6-8-09-Monday

Well, I thought I wasn’t going to write a blog for Monday, but the rain that started as we just got home from shopping has not stopped nor slowed down. As we do not have a car and we are all dressed in business clothes, we sit here waiting for the BIPAI driver to get to work and then pick us up. So, although I will get to clinic a couple mins late this morning, it gives me a chance to write about my first experience in clinic.

I was nervous. I know that the attending docs know I’m just a medical student, but there is little time for slowing down to teach. We start seeing patients at 8:00am sharp and see them until there are no more to see. No lunch, no break. It is a very intense way to practice, but seemingly the most effective because the people who come to our clinic travel from all over and none have cars. It is simply unreasonable to expect them to uphold an appointment time. So, we give them a day to come and most show up on that day.

I was with Dr. Norma Perez. An American trained doctor and a very kind woman. She was one of the most experienced doctors there having already completed her fellowship in Peds ID. Anyways, she walks through the procedure with the first kid, a child that has HIV, but is well controlled. A little talking, touching, typing in the computer and child is gone.

Next, Norma wrote down a list of 6 things.

1. Interview
2. PE
3. Staging
4. Dosing
5. Labs
6. Plan

This was for me. The room was now essentially mine (with her watching over me) and I was to talk to the family to uncover any problems with the child’s health or medication adherence, do the physical exam (which was a very focused and quick head to toe making a tally of all the problems), figure out the World Health Organization’s Clinical Stage of each child (which is important for giving medications and other organizational things), figure out if, according to weight, the child was on the correct medication, order Viral Load, CD4 counts, FBCs, Cholesterol, or a resistance assay as needed (this was the most difficult part because most of these are judgment calls). Finally, the plan. This is the hardest and I had no clue how to plan an HIV treatment, but this is where Norma stepped in. She would basically do this part (especially because 90% of our patients on Monday were failing 2nd line; which means that they have developed so many mutations that they are resistant to the drugs and now have only one shot to stay alive; poor adherence leading to a couple more mutations would lead to a 100% resistance strain and certain death).

We had many difficult patients, like I said. It ranged from poor care of a 24mo to a teenager rebelling against HIV but all the problems were from the same cause. Poor adherence.

It is shocking to see this things play out right in front of you. A 14yo with extensive HPV, a baby with oral thrush, a 15 yo with 4+ tonsils, everyone with carries and worst of all, everyone is wasting away. Every failing case we saw (again ~90%) were below 10 percentile of the normal height and weight. This type of severe wasting qualifies them as stage VI (worst stage) in the WHO. These kids, without intervention, will be eaten alive by an opportunistic infections.

But, really, enough on that. I’m sure I will have many more clinical stories to tell. I will be in clinic today (Tuesday) and then hopefully get some work done on my project in the afternoon.