even if it is a diagnosis you have never seen or read...you can still come to the most logical answer, even when no or limited lab/imaging studies are available.

These cases illustrate both the challenge and the privilege of augmenting traditional pediatric training to include a global health focus. Building relationships and working with physicians who have diverse training and experience is eye opening and valuable. It isn't always easy to find time to make an International Elective experience come to fruition, but experiences such as this I find to be professionally enriching. If you ever find yourself contemplating spending time in East Africa, I certainly would encourage you! 

Emily Hall's (PL3) Dreams Take Flight Again in Tanzania

Posted on behalf of Emily Hall (PL3)

If you had asked me 20 years ago what my life would look like if I were to become a doctor--flying into remote areas of Africa and providing medical care to those in need would have been on my short list of career ambitions. Decades later a dinner conversation and some networking led to the opportunity of a lifetime. 

I was invited by the Flying Medical Service (a NGO based in Arusha, Tanzania) to fill a last minute need to see patients in rural Tanzania. A pilot, a pilot in training, a local chief medical officer, and I traveled for two days landing in remote areas to see patients and provide medical care. Much of my role was to complete prenatal assessments and serve as a pharmacist of sorts--counting pills and dispensing medication. It wasn't pediatrics per say, but I was eager to be involved and willing to help in any capacity. Despite no formal plans to see pediatric patients there always seemed to be a sick child (or many) in each location inviting me to jump into a more familiar role.

We landed in various regions of the country and I felt literally "dropped" into the Maasai culture. The beauty of the villages and people mesmerized me. Their dress and way of life is so contrasting to anything I'd witnessed before. It was such a privilege to be immersed into the culture in this way. They believe pictures capture and take away their soul; so out of respect, I did not photograph any people during my visits. However, the images of the experience are imprinted in my memory. I apologize my writing ability cannot portray the pictures recollected in my mind--you'll just have to trust me: it was incredible.

Aerial view of a Maasai village as we fly low alerting inhabitants that clinic will soon begin

Returning from this experience I couldn't contain my enthusiasm. Bush flying had proved to be all that my childhood dreams had imagined. It provided an element of danger, fulfilled the desire to do good work, and allowed me to be surrounded by like-minded people. A few weeks later I found myself discussing the opportunity with a midwife at the hospital over tea. She herself has lived quite an adventurous lifestyle, which is reflective in her career endeavors, and I was eager to hear her perspective of medical humanitarian aid. 

I left the conversation identifying with her ambitions and taking away a new understanding of why some people are drawn to global health. In a career field so formulaic -- blended with my personality that is anything but -- I crave to connect with people to have alternative medical perspectives. The global health community embodies this notion. People who have sought and created an alternative career path surround me here and being in Tanzania has allowed me to learn from many who have found their way in medicine despite not conforming to a linear trajectory. 

On reflection, I realized the rigors of medical school and residency had quickly quieted my childish idealism. The perceived ability to make a change in the world and the naïve enthusiasm that surrounds such big dreams was a feeling I had nearly forgotten. Returning to Africa has been oddly rejuvenating and in some ways has given me permission to again have lofty and alternative career goals. So again, I find myself making a list of career ambitions. This time, becoming a Bush Pilot/Physician in Africa probably won't make the shortlist but I'll credit the experience with making me a bit more prepared for whatever opportunity comes next. 

Emily beside the Foreign Medical Service plane

Jambo from East Africa - Emily Hall in Tanzania

Blog Post written by Emily Hall, DO, 3rd Year Pediatric Resident

Jambo from East Africa!

I have spent the first few weeks in Arusha, Tanzania settling in and acquainting myself with the resources, medical facilities, and the community. As true with all my adventures abroad--this has not been what I expected, but equally holds exciting potential and opportunity. In future posts I hope to tell more tales of adventures. However, before things get too exciting...let me explain my perspective of life here in Arusha so if you are considering this as an International Elective you will know a bit of what to expect.

Danielle (another U of MN Pediatric Resident who most of you know) and I initially started our work at Arusha Lutheran Medical Centre, which is located in downtown Arusha and offers more specialty hospital and outpatient clinic care. They have a small NICU which was impressive to tour and have a total of 2 pediatricians on staff in addition to a pediatric registrar. In contrast, we observed and in the past few weeks have found our place at the Council Designated Hospital also known as Selian Lutheran Hospital (subtle name difference to the former mentioned). This hospital is in a semi-rural location in a village just outside Arusha serving both Maasai, Waarusha tribes, as well as people of Arusha. We walk to the hospital with beautiful views of Mt. Meru along the path. (see photo below) The resources here are limited in comparison to the Arusha Lutheran Medical Centre.

Mt Meru

We have been working with two Tanzanian trainees in pediatrics; one of which received his medical training in China the other from Dar es Salaam, Tanzania. Our primary physician contact here is from Australia; she has been a truly wonderful mentor. We round with two nurses and the four of us trainees. Together we have been discussing and collaborating on patient management decisions with particular consideration of differing International Guidelines of management and factors relating to a resource limited setting. This type of work and learning environment has taken a few weeks to develop, but has recently started to come together in an exciting and highly educational format. Later in the week the physician from Australia has been joining us--by this time we have had some autonomy to make decisions and can discuss in more details questions or concerns regarding patient care that have been debated in her absence. Additional training opportunities have included pediatric HIV clinic, pediatric general clinic, and serving at rural outreach clinics.

There have been several very interesting patients and cases, some of which are still a bit of a mystery. Perhaps in the coming weeks Danielle or I can write about one or two interesting patients to give you a taste of the variety of medicine and the diagnostic approach here at Selian.

Arusha provides quite the balance of work and fun. There are limitless things to do in the city and in the country. It is my hope in the coming weeks we can provide a bit of insight on both the medical and culture opportunities we have explored.

Until then, wishing you all well in Minnesota or wherever this missive finds you.

Emily Hall, DO, PL-3

U of MN Pediatric Resident