The process

Wow, I love Charlie Haden and Pat Methany’s Beyond the Missouri Sky album so much. I also love peppermint tea with a dash of 2% milk. This might be a short entry. Sorry, mom, but I am staying daily so you can hardly complain.

Seven momentous days in a row is a lot to handle. Today my first patient died. When Mdate (“mister”) L. came into the hospital on Tuesday he seemed like the healthy guy on the ward. He was having some difficulty breathing but could speak in full sentences of broken English, helped by his lovely sister, could walk to the bathroom without oxygen on and, with a brave smile, told me to pull the tourniquet tighter to expose his prominent veins to draw his blood. Like nearly every inpatient, he was HIV+, but had the relatively high CD4 (immune cells preferentially decimated by HIV) count of 138 a couple months ago. A count under 200 designates AIDS and puts people at risk for serious opportunistic infections that I’ve never seen in the States, like PCP (Pneumocystis Carinii/Jiroveci Pneumonia), Toxoplasmosis, and Cryptococcus, but CD4 counts in Lesotho tend to be ridiculously low, so he seemed in relatively good shape. He was a smiley and tender 32yo man who had worked as a driver until September, when he had started wrestling with bouts of fatigue that precluded work. He also had some bilateral nontender facial swelling, broken blood vessels on his tongue, an enlarged heart, and some very recent blurring of distance vision. His difficulty breathing was his most serious problem so, using our limited formulary, we gave him antibiotics and steroids to cover possible PCP, antibiotics for community-acquired pneumonia and a possible oral infection (which might explain his salivary gland swelling), collected sputum samples which did not reveal tuberculosis buggies, and he seemed to be getting better.

This morning Phil picked us up at the convent house (he lives in a neighboring houselet) and we swung by the Leribe Hotel to get a visiting family medicine doctor from Blomfontein, South Africa, who is a specialist in tuberculosis, and drove to the Maluti hospital. I was seriously bushed and read Don’t Let’s Go to the Dogs when I couldn’t muster conversation in the truck. She gave a helpful lecture to several residents, doctors, and us visiting medical students on pediatric TB and, after a short tour of the Maluti facilities we picked up a hitchhiking nurse and headed back to Motebang.

I thought my female patients were pretty stable, so I went to the Male Medical Ward to round on Mdate L. The nurse, whom Ethel had warned me was potentially senile and certainly unhelpful, was leaning into the window onto the patient room as if she were watching a Little League game. I introduced myself to her before I followed her gaze. She then said, “One of the patients is ill.” I saw that the brother of a very, very sick patient was standing at the head of Mdate L.’s bed wiping his mouth. His head was slumped onto his chest and the kind brother was wiping trickling saliva from his lips. As soon as I saw his irregular gasps I knew he had turned a really bad corner. (Jeez, I just wrote “coroner” by accident; thanks, Sigmund). I listened to his lungs which were junky and infrequently used, listened to his heart which was strong but somewhat irregular and 40 beats per minute slower than it had been the evening before, and was unable to feel a radial (wrist) pulse, a clue that his blood pressure was likely lower than maybe 90 systolic. I sat him up, put oxygen on him, and went for a bag to help him breathe and IV supplies while Ethel went to get Phil. The supplies are terribly hard to find, since they’re in short supply and erratically placed around the ward. I managed to find IV supplies but no bag-valve mask.

I had tied a glove around his biceps (for lack of a tourniquet) and was about to start the IV when Phil arrived and, when he said, “I don’t think that will help” I immediately knew he was right. Mdate L. seemed remarkably comfortable despite his brainstem-driven agonal breaths so we held his hands, kept his oxygen mask on, and listened to his heart and lungs every few minutes. I stepped away to speak with his sister, who was looking on wide-eyed from behind the male nurse who had gathered potentially helpful supplies. (The female nurse stood by silent and remarkably inactive for fifteen minutes before retiring to her desk; what?!) Kevin and Ethel had told me about the ways that the Basotho people seemed most comfortable (not) talking about death, so I put my hands on the arms of Meh L. and said, “I’m so sorry, Meh, but your brother is critical. He is close to the end and there is nothing we can do for him.” She scrunched up her face and said, “Is he gone?” I said, “Not yet, but soon I think he will be.” She sank towards me a little, turning her face towards the outside window and cried a very little. I told her she could stay or leave, whatever she wanted and, making sure she was steady on her feet, let her walk into the hallway with the other sick man’s brother at her side. For the next half an hour Phil and Kevin and Matheko and I stood holding the man’s head and hands and just being with him as his breaths and heart beats got farther and farther apart. A couple minutes before his last heart beat he pulled his left arm towards his body, protruded his tongue a little, then relaxed one final time. It was good to be there with him.

After we had removed the oxygen, closed his eyelids, and pulled his blanket up to his chin Matheko helped me talk to his sister and her husband. I squatted down at his sister’s feet and, trying to feel out what she wanted to know, explained a little that his lung disease had gotten so bad that trying to help his heart would have been a futile effort. Looking calm and resolute she said, “Thank you, doctor. I am satisfied.” I walked with her to give her one last look at her brother then wrote the final paperwork, including the traditional “R.I.P.” at the end of my last note. I found out later today that the family had told Matheko they had lost a sister just last week. What an overwhelming disease this is for this little country.

The rest of the clinical day was long and inefficient but allowed me to feel useful and even to feel nice connections with patients and nurses. And what a comfort it is to take care of patients with friends. A girl who was stung by bees developed hives and low blood pressure but responded well to medication and never had airway problems. Fadya left me with her to track down medications, keep her IV open (despite the crap-ass cheap plastic tubing which kinks if you look at it funny), and decide when it was safe to leave her for the night. It was nice to be trusted. Kevin and I took turns trying to place an IV in an older woman with terrible veins. Something was therapeutic about the focused task and I felt a disproportionate rush of satisfaction when he finally found a good vein and the saline we attached flowed easily up her arm. Small victories. The mother of the young woman who had vomited on her nasal cannula and been moved to the isolation room to die overnight grabbed me in the hallway and beckoned me into the small converted storeroom. The girl was sitting up and smiling at me with a light in her eyes I certainly hadn’t seen when I stole her oxygen for the seizing mother yesterday. I got tingles down my spine and the mother clutched my shoulder and said, “You doctors work so hard”. I had a hard time finding my voice to say, “I am so happy to see your daughter looking so strong”. Just then an old woman lost control of seven chickens in the hallway and somehow wrestled them into two cardboard boxes now empty of IV fluids. The heaved the boxes onto a nurse’s cart and rolled the cart outside while the nurse yelled, “She’s stealing our cart!” and we busted our guts laughing. I gave out only one more sticker, a shiny dragonfly perched on a daisy, to a 5yo girl with a secret shy smile who then tried to place the sticker on the face of her infant brother papoosed in a blanket on the back of their amused mother.

The visiting doctor gave us another lecture, this time on neonatal care, and I had to change position in the warm room every ten seconds to keep my eyes open. All of us-- students, residents, and attendings-- seemed to be fighting the sleepies despite the quality of the talk. We all seem wiped out. This is hard work, even for those used to it. After a little evening email session a couple public health interns dropped us at the Pelican where we picked up the same old chicken and rice take-away meal and strolled, sipping our beers, back to the convent to eat dinner and play Bananagrams to the soothing voice of Johnny Cash. Ethel and Kevin finalized details for their upcoming tour of Southern Africa while I knitted for Miss Cletus the Fetus and reached my goal of transferring to my second skein of yarn before Coach Ethel’s departure. In a strange way, all is right with the world (except that Kevin’s Smartwool socks are missing from the laundry line, a problem which is comforting in its pettiness). Tomorrow I’m hoping to start two patients on TB medications, get another tested for HIV before she transfers to a smaller hospital closer to home, and send bee sting girl back to school in her uniform, hopefully in time for us to get a ride to the women’s weaving cooperative before it closes. And this weekend I will sleep. Good night, Liz