Internal Dialogue

"I have a 40 year old male with uncontrolled asthma..." begins the case presentation by Dr. Kinne, a senior resident. Aha (my first thought), this I know how to treat. Asthma is common in the U.S., and generally considered to be a bread-and-butter outpatient medicine management issue. In our four weeks so far in Cameroon this is the first case of this I've run across. I wonder if it's just less common here, underdiagnosed/underrecognized, or has a lower prevalence because children die from childhood exacerbations more often than in the U.S...maybe I can look that up later.

"For the past several months, he's been using his inhaler multiple times each day and waking up several times each night, only getting 2-3 hours of sleep" she continues.

Phew. I'm feeling relieved by the organized presentation and energized by the familiarity. Apparently clinical details I'm used to - impairment of function, frequency of inhaler use - are important here as well. Human lungs, after-all, aren't country or culture-bound (are they?). Seems like a good time to insert some affirmation combined w/ a Socratic teaching moment: "Great presentation so far. Based on the information you just gave me, what category of asthma would he fall into?" She answers correctly and confidently, and I mentally exhale. Thanks, Lord, for a case that fits my comfort zone, just a bit.

"He's gone through 4-5 Salbutamol inhalers in the past month, and I'm wondering if we can put him on an inhaled corticosteroid."

Blast, I think, as I whip out my smart-phone, accessing one of the commonly used pharmacology apps. "Salbutamol. Is that the same as Salmeterol?" My app is not loading, as the internet is down. For every one familiar aspect of a case, there are twenty unfamiliar.

"I'm not sure," she replies, pulling out her tablet, "but I was thinking he may need a long-acting inhaled corticosteroid as well?"

My other pharm app does not include Salbutamol in the database, though it does list Salmeterol. Since my two references failed me, let's try google...nevermind, the internet is down. We have a brief conversation about specific pharmacologic classes and the difference between short-acting and long-acting beta-adrenergic agonists in the management of asthma. Dr. Kinne is fairly confident Salbutamol is not the same as Salmeterol, and so can be continued. [As I write this, google is functional, and I find that Salmeterol is, indeed, another brand name for Albuterol, the most commonly used short-acting bronchodilator. Mental note - trust your residents.] We move on to the every-day every-patient question of "Do we have the medication he/she needs?" It is determined our hospital pharmacy does not carry it. Dr. Kinne proceeds to call a pharmacy in the nearest city. Whoever answers the phone does not seem to understand her English, so she tries Pidgin English. Still not getting an answer, she politely asks to be transferred to the pharmacist and waits on hold for a few the minutes. The pharmacist is not able to answer the Salmeterol vs Salbutamol query, though does confirm the presence of necessary inhaler in two dosages. Dr. Kinne hangs up.

"I'll write the prescription, and he can go fill it." We talk about dosage, titration schedule, and followup. She realizes she forgot to ask about cost, and we repeat a familiar script both here and in the U.S., about the cost-effectiveness of treatment, alternatives available (essentially none), and how this may affect adherence with treatment. The patient is a business man and so more likely than most here to be able to afford it. If he can't... What goes unspoken (not yet un-thought...) is that if he can't afford it, his options are limited to none. Asthma is not a zero mortality condition. In other words, adults and children even in so-called developed countries still die from asthma. I should make a note to look the actual mortality rate up...

"Good work Dr. Kinne," I say, as she heads back to conclude the patient encounter. Do they even call them "Patient encounters" here?

~Mary