Listening through both ends of the stethoscope - A patient encounter, Part 1

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There are two ends to a stethoscope, and it matters which is which. At least I used to think so.

I once put on a stethoscope with the earpieces turned around (for these two-ended diagnostic tubes are also two-sided). I was a first-year medical student, and there was no reason for me to know better. Still, I recall vividly my feelings of embarrassment and awkward self-awareness after I had unwittingly demonstrated to the patient and mentoring physician in front of me that I had no idea what I was doing.

In well-meaning words with a slightly demeaning tone, the teaching physician explained to me that, because of the anatomy of the human ear, if the earpieces are in backwards, the doctor cannot hear. I believed him at the time, but now I know that he was wrong.

[As those who have read this blog before know, my patients are HIV positive children. Due to the humanity and diligence of scientists and advocates, in recent years, these children have had access to life-saving medicines-so-called ARVs. By some miracle, it is my job to help them take these medicines, and take them appropriately. The result is that, once on ARVs for several months, they are rarely sick. They have HIV but are on the correct and merciful zone of the healty child-to-AIDS spectrum. In other words, when I listen to the hearts and lungs of these children, they are essentially all normal.]

As a pediatrician, I was taught by many men and women in white coats to place the forked end in my ears and to place the end with the bell and circular disk on the patient. Then, yesterday, I began use the patient's end of the stethoscope, and I gave the patient my end. In other words, I asked the kids to listen to my chest.

In doing so, I learned that I can listen...and hear...through both ends of the stethoscope.

To be continued…

One hundred and one Botswana destinations: #1 Soweto

Km 26 (or ~mile 15), photo courtesy of Dr Andres Gomila.

In my previous blog, written from Swaziland (http://www.pediatrician-in-swaziland.blogspot.com/), I listed a couple dozen local destinations that were worth checking out. Here is the first in a series of destinations that can be reached from Botswana.

Soweto (Johannesburg, South Africa's SOuthWEst TOwnship) is actually equidistant from the border of Swaziland and Botswana, about a five hour drive from Gaborone. Last weekend, with a group of friends, I ran the Soweto marathon. For those who have not run 26mi and three hundred and something yards, I can now tell you that it hurts.

I wrote my name on my shirt so that the people of Soweto might cheer me on...and they did. Though pronounciation varied from "Ree-on" to "Ree-yon" to "Rye-ann" "Hy-ahan" to "mlungu" (the last one simply means "white person"), 30 seconds did not pass without my hearing my name. I received no less than five hundred such cheers, maybe more.

Soweto is an historic place. It is home to an estimated 65% of Joburg's residents. Over past decades, Soweto's citizens were pulled there by the need for cheap gold mine labor and pushed by forced removals from legally-designated white areas.

Civil rights were fought for an won here. The June 16, 1976 Soweto Uprising led to the deaths of 566 people and, in their aftermath, economic and cultural sanctions were imposed on the nation (and its the apartheid government) from abroad, while Soweto and other townships became the stage for violent state repression. Since 1991 this date and the schoolchildren that were killed have been commemorated by the International Day of the African Child.

It is humbing to run a marathon, for at some point strength whithers, pain dominates your consciousness, and your legs, well, they just stop working. More humbling still is that, when it comes down to it, I know little of strengh and pain compared to those who call Soweto home. Nonetheless, they watched me slowly pass and shouted "Goooo Ree-yawn!" "Good work Mlungu." "Do not give up!" "Go! You are almost there!"

On one particularly difficult hill late in the race (around mile 22), an older gentleman came from behind me (for I was being passed by many at that stage) and took my hand. He clasped it with alternating, interlocking fingers. "We are going to do this together." he said. "We are going to run up this hill."

And we did.

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[I have several other images from Soweto that I will share once I find my camera, which is arond here some place. Stay tuned.]

Good girl - A patient encounter

Pona, eight years old, slowly and ceremoniously took a piece of paper out of a plastic sheet and handed it to me. She placed it in my hands with such care that I myself began to fear that I might drop it. I worried what might happen if I did. Might it shatter?

Once I had a secure hold on the leaf of paper, I saw that it was a page from a hand-drawn calendar. Written on the top of the page in perfect block lettering was a name--“PONA”--and the previous month: “SEPTEMBER 2008.”

Below this text were perfectly square, ruler-guided boxes representing each day of the month. Within each of these boxes were two small smiley faces. Each sticker, it seemed, represented three pills that the child had swallowed on that particular day.

“Wow…This says that you took all of your medicines!” I said with appropriate fanfare.

“She is a good girl,” said the grandmother, seated beside Pona in one of the exam room’s small wooden and fabric chairs. Hearing this, Pona stood a bit taller.

It was then that I noticed the grandmother’s shirt, which read, “Live and let live. End stigma and discrimination.” On her handbag were the words: “We demand free and compulsory education in Botswana,” and “We recognize and respect women’s rights.”

“I like the messages on your shirt and bag,” I said.

“Why doesn’t your tie say anything?” she asked.

I did not know how to answer. “What should it say?” I asked, glancing down at the faux-silk maroon kerchief dangling below my chin.

“Anything you want it to say,” she replied.

I thought for a few seconds and came up with no inspiration messages, so I turned to Pona and asked her what my shirt should say.

With a smiling face, she said, “Pona took all of her pills and she is smart and not sick...and...”

"And?"

"...and good!"

"A perfect message for my tie!" I proclaimed. I will have to drop off the tie for printing later.

Pona stuck a small smiley face midway between the tie's knot and inverted triangle, so that I would not forget.

Team captain - A patient encounter

The time had come for me to quiz the child in front of me. His name was Letsego. The quiz is part of a step-wise process we call "disclosure", where a child is made aware of the essential components of his illness and treatment. He seemed to know these questions were coming, and paid careful attention.

MD: What are the names of your medicines?
Child: AZT, 3TC,and… N…VP!
MD: Awesome. Why do you take them?
Child: To have strong soldier cells.
MD: Great! What do the soldiers do?
Child: They fight the bad guys.
MD: Perfect. Who are the bad guys?
Child: The HIV viruses.
MD: Good! How clever you are. Do you have any questions for the doctor?
Child: When will I be strong so that I can play football?

The child paid even more attention. An electricity-like sensation, originating in my chest, spread to my arms and legs, briefly occupied my hands and feet, then dissipated. It was, as I have come to understand it, the physical manifestation of compassion made heavy by anxiety, the feeling I get when I want to do something good but worry that I might falter.

Letsego was a 8 year-old boy, and he wanted to play football (“soccer” for those of you who associate football with helmets and hands). The boy had answered my questions, told me things to show me that he knew what I wanted him to know, to demonstrate that he could parrot the trivial details that we doctors and other adults fixate on: names mostly.

Now it was his turn, and he wanted to play with his friends, so he asked me when he could. His eyes, which had witnessed the death of two parents, the withering and near death of his baby brother, both pointed at me. His hands, hands that usually held a cattle prod in dusty pastures instead of a pencil, rested palm down on his knees. His back, which spent nights pressed against a hut floor, was straight. He tilted toward me. His expression and posture were that of a child sitting impatiently on a bench while teams are being chosen before an informal schoolyard game, waiting for his name to be called while thinking “pick me…please pick me”.

MD: So, you like football?
Kid: Yes.
MD: Why?
Kid: Because it is fun.
MD: It is isn't it. Hmmm. Let's see. I have an idea. Every visit, you come in and show me that you have been taking all of your medicines, okay?
Kid: Ok.
MD: Then, to make sure the medicines are working, you can tell me how football practice is going, okay? But, start by kicking the ball around with friends, and practicing shooting into the goal. Only run if you feel strong and if you can breathe well.
Kid: Ok.
MD: Do not make yourself too tired, but keep practicing because I can see that you are already getting stronger from the medicines. Sound good?
Kid: Yes [smiling]

Letsogo stood. His small, diminished body reminded me of the physique of those kids who used to get picked last, those that were placed in the least important defensive positions, like left field in baseball or, in soccer, left fullback.

But, everything about the boy (except for the body itself) dripped with confidence.

Fortunately, bodies, when permitted, heal, especially young ones. Once healed, they run and kick as well as the next. Some better even, for having wanted to so badly.

Spirits lifted - A non-clinical patient encounter

To meet local requirements for the disabled, the Baylor Centre where I work has an elevator. [As an aside, individuals with disabilities here are called “paraplegics” and elevators are called “lifts”. Both substitutes seem incomplete as there are many disabilities that are not paraplegia and elevators do not only lift. Nor do they only elevate, I suppose….come to think of it, “disabled” as an adjective leaves something to be desired. So much for my defense of American argot.]

So, as I was saying (or trying to say before I backslid into above amateur linguistic interlude), our clinic has an elevator. It is a simple elevator, not like those in Houston’s Texas Children’s Hospital where there are stipples of light reminiscent of the night sky above and wavy mirrors like those in a two-ticket circus house. However, as there are few multi-story buildings, the device is a bit of a novelty around here, and few of our patients have seen or used an elevator. An ascent/descent on the automated lift is so highly sought after by some of our adolescent patients, in fact, that we have put into place official restrictions on its use solely for recreation. The more assertive teens still try to finagle a ride, for that is what adolescents do. Regardless of continent of residence, teenagers finagle.

Younger children in the waiting room (pre-finaglers), with expressions of wonder and nervous anticipation, watch the closed frosted silver doors with the anticipation of a child about to open a gift, or watch a firework display. When it opens, the response is almost universally one of gleeful rejoice, as if a wonderful thing has happened.

The wait to see a doctor in the Baylor Centre is sometimes quite long. Though I prefer the stairs, I sometimes take the lift down to see if I surprise any spectators below. It feels sort of like jumping out of a music-less, adult-sized jack-in-the-box.

I have never jumped out of a cake, but it feels something like that, I imagine. Cleaner, though.

“If you can’t say anything un-nice…”, Disney World, and other illusory constructs - A cultural encounter

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Dreadful things happen in Africa. Even those that have never been to the continent can name three or more dreadful African things.

I can name plenty.

I can also name several dreadful things about Disney World’s Magic Kingdom (queues; gum on the sidewalk; castle actually uninhabited; that vague creosote odor; teenager dressed as Mickey hard as heck to find; “it’s a small world” lily-white and pretentious; central Florida is all around you; etc). I can certainly divulge plenty of horrible things about each the solar system’s inhospitable eight or so other planets (Jupiter, for example: stormy; cold; gaseous; excessive moons; crushing gravity; that silly, mysterious “Great Red Spot”; no Wal-mart, etc.)

As this blog implies, I live in Africa and, despite getting no kickback from the, AU, SADC, or local Chamber of Commerce, I maintain that there are several not-so-terrible things here.

As an example, I have included the story below. Like most stories in this blog and the Swaziland version that preceded it, it showcases one of the continent’s many protagonists.

For no reason in particular…except to generate intrigue, I will call this brief story “Deus ex machina.”

In my free time, I like to mountain bike. Recently, we took a dusty, grueling loop in Botswana’s so-called “bush” (of Ladies No 1 Detective Agency fame). At our destination—the parking lot of a BP garage—one of the group, to his dismay, noticed that his GPS, which he had secured to his handlebars that morning, was affixed no more. Retracing our steps (or rather tire tracks) some 10km's back proved fruitless.

Two weeks later, about half way into a similar bush-ride, we encountered a lady standing on the single dirt track deep within the rural countryside. In her hand she held the GPS device. She had found “the telephone that didn't ring" in the grass near the trail two weeks prior and had been waiting since early that morning for “the men on the bicycles" to pass by. She had stood in the same spot all day the week before, but we had not ridden that weekend.

Neo was her name. Thanks, Neo.

Quand on a terminé sa toilette du matin, il faut faire soigneusement la toilette de la planète – Eight patient encounters.

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1) She was six. She came in the room and gave me two thumbs up.
2) He was seven. He was given stickers for remembering the names of his meds, one on each hand, and, to protect them, he spent the remainder of the consultation (fifteen minutes) with his hands held upright, as if holding an invisible basketball.
3) He was sixteen. He had no family, at least none that claimed him. He was by himself at the clinic. He was not attending school. He asked if we could help him become a student again.
4) He was five. He spent the visit playfully chewing the edges of a Styrofoam cup, until there were about a hundred such pieces scattered around the floor around him.
5) She was nine. She was angry with her mom for delaying her visit with the doctor. (Mom had been next door refilling her own ARVs.) I reached out my hand for a high five. She frowned at me. I asked what was wrong. She said she was hungry. I gave her a cookie. She smiled, gave me a high five, then remembered she was cross and frowned again. I gave her another cookie. Her mood was thereafter cured. The virus that brought us together was not, but it was not detectible in her blood.
6) She was eight. “My last name means ‘little snake’ she explained. “The snake lives underground and is not a poisonous one. We only see it when we plow. It is a nice snake.” This marked the very first time I had heard an African compliment a snake.
7) He was five and named Prince, but his name was pronounced “Prin-see,” with an emphasis on the second syllable. When asked how he was, he said “Well, doctor, I am just fine.” His mother, in agreement, said, “Prin-cee is very well.”
8) She was eight. She looked four, maybe five. She had a thin face, with sunken cheeks. I asked her to draw a flower for me. She had drawn the same flower a year prior and I wanted to see how she was developing. She refused. “I want to draw a boy,” she insisted. She drew a boy holding a flower.

Because of the HIV medicines now available to these eight and tens of thousands of other African children, they have the opportunity to survive childhood...just like we did.

Isn’t that just wonderful?

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"For me, this is the loveliest and the saddest landscape in the world...I've drawn it one more time [below] to be sure you see it clearly. It's here that the little prince appeared on Earth, then disappeared. Look at this lanscape carefully to be sure of recognizing it, if you should travel to Africa someday, in the desert. And if you happen to pass by here, I beg you not to hurry past. Wait a little while, just under the star! Then if [a child comes to you], be kind! Don't let [him] go on being so sad: Send word immediately that he's come back..."
-The Little Prince, Antoine de Saint-Exupéry