Like cheese and chalk

13 Nov 2008: Like cheese and chalk

My first full day in the hospital was certainly interesting. Mornings start off with intake rounds, in which the overnight interns read off the census from the night to the remaining housestaff and attendings. Today’s was a singularly terrible meeting. It turns out that the chief of medicine, Doug Wilson, who is reportedly an excellent teacher, just left the country for the US and won’t be back until December; if we overlap, it will only be by one day. Since he normally steers these meetings, it felt quite rudderless. Indeed, we spent the whole time discussing logistics of who would cover what floor, and the attendings got angry about how many people were still awaiting admission because the wards were all full. This lasted one hour. No medicine was discussed.

The housestaff (interns and “registers”, which are like our residents) went off to do their work, accompanied briefly by the few attendings who were present today; the attendings (“consultants”) all had obligations at other hospitals or in clinic so they did not spend much time on the wards. I spent much of the rest of the morning getting oriented, which involved a tour of the wards, clinics, ED equivalent (MOPD and Resusc), getting my TB mask fitted, and getting a brief talk on the culture of the hospital and the goals of the “iTEACH” program of which I am a part.

The demographics of the hospital are staggering. The hospital is the only truly public facility available for a cachement area of over 1 million people, referred in by 23 clinics. (Contrast this to Boston, with half a million people and probably 50 hospitals.) People come from a great distance, and in part because it is such an intrusion in their lives to come at all, they tend only to come at very advanced stages of disease. Despite this, the hospital is busy enough that it is difficult for them to get beds, like today, when 20 people requiring admission were sitting down in the admission area, often lying on benches in the waiting room. (Some of these people waiting have freaking bacterial meningitis! In the US, they’d be in respiratory isolation; here, they lie on a public bench and occasionally get ceftriaxone, when people remember to think of it – standing orders tend not to be written until patients are admitted.) And the patients are young; many are admitted with end-stage AIDS (often previously undiagnosed) or TB in their 20s and 30s. Probably younger too, but I don’t see the peds patients.

Ethnically, too, the situation is interesting. The housestaff (this month, at least) are nearly all white or Indian, only one black who was there today. The attendings are also more white than black, while the patient population from what I’ve seen is literally 100 percent black, and 90% Zulu speaking. Zulu has many different clicking sounds that people not raised in the language have great difficulty intoning; as a result, most of the housestaff can only barely communicate with most of the patients. Interpreters are available, but as you can imagine at a place with resources this limited, they are not plentiful.

The difference in resources between providers and patients could not be more stark as well. The housestaff deal with it as best they can; they all find it very frustrating to work in a setting with such scant resources (they also rotate through two other hospitals with more resources and find Edendale the most challenging). One I was talking to for a while today commented on how frustrated she was by this point (near the end of a two-year transitional internship); it made her almost stop caring – she couldn’t talk to her patients, they mostly ended up dying, and she didn’t even always have the resources to keep them comfortable while they died. She also reflected on how many of the patients were her age: “Imagine if that were my life?” Later, the same intern was talking at length with other housestaff about what dress to wear to the upcoming formal, and how her gold jewelry didn’t really go with her tan dress, and how it was really hard to match that dress but she liked it…. The dichotomy was striking. I suppose it’s healthy to continue to live your life within your own means, and it would be maddening to constantly focus on the limited resources of others in assessing your own status.

I also learned a new idiomatic phrase, one of my favorite parts of meeting people from other cultures. One of the interns commented on how government hospitals (like Edendale) and private hospitals in South Africa were “like cheese and chalk”. When I looked quizzical, she clarified, “You know, completely different.” After explaining the American version of the related idiom, I was forced to admit that, yes, in fact apples and oranges are not that different, certainly not compared with cheese and chalk. (My all-time favorite foreign idiom is the Greek equivalent of “the pot calling the kettle black”, which is “the donkey calling the rooster big-head”.)

I came home exhausted, ate a Zulu meal prepared by my host Gugu, and am ready to turn in at the crotchety hour of 9 pm. (I do have to wake up around 5:30 am to beat traffic, so it’s not all bad). I also tried to make plans for a place to stay this weekend in the Drakensberg mountains, which should be fun. Tomorrow evening the other MGH resident arrives, so the house should perk up a bit and I’ll have someone to share thoughts with; perhaps then my blog will get less cumbersome. Thanks for reading so far.