April 12th, 2018 by Daniel Boron-Brenner

Today was a busy day in the clinic. Typically, clinic is where we go after we have finished seeing the patients on the wards and there isn’t something else to do. It’s a kind of default place where everyone, from the medical students to the visiting residents to the physicians, will see patients. There are two regular desks, a smaller desk for our nurse Victor (or his alternate, Gift), and a small exam room. We have basic supplies (mercifully, gloves are rarely absent), a blood pressure cuff, a combination otoscope/ophthalmoscope (brought by one of the visiting medical students), and equipment to start IVs. There’s a light box for x-rays that sometimes turns on, opposite a window which lets in the breeze and sun. Most of the time there’s power.

People come for all kinds of ailments, from medication refills to vaginal bleeding during pregnancy to wound checks for old snake bites. There are also emergencies that come to our door, typically people presenting late in the disease process, to the point that they are burning with fever, unconscious, or (as we saw several times today) both. We deal with them as best we can but, given the low-resource setting Macha finds itself in, this typically means approaching each of these cases with our eyes wide open, examining judiciously (and trying very hard to broach the language barrier) for any clue we can find that will point us towards the cause of their condition. We initiate management in clinic–placing an IV, ordering some blood tests (relatively few available), and either starting fluids, antibiotics, or other medications (perhaps all three)–but the bulk of our interventions revolve around furiously admitting them to the wards for comprehensive management. All in all, in spirit if not in scope, not that different from an American emergency department.

As I mentioned before, today was something extra. The morning was relatively calm, just a 15 year old who may have had TB and another patient with very elevated blood pressure who we considered admitting but eventually let go home, and then we had a break for lunch. When we came back, we found Dr. Munga working and a waiting room full of people. We quickly got to work divvying up patients.

I was seeing a man with HIV and suspected urinary tract infection when someone was carried through our door. An old woman, emaciated and frail, was in the arms of one of the security guards. He placed her in our exam room as Dr. Munga examined her and quickly decided to admit her. While he was working on her paperwork, and the visiting resident and I scrutinized the vital signs and lab work for my patient (also deciding he needed to be admitted), another unconscious patient was carried into the exam room and placed in a chair next to the first. Eyes fluttering, she was barely responsive to my voice or the vigorous sternal rub I gave her. With Victor translating, we learned she had HIV, had been complaining of abdominal pain for the last few days, and had been like this (essentially unconscious) for a day. Between her presentation, her obvious fever, and some tenderness around her bladder, it quickly became clear she was septic, probably because of a raging urinary tract infection. With the visiting resident admitting her (and all of us now wearing TB masks because we honestly didn’t know what these new patients had), I finally sat down with my patient and told him, via Victor, we would also be bringing him in. He looked around the room, gave a half-hearted shrug, and said “ok” in Tonga.