Statistics and Stories

One of the unique traditions of medicine is what we refer to as M&M conference, or morbidity and mortality conference. I'm unaware of any other profession that conducts such a humbling practice. Once a week, all the physicians, residents, interns and medical students meet to review the unfavorable outcomes. The walls are lowered, the defenses are dropped, while a medical professional stands before a group of peers and admits a mistake or an unforeseen complication. It is generally a supportive environment where everyone learns from a mistake and hopefully next time a life is saved. Sometimes, it turns ugly.

While on my surgical rotation in the US, I have seen physicians rip a resident to pieces for a negligent mistake leading to the death of a patient. As if it isn't hard enough for a person to admit a mistake in front of their peers, especially a mistake leading to a human death, they are sometimes grilled for their actions. At times, the resident is presenting a mortality they had nothing to do with; one that occurred before they came on the service. They humbly accept the criticism and don't mention the fact they had no knowledge of the case until they were asked to present the day before.

Overall, I have found these M&M cases extremely educational, and I think most physicians would agree. Africa is no exception. Once a week a different service (Medicine, Pediatrics, Surgery or OB/GYN) presents their statistics and then a few cases with unfavorable endings. Last week I heard a startling number. 22% of patients admitted to the medicine service end in mortality. That's nearly 1 of every 4th person on their service dies. This is not a reflection on the quality of medicine practiced here; there are many reasons for such a high death rate. Almost 50% of patients on the medicine service are HIV positive. This immunocompromizing disease leads to many complications. Patients here also present much sicker than they would in the US. If someone got a deep cut in the states, they might clean it out and go to the ER for stitches. That costs a lot here. First there is the transportation, usually to a hospital that is not so near. Then there is the time they can't work while seeking medicine. The hospital bill is all out of pocket. And why should they seek expert medical advice when they have herbal medicine? They have always got better before. A few days later, after working in the field, the wound seems to be a bit more painful, and they notice this funny numbness in their hand. The next day, they can't contract their muscles as well. It must be that they didn't take enough herbal medicine, so why not just double it? A few days later, the infection has nearly incapacitated them, and the tetanus bacteria has spread proximal, now threatening their ability to breath. Now seems like a good time to go to the hospital.

I found it interesting that the busiest time in the Casualty or Emergency Room here isn't the same as in the US. Typically, Monday evening is the busiest in the US. This is because no one wants to be sick on the weekend, so they deal with it. Come Monday, when it's time to go back to work, suddenly being sick doesn't sound so bad. Maybe they try to tough it out for a few hours, realize how sick they really are, then break down and go the the ER.

Not so in Kenya. A day off work means the cows don't get milked, the chickens don't get feed, and you don't make it in to get paid for the day. Translation... you and your kids don't eat. This is probably why working in the casualty here is so exciting. Surprisingly (or not) there isn't a high prevalence of fibromyalgia here... (I apologize to those who do suffer from this, I'm not meaning to belittle this disease)

I have also been surprised by what is considered an elective surgery here. Apparently, osteomyelitis is not an emergent, or even urgent surgery. People live for years here with a fistula connecting their bone to their skin which drains pus from the infection. This is one of the few exceptions to the rule of only emergent surgeries for the orthopedic service. There are just too many emergent cases to worry about hip replacements, ACL repairs, etc.

The last few nights of call have not failed to live up to expectations. Last week while taking call for pediatrics, I was admitting patients in the casualty. A nurse came up to me and with a frantic look on her face, asked who was the attending physician for surgery. It seemed like an odd question. There is a very well established hierarchy in medicine. At the bottom of the totem pole lies the medical student. Above them comes the intern, then resident or a chief resident, and a the top is the attending physician. When a patient is to be admitted or worked up, it is always the medical student or intern to see them. Then, after working up the history and physical, they present to the resident. They may ask a few questions, add a few lab tests, and then when everything is in order, you make the page to the attending. At this point, you want all your ducks in a row if you will. Everything should be ready to present when the attending is called. This nurse wanted to bypass the whole system. Surely she was familiar with the hierarchy.

As it turns out, there was a head on collision involving two matatus, the main form of transportation for most Kenyans. Supposedly these are 14 passenger vans. Traditionally, matatus are blasting rap music, being driven by a teenager who is high on miraa (similar to amphetamine), and have names like Homeboyz, Blood Fist, and You Are Lonely When You Are Dead. I actually choose not to get in one matatu base on the name, "14 Black People." I didn't want to upset the balance. My personal record for most people in a "14 passenger" matatu, is 25 people. See below.


Back to the story, the traumas started rolling in, and you better believe that I gave her the name an the home phone number of the attending physician. (I still couldn't bring myself to call the attending, I made the nurse do it. I guess some things are just too ingrained by this point in my medical education.) I was pulled off Pediatrics call that night while we simultaneously ran three OR rooms throughout the night. At one point, my chief resident, Dr. A (see post on Perspective), asked me if I wanted to place the chest tube on our patient with a pneumothorax. Of course I did, so he briefly explained to me how to do this procedure I had only seen once and never actually preformed, while he went to the next OR to elevate a skull fracture. A crazy night, but finally the morning came and the traumas stopped pouring in.

I mentioned the high mortality rate here. I don't think I have been on a call yet where we didn't loose a patient. Last call was no exception. While admitting 11 kids from casualty, my resident grabbed me as she was running to the nursery. She was just paged, one of the quadruplets (the local tribe has a high number of multiple births) had a falling O2 saturation. This one survived the night. Two other kids in the nursery were not so fortunate that night.

Books about medical missionaries don't sell very well if the dwell on the bad outcomes, so I'll conclude with a few happy cases. I've been rounding in the Peds ward during the morning, then the nursery in the afternoon. The nursery is full of premature babies, many suffering from neonatal jaundice, sepsis, hypoxic ischemic encephalopathy, etc. After rounding there for the past 2 weeks, I was able to discharge 4 patients on Friday.

Picture of an incubator in the nursery.

Another of my Peds patients I admitted while on call was very sick. We were unsure of the diagnosis, and I was afraid the paralysis he was experiencing would soon compromise his breathing. After praying with his sobbing mother, I assured her I would do all I could. Unfortunally, we didn't have a spare ventilator to aid his breathing if he required it. Good news: this morning after church I stopped by to check in on him, and he was doing much better. I believe he has acute disseminated myeloencephalitis. I expect him to improve over the next few days with few if any neurologic deficits. Pictured below is me supporting him and his concerned brother beside us.