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.