Week 3

1/30/09
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.


1/31/09
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.

2/1/09
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.


2/2/09
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.

2/3/09
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.