Narrative Medicine

An exercise in Narrative Medicine is an invaluable experience.  Physicians are constantly limited by time; it is rare to be afforded the opportunity to simply listen and learn from a patient’s story.  This is ironic, as it is the patient’s story and their interpretation of their experiences that shapes how they understand and perceive their illness including causes and cures, which impacts their day to day lives as well as their acceptance of western medicine.  An hour is certainly not enough time to hear, let alone fully understand a patient’s story, but it does give the listener a glimpse into the events that have shaped a person’s understanding of illness.

“Margaret” is a 49-year-old Acholi woman from Babo who was admitted to Lacor Hospital for persistent headache, right flank and back pain, and chest pain associated with a cough and several days of hemoptysis.  As I knew I was limited by time, I did not probe into the “normal” line of medical questioning regarding her symptoms.  Rather, I tried to ask questions that would allow me to understand her perceptions and beliefs regarding her symptoms.  Even this was difficult as there was a language barrier and my strong temptation to learn more about her symptoms. 

She proceeded to tell me that many of these symptoms had occurred before; this was the 4^th episode of headaches and vague body pains, but the first time she had chest pain and blood in her sputum, which is why she decided to come to the hospital.  Her prior 3 episodes (which started in 1982) were all treated either through traditional healers and herbs, or from western medications she obtained from a pharmacy; she had never been admitted to a hospital.

I have learned that like in many other cultures, the “left” is bad luck to the Acholi people.  She told me that she had left leg pain, which she was told could only be healed through traditional methods, as there was “no other option”.  I wondered if she thought this was significant.  My suspicions increased when she told me that her mother thought she was “charmed” and that perhaps someone had bewitched her with “ju-ju”.  But she did not believe this; she didn’t know of any reason for someone to do this to her and if this were true, she would be dead by now, she explained.  She told me that she believes that western medicines are effective, which is why she came to Lacor to be treated.  What wasn’t clear to me was why she didn’t seek western treatment in any of her prior episodes other than the fact that this time, she was coughing blood.  I believe her mother played a large roll in influencing the treatment choice.  Her mother was brought up a lot in conversation and then I learned that her mother is now dead.  Is this why she is for the first time seeking medical treatment at a hospital?

I learned more about her family.  She has 6 living children (with one set of twins) and 3 others who passed away as babies.  She wonders if her son, who was born in 1982 the year her pains started, also has the same affliction; he also gets similar headaches and pains.  She has had three husbands.  Her first husband was a much older man who “took” her when she was 14 and she became pregnant at age 16.  Her mother rescued her from him so that she might return to school, but that did not happen.  She was “taken” by another man who ended up beating her.  They separated in 1982 and he later died of AIDS.  At this point in the interview, it became clear to me that the year 1982 was not insignificant (i.e., this was when her symptoms started, her son was born, and she separated from her abusive husband).  I felt that she was trying to tell me more as she kept bringing up the year, but I could never get more (interestingly, she originally told me she was a widow before explaining that she had 3 husbands and that the last one was still living).  Her third husband is still living, but again, her mother “rescued” her from him 3 years ago because he also beat her. 

Just as I felt we were starting to uncover her story, our time was up.  I wanted to ask her so much more.  I wanted to know what her childhood was like and if the war disrupted her upbringing.  I wanted to know how much schooling she completed, how she provided for her children, and what role religion plays in her life.  Does she have a social support?  Any siblings or close friends who she can confide in?  What brings her joy, sorrow, and sadness? 

Frustrated that I didn’t have time, I thanked her and asked her if she could tell me anything more that she felt was important for me to know about her.  To this she responded, “Please, tell me what is causing the pains I’m having and what you are doing for them.  Also, I want to know how I can make sure my children can attend school.  What can you do for them?” 

More Pictures

I'm trying to get more pictures posted on my facebook page: embeck84.

Extra Curricular Activities

Not only is the course called “Social Medicine”, I am finding that my classmates are all VERY social.  There is actually a social committee in charge of planning events and they take themselves very seriously. Thursdays we go to BJZ (a club pronounced “B.J.’s”) for trivia night.  One of the Ugandan students was talking quite a bit of trash about his trivia skills. He is actually on a team and they are the raining trivia champions of 2010, something they are very proud of (although I’m not sure if there was a trophy involved). 

So here he is (I think there are only 3-4 people on his team) up against 2 teams of 10-12 American and Ugandan medical students (85% of which are “gunners” in my opinion).  Needless to say, his team got rocked!  What was more surprising to me was that Jim, yes MY Jim is a trivia powerhouse!  Between him and  Ugandan Lucy (the trivia “queen”) our team won by a landslide.  Jim and Lucy won us a case of beer.  Here are the celebratory pictures:

Leslie, Nicole, Natalie, Katherine, and Anna celebrating.

Lucy, Robert, Ham, and Richard (celebrating with non-alcoholic malt beverages?!).

Notice the case of beer: our prize!

1/2 the guys here have beers!

Our second social event was a “goat roast”.  Unfortunately, I missed the butchering process (during which one of my American cohorts proceeded to dissect the uterus…only a med student would geek-out during the butchering process), but snapped a couple of shots of the remains and party to follow:

Gloria, Anna, me (only one drinking...)

As I’m not a night owl, there have been quite a few activities that I have missed including dancing and concerts. Other activities include Salsa dancing lessons, American’s cooking an American Breakfast for dinner (French toast), and enjoying dinner in town at the Indian and Ethiopian restaurants (which is a huge ordeal, i.e., it took 1.5 hours to get served one night...I'll have to write more about that experience later).

We had a dual baby shower for one of the students Jackie and for Amy, our course instructor.  We ate dinner at the Ethiopian Restaurant followed by medical students’ variation of baby shower games which included Pin The Sperm on the Egg.  Lucy drew a very anatomically correct picture of a uterus, fallopian tubes, and ovaries.  The egg, of course was near the entrance of the uterus and I have to say that by far, the men in the class were most entertained by this activity.

Many of the girls in the class have had a fun time going to the market to purchase beautiful African-print fabrics and having tailor-made dresses and skirts.  I can’t exclude myself from this group of girls and look forward to showing off my new digs when I return home.

Social Medicine Topics, Part 1

We’ve learned quite a lot in class the past couple of weeks and have seen some real eye-opening things.  It’s difficult to know where to even start with it all and I am still processing much of it internally, besides.  There are a few topics that are sticking with me that I will try to share in a somewhat coherent way.  I hope I can articulate my thoughts here, so please bear with me!

Malnutrition:

This is a topic we learn about in the States, specifically in pediatric rotations during our third year of medical school.  I don’t feel like any American medical student truly knows what this means, however.  While there are always exceptions and outliers, and perhaps some of my cohorts in the US have seen malnutrition, I don’t think anyone can say they have seen the severity that we learn about in textbooks and only see pictures of.  I’m speaking of kwashiorkor and marasmus.

How does one diagnose and measure the severity of malnutrition? 

Objective measurements of malnutrition that rely on laboratory tests such as a measure of serum proteins, micronutrients, red blood cell enzymes, and urinary micronutrients are likely not available in most underdeveloped countries.  It is much better to rely on anthropometric indices including weight for age (W/A), height for age (H/A), weight for height (W/H) that most of us are familiar with.  Anyone who has seen a child’s growth chart knows what I’m talking about.  This is any proud parent who takes their child to the pediatrician and then brags to their friends that their kid is above the 50^th percentile for their height, weight and head circumference. Practically, this gives cutoff points that alert clinicians should a child fall below what is “typical” for a healthy child of the same age.  This is called a Z-score.  The ratios (W/A, H/A, W/H) are expressed as a % of the reference standard, or as a standard deviation from the mean of a reference population.  For example, if a child is 2 standard deviations below the reference value for a parameter, his or her Z-score would be -2.  Using this system, malnutrition can be classified as follows:

·      Underweight: decreased W/A (Z-score <1 mild; <2 moderate; <3 severe)

·      Stunting: decreased H/A (same Z-score as above)

·      Acute Malnutrition: decreased W/H (also called ‘wasting’). 

o      Moderate (aka “global acute malnutrition” or GAM): W/H Z-score <2 or W/H <80%

o      Severe (aka “severe acute malnutrition” or SAM): W/H Z-score <3 or W/H <50% or the presence of bilateral edema (swelling)

A less commonly used measurement in the States, but common a measure in developing countries is the mid upper arm circumference (MUAC).  This is an easy measurement around the dominant upper arm, which has useful cutoff values in children between 1-5 years old because MUAC increases slowly in children.  Here, a MUAC of <110mm (in a child 1-5 years old) would be consistent with severe acute malnutrition (see above and note that if a child has edema, this will automatically earn the label of GAM and the MUAC may be normal…this is important in kwashiorkor malnutrition), a value of 110-125mm is consistent with global acute malnutrition, and measurements between 125-135mm identify children who are at risk for malnutrition.

How do I assess malnutrition clinically?

All medical students know that 99% of the answers to our questions can be found by taking a good history (including a thorough social history) and performing a physical exam.  Questions we should ask the parents include the child’s normal eating habits (including breast feeding) and whether those have changed.  Is there an adequate food supply for the mother? Children?  Is the mother ill/malnourished?  Are there other diseases such as TB or HIV in the family?  What is the quality of the food?  Frequency of feedings?  Is the child thirsty?  Does he have access to clean water?  Does he urinate regularly?  Is the child ill?  Has the child’s behavior and activity level changed?  Are there any recent deaths in the family and if so, what from?  Was the child born at term and healthy?  Have the normal developmental milestones been reached?  Is the child immunized? 

The physical exam should include vital signs (temperature looking for fever or hypothermia, pulse and respiratory rates), general appearance (pallor, jaundice, sunken eyes/fontanelles, facial appearance, skin rashes), behavior, and mood (lethargy, apathy, irritability); assessment for signs of shock (cold extremities, weak pulses, decreased capillary refill time, decreased level of consciousness); appetite/reaction to offered food; edema; enlarged liver; distended and/or tender abdomen.

Are there certain types of malnutrition?

Kwashiorkor and marasmus are two distinct types of malnutrition distinguished by clinical differences.  Kwashiorkor is a type of severe malnutrition characterized by protein deficiency.  The child appears edematous (with only a moderately low weight), which may be misleading as an observer may think the child is “plump” and well, and also makes assessment of the child’s hydration status very difficult.  Other features include misery, apathy, and a poor appetite; pale, sparse hair with weak roots; wasted, weak limbs; pale, thin, peeling skin; and enlarged liver.  A child with marasmus, or generalized nutritional deficiencies, appears emaciated (and may have a “pot belly”).  He may look like an “old man” with thin, flaccid, wrinkly, “baggy pants” skin due to loss of muscle and fat tissue.  The child is alert, but irritable; he is hungry.

We saw two children with severe malnutrition last week.  One with kwashiorkor and one with marasmus.  The images of these boys will be forever imprinted in my mind.  The 5-year-old boy with kwashiorkor was doing well.  The boy’s skin “looked like a girrafe’s hide” as described by the father and his hair was sparce and white.  He looked small for a 5-year-old, but was eating Plumpy’nut (a high calorie food product made from peanuts, powdered milk and sugar, and enriched with vitamins; please watch the 60 Minutes article about this high calorie food for treating malnurishment in African countries) vigorously as we talked to his father.  The family was growing (there was an 18-month at home and one on the way), and he was a simple “peasant farmer” which means he works the land only to provide for his family.  He said that food is scarce and he didn’t know what he could do for his family.  The good thing was that no one in the family has HIV.

What can we do for malnutrition?

This is a bit of a loaded question.  The obvious answer is to admit the child to the hospital, follow algorithms for appropriate caloric requirements based on the level of malnutrition, and treat other contributing illnesses.  So let’s say things are pretty good here in Lacor and we are able to do that in the hospital (which is not always the case, but let’s just say that for argument’s sake).  The child recovers, gains weight, and is now healthy.  So now what do we do?  “Send him home”, you say.  “Educate the parents.”  But have we solved the problem?  What is preventing this from happening again?  What if the family does not have access to adequate food or clean water?  What if the mother is pregnant and food is scarce?  Now she has another child to feed and this child will have less attention from her.  Even worse, what if there is no mother or father because they died from AIDS and now children are raising children?  Who is responsible?  What do we do?  How do we empower people so that they can provide for their families?  Does handing out free Plumpy’nut once weekly solve the issue?!  NO!  This may work in the short-term (and don’t get me wrong, I think it’s a great product), but it is not a long-term, sustainable solution.  It does not empower people or provide them with a means to provide for their families.  There has to be something better.  Any ideas?