Diagnosis I

“Oh, this woman, she no look well.” Bailor’s voice was concerned but matter-of-fact. The consulting room was cramped, with Katie, myself, and Dr. Lenny crammed into different corners. Bailor was behind his desk, and Bori was in front of it, waiting to translate.
The woman entered the room. There was a practical desperation in her movement; it clung to her and hid in the way she sat down and settled into a vacant stare. Her eyes were wide but sunken, and hunger had tightened her wrinkles against her bones. She was robed in a magnificent turquoise and lime green diamond patterned dress. As Dr. Lenny would later point out, she did not look like she was having a good day.
“Wetin na de problem, mama?” Bailor asked her what was wrong. I fiddled with the “Children’s Hospital Care” book on the corner of the desk. Bailor later called it his bible. “Why you come today?”
She rubbed her stomach and looked plaintive. Bori translated. “E’ belly de hurt, e belle de hurt... she de feel snake insigh, crawling insigh, crawling... e’ de hurt beaucoup...” and after some prompting, “e’ body de wam, de joints dey hurt...” While translating, Bori began gathering vitals. He motioned for her to remove her shirt and then slipped a blood pressure cuff around her arm.
“What did she say?” Katie asked. Bori had translated into Krio, which sometimes needs further translating.
“Her stomach hurts,” I slipped in, rather unhelpfully.
“She say, that she feels a snake inside, that her stomach hurts,” Bailor had the real answer, “you know, these people, they will tell you that there is a snake, and they feel it crawling,” his hand traced snake-crawling around his belly, “and then it will bite them here,” his hand made a biting motion at the center-bottom of his ribcage. I nodded sagely. Gastritis, or ulcers, or heartburn, I thought to myself. “Tha’s why you need to know your patients, you need to know where they are coming from, so you can understand,”
“Well, not to downplay the role of understanding,” Dr. Lenny held his hands up and looked bashful, “but I think any good clinician would think of gastritis when a patient mentioned upper chest pain,”
“Does malaria cause that?” Katie asked, about the gastritis. Asking about malaria is always a good idea here; since the parasite attacks the red blood cells, the disease can manifest in many different ways. Bori had written down the blood pressure cuff results on the back of the patient registration card and then pushed it across the table. I eagerly peered at the numbers. Pulse 87 bpm, blood pressure 100/78.
“No, is probably peptic ulcer disease,”
“Well even giardia can cause gastritis, though,” Dr. Lenny added, with a humble shrug of his shoulders. “And even in the US it’s hard to tell whether or not it’s H. pylori, peptic ulcer disease,” he added, “here I bet it’s just that much harder.”
“Yeah, yeah, you know, that’s why, that’s why, I’m not sure, but I will prescribe her [some antibiotics and an antacid].”
“That’ll take care of the giardia too.” Lenny replied, but I was looking at the patient. She didn’t look healthy, and even though she had come in because of the pain in her stomach, that might be masking a more chronic problem. Hmm. Should I say something? I wondered. I was sure the experienced clinicians have already thought of what I wanted to say.
“But, are we going to test for malaria? Maybe the peptic ulcer disease is masking something else, something more important?”
“Well yeah, yeah,” Bailor motioned for her to lie down on the consulting room mattress. He listened to her pulse, “I know we have the pulse, but I’m just listening for to see if it’s irregular, if there’s a gallop,” and then he palpated her abdomen. Then he listened to her lungs. The woman was now sitting up, hunched over. Her head was wrapped in cloth with a similar but not identical pattern to her dress. To me, it looked like it was randomly tied, but I was pretty sure it was very intentional. I could see her ribs, but she wasn’t emaciated. Along her belly there were folds of skin, empty of fat and water. It looked to me like she had been losing weight.
There were several loud knocks on the door while Bailor was doing his exam. He yelled at the door in Krio. Soon he was done.
“Katie, you want to listen? See if you can hear what is in her lungs.” Bailor’s Krio accent always sounded informal and cool. He dropped all kinds of final consonants, and said “I” with an “ah” sound.
Katie started, surprised at being switched from observer to participant. “Yeah!” Bailor handed her the stethoscope. She held it for a moment, and looked back at him. “Well, I don’t really know what to do.”
“Oh! Sorry Katie, I jus’ think you are medical student, that you already know all these things. The idea is to listen symmetrically, okay? Here, here, then here, here, then here, here...” Bailor placed the stethoscope in four spots on each side of the patient’s chest, starting near the armpits and moving down around the ribcage in a J shape. Then he switched to the back and pointed out four spots on either side of her back, the first three moving down the spine and the last one out to the side.
There was more loud knocking. They needed the calculator out at the reception desk. The calculator was sitting on the desk in front of me. Bailor sounded a bit annoyed when he said “Le ‘im come, gi’ ‘em calculatah.” Bori passed the calculator to Dr. Lenny, the door opened a crack, and the calculator disappeared out of his hand. It was more respect for the door than usual – a week ago when Katie had been sick, the clerk had walked right in during her exam, after Yusuf had asked her to remove her shirt so he could listen to her heart.
After he gave up the calculator, Dr. Lenny said, “So, this lady, this woman, one of the ways you know she’s not well is that she is breathing very quickly, and she really doesn’t look like she’s having a good day.” In my mind’s eye I saw her sitting down in the chair at the beginning, her shoulders heaving weakly. Dr. Lenny was right, she had been breathing fast. Katie had put down the stethoscope, and Dr. Lenny picked it up. “Do you mind if I listen?” He asked Bailor.
“No, no, go ahead,” Dr. Lenny went through the same steps. But when he reached the outside of the ribcage, on the woman’s back, he asked Bori to get her to make an “eeee” sound, and then an “aaaa” sound.
“I think there is something wrong with the air intake,” said Bailor, “something wrong. When you listen, you are trying to compare both lungs, to see if there is some problem. But her right lung, it’s not well. I think maybe she has tuberculosis, even though she’s not coughing.” Bailor looked back at Dr. Lenny. “So what you listen for, is some kind of crepits, some weird sounds, like a whistle,” he whistled, “or sounds like hair moving, or,” he gurgled. I was a bit impressed he could make those noises. It was actually pretty helpful.
Dr. Lenny finished, and the woman turned and sat with her legs dangling over the bed, shirtless. I wished I could speak Kono, to find out how she was doing, and what she thought of this mess of doctors and students and nurse inside the tiny consulting room. Dr. Lenny told us what he thought.
“I think there is some blockage in her right lung, at the bottom,”
“Yeah, that’s what, that’s what I heard, and so I think maybe tuberculosis.” Bailor agreed. “But the next thing, is an x-ray, and you know...” He trailed off. During the previous patient consultation we had met a sixty year old woman who had a bullet in her foot. The wound had healed, but her foot always hurt, and was often swollen. Then Bailor told us that there was no x-ray machine in the Kono District; the closest was three and a half hours by driving, or 30 000 Le round-trip by public transit. The x-ray itself was also 30 000 Le. The sum is enough to feed a poor family of six for ten days. At the end of her visit, I asked when she had been shot. After a brief debate about the year of a particular event in the war, I got my answer: 1998.
Dr. Lenny continued. “But you know, the left lung is not so good either. I here a whistle, some kind of a wheeze.”
Then Bailor held up the woman’s hand. “And look, here, you see this, this clubbing.” Dr. Lenny nodded. I remembered that Bailor had told me about clubbing a couple days ago. Katie asked him about it, and he answered, “It’s when there is not enough oxygen in the blood, and the fingers straighten out. This one is not so bad, sometimes they are like drumsticks.” Bailor straightened his fingers for dramatic effect. The woman’s fingers looked a bit swollen, too.
“Why does that happen?” I asked.
“Well, it’s when the blood oxygen is not high enough for a long time. It’s a sign of chronic illness, maybe tuberculosis.” Dr. Lenny’s answer was interesting, but not an explanation of why.
“You know, I was reading in some papers, some scientific papers, that they don’ know,” said Bailor. Okay, I nodded. There you go – a basic clinical exam finding, largely inexplicable.
Katie and I took turns listening to the woman’s lungs. I fitted the stethoscope into my ears, but it was kind of uncomfortable. The woman was impassive and her stare was vacant. But the moment I touched the stethoscope to her back, my ears were filled with a soft, low hum. It was full of life. I could hear the soft roar of air intake, with a small bump at the beginning, and I could hear what sounded like a wheeze. I couldn’t tell that there was something in her lower right lung, and it was hard for me to tell what was general background noise and what was something going on in the lungs. But it sounded like millions of tiny processes, millions of tiny cells transporting proteins and energy in and out, fluids flowing around and through, splitting from arteries to arterioles, perfusing out of capillaries. My head was alive with the cartoons of biology textbooks, but my ears were alive with the sound of life.
“I couldn’t really hear all the things you mentioned,” I told Bailor, a bit sheepish.
“That’s okay, you don’t even know what normal sounds like yet.” True.
Dr. Lenny gestured to the woman that she could put on her shirt again. She took her shirt and bra from him, but didn’t look at them. She looked at him the whole time. Then she sat down in the chair again.
“Bori, thank her for being so patient while we all examined her,” I had no idea if this thank you would be understood, even if every word was translated. Bori told her, and she made a small nod. Then Bailor spoke rapidly in Krio to her, and I didn’t catch it. But Bori translated the answer.
“No, she done sick li’ dis na ten years now. Ten years, she say,” Bori’s eyes were wide. Ten years sick, losing weight, tuberculosis... it sounded like it could be HIV.
Bori said more Krio, that I didn’t understand. Bailor translated. “She say, that you know why she is coming today? Only because her brother came and got her. She lives in the village, and it’s only because her brother came and got her and she is staying with him, and he is paying. That’s why she is here today.”
“Ask her if her husband is sick.” Dr. Lenny had a good idea. Bori asked her.
“She de say yes, ‘e sick, an he done ge’ sick befo her, but ‘e body no done done like ‘e,” Yes, he was sick, and he was sick before her, but he wasn’t losing weight like her.
“Does she have children – are they alive?” Dr. Lenny asked again. Bori asked her, and then translated.
“Ten, six alive, four dead.” Her face was still quite impassive. I didn’t understand. How did this look, from her perspective? She had been sick for ten years. And had not gotten better, had not been healed by traditional medicine. And now she was here, in Koidu, brought by her brother, to this strange clinic, staffed with strange doctors, and even white people. She’d been poked, prodded with strange devices, made to take off her shirt, and questioned. What was she thinking?
Bailor explained to her that he was ordering a bunch of tests. Urinalysis, malaria, typhoid (two types), white blood cell count and differentials, hemoglobin concentration, and a tuberculosis test that the clinic was not certified to administer because it did not have the treatment drugs on hand. It was almost every test the lab can do. Then he explained to her that he wanted her to go to the goverment hospital for HIV testing.
“Mama, okay. So you faut de go na government hospital for testing, okay? You no de go’ pay 100 Leones, test na free. But you faut de go na dere.” She nodded, and asked a question – today? “Yeah, if you go able for go today, i’ betteh. Den, you faut come back na ya, you faut come back ya.” You must go to the government hospital, today if you can, and then you come back here. Bailor slid the form back into her folder, gathered up her registration card, and handed them back to her. She stood up to leave, and her dress unfurled around her. The diamond patterns were edged with gold thread.
“Bori, can you ask her if I can take her picture?” Dr. Lenny had his camera out. Bori told her. She shrugged. “And can you tell her it’s not because she’s sick, but because her clothes are so beautiful. She looks beautiful in this dress, it is one of the most beautiful dresses I have ever seen.” Bori looked bewildered, but translated, and she hardly reacted. Languages can be translated much more easily than cultures, I think. She stood stoically and awkwardly for Dr. Lenny’s photo, in the particular way of someone who has never had their picture taken. Then her dress followed her out the door in a flash of color.