Last rounds at RFM

With the clinics over, we spent some of our little remaining time in the wards here, squeezing out whatever we could before our final departure. Weekend nights are typically busy in the Emergency Department, so after clinic on Friday I headed down, and the three of us spent a chunk of Saturday night there as well (we've done similar visits throughout the trip). Monday we sat in on an internal medicine department meeting, and tracked a few physicians on their complete morning rounds.

With a few years in the ED under my belt after undergrad (and most likely many more in my future), I was especially interested to get into the RFM ED and see what it was like. Much like in the US, in the RFM ED I was able to see a wide variety of illnesses/injuries, of all ages.

• Lots of thoracentesises (insertion of a hollow needle through the back, into the pleural (lung) cavity to drain accumulating fluid) due to the very high prevalence of tuberculosis.
• Not many beds in the department, so many patients sharing beds (one bed, generally used for Peds, almost always had 2-3 children on it, often with IVs running) or benches (one was used as a sort of waiting/asthma treatment room, with sometimes 3 or 4 patients packed together, inhaling nebulizer treatments).
• Witnessed a patient drinking charcoal solution (for the treatment of toxic ingestions); while this is a standard treatment everywhere, it was interesting to watch her drink the solution like a frat brother chugging a beer; I've seen this same solution used dozens of times in the states and almost without fail, it only goes down with lots of coercion from nursing/physician staff, threats of nasogastric tubes, swearing from the patient, and a few times, the cup being tossed at the staff. Seeing this compliance was, therefore, fascinating.
• Manzini is dangerous at night, and bottles are effective weapons (and the weapon of choice). And drunk patients will profess their love for staff, regardless of country.
• Nursing tools in Swaziland include a heavy, 1 1/2" open ended wrench, wielded to crank open oxygen tanks.
• Uniform/dress was a little looser... can't say I ever thought I'd see someone suturing in jeans, an argyle sweater, and a winter cap.
• In both the US and Swaziland, police had a regular presence in the department. However, while in the States, the police usually kept their pistols holstered, while in Manzini, one officer walked in with an assault rifle hanging from his neck across his chest.
• Similar to the US, even had some "full hospital" problems; at one point, the female medical ward was full to the point that several meningitis cases could not be admitted.

Monday morning, we sat in on a weekly meeting with the internal medicine department. Admissions from the weekend on-call physicians were presented, as well as any movement in the medical wards (censuses, deaths, etc.). We also had the chance to listen to the physicians discuss some administrative issues facing the department. While a shift from the clinical focus that most of our time in RFM has, it was interesting to learn about the additional struggles piled on to health care workers here. After the meeting, we took a final lap of morning rounds in the male medical ward, as well as pediatrics.

In general, it has been hard at times to capture this trip with words that I feel truly justify the experiences that I've been lucky enough to have. This has been especially true about our time in the wards at RFM, made even more difficult because we were asked not to take pictures in the hospital this year. Each trip into "Cubicle 4" has been uniquely powerful; with the constant turnover, there are always new cases and presentations, and the general appearance of the patients is often difficult to see, most of them in what would be primes of their life (20s-40s), but bodies broken an atrophied, usually by HIV and/or Tb. Most blankly stare out of sunken eyes, minimally responsive to the doctors questions (if at all). The last patient we saw was a man in his mid-40s, breathing so labored that he was sweating from exertion, repeatedly asking the nurse for oxygen (which, at this point, was already turned on to the maximum level). A quick peek at a chest X-ray showed the cause; the appearance of a thick haze over most of the chest cavity showed that he had essentially one-third of a functioning lung at that point. The doctor explained that courses of antibiotic treatments (including anti-Tb treatment) had showed no results, and the likely cause was lung cancer. In Swaziland, pneumonia/Tb occurs at such a high rate that it is almost always at the top of the differential diagnosis list for pulmonary ailments and almost an assumed diagnosis (especially with any sort of pleural effusion on CXR, and rightly so based on the prevalence here), whereas in the States, lung cancer would be detected much more often (and would be potentially treatable). For this man, at this point, there was little that could be done.

We spent a few minutes discussing Tb treatment (and the challenges of) with another physician, standing on the sidewalk between two of the medical wards. The challenge with Tb arises largely from the nature of the disease; with a slow life cycle (divides at a very, very low rate) and the bugs ability to survive both extracellularly and intracellularly, it is difficult for drugs to be effective. Tb treatment requires a 6 month course of multiple antibiotics, and stopping short can allow recurrence of the disease if it has not been eradicated from the body; this often also allows multi-drug resistant TB (MDR Tb) to develop, rendering antibiotics ineffective against the pathogen. Many patients start their course, feel better (as the bug is subdued by the drugs), and as a result stop their medication. Generally, the bacteria is still present in low numbers, and comes creeping back. Patients, nervous about the diagnosis, tend to refrain from returning to the doctor, and wait until the disease has a strong hold, often to crippling levels.

While his insight into Tb treatment was interesting, there was a particular moment that grabbed all three of us. As we talked, two porters wheeled a bed past. I assumed it was a patient headed for surgery, or perhaps returning from X-ray, until it was next to us and we saw that the head was covered with a black garbage bag. Neither the doctor, nor the three of us, really broke from our conversation, as a sight like this is something we'd become used to in our month here. In the US, when I would transport the deceased, we used a special, covered cot, back elevators, and moved through the belly of the hospital to reach the "cold room" to avoid crossing paths with any visitors or other patients; here at RFM, this cot wheeled through an open, crowded sidewalk, with no effort to cover the body or hide what was being moved. The moment captured one of the overriding themes I've seen over and over again on this trip, bred largely from a skyrocketing HIV rate and a life expectancy lower than any other country on the planet. TIA.