An old woman is looking for you - A patient encounter

Mycobacterium tuberculosis (www.filterair.info)

“An old woman is looking for you,” one of the nurses said.

Curious, I wandered into the reception area of the clinic.

A familiar face approached me, though I could not place it. It was a kind face, but the faces of elderly women in Swaziland always seem to exude kindness, so that didn’t help me.

“Good morning,” I said.

“Dokotela.” She responded.

“How are you?”

“Dokotela,” she said again, then she launched into a long SiSwati phrase, and I looked at her as if I understood her until she was finished, to be polite.

“I do not understand. I am sorry” I then said.

More SiSwati, with the word “dokotela” at the beginning and at the end. I understood this word, for I have heard it hundreds of times. It means “doctor.” The other words she spoke I did not understand, not even a little bit.

“Who is this lady?,” I thought.

Looking at her, I could still tell that she was kind, that what she was saying was very important, and that she felt pain when she walked, for she held a small, thin walking stick in her left hand. It was worn at both ends, rounded by contact with the ground at one end and the thumb and palm of her hand at the other. The end where her thumb was perched was shiny and dark, polished over time by perspiration and the oil that skin makes to keep from drying out on long, hot walks.

It was a hot day outside. It was a hot day everywhere in Swaziland that was not air conditioned, and Swaziland has little air conditioning. Swaziland also has few cars, and so there is a lot of walking.

I wondered where this kind-faced lady who somehow knew me came from. How early had she woken up to come to the clinic and ask for me?

The elderly lady planted the stick on the ground in front of us, placed both of her hands on top of it, palms down, and began pursing her lips in the shape that is required to make a hard consonant sound.

As she did this, I gave a quick glance over to the reception desk, the kind of subtle matter-of-fact look one gives when needing help.

“Dokotela,” the lady began again. She spoke some more, a longer phrase this time. Then another long statement. And a third. Each sentence she delivered was more animated than the one before.

It is interesting how not knowing the literal meaning of speech enhances one’s ability to appreciate intonation.

I waited, looking into her shining, aged eyes, nodding, feigning comprehension, extracting as much of the emotional content as possible.

One of the interpreters was now standing next to us, and after the old lady wrapped up her story, the interpreter said,

“She says the cough is gone”

“The cough is gone?”

“The cough is gone.”

“That’s really what she said?”

“Yes.”

“What else did she say?”

“That she knows you and that you know her.”

“Okay.” (Half correct, I suppose.)

“She said that you know her granddaughter.”

“Ah! Okay. Where is the granddaughter?”

“Over there, in the pink dress,” said the interpreter, pointing. I didn’t know how she knew this, but I went along, assuming that the information was buried somewhere in the old lady’s most recent monologue, though I do not remember any pointing. In any case, I was one step closer to figuring out what was going on.

The elderly lady, seeing we were looking over at the girl, said something else in SiSwati, this time quickly, turned around, and walked away.

“What now?” I asked, realizing that maybe I was never going to figure this one out.

“I don’t know,” said the interpreter. “I didn’t understand her.”

I felt a little better, though still embarrassed that my Siswati was so poor after six months in Swaziland. (Mind you, it is a difficult language, with daunting letter combinations and sounds that can fake out the most able linguist. I am not the most able linguist.)

The old lady’s back was now toward us, and she was walking quickly away. She bolted over to one corner of the waiting room, said something to another younger lady while tapping the small stick on a large handbag. She then scooted nimbly over to the girl in pink, handed her the stick, and stepped back.

The girl planted the stick on the tile floor, holding it three-quarters of the way up. With her other hand, she cupped the top of the stick and pulled herself to a stand. Then, with the elderly lady walking just behind her, she walked slowly and deliberately toward us.

As the child approached and her small, thin, also-kind face came closer, and I knew immediately who it was.

She is 12 years old, and her name is Vumile. I had seen her about a month back and had referred her to the TB clinic.

We walked back to the exam room, and I had a look at Vumile’s chart.

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The last time I saw Vumile, she was sick. Well, she was sicker.

Previously, when she took a breath, there were few sounds suggesting that air was actually entering her lungs. She was weak and her lungs were reluctant to inflate. The sounds I did hear within her uncooperative lungs were not normal.

If you have ever been to a concert or sporting event and either arrived early or left late, you know what normal lungs sound like. A healthy breath, when inhaled, sounds much like a stadium of cheering fans from a few blocks away. It is the crisp, clean, synchronous sound, like the one heard inside a medium-sized seashell.

A few months ago, Vumile’s breath sounds sounded nothing like that. When she inhaled, I heard two very different sounds. One reminded me of the guttural sound what one hears immediately after pulling the plug out of the bathtub, the sound of water moving quickly downward, pulling some air with it as it rushes underground. The other was similar to the sound that I hear (or rather used to hear) when I blew bubbles into my full cream milk. Now I drink skim.

These sounds were heard everywhere I placed my stethoscope. Of course, medical school taught me several words that allow me to document these sounds without awkward comparisons, so I had jotted these words into her chart. I had also written during the previous visit that she was too weak to walk and had been losing weight (~5kg), sweating at night (drenched sheets), and coughing (a lot).

As a matter of fact, she had been coughing constantly for several weeks, despite treatment with several antibiotics. The x-ray of her chest, reviewed at the last visit, showed enlarged lymph nodes around her heart and, for lack of a better word, ‘junk’ throughout her lungs, including an area that looked like a cavity outlined by junk. Given how her lungs sounded at the time the film was taken, I knew that it must be wet junk.

Finally, I glanced at the patient’s social history and noticed that our social worker, several months back, had written “Grandmother attributes illness to witchcraft. (…) Does not like medicines. (…) Little understanding of HIV.”

Oh dear.

I looked up from the chart and asked the grandmother for the child’s “blue book”. I made the request with some trepidation, for this blue book was the document that the government TB clinics issue when they are starting a patient on TB medicines, and I knew that there was a chance that the girl had never gone to the clinic, especially given what I had just read. I also knew that, given the previous exam and x-ray findings, there was little or no chance that the girl did not have TB,

After the interpreter relayed the question, the old woman looked at her strangely, shook her head, and muttered a few words.

“Darn,” I thought.

“It’s in the bag outside in the waiting room,” the interpreter said.

“Good,” I thought.

The old lady darted out the door and was back in record time. Though she was not winded upon her return, I am to this day suspicious that she might have actually sprinted there and back.

The blue book read “RHZ”, an abbreviation for “rifampicin, isoniazid and pyrazinamide”. This trio is the first line of TB treatment here in Swaziland, and the medicines had been started within 2 days of my previous referral.

“Great,” I thought.

Through the interpreter, I spoke to Vumile, asking her how she was doing. Looking down at her pink dress, she timidly reported that she was able to walk now, with the help of her stick. She was now gaining wt (~2kg according to her chart) and was no longer sweating at night.

“…and the cough is gone!” the grandmother chimed in. Indeed it was.

I listened to her lungs, and they sounded much more like the inside of a seashell.

I told Vumile and her grandmother that I was impressed how quickly she had gotten better.

“Dokotela, it is the medicine,” said the lady.

“I agree that it is the medicine.”

“Dokotela, now we must stop the HIV.”

“I agree.”

“Can you give us that medicine, dokotela?”

“Yes, of course. As soon as Vumile she gets another four weeks of TB medicine, we will add the HIV medicine.”

I wrote Vumile for a couple of needed medicines (bactrim and vitamins) and scheduled her return appointment.

Vumile and her grandmother stood to leave.

I shook Vumile’s small hand. It was moist. I wondered if I made her nervous. I hoped not. I then shook her grandmother’s hand. It was drier and harder than my hand, and stronger. As the interpreter and elderly lady ushered the child out of the room, the kind-face suddenly whipped back around.

“Dokotela, I have a stiff neck and headache some times. Is there medicine for that?”

“Yes, there is. Would you like some?”

“Yes, dokotela.”