My real reason for the title, "let it go" has to do with my experience in the hospital the past few days. Like being at home, I am able to be "assigned" a patient for whom I check on every day, get lab tests, and then present their information to the attending (or boss) physician. I was assigned a patient called Innocent (I feel like I can say this without violating some confidentiality because there are 36 million people in this country and based on my own extrapolation of the number of people I have met with that name, there may be around 5 million Innocents). On Monday, I was assigned him as a new patient, mostly because he had caregivers who spoke English. From the start, he didn't look good and our clinical suspicion was that he has Tuberculosis that is in his lungs, abdomen, and probably hiding in other places, too. However, in order to start treatment for TB (which is 8 months long with lots of side effects and needs to be monitored daily) there needs to be a test proving the diagnosis.
Monday I spoke with the mother and father of this 30 year old man they were very helpful and grateful for me for taking over an hour to spend with them. I carefully examined Innocent and realized that he was having a difficult time communicating but he was able to follow along with requests I made. I was very thankful when I went to collect his blood samples that I was able to do it on the first try (at home we use fancy needles and usually phlebotomists or nurses do it so my skills have been tested here and they are finally getting better!) because it meant less pain for him. I felt like I had a pretty good plan for evaluating what was wrong, but knew that we were just confirming a very likely diagnosis.
On Tuesday, I decided to stop by the ward early on my way down to eat my usual monotonous breakfast of a Queen Cake and black tea. I didn't see too many new patients and I was ready to continue on my way but then I took one last glance down the hall which we keep our more sick patients (the ones that would be in the ICU at home with dozens of monitors and individual nursing care but here just have a bed closer to where the main office is) and was flagged down by the parents of my patient. The were distraught because he had more trouble breathing during the night and had appeared more disoriented to them. I took a look and realized the oxygen tank he was on wasn't actually working and so I got one of the interns to move him to another bed. He was hooked up to another tank with multiple other patients (we sometimes call it an "octopus" of oxygen because we have no idea how much of the 7-8 liters of oxygen are getting to which one of up to 8 patients one might be getting). I checked the results of his ultrasound and chest X-Ray and could confirm that he has a disseminated Tuberculosis infection. I informed the intern and we knew we could start his anti-TB medications that day, but that they weren't likely to take effect for at least a couple of weeks.
I left the family to grab breakfast and then check on a few other patients. By the time I got back, Innocent was still doing poorly and maybe was a little worse. The attending from the US who has been on the wards a lot lately saw myself and the intern at Innocent's bed as we were ordering his new drugs. At that time, the family couldn't find his file - a pink folder made of folder construction paper and they frantically searched for it. In the commotion, the patient's mother accidentally had her finger stuck by a needle attached to an IV pole that was left by the last patient in that area. Of course, we had no idea which patient that was or why they were here but the chances of them having HIV or some other serious transmittable disease are very high so she needs to get tested and probably take PEP (post-exposure prophylaxis) drugs to make sure that if she was exposed, she will not actually develop an HIV infection.
During this time, we determined that Innocent was in Shock, likely Septic Shock from either the TB or another bad infection in his blood or organs. I think by that point the Ugandan intern and senior resident didn't really think there was much point in getting worked up about it, but the US doctor convinced them to stay a little longer. (At home this would probably be a time where somebody pushes one of the emergency call lights and a patient has a "code" with a team of doctors, nurses, and pharmacists rushing to his bedside) We gave him lots of fluids and some steroids and he was able to breath a little better, but still didn't look great by the time we left his bed. We decided on giving the strongest doses of antibiotics and then moved on to the next patient because there were really no other interventions we could do for him.
When we left his bedside, I was sure he wasn't going to live past this infection. We have had many cases like this the past 4 weeks and they don't end well. The mortality rate on the ward is about 30% and it is usually because of patients coming in very late in their infection, like Innocent. I think I still was holding out hope that maybe something we would do would change his outcome. Maybe if we give him just a little more attention and dedicated support, he would pull through miraculously. Maybe the steroids would help him and the new antibiotic would buy him some more time. I had been thinking and praying about being here this weekend and had decided I didn't want to unaffected by all of the death and suffering I have seen because most days when we find out patients have "passed" overnight, we just shrug our shoulders and move on. I think there comes a point, especially on this particular Infectious Disease Ward, when you can't get too attached because there are just so many very sick patients and losing them is a constant reality.
Before I left the ward after 1 pm, I checked on him and it seemed he was breathing just slightly better, but I informed his mother that he is very sick and it doesn't look good. Despite the poor prognosis, she was extremely grateful. She said, "please thank everybody on the team for taking time to be with him and trying to make him better." She went on to say that it was now in God's hands and all we can do is wait. I had a sinking feeling that when I showed up the next day, I would find a new patient in his bed, but I secretly hoped I was wrong.
This morning, I took a short stroll around the ward and didn't see Innocent's parents, which was not a good sign. I went from bed to bed to see if he had been moved, but as expected, he was gone. I went back to check the log book and sure enough, at 2:20 in the afternoon, he had passed away. He had been suffering and was hardly able to get oxygen into his extremely infected lungs, so it wasn't a surprise. I felt a little guilty that I had left the ward to meet with some other students and didn't stay until past 2, but part of me was glad I wasn't there when he passed because I felt attached to him and his family even though I had known them for only 24 hours. If I had been there, I probably would have been wishing for CPR or intubation or some last ditch effort at saving him. I felt worse that I hadn't been there to say anything to his family, especially his mom. Thankfully, his father and brother came in in the middle of the morning to pick up the death certificate before traveling 300 kilometers for his burial on Friday. I was able to chat with them and offer my condolences. They thanked me for helping to take care of him and taking time to talk to them.
For some reason, the rest of the day I was just mad. Mad that patients, often young ones, suffer and die so often. I was mad that there is not a system in place to treat severely sick patients. I was mad that people don't come in early enough for us to do anything useful. I was mad that there wasn't more I could do, especially since I am often just learning what to do myself. In the end, I realized I just have to let it go. There isn't much I am able to change about how things work, at least not in the short time I am here. I can only do what I can with what I have and hope that it makes a difference. I prayed that I wouldn't be numb to the things I saw, and I guess something has changed in me. I
feel sad and frustrated but at least I am feeling emotions. I have to ask myself sometimes how the doctors are able to continue working at this hospital day after day, knowing that they are treating lots of patients, but that so many end up not making it. They continue working hard and intervening where they can, but face the reality of losing 3 out of every 10 patients that are admitted to the ward. I am amazed at how well some of them take it in stride and not surprised when others simple don't show up for work.
Overall, the week otherwise has been just fine so far. Angella's birthday was on Tuesday so we celebrated with a cake for dinner and we will be going out on Saturday night to have a real celebration with some of her closest friends. Match day is tomorrow and I will find out where I will be training for the next 3 years, which is really exciting. I have gotten a few really nice runs in around our neighborhood and met some really great students that just arrived this week. I do love how things are different here and every day is a reminder that I'm not in Minnesota. Since I really don't have any pictures to go with today's post, I will end with this rooster. Every morning when I go to the canteen to get my Queen Cake and tea, I sit at a table and this guy is walking around the restaurant, making noise and getting to close to my feet. The past few days though, I don't think he's been around. They do serve a lot of chicken so I hope he didn't end up on a plate. Also, while I was walking to the ward this morning, I heard a loud rooster call and realized that there was a similar bird just sitting next to a suitcase in the triage area inside the hospital. I am sure he was somebody's purchase while they came in from the village, but it still always shocks me a little when I see them carried around like another piece of luggage.
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