Thursday, January 29, 2009
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.
1/29/09Today 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.
Sunday, January 25, 2009
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
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.