Sep 12, 2012 - Medical Talk    3 Comments

Decision making

When watching me try to decide what to order in a restaurant, it would be easy to assume that I am a person who is incapable of making a decision. I sit on the fence pondering over the chicken burger or the pasta of the day… At work, faced with slightly more pressing issues, I leave the indecision at home. Doctors need to make decisions, and quickly.

In the UK, the complexity of the decisions that a doctor is required to make increases with the doctor’s seniority and prior experience. That concept is tipped on its head when you uproot to an understaffed, rural hospital in Zambia.

Here at St Francis Hospital, on a regular basis, I find myself having to make difficult decisions that are either beyond my level of experience, or are just downright hard.

The high prevalence of HIV and tuberculosis (TB) means I have had to change my entire approach to certain symptoms. When someone presents with a headache here, I no longer use my UK thought process of ‘migraine, tension headache, stress,’ and instead have to think ‘malaria, cryptococcal meningitis, TB meningitis’.

There are no radiologists here. I have to interpret any X-ray that I request. The abnormalities are usually so blatant that they can’t be missed, but deciding on a diagnosis can be hard. The patient who has HIV and a horrible chest x-ray could have pneumonia, but if you stare at it long enough, you start to see TB, PCP ( a nasty type of lung infection in patients with HIV), and cancer… In such cases, I have to accept I am not a radiologist, decide on a treatment and revise the diagnosis if it is not working.

There are also no oncologists or palliative care physicians here (or any other specialist medical doctors for that matter), so I find myself having to diagnose cancer and treat it when possible (we have a limited stock of chemotherapy agents for cancers common in HIV such as Kaposi Sarcoma and Non-Hodgkins Lymphoma). All too often, I also have to explain to patients that they have a cancer that I cannot treat here, and that they are going to die.

Some of the trickiest decisions are about the rationing of limited resources. There is only one oxygen machine on the ward. There are 45 beds and a large number of patients with pneumonia, TB, heart failure and other illnesses that commonly require oxygen. A few days ago, the oxygen machine was in use by an elderly patient who had suffered a thoracic aortic dissection and was very unwell. A young patient was admitted with septic shock in HIV. She had oxygen saturations of 69% and was profoundly shut down. Within seconds of viewing the new patient, I told the nurse to move the oxygen over… The elderly patient died later that day. Was it due to the lack of oxygen? Probably not (but it doesn’t stop it from playing on your mind). The young patient recovered and although cachectic and weak with Stage 4 HIV, she has been discharged home today. Did the oxygen save her? I don’t know.

Do I enjoy having to make such decisions? Not really. It is certainly not my favourite thing about being a doctor.

Am I going to continue to take my time when I find myself in the non-pressured situation of choosing between a chicken burger or pasta? Most definitely.


  • Thanks for sharing your stories Nat. I can’t imagine how tough it would be to make those kind of decisions and the way the later events will play on your mind. Keep up the good work. Love the stories too!

    Thanks for sharing.

  • You’re doing what most doctors never have to do … make life and death decisions under very difficult circumstances with limited resources. That is not for the faint of heart. You have courage, that’s for sure, and you can rest assured that you’re providing the best possible care for your patients.

  • Truly inspirational Nat, am really enjoying reading your blog and truly impressed by all you are doing. What a fantastic experience, you are clearly learning so much and doing your very best for your patients. x