Examination Day

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Every week, every clinic has a teaching session and every quarter the medical assistants and nursing staff take an examination to make sure that they were paying attention, to see if any important points have been missed, and to validate the training. This photograph shows medic Win Gate and nurse doing some revision at MRC prior to this afternoon’s quiz.
The kick off was delayed by quarter of an hour while we attended to an elderly inpatient, who was very poorly. I handed out the question papers, and left the health workers to start writing. Meanwhile, I went back to our old lady, to “stand guard”.
She gave her age as 100 when she was admitted 36 hours previously. But we found her old medical record from last year, in which she had claimed to be 101. So she’d lost two years. She said that she could remember World War 2 but was not able to tell us how old she would have been then. She only weighed 30kg. Her main complaint was feeling tired and worn out, and then had started passing copious diarrhoea. She had looked dry and dehydrated on Tuesday, so we asked her to drink rehydration solution, but she couldn’t drink much. We put up an intravenous infusion, which made her feel a bit better, but her breathing became worse, suggesting we had tipped her into heart failure. She had developed subcutaneous bruising on her arms, something that happens quite commonly in typhoid here. I gave her a bonus of diuretic to help her breathing.
I discussed her case over the telephone with the senior clinician, telling her that I thought she would succumb. We decided to give her some intravenous antibiotic and discuss the prognosis with the old lady’s family. We suggested that she would get more sophisticated care from the local Thai hospital, or she could stay with us and we would do the best we could for her, but she was very ill. We even suggested that she might want to go home to die, but the family wanted to stay at our clinic, in one of the small isolation rooms.
So, I made a cup of tea and sat down on the doorstep to keep vigil. The woman accompanying her seemed about 50 so she could have been her grand daughter, and a small child about nine years old was also helping to look after her elderly relative. My Karen is atrocious, so I couldn’t communicate very well. The old lady looked uncomfortable lying on the wooden floor – bamboo floors at her home are more pliable and comfortable. I folded up a blanket and we managed to do that fancy nursing thing of rolling the patient over and back again, so she could rest more comfortably.
The little girl was suspicious of me at first, but I retrieved my iPad and showed her photographs of Myanmar, markets and food. She was delighted and she tried to teach me the Karen words for everything I showed her. Other children started taking an interest in the pictures, too. The old lady was slowly deteriorating, just holding on to both her carers, touching, being in contact. After an hour, the medics and nurses started leaving the examination hall (outpatients), handing me their completed papers. I left the old lady to go the OPD and collected the papers, ensuring they all had put their name at the top of the first sheet.
The medic in charge of the inpatient ward beckoned me over. In the few minutes I’d been away, the old lady had died. My heart sank. Being a bit of a coward, I had hoped I might have left the clinic when she finally passed.
It is always a good plan to take your time when certifying death. People sometimes make Lazarus-like recoveries, but she didn’t. Her carers looked at her body, didn’t cry or make a fuss, and left to find a priest to do the formalities. Before she went, I spoke softly to the older carer and expressed my condolences, but her eyes avoided my gaze and she had nothing to say to me. No matter what we do, all our patients die.

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