Too much

People in Uganda love to use the adverb "too".  Where a Californian might say "I'm hella hungry," or a New Englander "I'm wicked thirsty," Ugandans say "I'm too tired" or "she's too weak!"   This kind of statement might be accompanied by a shake of the head, or a clucking noise, and does not need to be preceded by a question, like "Do you want another serving?"  "No, I'm too full."  It's not usually a response or a qualification of anything, rather a superlative adverb, used in place of "very," or "so."

Another favorite thing to do is to interject the word "what?" into sentences for rhetorical emphasis.  "The patient presented with thrush, evidence of clinical failure, and that is why we decided to change the what? the anti-retroviral regimen."   The first few times I heard this on rounds I thought it was pimping, or maybe someone forgot the word they needed, but it's neither-- you are not meant to actually answer.   The "what?" is meant to slow the conversation down and call attention to an idea.

As I've alluded to before, I have yet to figure out what warrants ICU admission in Mulago hospital.   I have seen many critically ill patients die on the ward, usually because there was "no space" in the ICU.  But I've also heard of patients who were transferred that surprised me, most recently a patient on the neuro floor who was pronounced braindead, but the family could not understand this since he was still breathing.  A visiting American neurologist explained that he was effectively dead, and refused their request to transfer the patient to the ICU for mechanical ventilation.  Then, the American left for the day and the Ugandan doctors transferred the patient and intubated him.  The mzungu would be gone next week, they justified, but they would still be here, and feared that the family would tell their community that they brought their loved one in to the hospital and the doctors did nothing to help.  I have heard this same rationale for prescribing antibiotics for the slightest cough or diarrhea, and steroids for just about everything else (malignant bowel obstruction?)

Dangerous consequences of this mindset abound.  Excessive antibiotic use leads to widespread resistance.  Overzealous steroid use leads to adrenal insufficiency, immunosuppression, diabetes and ulcers.  Both doctors and families place a huge emphasis on feeding patients, and aspiration pneumonias pick off vulnerable, delirious patients after oral feeding goes down the wrong pipe.  I also learned today that the concept of using performance status prior to deciding who gets chemotherapy is not popular, and incredibly weak, frail patients with poor nutritional status get chemotherapy right up to their last days.

"She's too frail for chemotherapy," we tried to advise the oncologist today, about a young woman with metastatic cancer who weighed about sixty pounds and was bedbound.  He agreed, she's very frail-- let's feed her!  He assured us that he would drop a nasogastric tube and get started with feeding her right away.  We shook our heads no, it's too late.   She's dying.  We should focus on her symptoms.  He stood his ground: "But we can't do nothing!"

The first thing that impressed me about medicine in Mulago was the under-treatment-- insufficiently broad antibiotics, infrequent labs, poor access to imaging and specialists.  But I'm starting to notice that sometimes, the problem is the what? the over-treatment of patients, in order to do something, anything-- even when it's too much.