Day Four: When Zebras Become Horses

In medicine, there is a funny tradition that refers to common diseases as "horses" and rare diseases as "zebras." It's typically the "zebras" that will earn a lucky doctor the chance to publish a case study and be famous. For American physicians (or those in wealthy countries), it's the patient that rolls in with malaria or typhoid fever that gets people excited.

How interesting to be placed in a situation where all of your "zebras" turn into "horses."

And this is, in essence, what has happened in the past few days that I've been here in the DR. I'll admit it...there's something tantalizing and very refreshing about seeing things exotic and out of the ordinary. And already, since I've been here, I've seen dengue, tetanus, and at least two cases of adult meningitis that were precipitated in some way by pre-existing head trauma. None of the other residents or doctors blinked an eye when we asked specifically to see these patients. It still amazes me that these cases are considered "bread-and-butter" down here.

But all that aside, I think there is a fundamental difference in how people approach rare diseases. Where as in the U.S., we'd be content to use all resources available to work up an interesting case, decisions for expensive tests are made with more care--as if the medical providers involved are always cognizant of the fact that they don't have very many resources. Rule is--if they can't do anything to fix a problem, all investigation stops there. The charts here are filled with so many abnormal lab and imaging results that haven't been pursued farther. For example, once a tumor is identified, there is very little motivation for doctors here to pursue further studies. Chemotherapy and other treatments are limited, and patients usually can't pay for it...so to Dominican providers, there's really no indication to do more.

But it's the patients with these diseases that turn out to be sad cases. There was a 37 year old with Cushing's Syndrome due to an adrenal mass with a compression fracture who had been bed-ridden for 3 months. In the United States, her outcome would probably be much better given our access to physical therapy and bone-building agents. But here, she was doomed to wait in a room she shares with 3 other patients, awaiting possible surgery that may or may not occur. There was also a 16-year old who had a perforated appendix just a few days after having a cesarian section. She eventually returned to the operating room to have surgery as well as a drain to get the infection out of her abdomen. Afterwards, she seemed to develop every complication in the book: sepsis, DIC, pleural effusions, anemia...the list goes on. And all this at the tender age of 16. It is difficult not to wonder how different her medical course would have been if she were treated in the U.S.

We had an easy afternoon today. Our attending presented a gazillion x-rays for the Dominican residents, who seemed overall to be extremely pleased to have such a great lecture. I was stunned at how much they were able to distinguish. When we, the medical students, looked at the films last night, we were overwhelemed by the unusual diagnoses we were presented. But the Dominican residents seemed pretty unfazed. There was one film showing Varicella Pneumonia (a complication of chicken pox) that essentially stumped all of us Ameircans. But the Dominicans got it almost right off the bat.

Dinner was a feast, as usual. I shared cooking responsibilities tonight with Heather, the resident. She made Dominican-styled beans, and I cooked up fried rice, chicken, and a Pad Thai stir-fry.

Tomorrow will definitely be an action packed day. We head for A Mother's Wish...the organization that sponsors a clinic way up in the Mountains near Santiago. This should definitely be a change of pace, which, at this point, is much needed. I can't wait to spend a day outside of the hospital!