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.