Saturday, November 26, 2005

Clinical Journal

The strike among the interns and residents had been going on for 5 days. This day, they had planned to do a large demonstration and march from the hospital to downtown about 3 miles away. Four days ago, there was no qualified physician to see the patients for the ward rounds, and i had run the rounds with the medical students.

As Jeff and i were walking to the hospital, i said, “i have the feeling this is going to be a very interested day. i don’t know what will happen, but it will certainly be interesting”.

We arrived for the grand rounds presentation shortly before 8 am, and the door to the conference room was gated and locked. Certainly, no one had entered this morning.

“do you think we should see if anyone is up on the ward?”, jeff asked.

“sure, let’s go check it out”. we walked up to the second floor ward and said hello to the head nurse. she told us that indeed the interns and residents were still on strike. I asked if she thought anyone would show up today. She said she there may be someone coming to see the patients around 9 am. I started having visions of seeing the patients by myself, with the head nurse. I didn’t feel too comfortable with that. Given what was about to come, those feelings were justified.

Jeff and i had about an hour. we went to the little cafe next to the hospital building. I had a Sprite and a little donought. it reminded me of being on call in the states. there is always the morning after being on call. i would wake up all groggy and need something to put in my system to get it going again. i felt a little groggy this morning.

For the first few minutes, i just sat there, going over different scenarios in my head. Jeff started asking questions about our fellowship. he asked if he should forward an article about ‘brain drain’ to the larger fellowship group. “sure”, i said, “i think some people will find it interesting and it’s an issue that affects all the countries we are working in”.

Then, i saw a man selling newspapers at the front of the cafe. Here, newspapers are sold by people walking around the streets. No need for a newspaper box, when there is someone to walk around and deliver it to you. so i bought a paper.

The front page had the headline, “Muhimibi doctors end strike”. i read the article and it described how the residents agreed to a salary increase for nearly $200 per month to almost $380 a month. The increase was almost 80%. This is great i thougt, but clearly contradicted what i had just heard from the nurse. Originally, the interns and residents were asking for 1.2 million shillings a month, which is a little over $1,000 per month. A doubling of the salary seems more than generous.

After an hour, I went back to the floor and Jeff left for the office. Again, it was just me and the head nurse. I was ready to ask her what she wanted to do, and just then two attending physicians walked onto the floor. I was relieved.

Jeff had just sent me a text that said, “strike not over. paper wrong”. A few minutes earlier i had told the attending physicians that the paper reported that the strike had ended. they said, ‘oh, that is wrong. that was a statement made by the Ministry of Health. they are publishing their offer and the residents haven’t agreed to anything. the strike is still on.’

We started seeing the patients.

Most of the patients, despite not having care for the last 3-4 days, were doing remarkably well. “we have to discharge as much as possible”, Dr. I said. There were some typical patients, hypertension, diabetes, TB.

Then, we arrived at a patient half way down the long wall when the director of internal medicine for the hospital walked onto the floor. He is a very pleasant, well demeanored man who smiles a lot, and that just makes me smile. We had already been discussing the patient before us, about 16 years old and HIV positive. We were planning to discharge the patient and ask her to follow-up at the outpatient HIV clinic. I felt that if she could get home, then she would have more people to take care of her and she could receive her care on an outpatient basis. The director informed us that she hadn’t been told about her HIV status and that he wanted us to counsel her as well as her parents. This sounded reasonable, but i didn’t know when these replacement docs would have time for counseling. So we kept the patient on the floor.

Soon after, the director left the floor, and we continued seeing patients. Another patient that had been on the floor for awhile had a very distended abdomen. She had a lot of fluid in her abdomen, called ascites. I’ve looked up ascites in my Western medical books. About 80% of cases are due to liver cirrhosis, which is common in the US, given the high prevalence of drinking alcohol. There is no mention of Tuberculosis in my books.

In Tanzania, it is believed that most cases of ascites are due to Tuberculosis, called ‘TB peritonitis’. It is something that i have never seen in the US, and is quite rare. Here about 80% of ascites is due to TB and the other 20% may be liver cirrhosis, heart failure and other causes.

We had to take some fluid off this woman’s abdomen. She we did a procedure called a paracentesis. Basically, we stick a needle into the abdominal cavity and set up a small tubing that drains the fluid to a large bag sitting on the floor. We did this for the patient and her fluid was draining nicely. The procedure took us about 20 minutes and was a clear interruption of all the previous patients who didn’t require procedures.

The next patient we came to on the floor had an almost identical condition. Her belly was just as large, and immediately Dr. I and I knew we had to do another paracentesis.

Dr. I decided to hear the next patient’s problem. She clearly wanted a break. The next patient had a headache for 9 months, some confusion, and vision problems. I remembered seeing this patient with the medical students on Friday. We had requested a CT of her head. She now had the films but no radiology report. We clearly needed to serve as the radiologist and review the films with the patient’s chart.

“Let’s go sit down and review this patient’s chart”, she said.

We walked up to the front of the hall and she sat at the desk. There is only one desk and one chair. I was fine standing and declined her offer to have the chair. She kicked off her shoes, and took a breather. She didn’t look at the chart for a minute or two. She said, “can you do a venipuncture and a paracentesis?”.

“sure, i just need the supplies”. I waited for the nurse to get the supplies, since i didn’t know where anything was located.

I had unrolled the CT scan and was looking at a huge ‘space occupying lesion’ on the middle right side of this patients brain. We discussed it and couldn’t tell if is was filled with fluid or was solid in nature. She said a neurologist would have to look at it and take a biopsy.

Shortly thereafter, Dr. I rose from her chair, grabbed her purse and said, “come with me”. She motioned for me to come quickly and appeared hurried. I didn’t know what was happening, but i followed her and the other physician.

She grabbed a key and we left the ward through the office door. We walked into a small consultation room in the center of the building, between the two wards, and locked the door behind us.

I felt rushed and a bit uncomfortable, but i wasn’t sure why. I looked out the window and saw some workers. It appeared to be normal activity. “What is going on?”, i said.

“just be quiet”, Dr. I said. Then sat in chairs as quiet as a mouse, and i stood along the side wall.

After about 30 seconds, there were loud chants and a large gathering of people had entered the floor.

These people were the residents and interns! They wanted to ferret out anyone who was still seeing patients!

Almost immediately, they had arrived at our door. They turned the handle and tried with a great deal of force to open it. It was locked. My heart started racing.

I had now idea what would happen if they got the door open. Was this an angry mob? Would they attack us for undermining the efforts of their strike? Would they beat us for crossing the picket line?

They rattled and shook the door. They turned and turned the handle. The lock was holding.

Then, we realized there was an window above the door. The window had metal grating in one inch squares. We knew they couldn’t climb in, but they could certainly see in, if someone rose up above the door. So, we cowered up against the door. The two doctors were on either side of the door and i was crunched in the corner.

We watched the handle as they kept turning it and trying to open the door. They were shouting just outside the door. “they are in here”, one of them said.

Many of these residents and interns must be within internal medicine, i thought. These are the same people i had spent much of the last three months working alongside and building a relationship. We had clearly come into opposing forces. I was clearly angry at them for abandoning the patients on the floor. Now, they were clearly angry with me for seeing patients during their strike.

The key started to turn. ‘Were they able to manipulate the key with something’, i thought. One of the doctors turned the key back into place. We never took the key out for fear it would make too much noise. They continued to push and pull the door. The key would occasionally turn about half way and we would put it back in place.

The door was a cheap, frail East African door. Someone can easily knock this down with a good shoulder. Furthermore, the lock is cheap and no doubt being held into the wall by a couple of small, cheap screws. If someone really wanted to get in here they could.

We heard one say, “there are three doctors, two Tanzanian and one ‘muzungo’ (white person)”.

I realized i had left my bag on the main table of the ward. I wondered if they would take it as a punishment for seeing patients while they are striking. Damn, i left my nice digital camera in my bag. I really hoped it was still in there.

I started to look at the window as an option. The window had several glass panes, which could be rotated similar to venetian blinds, except there was no way to pull up the glass panes. We would have to remove several glass panes if we were to get out. Furthermore, we are up on the second floor, about 20 feet from the ground and we have nothing in the room to lower ourselves to the ground.

My heart was still racing. The handle was still being turned vigorously and the door was shaking on it’s hinges. There were many people talking just outside our door, and i couldn’t understand what they were saying.

I sent Jeff a text that said, “we locked ourselves in a room. r okay”.

he wrote back, “need help?”.

“no”, i replied.

After about 10 minutes of this activity, a note was passed under the door. It was written on a patient treatment form and said, “Habari zetu. Karibu, hata kama mnapata millioni msijifiche. Tumewaona. Tunawajua. Karibuni.” This means, “greetings. welcome, even if you earn millions, do not hide. we have seen you. We know you. You are welcome.”

A few minutes later the noise and commotion started to die down. They were leaving the floor and building. We just had to make sure they were really gone before opening the door and stepping into the hallway. We waited about 5 minutes and it sounded like all the activity was gone. Slowly, we opened the door and cautiously stepped into the exposed hallway.

Realizing the immediate danger was gone. We walked back down to the medical ward and walked through the double doors. Most of the patients were out of their beds and standing up watching us walk in. All eyes were on us three as we reentered at the head of the ward. They chatted among themselves and everyone seemed curious to see if anything happened. They also seemed anxious.

We went over and talked to the two nurses. One nurse described how she got into a bed with the patient and pulled the blanket over both of them.

They other nurse was more defiant. She said, “I just sat here. I told them i am in charge of the patients on this floor and i’m not leaving.” She seemed proud, as well she should. She told us, “they said, ‘okay mama, we understand’”. I felt a little compassion for the protestors, but then that quickly subsided when i reminded myself of their neglect of patient for money.

I then thought about my camera and bag. I went over and looked on the table where i had left it. It was gone! ‘SHIT!’, i think i may have said aloud. I can’t believe they took my bag! I started looking around. Then, i spotted it in the corner behind where the defiant head nurse was sitting. Ah, relief!

I asked her if it was okay, and she said she moved it for me and no one touched it.

I finally had a chance to ask them what had happened. Dr. I said, “i heard them outside and saw them coming through the open window. Then the head nurse said ‘they are coming’. So i knew we needed to hide.” The demonstrators wanted doctors to stop seeing patients and wanted people to join their protest.

After we quickly shared our stories, I thought we should get back to completing the ward rounds. After all, i had a venipuncture and a paracentesis to do. We also had about 10 other patients that still hadn’t been seen.

Dr. I grabbed her purse and said in the typical polite Tanzanian way, “okay, so maybe we will see you tomorrow. I’m going to go home to rest.” Before i had much of a chance to answer, she was out the door. Gone!

I thought, there is no way in hell i’m coming tomorrow morning. I’ll be lucky to come back on my scheduled friday morning if the strike is still occurring. Even if the strike has ended and i have to face the interns and residents, i’ll still be bit nervous.

I talked with the head nurse a little more before leaving. She was clearly staying on the floor. I asked her when she thought the strike would end. She said she didn’t know, but hoped it would be soon. She was clearly concerned with the patients, and my respect for her was growing quickly.

As i grabbed my bag and was leaving the ward, she said, “so how much fluid do you want to take off?”, referring to the women who just received the drain in her belly.

“Two liters”, i said.

I left the ward realizing we never finished our morning and didn’t even see about 10 patients. I didn’t feel good about it, but i was still scared.

Outside the building i saw one another attending physician. i went over to talk with him. He was treating patients on the same ward earlier this morning. He told me he was back in his office when they came. “i just locked my door”, but i could hear them out in the hallway.

he was rather calm and i asked him about the strike. “well, they currently make about $200 a month, and i think $400 a month is reasonable. They were asking for an increase of 600% and their salary would be doubled with this offer”. he said, “the interns don’t want the doctors to see patients”.

I agreed. After a little more chit chat i wished him a good day and started walking to the front entrance of the hospital.

I walked through the long outside corridor. As i approached the entrance i saw the crowd and some television cameras. I remembered i was walking past the administrative building. The large crowd seemed to be gathered around the admnistrative building, which was next to the main entrance. The crowd was rather large.

Upon seeing the size of the crowd i quickly realized i didn’t want to take the front entrance. I was carrying my white coat, a sure give away. I immediately made a U-turn and ducked into the main lab building. I walked through the building and it led me towards one of the back entrances. I saw several policemen dressed in full riot gear in the back of a truck.

i walked quickly and within ten minutes was at the back gate. I walked through the gate, breathed a sigh of relief and walked to the office from there.

I went straight to the office. i knew jeff would be in there and a bit concerned. I opened to the door to the office, smiled, and said, “i told you it was going to be an interesting day”.

We left to go have lunch and i told him the story.

Monday, November 21, 2005

Photos from safari with Sarah.