Monday, August 25, 2008

It has been a rough weekend for me. The reality of what I am facing here suddenly took hold and I have not been my happy, cheery self.
Friday was a rough day. Outpatients just seemed to be a continual stream of difficult patients. I was also managing the patients in ED and my patients in the ward. I was being drawn from every angle. I had an old man present to me because he couldn’t walk because of excruciating back pain. He had to be to outpatients several times with this complaint and had been given analgesia. I started to think that we better investigate the pain further. I ordered an x-ray of his spine and found that he had a crush fracture to L1. The fracture did not look typical and I started to think that perhaps he had TB of the spine. I have never seen this before but only read about it. Trouble is, I do not know what the findings are on x-ray. I consulted the textbook that I have but it was very non-specific. I was getting incredibly frustrated as I had the potential to truly make a difference in this man’s life by making the correct diagnosis. Being a Friday afternoon, there were no other doctors around to ask for advice. As I have said previously- I am the only doctor in internal medicine. I ended up sending the patient away with analgesia. I cannot start a patient on 6 months of TB treatment if I am not sure of the diagnosis. I am going to try and get some help from my colleagues in Australia and hopefully the patient will return at some stage so I can help him further.
On Monday, I admitted a 13 year old girl called Patience. She is exquisitely beautiful, but she came in septic and very unwell. What I have failed to mention previously is that almost all patients present to a “Traditional Healer” (witch doctor) before they present to use. Often the patients are given herbal remedies and often there is cutting of the skin involved (I think this is an attempt to “release the poison” that is making them sick)
Anyway, Patience had multiple cuts to her legs (thanks to the traditional healer) and the leg was badly infected. I did a lumbar puncture on her and the lab reported it as negative, which was of some relief to me. I commenced her on antibiotics and throughout the week, as she has deteriorated, I have tried more and more different types of antibiotics. She is not improving. Her fevers are still above 39 degrees celsius and she is now in a coma. I have examined her many times, increased all her meds and she is getting worse and worse. I have sat by her bedside and racked my brains as to what I can do for her. I know she is going to die. I wish I was smarter. I wish I knew what else to do. For the first time in my life, I feel hopeless.
I am not a brilliant physician. I communicate well with my patients and because of this, I am often able to find out their symptoms etc. If I am unclear of what is going on, I ask someone smarter. I have never been inhibited by my ego. I can admit what I don’t know something. I also have a good relationship with my colleagues and this combination has always led to the best outcomes for my patients. Here, I am alone. I don’t have anyone to ask. I am limited in my knowledge as I am facing diseases I have never seen before. I feel like I am failing my patients. I have never had this feeling before. These people have nothing and I feel that I am letting them down.
In an attempt to remedy this, I have spent the weekend reading. My beautiful friend, Julia, found me a copy of the National guidelines for treating TB. I have devoured every word. We have a TB clinic here and they manage most of the patients here, but they refer to me the difficult cases- quite ironic given that I am the least experienced of the lot of them. Today I will read about HIV.
I saw my patients yesterday despite the fact that it was a Saturday and I am not expected to work. I just had to check on their progress. I performed a lumbar puncture on a lady who presented on Friday afternoon. I had to take the specimen to the security guard who then took it to the house where the lab technician lives. I think I am the only doctor who has called the lab technician in on the weekend, but I will deal with the repercussions on Monday. The positive about this story was that the LP identified a bug called Cryptococcus. This allowed me to give her a drug that I had not prescribed her. I had given her antibiotics against bacteria and this lab result told me that I needed to treat her with an anti-fungal. I was so happy to have a firm diagnosis and to be able to give her the correct treatment. My happiness was then overshadowed by the thought that I will probably have to tell her that she also has AIDS. Success is only momentarily sweet.
I was going to go in today to check on my patients again, but I have decided against it. I need one day where I do not have to pay witness to the devastation and hopelessness of this situation.
Tomorrow is another day.