Professional Preparation for the Mission Field

I thought this was a rather interesting and inspiring anecdote for any medical student or resident thinking about medical missions! - Jon

Professional Preparation for the Mission Field by David Stevens, M.D.

What would you put on your mental differential diagnosis list for a four-year-old with profound anemia? I’m not talking about a hemoglobin of eight. I mean, “I can’t believe this kid is still upright anemia!” with a hemoglobin under three.

Okay, you’re right! First you need to get a history and physical. Here is what I found as a young physician fresh out of residency.

Pertinent Hx – Child has grown weaker over a couple of months and now is not playing or swimming in the river with the other kids. Mother states sometimes he coughs after getting choked up and there is some red tinge in his sputum. No nausea or vomiting. Stools may be a little darker than they used to be but she has not seen worms in them. No diarrhea. No mucous in the stools. No TB in the family. Some weight loss. No abdominal complaints. Immunized to date. No history of fever, chills or joint pains. Appetite fair but not normal. Diet includes protein and vitamin sources.

Pertinent PE – Appears weak and somewhat listless sitting in mother’s lap. VS – No fever, BP – low normal. Pulse – elevated. HEENT – very pale conjunctiva. No nodes palpated. CVS – normal though increased heart rate at rest. Lungs – clear. GI – spleen slightly enlarged. No tenderness. No worms palpated. Stool – hemoccult positive but no melena noted. GU – normal. MS – normal. Skin – pale. Neuro – normal. Skin – very pale with poor nail blanching.

What labs do you need?

This is a mission hospital so you can’t order everything in the book. The lab doesn’t have time to do it and the family can’t afford it. Remember, common things are not common.

The most common causes of anemia in children in Africa that fit with this history and diagnosis?

1. Malaria – very common in children
2. Parasites – round worm and hookworm in particular
3. TB – anemia of chronic disease but the hemoglobin is usually not this low
4. GI Pathology – Peptic Ulcer Disease – common in this culture but uncommon in four-year-olds, Meckle’s Diverticulum. Hepatitis.
5. Hematological Pathology – Hemolysis – Sickle Cell, G6PD Deficiency, Under Production – Iron or B-12 deficiency. Leukemia.

I ordered a:

1. CBC with morphology and a reticulocyte count
2. Stool for O & P
3. Chest X-ray
4. Malaria smear
5. SGOT

The malaria smear, stool, SGOT and CXR were normal. The CBC showed a microcytic, hypochromic anemia with an elevated reticulocyte count but not as high as you would expect with a hemoglobin under three.

What is the diagnosis? What should you do next?

We didn’t have a scan for a Meckle’s, nor scopes small enough to do an EGD but something was going on in this kid’s GI tract. My only options were to do an upper GI barium swallow or a barium enema. Since we had no radiologist, I would have to do and interpret them myself. It was a lot of work and expense with a low chance of finding peptic ulcer disease, a tumor or identifying a Meckle’s.

So I went and got a sidewalk consult. I found Dr. Steury, my mentor and the founder of Tenwek Hospital and gave him the case in a nutshell. He smiled and told me to get a tongue blade and an anesthetic throat spray and he would be up to outpatients as soon as he finished with the patient he was seeing on the ward.

I reexamined the kid’s throat while I waited for Dr. Steury. It was normal except the saliva in the back of his throat perhaps looked a little pink.

Dr. Steury arrived, quickly sprayed the child’s throat, adjusted the light and then instead of pressing down on the tongue, elevated the soft palate.

Hanging in the nasopharynx was a soft, glistening, fat, green-black mass about two-thirds the length of my little finger. Dr. Steury commented, “There is the problem.” He then looked at me and asked, “Know what that is?”

It didn’t look like anything I had ever seen.

Dr. Stuery didn’t let me stew in my own ignorance. He went on, “It is a leech that has fixed itself with its sucker onto the mucous membrane and it has been sucking this child’s blood. It secreted an anesthetic so the child doesn’t feel it and an anticoagulant that keeps the blood from clotting. The child is constantly oozing blood into his GI system.

“Want to know how to take it off?”

“If you just pull at it with forceps, the head may come off and lead to an infection. It also may regurgitate into the wound and leeches can carry Hepatitis for months after biting a human.”
He gave swift advice, “Get a swab and paint it with viscous Xylocaine. The leech will absorb it, become paralyzed and fall off. Give the boy an injection of iron and some iron tablets. You can check his blood count in a month.”

I don’t know about your experience, but they didn’t cover leeches as a cause for anemia in my medical school or residency, much less tell me to look for them in the nasopharynx! I found out later that Napoleon lost many soldiers to leeches when they crossed from Egypt into Syria in 1799. The soldiers drank contaminated water and got leeches that caused severe blood loss and even respiratory obstructions leading to death.

What is my point?

You can go from one residency to another for the rest of your life and you will never be fully prepared for most practices on the mission field. Most missionary medicine is very different from practice in the U.S. If you train as a general surgeon in the U.S. it is essentially GI surgery. Overseas it is orthopedics, neuro, gynecological, urological and everything else from the bottom of the feet to the top of the head – the skin and its contents.

Most pathology is acute or far advanced. Chronic diseases, common here, are more rare there. Because of this you can often make a dramatic difference in a patient’s life or you are faced with a palliative challenge because you can’t really do anything.

So how do you prepare?

Most specialties can be used in some mission situations but the most common needs are for surgeons and primary care doctors. Here is my advice if you are in one of these categories.

1. Get as broad a training as you can and learn how to take care of really sick patients.
2. Get experience in as many procedures as you can.
3. Do your elective rotations in areas that you will commonly handle but you won’t have colleagues to refer to. In my FP residency, I did extra OB/GYN, dermatology, ENT, ophthalmology, orthopedics and surgery rotations. I felt weakest in ortho when I got overseas. They didn’t let me do supercondylar fractures in training but I saw them almost every day at Tenwek.
4. Learn to learn. When you finish your training, your real training will begin.
5. If you can, get an idea of where you are going to serve and then visit during training to see what common pathologies you will face. Get extra training in those areas.
6. If you are going to pioneer or be the only doctor at a facility, work for six months or a year in an established mission facility with colleagues who will train you in missionary medicine.Consider a “missionary fellowship” if you are training in family practice. The first of its kind just started at Via Christi Hospital in Kansas City. It includes five months working in a mission hospital beside superb missionary doctors as well as doing rotations in tropical medicine, public health and common procedures. Check it out at http://internationalfamilymedicine.org/.
7. Leave your preconceptions of practicing Western style medicine behind. Here, unless you are competent or under direct supervision, you don’t do a procedure. Overseas, you get the most competent person to take care of the problem but often times, that might be you. You are the only hope the patient has. You grab the nearest book and prop it up by the operating table, you grab some colleagues to help you figure out a diagnostic dilemma and most of all you pray a lot. You know, urgent prayers like the disciples prayed when their boat was battered by the storm. My favorite painting by Nathan Green is on the wall across from me in my office. It is Christ in the operating room with an arm around the shoulder of the surgeon and the other guiding his hand.

I’ve been there and experienced that.

You will save many lives and sometimes you will lose people that a more skilled doctor or with the right equipment could have salvaged. Ever try to take a barbed arrow out of a right atrium in a beating heart? Dr. Steury had to attempt it on a young man who walked into the hospital with an arrow sticking out of his chest and pulsating with each heart beat. With no heart lung machine the patient died on the table from massive hemorrhage. Ever try to get a barbed arrow out of the aorta when you don’t have a vascular clamp that large? Ernie did it with a makeshift noose made out of a red rubber catheter and a piece of suction tubing. I’ve used Sears bolt cutters in the abdomen to cut the tip off a barbed arrow that shiskabobbed the descending colon and left kidney before burying its head in the spine.

When you are successful you thank God. When you’re not, you don’t despair. God is still in control and had another plan.

All of this is the challenge and the joy of missionary medicine. American medicine will likely become too tame and boring after you’ve practiced overseas. You will get to save lives, every day! People so much appreciate what you do for them. Most of all, your service will open their hearts to the Savior. Because of you, people will come to know Jesus and live forever!

No matter how good a doctor you are, you can’t make people live forever, but God can and He will let you be a part of the process!