Week 2: part 2 of random thoughts

Posted by Rachel Ng, MD (a second year Internal Medicine resident from Kaiser Permanente, San Francisco serving a global health elective at John F. Kennedy Memorial Medical Center in Monrovia, Liberia through the Yale/Stanford Johnson & Johnson Global Health Scholars Program).

3/7/10

To admit or not to admit:
Clinic here is not necessarily too different than from clinic at home. However, if I order labs during the clinic visit, the patient needs to return the next day to bring me the result for review. I’m not sure if they need to pay twice.

In the US, for the most part, I have always considered care over cost. Thus if I think the information acquired from a test will help me in better managing the patient, then I just go ahead and order it. Here, I find myself debating and thinking two, three times whether a test is absolutely necessary as health care is so expensive here for most people.

Here, I feel like I have a higher threshold for sending people to the ED from the clinic or else to admit them to the ward. Example of people who walk into the clinic with systolic pressures of 80s to 90s. Maybe slightly dehydrated. Will they be okay with just a prescription of ORS? or should I send them to ED for IV rehydration? One of the good things about being here has been developing a heightened sensitivity for the “eyeball test” and clinical judgment based on just history and physical.

The medicine attending here reminded me that as a physician, he doesn’t think about the cost; if the patient needs the test or treatment, then go ahead and order it. As for the rest, leave it to social work to deal with.

I will take this advice with a grain of salt.

Sample fees:
CXR = 250 LD (liberian dollar)
Chem 4 (Na, K, Cl, Co2) = 600 LD
Clinic visit = 50 LD
ED triage =100 LD
Ward admission = 2500 LD
Ward deposit for treatment = 2000 LD

There is also a fee to pay to remove a body from the morgue when a patient dies. It is sad and ?unethical to hear (from my pediatrics colleagues) that some parents were advised by other parents to carry their sick child home when they are almost about to die, as to avoid the morgue fee.

Survival of the fittest:
I’m convinced Darwin/Spencer’s coined phrase of “survival of the fittest” exists here. And I’m grateful for it. Otherwise, my time here would be much sadder with a higher death rate. There must be some in-grain resilience that runs through the genes here. If the life expectancy in this country is so young, then anyone who’s passed that expected age essentially “passed the test”.

One success story—actually, a real miracle—is of a 70-something-year-old guy who presented to the ED in flash pulmonary edema, oxygen saturation at 33%. Extremely tachypneic and dyspneic. Diuresed him crazily, slapped on nitro, and actually survived the night with partial ambu-bagging and nonrebreather mask on 5L (that’s the max), satting at 55% to 65%. Still oriented. Day 2, O2 sat came up to 70s-80s. Day 3, O2 sat to 90%. …Amazing, something I’ll never quite wrap my head around unless the objective data I was getting was false, but still, quite a miraculous case. Now, 10 days later, will send him home soon with outpatient rehab. Yeah!