Isolation

A driver. Really?

I step out of what felt like "hell" in the midst of a finished Queen II hospital experience and was introduced to the fact that I will be required to have a driver take me to my outreach site and stay the entire week with me while I am there. Safe- says some of you. Aww yes. Says I . Maybe safe because I have another Sesotho speaking person with me who can help fix a tire or get me out of the mud. But safe for my life? Well, that I can argue is a much different answer.

I was quite irritated to hear that I would lose my wonderful time spent on the mountainous hills, listening to whatever music I felt like, and allowing my brain to sift through whatever material came through its way. Then I felt the loss of independence as I would have to wait for the driver to come pick me up, late, and take me to wherever they day would send me whilst he slept or played games in the car. It actually felt quite silly to me. But the third loss what control. Here I had someone else who was deciding the destiny of my life as we sped around curves and cliffs putting my poor own life to risk. And I say to myself...A driver. Really?

Needless to say, the crankiness dissipated as Mpho and I met at 5:30 in the morning for our daily high altitude run. With the sun just warming up the land and the birds already up for hours, we headed down new foot paths to a long footbridge that went over a beautiful winding river only to have to crawl back up the mountain again saying "dumela" to all the Ntates already up. Then we would take the 1-2 hour journeys to all of the outreach sites meeting with the staff, helping with treatment and initiation of HIV medicines and training.

These unbelievable rides to and from my sites are probably one of my favorite parts of my journey to Africa. Children still run up to the road just to wave you by and sheep still try to figure out what a road is really meant for. The mountain ranges seem to go for miles even though I feel our drives are just that long.

I did feel the pain of any job where you encounter those who are not passionate about life or their job, and you wonder why they even bother since they try to make your life miserable. But you just find that child that makes you smile and it all seems to move on.

But with this job, it seems that with every good bit comes a piece of sadness. I lost a child this week. I was very sad, and in fact had to stop to let my tears flow. Unfortunately, this is one I actually had hope would make it. And, of course, these are the ones that you put hope into and feel like you have "caught" them just in time to only find out they are gone. This child came to me in the hospital. She had short hair and cherry red lips to match her fever of 105. You could just tell that she was uncomfortable. I, for many reasons, was concerned but her mystery diagnosis had me dreaming of her at night. Before I transferred her to South Africa to receive better care, I felt in my heart that she must have cancer and we were going to "save her" by having them diagnosis and treat it.

But, the email that none of us ever want to get gave me the date and time of her death along with all the efforts they did to save her. She did become an "interesting" case to them as well, but her loss became more of my memory than what she had. She would give me her arm so willingly as I would, yet again, try to replace another IV that had stopped working. Or trying to give her water as she so desperately would slurp it down wanting more. My resources were limited and the antibiotics I had seemed so minimal. But the thoughts just poor into your head- did I keep her too long? Could I have given her a treatment earlier that would have saved her? Could I have prevented her death?

Of course, I will never know. We did not have any of the resources they used in South Africa, but there is always the "what ifs". I know that I "did the best I could", but as a doctor it sometimes does not feel good enough. And you are just left to wonder. The guilt I can learn from and I do, or at least I try to. It makes you really sit down and think about that next patient that you don't want to die because of you.

In fact, that held true with a kid that came to me in outreach this week. Her arm dangling after falling with painful tears rolling down her dirty little face. She, in my eyes, had obviously dislocated her elbow anteriorly (not one we deal with as often). With the last child I had, they refused to go to hospital. So I tried my best to relocate it there. For days, that child haunted my thoughts with what the right decision was and I wondered if it ever went back. Fortunately, I just popped the girl and the mother in my car and we drove straight there to confirm the dislocation and provide analgesia to help her.

Emotionally, it has been a good week and month despite the sadness I carry with the loss of that child. I find the isolation from Baylor this month (whether it be Mokhotlong or my 3 week journey in the hospital) to be quite refreshing in moments like these. But it does make you feel isolated from everyone else who has been paralleling their lives at the COE. I am thankful to have people in my life that I can confide in and have put smiles on my face when I felt these moments of hardships hit me the most. It has been uplifting and comforting.

Queen II Hospital- Week 1

I have officially completed one week at Queen II Hospital- the main establishment in Maseru which is the capital of Lesotho.

I say that because as I round in the morning with the medical officers- I often drift off into space and count the cockroaches on the seeping walls wonder if there are more of them or more patients. The place would be condemned in the United States. I see a cockroach scatter across a baby's bed, on their food, in the cracks...they are everywhere. The babies sometimes share a bed, especially when we can't find room for them. The ceiling holds lights by electrical threads and the walls, I think you can see to the outside with the cracks.

HIPAA does not exist. I have tried. But the mother's sit on the bench next to their children and there is no privacy. The nurses may remember to check on a patient through the day or night, but the mother's are responsible to feed, bath, administer medicines to their child. And all the parents have for rest is the ground, or the hard bench next to the crib of their child. It's a mess.

Sanitation is a joke. But you try. I have gloves. That's a start. A mask in the TB ward is not heard of. In fact, you just give the children medicines and open the windows and hope your next PPD is negative still.

I have two patients that seem to stick out in my head and are worth mentioning.

My first is a 14 year old girl. She weighs 44 lb which gives you some inkling of the bones and skin that exist on this child. I have fought with her to take food and she has been a wild mess as to what she wants. I can't say too much more about her since I don't want to violate patient's privacy even though it does not exist here.

The second is baby death. Baby death was born a mere 5 lb. Mother stopped feeding the baby milk and started to use bread flour and water. The baby is 3 months old and weighs less than 4 lb. I think her weight is how much her bones, head, and organs weigh. There is nothing left. She came in grey, gasping, and with a very little heart rate. The only things we have to offer are bagging (thanks to NICU), some dextrose, warmth, and fluid. She decided she liked that, the first time.

After rehydrating her, we started feeds. She didn't like that and went back to dying. After I bagged her back and gave her more glucose she decided to live.

This morning, I walked by her crib and noticed her gasping like a fish out of water. No breaths. No real heart rate. And their sat the mom. Just watching her. I wondered if she just brought her to the hospital to die. She seems not so interested. But maybe that's the culture.

After bagging her back, checking her sugar and giving her more, adding more antibiotics than before and reassessing her bad line, I found a scalp vein and started her fluids once again. it's not like the fluids will save her. She needs food. But with her gut not probably getting the blood flow it needs, it's a tough spot to be in. We have no other way to feed her but the gut. But the fluid is giving her the sugar she needs now.

Well I will tell you how done I was with this child when I came back later and noticed the fluid had run out. Do you know what this means? Losing fluid means you practically lose your vein and access to this child! I had spent and hour finding that darn vein and now it was gone! I looked at the mom wondering if I should put any more effort into her child since she obviously was not. In this world of the hospital you teach the parents everything. I had to teach her about the fluid, the warmer, how to feed her child...etc. With the fluid, the instructions were...if this gets empty get a nurse! Your child needs this.

So for another hour I played with that same scalp vein fishing out clots with a catheter and finally getting it to work. I could not believe it. There the drips flowed from the bag to my baby death. Again- another small success.

With little left in my back pocket to use, I told the mother we are just going to have to start feeding your baby. This child will die if we don't, and maybe she will die if we do. But I can't chance not feeding her anymore.

It has been quite a week and there is the weekend and 2 more of these for me to have my fill on! I have so much respect for the medical officers who are doing it all in addition to running to the c-sections to assist in surgeries! At home, I feel that we have nothing to complain about. These medical officers are run to the ground. No duty hours making them go home at noon post call. And at night, they have to hold down all of the hospital.

That is QEII hospital.

Week 1.

Mokhotlong Revisited

I have secretly fallen for this rather desolate homely piece of the world! Spare me as I repeat the description of this district.

Set against the majestic Drakenburg Mountain Range with the highest peak over 11,000 feet (Thabana Ntlenyana). I drive over the smaller ranges of 10,000 ft to get to the town of Mokhotlong. It really was thought of as the most remote location in Africa, but now a road has been constructed all the way to the center. However, that is it. Even the road here has the occasional large pothole that will take out the bottom of your car, and is impassable in the winter with snow that can leave people without access for weeks.

But as I sit in the Senqu hotel and look out my door, there are layers of mountains that paint the background as the sunset creates various shade of blue. The children are laughing below as you can hear them running after each other trying to kick the ball between the two makeshift goals on the dirt. I watch everyone walking home from work, school, or just walking talking to each other on the goat paths with no fences that separate people's lives here. We lose that at home. The poverty here makes it impossible to find work and people just work hard to survive. The farms are packed against each other as people have to farm their own food in order to eat. There is not much here, and people often feel as though everyone including the government fail to remember that they are here.

The potential of Mokhotlong is here and there is already an amazing group of people already in place, if only people would stay. This area is so remote that they are unable to keep anyone, especially for how low their salaries are for how little it appear people seem to appreciate their work. People, in general, seem to only want out once they are forced in. But there are a few that have remained, mainly because they are from here. Mpho is my partner in crime and who I rely on to help me find information. She is young but with a great sense of humor that keeps me on my toes. She keeps everything going including me and has it all ready by the time I arrive every month. Siti, her sister, is the numbers girl and keeps all the statistics in line. She has been an amazing asset when trying to get a new clinic accreditated for HIV treatment, and the only thing that seems to hold this team back is the ministry. The clinics in the Mokhotlong district are "hole haholo" (Sesotho-far) and are so remote they can't even get Ibuprofen supplied in sufficient amounts. They send request to the ministry but will only see a response months later. It feels as though people are left with little hope but will do anything with what they have.

I can see the potential but this district, this country needs a voice. They need a change. And I feel like it all starts with the Ministry who runs this joint. The funding- is it really not there? There must be. Is it not odd that the government will guarantee HIV treatment suppplies to be readily available to all facilities (thanks to Baylor's voice and push) but they can't treat the daily events of pneumonia, pain, broken bones, etc. It's almost surreal. I met a boy whose arm he held by his side, deformed a bit from kids beating him. I could tell the elbow was out, but could not get him to settle to put it back in. The mother refused to go in because she could not afford the xray. The little I could do may have put it back together, but without painkillers the child refused to have me near him again. It made me realize how little we are trained for general medicine out here, and how much I want to help and find ways of improving this impoverished place.