Pathology volunteering (and playing) in Kijabe kenya : Graduated Responsibility and Giraffes

Although nearly everyone agrees that "graduated responsibility" is a good thing during pathology residency training, the definition of "graduated responsibility" is vague and unclear. It is also a phrase that I really can't stand anymore. As Rochelle mentioned, last Wednesday, I experienced it.

It was initially a slow morning, as I didn't have anything to gross or look at.

Things changed quickly.

"You have a phone call, they want to speak to a Pathologist" said John, one of the techs. I answered the phone.

"Hi this is Dr. Murphy with Pathology"

In a heavily accented woman's voice, the other side replied, "we have a baby here that needs an FNA. Would you be comfortable doing that?"

I had been doing some FNAs with one of the medical assistants over in the surgery clinic, and was starting to get the hang of it. We never had any lidocaine but the adults let us be aggressive enough that we were able to get some diagnoses. I asked them to try and see if that medical assistant was available to help (he does a much better job). They called back later to say that they could not find him (did they even try?). I said I would do it, and to send her over here since they didn't have a space for me to do it in clinic.

5 minutes later:

"You have a phone call, it is Dr. Davis, " said John.

Dr. Davis is a very talented general surgeon. He was doing a whipple (?!?!?) and saw some enlarged lymph nodes. Could I do a touch prep? Yes, I could, and would he make sure to send it over fresh?

30 seconds after I received the lymph node, the mother and baby came in. John gave the mother some chai as I prepared a touch prep and smear. I gave John the slides to stain so I could talk to the mother. Her english was good enough, and I read the notes that she came with. The baby had mumps in November, and she has had persistent lymphadenopathy since then-- and despite a course of antibiotics. I was to FNA a submandibular lymph node. I felt the baby's neck, and found a 1-1.5 cm lymph node that was mobile-- but by that time the slides from the lymph node from Dr. Davis were ready.

I searched the slides for any malignant cells. Maybe like 3 times. I called Dr. Davis back-- negative-- but made sure he knew Rochelle wasn't here and it was a resident's diagnosis. He said he would continue anyway, but to call him after she reviewed the slides.

Back to the baby. I prepped the site, and assembled my slides, needles, etc. I stuck her twice in the neck, trying to be aggressive but not disturb too many adjacent structures. Screams echoed throughout the room for about 30 minutes as I looked at the smears. Blood only. Great. I went back to the primary care doctor in clinic and explained the situation. Non-diagnostic/inadequate. I proposed we not charge the patient. She was fine with all of it, and appreciated my feedback and willingness to try.

I later reviewed the new cases for the day, including a uterus with endometrial carcinoma, TURP with prostate cancer, 6 blood smears, a mastectomy for a very large ductal carcinoma, a brain tumor, and a pigmented acral skin lesion, amongst a sea of thyroids and fibroids. One of the neurosurgeons stopped by to talk about two cases as well. It was quite a day, and by the end, especially since Rochelle agreed with my "frozen" diagnosis, I felt very proud of myself.

And with that, I leave you with yet another excursion we went on last weekend. At the Giraffe Center.

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******African Fund for Endangered Wildlife Kenya limited (AFEW (K) LTD) also known as the Giraffe Centre was founded in 1979 by the late Jock Leslie- Melvile, a Kenyan citizen of British descent and his wife the late Betty Leslie Melvile, an American citizen. Jock’s extraordinary vision of creating an educational institution in conjunction with rescuing the endangered Rothschild giraffes resulted in the present day Giraffe Centre that has become a World famous Nature Education Centre.- http://giraffecenter.org/