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LION MAULINGS, MALARIA, AND RABIES
Volunteer doctors need fresh
skills
and a healthy dose
of self-reliance overseas.
BY VOLUNTEERING OVERSEAS, Drs. Sue
Abkowitz-Crawford and Glen Crawford have faced medical conditions
that they would not see in their Newburyport, Mass., practices.
American doctors may see plenty of gunshot wounds, but probably
few come upon patients with arrow wounds. In Tanzania, the Crawfords
saw a case where an arrow was still fixed in a man's chest. What's
more, the arrow pulsed with every beat of the man's heart -- it
had settled precariously close to the patient's pulmonary artery.
The couple also observed victims of lion mauling and a rare case
of full-fledged rabies in a Tanzanian man. Sleeping sickness was
a common malady and a serious one; patients often arrived at the
hospital only after they'd started getting seizures or slipped into
a coma, by which time they often had permanent brain damage.
When a doctor in the United States sees a patient
with a fever, some likely diagnoses are flu, pneumonia or a urinary
tract infection; but in other countries, Sue points out that her
diagnostic checklist begins with malaria, typhoid and parasites.
(One woman in Tanzania seemed a walking demonstration of a Murphy's
Law for fevers; she not only had cerebral malaria but also typhoid
fever and an abscess in her liver.) By the time people reach a doctor
in much of Africa and Asia, their problems tend to be much more
advanced. Patients often must travel for days to reach a hospital;
some that saw the Crawfords had walked out of the Masai plain or
taken a yak out of the mountains of Bhutan.
"You used your clinical judgment a lot more rather
than relying on tests," says Sue, an internist. She learned to listen
carefully to heart murmurs, for example, because she could not send
patients for echocardiograms. And doctors diagnosed tumors by touch,
with no CAT scans, ultrasounds or pathologists present. Sue also
learned a new way to diagnose diabetes on her travels: Because catheters
in patients' bladders were drained into bowls, ants thronged to
the bowls of people with diabetes, drawn to the unabsorbed glucose.
As the orthopedist, one of Glen's jobs in Bhutan
was to treat TB of the spine and joints. To drain an abscess full
of bacteria pushing against the spinal cord, Glen would operate
through the chest, deflating one of the lungs to reach the backbone
to drain the abscess before puffing the lung back up and sewing
up the patient.
In Indonesia, a man in his early 30s came to see
Glen with a chondrosarcoma of the shoulder that had grown as large
as a basketball and invaded the nerves of his arm, leaving no feeling
in the limb. Though Glen had only reading knowledge of the procedure,
he performed an amputation, removing the man's shoulder blade and
collarbone as well as his arm. The surgery proved successful and
Glen received a letter from the patient a few years later saying
that he was doing well.
In some places where sanitation was a problem, doctors
avoided surgeries because of the increased risks of infections.
"In Bhutan, you had to use one hand to wave off flies," Glen recalls.
Rather than perform surgery to reset a bone, doctors would often
allow fractures to heal without intervening, even if that meant
leaving a patient with a crooked limb. Fortunately, says Glen, people
there seem more tolerant of living with a badly healed fracture
than patients in Newburyport, who expect their doctors to make them
as good as new. -- KJ
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