Come to me, sweet weekend!

Tapiwa, Joe, Liz at the snazzy Leribe Hotel bar, awaiting our food delivery from across the courtyard.

Oh man, did I ever need that beer and pizza and episode of pan-African soap opera tonight at the Leribe Hotel.

I decided today that the source of my week-two woes is my new-found sense of responsibility for my patients here. I can’t really stand the fact that I know my new patient is dying. I hate knowing that. I first met him and his brother yesterday morning when I went to round on my existing patients. He looked like s#%t so I went to his bedside first, putting off exams of patients who might last the month. He was covered in beads of sweat and small skin lesions, his chest nearly frothing with perspiration, his eyes sunken but following my movements as I honed in on him impersonally with purpose, stethoscope, and penlight. It was clear from the foot of the bed that, if he needed to move at all, he was moving his entire head and torso as one fixed entity, a give-away for the stiffness of his meningitic neck. This was trouble.

His brother explained, over the course of the next day, that the patient had made a lot of money in the mines, thought he was above the AIDS clinic that catered to the needs of the poor, had drinking and marital problems, and hadn’t been taking his anti-retrovirals or his TB medications. I know people the world over die of shame and denial in their own ways, but this is so much more stunningly obvious to me than all the smokers in the U.S. thinking that their deaths won’t be the choking, gray-skinned, barrel-chested deaths of their neighbors from whom they turned their heads. This is AIDS, folks, don’t you get it?! This isn’t COPD when you’re 82. You’re 42 and supposed to be seeing your kids through middle school! Diamond money doesn’t buy your way out of this crazy-ass scourge! This makes me angry, apparently...

Unfortunately, I like this patient too, and I like his brother: two facts which have made the last couple days hard. Phil advised me today that it was ok to create a little distance between me and the patients since there are so many cases where there’s nothing that can be done. People present so late in their diseases here that hospital treatment can seem like hospice without the mutual understanding of the outcome. I guess that discrepancy is my mistake to sort out over the next four weeks. I don’t yet think of hospitals as places to go when all else fails, when there are only last-ditch efforts to be made. I want hospitals to be places stocked full of nurses and doctors and pharmacists who can use their art and well-researched tools to help people lead long, healthy lives. Maybe I need to spend a few days in the maternity ward and see some healthy babies who, because their mothers were treated properly, won’t contract HIV.

Today he’s doing worse. The nurses who hourly threaten to ruin my mood with their passivity told me that they could gather neither oxygen tanks nor IV fluconazole and that I would have to do that myself if I thought it was worth it. Choosing to explain my reasoning –the poor man has candidiasis (another fungal infection) down his esophagus so can’t swallow your damned pills-- instead of yelling at women whose source of apathy I can’t pretend to understand, let alone stand above, I went to the AIDS clinic in search of anti-fungals for cryptococcal meningitis. The patient’s brother was already sitting at the front of the long line of patients and, while we waited for the pharmacy assistant to get us a couple precious days of fluconazole, we had a sweet ten-minute talk about his brother’s condition. He asked me if there is hope. My healthy-American-upper-middle-class-product-of-a-family-where-people-die-at-the-right-ages-heart screamed, “yes!” but I tempered that with the experience of my two weeks here and said, “Yes, I have some hope”. I also told him straight up that his brother was extremely sick and that the next couple days would tell us whether he would get any better. I told him that I thought this medication was very important and that it might help. I told him that I was giving him medication in case the meningitis was caused by bacteria, tuberculosis, or fungus, and that I was also giving him medications for the infection in his lungs, perhaps a combination of poorly treated and now drug-resistant tuberculosis and PCP, an AIDS-associated pneumonia.

I can’t really imagine that he’ll make it and I think that made me sad all day long.

A young woman died Tuesday from sepsis after I thought we were saving her. She was the young woman from whom I had stolen oxygen last week for the seizing mother. Her mother’s wails when I told her that her daughter was at the end and the aggressively insistent efforts by other patients’ family members to make her drink water made my neck tense and my eyes sear as I stood from crouching at her feet to avoid the spill. A young man died Wednesday from aspiration during the induction of anaesthesia before abdominal surgery for a suspected bowel obstruction. He had seemed quite well though may not have understood how serious I was about not eating all the food his wife had brought him before surgery; I explained it several times. Was it the food? Was he already septic before anaesthesia? Did something react with an herbal remedy he’d taken? Did he have an unknown allergy? His red-eyed and beautiful wife seemed overly grateful to me as I filled out the death certificate the next day.

Reality check: two of my patients seem super boring right now because they only have tuberculosis and HIV. They’re gonna go home, take their TB meds, and likely be OK for a good while. My prisoner patient with crazy anemia (hemoglobin of 1.7) probably doesn’t have a massive GI bleed but only had a reaction to his AZT. He’ll go back to prison on a replacement medication and do well… and he’s had a relaxing break from jail.

Joe and I planned out most of the next five weekends here, filling them with dinosaur footprints, rappelling adventures, pony trekking, an Easter long weekend to a bike-friendly game park in Swaziland with public health interns, and national park hiking.

It got way late again. I’m gonna pass out now. Nicholas: I’m SO excited I’ll get to see you play Bottom i-ham-bing it up in early June. Xo, Liz