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CLINIC
Occasionally you might try to sneak out between patients to survey the waiting room. Clinic day is never pleasant for the surgical intern, and you always hope that maybe no one else will show up. Maybe there’s a blizzard and everyone decides it’s just too dangerous to go outside. Usually not, though, and you peek through the Staff Only door around the corner from the physicians’ restroom and the free coffee and count the afternoon’s lineup. Every hour or so you may reassess the arrangement of comfortable patients in their cushioned chairs. Eighteen more. Twelve. Seven, then home. Clinic isn’t unbearable, but it only resembles what you think of when you think of medicine and try to remember why you wanted to become a physician in the first place. There is no real detective work, no mystery. Almost everyone comes referred with CT scans and full workups and diagnoses already assigned by their primary physician. There’s barely any examination to do and you almost always know exactly what the story is from the chart on the door: Patient referred by primary physician for (fill in diagnosis) requiring surgery.

From here the surgery intern does what he knows best: paperwork. There are insurances to check, clearances and consents and confirmations. Maybe someone will need a few more tests to avoid a lawsuit or console the anesthesiologist. There are instructions to go over and over and sign and review again. After 45 minutes the attending may or may not appear, announce the time in his schedule when the case can be slotted in, and then quickly retreat to his office where he can complain about how little he will be paid for the procedure you just spent an hour arranging. So goes clinic day in the large metropolitan US city.

Transfer the same surgical intern from the climate controlled architecture of the modern US city to a sweltering cinderblock box. Transfer to this village and its adjacent camp of refugees recovering from what the United Nations called the most brutal civil war of the ’90s. You are now in Sierra Leone, not far from the Liberian border (where another brutal civil war just officially ended), and you are once again on clinic day. Only you aren’t a surgical intern anymore, you are The Doctor and you are not here to do paperwork. There is no paper. When you arrive in the morning there are 50 starving women hovering over emaciated infants, waiting for you. They live next door in the camp, away from the relative wealth of the devastated subsistence agricultural economy in the village. They are the ones lucky enough to have walked here from the Mano River, crossing without being killed by the Liberian army or the Sierra Leonean army or the rebels or the local militia or the gangs of armed children that sprout like weeds in any country that survives a “brutal civil war.”

The cinderblock box has two rooms and you set up your pharmacy in the first. The pharmacy is donated by wellmeaning persons who gather supplies from other wellmeaning persons in the United States and other Western countries. It contains many lifesaving items like antibiotics and antimalarials and rehydration salts. It also contains many useless items like colostomy supplies and Chapstick. You set up your office in the second room—a small wooden desk, a steel basin of well water, a keg of soap, a small bag of disposable scalpels, lidocaine, a flashlight, and some gauze pads. You are not sure what you are supposed to do with any of it. The sea of rags and bones swells on the broken benches outside your room.

There is no chart. There is no referral from a primary physician. There is no primary physician. There is no diagnosis neatly packaged and ready to be checked off on the office visit face sheet. Patients file into the 6x6 room and present themselves at the tiny schoolchild’s desk behind which sits The Doctor, fresh and white and reeking of health. Sometimes the translator can help decipher what the Sierra Leonean villagers are saying, cobbling together enough Mende or Krio to get out a rough history. There are no translators for the Liberians. Individual histories are impossible to ascertain but the collective story you can guess. You have seen the empty rice sacks and corrugated tin that frames their houses. You have seen the grids of sewage that form their property lines. You have tasted the cassava pap and fetid water that keeps them (barely) alive. You have bathed yourself in designer chemicals and prophylactic antimalarials to fend off the swarms of insects that are the only creatures to have found a paradise here among the sweat and heat and excrement of so many disrupted lives. The path that most took to get to the camp can be estimated as well from the same stories we know from other brutal civil wars. Accused of being rebels by the military and accused of being military by the rebels, these particular Liberians faced a very simple choice: leave for an uncertain future in an unknown place along an unsafe route or stay and die for sure at the hands of whichever group decided first that today was the day to murder everyone in the village.

A mother walks in cradling her half-dead child in layer after layer of filthy blankets. The child wears a diaper made from a frayed dishrag and a torn plastic bag. The mother’s dark yellow eyes, stained by malaria and unrelenting dust, tell yet another story of suffering and desperation. You do not need a translator to see the fear in a young mother’s eyes, you don’t need words to make you understand that she is saying “I am hungry and sick and my child is hungry and sick and we have nothing and nowhere to go and please help us because even as miserable as this existence seems we still don’t want to die today.”

The child is on fire. The skin, marred by superinfected weeping scabies, looks shrink-wrapped around a toy-store skeleton. The muddy eyes barely move and the child doesn’t make a sound as you poke it and roll it over and squeeze the chest to appreciate the raging pneumonia. She weighs 12 pounds. Maybe 15. There is no scale and there is no one who can say her age. She does not look like she will get much older. She seems destined to become one of the 240 out of a thousand here who do not reach 1 year of age. You can treat the malaria, the worms, and the pneumonia. You can cure the scabies. You can bring down the fever. We have all these medicines and the mother will get them all today. With pantomime and broad gestures we will try to explain what to take and when. Pills for malaria crushed and taken with pap. Syrup for the fever and pneumonia. Creams to spread on the scabies. The mother will get everything we can give— from chloroquine to Chapstick. And she’ll be shuffled out and the next ghost will walk in with her half-dead baby and her malaria and her cataracts and her malnutrition.

The acutely ill patients are in some way easiest to see. Typhus and malaria can be treated. Parasites can be cured with one dose of medicine that costs less than a quarter. Diseases are easy. Life in a refugee camp is not. The children without pneumonias, the mothers without malaria, and the fathers with nothing more pathological than a lack of food are the most troubling. There is no cure for them, nothing you can pack in a bag and dole out from your makeshift pharmacy. To be a doctor here for even a day brings you face to face with the ordinary brutality of a life filled with hunger and violence and hopelessness. You are faced, too, with the insignificance of everything you have learned and forced to rethink the illusion of power you may have once felt at being able to cut someone open, fiddle around a bit, and put him back together. One day in one clinic a few kids were lucky enough to get sufficiently disinfected and sent back to their tin shacks to slug it out a little longer. A few mothers were relieved of having to watch their children die. For now.

Occasionally you might try to sneak out between patients to see what kind of dent you are making in the line of 50 that started in the morning. Clinic here is sometimes overwhelming and you hope that maybe a freak rainstorm will keep everyone away for the rest of the day. You peek out of the suffocating cinderblock room at the herd of bones, stiff and limping, littering the broken benches and spilling onto the cement floor. A hundred. A hundred fifty. They keep streaming in, dreaming that you have some magic that will make it all better, counting on their faith in The Doctor just as you have been losing yours. Off to the side, under a dying tree, in the sunbaked dust of the view from your window, you see the Liberian woman, holding on desperately to her infant with the same stained eyes, eating a tube of Chapstick.

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Posts: 10177 | Registered: Apr 2001  |  IP: Logged | 

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This ain't no Toto Song:

So I have been in Ethiopia for 2 nights. It has been poretty intense. I saw 20 patients in 3 hours at the HIV hospice this morning, all of whom in various stages of dying or hopeless illness. The nuns try, and they do have some meds, but we have little or no diagnostic tests. It takes several weekes to transfer a patient to the public hosptal; where they would wait for another week anyway for the tests they need. The epople heer are very kind, but I can hoinestly say that this is the poorest place I have ever been. The per capita income is $700 (this may be generous) and the dcountry would starve without cahritable contributions and NGO's to feed them. You know things are bad when there is an entire expat community who mostly work for charitable organizations rarther than real businesses.

The food is decent (mostly befcause of all the expats). For those of you who have been in Dalak at West Philadelphia, the food there is actually
relatively authentic. However, injera (the Ethiopian bread) can get old after a few days because it is so salty. I'm not sick of it yet, btu give me a week. The coffee is magnificent, and everything is cheap. getting around in Addis Abeba has been a challenge because there are NO street signs, and if the streets have names none of the locals know what they are.

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I think my hotel is a brothel:

So I'm sitting on the porch of my hotel drinking a beer, minding my own business when I see this man and woman drive up in a cab. The man gets out, goes to the reception desk. He walk out a few minute slater and he and the woman go upstairs. He and then woman then come out an hour later and leave. Weird I think. This happenes a few more times over the next three days. I then ask the reception if it is possible to get a room by the hour and they answer taht it will cost app. 65 birr ($8) an hour.

This week I have seen the same guy on 2 different nights with different women. I should have known something was up when I found a box of condoms amongst the towels and soaps that were left in my room by the woman who cleans it. Apparently they expect everyone to use it, so they leave it their with the soap.

Apparently this sort of thing is common in Ethiopia, almost all of the budget hotels in addis do this to supplement their income. This place is crawling in prostitutes, I woudl say every ethiopian women in the club I went to Friday night was a prostitute. Nice.

Went hiking yesterday, should have remembered that it takes about 5-10 days to get truly acclimated to high altitude, nearly passed out on a hill. Played soccor today with the kids of Dr. Hodes, tralked them into letting me play goalie so they wouldn't have to do CPR when I had my cardiac arrest.

Also wen tback to the clinic, saw 15 patients in 2.5 hours, 2 of whom were babies. One was 6 months old and had not eaten in a week and had watery diarrhea. Looked like crap, was not really moving and was staring at me with sunken eyes. Had a sunken fontanelle too. My pediatrics attendings in med school would have been proud. I admitted her and gave her oral rehydrating salts. The other baby had an ear infection (I hope). Also saw recurring fever a few times and acute HIV. I admitted the acute HIV patient for a viral load, we'll see if thsi actually happens. Hopefulyl he will be negative and will turn out to have mono, and be scared enough to stop sleeping with the ubiquitous prostitutes in Addis Abab. Seeing children is pretty stressful, esp. since I haven't actually seen one in 3 years. They are not just little adults unfortunately.

Anyway, I'm going to get Indian food. Supposedly it is good, but you never know. I've been fooled before. The pizza has been pretty good though, but I haven't the guts to try the Chinese or Korean food yet.

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Driving Miss Daisy across Africa...:

So I met these two British guys with enormous motorcycles last week. Apparently they are doing a cross continent motorcycle trip and are on their way to Johannseburg, South Africa. They started in London, took a ferry from Spain to morocco, tan drove west. They took a flight over Chad and Sudan (apparently they were not crazy enough to drive through tose two countries) to Addis Ababa, where I met them. I aksed them when they hoped to get to South Africa, I guess the plan is Christmas, though one of them admitted that is might take a few more months than that. I than met 2 more brist who were doing the same thing, though they only started in Cairo and were drive directly South. I then met an Australian doing the same trip but in reverse, he started from South Africa and was heading north to Egypt. I asked him about driving through the Sudan and he said it wasn’t a big deal (“Just follow the Nile all the way, it’s easy.”). Right. I’ve decided that I’m avoiding traveling for FUN in countries where genocide is occurring in messy, socially unacceptable ways. That leaves Sudan out I guess.

Working at the mission has gotten easier. I’ve decided I don’t see kids anymore, which has made my life much less stressful. Funny thing today, these first year med students from McGill University showed up. Talk about deer in the headlights. One of them asked me if they should be concerned about “catching” anything. I replied “do you really want to know? Because I’ve got a list. It might just be better if I don’t tell you and you just wash your hands a lot.” He didn’t seem to happy with my answer, but he should have known better.

Anyway, things are going well here. I met some nice students from George Washington medical school who showed me the ropes and put up with me for two weeks, but they have now left and I am alone. I am working on this project now, hopefully I will have everything done in two weeks at which time I can also travel. It also might not be the worst time in the world to be out of Addis since the election results will be certified July 8, hopefully people won’t go crazy. I don’t think they will, but you never know.

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Posts: 10177 | Registered: Apr 2001  |  IP: Logged |