Queen Elizabeth 2 Government Hospital

Wednesday, December 19, 2007

Today was my first day as pediatric AIDS corps (PAC) doc assigned to the Children’s Medical Ward (CMW) at QE2. I can already tell that these are likely to be two of my most trying and memorable weeks during my assignment in Lesotho (though I think I get to do this again in 2008). This morning I met with Dr. Guada Richter, PAC pediatrician who was finishing her two weeks on the CMW. We rounded on the current list of patients that the Baylor docs are in charge of. Malnutrition, tuberculous meningitis, bacterial pneumonia, pleural effusion with shifted mediastinum, bacterial meningitis, impressive hepatomegaly, and gastrointestinal bleeding were some of the “run of the mill” diagnoses. Queen2 is rich in contrasts. It affords a wonderful teaching opportunity. The variety of diseases seen, the autonomy it provides (think of the opposite of inpatient peds at Sutter – when it used to have inpatient peds), the procedures – all bring amazing learning opportunities. I started my first scalp vein IV catheter on a baby that had poor peripheral venous access. I have no attending. More unbelievably, I’m the “private” referral doctor in charge of patients on the CMW of the national referral hospital. Yes, it’s ridiculous. I’m way out of my league.

I was rounding in the nursery, a small oven of a room with babies stacked in neat little rows lining the room – tiny premature babies, babies with communicable infections, all lined up next to each other in their cribs. It really catches your attention the first time you see a roach scurrying up the wall next to a row of cribs. I asked why my 20 day old baby with suspected meningitis hadn’t had his temperature recorded (this is normally done only once a day in the nursery at QE2).
“The thermometer (mercury) is broken”.
“OK, could you borrow one from the busy maternity unit next door (I’m sure it has hundreds of deliveries per month)”
“No, they don’t have one either”.
What? Wow. It turns out they can only get one from the pharmacy on Fridays and Mondays. Oh. I see.
Back at the CMW, I was starting an IV on a child on one of the two exam tables in the treatment room and looked over at a small, still form. A 4 month old child was covered with a sheet, left alone on the exam table. My first thought, Why is there a dead child on the procedure room exam table? Where is the mother? Why are the same tables that are used for lumbar punctures and initiating IVs also used for holding the deceased children? Why do children die on the ward almost daily? The child had been seen in the Casualty Department, our version of an emergency room and admitted to the CMW. While the child was waiting in his mother’s arms on the bench to see the admitting medical officer, the child died. No Code Blue called, no rush of doctors and nurses to bring the child back from the clutches of Death. Just a child that presented too late to the doctor due to a hundred reasons. I quickly (and coldly?) thought to myself, move on, keep working on your list of patients to save the ones that you still can.

Day 2

Really the morning of day 3 before work; I was too tired and depressed to write last night. Yesterday was a tough day. Rounding on patients throughout the day, catching up on things that needed to be done to the patients I was getting to know, admitting new patients, doing procedures. Blood that needed to be hung over night and wasn’t, meds that should have been given but weren’t. Kids in respiratory distress with only a weak hint of oxygen piping through tubing from an oxygen concentrator split between 3 kids. No ventilator for kids in respiratory failure. Bad attitude from nurses (How much can I blame them? They have too many patients, they see death all the time, and they get paid $8,000 a year). Still no thermometer in the NICU. A patient trying to kill a roach on the wall with her shoe. I expect at least a few kids to be dead this morning. Most of the deaths would be preventable in the States. Man, I’m already getting depressed.

The Weekend

Weekend rounding went more smoothly. I was able to see the patients and get out into the fresh air by midday. Going for runs, reading a book, trying to learn the guitar – all keep the sanity in my life during this tough rotation.

Holiday

Christmas Eve at the CMW was tough. Patients are often kept two to three in a single bed due to overcrowding. I was rounding on one of my patients (a child that had seized for an hour at home because the mother didn't have money for a taxi ride to the hospital - the fair was 50 cents) when the mother of the child sharing the bed started wailing. The translator told me she was crying because her child just died. What? I called for the other doctor, and we brought the child into the procedure room and started resuscitation. The attempt was futile. The heart had already stopped. There was no support staff. The was little equipment. The child had gastroenteritis and likely bacterial sepsis and died from cardiopulmonary arrest, due possibly to aspiration or electrolyte imbalance. There was nothing we could do.

Coming home that afternoon, I decided to go with my friends to the Drakensburg mountains for Christmas. This expansive mountain range runs through Lesotho and South Africa (SA), and we visited a resort in the central Draks located east of Lesotho in SA. We camped on Christmas Eve in a light, mesmerizing drizzle that soothed my hospital pains, and I stayed in a swank room the following night. Christmas dinner was OK, but it sure didn’t compare to the feasts at the Pierce house in Corpus. I thankfully was able to talk to the family as they opened presents and sipped on their morning coffee. Wednesday I was off from work for Boxing Day, a holiday that reportedly has nothing to do with fighting or underpants (though there is Dad in his undershirt; caught with my webcam!). We had a leisurely drive back to Maseru, stopping once again in Clarens for a little microbrewery reward, in celebration of Boxing Day, of course.

Back For More

Back from the beautiful Drakensburg mountains, I awoke Thursday morning with the intent of a run. The days can be long at QE2, so I like the idea of running before work. Unfortunately, the bed gravitational pull (BGP) was again too strong (perhaps the 3rd failed attempt so far while on the QE2 rotation). On the way to work, I was expecting the worst. I felt pretty sure that there would be at least a few of my patients that had passed away over the holiday. Believe it or not, all of the patients that I was in charge of were alive. In fact, most of them were getting better without me. It made me wonder if I should try coming to work every 3rd day more often. I was able to move all of the “sick” patients out of the acute room and into rooms where the more stable patients stay. I also discharged a number home. I am amazed how the reaction to the news of leaving the hospital is universal: giddiness, smiling, even occasionally dancing. I guess most people aren’t happy in the hospital. I suppose that includes me as well.

Note: Roach count today - 2 in the nursery, only 1 on the children’s ward.

While I was seeing my patients another child with advanced diarrhea died. Eerily similar to Christmas Eve, I was rounding on my patients when a mother started wailing. Resuscitation attempts were again futile. This time I realized that we do have some suction available. It is a plastic looking contraption that you have to pump with your foot to create a weak suction. This “code blue” and aftermath were so starkly different from similar events in the US. A nurse would briefly come in the room and then leave. It’s as if they have no training in resuscitation, almost as if they are afraid to be involved. The medical officers found the medications, and drew them up in syringes; there was no one from lab (“stat labs” mean within the same day), no one from x-ray (no portable x-ray device that I’ve seen), no intensive care expert from the ICU to lend a hand (no Jim Gude or Ken Lamb; no Bombers). Just fumbling with worn down equipment, expiring medications, and apathetic staff. The environment in the acute room where the child had been staying was also sad and intriguing. The mother was not taken from the acute room after the death (though I offered; there is no “quiet room” for families of the deceased); instead she stayed there, crying while the other mothers fed their babies, changed their diapers, and joked about various things. Though childhood death is so common here, there seemed to be no camaraderie among the mothers (I expect this had something to do with her being new to the ward). The doc who had seen the baby in the morning didn’t stop rounding on her other patients, so I did what I could to help console the mother.

For a further look at QE2 in the news:

CNN online special that mentions Queen Elizabeth 2 hospital (check out: http://edition.cnn.com/video/#/video/international/2007/12/05/inside.africa.hope.for.aids.orphans.cnn?iref=videosearch)
You can also see the recent (though fairly inaccurate) LA Chronicle article on Queen 2 and Bill Gates funding (see: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2007/12/16/MNJFTVFK3.DTL).

Friday and Saturday

I’ve been getting more into the swing of things. There have been several days without an admission, there have been fewer IVs to struggle with (I’ve become best friends with IM ceftriaxone), and I’ve had a chance to discharge some patients. Discharge basically comes down to: the patient no longer needs IV meds or oxygen? Ok, pa' la casa - they’ll probably do better at home. I’m sending patients home in worse condition than I would in the States, but with the lack of quality nursing care (there are medication errors every day) and infection control (I’m almost the only staff person that washes his hands) I feel the hospital is a danger zone, a ticking time bomb. We’re working with the medical officers and the nurses, giving suggestions and the occasional lecture, but we’re not in the position to make major changes. I wish we were. Take, for example, the 12 year old girl that has been walking around the entire CMW. She plays with the other children, jokes around with the nurse and the patients’ parents, goes up to the medication cart and receives her meds along with the other patients. She wears a surgical mask. Why, you might ask? She is being treated for pulmonary tuberculosis for the third time and still has TB in her sputum. She most likely has multidrug resistant TB (MDRTB), a form of TB that is very difficult and very expense to cure, even in the US. Her mother doesn’t visit often, so she gets lonely in her “isolation room” with is about the size of a closet – similar to what I imagine solitary confinement cells are like in prisons. The docs and nurses have all tried to keep her in her room but sympathize with her loneliness; she therefore has been allowed to pretty much do as she pleases. I called a meeting of the staff and talked with the child. We made a compromise where she is allowed to be outside in the little playground when she isn’t in her isolation room (TB is very hard to catch when you are in the open air). Also, I bribed her with a cookie. We’ll see how long the deal lasts.

I’ve got 5 more days to go on this rotation. I’ll let you know how it goes.

A story about the Mission Aviation Fellowship that flies docs around in Lesotho just came out in the Houston Chronicle. Our work in Mokhotlong is mentioned in the article; make sure to also click on the audio slideshow. Smiley Pool (photographer and longtime comrade to the PAC and BIPAI) did an awesome job.

http://www.chron.com/disp/story.mpl/life/religion/5408265.html

Take care,

Jeff