It is that time again

Believe it or not, I have actually spent the last three weeks in Swaziland working. This is why there have been relatively few posts. Work posts are probably the most interesting for everybody to read, but by far the hardest for me to write. Here goes...

Since Christmas, I have spent the majority of my time at RFM hospital in Manzini. I have posted about the hospital in the past. I really enjoy RFM for many reasons. We have a great, hardworking team (expert clients and nurses) that help keep me going. Most of my time is now spent in the clinic, but I also get to spend some time in the wards following the children I have admitted or new diagnoses. I also get great continuity of care. I have gotten a change to really get to know a lot of the children and their families. I know when they walk in the office exactly what we had discussed last time and can jump right in instead of having to flip through the chart. The only downside to RFM is that we are really busy and because of staffing issues we are only able to send one doctor right now. Luckily, we got fortunate to get a second nurse a few months ago. The nurses are wonderful and through task shiftting are now able to provide refills for our stable patients. This is an amazing help, but occasionally still the sick visits are overwhelming, charts stack up and we don't leave manzini until late. The other challenge being alone is not having someone there to review complicated cases with on the spot. A few times a week I call either my medical director or one of the other doctors for a phone consultation. I am also frequently bringing back x-rays to review with other people...how I wish I could go back to my radiology rotation in medical school and actually pay attention!

The good and bad thing about the continuity of care is that I have gotten quite attached to the patients and their families. When I see the six month old baby who weighs just over 6 pounds go to a chubby 18 pound 10 month old in just a few months, I share in the mother's joy. However, when patients get sick or die I also share in the families grief. Last month, we lost two patients within the same week. One was a 9 year old boy who had been with the clinic for a long time. He was on the HIV medication and his CD4 had improved. Unfortunately, he had horrible lung disease either from previous TB or as result of his HIV. As a result of years of his lungs being so bad, the right side of his heart was failing. We had admitted him earlier in the year and tuned him up. He was doing pretty well, but in addition to his HIV medications he was also on 4 different medications for his heart and lungs. His condition and adjustment of the medications was requiring frequent (every two week) visits to the clinic after discharge. The aunt I knew was really good, but unfortunately not the one staying with him because she is in school. I never met the family members who were actually providing the care at home to be able to review how and if the medications were being given. His regimen would have been complicated for the most educated medical person let alone a illiterate gogo. The last time I saw him, his aunt begged for a month refill because they just did not have the money to come to clinic that often. She promised if he had any problems with his breathing or swelling she would bring him back. That was the last time I saw him. When we called the family, they said he had died. His prognosis would have been poor in the US, but with the added complications of poverty and multiple caregivers his condition was fatal. He was a sweet boy with a beautiful smile.

The other death we had was a 12 year old who was only in our care for a month. His CD4 count was less than 20. We were in the process of initiating him on the HIV medications. He complained of a chronic headache so I did a spinal tap, which was ok. He also was having cough, fever, and weight loss, which are all concerning for TB. He was not able to produce sputum for testing so I sent him home with an antibiotic to treatment pneumonia with the plan to do an x-ray when he returned to evaluate for TB. When he returned a weak later, he had been vomiting for a few days and that morning had started having a nose bleed. When we checked some blood work, we found that he had very low white count, severe anemia and very low platelets. Platelets help stop bleeding so he was bleeding because his were low. Amazingly, the hospital had both blood and platelets (sometimes we wait days) so he was able to be transfused once. Unfortunately, both his red blood cells and platelets kept dropping. He continued to bleed from his nose and I believe was having bleeding from his stomach. This was very concerning for a problem with his bone marrow like leukemia. At RFM, and really I think in the whole of swaziland, we are unable to do a bone marrow biopsy or any of the other tests to help us diagnose this. We started steroids and antiretrovirals hoping against hope that he would turn around. He did not. He was a bright boy, who knew what was going on. I remember one day he was very sick, his mom was holding a bucket as he vomited up blood and she just started to cry. I will never forget the look in his eyes as he watched his mother cry for him. Again, his prognosis likely would have been very poor even in the US, but knowing that there is more that could have been done for him if he was only in a different country is hard. His father actually stopped by our clinic today just to say "hello". He asked if I "remembered P.". I was not lying when I said, "Yes, I remember P. I will never forget P.".

The simple gesture of the father stopping by the office was one of the signs of gratitude that keeps me going. I have a little girl who has been in the hospital now for two months and has not only not improved, but quite possibly worsened. Yet when I told the make (mother) that I was going home to see my family for two weeks all she said was, "two weeks? you need to come back". Why she still has faith in me I am not sure, but I promised I would be back. Hopefully, to see P.N. smiling and playing.

My last story is a bit more uplifting. We have an 8 year old patient who lives with his brother and grandmother because both his parents have died. He was having bad adherence to his medications, which puts him at risk for developing resistance to the antiretroviral medications. He was coming to clinic with a caretaker from one of the rural neighborhood care points. The caretaker said that the grandmother was refusing to come to clinic and was accusing the caretaker of things. The nurse and I decided that I would drive one of the clinic cars one day so that we could do a home visit. This was a great experience for me. We drove to an area of manzini that literally took us 30 minutes to get to because the roads were so bad. It made me realize that even when patients are coming from "Manzini" that they might still have a good walk then bus ride to get to clinic. We finally arrived at the homestead to Gogo walking in from the fields with a walking stick obviously in pain. She sat on a mat under a tree and said something to the other little kids. The kids disappeared then returned with two chairs. We sat under the tree surrounded by chickens running around, some children sitting on upside down plastic tubs, others rolling metal pieces down a board and spoke with the Gogo for over an hour. She was upset by a misunderstanding at the clinic regarding the child going to stay with the caretaker. She insisted that he is family and should be with her. We finally convinced her it was a misunderstanding and negotiated a truce between her and the caretaker. We also spent time trying to empower the child. I was not sure what we had accomplished when we left, but I have now seen the child three times and each time his adherence has been 100%. It made me realize that while home visits are a very resource intensive intervention that they can be very effective.

Well, I think that is all for now. These are a few of the sadder stories that have impacted me this month, but please remember that for the two deaths we also had 16 children (at RFM alone) that we initiated on antiretrovirals who will most likely thrive. Every day I see a child who was behind in weight and development who is catching up. Today, it was a nearly two year old who I initiated in February who has started to try to walk since I last saw her. There is some rough going for the children here, but there is also still a lot of hope.