Mourning and Contemplation

At times, it seems the hospital is bursting at the seems. It's not uncommon to have 2 patients to a bed. Occasionally I've seen people sleeping on the floor, but I'm pretty sure these were family members who didn't want to leave their loved one alone. Currently, there are a lot of visiting staff here. A radiologist, pediatric emergency physician, ENT head and neck surgeon, a maxillofacial surgeon, and a neurosurgeon. And it seems as if the whole country knows about it (people are lined up all day to get into clinic). In fact, the ENT doc has had cases scheduled for more than a year, cases he wasn't able to get to last year when he was here.

This is great for individuals getting procedures, however patients literally spend all day at the hospital. It's a full day event (and sometimes multiple days). My last patient of the day had taken public transit from hours away, and due to the long clinic wait, wasn't able to get the ultrasound she needed. Instead of going home, I think she is sleeping on a bench somewhere near the hospital. This was after we had to negotiate what tests to order. She couldn't afford a TSH level, a simple test we order in the US without even thinking about it. In fact, we order a TSH, T3, T4 and then maybe even a free T4 just to be sure.

I wonder what Americans would say if a simple clinic visit was an all day event? I guess this is why there is so much fuss over the health care reform bill. People are afraid of change, and for good reason. In Kenya however, you wait all day and then still have to pay for everything out of pocket.

I took call last night. The intern presented all his cases to me before calling the attending. I was able to teach him how to read a chest and abdominal XRay. A weird role reversal. Today I rounded in the morning, ran back and forth between clinic and the ED during the day, and finally scrubbed on the OR cases I had booked this evening.

Perhaps it's a good thing that doctors are so busy. You don't have time to think about what you just experienced. In clinic today, I told my first three patients they have terminal cancer, and there is nothing we can do. This was after my patient introduced me to his newlywed wife. He was 29. I looked another man in the face who just realized his mother was going to die of starvation in months due to her constricting esophageal cancer. I offered chaplain and hospice service, but he wanted more; he asked me to pray with him. Despite feeling that prayer was the only thing I could offer this man and his mother, I have to remind myself that prayer is a powerful thing.

A question I think many people ask themselves while working internationally is, "Am I really making a difference?" Is there any lasting impact, or would the hospital here continue to function without me? For me, this question isn't as relevant. Sure, I may make a small contribution here and there, but my role is fundamentally different than that of a long term physician. I'm a student, and while I'm here to serve, it is also a learning experience.

But, it's interesting to hear the other staff deal with grief. The death rate here is high. I'm sure there are many reasons: patients present very late in the progression of their disease, there is limited preventative medicine, resources aren't available, etc. After a while, it makes you start to wonder if you are making a difference. Here, I have seen many short and long term physicians mourn the loss of a patient. In a way, it is refreshing to see.

I guess if what they say about 7 positive comments being needed to make up for one negative comment is true, and can be applied to medicine, then I'm in need of some reflection.

1) I operated yesterday with a neurosurgeon on a 10 year old with an open skull fracture. He'll likely have epilepsy for life, but he wouldn't have survived without the operation.
2) I treated a Catholic nun with a GI bleed. Her admission hemoglobin was 5. (see picture below)

3) I admitted a child with a gastric outlet obstruction (according to Mom, he hadn't passed stool for 2 months) due to a duodenal stricture secondary to H. pylori. I didn't believe the mothers story until I saw how cachectic he looked.
4) I scrubbed on a case where we released a muscle contracture caused by a burn on a 3 year old girl. She will now have a lifetime of normal function of her arm, and not be a cripple.

5) I took the H&P of a child with likely Burkett's Lymphoma.

6) I helped wash out a septic wound, then a few days later assisted in the amputation of his leg. Without this operation, he would have died.


7) I'm helping CRUSH AIDS!


So, in the end, I think the answer to the question, "Am I making a difference?" is rather simple. It depends on your goals. Am I, or is anyone going to single-handedly save the world? No. Will I make a difference to an individual, where there would have potentially been no medical help? Yes.