Wednesday, January 31, 2007

Listless lists - How I decided to go home for the holidays

Entrance to "Phelps Ranch". Note the 'P' above the longhorn.

One day in late December last year, the Baylor clinic where I worked switched to a skeletal staff and patients stopped coming. I was on call early on that first skeletal week when our usually bustling clinic became just another one of the many quiet, empty buildings that stand in Mbabane waiting for 2007, waiting for ‘business’ to resume.

The weeks of late December and early January are weeks when Swaziland slows to a crawl and the national focus is on the church and the family. Parents who are away from home working travel back to their villages, and children who are away from home do the same.

On that day in late December, our clinic was empty except for me. The waiting room was vacant, quiet.

I didn’t like it much.


Familiar sounds, I find, can be quite calming. To me, the din of a pediatric waiting room is calming. It reminds me that there is work to be done, for the work itself is making most of the noise.

I was assigned to the quiet, empty clinic all day on that Tuesday in late December, in case a patient arrived with an emergency and needed of a doctor.

It was still early and there were no emergencies. I was listless, restless, with nowhere to go.

I needed my ipod.

I had left the ipod at home.

No noisy patients and no Beatles.


On a typical clinic day, I arrive between 7:30 and 7:45. As I walk up to the main entrance of the clinic, I can already tell if it is going to be a busy day by the number of parents sitting on the waiting room benches. The children are usually running around or fastened tightly to the back of a seated mother, and are therefore much more difficult to count.

Patients begin arriving up to two hours before I arrive, and if more than forty beat me to the clinic, my colleagues and I can expect to see patients until at least five o-clock. If there are fewer, we can take a break for lunch, perhaps even check email or read an article while the translator has a brief tea break mid-morning.

In any case, it is my practice to peer through the glass as I arrive.
Then comes my favorite part of the day, or at least one of them—the instant when I open the door and enter the room where the patients are.

I try to remember to open the door slowly, for rare is the morning when there is not a child playing just on the other side of the tinted glass. Once inside, I speak some sort of greeting (sometimes in English, sometimes in SiSwati), though I do not speak so loudly that it obligates a reply, so as not to interrupt ongoing registration, triage, small talk, or play.

Our waiting room has a high ceiling and walls of concrete. Every noise made is heard at least twice as it bounces about, and sounds dissipate slowly, as there is little fabric to absorb the sounds except the clothes of those waiting there. A child’s laughter, therefore, can fill the room, but usually the room is dominated by the reverberation of several simultaneous speaking voices and at least one two-year-old’s Oscar-worthy temper tantrum. Other age groups sometimes join the dramatic protest, usually shortly after or in the anticipation of having blood drawn. In the late afternoon, a few children cry because they are hungry.

Sometimes, when I arrive a bit later (~7:45), the loudest noise in the waiting room is the voice of one of our nurses, who gives daily waiting room talks about the importance of knowing one’s HIV status, minimizing stigma, and related topics.

After smiling and saying “good morning,” “sawubona”, “hello” or “unjani”, I check the doctor’s chart box to see how many patients have been triaged. I then slip into exam room 6, 7, or 8 in the back hallway. I close the door, for the noise from the waiting room easily reaches the back hallway. I open the exam room window (better ventilation = prevention of TB and other airborne pathogens). After organizing my reference books and signing on to the electronic medical records system, I open the door and follow the echoes until I am back in the waiting room.

Then, for one instant, as I [gently] shout out the number of the next patient in line, my voice is heard above all others. A brief lull in the rumble of conversation follows. As soon as someone rises from their seat and begins gathering his or her child(ren) and belongings, the rumble resumes.


In late December, the clinic was all lull and no rumble, and I sat in silence.

Our clinic wiating room after closing time.

Man, how I lamented leaving my ipod at home. How I wished that the internet was fast enough to listen to KFOG online.

San Francisco radio at its finest.

I started reviewing labs and entering them into the database. Four hours passed, albeit tediously.

I needed a break. I walked the empty halls of the clinic. I ate two chicken hot dogs.

I returned to my desk. Still no noise. Still no emergencies.

I thought about running home to get my headphones so I could listen to Rocky Raccoon.

But, what if I was not around for the one big emergency of the day?

I tried again to log onto KFOG. No luck. Not even close.

I had heard that one way to calm (or at least distract) a restless, listless mind was to make lists. I had counted sheep once before, and it helped. This was sort of like making a list.

Having no better idea to pass the time, I took out the notebook where I sometimes jot down ideas for things to write about.

My first list was a list of potential emergencies that our patients might have to face while the clinic was closed (for the following week the skeletal staff became no staff and the doors to the clinic were to be locked).

List #1: Potential patient holiday emergencies
- Lost ARVs
- Spilled ARVs
- Ran out of ARVs for some other reason
- Forgot how to take/give ARVs
- Got very sick
- Got very very sick
- Had no food for child

List #2: What the patients could do in case of holiday emergency
- Come see the on-call physician (at least for the first week of closure, when we were on duty)
- Call our on-call pharmacist (available through holidays to cover all ARV issues)
- Go to Mbabane Government Hospital (MGH), which was going to have some staff in place for inpatient and outpatient care (for the very and very very sick, albeit with the limitations of a poorly funded public hospital). For more on MGH, see my two previous blog posts, “You have the wrong hospital” and “A matter of conscience.”

My second list stopped there, for I could come up with no holiday solution for food insecurity. I hadpersonally never known a holiday without excess food; the notion of hunger on the holidays saddened me.

List #3: Why the Baylor clinic was closed in the first place
- Baylor clinic staff had not had a day off since the clinic opened in February 2006.
- They needed time off.
- It is customary in Swaziland for outpatient clinics to close for the days around Christmas and New Year.

List #4: What are my plans while we are closed?
- Drive up Mozambican coast and camp
- Mountain bike in the Drakensburg Mountains
- Maybe a brief safari along South Africa’s coast
- Catch up on reading, that is to say continue to sift though the large body of literature on pediatric HIV so that I might someday be able to call myself an expert.

This was the holiday I had planned, and I had been looking forward to it. It was going to be cheap, relaxing, adventurous, and all of those other adjectives that people seek when planning an exotic road trip. It was going to be the perfect hiatus, the ideal respite to get some summer sun and ward off burnout.

I was to leave the day after tomorrow.

List #5: Why am I so restless
- It is very quiet
- There are no patients to see
- This list-making is not working
- For 30 years straight, I have always been home for the holidays, and this year I would not be

List #6: Why I am not going home for the holidays
- Far away
- Expensive
- I have no plane ticket

List #7: Why I would [perhaps] rather go to Texas than Mozambique, Lesotho, and South Africa.
- My brother (birthday = late December)
- My sister (wedding anniversary = late December)
- My brother-in-law (“ “)
- My mother (wedding anniversary = late December)
- My father (“ “)
- My aunts
- My uncles
- My cousins
- My cousins, once-removed (I think that is what they are called)
- Grandmommy
- Granddaddy
- Chad (my friend since kindergarten)
- I can go to Mozambique, South Africa, and Lesotho next year, perhaps on the weekends
- I live year-round in Swaziland, an exotic place in its own right
- Besides, Texas is arguably exotic as well, in several ways

List #7 was much longer than #6, I realized.

One email and two hours later, I had my flight. Eighteen hours after that, I was on a plane, homeward bound for the holidays.


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