It was one of those days when I was happy to be a doctor, when being in clinic brought me a surge of energy and joy. My first patient was one of my favorites. She used to come in every week as we talked about how to live a healthier lifestyle. Now, she was in a healthier relationship and had stopped abusing alcohol. Her depression, which was concerned me because of her suicidal thoughts on our first visit, was now well-controlled, and she was ready to discuss stopping smoking. We brainstormed how to do this, how stopping smoking could be more difficult than when she quit cocaine, and how she would need a careful plan and a good support system. But she thought that this was important and she felt confident to change. Her concern for her heart and her respect for her boyfriend would motivate her. We set a quit date for one month.
My next patients were a couple who always brought smiles to my face. I hadn’t seen them in about 9 months, they had been traveling to see their parents in India and their sons in Japan. We laughed at how their weights were the same and how their cholesterol measurements were within a few percentage points of each other at their last visit. They beamed, saying that they did everything together and that they weren’t surprised they were so similar, as they had been married 31 years. Even with similar measurements, he was 6 years older and his 10-year heart risk was high enough that he should be on some medication to prevent heart attack. We agreed for a new cholesterol test for both of them next week, and discussed the importance of continuing the medication once started.
My next patient was another one of my favorites. I’ve known her for seven years, and the transformation in her life during that time has inspired me. After making some boundaries in her social and business life, her depression and anxiety had come under control. I still remember the day I met her, when she was so anxious she couldn’t talk about her concerns, and five years ago when she cried in my office for almost an hour. Today we talked about her diabetes. The test that should have told us about her long-term sugars over a 6 week period was great, but her sugars at home were two to three times normal. She brough her home machine with her and it matched our clinic machine, so I had to conclude that the first test was in error. That happens about half the time for that particular test in our city. At one lab, some years ago, I learned that I could trust test results from the technologist but not the tests run by the technician. Others I suspect might have an issue with the quality of their machines or reagents. But either way, I’ve become used to mistrusting certain laboratory testing in this town if it doesn’t match other evidence I see in my patients.
We talked about this patient’s 18-year old son, who had shed a few tears in my office last week as he discussed his struggles with stress, insomnia, and pressure at school and in sports. The family had been working through some new methods of supporting each other and letting go of certain expectations, and I was thrilled to hear that he was sleeping better and the whole family was feeling more positive. Days like this make me so happy to be a family medicine doctor who can take the time to really promote lifestyle and prevention.
My last patient came an hour late. Her husband had called, saying she was on her way. But she hadn’t gotten any lab tests since her visit last week. That was troubling because she had an infection around her eye that wasn’t improving after four different types of antibiotics. She stayed in the Central Hospital for four weeks without improving before she checked herself out and decided to see me. Her husband is a gardener and his employer recommended me after I was able to help the wife of her friend find a diagnosis of lumbar tuberculosis that others had missed and which had been disabling her. Really it was the physiotherapist who recommended the testing to find that diagnosis. At least I had recommended the phiosiotherapist, but I am well aware that I was stumped by the diagnosis at first as well. But with this patient, I fear there will be no miraculous recovery. I am afraid that the infection has spread to her brain, and that we can’t source the right antibiotics to fight it. In Malawi, it is easy to buy antibiotics without a prescription, and so people will take amoxicillin for a backache or two different antibiotics for a cold. So many of the serious infections are resistant to most drugs. Last week, I tried to emphasize the importance of the family going to get a culture analysis of the drainage from the eye, so that we could know what kind of bug this was and how to treat it. In the meantime, I prescribed two pills which are recommended for severe infections in the eye heading to the brain which would be used for the most common resistant bacteria in the west. It hadn’t helped. So the patient is laying on the bed in the hallway, her eye swollen shut, and looking weak. Her husband is trying to see if they can get her a CT scan today, but he arrived so late that the machine is already turned off, and because she has eaten, the tech recommends against it. We discussed last week that this type of infection, which seems to be showing signs of brain involvement, was very serious, but sometimes it’s hard to know how far to push, how much to hope.
I dragged a few of my Malawian colleagues to see her and to recommend if there was any additional treatment. They agreed we should try one more injection, they recommended we should keep her in the hospital overnight. We discussed the swelling in her legs and the kidney failure manifesting itself in her labs. And how the specialists at the Central Hospital had already tried everything they could for a month. If she recovered from this, it would take a miracle. I’ve seen plenty of miracles in these parts, and I always pray for miracles. Today I pray with the family and the patient in the hallway as they clutch their admission paperwork and struggle to decide whether to stay for the night, whether they can afford the $20 per night fee as they wait for a $120 CT scan that the employer agreed to sponsor. I leave work two hours after my last appointment. I’ve missed the dinner plans we had, I told my husband to leave without me. Some days I have better boundaries and leave clinic on time and tell late patients that I can’t see them. Tonight I gave a little extra of myself, and I feel drained. I wonder if it made a difference. I wonder if my colleagues will feel less comfortable making decisions about her care overnight because she was seen by a Western doctor first. I feel down as I leave clinic – is there anything we can do that will lead to healing for this woman?
Some days I have trouble shouldering the stress of working in this context. I love the years-long relationships and the transformation I see. But sometimes the feelings of helplessness as a patient suffers from a disease that could be treated elsewhere leaves a heaviness in my heart as I leave clinic, and a dread that keeps me from wanting to return next time.
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