Too much death

Too much death
8/9/11:
In retrospect maybe I should have discussed a couple of the OPD cases I saw yesterday because 2 of them were admitted and sadly died.

The first one was a 1 year old baby girl who was very weak, anaemic and malnourished. Contrary to what I thought when before I came here not that many patients tend to be undernourished in fact if anything they tend to be slightly on the larger side. The only patients I have seen who looked emaciated were those who have chronic diseases such as HIV.
So I am not sure if this girl’s anaemia/malnourishment was due to lack of food or because she also was suffering from a long term condition. On the weight chart her weight had dramatically dropped on the last couple of readings. In the morning meeting they reported that she had died over night :(. Just too weak to survive the infection I suppose.

The second patient was a 23 year old girl who had pneumonia as a result of being immune compromised. Her HIV had been diagnosed over a year ago but weirdly she was not receiving any anti retrovirals - these are fortunately one of the few drugs that the government prescribe free of charge so expense is not why she was not getting them. Her CD4 count (these are immune cells that are destroyed by the virus) was very low when checked yesterday at 160 cells per uL. A good CD4 count is over 500, so she really really really should have been receiving treatment and the doctor was not sure why she was not - it was not due to patient refusal. I remember when I saw the patient yesterday that I was struck by how weak and fatigued she looked - she couldn't put her own shoes back on, her mum had to do this for her. I also realised that the girl was basically my age and yet our lives couldn't be more different - all I was worried about yesterday was whether or not I would get to practice taking blood while I was here but she was clearly literally fighting for her life. Whilst I was not surprised to hear she hadn't pulled through because she was clearly very very ill, I was still quite shocked because she was still so young, such a massive waste.

Unfortunately this was not the only death we heard about/ experienced today. In the afternoon we went to OPD and we entered a consultation room behind a nurse (here you can't wait for patients to leave like you would as a student in England because more often than not the next patient will enter whilst the first patient is still there so there is no gap between patients). The nurse was mopping up pus from someone’s leg which was on the floor (Ick!) and the doctor was talking in Swahili to a husband and wife whose small baby lay on the examination bed wrapped in multiple blankets (as commonplace here in spite of what seems to us as very hot weather!). As ever the next patient was standing behind the husband and wife. It wasn't till halfway through the consultation that the doctor turned to us and said the baby was dead on arrival at OPD and he was filling out the death certificate. I was horrified that we had accidentally stumbled in on the middle of what should have been a very private moment for the grieving parents. But at least we had not done so intentionally - why on earth the nurse had been moping the floor during that particular consultation or the next patient had not left the room when he realised what was going on (after all they both spoke Swahili so should have realised pretty quickly), I have no idea. Also the doctor could have simply locked the door (I have seen this done during some consultations) which would have stopped all 4 of us from coming in the first place. From an outsiders perspective who is not used to the culture it seems people here receive very little privacy even when they may need it most. I definitely prefer the way death and grief is treated in UK hospitals.

The rest of the day consisted of watching a vesicovaginal fistula (essentially an abnormal connection between the vagina and the bladder resulting in incontinence) repair, going to a diabetes clinic, and examining a patient with heart symptoms without the aid of a translator. The VVF surgery was unfortunately not successful as the fistula had been there since 1989 and so the acidic urine had eroded lots of structures. In the diabetes clinic we learnt that they only have 1 type of diabetic medication here as the others are too expensive. Therefore if someone’s blood glucose level is not well enough controlled by that 1 medication then they cannot put them on additional different medications like they can in the UK. As a result a lot of the patients we saw still had worryingly high glucose levels.

During the diabetes clinic a really awkward moment arose where the doctor asked us to write the patients name on the "patient signature" line of her insurance claim form... He said the patient could not write and he could not do it for her because then it would be a forgery as the handwriting would be the same as the rest of the form. Nevermind that it would be a forgery if we were to sign or that surely if this is being done regularly the signatures on past insurance forms must all be completely different. We were not comfortable with signing the form so refused as politely as we could and the doctor went off to find someone else who would do it. While he was gone we tried to explain (by gestures!) that virtually anything would do as a signature even a scribble and she started to practice on a notepad. She could write! Not especially well but definitely well enough for some form of signature. We explained this to the doctor when he came back with a very reluctant looking nurse, but he got the nurse to sign the form anyway. All very odd and ethically dubious. I was particularly disappointed by the whole situation because I had thought this doctor was one of the better ones!

That's all for now,

Halfadoc x