I am going to take a lesson out of the playbook of Heather Cox Richardson, one of my favorite daily reads for US and world politics as well as historical references (her daily blog is a must), though rather than taking Sunday off, I’m going to pause today on writing much for the blog and, instead, share with you pictures of our daily life here in Karatu.
Before I do that, though, I’ll tell you about a consult the residents did late last night after returning home from Teddy’s. There was a patient of approximately 50-years-old who had been either treated or admitted in Rhotia for a new headache of about seven days or so that was quite severe and hadn’t responded to standard analgesics. She came to FAME in evening and had been admitted to the ward for evaluation. Though her headache had migrainous features, she had really never had headaches this severe in the past and had never sought medical attention. Her examination was completely within normal limits and, most importantly, she had no focal findings nor evidence of meningismus (the resistance to flexion of the neck seen in patients with meningitis). In short, she had a very reassuring examination.
So, the question at hand was what to do about this patient’s headache and whether there were any concerns that she had a more ominous process that would potentially cause her immediate harm. In treating headache at home, we will often refer to what we call red flag symptoms or signs, which includes the history that we obtain. If one has these “red flags,” then we worry that the headache may be secondary to some other ongoing condition and the patient requires further evaluation, most commonly an imaging study (a CT scan in the emergency room or an MRI as an outpatient). New onset headache over the age of 50 is one of these red flags and this patient certainly fit the bill as she really had no prior history.
Though these “rules” are certainly based in good clinical practice, they must be tempered for the environment where one is practicing, for the difference in resources makes this vastly clear. Ordering tests for what is a possibility, despite how remote that may be, is a phenomenon that exists only in countries of unlimited resources, if there are any of these that truly exist. In the United States, of course, where there are few restrictions for ordering tests, or at least few that cannot be circumvented, billions of dollars are spent ruling out conditions that may have only the very slightest chance of being present, or possibly no chance at all. It is clear that we cannot continue that course for our healthcare budget continues to grow astronomically and will be impossible to sustain for much longer.
Here, in Tanzania, with our limited resources, the question I had for my team when I came to the ward to staff the patient was much different. When they had finished presenting her case to me and we had finished discussing all the possibilities, my question was simple. “What do you think is most likely going on with this patient and what would you like to do to treat her?” In the end, we performed no tests nor any imaging. She had a headache and a totally normal examination. We gave her a large dose of IV steroids that we often use at home in the emergency department to break headaches, and the following morning she was headache free and was discharged home.