Doctoring On

The first year of medical school one of my classes was called On Doctoring, which was – more or less – a formal setting to groan and complain about time spent in the library, difficulty of classes or strong personalities that needed to be navigated around in order to succeed as a medical student. When the wailing subsided, or when the holidays had just passed, we also learned physical exam and history taking skills. It was the first step in a career of medicine. By teaching us the learned talents of recognizing a normal heart sound and bringing together a community of people going up against similar challenges, we had entered medicine.

Today I felt I was living through another course, where there were no professors, no time for cramming and no neighbor to bail you out when you didn’t know the answer. School was out.

The clinical staff had spent the weekend in the capital, where the stores are not the size of refrigerators, the food extends beyond cassava products and medicines are not grown in the backyard. Rachele and I fully loaded the ambulance with new supplies and left at 7am to get back to the clinic by 9:30. Along the way, we were told that our doctor had been detained in Bujumbura despite his hopes for an early departure in our other vehicle. Our next call came to inform us that there was a national healthcare strike. Every government owned hospital – which is to say practically every hospital – would be closing if their employees did not receive a raise of salary from one of the poorest governments in the world. Until they had their answer, patients would not be seen. But our hospital, being a private, free clinic, was very much open. We were on our way to one of the only open clinics in the country where Rachele and I would be the closest things to a doctor for who-knew-how-far. We had a staff of 6 nurses, 2 of whom had the equivalent of an 11th grade education and 4 of whom graduated from school after grade 10 with a nursing degree.

While Rachele began training the nurses with our translator as we had planned, I made the rounds on the inpatient unit. One woman had stage IV HIV, had been spiking fevers through the weekend and was complaining of stomach pain, likely due to the fact that she had not moved her bowels in over a week. Next to her was a woman who had suffered a stroke 3 weeks ago that left the left side of her body completely immobile. To compound matters, she had lost control of her bowels and bladder. She was brought into the clinic, not for this, but because she caught malaria three weeks later. The next patient had cardiac insufficiency and was in her 4th month of treatment for active tuberculosis. Her legs were swollen and she wasn’t able to lie flat. There is no cardiologist, let along a cardiac surgeon, to look further into her condition. In the men’s ward was a patient who had late stage HIV and was left for dead by his family. More specifically, he was locked in one of the two rooms in his family’s mud hut, and had not been fed or cared for for a week. One of our community health workers was near his hut and had heard of him, so notified our clinic. When we took the ambulance to bring him to us, he was completely wasted, unable to stand, suffering from almost continual diarrhea and was completely naked. His wife came with him to the clinic for one day, then told him he was going to die, the she wanted another husband and disappeared. It took two days to convince him to take medicines for HIV, for he wanted to die too. Now he is slowly improving and was able to stand on his own for the first time in about a month. But he, too, has been spiking fevers and has lost the appetite we were so excited to see return last week. And so it went down the line of the nine-bed inpatient ward. Sick patients needing care and a growing line of people waiting to be seen, and possibly hospitalized.

One of the brighter nurses and I began with the long line of consultations. But I would never see more than one of them. The first person to walk through my door was a young woman, carrying a child – her first – who she told me was 3 weeks old. He had been born without complications, but began vomiting 3 days ago. Yesterday she began to worry and brought the child to a local ‘healer’. The community healers have no training, but find ways to offer treatments they bill as cures and charge a hefty price. For Josue, her son, the treatment of choice to combat vomiting was to cut off his uvula, the piece of tissue that hangs down in the back of your throat. So with a pair of scissors, Josue’s was cut off. She brought her child to us because he now had a fever, was having difficulty breathing and seemed to be going in and out of consciousness.

It took all morning and afternoon for me to treat him and feel comfortable doing what I knew – but still doubted – to be correct. We burned precious fuel for our generator to use our oxygen concentrator and keep his lips a lighter shade of blue. We gave him an IV line – started skillfully by one of the nurses – and calculated the dose of antibiotic, after discussing which would be best. Rachele was an amazing nurse, helping with whatever needed doing and holding Josue while suctioning the secretions he was choking on. It was a moment of true doctoring, one of my first. It wasn’t for practice, or without consequences, and there was no one else. A newborn child who looked into my eyes as he gained and lost consciousness was banking on us making the right decisions and seeing them through.

When the doctor arrived that evening, Josue was still having difficulty breathing, but his fever had improved and he was interactive with his mother. It will still be a long road, and there are many things that could send him in the wrong direction, but I felt like we did our job. Working here can feel like horse jumping with a mule, but we got over the first hurdle and are on the right course for whatever is next.

When the goal is life, and not a favorable evaluation, the game changes. In fact, it’s no longer a game at all. What has brought me success as a student, were not closely tied to the skills that allowed us limited success with Josue today. Sure, knowing the answer on paper needs only to make a leap to real practice in order the bridge the gap, but that gap is much bigger than I had imagined. When the consequences are death rather than a few points on a quiz, it’s a lot harder to check the right box, even when you know which box is right.