Thursday, September 8, 2011

Lessons from Job

Why do the sickest patients always end up being the last to be seen in outpatient clinic? I had noticed the emaciated man earlier, waiting outside to be seen. I thought perhaps he was waiting to see our nurse who sees HIV and TB patients. But no, he was there to see me. I get the history: seven months of weight loss, night sweats, fevers. Appetite is good, he actually eats a lot of food, according to him. This belies his emaciated state-his temples are sunken in, as are his cheeks. The boney prominences of his face are clearly visible. His arms and legs are wasted, making the joints look unusually large in comparison. I can see each rib on his chest rise and fall as he breathes. If he’s truly eating well, then something is using up more calories than he can eat. There are three major things that will cause that here: HIV, TB, and cancer. Finally I moved to the abdominal exam. Rather than the concave shape I would expect to see given his malnourished state, I notice it is a bit distended. One touch of his abdomen, and I inwardly groan: his abdomen is firm, with a large mass in the middle. His ultrasound had revealed a pancreatic mass, and multiple metastatic looking lesions in the liver as well as in the abdomen. “Oh, papa,’” I think. “You’re so late in coming. Oh that I had a means of treating you, making you better.”  But I do not say this out loud.
Breaking bad news is difficult in English, in my own culture, let alone in French or Lingala, in a culture I do not fully understand. Do you tell the patient he is dying? Do you tell the family? Who is the head of the family? Are they present? Do you have to wait for them to be present to explain what is going on? Some of these are readily answered by the situation, others are less clear. I discussed it with a Congolese intern who was working with me. He recommends it best not to tell the patient at this time. I have asked for some tests, and we can wait until the results come back to discuss it further. 
He is admitted to the hospital because he is so weak. His HIV and TB test are negative. The metastases in his liver appear to be calcified, which is more consistent with a malignant (cancerous) process. He becomes weaker and weaker. Sunday the doctor on call talks with the family about taking him home to die. It’s must cheaper to transport a mostly-dead person than an already dead person, and these patients don’t have much money to begin with. There is nothing further we can do medically. The family searches for a ride, and asks the wife of one of the other physicians if they can put him in the back of the truck. She agrees.
The family gathered all their belongings, putting them on top of the cab of the truck. They placed a straw mat on the truck bed, and gently placed their loved one on it, his mother sitting at the front, so she could hold his head on her lap. He’s still alive, but barely. I can see his slow respirations through the thin jacket covering him. “Any time now,” I think. You can’t survive long breathing 4-6 times per minute. The rest of the family gathered round him-about 8 people all together-for the ride home. I’ll never forget the mother’s solemn face, the silent tears falling down her cheeks as she held her son one last time. We arrive at their home. Before taking him out of the truck, they prepare a ‘bed’ of sorts for him-a low frame with several sticks across it for support. One man takes the front door (which was not attached to the house) and places it on the sticks to provide a flat surface. He is then gently transported to this ‘bed’, no doubt his death bed, the very place he will lay while they mourn him. He’s still alive at this time, but barely. The tears fall more freely from the mothers face. Soon, no doubt, the cries and wailing will start. They will mourn him loudly, crying out in their sadness and grief.
I have heard the sound of wailing many times at the hospital. Sometimes, I wish to join in. I wish to cry out to God “Why are you letting this happen? Why are these children dying? What did they do to you? Have you no mercy?” My heart breaks for these people. Through my sadness I can see that God loves these people even more than I can ever dream. His mercy is far more than I can imagine. When my heart breaks, His breaks more. His heart breaks for the sadness of the parents as they lose their child. His heart breaks for the sin that so encompasses the people-idolatry, infidelity, stealing, lying, sorcery. Oh that they could know Him, and He would set them free! 
God, to Job:
“Would you discredit my justice? Would you condemn me to justify yourself? Do you have an arm like God’s, and can your voice thunder like his? Then adorn yourself with glory and splendor, and clothe yourself in honor and majesty. Unleash the fury of your wrath, look at every proud man and bring him low, look at every proud man and humble him, crush the wicked where they stand. Bury them all in the dust together; shroud their faces in the grave. Then I myself will admit to you that your own right hand can save you.”  

Job’s response:
“My ears had heard of you but now my eyes have seen you. Therefore I despise myself and repent in dust and ashes. “
Job 40:8-14
Job 42:5-6

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