Sunday, May 20, 2007

Kenya: FACES Home Visit

Home visits represent to me the quintessential experience of being a doctor. I get an amazing diversity of background and information about a patient from observing them in their home environment rather than in the clinic. I get the privilege of seeing how they eat, how the sleep, what they do during the day, how they interact with their family, roommates, neighbors. I can assess their sanitation and safety. It much more adequately satisfies the part of doctoring that is a bit of an anthropologist … but goes much further than the anthropologist by synthesizing the information into an intervention that is best suited for that particular patient / subject / person.

The downside of home visits is that often you uncover complicated and difficult issues that you can’t solve. We as doctors are trained all the time to solve problems and “fix” people. This of course is very difficult and a stressful expectation, in any setting – be it clinic, the hospital, or the home. If you go by yourself to do the home visit, which is what I do in the US, you then have to figure out how to address the psychosocial and financial problems that you don’t have time or skills or resources to deal with. The nice part about doing home visits in Kenya is that you automatically go with a team. In fact, usually the community health workers often go by themselves, so they especially appreciate it when a clinician goes with them to help with management issues. It makes a world of difference to have a team. You feel so much better supported and able to focus on the issues that we are trained to deal with: medical and psychiatric management.

We went to visit Margaret (pseudonym), a 22 year old with a rapidly falling CD4 count (from 500 to 200 in 3 months) and failure to thrive. She had also been pregnant and miscarried at 7 months at home – one month before our visit. The clinicians had been concerned about her weight loss and falling CD4 count, so they initiated her on HIV antiretrovirals and TB medications. She stopped coming to her clinic visits and the staff were concerned that her family was not supportive, so we decided to make a home visit together.

It started out very strangely. I sat back and let Kendi, the clinical officer, Elija, the community health worker, and Nicolas, the nurse, take charge of the visit. I also wanted to observe how they ran it. The home was small but very neat. Margaret’s older sister kept the two-room home very clean: swept, laundry done daily, food on the table for Margaret. Her sister greeted us at the door and sat with us during the interview. She seemed supportive. Margaret, on the other hand, was lying on a couch, barely moving, with an imperceptive voice. Her face was completely flat. She expressed no emotion, except later, when I sat next to her and asked some more questions. For the first 20 minutes, the clinic staff sat on the other side of the room, bombarding Margaret and her sister with questions, many of which sounded accusatory.

“Why aren’t you eating?”

“Have you been taking all your medications? Show us what you’re taking?”

“Why haven’t you picked your TB medications?”

No one shook her hand, sat next to her, examined her. They mostly spoke with the sister. After the 20 minutes had past, my assessment was that Margaret was suffering from untreated severe major depression, almost a state we call catatonic depression- where the patient is so depressed that they don’t move or speak. She barely spoke, in a whisper, and gave simple one-word responses. When I sat next to her, shook her hand, and spoke with her with much softer tone, she started to cry. She shed tears in the near-catatonic state: no change in her flat expression but now she had tears and mucus running down her face. After she started to wet her much-too-big t-shirt, she grabbed her kanga, which she was wearing as a skirt, and wiped her face. She told me that she was unable to walk, unable to motivate to eat, and lay on that couch all day, not speaking to anyone, not doing anything. She just cried when I mentioned the miscarriage. She didn’t say anything about it. But at least I addressed the elephant in the room.

She had no cough, nothing focal except for muscular back pains. She looked very very wasted: her skin clung to her bones except where it was stretched out for her recent pregnancy. Her eyes looked ghostly and glowing white in the darkness of her home, which has no electricity or windows. I held her skeletal hands while she tried to stand up during my neurological exam. She was very weak and her muscles contracted, stiff and thin.

In retrospect, I suspect that her CD4 drop was in large part due to her pregnancy (it was checked during the start of her third trimester) and that she probably doesn’t have TB, though in a person who was not as severely depressed as her, I would definitely think more seriously of treating for it empirically. I think that she has severe untreated depression, and while the clinicians in Kenya are often reluctant to acknowledge and treat psychiatric conditions, I pushed the issue and hopefully she has started on her antidepressants. And hopefully the staff sees the importance of acknowledging, treating and counseling people on depression – not in the accusatory way, but in a supportive holistic way.

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