3/24/13 Dying
and Death. Mazungo, How are you? And life changes…
DYING & DEATH
The past two weeks have flown by and every time I try to sit
down to write I find myself falling asleep at my computer or running off to do
necessary errands (i.e. buying toilet paper or box wine, the essentials).
My second week on the wards was difficult and there are two
experiences I will remember for the rest of my life. A 35-year-old man came across the border from
Rwanda to our hospital on “death’s doorknob,” as my attending Jerry said, after
he looked at him for 5 seconds. To put
this into context of clinical experience, it took me about 10 minutes of
speaking to this patient (who had mistakenly come to my chronic care clinic
instead going to the emergency department), that he was seriously ill and
needed much more that a medication refill or diabetes education. This also reflects two very important
concepts I have learned while practicing medicine here; patients are incredibly
stoic and are often poor historians- meaning it is very hard to elicit a
detailed story of when they got sick and what they are feeling. When I asked the frail man in front of me
what brought him into clinic today, he simply said that he felt very tired and
his belly was “paining.” Pain means
almost ANYTHING here. It means weakness,
numbness, difficulty breathing, anxiety, tingling, fevers, paralysis, coughing
etc. Also, “malaria” is interchangeable
for anyone with headaches body aches and/or fevers. In any case after learning more about
Stephen’s history, I realized that he was in liver failure. Most people here with failing livers have a
long history of drinking and have cirrhosis.
Stephen had a drinking history, a severe episode which lasted for 1-2
years, but no signs of cirrhosis (big, taught belly with ‘caput medusa,’ spider
angiomas, or gynecomastia- examples some of the classic things you see due to
increase in estrogen production in cirrhosis).
After carefully examining his liver, my attending came to the conclusion
he had hepatocellular carcinoma- probably from a long history of chronic
Hepatitis B (endemic here). His enlarged
liver was rock hard, his belly full of fluid, yet his arms and face were
similar to an anorexic. Stephen vomited blood at the basin near my feet, and my
resident told me he probably didn’t have much time left...meaning hours to
possibly a few weeks (if very lucky). He
was my patient and I spent the morning getting to know him and his brother, so
it was my duty to tell him his prognosis.
It was the first time I have ever had to tell someone they
are going to die very soon- perhaps even tonight. We gave him the option to bring his wife and
children to our hospital, or we could give him enough pain medication and he
could go home to die in the comfort of his own home. Perhaps he was in shock, or too much pain,
but his reaction was again, one of stoicism. He took a moment to understand
what I told him, he looked at his brother, and then he told me he’d like to go
home. He said it was easier for him to
cross the border alive, because trying to take a dead body across the border is
much more difficult and more expensive.
The whole conversation was surreal and I realized in that moment there’s
no perfect preparation to tell someone they are going to die. There’s only learning through doing. This was my first time, but definitely not my
last.
Later that same evening, I was finishing up my notes for my
patients when the Congo refugee camp nurse brought in a mother with her baby
for ‘emergency’ medical attention. Our
responsibilities only concern the adult medicine services and there are other
local doctors who take care of all the pediatric patients. We phoned the on-call pediatric doctor, but
of course my interest in children motivated me to at least see the child and
take its vitals to make sure he was stable.
I asked the mother to sit on the examining bed and I slowly unwrapped
the blanket covering her baby. The
minute I saw the baby’s face my stomach jumped into my throat and my only
thought was please let this baby have a heartbeat. His eyes were open but not blinking, his
pupils fixed and asymmetric. I listened with my stethoscope, wanting so badly
to hear something, to the point I even thought I did for a split second. But
then my hand reached down to touch the baby’s hand, and I felt his lukewarm
skin and very rigid limbs, I realized he was dead and in rigor mortis. Complete shock ran through me and I called
for my resident to help me confirm. I have never seen a dead baby before. I
have had child patients that I was taking care of (both in Zambia and in the
US) who passed away during the night and by the next morning they were gone and
I only saw the family. While of course
not easy, there was something so horrible and eerie about seeing this dead baby
and knowing that the mother had traveled all the way to the hospital with hope
that he could be saved. In that moment I
thought that because I’m going into pediatrics, I should be able to handle
this. At the same time I wanted to cry.
I took a deep breath, and told the mother that her baby had passed away,
covered him in the blanket, and put him in his mother’s arms. After trying to
comfort the mother for a few minutes, I was so thankful to my resident who took
things over from there because I walked directly to the call room and burst
into tears. It was the most overwhelming
experience of my life.
Later that night at dinner, we had a much-needed
conversation about the dying patient and death.
Talking about this was as much a cathartic process as it was an
education for what is to come. While I
never want to become the physician who is numb to the dying patient, I don’t
think it’s humanly possibly to feel that
emotional about every patient who dies.
But who knows, perhaps that is how I will always feel. The resident who was with me was so
wonderful, brave, sympathetic and professional – all at the same time- so I
asked her if it ever gets easier, or how does it change. She remarked that it doesn’t get easier, but
that over time it becomes less overwhelming.
I believe her, and it makes me wary of what I will see during my
residency. At the same time, her
demeanor and expertise during that situation was undeniably sincere and
comforting. I only hope to be similar one day.
MAZUNGO, HOW ARE YOU?
All the children here treat us (meaning
‘mazungos’ or white people) like celebrities. Everywhere we go, they say
“Mazungo, how are you?” quickly followed by an answer to their own question, “I
am fine!” Other kids also add, “Mazungo,
gimme money!” Some of these kids are
literally 2 years old and they probably have no idea what it means but just
copy big brother/sister. We’ve started
asking them back for money, to see if they get the joke…mostly they just laugh
and run away.
To recap the last few weeks quickly
(otherwise this post will be pages and pages):
-
On my one day off last Saturday we went
on a 6 mile run up over Hospital Hill (pictured below is the peak with our
guide mentioned before, Habati), down to the lake that you see into the
distance, and back up to Kisoro. We
walked back the other 6 miles, but it was so beautiful to hike almost at sunset
(don’t worry Mom, I went with 3 other
girls).
-
FISH!
We’ve been craving fish and ironically despite all the lakes nearby,
they don’t have fish swimming in them. Kisoro gets their fish from a lake near
Kampala (the capital) so they are brought on a truck to market every Monday and
Thursday. Of course the market opens at 9am and the fish are gone by 1pm. We start work at 8am and if we have lunch its
not until 1pm. Luckily one of the local doctor’s wife is amazing and bought us
fish, showed us how to clean it (de-fin etc) and we cooked a lovely meal (see
below). It’s called Tilapia, and it
similar to what we have in the states as far as texture, but a bit more gamey.
-
Electricity comes and goes here and I’ve just
gotten used to it. However our water was out for about 3 days, which really put
a damper on things. Especially because it was during my other day off
(yesterday…although me and a friend decided to make the most of it and have
brunch and wine at the nicest hotel here to make up for our circumstances). We had to fill up ‘jerry cans’ and lug them
to our house, then boil water for drinking (we do this every day), boil water
for bucket baths, put water into the toilet to flush, etc. By day 2 all of our
dishes were dirty and I really wanted to cook that night instead of eating out,
so I made Dad/Chuck proud by using my camping/Boy Scout techniques by making a
soapy bucket, a clean water bucket, and an assembly line, and in about 20
minutes all the dishes were clean. Who knew!?
See pic below.
-
Probably the reason I look this happy doing
dishes is that I was drinking a Waragi and Stoney. Waragi is the locally made gin (takes like a
sweet vodka) that is seriously strong.
It also comes in these funny packets (see pic below). One of the girls
here thought they were bra implants that you get in Victoria Secret bras….haha.
LIFE CHANGES…
-
I celebrated by 32nd birthday last
Wednesday and even after a long day on the wards I came home to great friends
cooking an incredible meal of spaghetti Bolognese and a very original dessert-
fried bananas with nutella and “chocolate ice cream” with cashews. The ice cream is in quotes because we’re not
really sure if it was ice cream. But it tasted amazing!
-
I also found out that I matched at UCSD’s
Pediatric Residency program (Rady Children’s Hospital) and will be finally
returning to San Diego (at least for 3 years!).
I was so excited as it was my top choice and I can’t wait to come home
to the support of my amazing family and friends…Rocky, and the beach. And
eventually to introduce Ben to the place where I grew up and to improve our beach
volleyball skills so we can dominate at the Thanksgiving tournament.
That’s enough for now- I miss you all very much and don’t
forget to send me updates on YOU!
Love,
Vanessa
