Jack, Bob, and Smith

This was my last week rounding in the adult wards. It has again presented challenges, but I have been determined to make this last week the best week. I have still been experiencing difficulty in gaining trust from the leading Kenyan physician on my team, but I decided if I couldn't gain her trust, I would gain the trust of the patients and nurses. It turns out that this may have made more of a difference than anything.

I'll tell you the stories of Jack, Bob, and Smith (names changed for privacy)...

It started with Jack. Jack is a mentally retarded 18 year-old boy, and he came in having convulsions and also developed sores around his mouth. For some reason, I was always drawn to spending extra time on his care; I think this was because either one or both of his parents were always sitting with him. I just did simple things like checking his treatment sheet ("T-sheet") to make sure medications were being give (which I did with all patients) and talking to his parents to make sure they understood what was going on and seeing if they had any questions. When we did tie-die for our craft day at the Sally Test day care center, I made a tie-die shirt for him. Jack could never speak, but his parents were really grateful. He improved after a long time in the hospital, and one afternoon his mom came up and hugged me and said "We're going home!" I was so happy to see them take Brinda out of the hospital where he could be loved by the rest of his family.

On to Bob... Bob is an extremely ill patient with HIV, cryptococcal meningitis, and tuberculosis- quite a load of diseases. He has been a challenging case since he arrived in the hospital, and his wife is also always there with him. It seems like his wife is there during the day, and another family member comes to spend the night with him. I think this is one of the reasons Bob has held on this long and is fighting for life.

I again would always check on Bob and talk to his wife (sometimes with a translator) to see if they needed anything. One of the physicians told me that he had not been taking his ARV's (HIV medications) for an entire week because he was out. This is not acceptable- the nurses should be making sure that they are taking their ARV's, even though the patient usually keeps them at their bedside and it is ultimately their responsibility. Compliance is vital with HIV treatment- even missing one dose puts them at an increased risk of deadly infections, and their disease can take a turn for the worst. I immediately went and got him a prescription and filled it in the pharmacy. I brought them to his wife, and she was so grateful. She gave him his medications every day, but she just didn't know how to get more and no one else bothered to help her or explain it to her.

A couple days later, she showed me that he was also out of tuberculosis (TB) medications. I wasn't sure how to get these refilled, as patients usually go through a clinic, but one of the nurses explained it to me. She discouraged me from going to get the medication myself because the patients need to learn how to get them and use the system. I understood this, so I brought Bob's wife with me to get him some more medications. I took her to the TB clinic, and told the doctors there about her situation. She had to wait some time to be seen, but she eventually was successful. I went back in the afternoon to make sure she was successful, and she showed me the medication and was not given enough to last for 2 weeks (the usual amount given during the initial treatment phase). I then went back and got her the correct amount and explained what to do when she runs out again.

Yesterday, the team noticed that Bob was in severe respiratory distress- his oxygen saturation was in the 80% range, and he was not yet on oxygen. He had indeed taken a turn for the worst. This lack of oxygen is deadly and can cause a lot of brain and other organ damage. After much persistence, we finally found some oxygen for Bob. I went back multiple times to see if he had improved, and he had not. I started talking to his wife, and she said that he had not been making urine for the past couple of days. This is a sign of acute renal (kidney) failure, and can be life threatening- definitely a contributing factor to his condition. She said she forgot to mention it to anyone else (nurses, doctors, etc). First of all, it is not her responsibility to monitor fluid "ins and outs." That is what we as health care professionals are there for. Secondly, I don't think she forgot to mention it, but she has not been treated with compassion, so maybe she was just afraid that nothing would be done or she would be scolded. I immediately told one of the physicians on my team (who actually did scold her a little for not mentioning this sooner), and she fixed his catheter and increased the amount of fluids being given. He started passing urine through the catheter, and hopefully today he will have improved a little. I really appreciated this physician's sense of urgency and persistence in correcting this problem. She did a great job.

I will be going back to the hospital today (Saturday) to deliver food to one of our extremely wasted HIV patients. He is so skinny, I couldn't even describe it without you seeing it first hand. He had a relative there, and I asked if he would be able to eat. He said yes, and that this patient was a fighter. Later that day, I brought him some leftovers from our lunch (eggplant casserole, chicken, rice, vegetables- lots of protein). He was awake, and his face lit up when I handed him the food. He immediately started eating, and I think he ate the whole container of food. He then fell asleep, satisfied maybe for the first time in a long time. Sonak said that sometimes food can save these patients faster than medication, and you can see them gain weight and literally come back to life. I will bring more food over the weekend, and hopefully he will keep fighting.

After I gave out the food, another patient (Smith) in this same cube (area of beds) came up to Bob's wife and gave her his empty TB medication container. (All of these patients have been in the same area.) She looked at me (along with every other patient in that cube) and said "We all love you because you help us and understand our problems." She then handed me the other patients medication, and Nicholas just looked at me. I smiled, told them I would be right back, and went to get another month's supply of this patient's medications.

Let me pause and give you a little background on Smith. He has what is called an empyema. He has an infection in his pleural cavity (the area where your lungs are), and pus has been building up inside of him. We put in a chest tube (literally a tube that goes straight into the side of his chest) to drain the pus. Within 48 hours, we had drained 6 Liters of pus (imagine three 2-liter bottles of pop). The chest tube is still there; Smith asked me if we could take it out so he could go home- the fact that he asked this is an improvement, considering he could not talk or move due tot he pain before the chest tube. I had to explain that his tube would not be removed for a few days because if we take it out, more fluid will build up and he'll be in the same spot he was a few days prior. I told him to relax and rest, and he smiled and accepted this news. I wish he could go home too, but I definitely don't want him to have to come back a second time.

Now, when I brought more TB medicine for Bob, he looked up and said "God bless you" with a huge smile. At this point, I knew that all this extra work of hunting down medications and staying at the hospital late was worth it. I finally gained the trust of the patients, and they were not afraid to ask for help. I saw the difference that could be made with a little bit of extra effort and persistence. Through these experiences, I learned that you can try to prove what you know to physicians all day long, but in the end it is the patients that matter. There is no way of knowing how long Barnabas would have gone without passing urine if his wife had not told me. The patients and their relatives are the ones that provide the most useful information, and you have the potential to directly impact their care by listening and going the extra mile.

This pretty much wraps up my time in the hospital here. Next week I will be spending a day at Sally Test, working on my research project, and I might spend a day on the AMPATH farm doing some manual labor (Ok, you can stop laughing now). Some days I have felt like I never want to leave here, and some days I have just wanted to come home. Kenya will always have a special place in my heart, and I hope to come back as a pharmacist, see how the program has developed, and try to help as much as possible. I am so grateful for this opportunity and for everything that Sonak, other students, and the patients have taught me. I have gained new perspectives and appreciations for the little things in life, and the things that I have seen and learned will always be with me.