Day 2 - a little better

My first Basotho thunderstorm is moving out of Leribe and the sounds bring me back to Huron City, my extended family’s Tip O’ Thumb Michigan haven. Oh, sweet, free, easy August!

I wrote in a journal recently, “I am someone whose thoughts are often on the future at some level of consciousness.” That can be a wonderful and balanced state of being but I also find myself fantasizing about being singularly focused in a Paul Farmer, slightly crazy kind of way. Even being a better student with a mind built for memorization and extensive differential diagnoses would be a good start at those wistful times. I give myself a hard time about that with some regularity but always circle back to my love of sanity and breadth; my true wish is to be a happy Renaissance woman.

I guess my favorite kind of sanity and breadth comes with those days or long periods that include feeling singularly focused on several activities I love in succession, like some high school day in 1995 that started with morning lacrosse practice, proceeded through beloved AP English with Mr. Pullman, lunch-time orchestra rehearsal, a double session of mouse dissection, and ended with club soccer practice, a Saxy Four rehearsal, and an overnight of laughing and arguing about the existence of god with my best friends. I think that was the last time I could list six things I did well and fill a day with them. I’ve always thought of sports and music as worlds in which I was forced to be in the present. And I think I need to have several active parts of life to feel like I can give myself fully to any of them. And therein lies Liz’s problem with medical school. Despite fighting hard for sanity and balance by injecting short bursts of athletics or friendship connections, for four years I have not had enough time to do anything else but medicine intensely enough to feel lasting satisfaction. “The rest of life” has been on hold.

This last two months of medical school, which I’m spending in Lesotho, is so damned different from what I’ve immersed myself in for four years that it feels like the beginning of that rest of life. And what on earth could feel more intensely present than learning from a friend how to do a femoral venous blood draw and then a spinal tap on a woman with HIV and suspected meningitis in a room full of sick women and their families in the middle of a small town in Africa where HIV prevalence is 30% and my TB mask strap is slipping slowly up over my head? Thank you, Kevin, for encouraging me through that and for helping keep the calm. There was the orchestral real-time coordination of encouraging the patient to stay in the right position, talking to her through the nurse/interpreter, handing equipment back and forth with Kevin while maintaining a sterile field, and inwardly acknowledging the intensity of the culture in the room which has seen the life expectancy cut from 70 to 40 in the twenty-three years since HIV arrived from the mines of South Africa.

Entering Motebang this morning I had that sophomore feeling of, “Oh this craziness? I know this craziness.” Day two of greeting nurses and families in Sesotho was mostly fun, not an opportunity to screw up. Day two of chickens wandering by the wards was familiarly funny, not distractingly odd. There are those chickens, again. Oh, those goofy old chickens! Building after building of really sick people became the organized surroundings of my particular patients for whom I had plans, not just a mass of awe-inspiring disease. This is not to say anything today was easy because it wasn’t. I still have to think through every tiny little step of my patient care, but at least I can start trying to do it myself, even if I have to track down Ethel or Kevin for every other step. Tomorrow maybe it’ll be every third. And they’ve both reassured me I can ask the same question over and over again until they leave Saturday. And next Monday I’ll start showing Joe, my friend arriving on Saturday, what we need to know.

In any kind of medicine autonomy helps. It’s much harder to take over care for a patient from a colleague than to greet the patient when they first arrive. If you get to take the initial history, ask the questions that make sense to you, establish a relationship with the patient as a primary one instead of being the substitute teacher trying to catch up on the goings-on of the first half of the semester, everybody feels better. Having admitted my first patient to Motebang I feel like I’m going to have a real job here. Even if I’m not ready for that job, I’m starting to have a sense of the goals, the players, and the tools.

Going into medical school I felt I had the paramedic advantage over many of my colleagues of being able to recognize “really sick” from “not so sick” which can be surprisingly difficult. Today, walking home from a skyped conference call to BU Family Medicine grand rounds (a big lecture) on the LeBoHA project, the three of us were talking about who was doing poorly enough that they might not make it through the night. I’m starting to recalibrate my sickness-meter. The question now is not, “who should be transferred to the ICU?” but whose bed may be empty in the morning? They would all be in the ICU at home.

Yesterday we did a transthoracic echocardiogram (an ultrasound picture of the heart through the chest wall) on a 16-year-old tiny, tiny girl with AIDS diagnosed at age 12 and newly suspected TB. Her heart was enlarged on a chest Xray so we took her to the archaic ultrasound machine and did our best, without a cardiologist, to make sense of the pathology of her heart. As her mother was pushing her wheelchair the girl’s head fell back to full extension and the mother had to walk snug up against the chair to prop the cachectic girl’s head up like that of a newborn. On the ultrasound table she lay flaccid and deliriously and repeatedly asked for her father. There is a cardiologist from Canada volunteering in the AIDS clinic on campus and we were hoping to consult with him today but this morning the girl’s bed was empty. I am recalibrating.

Again, I’ve stayed up too late making some sense of the day. There’s a spider in the bathroom and something large and mewing outside. Good night!