TB ward

2008-10-24 00:00

I GUMBI Labaphetwe Ufuba/TB ward — I brace myself to enter. It’s winter and the recently installed air extractor keeps the air as frigid as the air outside. Fever-tree yellow, this sci-fi contraption snakes around the walls and over the doors into a crazy chimney outside. Above its top drifts a nebula of TB bacilli, both the old-fashioned ones and the newcomers MDR (multiple drug-resistant) TB and XDR (extreme drug-resistant) TB.

Dr Tony Mall has made Church of Scotland Hospital at Tugela Ferry famous. Going against the protocols, he sent the sputa of people with TB (on TB treatment and dying) for culture and drug sensitivity and found MDR and XDR-TB. So much, it seemed like a pocket of plague. “Don’t call us ‘the hospital of death’.” he said, “Seek and ye shall find them too.” And we did and panic gripped the nation.

In TB ward we now wear respirator masks, but in truth the enemy is everywhere, in the crowded taxis that bring the patients to Emmaus Hospital, in the reception areas and in all the wards. Orgies of transmission must occur in the congested and windowless passages of our clinics.

A conspiracy between HIV and TB has taken place and called itself Aids. Each acts as a recruitment agency for the other and our behaviour, the sociologists tell us, makes us the CEOs. Aids is decimating the young, those who were meant to carry us into the future. The old now bury the young and the gogos struggle with the grandchildren.

I Gumbi Labaphetwe Ufuba — “the ward of the chest problems”. Not any more. It’s the ward of the problems of stomach and skin and heart and soul too. TB is bolder now and has ventured from its old habitat, the lungs, into every organ of the body. Harder to find and to treat. Extra pulmonary disease: EPTB.

I brace myself. It’s Monday and the ward will be full — D&V, SOB and GBM, hospital shorthand for diarrhoea and vomiting, shortness of breath and general body malaise. These are the most common reasons weary relatives bring their loved ones to hospital. Most are variations on the theme of EPTB, HIV stage four. Aids the leveller. How alike in appearance its victims become — emaciated with excoriated skin, coated tongues and staring eyes. The stigmata of the retrovirus.

One woman does not have the fatal resignation of her sisters. She is writhing around and wailing incessantly. Does she have HIV dementia, meningitis or is she simply raging against the dying of the light? I’ll have to do a lumbar puncture. It’ll be easy to find the correct place between the lumbar vertebrae to insert the needle. She has no fat to hide the landmarks but we will have to restrain her physically or chemically.

I start the ritual of drawing blood to check the organs and the electrolytes. Usually from the groin, as veins are hard to find. I sign X-ray and ultrasound forms and book CT scans. “Leave no stone unturned,” I tell my co-workers. “At least if they die, we know we have done our best.” Have we? Have I? Have we reached out and held their hands in their lonely dying?

See us on our grand ward rounds. We cogitate and compete around the symptoms of a stricken patient. The stars would be easier moved to pity. We must be like this to do the job, we tell ourselves. Do we create our masks or are they forced upon us? To occupy the space between our inadequacy and their misery.

We move across to the men’s side. With trepidation I pull out the chest x-ray of a patient with a lung abscess. If it’s still there, I’ll have to refer him to King George Hospital and that means overworked staff must book the transport. And he’ll come back for sure with a note from the udokotela omkhulu saying: “continue treatment”. Empyemas (pus in the lungs) is the worst. The wretched patient has to drag a chest drain and bottle around for weeks. “Continue the drain and we’ll review in a fortnight”, is the message from the chest clinic. The X-ray shows that the abscess has cleared. “Ngiyajabula!” I cry. The new chest image has made my morning.

The next bed is still empty. Three days ago, a man from that bed called out, “Doctor! Doctor! Come!” Exhausted after so many patients and problems, I retort irritably, “Wait your turn!” Moments later, there is a horrible outpouring of blood from his mouth. A haemoptysis or a haematemesis? Certainly an exsanguination. I rush to the bed to thump his chest. Too late. Remorse and revulsion surround me like an aura all day.

I come to Mr Ndlovu. He has pulmonary TB and cryptococcal meningitis and is doing very well on intravenous antibiotics. He has HIV that’s for sure, but he is adamant that he is not interested in voluntary testing and counselling (VCT). I begin my catechism: “TB and HIV are twins — amawele. If we treat only one, the other will get you in the end.” How tired the staff must be of my high-frequency rant. But this I have to do. I cannot leave HIV out of the equation.

Next to Mr Ndlovu is a young boy who has undergone VCT and had the soldiers of his immune system counted (CD4 count). But, strangely, he doesn’t want to have adherence sessions to learn about HIV and access ARVs. “I don’t like pills,” he says. “Why don’t you go to the ARV clinic?” I exhort. “You’ll see how the sick people are becoming strong and beautiful again. Many people are now getting so fat we are telling them to diet.” I am full of zeal on this point because it’s true. But, he’s not interested in beauty or strength or pills. Exasperated, I tell him to go to a traditional healer and discharge him. But, the next day he is still there like a reproach. “I have no money to go home,” he says.

I used to teach captive and reluctant children. I hated the nag I became. I’m her again. I thought this would be different. I thought patients would actively seek medical assistance and I would generously dish it out.

Themba, the next patient, has a problem with vomiting. Like so many of his ward fellows. Almost daily, I am adding drugs to the blue ward prescription chart — three ARVs, three TB drugs, vitamins and analgesia. Ten drugs in all. Throwing a pill at every problem is the best I can do. Now, his stomach has revolted. I will have to add Maxolon intramuscularly.

Sitting in a wheelchair is a patient transferred in from male ward with swollen legs. My colleagues are quick to pounce on a stray acid fast bacillus (AFB) trapped in mucous, or a para-aortic node spied on an ultrasound. This means the patient can be tiddlywinked to TB ward leaving me to deal with the confusion, the anaemia and the deep-vein thrombosis. Pointless being resentful. There is relentless pressure on their beds and mine. I keep discharging patients who are sent home to be recycled back via out-patients to TB ward.

We move our trolley on to a patient who has a favoured bed — bathed in brilliant sunshine. Germicidal, sunshine was recognised as a big gun against the bacilli and the early TB sanatoria had many windows. We seem to have forgotten this. He has recovered from his delirium and I encourage the nurses to begin his mobilisation. “But he can’t walk, doctor. He has weak legs.”

“Phakamisa imilenze yakho,” I command. No go. Heart sinks. Tracking down a diagnosis (myopathy, myelitis, spinal TB …) means doing a neuro exam, getting spinal x-rays and perhaps even CT scans and MRIs in distant hospitals. Transport problem again.

Sometimes, on closer examination, weak legs are actually painful feet. Easier to deal with. Sometimes weak legs are part of a general weakness — a weakness of the spirit, a renunciation.

The last patient, Mr Khumalo, is a 50-year-old man staring at the walls with an air of stolid resignation. He is sitting out an eight-week course of Streptomycin injections as AFBs have been found in his sputum after six months of TB treatment. It’ll take up to six weeks to culture the bacilli to find out if he has MDR. The germs are insidious and fastidious, and some of them replicate terribly slowly. The sloths of the microbial world. This makes TB difficult to cure. Some say never. Some say they can — like the HI virus — remain in sequestered places in the body,

forever.

My last duty of the ward round is to sign the death certificates. Two folders today, bearing ominous little green cards signifying that bodies and souls have parted company. I leave the ward for the ARV clinic. Place of merry chatter and hope.

JENNY ROBERTS

Jenny Roberts is a medical doctor at Emmaus, a rural hospital outside Winterton. She runs TB ward and also works in outpatients, ARV and satellite clinics. Roberts trained at Groote Schuur and worked in day hospitals and Conradie Hospital in Cape Town before moving to KwaZulu-Natal, where she worked at Grey’s and Emmaus.

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