Janell Routh

Pediatric Resident, UCSF
Suba, January-February 2007

My name is Janell Routh, and I am a third year pediatric resident at the University of California, San Francisco. I completed a four week international elective at Suba District Hospital in January-February of 2007.

During medical school, we learned about the spleen. For me, however, it was always the most elusive organ on physical exam. Despite knowing it was there, I could never feel it. And in pediatrics, trying to appreciate an enlarged spleen on a crying, wriggling two year old was outside my capabilities as a clinician.

Not anymore. The most valuable lesson I will take home from my time in Suba is learning to feel a spleen, trust my clinical exam, and make medical decisions based on that information.

For the past four weeks I have managed a pediatric ward at the district hospital with guidance from the Medical Superintendent of the hospital-a Kenyan trained pediatrician. The ward has on average approximately 10 patients at any given time: some “routine” cases of malaria and others severe enough to be in an ICU back in America. For the first time in my medical career, I had to rely solely upon my neurological exam to tell me whether to perform an LP. There is no CT scan for backup. I depended on peripheral edema to judge sodium levels, as there is no method of checking electrolytes. We used hepato-splenomegaly in conjunction with fever as evidence for malaria. Conjunctival pallor became the preferred method of diagnosing anemia, and at the end of the month I could tell a hemoglobin of 7 from 10! It is here in Suba that the information we learned in medical school actually becomes important, because there are no diagnostic studies to confirm your “impressions” on exam. The exam is all you have to decide whether this person will get treatment for TB, or for malaria, or for typhoid. And occasionally, in the sick child, they will get treated for all three diseases.

Because of the reliance on exam skills in Kenyan hospitals, the clinicians at Suba are all wonderful and good teachers. I appreciated the time they took to help me re-learn the skills I’d forgotten. I learned that to best feel a spleen, the patient should be on their right side! I am returning to UCSF with more confidence in myself as a clinician, and a different approach to diagnosis. While I will still use the resources available to me at my hospital, like the luxuries of being able to order electrolytes and blood cultures, I will also take more time with the patient. I will listen closely to the history, and do a very thorough physical exam.

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