Wednesday, January 18, 2012


The first drive can be simultaneously the longest and the shortest - long in the sense that you wonder with anticipation what turns are coming next and when will you arrive at your destination, yet short because of the new sights upon sights that you pass in a hurry without being able to stop and admire.

Before I know it, into the doors of Edendale Hospital we step. Our footsteps sound a little hollow in the still not fully awake building. We walk up the stairs, meeting Dr. Wilson on the way.

First stop of the day, morning report - or 8 am conference. Held in a small room, a case is presented from overnight, a middle aged man with RVD and epilepsy who presented with seizures. The ensuing discussion is quite academic and similar to our morning report cases. Lots of question and answer, generating differentials and talking physiology. We determine a preliminary course of action for this patient – some labs, some meds - then all disperse to their respective morning duties.

Onto the wards: we rounded in the H ward, female side. My first impression of the ward was its size. Not big, but set in a fairly large room with windows along the side walls, filled with 36 beds arranged perhaps 2-4 feet apart from each other (I am a poor judge of actual distance). No curtains. There is a naked woman sitting in her bed near the back of the room, her bottom half wrapped in a blanket, her top exposed. She is yelling - to me, incomprehensible because it is in Zulu; to the staff, also incomprehensible because, I was told, her words were nonsensical. She lets out an intermittent holler or sings a few musical words, piercing above the hum of the room. It is almost comical. Later, I learn that H ward often houses the psych patients who are undergoing medical evaluation.

Next, the infamous 5B1 ward. We only see half the patients, as is the routine here. The consultant and/or registrar rounds every other day, leaving the intern alone on the alternate days to round, manage, and discharge. The first row of patients are the most acute, though as we move further, we find that is not always the case. If you need oxygen, you need to be in the first row. Even then, there may not be enough oxygen connections or tubing to ensure a constant supply of O2 therapy. The theme of the day: cryptococcal meningitis, viral meningitis, nephrotic syndrome and renal failure, PCP/pneumonia.

The Time Factor...

Monday starts as usual with morning report, which turns into a town hall meeting of sorts by the end. We are in the midst of a lab strike! The lab, operated by independent organizations, has gone on strike with workers demanding an increase in pay. The situation has worsened from having two remaining technicians processing really urgent samples to the entire lab being closed with doors locked. Things are at a standstill, yet there is nothing that hospital administration can do. We have no idea what is the status of negotiations. Is there legal action that can be taken? It seems our hands are tied. The situation persists for another week; during this time our skills are tested on the wards. Hemoglobin low? Check the conjunctiva. Renal failure? Check for worsening swelling (urine outputs are not charted). It's satisfying to make use of that armamentarium of physical exam skills we are taught in medical school, like the way all the older docs know how to do. It's almost embarrassing, though, because a feeling of uncertainty still lingers, the side effect of what we're used to back home - data, data, and more data.

After the meeting, I proceed to round with the intern on 5B1. We come across a 15 year old girl who presents with shortness of breath. She has no known past medical history, but things are suspect. Her x-ray tells the story before her. The ARV warrior is at her bedside. All are awaiting the results of the rapid HIV test kit that lies open on the table. Two pink lines; it is positive. The ARV warrior tells the patient in Zulu her diagnosis. She seems to take the news without much reaction. I am told she will tell her mother; her father was HIV positive. Age of consent is 12. Now we await the TB test. She stays for the next week on the wards. The ARV warriors visit her often; she is still waiting for her mother to come to the hospital.


Not knowing really what to expect at Edendale, I spent the first week trying to just observe and walk around, get situated. Oddly enough, I didn’t feel too weird being here. At first glance, the wards and physical facilities are clearly very different from what we see at home. Each “ward”, which would be the equivalent of a floor, really is just one big room. They are first and foremost divided into male and female wards. There are minimal patient dividers, so every bed is located only several feet away from the other. Patients are examined and undressed while trying to provide as much privacy and draping as possible using whatever blankets and sheets are available. Most of the time, this is not really complete. No one seems to mind, however. Patients look on while their neighbors are being examined. There is no shame or judgment. Patients visit with one another and really try to look out for one another.

I definitely do not sense as much hesitation to talk about HIV/AIDS here in Edendale, which is encouraging. Yet patients are not immune to stigma. People learn to identify those who look ill, those who are weak, emaciated, those they assume have the RVD, even if that is not the actual diagnosis. With the help of education and outreach efforts, people have learned to not shy away from medical care. Some, however, especially men, often refuse treatment and follow-up.

Patient education. That is a theme constant here as well as back home. We need patient education. While the literacy level is not low in Zulu, understanding medical conditions and the necessary steps for help maintenance is a harder task. This plays a huge role in follow-up rates and treatment adherence. In fact, we had a young woman in her 20s who presented with DKA multiple times in the setting of insulin non-adherence. I realized that the medical staff just don’t have time to sit down and have extended conversations with patients about why they did not take their meds. Even ordering a psychiatry consult could take days to happen. The result? We hope the patient listens when we round for those brief 10-15 minutes at the bedside, and that she will follow-up in clinic as told.

The population here at Edendale hospital, while being quite sick, are also some of the friendliest, strongest, grateful people I’ve worked with. They tolerate, rarely complain until they cannot bear it anymore. When asked, “how are you?”, they may say “well”. You must ask, “how are you feeling today, what is bothering you?” Their answers are often brief, you need to ask further and draw out more symptoms. Maybe it is a reservation towards doctors or an expectation that patients should not be too forward. Even if pain medications never arrived, most will not say anything negative about the doctors or nurses. They are at the mercy of the system.

Daily life for patients at the hospital is fairly routine. Morning, a breakfast meal of pap with milk. The nurses, called "sisters" and "sirs", make their medication rounds. One nurse from each side of the ward rounds with the intern/registrar. The patients are mostly up by now. Their sheets are still pulled, each bed has a thick fleecy blanket - provided by individual patients' families especially for the hospital stay. The patients have their few personal belongings tucked away in a small drawer by the bed. There are no TVs, no phones. When visiting hours come around, the ward changes and starts to hum with the voices of all the patients' family members coming to check in on their loved ones. It's not noisy, but rather a lively vibe. Scents of home cooked meals can sometimes be caught wafting around the corners. By mid to late afternoon, a heaviness settles back in, the floors start to echo again. The sisters are mostly gathered in their conference room, wrapping up the day; patients move back from their chairs into the beds; the doctors have gone.

Swings and Waits...

The first time the intern told me that a patient passed away during the night was a blow. She was an elderly woman who had a history of breast cancer and returned with a new left sided pleural effusion. She was clearly tachypneic and hypoxic. She needed a therapeutic thoracentesis, which we did, but we were only able to drain 500 cc of fluid. The needle/cannula was too short to really be effectively secured to her back. Not surprisingly, she became progressively more short of breath over the next few days. She needed another thoracentesis, and a chest tube was planned this time. The next day we come in and we’re told that she arrested and died during the night. Hearing the news, I just felt kind of empty inside; it was a feeling hard to describe, like we had let the patient and her family down.

Perhaps one of the most frustrating and sad parts of medicine and being a physician is dealing with poor patient outcomes. Here, I feel the burden is exceptionally great. Coming from a health care system and hospital where blood work and radiology studies happen expediently with usually minimal delays, it’s very painful to watch patients wait days and days for even small things such as viral load tests or urine studies. An “urgent” chest x-ray for a status post thoracentesis patient gets done in maybe eight hours time. If a study is ordered in the afternoon, that essentially means it will happen tomorrow. Hence, we have many patients on the floor, in distress or pain, or simply not improving, while we await their imaging, which is needed in the diagnostic process.