In medical school, there is an overused saying that paraphrases
to "if you hear hoofbeats behind you, think Horse, not
Zebra". The idea is a good one. If a patient presents
with a headache, for instance, you should think migraine before
thinking of something like a brain cyst secondary to
Many medical students struggle with this concept early on during
their training. After learning about all the different
pathologies of the human body, it can sometimes be difficult to not
let your imagination run wild. Chest pain suddenly means
miliary tuberculosis. Abdominal pain equates to a parasitic
infection. Back pain can be nothing other than Ankylosing
Spondylitis. Instead of thinking heart attack,
gastroenteritis, and lumbar strain, students are eager to dig for
the 'Zebras' instead of the 'Horses'.
In Kenya though, this saying doesn't quite carry the same
weight. American 'Zebras' are suddenly horses, and things
like Malaria, Leishmania, Typhoid, Tuberculosis, and HIV quickly
jump to the top of any differential diagnosis. Similarly,
many of the 'Horses' I've come to look for in the US are no longer
guaranteed regulars on my ward rounds. Rampant American
diseases, like type-2 diabetes and coronary artery disease, play
second fiddle on the Kenyan Wards.
This saying popped into my head recently for two reasons, both
of which can best be summed up with photos. The first photo
shows a disease process that truly is a 'Zebra' in the US:
Hydatid Cysts secondary to Echinococcosis. Simply put, this
is a disease caused by tapeworm that harbor in farm animals and
dogs before settling into humans, causing cysts in the lung, liver,
brain, heart, or kidney. Unfortunately, there is a patient in
the wards with exactly this. He is a farmer, who (from my
understanding) presented with gradual worsening neurologic
symptoms. His actual head CT is shown below.
The second reason this saying popped into my head is because,
quite frankly, I spent this past weekend surrounded by actual
Zebras while at Crescent Island, off of Lake Naivasha.
You didn't think this Kenya Rotation would be ALL work, did
Quote of the Post:
In a gentle way, you can shake the world.