The clinic, the hospital, the LP that never was

I spent most of today on the TB ward with Dr.E. We rounded on a few patients who were in a shared room with 6 beds. Most with HIV/TB coinfections. The first man had lost vision in his left eye from uveitus from TB infection, was being treated with steroid eye drops. The second had Potts disease, or TB infection of the spine. He had made remarkable recovery, from paraplegia to being able to walk on his own. Interestingly, he was HIV negative. The third had TB and HIV coinfection with off the charts viral load, but appeared to be doing relatively well.

Dr.E had clinic afterwards, in a room across the hall from the TB ward. He was seeing follow ups from hospital discharges: Disseminated TB that had an open poorly healing abscess in a woman’s groin, TB/HIV/COPD trifecta that had been complicated with a pneumothorax, pediatric reactivation of chickenpox after starting hiv treatment.. He also saw patients who had special requests, like a woman being treated with peripartum cardiomyopathy who was there with her mother, requesting a temporary discharge to go home and “slaughter a goat”. They wanted to do a ceremony to try to rid her of evil spirits that were causing the disease. Dr.E said no. He was concerned what would happen to her treatments while away, or what alternative treatments she might get. She was upset and left the room, but sitting there upright on the bench, you could see her distended neck veins pulsating. Dr.E seems to know a decent amount of Zulu but had a nurse help translate once in a while. Some of the patients also have a fair use of English, understanding a word or phrase here and there.

Dr.E is an incredible doctor. He seems like one who goes the extra mile for all patients. Much of his time was spent calling doctors directly to make referrals (standard here, but very frustrating when phones don’t work reliably), making appointments, and tracking down missing lab results. All over phone. He is conscientious, holds people accountable and thorough. What’s amazing is that the doctors here are able to do so much – like the others, he will also do c-sections, we took a look at a womans uterus with the ultrasound, and he’s seeing kids as well. 

In the late afternoon I went to the ARV (antiretroviral) clinic and worked with Dr.M. We saw a woman who had LOE, LOA, LOW (loss of energy, loss of appetite, loss of weight). Her BMI was 16 and she had lost over 10 kg over 2 years. He suspected she was no longer responding to her HIV meds but sent her to the hospital for expedited workup to rule out other opportunistic infections including TB, considering how weak and sick she looked. 

Dr.M had been on call the night before and spent the morning with a reporter who interviewed him about XDR TB (which was first described at this hospital; The Church of Scotland Hospital, or “COSH”) and seemed a bit tired but very kindly gave me a tour of the hospital. During the tour he stopped to say hello and chat with a maintenance worker in the hospital, joked with nurses, checked in on a lady he admitted a while ago who was doing well and being discharged. He is the founder of the NGO that shares space with the hospital, and is the South African host of my international elective. He seemed as sharp and compassionate as Dr.E, with a warm heart and soft voice. And laughing eyes! More cliches but all true! He is santa claus!

At the end we ran into one of the British doctors who are here for a year. He is interested in IM/Crit care but also is doing some training in ER. The British and US systems are different but he and I are probably close to equivalent levels in the big course of training, although he seems to have more generalized skills (e.g.general anesthesia). He thinks his system puts more emphasis on clinical work (“service”) rather than education. He was outside trying to figure out where the lumbar puncture results were on a young man who had come in with altered mental status but quickly recovered with antibiotics and was eager to be discharged to write a school exam. If he couldnt track down the LP results, he was considering whether he’d need to repeat one, although it was already after so many doses of antibiotics and could be falsely negative. I offered to do the LP, but he would have to supervise me since I haven’t had much experience with them. Since our intervention radiology departments back home are so great, it often becomes in the patient’s better interest to have the radiologist do it rather than a learning resident. But it does end up costing more and takes away learning opportunities. I’ve only gotten to do them late in the day or in the middle of the night after radiology has gone home. So we don’t get many chances to do them back home, and when we do, they are often really tough to get (larger patients than here). Anyway, it still felt a little evil to put this poor guy through another LP which might not even be helpful, so the British doctor went to the lab to see if we could track down the results. We weren’t hopeful. But with minimal information, they were able to produce the results from the original LP. I was pretty impressed, it had been done days ago and it’s all paper documentation. Lucky patient. For me, I was promised that there would be many more chances to do LPs.

They are doing amazing things here with minimal resources. It doesn’t run smoothly always, but then again, it doesn’t always run smoothly back home either. I can sympathise with the amount of non-medical troubleshooting these doctors (and all other healthcare staff) have to do moment to moment, and how frustrating that can be. Hours on the phone, painfully sifting through books of paper charts… I wonder if they are burnt out or if they feel they are making a difference. To me today, as an outsider looking in, they really are.

P.s. There are some posts from the weekend that I havent published yet because the internet here is struggling to upload the photos. But they will be up eventually, possibly without pictures. We’ll see!