Broken Hearts Many American physicians have lost their ability to perform detailed physical examinations and rely on technology, such as echocardiograms, to diagnose valvular lesions and other abnormalities. I encouragingly tell Ethiopian students that they have the opportunity to become much better clinicians than American students, for they are forced to use their eyes, nose, and hands to arrive at a diagnosis. For Americans these may be overlooked or cursory steps on the way to ordering tests. "Don't be controlled by technology," I would tell my students. "Use your brains, figure out what's going on." I thought of this as my colleague and I stood at Bewoket's bedside this Tuesday evening. "How long has he been ill?" I asked. "Five or six years," the nurse replied. "He was hospitalized a couple of times in Gojjam and it helped a lot, but this time he got sick and his family decided he should stay home and die. He tells us he walked to Addis Ababa instead." I found it difficult to believe that a boy who could barely sit up in bed could walk 300 kilometers to the capital. He told me later that he had collected food that had fallen onto the sides of the road, and resold it to passers-by. He was determined to be treated. It took him two months to save 16 birr ($ 2.50). He paid two birr to ride on the top of a truck for two hours to a bus station. At the bus station he learned that the bus to Addis Ababa cost 18 birr. However, someone took pity on him and agreed to sell him a ticket for 14 birr. He rode for two days, without any food. At night he slept on the dirt floor of a "hotel" room, for which he paid his last half birr (7 cents). He arrived in Addis Ababa hungry, penniless and knowing nobody. Luckily, someone at the bus station saw him and brought him to the Black Lion Hospital.

I borrowed a stethoscope, and briefly listened to his heart and lungs. "To me," I said, "the problem is all in the mitral valve." From my exam, it was obvious that he needed aggressive treatment. I checked his bedside chart: he was getting a variety of tablets: digoxin (which strengthens contraction of the heart and slows the heart), quinidine (to correct the abnormal heart rhythm), lasix (diuretic, or water pill to get rid of excess fluid), and anti-acids. "He is on the wrong drugs at the wrong doses and the wrong method of administration," I thought to myself. I decided to start off slow so as not to antagonize the local doctors. I asked the nurse to pass on my thoughts about the case and decided, if there was no change, I'd try another course. A couple of nights later Bewoket looked even worse. His neighbors reported that he had not eaten anything all day and he was breathing more rapidly. He was coughing up blood-streaked sputum, a sign of pulmonary edema, fluid in the lungs. I was afraid that he would not live through the night, and so I tracked down the doctor on duty, and suggested that he be put on IV lasix to rapidly help his kidneys excrete the extra fluid in his body. "What is he on now?" he asked. "Oral lasix," I answered. I purposely did not report the dose, because I was afraid it would prejudice him regarding my proposed dose of IV drug. "What dose?" He asked. "20 mg," I reported truthfully, followed by, "It's far too little." "Okay, but there is no IV lasix in the hospital," he replied. "Give me 15 minutes," I said, "I'll go out and get some." I drove back to the hospital and delivered the medicine, having persuaded the attending physician to increase the dosage, and the next day I typed a politely worded memo to his physicians with advice on how to care for Bewoket. In this country, consulting physicians are not accorded the respect they are in America; I felt that I was invading their territory and had to offer my opinions very diplomatically. In Bewoket's case, the doctors accepted my intervention to a certain degree.