Metaphors

Usually I am not terribly fond of the idea of “illness as metaphor”, but on occasion certain patients and their illnesses seem to cry out for further reflection, to see if they might contain deeper lessons than just the everyday flux of life and death that characterizes medicine here.

I have already written about Jackson, the 76 year old who was found to have a subdural hematoma on CT scan, and subsequently underwent brain surgery here. It wouldn’t be right not to share the rest of the story, which unfolded over several weeks, and unfortunately is not as edifying as the first installment.

After surgery, he seemed to be recovering well over the first few days, which is when I first wrote. But I was then off the male ward for 2 or 3 weeks, and only heard that he had had some setbacks. I know that he had some fevers, and was treated first for malaria and then for meningitis. I kept hearing that he was finally starting to improve, but when I rotated back to male ward, I found him obtunded, barely responsive, unable to even eat or keep awake for more than a few minutes at a time. I called the surgeon and asked if he would re-evaluate, but of course his first reaction was “repeat the CT scan.” I relayed this recommendation to the family, but added my belief that it was unlikely that a second CT scan was going to find anything amenable to further treatment, and they ought to think about just taking him home. To my surprise, by the next day the family had organized to take him to Eldoret by private vehicle and get the repeat CT scan (they seem to have had more resources than any other family I have dealt with here). It showed a small amount of blood had re-accumulated, really quite minimal compared to previously. I quietly voiced my skepticism, telling them that repeat surgery was unlikely to produce a dramatic improvement. I don’t know what the surgeon’s conversation with the family was like, but within a couple of days he went back to the OR. He died on the table, too weak to survive the second surgery.

Looking back on what I first wrote, it now seems naively optimistic. I had fallen prey to what Dr. Ron Pust has called “the seduction of surgery” here in the tropics, the belief that heroic surgery is what makes the biggest difference. The end of Jackson’s story seems to be saying that even though sophisticated tests and surgery are occasionally available, we are still working in a system that does not do well with complex problems. It is as if the modern technology is just tacked on to the underlying dysfunctional system, rather than growing naturally out of it – and therefore has little ultimate effect.

The second case was this past weekend. Jacob is 47, had been on ARV medication for HIV for the past year. Ten days previously, he had been seen at a government hospital and had an x-ray because of shortness of breath. All I could glean was that he was then started on anti-TB medication, but the reason wasn’t clear. They had not brought the x-ray with them, and because it was the weekend we couldn’t get a repeat. When the next day the family finally brought in the old x-ray, it showed a complete collapse of the left lung, with the heart displaced to the right side of the chest, a so-called tension pneumothorax, normally considered a life-threatening emergency which needs immediate attention. By the time all this unfolded, his breathing had deteriorated to the point where I didn’t think he could survive the night. So late Saturday night, we put in a chest tube, getting not air (which I had expected, based on the old x-ray) but 4 liters of fluid. His breathing improved immediately, the chest tube is now out, and he should recover, although of course he still has his HIV and TB to contend with.

Just before all of this unfolded, I was informed that Derrick, a three year old whom we had admitted seven hours earlier, had died. He had a grossly swollen belly, heart failure, and extreme respiratory distress. I knew as soon as I saw him that his chances were slim. We drew off a liter of fluid from his belly, hoping that it would make his breathing easier, but in the end he succumbed, most likely to a variant of TB involving the pericardial covering of the heart.

As I finished with the chest tube, there was a call to come quickly to the pediatric ward, to evaluate a child admitted earlier in the day, with malaria and pneumonia. I had seen her two or three times over the course of the day, and although I knew she was very sick, I was cautiously optimistic that she might pull through. But it was not to be; she died before I could even get there. With both children, we had done everything within our (limited) capability, but they had both come too late to be helped.

So in the end I was struck by the contrast: here was Jacob, getting all that expensive and sophisticated HIV care (through a program generously funded by international donors). Meanwhile, the children keep dying. Of course, it is not as though there is a direct trade off between Jacob and the children (i.e., even if Jacob was not getting his HIV treatment, the children would still be dying). Rather, when one disease is lifted out of the context of the entire health system and treated separately, the wider system inevitably suffers. For instance, my friend Jan Armstrong tells me that at the District Hospital in Webuye, they can have 100 children in the pediatric ward, with only one nurse covering the night shift. She estimates that because of the nursing shortage, only half of the ordered doses of IV quinine actually are given. This right next door to a state-of-the-art HIV program, funded by international donors.

Difficult questions; it will take “the wisdom of Solomon” to sort out. But it seems that at the end of the day, what is needed are programs to improve the entire system.