Softball

Someone tossed me a softball the other day.

She was three years old, her head shaved an eighth of an inch to the scalp. There were thick secretions spilling from her open mouth, her limp body hanging in mother's arms, the two of them slumped over in the corner of the bench.

It was the middle of a long day, a long week, a long month at Queen II, and I was walking out the door on the way to the lab, in search of missing results. I saw her from the corner of my eye, and like a cartoon character rubber necking at the site of a big juicy steak, my gaze ripped my body around to look at her. If I've earned nothing else here, I've at least honed the skill of recognizing who's sick and who's not. Who's checking out tonight, tomorrow, or maybe in a week, and who might actually make it through. This one looked like she was still making up her mind.

Her eyes barely flickered when I rubbed my knuckles on her chest, hard. Her ribs heaved with each breath, the liquid trapped in her lungs reminded me of the sound of blowing bubbles through a straw submerged in a glass of cold milk. I didn't need a stethoscope, I could hear her lungs from practically the other end of the room.

And like so many times before, I turned to the closest nurse, ordered her to the acute room, and told the medical officer to follow and figure out what was going on. I'd seen something like this before, and I knew where she was headed, and I knew what was coming. I was literally praying for the diagnosis, because in a way, I needed it.

The past two weeks have been especially difficult. Every morning finds me face down in my pillow, pushing the snooze button on my cellphone one more time than I did the day before. It's partly due to the sheer physical exhaustion of the job, of waking early and pushing through the day, but lately, it's a little bit of my head and a little bit of my heart that are having a harder time rolling out of my bed.

Maybe it's part of coming down from an amazing holiday, from the perfect trip with good friends. Or maybe its the recent departure of my brother, on his way back home, that made this month a little bit harder from the start. Maybe it's just the job.

There are parts that are taking their toll. The medical officers for example. They're the ones that worry me the most. They have varying years of experience; all have completed medical school and one year of additional training as interns, but outside of that, their work experience are varied with no semblance of consistency. They're randomly assigned to work the medical wards, at the discretion of the medical superintendent, and this randomness in assignment and experience results in their taking less ownership in the day to day operations of the children's ward. If forced to, I could do most of the job without their help. I could round on all of the kids in the ward and manage patients exactly like I wanted to.

But part of their being here, and my being here, is so that some training can be passed on. After all, I'm only as good as the work that's done while I'm here. If I really want to make an impact in this country, one that lasts long after I've left and extends to more patients than the ones I see in my time here, then I need to pass on as much as I can in the relatively little time I have.

So it breaks my heart when I see them dragging their feet, not following up on their patients, or making excuses for places that they'd rather be. One in particular has been particularly draining. He's been absent for about fifty percent of the time that I've worked with him, making it very difficult to rely on him. If I can't rely on him, he's more of a liability than a boon, and I'd just as soon have nothing to do with him. When he called me last week, after being two hours late, he explained that he had wrecked his car that morning. That it was still driveable, but that he wanted to shop around, take his car to a couple mechanics and get some estimates. When I asked him if he had any plans on seeing his patients that day, he said he wasn't feeling up to it, that he had too much to do.

I railed on him. I told him that his first responsibility was his patients, and that any issues with his car, which was still driveable, could wait until he ensured that his patients were still alive. I hung up the phone, smoldering over his decision, and apparent irresponsibility.

Every day, I worry what will happen when my time here is done. Because the simple fact of the matter is that there are not adequately trained personel. Before Baylor stepped in, there was only one pediatrician, Dr. Phiri, serving the nation. And when we leave, who fills those shoes if not the medical officers? We train nurses to do HIV counseling and management of complex drug regimens. But its the abstract thinking that extends beyond simple drug management and single disease focused care that our patients need. More than nurses, more than medical officers and general practitioners, we need pediatricians to serve the children here. We can prop up the health care systems with these providers for a period of time, but at some point, we're going to find that this country and its people won't escape the adolescent state of its healthcare system unless appropriately trained professionals can step in. So I take it especially hard when they don't deliver. When they don't show up to work, when their priorities are somewhere else. For the portion of the day that they are one the wards, I want them to give everything, to raise the stakes, to treat every child as if he or she is their own. And I worry when they don't. So it's got me down a little.

It doesn't help when the hospital is full, when we're literally up to our ears in patients. When the beds are full and the only room left in the inn is on the floor. Then I worry that someone will get forgotten, someone will fall out of sight, only reemerging when the mother realizes the fight is over, and letting the ward know with her screams.

I spent all week watching things go from bad to worse for one of my patients. A little less than five years old, she came in on Monday with her right side paralyzed. We worked her up for meningitis, and started her on broad coverage including TB, just in case. Tuesday, she was obtunded - unresponsive. Wednesday she had a seizure and developed respiratory distress, likely choking on the vomit that came up with the seizure, resulting in aspiration pneumonia - a particularly disturbing diagnosis because it implies that the fluids produced by the body to digest the proteins and fats that comprise your daily meals are now sitting around in your lungs, chewing through tissue, to say nothing of the bacteria that have now found a new home. Thursday she started having large bloody stools. Friday she started posturing, her body taking the tone of a iron rod, responding to the crushing pressures squeezing her brain through the base of her skull. Saturday she started seizing. And today, when I walked in again for weekend rounds, she was gone.

Its been another difficult couple of weeks. The frustration of a medical system I know I can't turn around by myself, the apathy of a few medical officers who will inherit this country and its shortcomings, and the continual reality thrust upon me, that I'm in over my head; they've been adding up.

So I thank God for the three year old who came in, ready to die. Her mouth foaming, her pupils constricted, her breathing agonal. Turns out, she had been playing at a neighbors place, unsupervised. About an hour after getting home, taking a bath, and being put down for a nap, she awoke with a wail, and then slipped into the troubling mess of diarrhea, salivation, labored breathing, and comatose state that she had become. My guess was organophosphate poisoning. The chemical compounds used in fertilizers, pesticides and agricultural products were legendary for the constellation of effects they caused. We loaded her with atropine, gave her lasix for her lungs and waited to see some change. In an hour her breathing slowed. Her salivation dried up. Her lungs started to clear. Her eyes flickered. When I saw her the next morning, she was speaking in full sentences, playing with her mother, smiling at the staff. We all needed to see that. We all needed to know that there was one that we could save, atleast for the moment. One that we could definitively fix. One that could show us what it felt like to win. One that could keep me rolling out of bed in the morning.

I don't mean to sound arrogant, but someone tossed me a softball the other day, and it felt good to blast it out of the fucking park.

Progress

There must have been about forty of them. Some were shirtless, some were wrapped in rags, some were dressed in their best. They say at the foot of the table in the shade taking it all in: the dignitaries, the marching band, the events unfolding in front of them, the implications of which they couldn't possibly understand.

We sat a couple rows back, looking on as the events unfolded. Another PAC doc and I had been asked by the director of our center to accompany her to the unveiling of a new vaccine. The question was which vaccine would it be? Not even the director knew and so we waited patiently under the canopy reserved for dignitaries including the minister of health, the minister of education, in-country directors of WHO, UNICEF, UNAIDS, and other movers and shakers who had dedicated their lives to children, the same children who had gathered at the front of the tent. They huddled together in the grass, happy enough to take part in the celebrations, occasionally a few would shoot shy smiles over to me and the other PAC doc, checking to make sure we were enjoying ourselves as much as they were.

After my last month on the wards at Queen II, I have a greater appreciation for preventative health care such as vaccines. Back home in the states we memorize schedules and tables and admonish mothers when they fail to bring their child in on time for shots. But the truth is, we've done such a great job in most cases that things like epiglottitis and meningitis are rare enough that they're becoming relics relegated to text books and discussed more in lecture halls than on hospital wards. Here of course its very clear what the absence of these vaccines mean. Most of my frustration over the past couple weeks dealt with handling these illness and the fallout that results from their devastation.

It's been a difficult, but I've come away with a handful of victories that still burn bright in my mind.

About three weeks ago, a nine year old was carried through the door in the arms of a caretaker who worked at her orphanage. I had gotten a phone call warning me of the situation, but I hardly had time to prepare as I was rushing to stabilize another child in the acute room. By the time I made it to her bedside, a number of people had gathered, encircling her. There was her sister, roughly in her early twenties, who looked on, not entirely sure what was happening, and why her younger sister had gone from walking, talking, and playing to comatose and unresponsive to pain, the events around her, and the people who were squeezing her hand and calling her name. There was the elderly caretaker who worked at the orphanage, the Brit who appeared to be in his early twenties, here with intentions as good as any others, and the elderly gentleman who had helped drive them their. These were her family members, as HIV had claimed the lives her parents just a few years back.

Its the orphans that I think are the most compelling in terms of my being here. They are the ones at greatest risk, not only because of their lack of social support, but also because whatever disease claimed their parents typically also holds them in its grip, whether it is HIV, TB, or more generally, grinding poverty.

She looked like what I sometimes describe as "critically ill" when I write my progress notes. Its the look and general condition that makes your insides wince every time you walk by a bedside, realizing that someone's fate is out of your hands. Its that realization that makes it a little harder to breathe, a little harder to process and think straight.

I grabbed one of the medical officers and had him prep the procedure room. Minutes later, I scooped her up in my arms and followed after him. Making my way to the table inside we set her down. Moments later, we had popped a needle in her back, pulled off 10ccs of yellowish fluid, and carried her back to her bed. The fluid had come out under such pressure that I worried if in fact that move had been prudent, and if her brain was at risk of herniating through the base of her skull given the elevate pressure squeezing on it. By now she was a little more awake; perhaps the needle in her back had something to with that. She had started to thrash around and soon afterward she jerked in her bed so violently that her face came crashing into the beside rails, blood trickling between her lips.

By late afternoon, I had the results of the LP (spinal tap). Under the microscope I saw tiny little spheres in pairs; the bacteria had picked up the blue tint of the dye used to stain our micro slides. I rejoiced at what I saw: Strep Pneumonia. A virulent bacteria, as previously described as vaccine preventable, it was also one that was very treatable. So that very same evening I started her on double coverage antibiotics, started her on fluids, and updated her makeshift family on her odds. She was very sick, and paired with her HIV, it was unclear what her outcome would be. I wanted to tell them that I had never before cared for a child this sick with fulminant meningitis, but I withheld that information as it would do little to inspire confidence in them or in myself.

Instead I watched for days as she seemed to get sicker, her fevers climbing higher, as high at 1o6. Remembering the way the fluid sprayed out of her back when we tried to drain it, I started adding medications that would alter the fluid balance in her body. Diuretics to make her urinate, a carbonic anhydrase inhibitor that had the fortuitous side effect of decreasing CSF production, the fluid that bathes the brain and is manufactured in its inner crypts. I propped her head on pillows, sedated her with Valium when the trashing got worse. This was one of the weeks when I was on the wards on my own. So instead of finding help in another doctor, I turned to the wisdom of Nelson's Textbook of Pediatrics, a four thousand page volume of wisdom compiled by the some of the greatest minds ever to care for children.

Its pages urged me to keep faith, to continue treatment, even as the fevers climbed and her mental status remained just short of militant. A nasogastric tube had been placed a couple days later to try to get her calories, but she wasn't having any of it, and after four failed attempts, blood pouring out her nose, we decided to hold off for a couple days.

Days passed, each one brought a different caretaker to her side. Every time I walked by her bed, I looked on to see if we had any reason to be hopeful. Not knowing where we were headed, I offered only guarded optimism to the family.

And then one day, her eyes opened. Just the night before she had strangely found peace. Her thrashing had stopped and with the touch a hand or the sound of voice, her eyelids would flutter. Each event was reported to me be her caretakers, each moment a little victory in their minds. Despite my skepticism they inspired hope, and by the following week I had found myself looking forward to work, the moment when I would pull up to her bedside, and perhaps hear a piece of badly needed good news.

And when it finally came, it came with such speed and such force that it left me speechless. Within days her eyes had opened. Her lips started to form words. Water. She begged for water incessantly. She had been dried out like fruit left on the vine too long, an attempt to control the pressures in her brain. And after days of endless urination and fluid restriction, he body was screaming for fluid. Giving the go ahead, the green light to let her drink to her heart's content was a big day, a great feeling.

Day after day she claimed another victory. First there was speech. Then it was the ability to sit up with support. Movement of arms and legs followed soon afterwards. By the end of the week she had found her way out of bed and started taking her first steps again. It was liking watching an infant speed through the stages of development in front of your eyes. She was a walking, talking, chewing little miracle. The day that I saw her take down a quarter loaf of bread washed down with fruit juice was probably one of the finest moments of my medical career. I couldn't help but stare at her, to gawk. Her nurses, her caretakers, my translator - we all basked in her glory, because finally after all the defeat and all the heartache, here was one that was going to walk away.

I recently shared with someone close to me that its the defeats we look to forget. We take our lessons, our beatings, and then we move on. It's the victories that we hang on to. They are hard fought, they are slow to come, unlike our defeats, but nothing, nothing will take them away. At the end of all this, I know that nothing is guaranteed, least of the all the future of this little girl growing up with a disease that is ravaging her country, but at least she's bought herself another chance. And that's something that I can be proud of.

Clearly not every victory can be miraculous, but there are still others that I find myself proud of. In the states we have children who we call, "Children's Specials". If they were adults, they might be insensitively be called train wrecks. I might as well be honest and admit that I have called a couple patients such names before. We call them train wrecks because when they "walk" into the ER, (more often they are wheeled-in in specially built wheelchairs), they have a number of medical problems, each one potentially life threatening, and each one complex beyond measure. They usually have home ventilators, feeding tubes, a list of medications that can reach the high twenties, and complex care regimens. They require full time nursing either by devoted and very loving parents, or by special nursing facilities.

When these children were admitted to hospital, they usually ended up staying for weeks on end. A resident assigned to one of these patients usually spent a good part of his or her mornings navigating through each issue in attempt to formulate a reasonable plan of care for the day.

Most of these children had been affected by illness at birth whether by result of prematurity, or infection, or both, and they had found themselves in this state only because we had developed the skill and ability to keep them alive beyond what their little bodies were capable of doing if left to their own devices.

I have often wondered the ethical implications of prolonging life because we can. I understand the moral argument that where life can be sustained, it should be, and I can only imagine the grief and heartache one must feel at losing a loved one to a devastating illness that robs them of their personality, and then to be asked whether they would like to withdraw care from their loved one. It takes a certain appreciation of complexity, of faith in there being something better after this life, to allow one to "pull the plug." So though I never have completely agreed with it, I understand why we do what we do to prolong these lives, and arguably prolong suffering.

I just never thought I would be advocating for it. I never thought I that I would choose to specialize in such children's care.

And yet, that's where I find myself these days. Even after I complete my month long shift at Queen II, there's work left behind, and if I'm lucky, there's work that follows me out the door.

About a couple weeks ago, I walked up to the two medical officers with chart and textbook in hand. "Guys, how do we treat TB meningitis?" Having learned the answer the hard way just the week before, I wanted to ensure that my trainees wouldn't make the same mistake. When they offered the standard response, I flipped open the text and pointed out the new recommendations, the ones that advocated for second line drugs usually overlooked, the only drugs that would penetrate the blood-brain barrier. After grabbing their attention with this little nugget of information, I flipped open the chart in hand to the list of medications this child was on. Neither Ethionamide nor Streptomycin were to be found.

He was a two year old who had been taken hostage by TB meningitis, and to large part had lost the fight. Over the past two months, his mental status took blow after blow, to the point that his quality of life meant endless seizures, rigid posturing of his entire body, so that it resembled more a plank of plywood that a limber little boy, and high pitched screams throughout the night that keep the wards awake. In attempt to relieve the pressures on his brain, a shunt had been placed a month prior in Bloemfontein. Running from the inner core of his brain to the surface of his skull, traversing over the muscles in his neck to the surface of his sternum and finally diving into the depths of his abdomen, a piece of plastic tubing provided the only exit for fluid incessantly dripped out the depths of his brain like some leaky faucet. It provided some relief, but it was hardly a cure, and eventually he was shipped back to our care. Knowing that he had never been optimized on treatment, I took him onto my service on his return.

I restarted his TB meds, restarted his steroids, and re-engineered his antiseizure regimen. It took weeks, but before I left Queen II, I had another partial victory on my hands. It's true that he will never play, talk, or walk again, a point I made very clear to his mother, but both of us reveled in the little victories that we could now claim. He no longer shrieked through the night, his sleep was restful, his arching was better, and what's more, the seizures that lasted hours on end day and night were now reduced to one or two daily episodes, each lasting less than ten minutes.

Sometimes you have to take what you can get. Not every child will get up and walk away from an illness relatively unscathed like my nine year old. Sometimes you have to deal with the fall out of survival from a disease that was supposed to take a life. In this case, we had beaten back an acute illness only to find that it had left behind a two year old deeply debilitated. This was a child that would have earned the title "complex" if he were in the states being cared for by a tactful practitioner, "train wreck" by one who was a little more insensitive.

Either way, I never imagined that a child like this could survive in a health care system that had yet to reach every child in providing the most basic of services, let alone provide life long complex to care to a survivor of TB meningitis. And I guess I should be honest, it can't. I realized this when I had the child follow up to see me this week at clinic. Leaving Queen II, I took a handful of patients with me who I wanted to follow up. Only about half of them had HIV, but their needs were so great that I worried that they would get forgotten in the health care system, only surfacing when their parents were at their wits end, when every other practitioner had turned them away, when they were on death's doorstep as children such as these find themselves inevitably.

So instead, I promised each of their mothers that if they came to our clinic, they would be seen, that I would coordinate their complex care, ensure that they were made comfortable, that their weight would be checked and their calories counted. There are a total of four children I expect to see over the course of a week. Each one of them has been affected by some sort degree of neurological devastation. If we were in the states they would eventually receive tracheostomies to help the breathe, feeding tubes to give them nutrients, and round the clock nursing care to provide for most of their needs. But here such things aren't imaginable for most, and I still deliberate the ethics of providing such measures anyway when it prolongs the inevitable. Regardless, I look forward to opportunity of at least providing palliative care, measures to provide comfort to them and their families as these children march towards their inevitable end. Because in my mind that's a better life then some horrible death in a sweltering, overcrowded hospital ward, and the fact that I'm even in a position to provide such care means that at least on some level, something was done right, and a victory however small can be claimed.

Of course the greater victory is largely unsung: victories won where prevention has staved off some horrific fate. We take for granted in the States what we've accomplished with prevention: the virtual elimination of small pox, polio, tetanus, diphtheria, and a host of other illnesses. Some of those victories are shared here, some are still in the making.

As we sat there under the shade of the dignitaries tent, I reflected on the wins and losses of this past month. Some were big, some were small. The ones that hurt the most were the ones I thought were preventable. And so, as they finally announced the new vaccine, Hemophilus Influenza, a bacteria responsible for meningitis and epiglottitis, I felt a wave of relief knowing that in less than a year, the entire face of pediatric care in this country might just take a giant step forward and in doing so ensure the health of its children. Most of them in our company were happy enough to take part in the celebrations, dancing along to the marching band. Me, I was happy enough being their pediatrician.

A Little Multimedia

UNICEF France just did a quick film featuring some of our patients. They offer funding for various programs within Baylor Lesotho and also have a couple shots of life and work in and out of the clinic.

Click here to the see the video

Borders

When I first heard the news, it was just one more piece to add to the pile that was adding up to a bad day. It wasn't until I sat down about an hour later that I realized just how hopeless things had just gotten, what the implications of this new development were going to be.

They say that one of the perks of being in medicine is that you and your job are relatively immune to the ebbs and tides of the world economy. Turns out, patients aren't. With the recent worldwide economic meltdown, hospital endowments have taken a big hit, and the one that we depend on for advanced imaging, chemotherapy, complicated cardiac surgery, and other methods of medical management far beyond what we can muster at our public hospital in Lesotho had found itself in a financial crisis. A memo had been circulated to staff, and in hushed tones, a doctor on the other line, the one who I would consider my go to person for times when I'm in over my head, a woman who I am convinced has her spot in heaven well secured, whispered to me the situation. No, they wouldn't be able to do a CT for the child with presumed TB meningitis. No, they couldn't see the child with obstructive jaundice with a liver the size of a basketball. No, evaluation of the child with chronic lung disease was just out of the question.

I've never met the woman before, but her thick Afrikaans accent betrays a mountain of compassion, the sound of an older woman who's life and commitment to children are inseparable. She uttered profuse apologies on behalf of people who had made decisions she would never have agreed with. She knew this spelled a grim fate for dozens of those admitted to our wards.

I spent all of last week on the phone with physicians of various pediatric subspecialities. I asked them how they would manage patients that were in my charge. Each offered recommendations, and each offered regret that those recommendations were the best they had to offer. Not a single one agreed with what was unfolding, each one's hands tied just as mine.

I'm starting to understand what it might feel like to live in a Mexican border town. When your lot in life is decided by a line that separates you from one of the wealthiest countries in the world. When your child doesn't stand a chance because he doesn't have access to simple measures that can make all the difference.

I can't tell you how angry I am that I have almost half a dozen children in my charge who are dying from meningitis. They're infected by bacteria that we have vaccines to in the states: H. Influenza and Strep. Pneumonia. By the age of two, every child in the states is mandated to have a series of shots that provide protection against these insidious bugs. Here in Lesotho and in the developing world, it turns out these particular vaccines are too expensive. So instead I sit there and watch as brains literally melt away. And now with the loss of our referral center in South Africa, there's even less recourse for these children. When they get so sick that they're necks arch back, they lose control of their motor function, their ability to swallow, I have nowhere to send them. So instead I read. I call up other docs. I cross my fingers and pray. It's made me a better doctor. It's put my back up against a wall, forcing me to fight my way out. But it takes its toll when one after another slips between your grip. And they keep coming, sick ones to replace the the sick, the dying coming to replace the dead.

This weekend, while I was rounding on the wards, I bumped into a young mother who was crying in the family room. She was barely 18 and her child had been admitted for an acute case of gastro: diarrhea and dehydration, one of top three killers of children in the developing world. Her child had shown promise shortly after admission and within days had recovered his original weight, his diarrhea resolving just a couple days afterwards. But she had no money to pay her hospital bill and no one that she could contact for the needed funds. So she sat on the hospital wards for an entire week waiting for a solution.

The past week I had been scrambling to cover the wards on my own, and when her child recovered, I let the medical officers follow him, thereby allowing me to focus on the sicker kids. It was mentioned to me on more than one occasion that she was waiting for money to come through, and then she would be discharged. When I stopped by on Friday to check on her and her child, she mentioned he had a cough that had just recently developed. When I finally made it to the bedside of her child this past Sunday, I noticed it was empty. Bracing myself for the inevitable, remembering the sight of her crying in the empty room just hours before, I turned to the english speaking mother next to me and asked what happened.

Her child had passed away that morning from sudden respiratory distress. Without warning her child started gasping for air and just hours later, his lungs gave out. I thought back to the cough, to any possible sign that would have signaled this fate. Nothing came to mind.

The english speaking mother of the child in the next bed added that she still remained here because she still didnt have to funds to pay the hospital or for transportation home. Realizing that I had failed her in what felt like every conceivable way, I opened my wallet and pulled out a 20Maluti bill, the equivalent of two dollars. As I reached to hand it to her, I realized with horror what I was doing. I was trying to assuage my guilt and buy her forgiveness with two US dollars. And even though I made it a point to admit fault to this mother and make it clear that this in no way was supposed absolve us of our error, I think we both knew that I was trying to make myself feel a little better, maybe a little less helpless.

I walked back to the nurses station, grabbed the chart with the tell tale R.I.P. at the top, and flipped through to the final note. I amended it to say that the child had expired suddenly, likely of complications of TB. In doing so, I bought the mother an exemption, a listing of one of four diagnoses for which a patient's hospital bill is waived. I lied through my teeth to get that exemption, I cheated the hospital and the health care system out of a bit of cash, a health care system that is barely surviving.

There are speculations that the hospital in Bloemfontein pulled its support because the country of Lesotho had been delinquent in payment of its bills. As part of an agreement to have our patients seen in South African hospitals, the Lesotho government pays a nominal fee as a measure of good faith for each patient, thereby helping to offset the costs in some small way. But this country has yet to pay off the one CT scanner it had installed in the public hospital, and now that it is broken, the manufacturer refuses to send anyone to repair it given that the original bill was never settled. There's debt piled upon debt, and with one health crisis after another, it's hard to see an end, or rather, where exactly to start. I don't blame the Bloemfontein hospital anymore than I blame our own hospitals and health care system for turning away sick patients whose only hope rests in our hands.

I admit I am naive. But it still shocks me that at the end of the day, health outcomes are still dictated by money. Whether it's here or in the states, your lot is ultimately decided by your paycheck. And whether we like it or not, in accepting this, we are putting a price on life. When we accept that care is governed by financial resources, we have compromised our commitment to our core values of "life, liberty, and the pursuit of happiness." You can't claim that all men are created equal if you let some die of disease where others are spared. Back home it's not so overt. The casualties aren't quite so high, so it's easier to overlook. But there's ample research to show that health outcomes are drastically different based on socioeconomic status. If nothing else, I'm thankful for the opportunity to know first hand how the rest of the world scrapes by, to feel what it's like to be on the other side of the fence, to watch a person lose to a disease because they lived two miles in on the wrong side of the border.

The Ambassador of TB

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.

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.

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.

Terminal 5

"On November 4th, you won't be able to vote, but we'll all feel the consequences" - BBC News

Sitting in the airport, halfway back to Lesotho, I was treated to live simultaneous broadcasts of Obama and McCain's latest entreaties to the people of Pennsylvania. It wasn't so much what they had to say that moved me, but rather the reactions of the international jet-set awaiting connections in Terminal 5 of Heathrowe.

I started this job ten weeks ago, and in that time, the work, the people, and the cause all have captured my attention in such a way that much of the outside world has been lost on me. I've missed Tina Fey, The Bailout, the faltering economy and the realization that thousands of people are losing their jobs.

Coming back was a little bit like walking into your old bedroom and flipping on the light and realizing that nothing's really changed, there's just a little dust lining your old pictures.

It wasn't a big transition. I somehow missed the dreaded "reverse-culture shock." More than anything, I realized that there was an alternate reality out there that I hadn't paid much attention to, and now that I was knee deep in it, I was a little embarrassed that I felt at times out of place. The past ten weeks have felt like I was in a parallel universe. Neither worlds overlap but in conversation, and even then it's easy to forget about the other world, except of course for the loved ones keeping us at bay.

The only time I felt one world invade the other, so to speak, was when the American Election found its way to the international terminal. Never have I been more proud of my country, never have I felt the incredible potential we have, and never have I hoped more for a still uncertain outcome. It's been titled by the worldwide community as "The Election That Affects Us All." Obama ended his speech with a quote from a supporter asking him to fight for them, in essence, to fight for injustice levied on the common American. And looking around that terminal, there were open jaws and stunned silence - think of what we can do if we are able to deliver on all of these promises.

The one thing that has bothered me with all of this, with the talk of fight, and the feeling of alternate realities, is how easy it was to turn off the light when I left the room, when I left Lesotho. It makes me wonder what it will be like at the end of all of this, when it's time to come home. Will it be so easy? Will I look back if I have no planned return. I've spent over two months here, but the minute I came home, it was business as usual. I realize that it's this feeling of parallel universes, and separate, unlit rooms that makes it easy to compartmentalize everything else that goes on in our world, to forget. I'd like to believe that with this talk of change, with the feeling of this impending renaissance, and the renewal of American benevolence, that the ability to forget/ignore this other world will become more and more difficult.

A couple weeks ago, a high ranking Sesotho military officer, in a moment of weakness imbued by drink, confessed to me that without the United States and it's aid, his country would be vastly worse off. Like it or not, there are people beyond our borders that are counting on us. It's easy to forget when you're on top of the pile how, ultimately, all of our lives are intertwined. With words like hope and change, I wonder if its finally the beginning of a movement, our time for redemption, our recognition that we have something greater to strive for. In Terminal 5, its very promise stopped some dead in their tracks.

Sometimes

The needle slid through her chest with a snap.

Her grandmother on her knees in the back corner, a murmured prayer filling the room.

And despite all our hope and desperation, nothing came back. Not air, not blood. The four people it took to hold her down all looked at me, a sick expression on each of their faces. Nothing on the right. Might as well try the left. I grabbed a fresh 21 gauge, hooked up to short IV tubing with a plastic clamp, and connected the end to a 10cc syringe. I found my spot: second intercostal space, mid-clavicular line. My finger jabbed each rib. Paranoid, I counted, recounted, verified the spot three times. Then I asked for a confirmation from a bystander. Then I rechecked. I felt nauseous. I felt anything but steady. I couldn't believe I was in the same shit again: another newly-diagnosed-HIV-positive-four-year-old-girl-with-impending-respiratory-failure. It's been a month of working in Queen II. A month of working in the most feared hospital in Lesotho. A month of trying to turn that reputation around.

The second needle went in as easily as the first. Nothing. I pushed the inch and a half needle all the way to the hub. Nothing. Not air, not blood, just a dead end. It wasn't a pneumothorax that was killing her. It wasn't a collapsed lung that was sucking the life out of her, causing her chest to cave in. The routine hardly ever changes here. They come in sick, they get sicker, we get desperate, we start stepping up care, and then we show up the next morning and absolution has come and gone.

But it was my last day, and when you’ve come to the conclusion that you really have nothing, absolutely nothing to lose, you start doing crazy things. I had never done one of these. I hadn’t ever seen one of these. It’s a pretty straightforward procedure done when there is the slightest suspicion of a collapsed lung, it doesn’t even require an XRay. The only difference in our case was that it wasn’t really clinically indicated. She didn’t have the requisite shifting of her trachea, the distension of her neck veins, the differential breath sounds between the two sides of her lungs. What she did have was a complete absence of any air moving through her lung fields, and she was getting dramatically worse in front of our eyes. Same song, second verse.

I looked at the other PAC doctor who was transitioning to take over the wards for a couple weeks in my absence; neither of us was entirely ready for this. But then, we had just spent the last twenty minutes resuscitating a child in the next bed. We had pulled her back from the brink, regained a heart rate, but she never started breathing on her own. And in the end, we bagged her, gave her breaths through a mask hooked up to a rubber balloon, until we could no longer hear her heartbeat. It’s gut-wrenching to try your hardest to bring a child back, to stabilize them, only to realize that at the moment when fates can change, you don’t have the what it takes to make the next step.

The only advice I got from the Dr. Phiri, the veteran doc looking on as we worked on her patient was: next time you do that, make sure tell all of the mothers to leave the room.

So when we walked back into acute room, our plan resolved, equipment in our hands, I took a look at the single nurse in the room.

“ I need every mother out of the room except the one for that child.”

The nurse translated, the mothers looked at each other, and then each one filed out. The mother for my child wasn’t even in the room, she was outside on the bench in tears, denying the obvious. It’s a bad sign when you’re child’s doctors are visibly scared.

After bringing her to the bedside, I tried to explain stepwise what we were about to do.

The reason – her child was very sick and we didn’t know why

The risk – if she didn’t have a collapsed lung, we could inadvertently introduce air into a vacuum cavity, thereby actually causing a collapsed lung. And if our aim was poor and we hit a major vascular structure, there would be bleeding – unholy amounts of blood.

The alternatives – none

The benefits – immediate improvement, comfortable breathing, re-expansion of her lung. But here was the rub, putting a needle in someone’s chest was only a temporary measure, it must be followed with a more permanent chest tube hooked up to a vacuum if in fact the lung in collapsed. I had neither the equipment for a chest tube, nor an available surgeon to assist me. DIY medicine only gets you so far if you don’t have training, equipment, or backup.

So as I stood there, planting the needle in her chest, watching for air or blood to come back into the syringe, I was secretly relieved that we had the wrong diagnosis.

With little else left that we could do, and driven by a mixture of desperation and bravado and the feeling that we had already gone this far, I wheeled a cart into the room and secured her 80lbs steel oxygen tank to the rails. Jill, the other PAC doc scooped her into her arms, and with grandmother and our translator in tow, we bolted for XRay, a ten minute walk to the opposite side of the medical campus, in an entirely different building. Because of its distance and our patient’s dependence on oxygen, getting an XRay was more dangerous than blindy putting needles into her chest.

Our group of four plus one sick child and weighted cart rattled over stone and pavement, through dirt and finally into the wards. As we sat her down on the xray table, her mouth opened wide, her eyes tearing, but not a sound came out. Something had stolen her breath, her voice, and hardly a whisper left her lips where there should have been a wail. There’s a condition described in the medical literature as “a look of impending doom.” I’ve seen it a dozen times this month, and each time, it has lived up to exactly its name. Bad things happen soon afterwards. Jill and I both recognized it as she sat there on the table. Everyone else in the room standing ten feet away from her as the XRay machine uttered a high pitch squeal, a click, and then fell to a hum.

Half an hour later, she was back in her bed, mother at the bedside, and we had an xray in hand. All of that effort - and the results: bilateral perihilar opacities. It told us nothing. We had come no closer to a solution, and I think it was at this point that I just gave in. When you’ve done everything, when you’ve thrown every antibiotic in your arsenal, when you’ve gone on a limb and done not one but two things against your better judgement and still nothing has changed, you know its time to start letting nature run its course. Sometimes it’s not about what we can and can’t do. Sometimes, despite everything, what our patients need most is time/luck/prayer. And sometimes, miracles happen.

Sometimes, they make it through the weekend.

I called Jill this morning to check on her. She was still alive, slightly more comfortable, still on oxygen. She had stabilized. I have no idea how she got there. I’m not sure what in the long list of things we did actually helped her, but something did. And for me, that’s enough. It’s enough to reaffirm all of this effort. It’s enough to make me take that next step, to use that desperation to push further, to fight harder for every single patient. The fact that three children left the acute room last week, escaped the hospital in better health than when they came in is all the encouragement I need to keep going. And even now, as things are starting to wrap up and I’m preparing for a short trip home, I am looking forward to coming back. The tone has changed. Nurses are working harder, the medical officers are engaged, and the staff is taking note. To borrow a term - there is a renewed sense of urgency.

Throughout Lesotho, the country's national referral hospital is regarded as a place to die. I'm making it my mission to change that sentiment.

Effort

They know I'm trying.

Monday morning:

I'm walking through the wards, stopping off at each bedside, checking how my patients made it through the weekend. It's always anyone's guess, seeing as how there are five medical officers running an entire hospital. Some nights, there's not enough officers to staff every ward, and inevitably the children's ward gets left behind. Those are the bad nights. The only time a doctor makes it to the bedside it's when it's too late, when it's time to pronounce death.

As I was turning the last corner in room three, annoyed that it was noon, and today was going slower than usual, a mother walked out of the back room we reserve as the malnutrition ward. I always feel uncomfortable walking into that space relegated to the end of rounds and the back of the children's ward. Those children are usually stable, but they can get sick pretty quickly and it bothers me that they are so far away from any of the nurses or anyone else's attention. A kid could die there and no one would know until the next morning. Or Monday morning.

She had a straight face and was clenching her child's chart. She said she needed to talk to me. I looked up, recognizing her, and told her I'd be there in a minute. I went back to finishing my note on the child with unrelenting seizures. She just stood there, clenching that chart. I looked up again, starting to realize that the tone of the room was starting to change.

On her child's chart were the letters: R.I.P.

That particular acronym used to conjure up visions of the wild west, gunslingers and tombstones. Now when I see it, it still feels like a sick joke: R.I.P. I'm getting used to those letters.

I realize what's happening. The child that I worked so hard to help for the past two weeks, the one with encephalopathy so severe that her back took the shape of a boomerang, the one that I had stabilized and was feeling so optimistic about had passed away. I felt sick. After all that, it took just two days for a medical officer to kill my patient, not intentionally, not knowingly, but by neglect.

I took the mother aside, my translator trailing behind. After searching for a quiet corner without much luck, I pulled her into the least crowded patient room, figuring that would be better than the hallway opposite the bathrooms. I sat her down and put a hand on her shoulder. I asked her what happened. She just looked at me, expecting me to answer my own question. I took the chart and started flipping through it. I saw my last note from the Friday prior. It was thorough, and detailed, and optimistic. It spoke of feeding regimens, completing courses of antibiotics, long terms plans for physical therapy. There was no note from Saturday. No one had seen her that day. And Sunday's note cryptically stated in four lines: patient critically ill, placed on oxygen, taken to acute room, continue Rx (code for I don't know what's going on/I'm too busy/I've given up). There was a follow up note four hours later: called to bedside, patient pulseless and apneic. Pupils dilated. Time of death 2 am.

"Where were you?"

and

"I begged them to call a doctor. No one came. I begged them to call you, to see my child. They wouldn't call you. They wouldn't give me your number."

Matsudisi, my translator deciphered mother's story between her sobs. I stood there, my hand on her shoulder, dumbstruck. In truth, I wasn't "on" that weekend and had taken the opportunity to leave town to go hiking, but I was back by Sunday. Had I gotten a call I would have been there, at the very least I would have talked the medical officer through the weekend, but there had been neither the time nor the will to call me.

"The mothers, they believe in you. They know that you try. She thinks you could have helped her child."

And with that, I realized that, though I had bought time for only a fraction of my sickest children, it had not gone unnoticed. I have questioned what those mothers think of me. I have wondered whether they look at me as an outsider, and a child too young to care for theirs. It's a feeling I had to fight throughout my training. But I'm starting to realize that my efforts, though rarely changing the ultimate course of my patient's lives, are giving my patients something else.

As I coded two more children this week, I noticed when people started to walk away. First it was the translator. Then it was the nurse. Finally it was medical officer. And then there I stood, alone. Rushing to hang IV fluids, flush a clogged line, do chest compression, ventilate my child, and push cardioactive medications on my own. They see the flurry of movement. Those mothers see the round after round of compressions. My thumbs burning from pushing down on tiny little chests, breaking rib after rib. The desperation - it rarely amounts to much. But I want them to know that someone tried. I want them to know that when their child walked into a losing battle, that their life meant something. It is shockingly easy to write off a life. You'd think it's impossible, that it could never happen. I look at my staff and my medical officers, and even the other doctor on the ward with frustration and contempt. Sometimes I think they too easily walk away from sick children. Its just another child. Its been three weeks and I've lost eight children. Tomorrow I'm sure I'll lose another. After all its Monday, and no Monday is complete without some child getting compressions.

And it's exactly that attitude that I'm fighting when I'm the only one in the acute room tearing my hair out, begging my child to hang on for a little longer. The fight finds itself in my outrage as I try my hardest to not bitchslap the nurse that took my child off oxygen, the nurse that refuses to change his empty tank. I swear sometimes I'm driven to just inches from violence with the frustration I feel. I fantasize what it would be like to put some of them in a headlock. I have no idea what it's like to be a mother of a sick child in Lesotho. But I am doing my damndest to show them that someone cares.

And even now, as my self-rightousness builds, I am tempered by the fact that not one, not a single child that I've done compressions on, not a single child that received epinephrine, not a single child that I've placed on more than two liters of oxygen per minute, a perfunctory dose, has lived. So cleary, everyone else in the room knows something I don't. But I'm starting to realize, thanks to the mother that believes in me, that it's not really time I'm buying with all these efforts; I'm delivering on a promise that declares that their child is going to get the best of what we can offer, and that someone will bear witness to a death that shouldn't have happened.

Middle Ground

I've never been so desperate in my entire life.

Instinctively, I put my hand on her chest. At this point, when you've gone through your list of medications, you've reached the bottom of your differential, and nothing you can do can fix her failing body chemistry, you start reaching. There's the phone call to the colleague, asking him to review everything you've done, there's the furious search through any available text book, there's prayer, and finally there's touch.

My two year old with advanced HIV was malnourished, septic, dehydrated, and hyperglycemic. The tell tale film on her eyes had hit by noon that day, and occasionally she would struggle to the surface and manage to blink it away, only to have it replaced minutes later.

I cared for sick children in the ICU during my training, and when there wasn't a parent by the bedside and they were really sick, unresponsive, I sometimes squeezed a hand, put mine on a forehead or a shoulder. I know it sounds ridiculous, but sometimes I felt like they could feel it, and as they lay in bed unresponsive and alone, I hoped that they would know that someone was with them.

It was the end of the day. I had gone through Penicillin, Ampicillin, Gentamicin, Ceftriaxone, whopping doses of Bactrim and IV Chloramphenicol, a last resort antibiotic rarely used in the west because of its ability to overnight end your body's basic functions, resulting in the apptly named "grey baby." And with each new attempt to pull her back from the brink, she slipped further away.

I put my hand on her chest, over her heart, with her mother looking on. She was nearly comatose at this point. I wanted her to know that I tried.

Her eyes flickered. A wince. And then, with one of the last movements I saw her make, she reached over with her left hand and grabbed my index finger. At first I panicked. I thought that I was causing discomfort, so I slid my hand away, to her stomach, and still her hand followed, latching onto mine.

We both knew that she was going to die. I had done everything I could possibly do. And when I turned from her to tell the only other person in that room who needed to know what was about to happen, her mother broke into tears. She had been holding back all day. That morning, when I first saw her I told mother that I was concerned about her child's blood glucose. I thought this was diabetes. We couldn't test for a pH to see if she was acidotic, so I did a quick urine dipstick, marvelling at my astuteness for considering the diagnosis in a child who had lost three of her nine kilos in the past month.

And when the test came back negative, I had told her mother that everything was going to be fine, that this was good news and that we wouldn't have to worry about managing an insulin drip in a country where IV pumps don't exist. What I was starting to realize though, was that I was running out of answers to explain why she kept getting worse, that not much was adding up.

I thought it was going to be okay, that if I tried hard enough, that this one would pull through. Surely she would atleast make it until tomorrow, and then maybe we could buy a day at a time.

But in a matter of hours, expectations changed, and at the end of the day, there wasn't a single thing I did that changed the inevitable. When I left that day, thinking that it was time to give mother and daughter time alone, I told mom to pick her up and hold her. All day she looked like she was afraid to touch her daughter, either fearing that it would be the one thing that pushed her over, or more likely, mettling herself for heart break. But in her waning moments, I wanted my two year old to know that she wasn't alone.

I realize that by claiming a death is one's fault, you concede that a person has control over the life over another, has the abilty to play God. It's a foolish conceit. And yet, knowing how ridiculous it is doesn't seem to make loss hurt any less.

I received some good advice last week, namely, "some bodies will fail no matter what, just because they're not built to withstand what they've been subjected to. Even mythical uber-doctors like Paul Farmer lose patients, and it's not even because they lack proper supplies or ... technology. People die because life is ultimately not a matter of any doctor's willpower."

And:

"We have to hold ourselves accountable to the people in front of us while also shoring up ourselves to be able to be in this type of work for the long haul...we are running an equality marathon, not a sprint, but...we aren't walking either."

I've spent a good part of this week mulling over the responses I received from both people. I concede that the death of a two year old girl, malnourished, with advanced HIV isn't the fault of one. It's the fault of many a failed system. But I struggle with accepting this reality, simply because I fear admitting it's truth engenders complacency. I wonder how the outcome might have changed if each loop in the net that was supposed to catch my two year old had held a little tighter - if the health official had pushed his charges to get tested, if her mother had gotten the pills that would have prevented transmission, if the local health clinic had sent her to us just days earlier, and if the doctor who saw her on her dying day had the resources and the wherewithal to hold back the tide.

A Better Doctor

In the end, she was my responsibility. I let her die.

I walked into the Acute room of Queen II on Thursday morning and saw a six-month old with a flailing chest and withering skin, dying of malnutrition. Her face, her hands, and her legs were swollen and the tissue thin skin was ripping under the added tension. She had been starving for who knows how long, and her particular brand of wasting was kwashiorkor, essentially a protein deficiency that results in fluid escaping to unintended pockets in the body, hence the swelling.

I struggle with a way to better describe her, but at the moment she looked like a tin windup toy ticking away, the key in her back unwinding slowly, inevitably. Her chest fluttered, pulling in whatever breath she could muscle. Mostly she just succeeded in collapsing her chest. Somewhere in the middle of her was a defect. Normally I would have called it a pectus, short for pectus excavatum - a structural deformity which causes the chest to take on a concave shape. It reduces the volume of the chest cavity and sometimes limits the function of the heart and lungs. In her, however, there was an additional deformity along her ribcage - three bony knots which bordered a concave region where her heart should have been. Either she had been neglected and abused, or she had a major congenital defect which caused her body to eat up far more calories, trying to stay alive, than she could take in.

In the acute room, a 10x12 space, much smaller than a single patient room you might find in the states, we managed to cram nine babies, eight mothers, five cribs, two oxygen concentrators and two tanks. She caught my eye. When I took her onto my team, I had every intention of giving her everything I could muster. She was the sickest kid in the ward, she was the reason I was there.

I started the antibiotics, started the oxygen, started the zinc needed for her skin, and the feeds she needed to turn around.

That was nine.

She was dead by three.

In the hours between, I was weaving through children, patients, almost, but not quite so sick. There was the six month old with meningitis so advanced that he could no longer feed, his neck and back arced back so severely that if I lay him on his back, only the back of his head and base of his buttocks would touch the mattress. He was on his seventh day of antibiotics without improvement. There was the two-month old wasting away, vomiting up bright red blood. There were the nine month old twins with HIV. One brother had suffered from his own case of meningitis. It left him devastated, blind, partly deaf and hypertonic - rigid as a board. His brother, slightly luckier, sharing his bed, was battling with dysentery - bloody diarrhea that had made him lose ten percent of his body weight. Their mother never left their bedside for a solid week. Every time I walked by their bedside, mother was either feeding them, changing them, or whispering secrets into their tiny ears. I love my twins. I can't help myself.

By the time I made it back to the acute room, my tin toy was winding down. The key in her back had begun to hesitate with each turn, with each breath. Each one was spaced a little further apart. Her limbs had slowed to a halt. Her eyes rolled upwards and her lips were quivering. Her eyes had stopped blinking hours ago and a filmy grey had settled onto the bottomless black that were her pupils. She was sick. That I knew. But despite my best efforts she was sicker.

In the states, when a child is dying in the hospital, alarms are screaming, code carts are being rushed into rooms, there's a confident sounding attending physician of skill and experience standing at the bedside barking orders and a flurry of staff tackling each one.

Here, there was a baby in a bed with mother a foot away, her head bent down on the mattress, trying to ignore the inevitable. And the confident sounding attending physician of skill and experience was nowhere to be found. Instead there was me.

I don't know why I walked away. I told mom that if anything changes, if her child gets worse, or doesn't seem to be waking from what looks like sleep, that she should call for me or the nurse right away. I think I was trying to buy time, trying to acknowledge that I was out of answers in a place other than in front of my patient whose eyes couldn't look away.

A question from another mother. A question I could answer. A problem I could solve. And when I turned away and looked back down the hallway, about to make my way back to the bedside, a nurse pulled me aside, summoned me into the treatment room. Two other nurses and Dr. Phiri, the other doctor on the ward, looked at me.

"Your patient," she started, "the one with the skin and the swelling, has expired."

Has died. And that was it.

It felt like an accusation. It felt like failure of the most personal kind.

I looked at my tin wind-up toy, lifeless on the table - the key in her back rusting in place before my eyes.

When my first one died that week, just two hours on the job, I knew we had come too late. As I mashed down on her cold bony chest, I knew that we were laboring to make ourselves feel better, a little less impotent. But this one, this one we had a shot. Back home, I wouldn't be her last hope, there would be a better doctor for her.

The only other doctor on the ward struggling to manage her own kids on death's doorstep, the two of us staffing what's supposed to be the major referral center for an entire nation's children, both of us overwhelmed.

I walked back into the acute room. I put my hand on mother's shoulder. She never looked up, her body quietly shaking, the mothers of the children around her circling, supporting her as best as they could, knowing that it could too easily be their child next.

In the end, I walked away, unable to deal with my own impotence. I couldn't save her child, and I couldn't comfort her.

I wonder what those mother's think of me when I walk into that room.

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.

Brothers

I felt guilty for asking him to do it. I felt guilty for asking him to do it infront of his fifty year old father and his 18 year old brother, the luckier of the pair. I felt guilty for being in that room, and I felt guilty that I needed a translator, someone with likely the same illness, to stand by me and help me through this.

"I need him to take his clothes off"

His face is angular, his eyes sunken but vigilant. Again I feel guilty, this time as I compare my patient's face to E.T. His father sat by his side just hours ago when he went into the counseling room. They pricked his finger twice, each time for a different test. One to confirm the other. Each one positive.

"Yes, all of his shirts need to come off"

He's 17. He has HIV. His father sat beside him the whole time. My guess is that he has vertically acquired HIV, given his lack of blood transfusions, sexual activity, and IV drug use. He didn't even smirk when I asked him about sex. In the states, even the innocent would manage a blush. The guilty might look away, or they may own up to it. He just looks through me.

"How long has he been losing weight?"

Brother spent most of the day waiting outside. He hasn't been told anything, his father says. Can I tell him? His father nods. I wonder how he could not know at this point. Sitting in the waiting room at the Baylor Clinic, surrounded by patients with HIV. They numbered close to one hundred that day. He must have realized that something had gone wrong when, after the test, his brother was asked to wait for the doctor to see him, and that it would be several hours. And yet when I ask Brother if he knows what he's about to hear, he shakes his head. Glancing at him, he looks down to the floor. Irritated, looking like he's concentrating on ignoring the obvious. I look back at his brother, my patient.

-He has HIV.

No response

-Do you know what that means?

He says yes. But the way he keeps his distance from his brother, my patient, the way he won't make eye contact with him, makes me think this could be trouble. My patient is 17 and frail, newly diagnosed, and dying in front of his family's eyes. Brother is a year older, and already seems irritated at what he's hearing. I wonder if he holds any resentment towards his brother who has always been smaller, thinner, sicker.

"Mae, can you help? Can you tell him that he has nothing to be afraid of? Can you tell him that his brother needs his help?"

My translator starts slowly. She looks at Brother. She looks at his father. I hear the words H-I-V. 29% of the population is infected, the third highest rate of infection in the world. It can't be allowed to be a mystery. She picks up steam and starts sharing information. At this point, my translator understands the nuances of care and disclosure much better than I do. She's done it hundreds of times by now. So I turn my back to that conversation and start taking a look at my patient.

I knew it was coming, but in the back of my mind, I really doubted whether something like this was possible. When he first walked in, he was outfitted in what I later counted as six t-shirts, some long sleeved, and a track jacket. Where they to keep him warm, or to hide his frailty? He's so wasted, barely a shadow.

I don't even have the heart to ask him to lie down. I start with his scalp. I run my hands through his short hair. No bumps. No loss of hair. His ears are clear. His eyes are bright, no sign of corneal clouding. He opens his mouth. There are missing teeth, and the ones that stuck around aren't in great shape. His tongue coated in white, except the middle. It's a streak of beefy red running straight to the back of his throat, where its meets up with patchy white covering his palate and the back of his throat.

Oroesophageal candidiasis. Its a fungal infection that is similar to when babies get thrush. Only in this case, it extends all the way down your esophagus. It makes swallowing an agonizing experience, and it might explain why my patient is wasting away. It hurts to eat. It hurts to drink. It hurts. It's an AIDS defining illness. It drops you down to WHO category IV. It means that we'll be moving fast.

His heart is pounds and his lungs are clear. My stethoscope balances from one rib to the next, as there is simply no flesh between the two to support the instrument.

When my hands slide to his stomach, I start to wonder if he thinks this is a joke. His belly is nonexistent, its just a valley that plunges down between the relative peaks of his rib cage and matching hip bones. I push down, feeling his abdominal aorta thump against my hand. If I pushed harder, I have no doubt that I could have felt his spine through his belly.

His joints look like broom handles plunged into grapefruit. He's bone, and joint, and very little else.

"Do they understand?"

Mae, (a term of respect reserved for women), tells me yes. She has spent much of the past half hour detailing the nuances of his illness. She has repeated the entire conversation that was shared with the father and his son just after his diagnosis. It takes time for news like this to settle in, and thankfully, its nearing the end of the day, and Mae and I have enough time to sit down and detail the information that his family will need. She assures me that Brother understands that he is not at risk.

"And will he get tested?"

Brother flashes me a smile, and gives me a most definite shake of the head, as if to signal that the case is not up for discussion. There's a good chance that he's not infected if he's this old and looks that healthy. But there's no telling. Here, as in most other places, there's a hesitation for men to receive testing, as if ignorance will provide the protection they need to escape an illness that every third neighbor is infected or dying with.

I refocus my attention on him. I look him straight in the eye. With Mae's help, I tell him: You have HIV. There is another infection in your throat that's making it difficult to eat. We're going to treat both infections. One will go away easily. The other one will stay with you for the rest of your life. But we can treat it. We can give you medication that you'll take every day. And even though it seems impossible, I promise you, you won't be sick much longer. You'll start to put on weight faster than you ever have. And soon, you and your brother will be the same. I know he doubts this. I'm sure he's entertained the notion, what it's like to walk around as his brother. And soon, we'll see.

I'm embarrassed when I ask him to strip in front of his family, but with camera in hand, I take pictures of his frail body. We need this for documentation. But more importantly, I need these pictures to show him, how in just a few weeks from now, he's made progress. So that years down the line, when he has a moment of despair and questions whether he can take one more pill, after a lifetime of pills, he'll look at his old pictures and remember how far he's come.

It's been a truly hard week for me. Distance, and illness, and so much more. I'm trying so hard to stay focused, and to stay well. Sometimes I start to waver on how long I'll be able to stay here. It was supposed to be eleven months, then eighteen, and now, sometimes I wonder if I'll make it three. But if I can see this one grow, then I'll have one less reason to question my being here.

Ghost Eyes

When I was eight years old, my life didn't depend on medication that I gave myself everyday. My caretakers hadn't left the country in search of work, and I wasn't left in the hands of a relatives who were illiterate and couldn't read the directions on my pill bottles. So how in the world can I pretend to understand what he's going through. He showed up at clinic at 9am this morning, probably waking up hours before dawn so that he can board a bus and travel down the mountain to make it to our clinic. We haven't seen him in over a year. We thought he was lost to follow up. We knew that he could refill his medication at a rural clinic in Roma, but had he? Has he skipped any doses? With HIV, resistance is most likely bred when pill adherence drops to the 70-90% range. In a medication taken once daily, that means that you can only miss 3 total doses. How many times have you walked out the door without taking a vitamin or a heart burn med? Let it drop lower than 70% and the virus cant be phased enough to be affected by "selection pressure." But make a half-assed attempt and you'll end up hurting yourself.

So there he is. He's been sitting in clinic now for over six hours. Its the end of the day and he's my last patient. His uncle is sitting in the corner. He must be younger than me. And his nephew looks up at me with ghost eyes. I see sadness. I see the loss of his parents. The tough choice his grandmother must have made when she left her mountain town to look for work in South Africa. I see a boy with entirely too much of his own care riding on his shoulders.

Has he been taking his medication? We ask for his Bukana - in Lesotho, patients possess a written summary of their medical record which is bound in a little notebook, carried along from birth to death. He hasn't brought it. We ask to take a look at his pill bottles. The best way to check and see if he's taking his meds. No dice. The uncle is all new to this.

It's surprising how there are some parallels to training in D.C., even out here. In the mid-eighties crack cocaine ripped though D.C., as in most other inner cities. With it came devastation, including HIV. And now, D.C. faces an infection rate as high as 6%, higher than many developing countries. That paired with economic woes have left many in the care of older relatives, and sometimes, during the transition, where new caretakers are presented with their new roles in life, care slips through the cracks. So I sit there with one of the other new PAC docs, and we struggle through a plan that will ensure this kid gets what he needs without risking him to drug resistance. Because when you're resistant to one line of drugs, here in Lesotho, you're only other hope is the second line. We don't have the testing abilities to tailor therapy like we would in the states. And by our estimates, 25% of our patients are already resistant to therapy. Second line drugs are more expensive, harder to keep in stock, harder to get our hands on. Some days, we run out of first line drugs; I don't spend a whole lot of time thinking about what happens after the second line.

I lift him onto the exam table. He's eight years old and 19 kilos. Forty pounds. He's eight years old and forty pounds. When I put my hand to his chest, the other holding my stethoscope to his back, his ribs lock onto my fingers, almost as if to shake hands. I can feel his heart thumping away at my palm.

What's it like to be so self reliant? To be able to count on no one else and have your life in your own hands. To be eight.

It's been a little more than two weeks, and I'm still struggling with the move. New country, new people, new language. I'm starting to know what it may have been like as an Indian immigrant coming to the States in the 60s. At times, it feels like a completely different world. But ghost eyes gives me purpose. Ghost eyes tells me that if I try really hard, I might make the smallest scratch in the giant ripping through the room. So we tell ghost eyes, after he points out the right pills on the picture card, that he's getting two weeks of meds. Bring back someone who can help, someone who can sit through the adherence sessions and learn what pills you need to take, so that if and when you get sick, you won't be alone. Come back to clinic in two weeks ghost eyes, and bring help if you can find it.