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.
Sunday, September 28, 2008
Sunday, September 21, 2008
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.
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.
Sunday, September 14, 2008
Hope (Brothers II)
It's not always bad here. Sometimes things work out. Sometimes our efforts amount to something.
Brother came back. He was wearing a wide brimmed hat, a plaid shirt, and something of a swagger. He walked in with an XRay in his hand and a slip of paper in the other. When Mae spotted him, she grabbed him by the shoulder and ushered him to my side. I was focused on another patient's bukhana (chart), and we she pulled me around, it took me a minute to recognize him. I guess I had written him off after our initial meeting, but either something we said stuck with him, or more likely, we had underestimated him.
I looked over his shoulder for his brother, but saw no one that looked like my patient. I turned to him with a confused look, he said that his brother was too sick to come. I panicked.
"Too sick? How sick? Is he eating? Is he gaining weight? Does his throat still burn?"
His brother replied that while he had started eating, he was in fact, still very weak. He was keeping down a small amount of the nurtitional shake that we had supplied him with, but it wasn't enough to pull him out of bed. So in his place, I had Brother, holding an xray, hoping to help.
I raced down the hallway with Mae and Brother in tow. I wanted so badly to have an aswer, to know what exactly we were fighting. Was it just HIV, or was there concurrent TB? I threw the film up on the view box and flipped the switch.
Airway - clear, no compression
Bones - no lytic lesions, no sign of malignancy
Cardiac- if anything, his heart was small - after years of malnutrition, his muscles had atrophied, including this one. Cardiac failure is a major complication of refeeding. Give someone too much fluid, or push too much volume too fast, and a weak heart won't be able to keep up with the bodies demands
Diaphragm- sharp borders, no sign of fluid collection
Extra-Pulmonary - no obvious nodes, no sign of soft tissue injury
Fields - Lungs...clear
A sigh of relief. I grabbed the second piece of critical information: the sputum culture and gram stain - negative
So in this country where the prevalance of TB is among the highest in the world (in addition to HIV), my patient is TB free. What this means is that his management just got easier. No worrying about drug interactions between the antiretrovirals and anti-TB medication, he won't need to take any.
So I turn to Brother and explain to him the good news. I ask him when he can bring the younger back with him. He shakes his head. Brother has plans to go to South Africa for a job. He doesn't know when he'll be able to come back, but he needs to go.
He can tell I'm dissappointed. He looks to the floor. I explain to him that his brother needs him. He's obviously too weak to manage all the medications that he's going to have to take, and most HIV patients need a caregiver to stand by their side when they initiate therapy.
He promises me that he'll find someone. There's a grandmother that's literate. Maybe she can help. So faced with little other option, I send him to social work, hoping that if I give him a transport voucher, he'll be able to pass it on to his his brother and grandmother so that the journey to our clinic will be a little easier.
I worry that my patient is getting sicker since seeing me, and I wonder if he'll even make it to the appointment in two days.
That was Tuesday.
Thursday was something of a bad day. One patient after another, each more complicated. There was the pregnant mother who had forgotten to take her HIV medications, thereby risking herself and her fetus to resistance. There was the family of three who had recently lost all of their possesions, including their meds and their bukhanas, to a fire set by an abusive husband/father who decided that if they wouldn't give him money, he was going to beat the hell out of them, and then burn all of their possesions. I was working through lunch, trying to stay on task, as I walked out to the lobby. I picked up the next chart and Mae comes racing up to me.
"Our patient! He's here! He's here with his brother!"
She rushes outside and I see a closed-bed pickup truck with a wheelchair being unloaded. Minutes later, my patient is being wheeled in, Brother behind him, and an uncle with the unmistakable wrap-around sunglass of the blind, mounted on his face.
I usher the three of them to my room, Mae on my heels. My patient is firmly planted in his wheelchair not making eye contact. Slowly we review all of the facts we covered last week. His throat no longer burns. He's been eating, minimally, but it's an improvement. The diarrhea and the abdominal pain are still there. But gone is the cough, which confirms what the xray had originally assured me. I look to my chart, 29 kilos. Thats a fraction less than what he weighed last week. I'm careful not to put too much stock in this. After all it often takes more than a week to see any significant change and he hasn't even started antiretrovirals yet.
I have to admit, I'm surprised that Brother is still around. When I ask him why he hasn't left for South Africa yet, he shakes his head. He's not going. He's decided that he wants to stick around, to see his brother get well. I don't know why I doubted him so much, but he's coming through in a way I hadn't expected. When we ask who's going to help with refeeding my patient, he steps forward without hesitation. He helps wash his brothers hands because he's too weak to stand up out of the wheel chair. And when we give him the packet of RUTF (Ready to Use Therapeutic Food), it's Brother that volunteers to feed him.
The rest of the hour was spent detailing what would be coming next for the patient. Now that his brother was here, and his uncle (though blind) had volunteered his help, we had the safety net we needed to push forward. After leaving my room, they would go onto our adherence counselers who would condense two weeks worth of information into one afternoon. Next they would go to pharmacy to pick up the prescriptions he needed. Finally, there would be another stop at social work, and then they would be on their way home. His next appointment would be in a week, but this would be last time I see him for a while.
Starting tomorrow, I head into Queen II Public Hospital, and that means I'll be away from the clinic for the next four weeks. In that time, my patient's life is bound to change dramatically. He'll start puting on weight, his diarrhea will resolve, and he may gain the strength he needs to leave the wheel chair. I'm sad that I won't be there to see the gains that he'll make. But I've introduced him to two of the senior docs, and together, they'll take over his care. I told them I want him back when I return.
Before they walked out that door, I made it a point to tell Brother how proud of him I am. I'm not sure if it registered, he didn't really react to the comment, but I hope it sunk in. I can tell my patient is hopeful too. That day he started carrying on a conversation with us. His voice is tiny and frail, but there's confidence in it. More than anything, I can tell he's not scared, and I convince myself that he's even a little hopeful now that he's got Brother in his corner.
So as I march into Queen II, where I'm likely to be surrounded by kids sicker than any I've ever seen, atleast I've got this one victory, and it gives me hope that there will be others.
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.
Sunday, September 7, 2008
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.
"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.
Sunday, August 31, 2008
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.
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.
Monday, August 25, 2008
First Day Blues
I think the frustrating thing about this or any job is the feeling that no matter how hard you've worked up to this point, no matter how well you thought you trained, most all of it is for shit. Try drawing blood on the four year old who offers you his arm. Then f' it up and try three more times until he's kicking and screaming and you have a dirty needle flying through the air. Then repeat that a couple more times. Little things like that used to be a piece of cake, but today, on the first day, it's bound to be inches from impossible. After that, get reassigned to the "treatment room," where the really sick come to hang out because its better than the local hospital. There they spend hours bartering time, trying to get well enough so that they can prove to us that they'll make it through the night. Guess we'll find out tomorrow. And then there's the 4 month old girl with a rare skin condition called epidermolysis bullosa which you, oh yes lucky you, saw three years ago when you were living the first day to end all first days as an intern. Only then, your patient with said skin condition ended up on hospice because her fragile skin would peel away at the slightest trauma, the slightest touch. Her IVs would fall out, and within days, her skin had been stripped to nothing so that she was a gob of gelatinous, bleeding, pussy, pile of bandages and agony. And on the first day, you, yes lucky you, get to see her in the Treatment room. And you sir, are tasked with peeling away her old dressings, and inevitably a majority of the most supperficial layer of her skin, so that by the end of it, you really wonder if maybe she looked better when she first came in than she does now.
Oh first days. First weeks. First months. Nowhere to go but up.
But thankfully, first days offer redemption. Like when you pick up the four year old boy and his eight year old sister who you think might have tuberculosis. Go ahead, pull the trigger. Start the workup, order the films, start the meds which may finally end the year-long cough. It's a start. It's something to build on. And while there weren't any big wins today, I think I'll start with this little one. Because truth be told, I think that I'm in over my head. I worry that I'm in over my head. I know that I'm in over my head. So I'll start treading water, and if anything, use this as motivation to be more and do more than I had previously thought would be good enough.
Because truth be told, I am literally in another world. And I'm starting to remember that in this world it'll never be good enough.
Oh first days. First weeks. First months. Nowhere to go but up.
But thankfully, first days offer redemption. Like when you pick up the four year old boy and his eight year old sister who you think might have tuberculosis. Go ahead, pull the trigger. Start the workup, order the films, start the meds which may finally end the year-long cough. It's a start. It's something to build on. And while there weren't any big wins today, I think I'll start with this little one. Because truth be told, I think that I'm in over my head. I worry that I'm in over my head. I know that I'm in over my head. So I'll start treading water, and if anything, use this as motivation to be more and do more than I had previously thought would be good enough.
Because truth be told, I am literally in another world. And I'm starting to remember that in this world it'll never be good enough.
Friday, August 22, 2008
Right-hand drive
Back in Houston, when we first met Kathy, we were asked what our
medical interests would be once we got to Maseru. Not having
specialists on staff, the new graduates were asked to pick a
particular role which they would like to fill in the clinic. There's
need across the board, but in the past, people have chosen to become
the resident expert on tuberculosis, outreach and suport staff
education, and epidemiology. I chose nutrition. I guess in my head,
I started romanticizing about what it would be like to "feed the
children"/tackle malnutrition in one the poorest parts of the world.
And of couse, I've started to realize that there's something
gratifying about feeding people.
So when we got our schedules a couple days ago, I guess I was kind of
expecting to have one loaded with time spent at QE2 (Queen Elizabeth
II Public Hospital). On the wards, PAC docs work hand in hand with a
local pediatrician, Dr. Pirri. Whereas hospitals in the states
are seen generally as the last stop when things get too bad to take
care of at home, it seems that QE2 has earned itself the opposite
reputation. Do everything you can to keep the kids out of there,
because if they end up on the wards, there's a decent chance that they
might not leave. Its also the last stop when malnourished kids are
unable to be treated at home or as an outpatient. After our intial
training is done, that's where I'll be headed next. Alone. It's got
me a little terrified, and as we sit here in the lecture room going
through current guidelines for everything from WHO Staging Criteria
for HIV infection to compliance training for the adolescent, I'm
scrambling to retain as much as I can. A lot of this material was
only mentioned peripherally in residency, if at all, and now as I
prepare to see it day in and day out, it makes me wonder how it'll
unfold. Time will tell I guess.
In the meantime we've been doing some shadowing with the vet PAC docs.
We follow them around as they pull patients into rooms and then try
to guess what we would do in that situation. I've been doing a lot of
guessing, and to be honest, I think I'm starting to get a handle on
some of it. Over the past couple weeks its been hard to keep things
in perspective, but I'm reassured by the fact that the fundamentals
for caring for a child in southern Africa are ultimately rooted in the
same foundation as caring for one back home.
Another surprise is how the days are filling themselves. Between
dinners and the weekly happy hour, most nights fly by. Last night
ended around 11:30 after 3 solid hours of South African Monopoly.
It's a little funny. All of the properties are listed in English and
Africans, and all of the currency has an extra pair of zeros to
accomodate for inflation. Tomorrow we head out to Bloemfontein where
we'll get a chance to pick up supplies in a South African chain
modeled after Target, and then we might get a chance to look for cars.
I myself had another big first today when Jeff, one of the vet docs,
tossed me the keys as we walked out of clinic. He's been trying to
sell his purple Volvo, and I guess I had coaxed him into a test drive.
Left hand drive on a manual transmission in the middle of rush hour
was entertaining to say the least, but we made it home safely, and
only after a handful of honks from other cars on the road. I kind of
felt like I was in driver's ed again. I was sitting straight up with
perfect posture and arms at 10 & 2, barely looking away from the road,
not even chancing a reach to turn off the heater which was getting
ready to lull me into submission.
In just a couple minutes we'll head out to Lesotho Sun for drinks,
then the chinese place Peace, (twice in less that two weeks!), and
then happy hour at a bar built into the big gym here. It's Jazz
poolside, or something like that.
medical interests would be once we got to Maseru. Not having
specialists on staff, the new graduates were asked to pick a
particular role which they would like to fill in the clinic. There's
need across the board, but in the past, people have chosen to become
the resident expert on tuberculosis, outreach and suport staff
education, and epidemiology. I chose nutrition. I guess in my head,
I started romanticizing about what it would be like to "feed the
children"/tackle malnutrition in one the poorest parts of the world.
And of couse, I've started to realize that there's something
gratifying about feeding people.
So when we got our schedules a couple days ago, I guess I was kind of
expecting to have one loaded with time spent at QE2 (Queen Elizabeth
II Public Hospital). On the wards, PAC docs work hand in hand with a
local pediatrician, Dr. Pirri. Whereas hospitals in the states
are seen generally as the last stop when things get too bad to take
care of at home, it seems that QE2 has earned itself the opposite
reputation. Do everything you can to keep the kids out of there,
because if they end up on the wards, there's a decent chance that they
might not leave. Its also the last stop when malnourished kids are
unable to be treated at home or as an outpatient. After our intial
training is done, that's where I'll be headed next. Alone. It's got
me a little terrified, and as we sit here in the lecture room going
through current guidelines for everything from WHO Staging Criteria
for HIV infection to compliance training for the adolescent, I'm
scrambling to retain as much as I can. A lot of this material was
only mentioned peripherally in residency, if at all, and now as I
prepare to see it day in and day out, it makes me wonder how it'll
unfold. Time will tell I guess.
In the meantime we've been doing some shadowing with the vet PAC docs.
We follow them around as they pull patients into rooms and then try
to guess what we would do in that situation. I've been doing a lot of
guessing, and to be honest, I think I'm starting to get a handle on
some of it. Over the past couple weeks its been hard to keep things
in perspective, but I'm reassured by the fact that the fundamentals
for caring for a child in southern Africa are ultimately rooted in the
same foundation as caring for one back home.
Another surprise is how the days are filling themselves. Between
dinners and the weekly happy hour, most nights fly by. Last night
ended around 11:30 after 3 solid hours of South African Monopoly.
It's a little funny. All of the properties are listed in English and
Africans, and all of the currency has an extra pair of zeros to
accomodate for inflation. Tomorrow we head out to Bloemfontein where
we'll get a chance to pick up supplies in a South African chain
modeled after Target, and then we might get a chance to look for cars.
I myself had another big first today when Jeff, one of the vet docs,
tossed me the keys as we walked out of clinic. He's been trying to
sell his purple Volvo, and I guess I had coaxed him into a test drive.
Left hand drive on a manual transmission in the middle of rush hour
was entertaining to say the least, but we made it home safely, and
only after a handful of honks from other cars on the road. I kind of
felt like I was in driver's ed again. I was sitting straight up with
perfect posture and arms at 10 & 2, barely looking away from the road,
not even chancing a reach to turn off the heater which was getting
ready to lull me into submission.
In just a couple minutes we'll head out to Lesotho Sun for drinks,
then the chinese place Peace, (twice in less that two weeks!), and
then happy hour at a bar built into the big gym here. It's Jazz
poolside, or something like that.
Tuesday, August 19, 2008
Comfort food
We had a long day of training today.
A little bit of epidemiology, mixed in with a little bit of public
health, and topped off with a whole lot of clinical care guidelines.
All in all, I'd say we were a little wiped out by the time we got done
with work. On the ride home, Paul, Meena and I hopped out of the van with Smita and the four of us spent the evening at Smita's house unwinding. One of my new habits these days is imagining what I would be doing at that very moment if I were in the states. It usually starts of with me asking someone to turn on the tv, (which none of us own), and then asking where we're going for dinner (especially difficult as we are currently sans car). Tonight's craving was pizza
and beer, and so when I half jokingly asked if someone would call in an order, I was pleased to hear a chorus of voices clamoring for the same. 45 minutes we were enjoying Scooter Pizza, topped off with pineapple, and beer purchased at the local hotel. After dinner entertainment including South Park streamed on Smita's laptop, followed by part 82 of our ongoing debate on the merits of a nationwide public health approach to HIV vs patient centered care (the
Paul Farmer approach).
A little bit of epidemiology, mixed in with a little bit of public
health, and topped off with a whole lot of clinical care guidelines.
All in all, I'd say we were a little wiped out by the time we got done
with work. On the ride home, Paul, Meena and I hopped out of the van with Smita and the four of us spent the evening at Smita's house unwinding. One of my new habits these days is imagining what I would be doing at that very moment if I were in the states. It usually starts of with me asking someone to turn on the tv, (which none of us own), and then asking where we're going for dinner (especially difficult as we are currently sans car). Tonight's craving was pizza
and beer, and so when I half jokingly asked if someone would call in an order, I was pleased to hear a chorus of voices clamoring for the same. 45 minutes we were enjoying Scooter Pizza, topped off with pineapple, and beer purchased at the local hotel. After dinner entertainment including South Park streamed on Smita's laptop, followed by part 82 of our ongoing debate on the merits of a nationwide public health approach to HIV vs patient centered care (the
Paul Farmer approach).
Monday, August 18, 2008
Welcomes
Today went generally pretty smoothly. After waking before dawn, (I
thought those days were over), I showered by candlelight - our
bathroom light only started working about an hour ago, and made my way
downstairs. Paul and I were picked up about half an hour later by
Dimpo. We made our way to clinic with stops to pick up John, and the
girls. Rolling into clinic before eight, we were greeted by awaiting
room was already full. Almost one hundred children and caretakers,
many elderly women who must have been grandmothers or distant
relatives, were huddled together, many wrapped in coarse colorful
blankets. We were greeted with a combination of curiosity, polite
smiles, and in some cases suspicion. I imagine we all looked a little
green, and I've come to realize that some patients get a little antsy
when they detect any hint of trepidation on the part of their
providers. And there was plenty of that to go around on our side.
8:30 sharp we reported to the waiting area and assembled for morning
prayers. Today was a little different in that the new staff, the six
of us, had to be introduced. And to herald our arrival, the entire
staff had assembled to sing a morning hymn. Usually a responsibility
relegated to patients, the fact that the staff wanted to sing this
morning had the veteran PAC docs buzzing. When they broke into a four
part harmony of literally the most beautiful song I've ever heard, I
was overcome with this incredible sense of well being. I think
there's something to be said about the power of song, especially when
applied to praise in a way that comes from a sense of knowing, and
longing, and joy. I envy other religions for that sometimes. Their
voices literally made the entire building resonate. I'm at a loss to
describe it other than to say it made me feel like I was stepping
inside from the icy rain, and being wrapped up in something heavy,
red, and incredibly warm.
Anyway, that was the highlight of my day, most of the rest of the day
was spent getting logistics out of the way and trying to salvage a
failed attempt at curried eggplant. Who knew you had to broil it in
the oven before you fry it up?
thought those days were over), I showered by candlelight - our
bathroom light only started working about an hour ago, and made my way
downstairs. Paul and I were picked up about half an hour later by
Dimpo. We made our way to clinic with stops to pick up John, and the
girls. Rolling into clinic before eight, we were greeted by awaiting
room was already full. Almost one hundred children and caretakers,
many elderly women who must have been grandmothers or distant
relatives, were huddled together, many wrapped in coarse colorful
blankets. We were greeted with a combination of curiosity, polite
smiles, and in some cases suspicion. I imagine we all looked a little
green, and I've come to realize that some patients get a little antsy
when they detect any hint of trepidation on the part of their
providers. And there was plenty of that to go around on our side.
8:30 sharp we reported to the waiting area and assembled for morning
prayers. Today was a little different in that the new staff, the six
of us, had to be introduced. And to herald our arrival, the entire
staff had assembled to sing a morning hymn. Usually a responsibility
relegated to patients, the fact that the staff wanted to sing this
morning had the veteran PAC docs buzzing. When they broke into a four
part harmony of literally the most beautiful song I've ever heard, I
was overcome with this incredible sense of well being. I think
there's something to be said about the power of song, especially when
applied to praise in a way that comes from a sense of knowing, and
longing, and joy. I envy other religions for that sometimes. Their
voices literally made the entire building resonate. I'm at a loss to
describe it other than to say it made me feel like I was stepping
inside from the icy rain, and being wrapped up in something heavy,
red, and incredibly warm.
Anyway, that was the highlight of my day, most of the rest of the day
was spent getting logistics out of the way and trying to salvage a
failed attempt at curried eggplant. Who knew you had to broil it in
the oven before you fry it up?
Sunday, August 17, 2008
Better and better
Lesotho has been growing on me in a big way. Yesterday Paul and I
walked down the road and caught a soccer/football game. Actually we
caught about two or three. All morning we had been hearing cheering
and the sound of a ref's whistle coming from over the hill. After
picking up supplies and getting back home, we realized that we didnt
have much to do. So we strapped on our shoes and made our way down
the hill. Instantly, all my concerns of being isolated were swept
away. As we walked through the fields and onto the hill that
separated two games in play, one a girls match, the other a men's
match that looked fiercely competitive, dozens of people looked our
way and said hello. A truck full of girls in the back of a pickup
even started shouting hello and singing a song for us. We got a lot
of attention. It's hard to say what was more entertaining: the
ongoing matches, or the subsequent celebration that followed every
goal, and ultimately, the end of the game. As soon as the whistle was
blown, a pickup would idle through the field making slow, tight
circles and onlookers would pile on and off the bed. Someone would be
blowing a whistle, another bellowing on a plastic trumpet, and another
would be waving a huge white flag. We couldn't figure out if this was
some kind of championship, or if every victory was herald with such
celebration, but it was fun to be an onlooker. With the setting sun
on our backs, I felt a little warmer, and much encouraged. It's hard
being in a new place. As I've mentioned before, the feeling of being
alone is especially pervasive.
With the night rapidly growing cooler we left the match and walked
about an hour through town and up a dirt trail that led to Friebel,
the main housing development where all of us will ultimately living.
We made our way to Meena and Lindy's, and then moved onto Smita's
house. By now it was dark and getting noticebly colder. As in any
desert climate, temperature changes happen pretty quickly and I've
been caught unprepared now a couple times. Walking through Smita's
doorway was literally like walking into a portal back home. Heaters
were on, the lights were up throughout her place, and music was
blasting. It didnt take long before we we're all giving in to Smita's
entreaties to stay for dinner - home cooked Chole. Over a candlelight
dinner we talked about the coming week and the transition we've been
making here. Just a couple of days ago Smita started tearing up at
happy hour. The rest of us had our own ups and downs and the impact
of the move started to really register. I think the hardest thing
that we've had to face is the feeling of total loss of independence.
Not having a car or means of regular transportation has been the
hardest. Actually I think my car lust is pretty much out of control.
Just twenty minutes out of town is Ladybrand, a South African border
town with a supposedly amazing vegetarian friendly restaurant that
everyone has been raving about. Smita went there with a couple
friends she used to work with here in Lesotho, and brought back the
most amazing chocolate mousse/cheesecake combo I've ever had. The
four of us at dinner polished it off as dessert.
Saying goodbye was tough, but we found ourselves right back over there
today as we met up for lunch. Yours truly made pasta sauce from
scratch. Afterwards there was dinner at a chinese restaurant at the
back of a chinese grocer. Our meal was punctuated by the sounds of
Chinese Karaoke. Apparently the textile industry is pretty big here,
with big manufacturers such as GAP buying garments from plants here.
In charge of those plants are the Chinese and they inturn manage low
paid Lesotho workers. Hence the Chinese are sometime viewed with a
wary eye. The restaurant itself was laced with iron bars and a
skeptical looking lady at the entrance. Just a few years ago, riots
has caused an even greater rift between the two communities.
I feel like eating, cooking, hiking, sleeping, and work will make up a
big part of living here. I can't wait for it to warm up though, the
views are spectacular and once things get setup, backyard parties are
apparently big. Barbecues are called "braai" here and much of the
social life here revolves around them. Thankfully I've stumbled upon
an abundance of fake meat/soy products here, including braai styled
links. Oh soy, I think I'm in love.
Tomorrow we head out to the clinic for our first day. My shirts are
pressed, I've got lunch in the fridge and I think I'm ready to go.
It's interesting hearing Kathy talk about the patient volume. Once we
pick up to full speed, each doc will see about 25 patients per day.
We work about four days a week, and have about 6 docs seeing patients at any time. So
thats about a five hundred patients a week. The compromise of course comes with standard of care. Kathy mentioned that its a fact that in order to see all those patients, you
have to get used to giving substandard care. Its hard enough to be
fresh out of residency without worrying about that, but this further
compounds that.
Over at a party we stopped by today, I picked up a book called 28
Stories of AIDS in Africa. Just a couple pages into it had me hooked
and got me really excited about the prospect of possibly, in some very
small way, being a part of the solution.
walked down the road and caught a soccer/football game. Actually we
caught about two or three. All morning we had been hearing cheering
and the sound of a ref's whistle coming from over the hill. After
picking up supplies and getting back home, we realized that we didnt
have much to do. So we strapped on our shoes and made our way down
the hill. Instantly, all my concerns of being isolated were swept
away. As we walked through the fields and onto the hill that
separated two games in play, one a girls match, the other a men's
match that looked fiercely competitive, dozens of people looked our
way and said hello. A truck full of girls in the back of a pickup
even started shouting hello and singing a song for us. We got a lot
of attention. It's hard to say what was more entertaining: the
ongoing matches, or the subsequent celebration that followed every
goal, and ultimately, the end of the game. As soon as the whistle was
blown, a pickup would idle through the field making slow, tight
circles and onlookers would pile on and off the bed. Someone would be
blowing a whistle, another bellowing on a plastic trumpet, and another
would be waving a huge white flag. We couldn't figure out if this was
some kind of championship, or if every victory was herald with such
celebration, but it was fun to be an onlooker. With the setting sun
on our backs, I felt a little warmer, and much encouraged. It's hard
being in a new place. As I've mentioned before, the feeling of being
alone is especially pervasive.
With the night rapidly growing cooler we left the match and walked
about an hour through town and up a dirt trail that led to Friebel,
the main housing development where all of us will ultimately living.
We made our way to Meena and Lindy's, and then moved onto Smita's
house. By now it was dark and getting noticebly colder. As in any
desert climate, temperature changes happen pretty quickly and I've
been caught unprepared now a couple times. Walking through Smita's
doorway was literally like walking into a portal back home. Heaters
were on, the lights were up throughout her place, and music was
blasting. It didnt take long before we we're all giving in to Smita's
entreaties to stay for dinner - home cooked Chole. Over a candlelight
dinner we talked about the coming week and the transition we've been
making here. Just a couple of days ago Smita started tearing up at
happy hour. The rest of us had our own ups and downs and the impact
of the move started to really register. I think the hardest thing
that we've had to face is the feeling of total loss of independence.
Not having a car or means of regular transportation has been the
hardest. Actually I think my car lust is pretty much out of control.
Just twenty minutes out of town is Ladybrand, a South African border
town with a supposedly amazing vegetarian friendly restaurant that
everyone has been raving about. Smita went there with a couple
friends she used to work with here in Lesotho, and brought back the
most amazing chocolate mousse/cheesecake combo I've ever had. The
four of us at dinner polished it off as dessert.
Saying goodbye was tough, but we found ourselves right back over there
today as we met up for lunch. Yours truly made pasta sauce from
scratch. Afterwards there was dinner at a chinese restaurant at the
back of a chinese grocer. Our meal was punctuated by the sounds of
Chinese Karaoke. Apparently the textile industry is pretty big here,
with big manufacturers such as GAP buying garments from plants here.
In charge of those plants are the Chinese and they inturn manage low
paid Lesotho workers. Hence the Chinese are sometime viewed with a
wary eye. The restaurant itself was laced with iron bars and a
skeptical looking lady at the entrance. Just a few years ago, riots
has caused an even greater rift between the two communities.
I feel like eating, cooking, hiking, sleeping, and work will make up a
big part of living here. I can't wait for it to warm up though, the
views are spectacular and once things get setup, backyard parties are
apparently big. Barbecues are called "braai" here and much of the
social life here revolves around them. Thankfully I've stumbled upon
an abundance of fake meat/soy products here, including braai styled
links. Oh soy, I think I'm in love.
Tomorrow we head out to the clinic for our first day. My shirts are
pressed, I've got lunch in the fridge and I think I'm ready to go.
It's interesting hearing Kathy talk about the patient volume. Once we
pick up to full speed, each doc will see about 25 patients per day.
We work about four days a week, and have about 6 docs seeing patients at any time. So
thats about a five hundred patients a week. The compromise of course comes with standard of care. Kathy mentioned that its a fact that in order to see all those patients, you
have to get used to giving substandard care. Its hard enough to be
fresh out of residency without worrying about that, but this further
compounds that.
Over at a party we stopped by today, I picked up a book called 28
Stories of AIDS in Africa. Just a couple pages into it had me hooked
and got me really excited about the prospect of possibly, in some very
small way, being a part of the solution.
Saturday, August 16, 2008
Touchdown
After checking into the Jo'berg hotel, I ended up watching several hours of obscure Olympic
sports like hammer throw, badminton, greco roman wrestling, and some
new sport that was the combination of basketball and soccer.
Yesterday morning had me on a quick plane ride into Maseru, and I have
to say it was a little different than what I expected. From most of
the city there are foot hills which obscure any clear views across
town. That being the case, you feel like you're in a much smaller
environment...say a small mountain side village. We call them "hill
stations" in India, because they are usually only accessible by train.
There is dust in the air and the occasional smell of wood and
charcoal fires. The resulting smoke and dust kicked up the wind has
led to a subsequent haze but by this morning, it cleared to blue
skies.
I had a nice little surprise at the airport meeting the COE driver,
Dimpo, (pronounced Dee' - po). Not knowing who was picking me up, I
walked out of customs and saw a man dressed in jeans and a baseball
cap holding a cardboard sign saying "Bailor." Granted it was
misspelled, but not seeing anyone else and assuming that this was a
common mistake or perhaps a local spelling, I walked up to the man and
said "Baylor?" He said, "Bay-lah" with a big grin. Satisfied I
started walking behind him. He offered to take my bag, but I thought,
no its ok. As we walked towards the exit, it dawned on me that maybe
he was here to pick up someone with the last name Bailor. I tried to
engage him in conversation, asking about the rest of the group and
their arrival and he just kept on walking. Just then two men, one
large with dreads, reaching several feet back, and a distinct American
accent, the other, I later realized, was Paul. John started yelling
at me "Are you Raj? Raj? Hey stop!" I turned and as John explained
to me what was going on, the guy with the cardboard sign ran off.
John explained to me that someone had been paying off the central
government and getting inside information as to when the Baylor docs
were arriving. He would then race ahead of their drivers and pick up
the unsuspecting staff. After loading them and their bags into the
car, he would drive off into the hills into some remote area and
demand a large ransom or threaten to abandon them up in the hills.
The police were helpless and no one had taken the threat seriously,
and in the past months several visiting residents and one doctor had
been kidnapped in such manner.
John is explaining all of this to Paul and I as we walked towards the
PAC vehicle. As I drop my bags in the trunk the man starts
approaching us pretty rapidly. I murmur to John, "Hey man, I thinks
that's the guy." John whips around, his dreads flying. Suddenly the
other man starts running towards the car screaming "Dats my car! Dats
my car!" He rips open the passenger door and starts pilfering the
glove box. John races around and starts talking in Basotho. A yelling
match ensues and the other man pushes John to the ground. I look at
Paul and he's standing there with a confused look. I figure I'm the
closest, so I start running to John's aid, not really knowing what's
going to happen next. Fists clenched am standing in front of the
assailant. There's a pause, I wonder, "what next?" Just then John pops
up and explains "No, no man its alright." The other guys breaks out
into a smile, gives me a hug and welcomes me to Lesotho. And that was
Dimpo. Apparently that's a scheme that's been long in the works and
John only now found the right victim. Apparently I was the one least
likely to freak out, and on the plus side, I got free drinks for the
rest of the night.
Most of the rest of the day was spent touring the office, meeting the
other docs, all of whom are really fantastic, and running errands such
as buying a cell phone and getting settled in. Last night we ate at
this really great Italian place with surprisingly good pizza. I went
to bed last night under flannel sheets, with a full belly, and a
little bit of optimism.
sports like hammer throw, badminton, greco roman wrestling, and some
new sport that was the combination of basketball and soccer.
Yesterday morning had me on a quick plane ride into Maseru, and I have
to say it was a little different than what I expected. From most of
the city there are foot hills which obscure any clear views across
town. That being the case, you feel like you're in a much smaller
environment...say a small mountain side village. We call them "hill
stations" in India, because they are usually only accessible by train.
There is dust in the air and the occasional smell of wood and
charcoal fires. The resulting smoke and dust kicked up the wind has
led to a subsequent haze but by this morning, it cleared to blue
skies.
I had a nice little surprise at the airport meeting the COE driver,
Dimpo, (pronounced Dee' - po). Not knowing who was picking me up, I
walked out of customs and saw a man dressed in jeans and a baseball
cap holding a cardboard sign saying "Bailor." Granted it was
misspelled, but not seeing anyone else and assuming that this was a
common mistake or perhaps a local spelling, I walked up to the man and
said "Baylor?" He said, "Bay-lah" with a big grin. Satisfied I
started walking behind him. He offered to take my bag, but I thought,
no its ok. As we walked towards the exit, it dawned on me that maybe
he was here to pick up someone with the last name Bailor. I tried to
engage him in conversation, asking about the rest of the group and
their arrival and he just kept on walking. Just then two men, one
large with dreads, reaching several feet back, and a distinct American
accent, the other, I later realized, was Paul. John started yelling
at me "Are you Raj? Raj? Hey stop!" I turned and as John explained
to me what was going on, the guy with the cardboard sign ran off.
John explained to me that someone had been paying off the central
government and getting inside information as to when the Baylor docs
were arriving. He would then race ahead of their drivers and pick up
the unsuspecting staff. After loading them and their bags into the
car, he would drive off into the hills into some remote area and
demand a large ransom or threaten to abandon them up in the hills.
The police were helpless and no one had taken the threat seriously,
and in the past months several visiting residents and one doctor had
been kidnapped in such manner.
John is explaining all of this to Paul and I as we walked towards the
PAC vehicle. As I drop my bags in the trunk the man starts
approaching us pretty rapidly. I murmur to John, "Hey man, I thinks
that's the guy." John whips around, his dreads flying. Suddenly the
other man starts running towards the car screaming "Dats my car! Dats
my car!" He rips open the passenger door and starts pilfering the
glove box. John races around and starts talking in Basotho. A yelling
match ensues and the other man pushes John to the ground. I look at
Paul and he's standing there with a confused look. I figure I'm the
closest, so I start running to John's aid, not really knowing what's
going to happen next. Fists clenched am standing in front of the
assailant. There's a pause, I wonder, "what next?" Just then John pops
up and explains "No, no man its alright." The other guys breaks out
into a smile, gives me a hug and welcomes me to Lesotho. And that was
Dimpo. Apparently that's a scheme that's been long in the works and
John only now found the right victim. Apparently I was the one least
likely to freak out, and on the plus side, I got free drinks for the
rest of the night.
Most of the rest of the day was spent touring the office, meeting the
other docs, all of whom are really fantastic, and running errands such
as buying a cell phone and getting settled in. Last night we ate at
this really great Italian place with surprisingly good pizza. I went
to bed last night under flannel sheets, with a full belly, and a
little bit of optimism.
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