I have gotten through the first week of clinical rotations. I spent my first day working at Chatsworth Hospice; this NGO offers free care to its patients and runs on charitable donations and volunteers. Chatsworth is a very interesting part of the city; during the apartheid, this section was where all the indians lived. Durban is home to the largest population of Indians outside India. When I arrived, uncle Roy walked me in and introduced me to sister barrel (Sisters are a step above nurses, what this actually entails I have yet to find out). Sister barrel is a large woman who always has a smile on her face, even when she constantly scolds her staff and driver. I also met sister Cathy who was raised somewhere near Cape Town, so she speaks Afrikaans, Zulu, and english. After a tour of the hospice, which only housed two patients, I went on home visits.
In CFHI’s manual, the one major rule is to always wear our ID/name card and our white coats. I have done minor research into the concept of societal trust in the white coat, but my day doing home visits made me realize how immediate the trust and comfort many sick patients feel when they see a white coat. Whenever we walked into a patient’s home, Sister Barrel introduced me and said I was a medical student from the US (I clarified with her several times that I was actually a premedical student, but she said that did not matter). I saw 6 patients and attended a Hindu funeral.
All of the patients I saw had some sort of terminal cancer. My day shadowing hospice was kind of my biggest fear. When my father was undergoing hospice, I found the women to be annoying and in the way. They asked stupid questions and wasted time my father did not have. However, Chatsworth Hospice starts seeing patients immediately after diagnosis, so they have had some patients for over 10 years. Therefore, when patients see Sister barrel, it is not a sign that all hope is lost. The day that I shadowed was sister barrel’s first day back after a few weeks though, so we saw the patients that had very little time.
Some of the hard parts were seeing patients in the final stages of cancer that I have known people to die of back home. For example, I observed the bathing and vital sign taking of a very old man who was going to die of some sort of throat or mandible cancer. A dear friend of mine lost her father to throat cancer, and seeing the man suffer made me realize what she had seen and gone through. Also, the son who was taking care of his father (the patient) told me “I don’t want to end up like him.” Sister Cathy scolded him and said he could end up worse than his father. The son than motioned that he would rather commit suicide, and Cathy said something about when the lord says it is our time, it is our time. Then they moved the conversation to HIV/AIDS. Cathy and the son talked about how this horrible disease has forced parents to be burying their children rather than the reverse. I observed this conversation rather than taking place in it because the naked old man was shivering on the toilet (where he had been given his shower) and I wanted to help Cathy cover him up, but they continued talking while the old man just looked miserable. The one thing he said was how cold he was on this warm day.
The second patient I would like to talk about was an incredible sweet lady. She had breast cancer which had metastasized to her bones, lymph nodes, and liver after she had already received a double mastectomy. She used to be a dress designer, but now she rarely leaves her bed. During the visit, I sat on the end of her bed while Sister Barrel took her vitals. As we were packing up to leaving, the woman asked for me to examine her. I looked at Sister Barrel who interrupted me as I tried to explain that I am just a pre-medical student. I was then told to sit next to the woman and feel her stomach and chest which was slashed with scars and lumps protruded from the cancer in bones. I attempted to look like I knew what I was doing in order to make the woman comfortable, but again, I honestly have no idea how to examine a patient. Just because I was wearing a white coat, this women felt comfort in me feeling her stomach and holding her hand. As Sister Barrel and I walked back up the driveway, I told her that I am not able to give any sort of medical examination. She responded and told me it did not matter, that woman was going to die, and if that woman thought a US doctor examined, she would not only feel more comforted but also more important and special. I still do not know how I feel about lying to that patient, but there are still some friends of my dad who I truly hate because they abandoned him during his treatment because it was too painful for them. When someone is dying, shouldn’t we do everything possible to comfort them? But then isn’t my interaction with this woman too far? I really don’t know.
The next day, I shadowed at malagasy clinic. Wow, I wish I could show pictures of this excuse for a clinic. There are holes in the ceiling, some floors are dirt, some have tile. The medical closet and patient exam room is one in the same. I sat in the tiny room squished inbetween the medical storage locker and the door. I observed the treatment and diagnosis of 16 patients. Every patient who came in received anti-biotics. This truly horrified me; the threat of superbugs because of poor adherence to treatment and over-prescription is a truly scary future. I now see where these bugs are being born. Although all consultations were held in Zulu, I had the opportunity to see the treatment of a man who I imagine will die rather soon. He had a blood pressure of 220/120. He came in because of an STI and he was HIV positive. The man took his anti-biotics and two packs of condoms and left. He did not take advice from the sister who told him to go to the hospital immediately and did not take my advice when the sister tried to involve me to make him understand how dangerous his blood pressure was and how it could lead to a stroke. The conditions of this clinic and the over-medication are things I have read about, but never really seen. I am still in shock by some of the horrors of this clinic. It is not that I saw anything heart-breaking, but I know what this clinic is doing with respect to superbugs and transmission of HIV/AIDS. The lack of hygiene and people not wearing TB masks and the fact that all shots were given using the same needle to get the medication out of the bottle truly made me bite my tongue.
The last two days of this week, I was at the Blue Roof Clinic which is sponsored by the Alicia Keys foundation and Keep a Child Alive. This clinic deals only with HIV/AIDS patients and checks adherence monthly. I worked in the pharmacy, handing out ARVs and also sat in with the doctor. This clinic seemed to work as well as any clinic I have seen in the states. However, the hygiene of the sisters inbetween patients is still questionable.
I have been given a really good insight into the treatment of primary care here in South Africa. Next week, I will be observing at St. Mary’s hospital to see their secondary tier care!