Small kindnesses

Yesterday, I met the first patient here who really made me want to cry. If I hadn’t gone to Nigeria, I think I would’ve been more shocked at the seemingly more futile nature of medicine here, but I was worrying that maybe I’d gotten too hardened. It seemed to me that I too quickly was able to shake my head, say “what a shame”, and move on, with too many patients. For instance, we see many patients who have chronic kidney disease. In the US, they would be seen by a nephrologist, had many tests done to diagnose the cause, put on many kidney-saving medications, get routine lab checks to make sure we’re preventing complications, and eventually, if they need it, be on dialysis. Here, if they have plenty of money, these things might happen; but most of them can’t even afford what we consider the most basic of labs or medications. People with kidney disease are put on meds that can cause dangerously low potassium; but there’s no use checking potassium levels, as there’s no supplemental potassium to give. They patients often come into the hospital with fluid everywhere in their body, as their kidneys can’t get rid of water appropriately. So we see these patients on rounds, we give them what meds we can and hope the side effects won’t kill them. We tell them they’ll die of their disease in a year, most likely, and we discharge them still fluid overloaded, but what can we do? And I have very quickly learned to accept that this is ok, as it’s just how it is. So we move on to the next patient. Don’t get me wrong, patients here do get excellent care and the doctors are so smart, but the reality is, they just don’t have as many resources as we have in the US. Of course, despite this lack of resources, many patients who come to the hospital are healed as well, but sometimes it’s easy to forget that when I see so many people die of curable diseases.

But yesterday, one of the students took me to the TB ward. We see LOTS of TB here. (I coughed just once today and freaked out---unlikely I’ll get it, but still!) One of the things I have been doing like crazy this week is to listen to case presentations. The 3^rd year medical students are required to have a number of observed case presentation and physical exams, and I am most definitely less daunting than their usual “seniors” (that’s what they call anyone in a higher position than them). One part of the case presentations is that I’m expected to quiz them endlessly in the Socratic method so it ends up being a very involved teaching session. So I walked with the student to the TB ward, a building at the far end of the hospital. Unlike the very crowded medicine ward, the TB ward seems deserted. There are only about 10 patients here and capacity is probably about 40 beds. It is very quiet and only half the patients have “attendants” (in Uganda, most of the patient’s care is provided by their family; the family is responsible for feeding them, bringing sheets, changing clothes, making sure labs get done, giving meds, etc; they are called attendants). If there is no attendant, if the nurse has time, she will attempt to give meds and maybe feed the patient. If the patient has no money, he can’t get any labs done, he can only get the few meds provided for free from the hospital and he only gets food if someone is feeling charitable towards him (I think it’s often a fellow patient or a nurse or student). This particular patient was a young 25 year old man without any attendant or money. He had bad TB which we thought had gone to his brain, so he was psychotic. He couldn’t talk. When we approached his bed, my med student waved his hand in front of this man’s face and the man didn’t react at all. He just started blankly in space. He hadn’t moved from the position he had been placed in on arrival about 18 hrs prior. The bowl of potatoes someone had given him the night before was still sitting on his bedside table untouched. His free medications from the morning had not been given. He was very cold to touch and dehydrated and looked AWFUL. The day before, the med student told me, the patient had been lying in his own diarrhea for 24 hrs and since he had no attendant, no one cleaned him. The med student took pity on him and had a nurse help him clean the patient up and brought in a pair of pants for the man to wear.

My med student started to present the case to me, but two seconds later stopped. He didn’t have the heart to continue with the man in such a sorry state. So, instead, he put the chart down and started to feed the man a small bottle of a high-protein beverage which someone had donated to him. The man could hardly swallow and still couldn’t focus his eyes on us but he was clearly pathetically eager to drink something. We coaxed him to take his meds and ever so patiently, my med student fed him the whole bottle. After doing that, we tried to find a nurse to help us give him his iv fluids and a few other treatments. The med student then presented the case to me. We discussed his problems, discussed what we should do to treat it, and then went back to find the nurse. She had a tray of things prepared for the man, but she indicated that she didn’t have time to do it and that we should do it. Now mind you, the med student had no obligation to do this. My student was in the medicine ward; once the patient is transferred to the TB ward, he’s officially under the care of another team and my student has no responsibility to him anymore. It was 4:30 PM; the student had come back of his own volition to present a case to me for his own learning and no other reason. He certainly could’ve told the nurse, “have the next shift nurse do it”, and left it at that. But he decided to follow up on it and do it himself, as we feared no one would do it in time if we didn’t.

Of course, the man was so sick, he could die no matter what we do. But I just thought it was so sad, that this man had a disease that could be curable, but he would probably die because there was no one there to give him his meds, or feed him. It seemed so awful that he should lie alone and forgotten in a hospital bed, and if it hadn’t been for one medical student’s compassion, he wouldn’t even have a pair of pants on. But if he were to live, in large part it would be due to one student’s kindness. And it was this that made me aware again that no matter how futile or unjust it all can seem, and no matter how hard it is to feel you can make any difference, you still have to try. Even the small things matter. Despite having more limitations, Ugandans use a combination of kindness, smarts, and strength of will to heal each other and themselves and I will endeavor to be remember that this can prevail while still being aware of the need to equalize care everywhere.