11/24/06

Thoughts \ Developed Thoughts \ Rants \ Raves \ Writing

06/28/2005 19:27 +0200 GMT

Lessons & Frustrations

Today was busy from the get-go. I woke up at a reasonable hour, but it was a bit cool, so I lazed in bed for another hour or so. Last night, as I was dozing off, I listened to a radio program in English, and the topic was about HIV, and ARV therapy. Lusaka has changed, and the very fact that this radio program is on the air is testament to that. Only two or three years ago, you would not have heard anyone talking about being HIV+, or discussing the importance of adherence to drug regimens, or about diagnosis. The energy that is pounding throughout the city with regard to HIV treatment is palpable. With the exception of Winston Zulu, who was the only openly HIV+ person I met in Zambia in the late 1990s, now there are scores that I have met, with hundreds more clamoring for the same hope and life that equitable treatment is now, finally providing.

As I sat reviewing some charts for quality, for contraindications mentioned in an earlier journal, the number of patients increased, sitting on the wooden and cement counter next to me, sitting on benches across the narrow corridor. And as I sat reviewing charts, focused about the importance of correcting erroneous treatment plans that slip through the volumes that pass through...I had a moment that came clear to me only later in the evening.

I was glad to be doing my part, but I still want to be connected with the patients in the hall, not reviewing their predecessors charts - not as much. The number of patients finally provided enough pressure that my supervisor stopped reviewing, and we saw three patients.

The first was a woman who was weak and very thin, supported by her husband walking into the 5x5 exam room crowded by three chairs, a cabinet and some of the staff's bags.  She wore a touque - what's another name? - woolen winter cap on her head. The woman had been treated for cryptococcal meningitis for two weeks, but had not improved. She was having trouble vomiting, and was still having stiff neck, headaches, anorexia, and decreased breath sounds on the right side. The woman needed to be referred to University Teaching Hospital (UTH), where she could have real diagnostics done for meningitis, and perhaps tuberculosis. Her conditions were underpinned by HIV.

By virtue of enrollment in the PEPFAR program, the UTH evaluation would be free of charge. However, the frustration of the process was that the patients didn't have transport money to get from Kalingalinga to UTH. That would be K30,000, or maybe K20,000. Regardless, it was more than the patient and his husband had. In two acts of compassion, my supervisor offered the patient her water bottle to share from, and offered the husband K20,000 for transport. The couple accepted both. The patient vomited the water and some semi-solids shortly thereafter, and the husband got the wash basin. There was a bucket with a faucet installed, hanging in a metal ring frame over a 2 gallon basin, to be used for hand washing. The woman carried a handkerchief to wipe her mouth. I don't know, but I hope...that the couple went to UTH, and that we will see them again for follow-up.

I will forego illustrating in depth with other patients. One was improving with ARVs, another was a tall woman whose CD4 counts had dropped at three times the rate of "normal" in an untreated HIV+ patient, from 500+ to under 200. Yet she was traveling to Kasama, where she intended to continue ART if she could just initiate it here. I felt more frustration. Would this woman really be able to get ARVs in Kasama, which is more remotely located in the Northern Province? Was her CD4 count accurate? Would she be well again?

From these few experiences, I discovered within myself a moment of clarity.

I don't want numbers and glory. I want to serve a manageable number of patients the way I think all patients should be treated, with full attention to all the patients concerns, and with whatever wherewithal it will take to alleviate those concerns. I can't see myself managing a massive number of patients. I'd rather get to know them closely, and to work with them in a cooperative effort to restore their health. Paul Farmer's model in Cainge, Haiti resonates with me. Already, the opportunity to be here in Zambia has had an important educational impact on me.

I listened to two chests, for heart rate and sounds, and for breath sounds. We evaluated peripheral edema, and tried to figure out if neuropathy was part of the problem. I charted for one patient, dictated by my supervisor. So a few experience points along the way, almost incidental to the more transcendental lessons.

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