Patient Encounters

I wrote this blog in darkness (other than the light of the computer screen, which luckily was fully charged.)  The power went out just at the end of dinner.  Julia, Raheel (my roommates for the week) and I were just finishing a pseudo tex-mex meal.  Anyone who has ever lived with me knows that I subsist largely on bean burritos.  In the States this means black beans and corn spiced with garlic, oregano and red pepper flakes and topped with cheese, salsa and avocado (if I have it), all wrapped in a large flour tortilla. Yum! I had that meal probably at least once a week for the last 10 years or so.  So it was much to my dismay to find that there are no black beans and no salsa in Botswana!  I thought there were no flour tortillas either; but I discovered them this past week in Gabs and felt it was a sign to try to recreate the bean burrito I have been craving for four months.  I did bring some black beans back from the states, but they are dried and require much time to make so tonight it was mashed kidney beans.  I even made guacamole – as there are plenty of cheap and good avocados (though lacking cilantro – another thing not available here).  It was a delicious meal and just as I was finishing my last bite all the power went out.  What great timing, it’s kind of exciting to be in darkness though I guess we are cheating since we have the help of numerous flashlights (aka torches).

 Ok enough about dinner.  Since it is dark, it seems like an appropriate time for some patient stories. 

 On Monday we had finished clinic and as we were walking out the nurse said “Ngaka Leah (Dr. Leah), wait there is one more” So Julia and I went back and began to see the patient.  One more turned into three as 2 other patients showed up.  Finally a woman and man entered the room carrying a baby.  It turned out they were there for the woman’s appointment, but upon further questioning they mentioned that the baby had been referred for evaluation too.  The baby was 8 months old, but the size of a newborn.  Upon reviewing his chart he had not gained any weight in the last 6 mths (a time when babies have extremely rapid weight gain).  He was also severely developmentally delayed as he was unable to roll over (a skill acquired at 4 mths) not to mention unable to sit or babble (6 mths skills).  As we began to examine him more, we grew more worried.  He was febrile and breathing faster than normal.  He had very sparse hair growth, lack of fat on his buttocks, and dermatitis (all signs of significant malnutrition).  He needed to be admitted and worked up for meningitis, TB, HIV, and re-fed. 

Given that it was after hours, and only one medical officer covers the entire hospital, we knew that if we did not begin the work-up it would be a long time before any attention was paid to him.  After bringing him to the wards we began the long process of convincing his parents that a lumbar puncture was necessary.  This was a hard sell as they believed that lumbar punctures cause paralysis.  Eventually the father agreed and the mother, though still not fully aligned, said that we could not say she had refused.  Of course there were no lumbar puncture kits in the hospital. After much searching, a spinal needle was located as were some regular blood collection bottles which (a call to the lab confirmed) could in fact be used for spinal fluid as well.  We found some sterile gloves and Bedadine and were in business.  As I opened the spinal needle I realized it was like no other I had ever seen, it was more than twice as long as the baby!!!!  But you gotta make due with what you have, so I went with it.  All those lumbar punctures in the St. Chris ER paid off. One stick, and many mins of waiting until the fluid finally dripped to the end of the longest needle ever, revealed a nice clear fluid which turned out to be a champagne tap, as they say (no red blood cells).  Two and a half hrs after seeing this "last patient" of the day, we had finally sent the rest of the blood work, ordered antibiotics, and high calorie feeds for the child and set off towards home.  The next day he was already looking much improved though he still has a long way to go to catch up on growth and developmental milestones. 

 
On Wednesday after giving a lecture on growth in Mahalapye, one of the medical officers came up to me and said that he needed me to see an outpatient and guess his age.  It was an unusual request as usually patients or their parents already know their birthdays.  It turned out that about 8 months ago a baby was found near the railroad tracks in town and brought to the hospital.  No one knew where he came from, his name, or his birthday.  He remained in the hospital for sometime (though luckily turned out to be medically fine).  After much searching for his parents or extended family, he was discharged to a potential adoptive mother.  But in order for the adoption paperwork to be processed he needed a birth certificate and that required a birthday.  Enter the pediatrician.  They wanted me to guess his age.  After watching him walk and asking some other questions about his development I guessed that he was somewhere between 13-16 months.  But that wasn’t good enough, they wanted a month.  Okay probably 14 months.  So says the potential adoptive mom that means September 2008?  Yes, that sounds about right.  “Okay what day?”  After much back and forth trying to explain that I understood that he needed a birthday, like all the other children, but that there was really no way to say exactly what month he had been born much less what day; I told her to pick her favorite day in September.  I documented my estimations and explanations and referred her to social work explaining that this was really a matter for the courts as they would have to go about creating a birth certificate.

 
Thursday brought us to Palapye.  The "inpatient wards" there are two of the most dismal, depressing, and dirty rooms that I have seen.  There were 3 patients in one very small room.  They were all severely malnourished.  One was a 1.5 year old girl who weighed 5.8 kg about what a 6 or 8 mth old should weigh.  She had not gained weight in the month long hospital stay and finally last week they tested her for HIV and found she was positive.  She had not yet been started on antiretrovirals because they were trying to work out the social situation.  Finally her grandmother had agreed to take primary responsibility, had attended adherence classes and was ready to start.  But then the hospital clinic said that she needed to be started at her local clinic.  This sounds like a great idea, having patient's go to the clinic that is closest to their house.  The problem is that these clinics are not well staffed.  The one closest to her house only has a doctor on Mondays and never dispenses meds.  The patients who are seen there have to wait all day to see the doctor and then make their way to the main hospital pharmacy where they wait in line again to receive their meds.  Not a great set up, especially when adherence is so essential.  After much discussion, and a phone call to the local clinic, the nurse there agreed to open a file for the patient and get her started on treatment that day provided the medical officer in the hospital prescribed all of the meds.  So the grandmother placed the baby on her back and began the trek through the rain (it has been rainy and cool for the last 3 days), to the local clinic.  The whole transaction probably took her all day, but at least the child will be started on medications that she has desperately needed for the last year and a half.