Medical Elective in India : Humanising and Dehumanising
In the last two or three days, I have encountered a lot of different patients who present with similar complaints. Cases of Tuberculosis and malaria are quite common in a slum resettlement township, which is where the clinic is located. Some of the common symptoms invariably are fever, sore throat, body ache, diarrhea, runny nose, cough etc. Given the number of patients encountered with these symptoms, some other signs and symptoms are more interesting for a first year med student:
1. Patient with icterus (yellow sclera of the eye) was worried that he had acquired jaundice even though his antimalarial course was not complete. Could it be hemolysis due to the antimalarial drug? G6PD deficiency?
2. A positive Murphy's sign. Cholecystitis? My first positive Murphy's sign. 3. A woman came in with two children and a Bisleri bottle, a common transparent bottle for packaged drinking water. She comes in, worried, and says, the bottle that contained some liquid drug for mouth ulcers was mistaken to be water and both her kids have consumed some. The son was very scared possibly because he had received a scolding from home but the daughter looked mischievous and smiled shyly. 4. Little girl presented with mouth ulcers and candidiasis on her tongue. Only drinks milk and has tummy pain.
5. 18 year old Muslim patient in a burkha walks in complaining of a rash on her bottom. In the health clinic, it is difficult to lie a female patient down and check her rash to adequately determine what it might be. A thorough history is absolutely necessary, and appropriate counselling to ensure future visits should the rash not improve is also important.
My experience has been a mix of two things: (i) talking to patients and seeing the catharsis on their face when they speak to a medical professional, and (ii) identifying clinical signs and symptoms to come up with a diagnosis and treatment. I have found both these aspects to be equally important from my limited experience but also from other reading and meetings with good doctors. Although case #2 above seems as though I have removed the patient out of the picture, and focused only on some medical sign (or jargon), I think it is important as a student to realise that it presents similarly in any other patient, and as such, I should be mindful next time.
That being said, medical signs are not good enough. I have had such beautiful moments with little children who have varying degrees of problems. Sometimes it is so easy to identify how much pain a child may be going through merely by looking at their behaviour. Those who have a minor problem, or a type of pain that is intermittent look playful, and will also smile when I smile at them; they will open their mouths with a passion when asked to say 'ah'. Then there are others who look forlorn, and speak softly if at all. Of course, this alone is by no means a method of diagnosis but gives an idea of the degree of discomfort and seriousness.
The doctor at the clinic talks extensively to each patient, and I like to think that every patient that walks in to the clinic is treated with respect and care. The doctor also explains the shortcomings of a small clinic and the need for going to a bigger hospital; he explains to them why getting certain tests is important for diagnosis. He clarifies the dosage and communicates with them about how to use inhalers, ORS powders, nasal drops etc. Sometimes it seems as though the patients are surprised by the time he spends on each patient, and often I have already spent some time on them taking histories and doing physical examinations. I want to ask them if they feel happy about spending so much time, or simply want a 'pill' and leave.
I came home today, feeling energized by seeing patients, and especially children. Pushpa, the lady who cooks dinner at our home asked me what is it that I do. She asked me if it was social work, and she told me she liked the fact that I did this work with imaandari, or sincerity. I did not realise I was exuding imaan when I spoke to her about how much I loved seeing patients today. She went ahead and told me about her experiences at the civil hospitals, and how poorly patients are treated there.
When Pushpa suffered from severe anemia, a woman in her ward was in pain, couldn't move and was being loud. The nurses and the doctors did not give her a glass of water or any food. The patient's nails had grown a couple of inches and had become 'round round,' Pushpa told me. Nor was she given anything to wear. Pushpa's son when visiting Pushpa gave this woman a few biscuits to eat but because of her long nails, she could not pick them all up. The ones that fell down on her bed were later infested with ants, and nobody killed the ants.
Pushpa recounted stories of pregnant women who have been slapped during labour, or have had their legs tied up in the air, or cursed for getting pregnant in the first place.
Sometimes I wonder if I have the courage to witness such situations, and momentarily feel better about taking a detailed history of the patients that I encounter because I am giving them basic human respect.
