Monday, September 3, 2007

The Patient from Zim

I was on call again this week and my team admitted 7 patients. It wasn’t too bad because it was dispersed throughout the day. Except this morning during rounds we mixed up two of the patients and we wrote a note after having examined the wrong patient. But actually, they had similar presentations, and a similar clinical picture and everything still applied, so it was okay. I felt really embarrassed because they were my patients, but I wasn’t that familiar with them since I hadn’t been around the week before when they were admitted. I felt a little better after we saw another team rounding, and they were talking to a patient and wrote a note on him, and then later, we found out that it was our patient they were talking to! So they did the same thing! It was pretty funny. :)

The most incredulous thing that happened today concerned a patient who I admitted last week. He spoke English very well, and was very nice, and it turned out, very religious. HIV tests are the norm here, and although we’re supposed to (I think) ask for consent, almost every patient, if we don’t know their HIV status, gets tested whether they want to or not. I actually went to the trouble of asking this patient, and he refused! Boipelo wanted to go ahead and test him anyways, especially since it had already been sent from the A&E without his knowledge. But anyways, the patient refused, so I had to call the lab and track down the blood and cancel the order. I tried for a long time to talk him into it, telling how important it was, and how it would help us diagnose and treat him. He said he wanted to get tested, but that he was very religious (praise the lord and all that) and wanted to get tested together with his wife. He promised that as soon as he was out of the hospital, they would go together to get tested. I actually sorta believed him, he seemed so credible.

This patient had come in with several months of weight loss, night sweats, productive cough, and progressive shortness of breath. He was a very fit guy – said he worked out for 2 hours every day – but obviously became short of breath even when walking. On his chest xray, he had a classic round “water-bottle” heart suggestive of a pericardial effusion (that’s fluid around your heart), which was confirmed by echo – that’s basically an ultrasound of the heart. It was only a moderate effusion though and wasn’t squeezing his heart significantly, and was probably too small to be drained, so we left it along. The upshot of this whole picture is that this patient very likely has TB, and although it’s not definite, if he has TB, he likely has HIV. We found a big lymph node in his neck which I biopsied, and stained for AFB, and it was swimming in it. He eventually consented for an HIV test, and we started treating him for TB over the weekend.

Anyways, to get to the interesting part of the story, when we saw the patient this morning, he was visibly upset, and had bruises all over his body, and had several teeth knocked out!!! We pieced the story together from several different sources. Apparently after we all left on Friday night, the patient started praying very loudly and disturbing other patients. He’s also Zimbabwean (there are a lot of Zim immigrants everywhere right now, but that’s a different discussion), although he has a Motswana (a person from Botswana) wife, and I guess started praying in a manner that let people know he was foreign. As the story goes, he was confused and acting strangely and wouldn’t be quiet, and he got up, and touched a prison guard on the shoulder, or perhaps slapped his shoulder or his face – it depends who you talk to. A single nurse claims to have seen the slap, the patient says he touched the guard on the shoulder, and the guard of course claims to have been hit. There were four guards camped out there in the male medical ward at the time – watching over 2 or 3 of the prisoners we had as patients. They had nothing to do with my patient, but after my patient touched/hit one of them, they ganged up on him, dragged him into the procedure room and held him down and beat him up!!! Absolutely awful!!! Even if he did hit a guard he was reportedly “confused” and should only have been restrained at the most. It was ridiculous what happened. Unfortunately, I think a lot of this happened because he was a foreigner.

The patient’s wife was incredibly upset, and rightly so. She took the matter to the police, and there’s going to be an investigation, supposedly. Although since the matter concerns prison guards, nobody believes that anything is going to happen. Boipelo had to fill out paperwork and give a statement about what might have happened, and the superintendent of the hospital had to get involved! It was pretty crazy. The poor patient – he had to go to the dental clinic the next day to get his teeth pulled.

And about a week later, a story appeared on the front page of one of Botwana’s papers – I have it at home, called “The View.” It had a head shot of my patient with his missing teeth and a somewhat exaggerated story about what happened to him at the hospital! Crazy. I’ll upload the article when I get home, but it’s pretty ridiculous.

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