I wheel the trolley to the next patient and look up. She is giving me a hard stare. Paddington bear-like. In fact, scrub that. She is not looking at me. She is glowering. Glowering balefully.
“Sawubona,” I say nervously. “Kunjani?” Her only answer is to turn away and sniff at me. “What is wrong?” I ask the nurse.
“She wants to go home. Why don’t you let her go home?”
This lady has a condition called lactic acidosis, I explain. She has been on anti-retroviral drugs for a year. One of these drugs in particular has the potential to cause a few unpleasant side effects, one of which is the build up of the acid lactate the blood. She was admitted 2 weeks ago with severe vomiting, abdominal pain and breathlessness all of which were due to the acidity of her blood as a result of the high levels of lactate. Her levels were in fact dangerously high and we had to stop her anti-retroviral medication.
“But she is better now doctor. Why can she not go home?”
“Well I know she feels better. We have given her fluids to rehydrate her. But her lactate is still very high – people can die from this condition and we need to wait for the lactate to reduce to lower levels before we can discharge her safely.” Last year someone discharged herself home feeling well only to return 2 days later extremely sick. She later died so we are very cautious with these patients now.
The nurse explains this to the patient who scowls and shakes her fist at me. The next lady is also here with lactic acidosis. She is a little more chilled and, the fraction of a millimetre of curtain that separates beds not providing terribly effective sound proofing, had been following our discussion. She grins and nods as I apologetically tell her she needs to stay.
I have nearly got to the end of the round when Sister-in-charge of the ward storms in.
“Hauw doctor. Why do you not discharge all the ladies? They are getting angry. I tell you doctor this morning they were all toyi-toyi-ing [kind of Zulu protest/war dance] in the middle of the ward!” she cries gesturing to the 5 people with lactic acidosis. I launch into my speech again. “Ahh,” she interrupts. “But doctor – in our culture we like to go home to die. We do not want to die in hospital.” I look at her nonplussed.
“Is that what you think? That I am keeping these people in here to die?” She detects a slightly taut note in my voice and says nothing. “Have you been telling them that they are here to die?”
“No doctor!” she cries, perhaps not entirely convincingly.
“I am not keeping these people here to die!” I cry, I fear stamping my foot slightly. “I am keeping them here so that they will not die! They feel better but they can still get sick and I want to make sure they stay better. If you have been telling them I am just keeping them here and we can do nothing then no wonder they are all so cross with me!”
Sister is back-pedalling fast now. I am all ready to continue my tirade when suddenly I am struck. These nurses left nursing school perhaps 5 to 10 years ago. This country has only been using ARVs for 4 years. They were taught nothing about them at training. All they learnt about HIV was that it was incurable and eventually fatal. Nurses that qualified before the ARV roll-out have received next to no training on them unless they chose to specialise in HIV treatment. The whole playing field has changed completely and most nursing staff have no idea. So I take a breath. I take a pencil. And I gather the nurses round and draw them a diagram.
“Sawubona,” I say nervously. “Kunjani?” Her only answer is to turn away and sniff at me. “What is wrong?” I ask the nurse.
“She wants to go home. Why don’t you let her go home?”
This lady has a condition called lactic acidosis, I explain. She has been on anti-retroviral drugs for a year. One of these drugs in particular has the potential to cause a few unpleasant side effects, one of which is the build up of the acid lactate the blood. She was admitted 2 weeks ago with severe vomiting, abdominal pain and breathlessness all of which were due to the acidity of her blood as a result of the high levels of lactate. Her levels were in fact dangerously high and we had to stop her anti-retroviral medication.
“But she is better now doctor. Why can she not go home?”
“Well I know she feels better. We have given her fluids to rehydrate her. But her lactate is still very high – people can die from this condition and we need to wait for the lactate to reduce to lower levels before we can discharge her safely.” Last year someone discharged herself home feeling well only to return 2 days later extremely sick. She later died so we are very cautious with these patients now.
The nurse explains this to the patient who scowls and shakes her fist at me. The next lady is also here with lactic acidosis. She is a little more chilled and, the fraction of a millimetre of curtain that separates beds not providing terribly effective sound proofing, had been following our discussion. She grins and nods as I apologetically tell her she needs to stay.
I have nearly got to the end of the round when Sister-in-charge of the ward storms in.
“Hauw doctor. Why do you not discharge all the ladies? They are getting angry. I tell you doctor this morning they were all toyi-toyi-ing [kind of Zulu protest/war dance] in the middle of the ward!” she cries gesturing to the 5 people with lactic acidosis. I launch into my speech again. “Ahh,” she interrupts. “But doctor – in our culture we like to go home to die. We do not want to die in hospital.” I look at her nonplussed.
“Is that what you think? That I am keeping these people in here to die?” She detects a slightly taut note in my voice and says nothing. “Have you been telling them that they are here to die?”
“No doctor!” she cries, perhaps not entirely convincingly.
“I am not keeping these people here to die!” I cry, I fear stamping my foot slightly. “I am keeping them here so that they will not die! They feel better but they can still get sick and I want to make sure they stay better. If you have been telling them I am just keeping them here and we can do nothing then no wonder they are all so cross with me!”
Sister is back-pedalling fast now. I am all ready to continue my tirade when suddenly I am struck. These nurses left nursing school perhaps 5 to 10 years ago. This country has only been using ARVs for 4 years. They were taught nothing about them at training. All they learnt about HIV was that it was incurable and eventually fatal. Nurses that qualified before the ARV roll-out have received next to no training on them unless they chose to specialise in HIV treatment. The whole playing field has changed completely and most nursing staff have no idea. So I take a breath. I take a pencil. And I gather the nurses round and draw them a diagram.
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