Sunday, September 14, 2008

Hope (Brothers II)

It's not always bad here. Sometimes things work out. Sometimes our efforts amount to something.

Brother came back. He was wearing a wide brimmed hat, a plaid shirt, and something of a swagger. He walked in with an XRay in his hand and a slip of paper in the other. When Mae spotted him, she grabbed him by the shoulder and ushered him to my side. I was focused on another patient's bukhana (chart), and we she pulled me around, it took me a minute to recognize him. I guess I had written him off after our initial meeting, but either something we said stuck with him, or more likely, we had underestimated him.

I looked over his shoulder for his brother, but saw no one that looked like my patient. I turned to him with a confused look, he said that his brother was too sick to come. I panicked.

"Too sick? How sick? Is he eating? Is he gaining weight? Does his throat still burn?"

His brother replied that while he had started eating, he was in fact, still very weak. He was keeping down a small amount of the nurtitional shake that we had supplied him with, but it wasn't enough to pull him out of bed. So in his place, I had Brother, holding an xray, hoping to help.

I raced down the hallway with Mae and Brother in tow. I wanted so badly to have an aswer, to know what exactly we were fighting. Was it just HIV, or was there concurrent TB? I threw the film up on the view box and flipped the switch.

Airway - clear, no compression

Bones - no lytic lesions, no sign of malignancy

Cardiac- if anything, his heart was small - after years of malnutrition, his muscles had atrophied, including this one. Cardiac failure is a major complication of refeeding. Give someone too much fluid, or push too much volume too fast, and a weak heart won't be able to keep up with the bodies demands

Diaphragm- sharp borders, no sign of fluid collection

Extra-Pulmonary - no obvious nodes, no sign of soft tissue injury

Fields - Lungs...clear

A sigh of relief. I grabbed the second piece of critical information: the sputum culture and gram stain - negative

So in this country where the prevalance of TB is among the highest in the world (in addition to HIV), my patient is TB free. What this means is that his management just got easier. No worrying about drug interactions between the antiretrovirals and anti-TB medication, he won't need to take any.

So I turn to Brother and explain to him the good news. I ask him when he can bring the younger back with him. He shakes his head. Brother has plans to go to South Africa for a job. He doesn't know when he'll be able to come back, but he needs to go.

He can tell I'm dissappointed. He looks to the floor. I explain to him that his brother needs him. He's obviously too weak to manage all the medications that he's going to have to take, and most HIV patients need a caregiver to stand by their side when they initiate therapy.

He promises me that he'll find someone. There's a grandmother that's literate. Maybe she can help. So faced with little other option, I send him to social work, hoping that if I give him a transport voucher, he'll be able to pass it on to his his brother and grandmother so that the journey to our clinic will be a little easier.

I worry that my patient is getting sicker since seeing me, and I wonder if he'll even make it to the appointment in two days.

That was Tuesday.

Thursday was something of a bad day. One patient after another, each more complicated. There was the pregnant mother who had forgotten to take her HIV medications, thereby risking herself and her fetus to resistance. There was the family of three who had recently lost all of their possesions, including their meds and their bukhanas, to a fire set by an abusive husband/father who decided that if they wouldn't give him money, he was going to beat the hell out of them, and then burn all of their possesions. I was working through lunch, trying to stay on task, as I walked out to the lobby. I picked up the next chart and Mae comes racing up to me.

"Our patient! He's here! He's here with his brother!"

She rushes outside and I see a closed-bed pickup truck with a wheelchair being unloaded. Minutes later, my patient is being wheeled in, Brother behind him, and an uncle with the unmistakable wrap-around sunglass of the blind, mounted on his face.

I usher the three of them to my room, Mae on my heels. My patient is firmly planted in his wheelchair not making eye contact. Slowly we review all of the facts we covered last week. His throat no longer burns. He's been eating, minimally, but it's an improvement. The diarrhea and the abdominal pain are still there. But gone is the cough, which confirms what the xray had originally assured me. I look to my chart, 29 kilos. Thats a fraction less than what he weighed last week. I'm careful not to put too much stock in this. After all it often takes more than a week to see any significant change and he hasn't even started antiretrovirals yet.

I have to admit, I'm surprised that Brother is still around. When I ask him why he hasn't left for South Africa yet, he shakes his head. He's not going. He's decided that he wants to stick around, to see his brother get well. I don't know why I doubted him so much, but he's coming through in a way I hadn't expected. When we ask who's going to help with refeeding my patient, he steps forward without hesitation. He helps wash his brothers hands because he's too weak to stand up out of the wheel chair. And when we give him the packet of RUTF (Ready to Use Therapeutic Food), it's Brother that volunteers to feed him.

The rest of the hour was spent detailing what would be coming next for the patient. Now that his brother was here, and his uncle (though blind) had volunteered his help, we had the safety net we needed to push forward. After leaving my room, they would go onto our adherence counselers who would condense two weeks worth of information into one afternoon. Next they would go to pharmacy to pick up the prescriptions he needed. Finally, there would be another stop at social work, and then they would be on their way home. His next appointment would be in a week, but this would be last time I see him for a while.

Starting tomorrow, I head into Queen II Public Hospital, and that means I'll be away from the clinic for the next four weeks. In that time, my patient's life is bound to change dramatically. He'll start puting on weight, his diarrhea will resolve, and he may gain the strength he needs to leave the wheel chair. I'm sad that I won't be there to see the gains that he'll make. But I've introduced him to two of the senior docs, and together, they'll take over his care. I told them I want him back when I return.

Before they walked out that door, I made it a point to tell Brother how proud of him I am. I'm not sure if it registered, he didn't really react to the comment, but I hope it sunk in. I can tell my patient is hopeful too. That day he started carrying on a conversation with us. His voice is tiny and frail, but there's confidence in it. More than anything, I can tell he's not scared, and I convince myself that he's even a little hopeful now that he's got Brother in his corner.

So as I march into Queen II, where I'm likely to be surrounded by kids sicker than any I've ever seen, atleast I've got this one victory, and it gives me hope that there will be others.

1 comment:

Unknown said...

Sounds like you and Brothers would be winners in this case. Don't loose hope. More victories are on their way.