Sick or not sick?

Sick vs. Not Sick

In medicine, we describe patients as being "sick" or "not sick". Developing the clinical acumen to collect all the information and then determine a patient's status takes surprisingly long - after four years of medical school, I am just beginning to understand the importance of and the thought process behind a seasoned doctor's declaration that a patient is "SICK". The definition of "SICK" has very little to do with the word's vernacular meaning, and can loosely be defined as "needing to be admitted to the hospital". When I have a cold, I tell my friends I am sick, but when a patient needs fluids, IV antibiotics, and oxygen to survive, I tell my residents the patient is SICK. It's important to note that in the hospital setting, our language can sound incredibly flippant. No daughter wants to hear a doctor say that their father, who she just rushed to the Emergency Department because of his terrible cough and fever is "not sick" but all that really means is that the patient does not need to be admitted to the hospital at that time. He is not in danger of dying if we send him home with appropriate follow-up. An example: If I am vomiting, I am probably sick with a stomach bug, but I am not "SICK" enough to be admitted. If I am vomiting up cups of bright red blood, I am SICK and needing to be admitted to the hospital for urgent intervention. It's an incredibly important, but often incredibly nuanced distinction.

We have been at Chidamoyo Christian Hospital for about nine days, and almost every patient we have seen, both in inpatient (admitted to the hospital) and in outpatient (not admitted to the hospital, as in, coming for a doctor's appointment), would fit the American medicine definition of "SICK". The burden of AIDS and tuberculosis, both separate and concurrent, is higher than I thought possible. Yesterday, we saw a thirty-year old patient in the OPD (outpatient department). Her respiratory rate was 60 breaths per minute, meaning she was taking one breath every second. She was taller than me but could not have weighed more than 80 pounds. When she lifted her shirt up, I was able to count all of her ribs and could see the small bony prominences on her humerus bones where muscles attach, markings that are normally so subtle one can only see after all the skin and soft tissue has been removed from a humerus. Her breasts were long and shriveled, implying that perhaps she had not always been this malnourished. She carried a plump 4 month old child on her hip, and had somehow managed to sustain his life thus far with breastfeeding (no one uses formula here). She said she has been this tachypneic (having a high respiratory rate) for one week.

We are really in the middle of nowhere. There are loose suggestions of paths that the hospital's outreach cars barrel down every Monday and Thursday to administer childhood vaccinations and family planning services to eager children and their mothers. Other than the hospital cars, there are maybe two combis (public transportation vans) that reach Chidamoyo every day. The vast majority of patients, even the "SICK" and dying patients, walk to the hospital. This woman had likely walked a few kilometers, gasping for air, child on her back, to the hospital. In the United States, we would have taken one look at her and sounded the alarm; nurses would have come running to lay her down in a patient bed, take a STAT H/H, chem10, CBC, arterial blood gas, transfuse her with a few units of blood if necessary, take a STAT chest X-ray, and put her on a non-rebreather face mask with the oxygen turned up high. Here, we told her, "You might have tuberculosis. You should be admitted to the hospital. Take your child and walk over to registration to buy an inpatient chart and to be admitted."

Yesterday I came down with a stomach bug, the kind that shakes your body to the core, complete with aggressive vomiting and diarrhea. After three Cipro pills (cause I barfed the first one up), a zofran pill (to help me not barf the second Cipro up), some Flinstone vitamin-tasting Gatorade-like dissolvable oral rehydration, and a good night's sleep, I am feeling mostly better today and haven't vomited since last night. (I have kept down a liter of water and 4 crackers today! Will try for a 5th cracker in a half hour!) I think that was the sickest, both in the medical sense and in the vernacular sense, I have ever been in my life. I had a fever and when I stood up, my heart rate skyrocketed to the 140s, a sure sign of dehydration. I was uncomfortable and scared, but in absolutely no danger of dying. I had the appropriate medications, clean water with which to rehydrate, no concurrent infections like AIDS, tuberculosis, or malaria, and the company of three almost-doctors who are quickly learning how to differentiate sick from not-sick. My body was not worn down by pregnancy or breastfeeding, and has built up more than enough fat stores and good nutrition to support me through a week of this bug. Even in this state, at my most sick, I would not qualify for the hospital definition of SICK.

I didn't write that last paragraph so anyone would feel bad for me. Stomach bugs happen. I'm alive and hardly worse for the wear. I should be feeling healthy enough to eat normally and go back to work tomorrow. I don't want to wrap this entry up with a cute little bow and spell out all the comparisons and differences between my life and the lives of the patients here, mostly because the differences are so painfully obvious. I don't have any enlightened conclusions to share from my experience thus far, except this: Humans are much more resilient than we think we are. If you had to, if there were no other options, you would wait a week with a respiratory rate of 60, before making the long trek to the hospital, child on your back. If you had to, if there were no other options, you would get up from the doctor's office chair, scoop up your kid, and walk to registration to be admitted, while gasping for breath. If you had to, if there were no other options, you would lay quietly as your respiratory muscles got weaker and you decompensated. We all would, if there were no other options.