Sometimes the beginning isn’t always the best place to start… sometimes there isn’t a beginning at all and you find yourself dropped into the middle where there isn’t time to worry about beginning, middle or end, or how things are “supposed” to run. I guess that’s what my first day was like. Dropped off by my protective husband with overpriced Cappuccino in hand, engagement ring intentionally left at home for the first time in my career, embarrassedly wearing hiking boots with my blue scrubs as our lost luggage and my other shoes have not yet arrived. Amused to reflect that wearing only scrubs without a white coat at my home hospital normally results in being called “honey, or sweetheart,” followed by menial requests from patients… a questioning security guard prepared to stop our unidentified vehicle sees scrubs and gives instead immediate deference and respect to the “doctor” he immediately allows to pass. I meet my team inside the 20 bed ER and admonish myself for the first time of many this day that I even gave a thought to worrying about my damn hiking boots… the rest of the physicians are dressed in scrub tops with jeans or entirely in plain clothes… I think how out of place my starched white coat with bold block “M” would be here, and how it would only make the communication rift between my Midwest American accent and my local patient population that much wider.
I join the team for morning rounds, change of shift so the night team can go home. We start in the resuscitation bays… four beds in a row, two of which contain intubated patients, one with unstable vital signs flashing on the monitor. Where are the bright surgical lights, the rows of carts with essential supplies… where are the nurses, respiratory therapists and techs monitoring these patients and the equipment that is keeping them alive? Why are there no fluids hanging on that hypotensive patient? What do you mean he doesn’t have central and arterial lines providing invasive monitoring? What do you mean your conclusion for the story of several days of worsening shortness of breath after long car trip now with hypoxia, hypotension and collapse, is head bleed? The morning attending frowns with doubt in his eyes regarding that diagnosis presented by the overnight residents… then he looks at me and earnestly asks what we should do…
Massive pulmonary embolism and septic pneumonia spring to my mind, where is his CT scan I ask… There are no CT scans available on evenings or weekends… he hasn’t had one… he is not on Heparin… PE wasn’t considered in the differential… I offer to do a bedside cardiac ultrasound… both grateful to Dr. Barton at home who taught me how and wishing I’d paid even more attention and asked even more questions… cardiac contractility sucks… right ventricle is grossly dilated… this patient is still not on Heparin… his blood pressure is still systolic 70… I ask about Heparin, that CT scan, fluids… I’m told that to get a CT scan the patient has be to transferred to another hospital for the scan and then sent back to this one for care… he’s not stable to travel… regarding the drugs, while the attending agrees, he says the patient has already been accepted by the inpatient team and it is at their discretion now…
Orientation… I’m shown where things are, informed that the two nurses on staff are responsible for triage and basic patient care for the entire ER… Doctors place all IV’s, do all blood draws, run blood gases, dip urine, hang fluids, dispense medications, adjust ventilators and get EKGs…. I think of the army of highly trained techs and nurses at home who converge on critically ill patients that enter our ER and within minutes provide me with information on vitals, EKGs, xrays, and blood work so that I can effectively analyze and manage multiple critical patients at once… I chastise myself again and try to rapidly remember what labs come from what color-topped tubes… why the hell have I never asked our pediatric nurses to teach me their tricks to starting peripheral IVs on babies… damn their veins are small… which one of these stupid EKG leads goes to which electrode sticker on the patient… damnit… I put the stickers in the wrong place anyways… patient needs a spinal tap… Thank-God something I finally know how to do!!
The attending and I finish orientation and he informs me that he’ll be leaving now, call him to discuss transferring a patient to another hospital if I feel a CT scan is necessary, otherwise, do what needs to be done. Okay, who supervises the residents I ask, who’s in charge? He smiles…
First new patient of the day arrives. I go with the 1st year resident physician who will be solely responsible for her care to observe. Triage nurse says it’s a 4 month old baby girl with “tight chest,” started on Albuterol. Walk in the room. Cute African baby in mom’s lap… breathing at a rate of 65 respirations per minute, oh and that’s what supraclavicular retractions look like, never actually seen them before… tachycardic, oxygenation 94% with the Albuterol… I look at the oxygen level on the wall… she’s at 5 liters… child is still awake and alert, crying… this is technically not my patient… I listen to the congested lung sounds on the right anyways… this baby sure feels warm to touch…
I don’t want to be “that American doctor” barking orders and overhauling my new teammate’s management on my first day, so for a minute or two I watch. I watch a very sweet, but very young physician sit at a counter 10 feet away and review the child’s immunization card… she hasn’t listened to the baby’s lungs, felt her hot skin or looked at the level of oxygen support she’s requiring… she doesn’t know what I know yet. Another minute goes by… I ask her as politely as I can what she plans to do with this patient… I’m looking around the room for where the airway cart is… just in case this baby gets tired of breathing, now 70 respirations per minute… I’m thinking of multi-million-dollar 12-story Mott back home and wondering if my favorite PICU fellow Ryan is on… My thoughts are interrupted by her answer, “Most of these babies with tight chest are viral, they get the Albuterol and go home,” to the mother, “Mamma, go ahead and feed baby.”
It takes about 45 seconds off oxygen and attempting to suck on the bottle for the child’s oxygenation level to hit 80s… “She’s hypoxic,” I point out… I tell Mom to stop feeding baby… kid is going to aspirate… My teammate is still sitting at the counter working on her note… “She’s hitting 70s, you need to do something,” I say not really caring anymore about being a condescending American as I walk over and put the mask back on the child and turn the oxygen back on… Teammate is up now, and I see in her eyes the brightness and fear of uncertainty… the same that I’m sure shown in my own eyes a few years ago when confronted with a patient like this as an intern, but then in my training I am never alone… “What do I do,” she asks me, with not a trace of anger or irritation, but rather gratitude that today she is not alone. Oxygen levels are back up with the mask… respiratory rate still sucks but not critically so, the kid is still alert and holding her own… “She has pneumonia. She needs a chest XR, an IV, labs, antibiotics and admission.”
I go back into the main ER and take a walk through the resuscitation bays… the already admitted, hypotensive, likely pulmonary embolism patient is still there… I walk closer towards his beeping monitor… oxygenation level says 55%… monitors are great, but only if someone is around to hear them chime. Another resident has noticed that I’ve wandered in the bays and follows, his eyes widen when he follows my gaze to the monitor. He adjusts the vent settings… sats up to mid-60s… I’m starting to pick up on what resources we do and don’t have and suggest a stat chest xray, suction, repeat blood gas, increase FiO2… he says this patient is rolling to the ICU right now… that team will have to manage it, there are too many others waiting to be seen.
And so the day went… I remembered how to start IVs, figured out what labs go in what tubes, spiked IV bags… I still haven’t mastered the system of how to move patients through the department, and I was probably more a hindrance than help to the other residents… but I’ll figure it out.
Before I close, I worry that I have painted this hospital and my new teammates in a poor light, and in truth I am nothing if not humbled by what they are trying to do everyday… this hospital, this country, are overwhelmed with medical demand and have not a fraction of the resources available in the place I call home. Quite honestly I’m not sure they can even envision the mammoth beast that is the University of Michigan Hospital. There was no attending there today because it’s Saturday and there are not enough of them on staff to keep the ER covered 24hrs a day 7 days a week … the residents work alone because if it wasn’t for them there would simply be no one. The residents make mistakes because they are residents, in training… and based on the South African training system some of them are not technically equivalent to US residents yet and do not have formal training in Emergency Medicine. Emergency medicine on this continent is still largely provided by general practitioners and is only recently recognized as a specialty of its own. My husband smiles and reminds me when I recount my day, this is Africa.
As I was leaving and saying good-bye to a teammate today the paramedics rolled in to the resuscitation bays with an unresponsive and intubated patient, with a bag of blood coming from the tube down his nose… It was my teammate that greeted the paramedics and accepted the patient, by himself. There were no nurses to get IVs for him, no techs to set up monitors… He turned on and set the ventilator himself, and prepared to do what needed to be done. This is HIS patient. This unstable and unresponsive man is in my teammate’s hands and his alone to do everything that needs to be done to save his life, and my teammate moves with no hesitation.
I have ten years worth of advanced education plus three years training in a top-notch Emergency Medicine residency program at a premier hospital in arguably the most medically advanced country in the world… could I do that same thing alone? I’m sure as hell going to try… and I have no doubt that over the next several weeks I’ll find out.
It’s a Monday, arguably the busiest day in any ER and judging by the overcrowded waiting room and the clustered hallways I weave through, this one will be no different. I am greeted as I walk into the main ER by a psychiatric patient dressed in a neon pink bathrobe, coarse black hair braided and spiked out from her head in all directions, she is doing what appear to be yoga poses next to the physician desk, she then transitions to a tribal dance inspired by a beat heard only in her head… perhaps I need some of what she is on instead of this Cappuccino.
Morning rounds consist of walking bed to bed… somehow the night team knows who all these patients are by sight, because they shuffle and move themselves, or are shifted by transporters, around the department with little rhyme or reason. No ‘customer service’ theme or HIPPA privacy policy here… we openly discuss all aspects of the patient’s medical record in front of them and whoever is 4 feet over in the next bed, and we are quite frank in our opinions. The only topic spoken in hushed tones is HIV status, which perhaps is a reflection of the national attitude as politics of recent years have favored to push the issue of HIV under the rug instead of tackling it head on as done by Botswana and Uganda… leading South Africa to surge ahead of its neighbors and earn the title of highest HIV prevalence in the world.
We proceed to round on the patients in the resuscitation bays… pink lady is now laying starfish on her back in the middle of the floor of the resuscitation area… we carefully step over her splayed arms and legs and proceed business as usual… after all she’s being quiet and not really causing any harm…
We come to one of the last beds in the main ER… young woman in her 30s or so, here for headache. She is awake but looks miserable, complaining of being cold. Night team begins to present, attending interrupts and asks in exacerbated voice, “Is that her blood pressure?” Monitor reads 61/33. Why yes, yes it is… Night team comments, “Yeah, her blood pressure started falling around 4am.” There is no mention of what they did to fix it. It’s almost 9am now. Night team proposes meningitis for a diagnosis, yet this patient is in the middle of the open ER without a mask, antibiotics have not been given. Dr. Manny Rivers would probably have a stroke… no sepsis protocol here. Rounds are interrupted to move the patient to the resuscitation area, start another IV with fluid boluses and cover her with antibiotics. Lumbar puncture results are reviewed… she doesn’t have meningitis, good thing for us all, but a nasty pneumonia has the upper hand so far… pressors are started.
The day goes on. Paramedics roll in with an elderly female brought in for family reporting bloody stools for several days and confusion this morning. Her once dark skin has faded to an eerie yellow. Her contracted muscles, remnants of a previous stoke, and bed sores suggest she has fared poorly the past few years. She responds only to loud verbal cues or physical stimuli. She is hypoxic and breathing poorly. A senior resident and I take the patient. I’ve learned we don’t jump to anything too quickly here, but the minutes tick by with no improvement. “She needs a ventilator,” I say to my partner. My partner does not look up or immediately respond, she rolls the patient and assesses her bedsores, she tugs gently on the contracted limbs. “I’m not intubating this patient,” she responds.
I’m confused. My program evaluations suggest I am doing well in my training, I’m comfortable resuscitating patients in my home bays… what am I not getting here? There are no advanced directives suggesting that this patient does not want all interventions attempted… family wants to know if she is going to be okay… I plead my case again, “She’s hypoxic, she’s altered, she’s barely protecting her airway, she needs a vent.” “She’s old and has low level of functioning at baseline. We don’t have enough ventilators and ICU beds to use them on her. We just don’t have the resources.” I stop short… it wasn’t the medicine that I had wrong… now I understand.
And while I’m still processing that patient, there comes another, younger woman in her 60s in severe respiratory distress, likely due to exacerbation of heart failure and fluid accumulation in her lungs. She is awake but combative and almost feral, an oxygen deprived brain literally fighting for its every breath. She is bolt upright in bed, eyes wide and wild, all chest and abdominal muscles working to move air through lungs drowning in their own fluids. 15 liters of oxygen bring her to the low 80s. I’m ready for this one… I had a patient just like this at UofM the week before I left…
It’s a different resident with me on this patient, and as I move for the airway cart and ask him what meds they prefer for putting a patient on a vent he stops me. “Look at her record, look at her long list of medications… they’re not going to be able to make her much better in the long run. She’ll go into heart failure again.” The same damning phrase as with my previous patient, “She has poor baseline. We’re not intubating her.” I look at the list of meds… its maybe 10-12 long… should I tell him that some of my patients at home have lists pages long? Should I tell him that a classmate gave a lecture on how to manage heart failure patients on left ventricular assist devices who are awaiting heart transplants… patients with far worse “baselines” than this relatively young patient. “We’ll manage her non-invasively… she might pull through,” he finishes.
I know that people die. I know that there are things I cannot fix. But I do not know how to let people die. For the last three years I have trained to take a patient like this one, slap Death in the face and say, “Nope, not today, not on my watch.” I admit that there have been times that terminally-ill elderly patients have presented to our ERs and I have questioned if I’m doing the “right thing” putting them on ventilators that I know will never come off… But our healthcare system’s rules keep it simple… unless I have clear directives to the contrary, every patient gets my very best and everything that I have to offer regardless of what philosophical discussions on end-of-life ethics may ensue later. And in hindsight I am shamed for those discussions with my colleagues… how brazen of us to theorize on whom we should and should not intervene when we live and work shielded by immense resources that protect us from ever having to make that choice. How do you train to analyze bedsores, medication lists and past medical history and within seconds conclude that this patient, your patient, does not warrant allocation of scarce resources? How do you watch someone die when they want to live… watch them die and know you did not give them your all, know there was more you could have done.
Let me tell you about the patients sitting in the chairs lined up in front of the row of full beds. Let me tell you about emaciated skeletons that move so infrequently you’re tempted to go check a pulse. Let me tell you about skin black as night, dull, lifeless, and drawn taught over gaunt faces… about eyes that stare endlessly. Look into the depths of those glazed eyes and see the years of sickness, pain, deterioration… look again, look deeper and be amazed at the defiant spark of life that still burns within. Let me tell you about the hopelessness of knowing there is not a damn thing you can do for them. Let me tell you about AIDS.
Well I’ll have you know that I have failed to master the paper trail that moves patients through the department… I don’t know who to call, I don’t know how to schedule their follow-ups, don’t know where to tell them to go to fill their prescriptions or be seen in clinic. But I have found a role for myself… I teach the medical students and younger residents. The attending provides good teaching on rounds every morning, but is stretched too thin to spend much time with the students later on, and so I have become their go-to person. I don’t have a clue how this hospital works, but I know the medicine.
I think they like my sarcastic, pragmatic sense of humor that my husband doesn’t think I have. We go over blood gases, EKGs, xrays… how to resuscitate a septic patient, management of traumas, burns, overdoses… I hear myself talking to them and wonder who it is doing all this talking… when in the world did I learn all of this… I’m even more impressed when they come to me on subsequent days, another EKG in hand and they remember what I taught them the day before… you mean they were actually listening? I find myself reading up on topics at night… I want to make sure I have things straight for them. I’m supposed to want a community job next year… minimum shifts, maximum money and time in the saddle… Academics?? Me??
Is that smoke? I watch in stunned fascination from the physician desk as yelling nurses run towards one of the psychiatric patients who has somehow managed to set his restraints on fire… yes, orange and red flames fire. I don’t think I’ve mentioned that we don’t have real restraints here… but “blue pads” or for those not in the medical field, cotton pads lined with plastic, wrapped around patient limbs and secured with duct-tape actually function to hold aggressive patients to the bed rather well… unless you fail to search for and remove dangerous objects, like lighters, first. The surgeon examining the patient in the next bed over quickly grabs a bin of water and douses the flames. I am entranced by the whole event… there was never any real danger to anyone except the psychiatric patient himself… really…
While I don’t manage the psych patients here, they are certainly part of my day. On my first day a manic bipolar man off his meds was brought in by police for wandering half-naked down the road babbling nonsense… as he was pushed towards the seclusion room on his arrival he planted his feet and yelled, “I will NOT go in there, its filthy, I’m from Holland!” I don’t know his real name, I call him Holland. Holland is actually quite calm and friendly… he is also working undercover for Pepsi and McDonald’s doing investigative reporting on the inner workings of this hospital and is drafting full report to the Queen… he assures me that I’m one of the good doctors and I have nothing to fear from his reports. The psychiatric ward is full. Holland is still committed to his investigative reporting and is not deemed by psychiatry’s daily visits to be stable enough to be released to the general public. Holland has been living in the ER for one week.
Aggressive patients are restrained by security, but the non-aggressive ones are pretty much free to roam the department, and they do become cumbersome… Now one week into my stay here I’m getting clever about resources or the lack there of… my solution has been to assign “good” psychiatric patients like Holland to watch the docile wandering souls that need supervision. Holland likes feeling important. He passes out bananas for snacks, asks politely for clean blankets… I apologize and tell him I don’t know where blankets are… he smiles, “No problem, I know, I’ll get them,” and he proceeds to gently tuck in the patients sleeping in chairs. I’m sure it’s not ethical, but his help makes the ER a safer place for everyone.
Now while we are on the topic of innovation… let’s talk about trauma. 30-year-old female comes in by paramedics after car accident. She is on a back-board and in a cervical collar. She is awake and complains of back and leg pain, she looks good, vitals are fine. Trauma is an extremely protocolized aspect of emergency medicine, there really isn’t a whole lot of room for negotiation on management. Patient needs to come off the back-board as soon as possible while spinal precautions are maintained… I know how to run a trauma, especially a simple stable car accident. Another resident has beaten me to picking up this patient. I go anyways to assist with getting her off the board. My jaw drops a little as I watch my teammate take off the cervical collar and throw it aside, she then has a paramedic hold the cervical spine in his hands for stabilization while the patient is rolled to see her back… patient rolled flat again and then to my utter disbelief out comes the duct-tape… blanket rolls are placed on either side of the head and two long pieces of duct-tape are placed, one over the forehead, the second over the shoulders… patient is securely taped to the bed! The cervical collar is lying on the floor… of all I’ve seen I haven’t seen anything quite like this.
Another psychiatric patient lights a cigarette… he has a box of matches in his hand… Never fear! Holland is here! Holland puts out the cigarette and then escorts the patient outside so he can enjoy it properly… yes, they are allowed to wander in and out of the ER… remember this hospital, like any other residence in Cape Town, is surrounded by gates and walls, it’s not like they can really get away.
Trauma number two. It’s my turn. 24yoM falls from his job as a window cleaner three stories up… arrives awake, stable vitals, on back-board and collar… I’ve seen how trauma is done here… I know what the paramedics expect me to do… I can’t do it… I feel the eyes of the trauma surgeons from home boring into me… I cannot, will NOT take off that collar. Patient complains of left arm and foot pain. He is concerned about getting back to work… he doesn’t want to lose his job. No pan-scan CT images here… expensive, wasteful. The medical student remembers how to find two of the four windows of a trauma ultrasound that I taught her yesterday, I help her with the renal windows… scan is negative. X-rays are ordered. While awaiting x-rays the patient removes his collar and gets up and finds me in the department… he has decided to clear his spine himself, he really needs to get back to work. He leaves, bare-chested, his shirt and overalls cut off by paramedics, and limping… his Tylenol prescription in hand… I think of patients at home with no appreciable injury who demand Vicodin, Valium and work-excuses after tripping over a rug… a teammate smiles at my concern… he recognizes the patient’s facial features, “He’s Zulu… they’re not called Zulu Warriors for nothing, he’ll be alright.”
I’m assigned to the pediatric section. I’m in my groove asking about how much baby is eating, drinking, peeing, pooping… how long has there been cough, diarrhea… no, that’s not diarrhea that’s normal baby poop… no, 99 is not a fever… Out of the corner of my eye I see triage deposit a limp lifeless toddler onto a bed… I turn my back mid-sentence on the mother talking about her smiling laughing infant’s poop. My new patient is unresponsive, limp as a rag, eyes sunken, skin hot, pulse thankfully full and fast. Mom is blissfully unaware, the only history I get from her is vomiting and diarrhea for several days… and I thought I was bad at pediatric IVs before… “Where is the intraosseous drill?” “The what?” my younger teammate asks. I breathe a sigh of relief when the baby starts to cry as I finally strike a vein in the scalp. Fluids are started. Patient admitted.
It’s later in the day. I casually wander back to the adult resuscitation bays looking to get a paperwork question answered… Two residents, a nurse and two medical students are busy around a patient who presented earlier for headache. The monitors are flashing. Patient is not moving. Apparently the patient’s mental status plummeted suddenly. The ER resident is attempting to intubate the patient and get him on a vent. It’s not going well. I’m quiet, letting him concentrate as he tries to thread the bougie and secure the airway. He has the bougie up-side down, but I guess it should still work. He slides the endotracheal tube in place. It’s in the esophagus, no good. Tube pulled. I remind the medical student she has to squeeze the bag to get oxygen in… this patient is chemically paralyzed and holding it over his face is not enough. The resident tries again, he can’t see the cords. The attending is in a meeting on the other side of the hospital and not aware that my teammate is putting this patient on a vent. I’m reaching for the N-95 mask in my pocket… I get the invitation… he’s ready for help, “Laurie, can you take a look?”
I know my tone is harsh and short, and I don’t care. There is a paralyzed patient on the bed with an unsecure airway. I forgive every attending I ever thought was hard on me. “Bag him. Get a pulse oximeter on his finger, raise the bed, raise the bed higher. Do we have a proper stylet for the ET-tube?” No. “Fine, bougie will have to do, it goes in this way so you can feel the tracheal rings as it passes.” I’ve lost count of how many intubations I’ve done at home, but the fleeting thought does cross my mind that this is the first time I’ve not had an experienced attending standing close at hand for back-up… the thought passes as quickly as it came… there isn’t time for thinking about that. Africa, America… the laryngoscope feels the same in my left hand, my right finger and thumb scissor the patient’s jaw open… the comforting sight of old friends… vocal cords white and shinny through the blood from my teammate’s previous attempts… tube slides easily into place… no end-tidal CO2 detector available, but I let my own breath out as the condensation from my patient’s breath now fills the tube… X-ray will confirm, but my tube is good.
Educational day… now these South African’s really have us beat here! Topic is toxicology including poisonous snakes, spiders, scorpions… and what better way to keep the residents engaged than to let them pet a live Puff Adder while discussing the devastating effects of its venom… the scales are softer and warmer than I’d expected… Now why doesn’t UofM have snake handlers bring in live demonstrations on conference day!
I’m tired. I’m frustrated. I’m fed up with “African” medicine. I’m tired of being forced to provide care, or more accurately NOT provide care, at levels far below my standards. I’m tired of the arrogance I hear from teammates who claim they don’t need expensive diagnostic tests to manage their patients… their mistakes that cost patients so very much… their jeers and jests at the “American” system that just “orders it all.”
I have successfully ordered one CT scan so far, on a 59 year-old woman who was sent to us from a day clinic “please assume management of confusion due to Grand-Pa’s Powder overdose.” Some searching on my iPhone yields that Grand-Pa’s Powder is a local over-the-counter pain medicine, high dose Aspirin and Tylenol… fine, sure, we can manage that… but did no one else bother to ask the family if they thought she overdosed on purpose… did anyone bother to ask why she was taking pain medicine in the first place? Well when I asked I found out that her original complaint was headache, and then several hours later family noted she was confused, they don’t think she took that much medicine… hmmm… I carry my CT order form across the hospital and up a flight of stairs to radiology… I’m told to put the order form in a box and the radiologist will review the request and decide if the scan is warranted… within the next couple of hours… “No, that’s not appropriate for this patient, she needs a scan as soon as possible,” I reply. The disgruntled technician who wants to go to lunch sullenly consents, “Fine, leave it on her desk and I’ll tell the radiologist.” I no more make it back down the stairs to the ER when my attending asks, “What happened in radiology, they just called and said you were very rude.” Lovely. But I get my way, if we bring her now my patient can have her head CT. There are no transporters today. My attending and I wheel the patient back across the hospital, up the elevator to radiology… the attending radiologist comments again on my rudeness as the patient is slid into the CT bed… unmistakable, irregularly shaped splotches of white dominate the screen where calm pools of black and grey should outline a normal brain… my patient has a massive intracranial hemorrhage… no one says another word about how “rude” I was.
CT’s of the belly don’t happen. Anyone with a questionably acute abdomen is taken directly to “theater” for exploration by the surgeons… honestly I’m not sure how that saves any money, but at this hospital the surgeons are more accessible than the CT scanner… and I find them refreshingly helpful.
My students and I draw all our own blood-work, drop tubes in a box with an order form, and then a courier picks it up and takes it to an outside lab for processing… Turn-around time for the most basic of tests is 4-6 hours. Gastrointestinal bleeding, diabetic ketoacidosis and the like are managed the best we can based on values from finger-stick blood sugars, hematocrit and the electrolytes I can see on the blood gases we can run here… hardly ideal… but we work with what we have.
Although English is the common language here, often it is not my patients’ first language, and even if it is, the cultural gap is often too wide to bridge and they stare at me blankly… Zodwa, a South African medical student, is my savior as she moves seamlessly between English, Afrikans and !Xhosa to get me a history I can work with. And of course, when all else fails, there are the wonders of modern technology. When an immigrant patient speaks only Swahili, Portuguese or French, leave it to my iPhone and Google to provide an online translator so that I can understand at least the bare minimum of why my 24-year-old female patient is tachycardic to the 150s and has a potassium level of 1… she vigorously nods her head “yes” to the Portuguese translation of “have you been vomiting” that she reads off my iPhone… thankfully this patient can read.
The newness has faded and my patience worn thin, I’m tired. I want things to work. I cringe when I come back another day and see the 93-year-old woman with a broken hip lying in the ER for a third day… orthopedics is trying to keep up… the 79-year-old in the next bed over with the fractured and dislocated shoulder has been waiting longer. Another patient discovered on morning rounds sitting in chairs holding her EKG that clearly reads acute heart attack… unrecognized, and untreated, by the night team.
I’m tired of breathing through an N-95 mask every day, but I have long since lost hope in the triage system here providing me any protection, so I wear it… constantly… And when paramedics roll in with a confused and combative patient and we remove her shirt and see the dark purpuric lesions, glaring warnings of the pathology before us, we pause, step back, and I am grateful for the mask I already have in place… I take a tab of the Cipro antibiotic that I refuse to leave the States without anyways… they may be nonchalant about HIV and TB, but Meningococcal meningitis is something even the South African system respects.
On a particularly busy day I accept a young female with abnormal vital signs back into the resuscitation area… she is sent from clinic for confusion and hypotension… something to do with her HIV and TB medications… at least that is what I can decipher from the hand-written scribble in the paper notebook that is her official medical record. I’ve just about had enough with this broken system, and as I tie the rubber glove around her arm in preparation to draw blood (there are no tourniquets here… of all the cheap stupid things I could have taken from the drawers at home…) I look up and her eyes catch mine… the whites of her eyes are the bright yellow of liver failure, but it’s the dark irises that I hadn’t really noticed before… windows to the soul… deep, quiet, questioning and afraid… and her reality and my own selfishness slam down around me. Who am I, merely a visitor… Who am I to be fed-up and irritated after only a few short weeks… how dare I become defensive and short with those that live and work here every day. I with the luxury of being tired and irritated with this system, for in just a short while I go home… If I were to become ill or injured I have some of my country’s best hospitals and doctors at my disposal, I have health insurance, I have the knowledge to understand the system… but my patient has none of that… She is in fulminate liver and kidney failure, a side-effect of her TB and HIV medication regimen… she is alone… this hospital is all she has… today I am all she has… There are no transplant lists for her, there is no dialysis. She is 27-years old. I finish the rest of that day and the ones to follow with a quieter demeanor, renewed patience, hardened resolve.
A week of vacation allows me to collect a sixth African stamp in my passport as my husband and I cross into Namibia on holiday. Far removed from posh Cape Town, a flight and then 6-hour drive on gravel roads ending in the Namib Desert reminds me how beautiful and harsh the majority of this forbidden continent really is. Herds of cows and the occasional goat herder are all we pass. There is no cell-phone signal. There are no stores. Gas stations are few and far between and even this stubborn, independent, prideful career woman is smart enough to spin my rings palm-ward and step closer to my linebacker-sized husband when stopping to refuel the car or buy more bottled water. As always, my Trevor gives me only the best this continent has to offer and we arrive in a luxurious desert resort… we have an amazing time, sheltered from the ‘real’ Africa that surrounds us… but the images of starving cattle and equally thin herders lingers… savor the taste of clean drinking water and fresh fruits, the children you passed on the road have likely not had either… play on red sand and forget how very far removed from the rest of the world you really are… forget that if you were to become truly sick or injured you are a day’s travel from something that resembles healthcare… and I’ve seen what goes on in these hospitals… “If I get hurt, get me to Europe,” I joke to my husband… but the undertones beneath those words ring uncomfortably true.
The red sands of Africa… said to run red from the centuries of bloodshed they have borne witness… silent and indifferent to the human suffering that plays their stage… Silent and indifferent sit the majority of the first world to the human atrocities faced on this forgotten continent every day. And when justice fails those who cannot afford to buy it, the people band together… and I’d rather not know the sins of my patient beaten into delirium and near-death for the crimes he committed as I quietly tend to him the best I can… “community beating” I’m told it’s called… vigilante justice… Rather just move on and wash the bruises and sew the wounds of the pretty young girl beaten and raped for the offense of walking home from work…
And I think again of the groups of children that loiter in the small Namibian villages we pass, the goat herders who follow their flocks… the dark eyes that meet mine in the streets that can no more envision the life of this misplaced blue-eyed American than I can understand theirs… yet there is something unspoken that binds us, something innately human that fixes our gazes longer than the casual passing glance…
And in South Africa the same exchange, this time in the setting of one of the most revered professional relationships that exists… a doctor and patient… and there it is… this is what brought me here… this is International Health… transcend every cultural, language, educational barrier… for just one moment forget my student debt, the sacrifice of my 20s and personal life, the friends I have disappointed, the relationships that have suffered… because here it is, this is what I’ve worked for… invited, trusted, needed, and after so many years of training, capable, into the lives of those who have so very little, who live at the ends of the earth in poverty we cannot imagine…
What is humanity if a country as great as the United States cannot train and give at least a few to find these peoples and attempt to give for the sake of giving… what is humanity if not to endeavor to conquer this great divide, the inequalities, the obstacles, the broken systems and broken lives. There is no profit in International Health… there is no end to the demand, no tangible gain to be had… but can you calculate a value on the obviously simple yet extraordinarily complex act of doing something merely because it is right? And it takes the resources of a nation, of family and friends, to support those few physicians who will accept this challenge. From the teachers, professors, and attending physicians who train them, the families and friends who lay their own needs aside and selflessly support them… I remember them all and the roles they played to help me reach where I am today as I smell the sea-air of the Cape and am warmed under an African sun… and each time I lay my hands onto one of these patients, it’s the hands of all who stood behind me that touch them as well… and sometimes, for one or one-hundred, we will make a difference… and that is what a little bit of humanity can do…
There is a beauty here that cannot be denied nor adequately described. A vitality, an energy, consuming, powerful and raw… calling back to the very origins from which we came. The landscapes are rugged, harsh, unforgiving and stunningly beautiful… but the heart of Africa pulses in its peoples. In the face of tremendous hardship and brutal realities they stand proud and without the indulgence of self-pity, their spirit defiant and breathtaking to behold. The baritone voices of the !Xhosa and Zulu men booming in harmony at work… the vibrant headdress and tireless hands of women with content and quiet babes tied to their backs… sun-leathered skin, shoeless soles hardened on hot pavement. Perseverance, warmth, and respect… the weight of their trust heavy on my shoulders. Fallible roads, lack of infrastructure, poverty, violence, hostility, corruption… there are risks… there are nights I lie awake wondering why I’m here… But something deep inside has brought me this far… something inside calls me further to a future I do not yet know… but I am not done. This All is Africa, and I will be back.