Laundry, Waterfalls, and Mary

It’s Monday afternoon, and I’m watching my clothes dry. This is one of my secret pleasures in life. As I often complain about at full volume, I HATE doing laundry at home. I hate hunting for quarters. I hate hauling my clothes down our sketchy back stairwell, praying it doesn’t collapse as I plummet to my doom. I hate trying to stuff my folded pajamas into my bottom drawer filled to the brim with old Stanford t-shirts and countless pairs of scrubs. I hate doing laundry at home.

But, strangely, I have always loved it while traveling in developing countries. And my favorite part is hanging the clothes up to dry. It forces me to slow down, to think about each article of clothing and its history – my scrub pants from my ob/gyn rotation at the General, my Obama t-shirt that draws so many excited comments here, my gym socks already turned dusty red from Ugandan hiking adventures, my despised white coat that I’m forced to wear every day on the wards here in order to fit in with the immaculately dressed Ugandan medical students. Socks, shirts, pants, skirts, they’re all dancing in the warm equatorial breeze now…. Probably been dry for a while, but I like watching them, and so they stay.

Technically, I’m playing hooky this afternoon, having slipped away after morning rounds with the Infectious Disease team. I need a break. Last week sucked me dry, emotionally, brought to a morbid finale on Friday morning. For those who aren’t familiar with the medical student gig, we spend the last two years of medical school exclusively in clinical settings, where we are assigned individual patients for whom we are responsible. We conduct the initial interview and physical exam, order diagnostic studies, choose treatment regimens, and then follow throughout their hospitalization to assess progress and make any necessary diagnostic or therapeutic adjustments. Here in Kampala, this responsibility is taken to the extreme – thus far, I am often the only person to examine a patient, to read their X-rays, to order their treatment, to discuss their care with their family members. And so, it was natural for Mary’s cousin to seek me out on Friday morning, grabbing my arm as I walked onto the ward, stating, “Doctor, my patient’s breathing is different.”

Mary is a 35 year old woman* who had suffered a massive hemorrhagic stroke 3 weeks prior, thought to be due to a protozoal brain infection, the end-stage result of her undiagnosed HIV infection. She was neurologically devastated from the stroke, unable to speak, paralyzed on her right side, but had been relatively stable throughout the week. In fact, I was already broaching the idea of discharge, brainstorming some kind of homemade physical therapy to maximize her recovery at home. Hard to believe now… (for obvious reasons, I changed Mary's name here)

I am not a doctor. The scary truth is that I’m pretty darn close, but I’m still years away from anything resembling expertise on anything. There are days when my cat knows more about medicine than I do. But somewhere over the past 18 months, I am grateful to have somehow developed what is arguably the most important skill a physician can have – knowing when to worry. I took one look at Mary, and my stomach dropped to the floor. She was breathing at twice the normal rate, clutching her sheet, pleading to me with her eyes, still unable to speak. Shaking, I took off my stethoscope, listened to her lungs, clear. Listened to her heart, racing. Took her pulse, barely palpable. Shit.

I ran to the next room, scanning each bedside for my resident. Nowhere. I finally found our intern, kneeling on the floor next to a new patient shaking with chills from malaria. I grabbed his arm, pulling him to my patient’s bedside, telling him everything I had just found, sharing that I was afraid that she had a pulmonary embolism – a dreaded blood clot in the lung vessels that can quickly kill patients. My intern looked at the patient with wide eyes, listened to her lungs, said something in Luganda to her attendant, and walked back to his malaria patient. I interrupted him again, assuming he disagreed with my analysis, praying that I was just being a paranoid medical student, and that my patient was fine. Instead, he looked at me and said, “No, you might be right. We can order a chest x-ray if you’d like, but she could die on the way down there. And I don’t know if they have the money for it, anyway.”

I’ve never seen someone die. I know that seems odd, but most medical students haven’t. The truth is, we’re pretty good at “controlling” death in the US. Patients die at home, in nursing homes, in ICUs after months on a ventilator. They don’t die at age 35 of reversible conditions brought on by treatable diseases, with only a medical student at the bedside. But my Mary did. Slowly, as the morning stretched on, while I frantically scanned the hallways for any attending physician who would suggest some alternate therapy, Mary grew tired. Her eyes glazed. Her breathing slowed. Her brother David pleaded with me, “Isn’t there anything you can do? Can’t you call the neurosurgeons?” I looked at Mary, and said aloud what I was only just realizing – “We don’t have the time. She is dying.” A few moments later, Mary took one last, gasping breath, like every movie you’ve ever seen. And then she just didn’t take another. Some dusty part of my brain remembered what to do: I shined my light in her eyes, no pupillary response; listened to her heart, nothing. And nothing. And nothing. I knew what that meant, but could not find the words. I looked into the kind eyes of her brother, and found myself as mute as Mary had been. Finally, I met the eyes of the Dutch medical student standing with me, and nodded to him. He put his hand on David’s shoulder and said simply, “I’m so sorry, sir. She is dead.”

I didn’t mean to write about this today. I planned to write about my weekend adventures in Sipi Falls on the Kenyan border with Dana and Patrick, fun travel stories about losing my camera, crazy matatu rides, watching my friends repel down waterfalls, the most amazing hike of my life. And I’m sure that’s what most people would rather read about. But Mary has been on my mind. I never heard her voice, never met her children, never shook her hand. But she had one of those faces you remember, that seemed familiar as soon as I met her. It was good to get away this weekend, to distract myself, laugh with good friends, old and new, hike in the pouring rain, stand meters away from the most powerful waterfall I’ve ever seen, struggling to stand against the wind and spray that drenched me to my core, marveling at the primal beauty of this land. But beneath it all was Mary. I pray for her family, and that she has found peace. And I pray for a world that would not tolerate the death of someone so young. She deserved more.