The Ambassador of TB has a shaved head and a portly build. He waddles barefoot from room to room, stopping by to say hello, to offer a polite nod of the head. At times, he reaches up and tilts his imaginary hat.
Sometimes the Ambassador of TB decides that today should be a no pants day, and then the Ambassador finds himself closer to nature as he lets it all hang out, not even giving shame it's due respect.
Man, woman, child - it doesn't matter. He'll come up to you, shake your hand if offered. And if you're lucky, he'll grab a handful of your face and wrestle you to the ground.
When I walk into the wards every morning, more often than not, he's making his rounds. He's stopping by the 6 month-old-would-be-Hollywood-starlet with two inch eyelashes, her TB meningitis the only thing standing in her way. He makes his presence known in the acute room, where he bids adieu to the mothers. Some mornings when I feel up to it, I rub his potbelly and offer a greeting. He usually furrows his bushy brows, gives me a quizzical little look and waddles on.
The Ambassador of TB gets himself into trouble sometimes though. The IV strapped to his foot usually drags behind him, getting caught in furniture, underfoot, and in the way. And as much as a celebrity as he is on the wards, he has a habit of getting overlooked. The last time I had a nurse run and get a dose of meds, she whipped around so quickly that a good portion of her rear gave him an ugly hook and left him headed for the mat three feet back.
The Ambassador of TB, with his swollen neck and matted lymph nodes, is a little dynamo of infection, ready to spread his love to the rest of the ward. Sometimes when he's violently grappling with the boy with dreads or bitch slapping the junior Sigourney Weaver look alike from Aliens 3, I wonder if the little parcel of love lodged in his neck is going to rupture, spilling highly infectious TB laden pus all over his victim. The Ambassador of TB is a giver. He's a generous soul. He'll fetch charts and deliver favors. His knowing gaze and loving smile win over legions of adoring fans, countless fellow patients, and most all of the staff.
And yes, while the Ambassodor of TB is only two years old and battling TB, he is in fact my role model. He just gets up and goes, pants or no pants. He's fearless, he's relentlessly optimistic, nothing gets to him.
And he is, of course, one of my favorite patients. They all hold a place, but sometimes you just need to see one who's not so sick, one who looks almost normal. And then there's the Hollywood Starlet who lies mostly motionless in her bed; I fall in love every time I look into her eyes. There's Cranky Pants who screams everytime I so much as glance at her, and there's Pukie who up until just a couple days ago projectile vomited just about everything we fed him.
I've just been through one of the most challenging weeks of my life, having to handle the wards as the sole attending physician running the show. But there are moments in the middle of all the chaos and absurdity when it all comes together. Mostly ushered in by patients like the oddball Ambassador of TB, these moments stave off exhaustion, and at the end of the day, have me looking forward to the next.
Thursday, November 27, 2008
Tuesday, November 18, 2008
Vigilance
This weekend marked three months that I've been here in Lesotho. To celebrate, I and eight other friends strapped ourselves to a line of rope, body harnesses, and a couple pieces of steel weighing a total of about five pounds. And then we walked off the edge of a 300 meter cliff overlooking a thundering waterfall that spilled into icy pools down below. As we rappelled down, the clouds parted to give us a perfect day, and the blazing sunlight scattered off of the mist of the falls to give us a brilliant halo of color through which we descended to the foot of the falls.
Lesotho is a remarkable country for its people, for it's incredible natural beauty, and for all the of the potential it has. These three months have helped me unearth so many wonderful things about this country, and have reminded me that as hard as the work is, there is indeed life outside of the clinic, out of the hospital, and this is what we're fighting for.
Obviously it's been challenging. Some days are harder than others, and when things get bad, they go downhill pretty fast. I know in the past I've spent a great deal of time meditating on much of the negativity I encounter. I've realized that I've needed to do so, as an outlet for the more difficult moments here. But at the same time, weekends like this past one remind me that with struggle comes opportunity, and I am indeed fortunate to be here, to be witness to what unfolds, and in some way contribute to a solution.
Still, there are moments of profound doubt. I was asked a couple days ago by two friends here who are not involved in medicine: What's the hardest thing about being a doctor? We had spent a good part of that evening recounting our week, our individual triumphs and falls, both personal and professional. My own recounting including a detailed description of how I felt I let down one particular patient. In the middle of the day, I was called to the adjacent HIV clinic, and remained there for a good part of the morning as we tried to sort through difficult cases. By the time I got back, another patient passed away. He was six months old, he was admitted for malnutrition, and he had spent the better part of the week tucked away in a corner of my half of the malnutrition ward. Then, the morning prior, Dr. Phiri, walked into my ward and took a look at my patients.
Since finishing residency, I've officially earned the title of attending. It means that I get to run the show as I see fit, and at the end of the day, I call the shots. It also means that my patients, and to some degree, their outcomes, are ultimately my responsibility. So when Dr. Phiri started examining my children, my patients, I got a little defensive.
I left the note I was writing in the other room and walked up to her, curious to see why she was spending so much time by this particular patient's bedside. As I walked up, she turned to me and in her quiet determined voice said:
"This patient, he is very sick. What has happened to him?"
It's been said that medicine is as much art as it is science. Out here, when you don't have the latest and greatest scientific tools available, you rely far more on instinct, experience, and yes ultimately what could be deemed as your own artistic merit. Sometimes I feel like a pretty shitty artist.
My patient lie there, with eyes sunken far back into his skull. Obviously things had taken a turn for the worse, and once again we were in a position where we would have to climb our way out of a hole. I remained optimistic. We pushed fluids, we got aggressive with his feeds, we transferred him to the acute room.
By the next morning, we had tumbled further down a treacherous path, and he was barely moving. His chest labored to pull in breath, his eyes rolled around aimlessly in the back of his skull. I "optimized" his care, which basically meant doing more of the same, crossing my fingers, saying a prayer, and hoping for the best. It was clear where things were going, and I have to admit that a part of me hoped that if he was going to die, he would take care of that unpleasant business before I got to work the next morning.
Sometimes, it's the obvious, the inevitable, that hurts the most. You see it coming, and you just wish it would hurry up and get here.
I feel guilty for thoughts like that, but in the end I'm asking for struggling and the suffering to end. I wish I could provide better options. A visiting doctor, a mentor, stopped by the wards last week and offered two points.
"Rule number one is that patients die. Rule number two is that doctors don't change rule number one." I am all too aware of the pervasiveness of this particular theme, and indeed how it is has filled this blog. But I suppose coming to terms with it has been among my greatest challenges here, and will continue to be. Even after three months.
My malnourished child, the one with the sunken eyes, he passed away while I was gone. When I was at clinic. And when I returned, I'm ashamed that a part of me was relieved that I wouldn't have to look into the eyes of another one of my failures. I say that, because even though I've been handed rules one and two, I think that such rules can't absolve accountability.
So as I recounted the story to two friends on Friday night on our way home from dinner, the weeks struggles were still fresh on my mind. And while it is the death count that makes this job hard, which let's not kid ourselves is heartbreaking, another thought came to mind.
The reason why this job is so hard, whether it's done here in Africa or back home in the States, is this pervasive sense of inadequacy. We trained in competitive environments from college to residency. And as in other fields, there is a compulsion to succeed, to keep up with your best friend, to perform with some degree of distinction. But that feeling never leaves, and in fact has only becomes more acute as I've entered the real world. I leave every day wondering whether I made the right call. Should I have pushed fluids in the malnourished child with respiratory distress? Should I risk destroying a liver so that I can treat a girl dying of TB infront of my face? Should I have gone a little slower on the kid who won't tolerate any feeds and is wasting away?
When a child gets better and walks out that door, I'm only afforded guarded optimism, and a quick pat on the back, because odds are they could turn around and come back weeks later, sicker than before. At least when I lose one, I know that that's the end of the story. At least I have a clear outcome. Discharging a child with HIV home is never the end of the story. I need to learn to be satisfied with that. I need to learn to be okay with my inadequacies and my lack of experience. I need to get good, and I need to do it quickly. Unrealistic as these expectations can be, they keep me in check, because if we only learn from our failures, then that means that I'll see a lot of collateral losses before I start making a difference, i.e. lessons come hard when they are the expense of another's life.
So I'm trying to make the most of what I've learned in my three months here. I've learned to be a little more forgiving of myself while holding myself accountable. I've realized that fear is a good thing, that time is more valuable than I could ever have imagined, and that pulling a child back from the abyss is far harder than keeping him away from its edge in the first place; there's no rope to keep him tethered to safe ground. And in that I've learned the value of vigilance.
Lesotho is a remarkable country for its people, for it's incredible natural beauty, and for all the of the potential it has. These three months have helped me unearth so many wonderful things about this country, and have reminded me that as hard as the work is, there is indeed life outside of the clinic, out of the hospital, and this is what we're fighting for.
Obviously it's been challenging. Some days are harder than others, and when things get bad, they go downhill pretty fast. I know in the past I've spent a great deal of time meditating on much of the negativity I encounter. I've realized that I've needed to do so, as an outlet for the more difficult moments here. But at the same time, weekends like this past one remind me that with struggle comes opportunity, and I am indeed fortunate to be here, to be witness to what unfolds, and in some way contribute to a solution.
Still, there are moments of profound doubt. I was asked a couple days ago by two friends here who are not involved in medicine: What's the hardest thing about being a doctor? We had spent a good part of that evening recounting our week, our individual triumphs and falls, both personal and professional. My own recounting including a detailed description of how I felt I let down one particular patient. In the middle of the day, I was called to the adjacent HIV clinic, and remained there for a good part of the morning as we tried to sort through difficult cases. By the time I got back, another patient passed away. He was six months old, he was admitted for malnutrition, and he had spent the better part of the week tucked away in a corner of my half of the malnutrition ward. Then, the morning prior, Dr. Phiri, walked into my ward and took a look at my patients.
Since finishing residency, I've officially earned the title of attending. It means that I get to run the show as I see fit, and at the end of the day, I call the shots. It also means that my patients, and to some degree, their outcomes, are ultimately my responsibility. So when Dr. Phiri started examining my children, my patients, I got a little defensive.
I left the note I was writing in the other room and walked up to her, curious to see why she was spending so much time by this particular patient's bedside. As I walked up, she turned to me and in her quiet determined voice said:
"This patient, he is very sick. What has happened to him?"
It's been said that medicine is as much art as it is science. Out here, when you don't have the latest and greatest scientific tools available, you rely far more on instinct, experience, and yes ultimately what could be deemed as your own artistic merit. Sometimes I feel like a pretty shitty artist.
My patient lie there, with eyes sunken far back into his skull. Obviously things had taken a turn for the worse, and once again we were in a position where we would have to climb our way out of a hole. I remained optimistic. We pushed fluids, we got aggressive with his feeds, we transferred him to the acute room.
By the next morning, we had tumbled further down a treacherous path, and he was barely moving. His chest labored to pull in breath, his eyes rolled around aimlessly in the back of his skull. I "optimized" his care, which basically meant doing more of the same, crossing my fingers, saying a prayer, and hoping for the best. It was clear where things were going, and I have to admit that a part of me hoped that if he was going to die, he would take care of that unpleasant business before I got to work the next morning.
Sometimes, it's the obvious, the inevitable, that hurts the most. You see it coming, and you just wish it would hurry up and get here.
I feel guilty for thoughts like that, but in the end I'm asking for struggling and the suffering to end. I wish I could provide better options. A visiting doctor, a mentor, stopped by the wards last week and offered two points.
"Rule number one is that patients die. Rule number two is that doctors don't change rule number one." I am all too aware of the pervasiveness of this particular theme, and indeed how it is has filled this blog. But I suppose coming to terms with it has been among my greatest challenges here, and will continue to be. Even after three months.
My malnourished child, the one with the sunken eyes, he passed away while I was gone. When I was at clinic. And when I returned, I'm ashamed that a part of me was relieved that I wouldn't have to look into the eyes of another one of my failures. I say that, because even though I've been handed rules one and two, I think that such rules can't absolve accountability.
So as I recounted the story to two friends on Friday night on our way home from dinner, the weeks struggles were still fresh on my mind. And while it is the death count that makes this job hard, which let's not kid ourselves is heartbreaking, another thought came to mind.
The reason why this job is so hard, whether it's done here in Africa or back home in the States, is this pervasive sense of inadequacy. We trained in competitive environments from college to residency. And as in other fields, there is a compulsion to succeed, to keep up with your best friend, to perform with some degree of distinction. But that feeling never leaves, and in fact has only becomes more acute as I've entered the real world. I leave every day wondering whether I made the right call. Should I have pushed fluids in the malnourished child with respiratory distress? Should I risk destroying a liver so that I can treat a girl dying of TB infront of my face? Should I have gone a little slower on the kid who won't tolerate any feeds and is wasting away?
When a child gets better and walks out that door, I'm only afforded guarded optimism, and a quick pat on the back, because odds are they could turn around and come back weeks later, sicker than before. At least when I lose one, I know that that's the end of the story. At least I have a clear outcome. Discharging a child with HIV home is never the end of the story. I need to learn to be satisfied with that. I need to learn to be okay with my inadequacies and my lack of experience. I need to get good, and I need to do it quickly. Unrealistic as these expectations can be, they keep me in check, because if we only learn from our failures, then that means that I'll see a lot of collateral losses before I start making a difference, i.e. lessons come hard when they are the expense of another's life.
So I'm trying to make the most of what I've learned in my three months here. I've learned to be a little more forgiving of myself while holding myself accountable. I've realized that fear is a good thing, that time is more valuable than I could ever have imagined, and that pulling a child back from the abyss is far harder than keeping him away from its edge in the first place; there's no rope to keep him tethered to safe ground. And in that I've learned the value of vigilance.
Monday, November 10, 2008
Imagine
John Lennon's "Imagine" speaks of happiness and a peaceful existence. It speaks of the world being as one. And the leading line is "imagine there's no heaven, it's easy if you try, no hell below us, above us only sky."
I'm not sure why, but standing there at the nurse's station last Friday in Queen II, that's the line that came to mind. It was my first day back at the hospital, the major referral center for the country, and I was making my way through the wards, learning each patient, memorizing their disease, measuring their odds.
It was the sight of the 12 year old, emaciated, eyes hollow that made me stop. I had seen another like her, one that had done remarkably well and almost doubled his weight over two months. But here was another adolescent, newly diagnosed with HIV, wasting away before our eyes. Like the other, her esophagus was presumably riddled with a fungal infection that made swallowing feel like downing a razor blade. Her body was ravaged, nothing on her face told me that I was looking at a girl, one who should be starting her life, not watching it come tumbling to an end. Her mother sat next to her, rarely making eye contact.
And it was then that it occurred to me that maybe this was hell.
What if hell is not an eternity of fire and brimstone. What if it isn't a just reward doled out after a life time of evil. Maybe hell was in fact watching one in four of your family, of your country picked off slowly, inevitably. Maybe hell is watching your children die in front of your eyes, and then watching their children follow soon afterwards.
I won't presume to be able to contribute to conversations that have carried on since dawn about the meaning of life and afterward, or in fact what truly does happen. But what if there is nothing better or nothing worse than what's in front of our eyes. What if instead of glory and damnation, existence is a little more subtle, and instead of some payoff at the end of this life, this is all that we have to hope for. Even the idea of rebirth. What kind of evil warrants a life like this? I can't quite understand it. I can't understand what I'm seeing in front of my eyes.
I can't understand why a seven month old died today, and when I starting compressing her chest, thick black liquid starting pouring out of her mouth. And what's worse, I can't understand why it hardly moved me. I can't understand why the sight of it made me want to give up, and made me feel like that was okay.
I thought coming back would be easy. A month's worth of experience, a hardened heart, and a death count in double digits should have prepared me for this. But walking through those doors today hammered home the reality of where I am. I can't count on my vacation at the end of this rotation to wipe the slate clean for my patients and their families. I may have had peace of mind when I left last time, but seeing just how bad things were when I got back made me lose a little hope. Whatever gains I made during my past three months here are hard to see now as I look across the room and see children dying of the same thing over and over. Even my 12 year old didn't make it through the weekend.
And it's this that brings to mind Lennon, and the thought that maybe there isn't anything but this, and that heaven and hell are infact what we witness here on earth, and there is infact no justifiable reason why someone should ever deserve a death like this. I suppose "Imagine" is supposed to inspire hope for something better, but if anything it suggests the possibility that maybe there is no peace at the end of this, no consolation prize for a life of suffering. What if it's this and only this. What if the Queen II wards are a little slice of hell? I ask myself that as I watch my patients and their families struggle to find a way out.
I'm not sure why, but standing there at the nurse's station last Friday in Queen II, that's the line that came to mind. It was my first day back at the hospital, the major referral center for the country, and I was making my way through the wards, learning each patient, memorizing their disease, measuring their odds.
It was the sight of the 12 year old, emaciated, eyes hollow that made me stop. I had seen another like her, one that had done remarkably well and almost doubled his weight over two months. But here was another adolescent, newly diagnosed with HIV, wasting away before our eyes. Like the other, her esophagus was presumably riddled with a fungal infection that made swallowing feel like downing a razor blade. Her body was ravaged, nothing on her face told me that I was looking at a girl, one who should be starting her life, not watching it come tumbling to an end. Her mother sat next to her, rarely making eye contact.
And it was then that it occurred to me that maybe this was hell.
What if hell is not an eternity of fire and brimstone. What if it isn't a just reward doled out after a life time of evil. Maybe hell was in fact watching one in four of your family, of your country picked off slowly, inevitably. Maybe hell is watching your children die in front of your eyes, and then watching their children follow soon afterwards.
I won't presume to be able to contribute to conversations that have carried on since dawn about the meaning of life and afterward, or in fact what truly does happen. But what if there is nothing better or nothing worse than what's in front of our eyes. What if instead of glory and damnation, existence is a little more subtle, and instead of some payoff at the end of this life, this is all that we have to hope for. Even the idea of rebirth. What kind of evil warrants a life like this? I can't quite understand it. I can't understand what I'm seeing in front of my eyes.
I can't understand why a seven month old died today, and when I starting compressing her chest, thick black liquid starting pouring out of her mouth. And what's worse, I can't understand why it hardly moved me. I can't understand why the sight of it made me want to give up, and made me feel like that was okay.
I thought coming back would be easy. A month's worth of experience, a hardened heart, and a death count in double digits should have prepared me for this. But walking through those doors today hammered home the reality of where I am. I can't count on my vacation at the end of this rotation to wipe the slate clean for my patients and their families. I may have had peace of mind when I left last time, but seeing just how bad things were when I got back made me lose a little hope. Whatever gains I made during my past three months here are hard to see now as I look across the room and see children dying of the same thing over and over. Even my 12 year old didn't make it through the weekend.
And it's this that brings to mind Lennon, and the thought that maybe there isn't anything but this, and that heaven and hell are infact what we witness here on earth, and there is infact no justifiable reason why someone should ever deserve a death like this. I suppose "Imagine" is supposed to inspire hope for something better, but if anything it suggests the possibility that maybe there is no peace at the end of this, no consolation prize for a life of suffering. What if it's this and only this. What if the Queen II wards are a little slice of hell? I ask myself that as I watch my patients and their families struggle to find a way out.
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