So what kind of work are you applying for? I ask. Is it manual work or a desk job? “It is both manual and desk werk” What will you do? Oxfam, do community education and I will help wiff dat. And I will haf workers working for me and desk werk.” From yesterday when I saw 4 people needing history and physicals filled out by a physician, the word must have gotten around, and about 9 others came in today for a H&P. Each one was essentially the same. Guy and gals applying to get jobs at Oxfam and needing this paperwork filled out and sent in, so that they could have documentation that they were healthy enough to do the job. I would think an employer would want to contract with one doctor to do all of theirs the way they wanted, but apparently not. The ones that the PA had seen, got lab work with hemoglobin, blood type, syphilis, malaria, urinalysis, random glucose. None based on any suspicion, but just because. The ones I saw were rather healthy, by their own description and my physical exam, so I didn’t order these tests. Later I was questioned by the administrator as to why I hadn’t ordered tests, guess it is the thing to do even though it wouldn’t change my recommendation or not for work.
“Doc, der tree emergency in de car” Where? “Outsite” I am very frustrated, by then having spent all afternoon doing H&Ps. People milling about outside are in an uproar, as they have been waiting in the sun all day to see the PA, who after working 7 hours is still on the 11th patient. I don’t see how many numbers there are, but plenty of people milling about. As soon as I walk out a mob of different people start pointing toward their car indicating I should see them first. A mini verbal battle ensues. Eventually I see the red car first and walk that way. Another man is still not satisfied, said that I had seen them Monday and recommended surgery and now they are back and ready for it. I realize that he is referring to the woman who had a gangrenous foot that I told needed an amputation THAT DAY, and they left because they didn’t want it. So in my current, annoyed state, I tell him he will be last! In the red car, there is a woman who has a history of hypertension who “fell off” yesterday afternoon. This means she passed out, or became unconscious. They said she had a headache for three days. Hadn’t taken her antihypertensive meds for three days and has a cough as well. I ask if the cough preceded the headache, no. Does she cough by herself, or when you try to feed her or give her a drink? With food or drink. Before yesterday while unconscious or after that, like this morning? Yesterday evening and this morning. So they are trying to feed and give water to an unconscious person, and they are aspirating it- thus the cough! I discuss the grim prognosis with them, and explain what we can do is supportive. Place a nasogastric tube and get her blood pressure down, and see what happens. They are content with that and want her in the hospital.
Before I see the next car, I am pulled back into the outpatient tent to see a chactetic woman who looks like she is almost dead sitting in a chair. She is 34 and has been unconscious for 3 days. Before that, she has had black stools for a month, and throat pain for a month, now cannot swallow her own spit. I look at the labs. She is HIV positive, and it seems since everyone has been interested in Ebola, that HIV meds are not being taken care of as before so the HIV patients are coming down with all the opportunistic infections that immunosupression can give rise to. I suspect she has HIV related encephalitis causing her unconsciousness. Her glucose is normal, so that’s not it. Gillian says she’s not seen anyone survive with encephalitis here. And considering the patients state, she will not last long either way. I tell the family that whether I admit her or she goes home, either way she will likely die. They decide to talk about it. Later after hearing that they would have to pay a hospital bill, they decide to go home. I’m relieved a little; I think she would die before making it up to the floor anyway.
I go to the second car. Again the same other guy tries to pull me to his car first. I tell him he is last. The other car has a heavy set old woman sprawled out on two peoples laps. Story is similar to the first. One day of headache then loss of consciousness. History of hypertension and diabetes. I ask the usual Ebola questions- all negative per the bystanders. I put on gloves and reach in and look at her eyes, pale. I rub hard on her sternal bone- she retracts up her arms, but doesn’t grab my hand. Not a great sign. I write admission orders for her as well, telling them the same grim prognosis.
I go and see the last car waiting. It is the woman I saw 3 days ago with a huge hole at the base of her big toe and rotten tissue oozing out of the middle of her foot. She is now taking very slow breaths, and is unconscious. So now he brought her in, because she is dying, or nearly dead, now ready to do the amputation. She appears to be in her last agonal breaths. I tell him to go home, she is dying, and that at this point, it’s to late for her.
It is tough sending people away to die! I know they would die even if I admit them though. At home, I would admit them, and try everything. But then again, I have tests, and ICU, a ventilator, continuous oxygen for days if needed, lab tests whenever and however often I need them, other doctors to help manage them if I’m stumped or want assistance, nurses that follow doctors orders to a T… Pretty much none of that applies here. So I send them home. In some ways I feel we go to far in the US, prolonging “life” beyond what was meant to be or called life. Here we are on the other end of the spectrum. I think some middle ground might be better.
I go back to the floor, to do dressings that haven’t been done this morning.