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.