BLOG: My first case of brucellosis

BySaleh Aldasouqi, MD, FACE, ECNU

In 1988, I joined Hamad General Hospital in Doha, Qatar, as a junior medical resident in the 4-year Arab Board specialty training program. I was assigned to Team B under attending Dr. James Davidson, a senior British physician. Dr. Davidson was the kind of old-school clinician carrying an old leather doctor bag. I learned quite a lot from Dr. Davidson.

One night I had admitted a patient from the ED, I took a history, did an exam and ordered the necessary workup. The patient came to the ED for some medical problem but to my knowledge he did not have diabetes; but I was proven wrong.

Dr. Davidson would always carry his bag during rounds and I could swear that he would pull out the large opthalmoscope and examine the fundi of all newly admitted patients regardless of whether or not they were thought to have diabetes. He examined the fundi and announced to the team at the bedside, “this man has diabetes,” judging from just the diabetic changes in his retina. When the patient heard the word “diabetes,” he said, “Yes, I have diabetes.” I was so embarrassed that I missed the diagnosis. It is not unusual that the attending physician would discover missed findings in history or physical exam. Despite my self-acclaimed skills in taking a history, I believe the reason I missed the diabetes diagnosis had stemmed from a communication disconnect, due to different languages. The patient’s second language was French and mine was English. But still, no excuse, I missed the diagnosis and it was embarrassing.

So, what about my first case of brucellosis?

On my first day at Hamad Hospital, I entered the physicians lounge to meet my team. The team leader, the Registrar, greeted me with a warm welcome. A Registrar, equivalent to a junior attending physician in the U.S. system, is a board eligible/certified physician who completed their residency. The next rank is Senior Registrar and then the physician will attain the Consultant status.

The Registrar said that they had just finished the round and wished to put me to work right away. He told me to go see a certain patient but not to look at his chart.

I went to see my first case on the first day of my residency with the utmost excitement, hoping that my first case would go smoothly. Just like everything else in life, the first impression is a major step. I came back after about 10 to 15 minutes very confident.

The Registrar asked me what the diagnosis was and I very confidently said, “Brucellosis.”

Brucellosis is a fascinating infectious disease, which is transmitted from animals to humans by coming into contact with infected animals or by drinking their raw milk. It causes an acute illness marked by fever and other manifestations, and it can cause serious complications in some cases. Fortunately, it is easily treated and cured.

Like tuberculosis, malaria and Typhoid fever, brucellosis is rarely encountered by the vast majority of American physicians, but that is not the case in other parts of the world. In the Middle East, for example, these diseases are not uncommon. One could expect at least one case of one or more of these diseases coming into the ED while on-call on any given day or night. In the case of brucellosis, for the last 25 years that I have been in the United States, I have never seen or heard of a case of brucellosis.

My first case of brucellosis was a personal experience; the patient was my uncle. I was just a beginner in medicine. Unlike U.S. medical schools, the vast majority of medical schools adopt the 6-year medical education pathway. The first 3 years are the basic sciences phase (preclinical) and the next 3 years are clinical.

I encountered my very first case of brucellosis 15 years prior to the case at Hamad Hospital. I had also seen numerous cases of brucellosis before encountering the case at Hamad Hospital.

One day my father told me that my uncle wanted me to give him injections. My uncle was being discharged from the hospital after 2 to 3 days for brucellosis. The doctors prescribed streptomycin daily injections for 2 weeks. The doctors had asked my uncle if he was going to go to a local doctor’s office for the daily injections and he responded that I would be doing them.

I could not say no! “But how was I going to do it?” I wondered. I have never seen a patient or given an injection. All I had learned this far was basic sciences, medical students don’t see patient until the fourth year.

When I went to my uncle’s house for the first injection, I was very nervous. Needless to say, besides the lack of experience in giving injections, it was also embarrassing to give my uncle the injections. My uncle stood up, ready for the injection and he was so confident of my potential skills. I could not see his face while I was giving him the injection, so I could not tell if he grimaced or expressed any facial expression of pain or discomfort. But, when I was done, I asked how it went and he gave me a big smile and complimented me on a “job well done.” We repeated this daily treatment course for 2 weeks and I felt that I gained quite the experience in giving injections.

That was my first case of brucellosis, my uncle’s case. So, 15 years later, when the Registrar at Hamad Hospital gave me the first case in my residency, it was a piece of cake. At the time, I had gained extensive knowledge about brucellosis, beyond the expected experience of my peers and I would imagine it all stemmed from the personal experience. Personal experiences, in self or in a relative, are usually powerful teaching enhancers!