Tuesday, March 17, 2009

Birthing Stories

2/18: Today I got a chance to work with nurses in delivery again. I am fascinated by childbirth and I really want to work in the delivery room. I walked in and there were two women on the laboring tables.  The women were completely naked and each sitting on their own respective yellow trash bag. The trash bags are meant to catch any leaking amniotic fluid or unexpected excretions. My favorite nurse was sitting in the room watching the women. I walked in and took a seat on the counter in the corner so as to be out of the way.  The nurse and I just sat in the room talking about our families, childbirth, and men. As we sat there chatting the two women continued with their labor. I noticed that the women were having their contractions at the same moment. There are no monitors here and the nurses listen to the fetal heart tones with a fetoscope. This instrument looks like a cone and they just place it one the woman’s abdomen and listen. General monitoring includes listening every hour and doing vaginal exams every 4 hours. As the pains increased the women began walking around the room and holding their backs. Every few minutes when the pains came they would reach for the bars of the bed and brace for the next wave. The woman were completely naked walking around and pausing every now and then with the pain. The nurses let me do some of the vaginal exams on the patients so that I could learn. One of the women was HIV positive and the other was HIV negative. The mother without HIV had a considerably larger belly but both moms were at term.

At one point I was sitting on my own in the room while the nurse went to go care for a lady next door. While I was sitting there alone one of the patients surprisingly vomited and ruptured her membranes in the same instant. It was quite a surprise. The vomit was bright green and the amniotic fluid splashed onto my foot. There are times when crocs are good and other times when I wish I had chosen the shoes without all the holes in them. The first woman to deliver was the woman with HIV. I was assisting the nurse with the delivery and when she handed me the baby I was scared. It wasn’t breathing and looked very purple. I did what I knew how to do to resuscitate the baby. I used the bulb syringe to suction any of the amniotic fluid that might be making a breath difficult. I rubbed his back and hoped to stimulate him to cry. Nothing. The nurse quickly took the baby from me and brought him into the other room to be resuscitated. I was left alone with the laboring woman and she had not yet delivered her placenta. I stayed with her to complete the work of delivery. The placenta came out easily but the woman had a rather large tear. I waited for the nurse to return so that she could repair it. What had happened to the baby? Did it take its first cry yet?

After this delivery the other larger woman approached delivery quickly. The water had broken and the fluid was meconium stained. Meconium is generally an indicator that the baby is under stress and that the labor may be complicated. It is a greenish color and makes what is normally an essentially clear amniotic fluid tinged with a yellowish color. The head seemed to be stuck and the nurse was yelling at the patient. I couldn’t understand what she was saying but I believe it was something to the effect of “Push. Stop crying and Push”. The woman seemed to be giving up. The baby was centimeters from delivery and she just couldn’t push. The nurse was frustrated and as she was yelling at the patient. The nurse started using her hand to coax the head out. It seemed almost as if she was trying to get a good hold on the head so she could pull it out.

I was dumbfounded. Finally the head did come out and like the first birth the baby didn't cry. The baby was purple. Limp. I suctioned and suctioned. Nothing. This time I rushed the baby to the resuscitation room. The resuscitation room is no different from the delivery room really. There are no fancy miracle machines or treatments to save babies, it just allows the provider a chance to do what they can in a more controlled and quiet setting. The baby was very strong and kicking but it wasn’t breathing well and hadn’t cried. So the nurse pushed a foot pump across the floor to me and asked me to start pumping. My foot moved quickly back and forth on the pedal to power the suction. The nurse suctioned the baby’s nose, mouth and even feed the tube down the child’s trachea to get any secretions that were deeper down.  She did it rather forcefully and the secretions became slightly bloody. The baby wasn’t crying but was so strong and it was at least two times the size of the first baby. But she was a gray color. The oxygen we were giving did seem to pinken her up a bit. I wished that the other doctors were in the room to help us and I asked the nurse if I should go and get them. She quickly responded yes and I left the room in a hurry to find help. I walked to the conference room and popped my head in to look for Sebaka or Fadya. I saw Fadya and from the way she looked at me I realized that I was still wearing the plastic apron that the delivery nurses wear and that it was splattered with blood and that my shoe was covered in blood and amniotic fluid. She sensed the urgency in my face and followed me. As I was giving her the birth history we walked into the room. She was there and yet there was nothing we could do. We took out the intubation equipment but realized that even though we could visualize the vocal cords we had no intubation tubes and would not be able to suction the amniotic fluid out of her lungs. So we stepped back and looked. The baby was still grunting and hadn’t cried. There was nothing we could do. So we left the room and left the baby in the care of the nurse.  I came back a few hours later and found the baby alone on the exam table. The baby was crying now but still rather grayish and the nurse had taken off the oxygen. 

Thursday, February 19, 2009

Malealea: Horse Riding

Week 4

Morala: a basalt rock a laboring woman carries with her when leaving your home to make it to the hospital before you deliver.
I was undressing a woman in the labor room and I heard a clunk on the flour. I looked down and thought maybe I had dropped my reflex hammer. Instead when I looked on the other side of the bed I noticed a rock on the ground. I couldn’t imagine why this patient would bring a rock with her to the hospital. I picked it up and showed her the rock. She motioned for me to put it down on the table for her. When the nurse came back I asked her what the rock was for and she explained to me that women bring the rock with them from home. It is a special rock that they keep in their clothing until they get safely to the hospital. It is supposed to protect them from delivering the child on the way to the labor room. Once they get to the hospital the patient no longer needs the rock and discards it.
I have learned so many things in medical school and many of them are things I will never see. I saw one of those cases today. A 16 year old was brought in by her mother. She was in active labor. She was known to be pre-eclamptic. Pre-eclampsia is actually a common medical condition in pregnancy the world over. I have seen many patients in the US that present with swelling in their legs, protein in their urine and high blood pressure. I have cared for these patients and managed their deliveries. There is a certain sense of urgency in these cases. The babies need to be delivered rather quickly to avoid devastating outcomes. When my patient presented in labor she complained of headache and should have been started on treatment right away. Instead she was admitted and allowed to deliver. It wasn’t until after she had given birth that she had a seizure. She was seizing for quite awhile before she was finally started on the correct medication. After her first seizure she was no longer responsive. She continued to breath but she no longer had the ability to speak. The first time I saw her was the day after her first seizure. We checked her medications and discovered that the maintenance dose of the medication to prevent future seizures had not been given. The patient was also significantly anemic from all of the bleeding during delivery and needed a transfusion. Her blood type was O+ and there was no blood for her. Not one pint. Not even in the main blood bank in the capital of Lesotho. So there was nothing we could do. We asked her mother who was there with her if she could donate blood and she informed us that she was herself 6 months pregnant. She was holding her 16 year olds baby and rocking him back and forth as we talked. In Lesotho there is only one official blood bank and it is in Maseru. The government hospitals are very wary about blood banks given the pandemic of HIV. It can be completely frustrating because so many patients are anemic and in desperate need for blood transfusion. So we had to transfer this patient to the capital hoping that they would do something to improve her outcome but knowing that they would no be able to give her a transfusion and fearing that she would continue to be unconscious. This woman had had the dreaded outcome I had learned about in school. Something that I had never seen in the US. This was the end result of a seemingly simple complication of pregnancy. Who would care for her new baby boy?

Today we talked about abortions and I was amazed. In one day we had eight "incomplete miscarriages" and you wonder why. I have been talking with the doctors here and it seems that women seek out alternative abortions frequently and when they go wrong is when the hospitals see them. The doctors have said that on vaginal exams of these patients they find matches and leaves. Sometimes they can tell that the cervix has been manipulated and sometimes they have seen uteri that are completely punctured through. What has been happening is that the nurses watch the doctors do vacuum aspirations or D+C and then use this experience to open up their own practices outside of the hospital. They can then offer the abortion services at a much cheaper rate and in a much less safe environment. In the capital hospital one of the janitors was doing abortions in a hospital room and then just sending them to the doctors in house when things went wrong. This is very frustrating.

Wednesday, February 11, 2009

24 school children oh my!


The highlight of my day today was at the outpatient clinic. We showed up at 2pm ready to see patients. Caitlin and I being mentored by a doctor visiting from Ohio State. When we came in the door one of the assistants approached us and told us that she had 24 little children who have all had fever and cough since Sunday. The children were boarding at the primary school and had all caught the same illness.

I looked at her unbelievingly and thought Really? 24?. I suggested that we have them come into the room 4 at a time so we could see them in groups. The first four came in and they were so shy.  They each held their green Bukana with a temperature written in it that had been taken by the nurse. They weren’t actually very sick and only a very few of them had a fever. Even so, Caitlin and I examined every single one of them and wrote them all for Tylenol syrup.

The matron had these children very well disciplined and they were so good about letting us listen to their hearts and lungs. They also were very good about letting us get a good look inside their mouths. Probably seeing their peers go through the same thing and not come out crying made them feel a little more at ease.

One of the cutest was a little girl named Palesa, which means Flower in Sesotho.  She was only 2 and a half and was dressed in a green and yellow school uniform. She had been watching us examine the bigger children and she walked up  to my chair and without request began taking deep breaths just like she had seen the other children do. I didn’t even have my stethoscope out yet to listen to her lungs.  It was such a joy to see so many healthy young children at the end of a hard day. 

Tuesday, February 10, 2009

Today I saw a young man who was all painted in red. He was red from head to toe. Three men brought him in to the casualty department. They carried him into the exam room and lay him on the table. He was pale and hot to the touch. The red paint came off with the alcohol pad I used to clean his hand so that I could place an IV. The red paint is part of the traditional Lesotho medicine and is used in circumcision rituals. Part of the frustration I feel here is that many of my patients present after the Lesotho Medicine has failed. By this time the possibly simple and straight forward problem has been given weeks to worsen. This patient had a small wound on his right foot but when I touched his foot it was rock hard. Without the ability to drain the wound our only option was to start IV antibiotics and hope that he improves.

What an odd day. I began working in maternity with one of the Registrars. The first patient we saw was in labor and fully dilated but the baby was not descending. The nurse told us that the head was still very high and that the membranes were still intact. The registrar did a vaginal exam to assess the fetal position and after this evaluation decided to rupture her membranes to help the labor progress. The patient was lying on the table and we placed a black trash bag around her bottom to collect the fluids. First she tried to rupture the membranes with her gloved hand. That didn’t work so she asked me to get her a needle. I got an IV needle because it was considerably longer than the straight needle and thus had more chance of actually reaching the membranes. She inserted the needle into the patient’s vagina and easily ruptured the membranes. I just stood there dumbfounded. What if she had punctured the child on accident? After she ruptured her membranes I removed the trash bag from underneath the patient and carried the dripping bag to dispose of in the trashcan. Meanwhile, on the other side of the curtain a lady was in active labor. I had seen her walk in the door and lift herself up on to the delivery table. She was alone and undressed herself and suffered alone throughout the contractions. She began screaming and waving at me with her hands gesturing for me to come over. I was the only other person in the room but I was definitely not ready to deliver a baby on my own. I poked my head out of the door and called for Dr. T to come quick. Instead of Dr. T a young nurse all in white came. She quickly put on a plastic apron and approached the lady in labor. I came to stand on the other side of the bed to help out if needed.
There was a black plastic bag on the stand next to the patient’s bed. It had a roll of thick cotton wadding, a white towel and two pairs of sterile gloves along with the patients Bukana.
The Bukana is the patient’s medical record. It is a green notebook that holds a record of all her medical visits and treatments. There are no office files or central record. The patient is responsible for keeping their Bukana on their person and this is the only “chart” that doctors and nurses use.
I opened the bag as instructed by the nurse and started to unroll the cotton. When I turned around the baby’s head was already out and one more strong push and the baby was on the table. Luckily the baby came out vigorous and screaming. As the nurse clamped and cut the cord I began drying the little purple baby off. I was rubbing the feet and patting the back to make sure that the baby was alert and taking deep breaths. Another nurse came in at that point and we transferred her onto the clean towel and the nurse took her away. I was smiling and turned to the mother to say congratulations but she looked at me plainly and without emotion. The baby was out of the room. Then the nurse delivered the placenta and after it came she checked the patient for any tears or lacerations. The patient had been lucky and had none. The nurse then removed the plastic bag from under the patient and gave the patient a piece of cotton. The patient folded it into a pad that she placed between her legs. She sat up and stepped off the bed. She then used one of the white towels and wiped the blood off of the table that had escaped from the plastic bag. After dressing herself she walked out. This all happened in a matter of minutes. She left the labor room walking on her own and returned to her room. I couldn’t believe that this woman did all of this on her own. She had no one with her to help her or support her. It was the business of birth.
I left the maternity floor with Dr. T and had to return to my normal duties on the Female Medical Ward. I went to see my patients and one of my patient’s beds was empty. I had talked about sending her home the day before and assumed that someone must have sent her home without telling me. As I was writing a note on another patient I noticed the supposedly discharged pt’s daughter sitting on the bench across from me. I wondered what she was still doing at the hospital. After rounds one of the doctors told me that the patient had actually passed overnight. She hadn’t been sent home to continue with her life she had passed. No one told me and I didn’t know to say anything to her daughter sitting right in front of me. I felt so bad. I had told the daughter the day before that the patient was doing well and was ready to be sent home. The daughter had resisted and I had told her she was already on treatment and she could continue the treatment at home. By the time I had found out that the woman had passed the daughter had gone.
After lunch I caught up with one of the doctors and she told me she was going to be performing a vacuum abortion on a woman who was having a miscarriage. The procedure is known as an MVA here. The patient was called into the exam room for the procedure. I helped the patient get situated on the table and hooked up the straps to hold her legs up. For pain control the patient was given 50 of fentanyl. As the doctor started the procedure I knew that the 50 would not even touch the pain. The patient was staying quite still on the table but crying loudly as the doctor used the vacuum over and over again to evacuate the contents of her uterus. I couldn’t stand the screaming. I wanted to ask the doctor to stop, to end the patient’s pain. The attending doctor and I were each holding one of the patient’s hands as she cried in pain and I could see in his face that he too was uncomfortable with how things were progressing. When the attending doctor finally asked her why she hadn’t used a different procedure, under general anesthetic, she replied that she wanted practice with the vacuum and had chosen this procedure instead. My jaw almost dropped. In a place where we can do so little to ease the suffering of our patients she had had an option to make this easier and hadn’t taken it because she wanted practice. The screaming finally ended. I helped the patient off the bench and helped her to find her underwear. I gave her a piece of the surgical gauze to help absorb the bleeding. As she walked in front of me I saw a fresh blood stain across the back of skirt. I felt sick. I walked her to her bed and helped her in. Woman should not have to suffer like this. I felt like I was traveling back in time to when woman in the states would have to seek out back alley abortions because they had no safe option. I returned to the room and the doctor was washing the medical instruments. She was only using the hot water because the cold water faucet only has mud.

Last week four of my patients died. I didn’t send one patient home healthy. I sent them all home on stretchers. It wasn’t anything I did or didn’t do it was the pure lack of resources that lead to their deaths. My role has mostly been to be a witness to these patients suffering. I am with them at the end and listen to their words even if I can’t understand what they are saying. Some of my patients loose their ability to communicate towards the end and are unresponsive but others seem to be completely aware up until their last breath. I imagine that I would prefer to be aware until the end but it is so hard to watch. I have been working in the Casualty unit for a couple of days and it has been a whole new experience. I have become used to the patients that slowly die in front of me on the wards and haven’t had to be confronted by the more acute and serious injuries. On my first day in casualty I put stitches into a woman’s scalp. I am still very slow at stitching and not very skilled with a needle. The needle was so large that the doctor working with me scoffed at me as I picked up the needle drivers. He insisted that I just use my hand to drive the needle through the tissue. I was completely uncomfortable with that idea which is one of the reasons why I only did two stitches. Today in casualty I was working with a new doctor and watched him put four stitches in a man’s lip without any anesthetic. I couldn’t believe it. With each stitch the patient wriggled his legs and moaned. Most things are in short supply including Lidocaine so some just go with out.

Wednesday, February 4, 2009

Week 3

This morning Dr. Thabane was called to c-section so I was responsible for rounding on the female medical ward. It was quite a lot of patients but I felt like a woman on a mission. I saw almost every patient (about 16 in all). I wrote their notes and adjusted their medications as needed. It was good to be so autonomous but I sort of felt like a fake. That being said rounds went pretty smoothly with exception of my two patients with Acute Bacterial Meningitis. These patients are laying next to each other and present in the very same way. They are both out of their minds with infection. They have necks that are stiff as boards and the only response I get out of them occurs when I try to move their necks. Otherwise, they are completely non-communicative. Their hands seem to move with movement toward a particular goal but they are grasping at nothing. Watching their hands, I can only imagine that they must be actively hallucinating. As I am doing my rounds they will call out with guttural noises but little more. Sometimes I worry that they will fall out of bed but the neck pain must be so intense because they stay quite centered in the bed. I have had to replace their IVs twice now because they simply pull them out. They need the IVs to deliver the more potent antibiotic. Unfortunately, the only way to keep them from pulling out the IV is to tie their hands to the bed using bandages.
There was a new patient in the back of the room that I didn’t see. She was sitting straight up in bed shaking. She was trembling and stick thin. I didn’t have the strength to see her right away and instead waited for Dr. Thabane to return.
I left on today thinking that at least a few of my patients would die over the weekend.
Caitlin, my fellow medical student, had a horrible experience today. She went to the clinic looking for the other Residents so that she could help them out in clinic. Instead she found only one Lesotho Doctor who ushered her into a room to see patients. He was simply happy for an extra set of hands but didn’t listen to Caitlin when she said she was just there to meet up with the residents. The assistants brought in her first patient. She was taking the history from the patient’s family when she noticed that his breathing was getting very irregular and then she reached for his hand to get a pulse. He had none. She reached for the Carotid pulse. He had none. The other Doctor came in to help and pronounced him dead. The family quickly left the room without so much as a word from the Doctor. The assistants placed the body on the exam table and brought Caitlin into the next room to see patients.

Today we went on a hike with Dr. Fadya El Rayess and her son. It was great they picked us up and we drove 3 hours to the hiking location. It was in the town of Morija. Morija is home to the only museum in Lesotho. The museum is quite small and consists of one large room. Before visiting the museum we went on a hike in the mountains behind the Morija Guest house. It was essentially a scramble up the hill. It was very steep but at the top there is a rock with pterydactyl foot prints. It was so awesome. It was so great to get out in the open, away from sick people.

Today Caitlin and I were thinking about going on an exploration near Leribe but Dr. Elkin, who lives nearby, offered to take us on a hike in the mountains. It was amazing. We headed into the mountains with him and his wife and it was absolutely beautiful.
It is much more rural in the mountains and more traditional. The villages have chiefs and the chief distributes the land but the people don’t actually own the land. Members of my organization and others have approached chiefs to ask them to allow AIDS education and some chiefs are quite conservative and won’t allow them in to teach. This is only part of the reason Lesotho is so far behind in HIV care.
There are so many international aid organizations in Lesotho. I can tell by the many different land rovers I have seen driving in and out of the Capital. The UN is here, although I am not clear exactly what their role is. Doctors without Borders is also in Lesotho and is working to develop the nursing force. Partners in Health also operates out of Lesotho. Partners in Health was founded by Dr. Paul Farmer. They run a flying doctors service to the mountain villages.
After a long walk and drive we returned home. It was still early and much too early to hunker down in our little haven of a house. So we decided to go check out the market and see if anything was still open. We have walked along the main street many times before but today was different. We picked up a group of young boys along the way. Somebody has taught the children in Lesotho to say “ Give me money”. So these boys greeted us with “Give me Money” and “Good morning”. The greeting of good morning is used indiscriminately throughout the day and makes me smile when I hear it around 5pm. So these young boys followed us on our whole trip. It might have been more enjoyable in other circumstances but after a week of caring for dying patients it was a bit much. We just wanted to take a walk and get our minds off medicine. As we walked through the market I felt as though this group of young boys was herding us.

I walked into the Female Medical ward expecting the beds of at least two of my patients to be empty, or occupied by new patients. But when I walked into the room, that held eight of my patients, I saw that they were still there.
I have become much better at detecting the rise and fall of the chest since being here. I have fine-tuned this skill because I get nervous while making my way around the room that my patients will pass and I won’t notice. So I periodically look over at my sickest patients to see if their chest is still rising up and down.
I was making my way around the room seeing and examining my patients when I looked up to check on a very sick patient and noticed that she had vomited and now her breathing was labored. She was gasping for air. I didn’t know what to do. She was so ill and I expected her to pass but as she was dying in front of me I wished there was something I could do. I asked the nurse what could be done and together we rolled an oxygen tank in to give to her by mask. By the time we got the mask on she was taking her last breaths. She gasped and as I felt for a pulse I knew it wouldn’t be there. The nurse asked me to listen for heart tones. Nothing. She had passed. The nurse said, “Rest in Peace” and covered her face with her blanket. We placed a curtain around the bed. I didn’t know what to say or do. I waited and then began to feel sick. I left the ward and didn’t come back for a few minutes. When I had returned the nurse approached me and showed me where the patients daughter was. She was crying and I couldn’t speak with her. There was so much I wanted to say but I didn’t speak her language. As I stood there with my hand on her shoulder she was whimpering and using her fist to knead her abdomen. It was overwhelmingly sad but there was nothing I could do. I still felt sick and went to the only place I knew I could be alone, the bathroom.
I returned to the ward and jumped right back in. I collected blood to run a blood count on yet another pt with AIDs and Meningitis. As I withdrew the needle I used my gloved finger to apply pressure to stop the patient’s bleeding at the puncture site. I couldn’t find the gauze at the time and used only my gloved finger. I slid the needle out from the patient and it passed under my thumb. In that moment I felt so stupid. What if I had punctured the glove and pricked myself? Well I didn’t, there was no hole in the glove and no way I could have broken my own skin but in that moment I felt so scared. I took the blood to the lab and returned to the conference room. I found an IV needle and a pair of gloves in the supply room and re-enacted the situation to make myself feel more at ease. I slid the needle under my gloved thumb many times before I was semi convinced that it would be very difficult to penetrate the glove and my finger. I have been looking at my thumb often to inspect it for any irregularities or any defects in my number one protective barrier, my skin. Of course there were none but I just realized how fragile life is and how scary it can be.
To top the day off we headed to clinic after lunch. The outpatient department is not extremely well run. The patients basically show up throughout the day and get in line. They come from all over and many travel very far to come. There are no appointments, the doctors just see patients until there is not more line. People could wait hours to be seen and there is no real organization. So Dr. El Rayess and I manned one room and began to see patients. After Caitlin’s experience the week before the staff made sure we were well supervised. We saw many patients but the one that left a lasting impression was the 10-month-old child brought in by her grandmother. Looking at the child I thought she looked more like a 2 month old. She was so small and had a clinical finding they call “saggy bottoms”. The Lesotho Doctors use this to describe the loose skin on baby’s who are malnourished. The first thing I noticed was that her head moved like it wasn’t attached to her body and that her left eye kept pulsating back and forth to the corner of her eye socket. A physician practicing in the states might think that the child simply had a lazy eye but after working here you would more likely suspect meningitis or possibly TB meningitis. The child could very well be HIV positive.
You might wonder why these very small infants are suffering from malnourishment. Well here is part of the reason. A lot of the Lesotho women work in textile factories. In fact, Gap has a factory outside of town that employees many women. The GAP name is not written on the building, as I doubt they would appreciate the attention. The workers are only given one unpaid month off after giving birth. This makes it almost impossible for women to breast feed longer than a month. Many women cannot afford the expensive formula for the child and some might not have the electricity to boil water to make the formula with. When the mothers return to work the children are left to be cared for by their grandparents who prepare the formula with tap water. In a country with reliable tap water this might be ok but in Lesotho the water is contaminated and must be boiled before drinking.

I think I have mentioned that the pharmacy formulary is very limited here. Well today it became even more limited. We were alerted that the antibiotic we depend on for treatment of meningitis is out of stock. They just don’t have it. So for my patients with acute meningitis I have to try a completely different antibiotic and hope that it offers the same coverage. I have many patients who already have very severe anemia and my second line antibiotic causes aplastic anemia so what am I supposed to do? What antibiotic can I offer them? At the hospital right now we have absolutely no medications to treat yeast infections. In fact a patient might go for days without antibiotic before the nurse will tell you that it has been out of stock.

Thursday, January 29, 2009

Neonatal Resuscitation

My Second Week


Today was my first Monday at the hospital. I was prepared for disappointment. I had been told that many patients would die over the weekend and to be prepared for that. Well, I showed up and none of my patients had died. In fact two of my patients were ready to go home. How encouraging. My other patient, Mampheng, that had been quite confused was now actually responding to the majority of my questions.  I had formed relationships with all of my patients and some of their family members. Lerato, my patient with AIDS and TB, was so sweet and when I told her she was going to be able to go home soon she smiled and asked for my card. 

After speaking with my patients the nurse, working with her back to me, asked me why I did not greet her. Her English was not so good and I couldn’t understand what she was saying at first, which made it even worse once I realized what she was saying.  I was trying not to bother her because she looked busy and I didn’t know what to say when she confronted me. It is interesting how different things are here.

After rounds my bags finally arrived from Johannesburg. I was delighted. It was like getting presents. I had packed one large suitcase filled with supplies for the hospital. It was quite a mix of things. I gave the medical supplies that had been donated by Beth Kouba to the wards and they were very impressed with the safety feature on the IV needles. In Lesotho there are no safety features on the needles. After you draw blood you then use the same syringe and needle to puncture the tube and insert the blood. This can be quite hairy considering the amount of pressure required to puncture the seal on the tube and the fact that 100% of the patients I care for in the hospital have HIV. So needless to say Beth’s needles have been quite appreciated. 

My grandma and grandpa gave me a set of books published in Berkeley titled “Where there is no Doctor”.  I gave those to the public health interns who work in the community.  My father got me supplies as well and I gave the penlights he bought to the new Lesotho Doctors who had none. He also got me tourniquets, which were also well received as they simply use a rubber glove instead of a tourniquet.

The stethoscopes and Blood pressure cuffs I brought were given to Mama Kara. Mama Kara is a very bright and hopeful nurse who is starting a nursing program and will use the gifts as incentives for nurses practicing in Lesotho.




It was a very hard day at the hospital. The Female Medical Ward was packed with patients. Every bed was filled. The Nurses were pressuring us to discharge our patients and the frustrating thing was that in the US these patients would likely be in an Intensive Care Unit for weeks. I am very thankful that none of the patients I have been following personally have passed. They are continuing to get better which is encouraging. That being said there are other patients that are dying all around me. We had been following a woman with hirsutism and uncontrolled blood sugars and we were befuddled by the persistent tremor in her left hand. She was started on Metformin to help with sugar control and to possibly treat PCOS. I don’t think I ever heard her speak. When I came in to work today I asked where she was and was told by the patient next to her that she had passed. There was a new patient in the bed she had occupied for two weeks. Given her abnormal hormone levels and presentation it was presumed that she had some sort of brain tumor which hemorrhaged resulting in her death. Unfortunately, we have no access to a CT here and so we will never know what caused her symptoms let alone her death. Today was a very hard day for the visiting OB doctor from Boston University. He had a mother with an intrauterine death during an attempt at labor. The baby was dead for 10 hours before he could get her to the OR and once he did he said he was essentially removing a decapitated fetus from the uterus of the mother. While he was in the OR with this patient another mother was laboring in Maternity. This mother was Eclamptic and had already had one seizure. Caitlin and I were advised to go and check on the mom to let them know to contact the resuscitation team when the mom was completely dilated so that they could attend to the baby.  The birthing rooms were like nothing I had ever seen. The mother was on an old gray exam table and the table was partially covered by a piece of thick plastic, the kind you might use to protect furniture when painting. There were three nurses standing around her and on the instrument table there was a very large wad of cotton. The cotton is used to cushion the baby as it comes out and to absorb the fluids and blood. It is their “sterile field”. We left shortly after letting the nurses know that we were standing by. The nurses didn’t actually contact anybody until the baby had been born and not crying for 5 minutes. At this point the doctors rushed over and the baby regained color and began crying. Caitlin and I went to see the baby after things had calmed down. The baby seemed to be quite vigorous and he was crying desperately from hunger. The baby was still in the resuscitation room and no one had brought him to his mother yet. 

On another note a very exciting thing is happening in Lesotho. Nurses are being trained to administer the first doses of Gaurdasil in any African country. This will hopefully decrease the cases of HPV and Cervical Cancer. The program is funded by Merck and has been put together by the LeBoHA program that I am working with and the Peace Corps. This is an amazing and excited time. The launch date is 2/20/09.




Today we talked with the Lesotho Doctors about how they approach discussing death with their patients and their families. I have noticed that the Doctors here do not talk to their patients much. Morning rounds are very quick and there is little time spent talking with the patients about how they are feeling. Even less time is spent discussing the patient's prognosis with the patient’s family. This has been very sad because at times I feel like the tender caring of patients is all we can do.  The Lesotho Doctors say they don’t talk about death with the patients because they don’t want to take the patients hope away.  In some way if they acknowledge that a patient is dying then they have admitted that there is nothing that they can do to help. For instance if a baby is born and is unlikely to live they take the baby from the mom and bring it to the resuscitation room until it passes. Generally they are not actually doing resuscitative measures but simply allowing the baby to pass without the mother present. The perception is that they are saving the mothers the sadness of seeing their babies die.  It seems that it might be more helpful for long-term closure to allow the mother to be with the baby when it passes.




Today my patient with meningitis passed. Her name was Mampheng and she was HIV positive and only 37 years old. She just died. I was talking with her yesterday. I remember worrying about causing her pain as I was drawing the blood to cross match her for the transfusion she would never receive. I came in today and the forms for the blood request were still in the outgoing request box.  I think that as I saw her getting better I felt like she was going to make it.  I thought she had a chance. Her mother sat everyday by her bed and was responsible for most of Mampheng’s care.  She feed her, gave her medications, collected the wheel chair to take her to X-Ray and delivered her blood samples to the lab. She was very kind and would try and teach me phrases in Sesotho.  She also made me laugh everyday. I will miss both of them.

Tuesday, January 27, 2009

Sunday, January 25, 2009

Golden Gate Park South Africa



I was so frustrated today. The nurses do no listen to me and I don’t know why. Maybe they think I am to young or maybe they are just to busy or jaded. Turns out my patient with drug induced hepatitis has been taking her efavirenz the whole time. For the past four days she has been taking the medication that is causing the problem she was admitted for. I am so frustrated. This is crazy. I wish I could speak with these patients and then I would be able to care so much better for them instead I survive on hand gestures and pieces of English.

After this frustrating experience I found my second patient with an infiltrated IV line. Her whole hand had puffed up two times normal and looked horrible. It was huge. Why didn’t she say something to the nurse why didn’t someone do something?

My other patient went to the HIV clinic yesterday and waited for four hours but was turned away because they didn’t want to see her while she was still in the ward. The doctor came over and told me that although my patient was recently diagnosed with AIDS and her CD4 count was 9 she did not need to start with the ARV training right away. She made it clear that starting ARVs is not an emergency and can wait. I guess I should have waited until she was ready for discharge and then sent her over but my patient was so motivated to start the process. I felt like there was so little I could do for her and this was something in my reach. I could send her to the HIV/AIDS clinic and maybe get her started on ARVs and that would be a success.

On our way home we came upon a group of young girls as we were entering the convent. The young college students live in a hostel the convent runs for young girls far from home. Their names were Mosa, Ledoll and Stao. Mosa was quite entertaining and outspoken. We spoke shortly and then were going to go home but Mosa insisted that we come see how they live. She grabbed Caitlin and I’s arms and dragged us in the direction of their home.  We walked past our little house and down the path toward their house. I only knew that that their house existed by the noise that would come from the hostel at very late hours. The whooping and laughter coming across the convent would keep me up at night. As we approached the building young girls were playing tag outside and running in an out of the gardens. The old building was two stories and clearly had seen better days. The entrance had a ledge above the front door and there where three women sitting up there chatting.  The place seemed to be teeming with young women. The smell didn’t hit you until you entered the building and worsened as you walked up the stairs to the dormitory. The smell of human feces was overwhelming. It was horrible and I couldn’t believe how poorly kept the house was. The girls who live in this house do their own cooking and washing and recieve little guidance from the sister that manages the building. The group had grown as we reached the top of the stairs and now we were surrounded by young smiling women and when Caitlin took out her camera the decibels increased by 100%. The dormitory was filled with bunks and accommodated 52 girls. It was unbelievable and a stark contrast to our little house. Mosa put a very large brimmed yellow hat on my head and wanted to take a picture of me with her cell phone. I posed with my usual funny face and they laughed and giggled again. We were escorted out by the young ladies and they asked us to come back.


Today we went hiking in South Africa with Phil, Sandy and Rick. We left the convent at about 9am and headed out into the countryside. We crossed the border in Ficksburg. We all had to get out of the car and have our passport stamped in South Africa and then we headed toward town. At the boarder crossing there were lots of people selling squash and I even saw a guy wearing a M. Jordan shirt. I had been talking with my father in the morning and he had particularly wanted to know about the squash and M. Jordan t-shirts. So as I saw both in the same minute I smiled. When you cross the border into SA there is a dramatic change. There is clearly much more infrastructure as evidenced by street signs at every intersection. In the town of Ficksburg there were tons of Africanns and it was weird to see so many white people.

The drive from Ficksburg to the Golden Gate National Park was beautiful. It was the same countryside as Lesotho but along the roads there were crops of neatly planted corn and large tractors rolling the hay. There were no herders for the sheep or cows as the livestock was fenced into their pastures. The landscape was impressive. The flat topped mountains were painted in reddish streaks of brillant color against the radiant green of the grass on the plains. The sun came in an out behind the clouds and created spotlights on the mountain tops. A team of bike riders passed by in their kits speeding by the small shacks where the farm workers were selling peaches. We went on two hikes at the park. One of which took us to the very top of one of the mesas and another which took us into a narrow canyon carved out by years of water and wind. As we walked we saw evidence of the baboons that live in the park. After the park we also went on a game drive. The game that inhabit this park are zebras, elands, antelope, and wildebeast. We sadly only saw one wildebeast and one eland.

After our visit to the park we went to Clarens. Clarens is a very fancy pants town with art galleries and coffee shops.  It’s claim to fame is that it is frequented by Brad Pitt. It was wild being there. I felt almost awkward as we walked through the square of this very ritzy town overflowing with white tourists each accompanied by a Mercedes Benz.

Thursday, January 22, 2009

Photos 1/21/09

Dr. Elkin and Dr. Long and ME

Photos 1/21/09

-Caitlin Outside of Motebang
-OBAMA Inaguration Leribe, Lesotho
-Our house at Convent of the Holy Name

My First Week


Today was my first day at the hospital. We went straight from the office in Maseru to Motebang where the district hospital is. There are two hospital systems in Lesotho the Government hospitals and the CHAL(Christian health alliance Lesotho) hospitals. The city of Leribe is home to our hospital and the second largest city in Lesotho. We drove up to the hospital and were waved through the gate by the attendant. The hospital is set up in a square of buildings connected by covered walk ways. The wards are separated for Men and Women patients. There are medical and surgical wards for men and women teamed by the same few doctors but separated by sex. As I walked onto the hospital grounds I wished my luggage hadn’t gone missing and that I was armed with my white coat, hand sanitizer, gloves, and mask. It is amazing the security that one feels with that white coat on. It says to the strangers staring at my white skin and blond hair that I am here to help and in my mind encourages a trifle more respect from my on-lookers. As we walk the halls men, women and children greet us with “hello, how are you?” and “I love you.”. According to the local young women I am traveling with it is rude not to greet people as you pass by. This comes hard for a woman who is used to staying safe by not encouraging conversation with strangers. There is a group of doctors in the lounge getting ready for patient presentations. The 5 young men sitting around the table are the young Lesotho residents who offer hope to their country as future doctors who can provide care in the patient’s native language. The three white doctors are faculty from Boston University. Phil and Fadya are full time faculty who will spend a full year here preparing and mentoring the young residents and Rick is an OB from BU who has come for three weeks to work. After rounds Caitlin, a fellow BU medical student, and I went to find lunch. Across from the hospital is a dark store labeled grill and bakery take-away. The smell of horse manure filled my nose when I entered and made me suddenly not hungry. The menu was fried dough balls, French fries and for the adventurous sausages. I asked for a Fanta and had some fried dough balls but couldn’t bring my self to try the sausage. It turned out that this was a wise choice as Caitlin, the more adventurous, had the sausages and sorely regretted it the next day. We returned to the hospital lounge for an afternoon lecture and then I returned completely exhausted to the Holy Name Convent where I will be living during my time here. I am living in a small house on the compound with a fellow BU med student and could barely keep my eyes open as I walked in the door.


I woke at 5am feeling a little disappointed that I hadn’t slept more and already feeling a headache coming on.  But it was beautiful outside, a perfect temperature. After a little bread and tea fro breakfast Caitlin and I headed to work. The hospital is a very short walking distance from out guest house at the convent.  I have been trying to prepare myself for the types of patients that I will see in the wards here. I expected TB and AIDS but as a medical student from the US this meant little to me. I had only followed one patient with AIDS in the US and maybe two with possible TB.

Our first thing for the day was to go with the group to do an ultrasound on an OB patient to look for a possible twin gestation. Seven doctors with white coats pilled into the room where a patient lay on an exam table. Half the table was covered with a sheet and half with a black trash bag and the patients body was covered in a fading teddy bear towel. We began the ultrasound but we were limited by the amount of petroleum jelly and were unable to do a full profile of the child. I don’t know if I can explain the frustration one can feel watching a novice do an ultrasound with an experienced technician standing by trying to in the same moment mentor the technician and teach a room full of doctors and students. The conclusion was that this was not in fact a twin gestation.

Then I headed to the wards with Dr. Thabane and Dr. Elkin. Dr. Elkin, a BU faculty member here for one year, was eager to give me some sort independence and structure and assigned me to two new patients on the ward. As I walked into the small room I was the only person wearing my N95 respirator. It seemed that the other visiting physicians had given up on this practice and no longer bothered. My first patient was an HIV+ 18 year old female who recently had a baby by c-section and who now presented with a two day history of acute onset right sided body weakness and facial asymmetry. I read the admitting note and jumped in. I quickly found out that the patient had also been unable to speak since the incident and all the questions I asked were answered by her sister who was as her bed side.  The patient was alert and followed my directions but she couldn’t respond and her whole right side was limp and immobile. It seems that she may have had a stroke or possibly CNS vasculitis associated with her HIV status. Feeling completely discouraged and unable to offer any comfort to my patient or her sister but simply stating that I would be back I moved on to my next patient. In my head thinking “I will come back with the real doctor”. 

The next patient was an HIV + 46 yr old woman with TB who had been on medications but had either chosen not to taken them or been unfortunate enough to have a drug resistant TB. As she coughed I was happy I had chosen to wear my mask. She spoke a little English and had a sweet smile. I took a peak at her chest X-ray and wasn’t surprised when I saw the evidence of diffuse TB disease. She had been unable to eat for days and looked quite weak. As I was caring for this patient a young women entered the ward and promptly began seizing. She was guided to the ground with the help of one of the Registrars. I looked down at her as she extended and shook and saw the saliva creeping from her mouth and wondered what I could do. Where was the phenytoin? Where is the diazepam? Was she aspirating? Was her head protected? She was moved to a bed and didn’t receive any phenytoin until she had been seizing for 25 minutes.

The flow of the day was a little disrupted by this and I didn’t present my two patients to the attending doctor until much later. I still managed to feel completely inadequate when forming my differential diagnosis and couldn’t remember basic drug names. After rounding with the team I stayed on the ward and finished things up with Dr. Thabane. While watching her place an IV in my older patient the woman in the bed across the room began barfing and sat bolt upright in her bed staring straight ahead. Her temples sunken from the ravages of AIDS and her limbs stick like.  I didn’t jump in to offer my poor blood drawing skills when the doctor offered me the opportunity. I know that one must always take universal precautions when drawing blood, or doing any procedure for that matter, but I have very limited experience placing lines or taking blood and I just didn’t want to take a stab at it when the prevalence of HIV is so high.  After finally finishing our work we headed to the conference room and as we listened to a lecture on OB ultrasound I heard singing from the devotional outside.



I have a feeling that as the days go on I will have less and less that I can write about my clinical experience. People are dying. Today a nurse said to me “Come back in 40 years and there will be no one in Lesotho. We will all be dead.”.  The young people keep contracting HIV and people are delaying the start of Anti-retrovirals (ARVs) and not using condoms. I visited with my two patients from yesterday and after many conversations with the sisters on the ward and the matron of the hospital I found that it would be almost impossible to get a head CT for my 18 yr old pt with an infarct. The only CT in the country is in Maseru. Maseru is an hour and a half by car and my patient has no way to pay for the ride to the hospital or to pay for the CT which if she was able to get would cost her 20 US dollars.  She is being cared for by her sister who knows a little English and helps me to communicate with a mute patient who only speaks Sesotho and can’t understand English. After discussing this with the Docs here it seems unlikely that the CT in Maseru is even working. Even if the CT was working patients can not be transferred unless they can pay off the hospital bill here and like my patient many can not afford this. I wonder if a transfer is best for her. She likely has an incurable stroke and will not benefit from any of the treatment she receives miles away.  Maybe she would be better of going home and being cared for by her family and not making the possibly useless trip alone.

I met a new patient today. A 37 yr old woman with large decubitus ulcers and likely Meningitis. The pt told me through the interpreter that she just lost her husband to AIDs and will be burying him in two days. She seemed delirious and her hopeless eyes lazily wandered about the room. I couldn’t tell what she had and decided to order a blood count to see the extent of the infection although given her history of HIV this might me meaningless. During rounds today we ran out of syringes and Dr. Thabane had to collect this patients blood with a needle and then allow it to just drop into an opened tube. The patient held her hand impressively still as she watched.

I also visited the Tsepong HIV/AIDs clinic today. We saw six or seven patients. The patients are scheduled for visits about every three months. At their visits their ART pills are counted and then given a score on their adherence to the regimen. We are hoping for a solid 100% adherence.  To start ARVs patients must take a class and a test on the material they learned. This is to ensure that patients will understand the importance of taking their ARVs faithfully.  In Lesotho there is the first line treatment and then a much more expensive second line treatment and that is it. In the US there are third and fourth line treatments and although adherence is very important in the US it is not so devastating If the patient is unable to comply with their first treatment. I observed and felt humbled and again depressed.


Monday, January 19, 2009


It was early when we left the mountain top. Only 3am. Dark but still warm from the abnormally warm winter days in southern California. After cruising along PCH and making our way down Lincoln we arrived with plenty of time at LAX. I quickly checked in and had my bags checked all the way through to Maseru. Looking at the tags as they traveled down the belt I saw the bold letters MSU and thought it would be a miracle if I actually saw them again. My first leg was LAX to Atlanta and quick 4 hour flight and the begining of a two day journey. In Atlanta I found my next gate and double checked with the counter that my bags were going to make it on board and I was assured that they would find me in Maseru.  I was still not convinced that they would. I found my seat and was next to a very straight clean cut ex-marine. We had a very uncomfortable political conversation which was mostly me holding my tongue not wanting to make an enemy of my neighbor for the next 20 hours. He turned out to be some sort of contractor for US shipments of missiles and spoke constantly in very vague terms about his job. As if he wanted to show off.  
We landed in Dakar, Senegal after our first 8 hour leg and the plane was refueled and re-stocked with food. We also had a visit from the Dakar security and every seat cushion and overhead luggage container was checked. All I saw of Senegal was the dark night sky and the lights of the city. 
Then another 8 hours to Johanesburg but this time to avoid more awkward conversation and to catch up on sleep I gave up on my natural methods and took an ambien. In Jo-Burg I found my hotel shuttle and was pleasantly surprised by the accomodations. I requested a second floor room facing the courtyard as I had been told that a student before me had been chloroformed (is that how you spell it?) in her sleep and robbed of everything because her room was on the ground floor and facing the street.  Needless to say it was hard to fall asleep. To make matters worse the rooms had no alarm clocks which ended up not making any difference because I didn't sleep a wink the whole night. 
The next morning I found myself once again on a 3 am journey to the airport for my last flight of the journey. I was much to early for my flight and entered an eerily dark and completely unoccupied international terminal. I found the counter for South African Airlines and sat down on the ground to wait. The terminal which had been so bustling yesterday was now quiet but not quite peaceful. After a minor snafu at the ticket counter concerning something about my ticket being closed, I acquired my boarding pass and another guarantee that my bags where going to be on the plane with me. We landed on a small air strip and the country around us was beautiful. It seemed to be much like a high desert with green grass and mountain tops reminiscent of New Mexicos mesas. During the flight the passengers had been talking excitedly about Obama and inaguration day and I felt so proud to be from the United States. A pleasant contrast to my feelings after sitting next to my ex-marine. After a very easy pass through customs I waited next to the belt and was not surprised when I didn't see my bags pass by.  Apparently this happens about 50% of the time and I am expecting my bags hopefully tomorrow. I was picked up by one of the staff members of the LeBoHA (Lesotho Boston Health Alliance) Program and we entered the town of Maseru. Driving through the streets it was hard to believe that almost 30% of this population has HIV/AIDs.  The streets were broad and children going to and from school were dotting the sides of the road. After 15 minutes we arrived at the LeBoHA office which is where I am comfortably sitting using WiFi and writing this blog.