Stories From The Field

It was two minutes past eight when I arrived at the Dean's suite of the University of Ruhuna, Faculty of Medicine. Upon entering the dean's office I was struck by the stereotypical nature of the décor. It was a exactly what you might imagine a high level faculty member's office in a tropical medical school would look like; dark hardwood floors, very stylish now but not by intention more by accident, heavy metal desk with green Formica cover and crooked aluminum drawers that have been rusted shut since 1983, squeaky metal swivel chair with faux leather upholstery, papers strewn about, some partially covered by brown file folders others just dancing naked in the artificial breeze generated by the clink-clank ceiling fan that teeters on its ecliptic as if it's about to come crashing down any moment, and a late model Dell Inspiron computer sitting on a corner table covered in a thin film of dust and neglect. I can't help but stare at the computer and ask myself, "Wonder if I can connect to the internet on that thing?"

Across the somewhat disheveled desk sits the equally disheveled, though much esteemed, Professor Ariyananda, former Dean of the School of Medicine. He is wearing a yellow short-sleeve button down with a brown tie. He's got on brown polyester pants and a pair of loafers aptly suited for the tropics. The Professor and I make small talk for a bit, fill out some paperwork, share in some stories of his time in the States (he worked at USC hospital for a spell back in the '80's, huh, small world), and then he invites me along for a tour of the medical school.

After a rapid tour of the medical school; anatomy labs, lecture hall, and departmental offices, Professor Ariyananda escorts me across a busy street to my new home for the next 4 weeks, Karapitiya Hospital. As we play slalom with oncoming traffic in an effort to get across the street Professor Ariyananda tells me a bit about the hospital. The hospital has over 1,400 beds and serves as both a teaching hospital for the University of Ruhuna as well as the leading tertiary care facility for all of southwestern Sri Lanka. As we dodge our last Tuk-Tuk and leap to the safety of the sidewalk he expresses with gusto that Karapitiya admits more than 100,000 patients each year and runs almost at full occupancy all year around.

The front of the hospital is subtle and calm. Other than the prototypical tropical architecture —red tiled roof, chipped stucco walls, palm leaves reaching over the façade, and rusted bars covering the windows the hospital has a romantic air reminiscent of Seattle-Grace or "ER's" County General. A tall, slender, European style ambulance sits idly in front of the main entrance as passersby make their way out of the hospital and down to the bustling sidewalk. Professor Ariyananda stops abruptly and waves his arm toward to the expansive stretch of driveway running along the front of the hospital, "The day after the Tsunami more than 600 bodies were laid out here." He gives me an expectant look curious to see how I will react to that macabre yet sobering detail. Silence was the only response that seemed appropriate.

We entered into the hospital in search of the 4th year medical students who were caravanning around the hospital on morning rounds. Something that would probably surprise most westerners is the fact that the hospital is a completely open-air facility. What this means, basically, is that there are no walls, doors, or fully enclosed spaces (except for the ER and surgical OR's). The entire hospital is open to the outdoors. I guess this allows them to save on air-conditioning, but it also allows for some interesting sights. As we pass the Oncology Unit I notice a sizeable female cat that has taken up residence under a desk. She is coddling and feeding her kittens while a line of patients stand just feet away waiting to be seen. As we continue weaving our way through the long hallways we pass the surgical unit and right under the sign, at the entrance of the surgical unit, rests a sleeping dog who barely gives an upward glance at our passing. Between being jealous of the dog for his ability to sleep on the surgery ward, and being floored by the casual presence of animals roaming the halls of a hospital my mind loses its bearings and for a second I find myself questioning reality —"Am I really in Sri Lanka, or is this some alternate universe in which animals and humans live as equals? Where veterinarian and medical hospitals are one? Maybe the dog is waiting for a gall bladder removal or a fine needle biopsy of his mange?" Before I can answer this enigma we turn the corner and there standing partially in the hallway of the hospital and partially leaning into the garden along the foyer is a huge brown cow. The cow shoots me a dirty look as I stare incredulously. I know people back home will never believe this. I took pictures.

We approach ward 12 where my team is rounding. We step over some patients that have taken up residence on the floor and I see a blob of white coats standing around a patient's bed. I'm amazed to find out that my team consists of 30 medical students and one attending —yes, 30, I counted. Introductions are made and the students welcome me with silent smiles. One of the students, a fellow named Mendis is asked to be my host and he obliges gracefully. As I look around I quickly realize that I am twice the size of everyone, including the attending. At 6'2 and 200 lbs I feel almost ashamed of my overbearing presence. I can tell the patients are entertained, they can't stop staring. The girls in the group whisper and giggle to each other and I can't discern if they're just awestruck by my size or if I have something stuck in my teeth.

The attending sees fresh meat and immediately asks me to approach the patient. The topic of this morning's rounds is the abdominal exam. The attending graciously requests that I demonstrate a complete abdominal exam. A little anxious and woefully unprepared for the impromptu exhibition I slide my way through the crowd and stand over the septuagenarian patient who has been admitted for enlarged spleen. I proceed to gently lay my right hand on the patient's abdomen, but before I can even apply pressure I hear the attending over my shoulder, "No, No, No you never, never flex your wrist when you palpate the abdomen!!!" I glance back at him and with the utmost respect I reply, "Huh?" And in that moment I am introduced to the most obvious difference between US medical education and that of Sri Lanka —here physical exam is everything.

In a hospital where admitted patients are responsible for providing their own bedding, food, and mosquito nets there is an obvious financial restriction on ordering shotgun diagnostic exams at will. In fact, a urine analysis and a complete blood count are about the only diagnostic exams that could be considered routine. To this end, the medical students and staff are forced to rely on the ever delicate combination of instinct, experience, and tactile-auditory perception. Eager to indoctrinate the wayward American, the attending briefly describes the essentials of the abdominal exam as I stand by respectfully. He demonstrates the most thorough abdominal exam that I have ever seen, eloquently elaborating on all the major steps; palpation to auscultation, to percussion, etc, etc. He fires a question at me, "When would you expect to hear hepatic bruit?" Once again my reply, "Huh?" "Hep-a-tomma, that's right!" he belts out. Quietly to myself I enquire, "The liver can generate a bruit? Interesting." Just as I make a mental note to look up hepatic bruit after rounds my attention is abruptly shifted to a strange sensation brewing in my own abdomen. I began to feel this odd turning in my stomach. It is like a mild sense of nausea or the kick of fresh gas building in my GI tract. I stare at the patient and shift my stance trying to relieve the discomfort. No luck.

The aching persists and now I get worried. "Was it something I ate? Could I be coming down with gastritis already!?" "Now, who can tell me how to find the liver's edge?" I hear the attending shout to the group. That was the last I heard the attending say. My attention is completely diverted from the teaching session and fully focused on my own personal gastrointestinal crisis. I know that I can't just walk away from rounds. That would be rude. I shift a few more times and I start to feel the pain subside a bit. What a relief, but now I'm sweating. And not just beads of sweat. I'm slowly melting from the inside out. "It's hot in here, but not that hot!?!" I think to myself. Truth be told, the temperature in Sri Lanka that day was 96 degrees with 88% humidity —it was that hot, but I was trying my best to downplay the heat, you know like cognitive dissonance. This of course reveals yet one more glaring difference between the practice of medicine in the US vs Sri Lanka. In the US we have the luxury of caring for our patients in the comfort of brisk temperature-controlled wards. In the US we take for granted those seemingly standard creature comforts, like air conditioning and clean water. There are no such amenities here. The heat is oppressive and it forces me to pull down my tie and unbutton my collar. I look up at the overhead ceiling fan. It looks rusted stiff —no hope for relief there. As I feel the sweat start to dribble down my brow I say a quick prayer to Willis Carrier (the American inventor of the AC) begging for a blast of Freon-chilled air. Now my head is covered in sweat, I can feel it running down my face, "I've never sweat like this before." Under my white coat I can feel my shirt cling to my body instantly saturated with sweat, my pants are starting to cling to my legs too and now I am feeling a little dizzy. "What's going on?"

I stare at the patient trying to find a focal point to concentrate on while I breathe my way back to normalcy....... No luck. Almost simultaneously I feel my hands go tingly then completely numb. I can hear the attending talking, but he is starting to sound muffled and distant. Then, all of a sudden, all I can hear is ringing in my ears. Next, my vision starts getting fuzzy, and I am seeing flashing lights. Right then with as much disbelief as a person holding a winning lottery ticket I admit to myself, "I'm about to faint!? My first day, first 10 minutes with my new classmates and I'm about to faint!? But, I've never fainted before." I gently take a step back as my vision gets hazier, my body turns to pins and needles, and my hearing fades. My last visual memory is of a cat strolling across a patient's bed and playing with the IV tubing. As the last tiny trickles of blood make it to my brain they encounter the final two oriented brain cells deep in a debate that went something like this...

Brain Cell 1: "OK, we're going down."

Brain Cell 2: "But, where? If we fall forward we will crush the patient and probably explode his already stretched spleen. If we fall in place we are likely to crush one of the medical students and suffer a head injury on the concrete floor. There is an empty bed behind us maybe we should aim for that?"

BC 1: "We should say something, we should just tell them that we're about to pass out."

BC 2: "And look like a fool!? No way. Let's fight through this. We can stay up!"

BC 1: "Look, we can just ease back into the bed behind us."

BC 2: "Have you seen the bed behind us? The mattress is crawling with insects, you can see them scattering all over. In fact, I think they know we're coming. I saw one calling to the others to get their passports. They're planning to hitch a ride under our Brook's Brothers collar back to the US."

BC 1: "If we pass out on the floor that makes us an instant patient anyway. One way or another we're gonna end up in that bed! Just sit down on the bed!"

BC 2: _____________flatline_____________________________-

BC 1: "Brain cell 2 come-in!? Brain Cell 2, are you there!?!? BC-2!!!WAKE UP!!!!!!!!!!!!"

BC 2: ________beeeeeeeeeeeeeeeeeeppppppppppp______________

The last thing I remember was a crying out in my head of that all too familiar mantra of the distressed patient, "Breathe!", "Breathe!", "Breathe!" Then everything went white.

I don't know how much time passed, but it couldn't have been more than a few seconds. I opened my eyes completely disoriented for a second and was amazed to find myself sitting upright on the side of the empty bed. My body didn't collapse! I must have maintained muscle tone somehow. I looked around and it didn't look like anyone noticed what I had just been through. My host, Mendis, and another medical student were standing to right of me whispering to each other which leads me to believe that they suspected something was wrong, but they didn't say anything directly to me. Otherwise, it looked like nobody else noticed, not even the cat, who was still batting away at the IV tubing -Toxoplasmosis anyone?

Rounds finished after that patient. I ran to grab a bottle of water that I had brought along with me. In my sprint for the water I stripped off my tie and white coat, I unbuttoned my shirt and fanned myself as I ran. I inhaled a liter of water instantly and went to the canteen to purchase two more liters. I drank those summarily. Throughout the day I would drink about four liters total and I didn't feel the need to void once. I must have been dehydrated? What's odd though is that my mouth never felt dry, my veins were puffy and full, and my skin still had its elasticity. It must have been paroxysmal dehydration brought about by an acute fluid shift due to the heat and humidity. Go figure?

The second half of the day consisted of lectures in a large lecture hall at the medical school campus. I sat in the back of the air conditioned lecture hall just guzzling down di-hydro-monoxide and staring off into the distance. I think I even dribbled a little bit without really noticing. Mendis sat close by and checked in every 10 minutes or so to see if I needed anything. As an ironically appropriate topic the lecture was on hypovolemia induced glomerulonephritis.

Throughout the duration of my stay I would become gradually more accustomed to the heat and humidity, but up to my last day in Sri Lanka I don't know that I ever became accustomed to the sights and sounds of a major hospital in a developing country. And I call Sri Lanka a developing country with some hesitation. The country was just recently freed from that somewhat discriminatory label by the World Bank based on the fact that Sri Lanka has the highest GDP in South Asia. Nonetheless, the per capita income still hovers around $1,300 and any real wealth that the nation posses certainly doesn't seem to have made its way to Karapitiya Hospital. Here, the patients line the halls waiting for the opportunity to occupy one of the 1,400 rusted, metal beds. If they are in severe enough distress they will be admitted to the hospital. For days they will share the open ward with 40 other patients, their only privacy; a thin curtain and a mosquito net hanging from the ceiling. Their only amenity: a ceiling fan that works intermittently between power outages.

Early in my stay I admitted a 7 year old boy to be seen for an enlarged liver and lethargy for 3 days. He was placed in an isolated corner bed, a common measure to keep susceptible children at a distance from the infectious adult male population. A thin paper mask was draped over the lower half of his face to protect his already infirmed body from the pestilence floating around in the air. I assessed him and then went about designing a beautifully architected laundry list of tests to be carried out; X-ray, ultrasound, complete blood count, hepatitis antibodies, basic metabolic panel, liver function tests, etc. My differential diagnosis included but was not limited to hepatitis, parasitic infection, cancer, glycogen storage disease, and biliary atresia. Unfortunately, for both the patient and me, I was blindly operating under the paradigm of affluent western medicine. The sad reality was that in Karapitiya Hospital we would not have the benefit of expensive diagnostic exams. I approached the attending with my findings and plan of care. He glanced at me over the top edges of his bifocals and quipped in his strongly accented English, "Here we do not have HMO's whom we can bill for these procedures!" If he only he could appreciate the irony of that statement.

We hovered over the patient for a brief moment. The attending passed his hands over the child's abdomen and scrutinized the skin from head to toe. He asked a series of questions and finally pulled me aside for a quiet conference. "We will order doxycycline, this is most likely leptospirosis."

I thought to myself, "That's it? No rule-outs? No precautionary blood cultures?" Given the pecking order of the relationship, not to mention the etiquette, I nodded in incredulous agreement with the dictated plan. "We will observe overnight and then send home tomorrow." There was something disturbingly plaintiff in his voice. But who was I to question the seasoned professional who had been practicing what I deemed to be middle-age-medicine since before I was born. And just like that, the reality of my backward logic dawned on me. Yes, I come from one of the most prestigious medical training facilities in the world, and yes I am versed in the latest and most advanced technologies of disease warfare, but in the global arena I am a neophyte. The frightening truth is that 85+% of the world's patients are treated with medicine of the Sri Lankan variety, that which I arrogantly called middle-age-medicine. It is not they that are at a deficit, it is me. The majority of the world's physicians treat their patient population under the protocol of minimalist medicine. A form of de-specialized medicine that relies less on diagnostic technologies and more on clinical acumen, perspicacious assessment, and the occasional leap of faith. And while I continue to praise my university for turning out some of the brightest medical minds of the future I regret that I may be somewhat ill equipped to exercise my craft outside of JACHO accredited edifice.

It occurs to me that the vast majority of medical students are in a similar position as I was before I elected to do this clinical elective. We competitively place ourselves on the fast track toward successful careers as specialist in any chosen field. Before we've hit the halfway point of our medical education most of us are already envisioning our future professional affluence without giving much thought to the multitude of poor, marginalized, and underserved of the world. Nonetheless, there exists a small, quiet minority of medical students who seek to extend their benevolence beyond the common and comfortable bounds of modern westernized medicine. Thanks to this experience, I now include myself as a member of this quiet minority. While I'm not the type that likes to flower my writing with quotes, there is one famous quote from Martin Luther King Jr. that has been brought to life for me as a result of my experiences in Sri Lanka:

An individual has not started living fully until they can rise above the narrow confines of individualistic concerns to the broader concerns of humanity. Every person must decide, at some point, whether they will walk in the light of creative altruism or in the darkness of destructive selfishness. This is the judgment. Life's most persistent and urgent question is: What are you doing for others?
— Dr. Martin Luther King, Jr.

I look forward to participating in many more experiences like this past one in Sri Lanka and expanding my ability to work in underserved areas. In the future I will remind myself to drink more water prior to going to a tropical country.

Beau Munoz is a fourth year medical student at Duke. This summer, he spent four weeks completing an elective rotation at Karapitiya Hospital in Galle, Sri Lanka.