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.