Wednesday, April 30, 2008

Teaching renal failure

Teachers help students believe in patterns in the real world. In any discipline everything seems so chaotic and impossible to understand at first. The descriptions of patterns in our textbooks seem sterile and nothing like what we have seen in the real world. A desperate, breathless man with a wailing entourage looks nothing like what a textbook patient with end stage kidney failure is supposed to look like. My reading on poverty, class and caste conflicts wont let him breathe easy. Wont let me breathe easy. At Sittilingi I've had two patients like this already. One died holding my hand after twelve hours of struggling to breathe as fluid irreversibly poured into his lungs for the last time. One went home after being successfully pumped with diuretics. He will come another day to die.

Why do people die of kidney failure? Its a long complex story involving chronic NSAID abuse, undiagnosed hypertension, drugs prescribed by unqualified local 'doctors' and blinding ignorance of methods of prevention. Add to that poverty, exploitation and a historical tendency to screw over tribal communities.

What do the current pundits of community health have to say about managing people with kidney failure in the community. Precious little. There is a huge difference between those who do things and those who write about things. The doers are brilliantly innovative yet deathly silent. Amazingly innovative ways of managing such situations do not leave the local context where they are practiced. There exists no peer review journal, no website/blog, no conscious effort to put suchlike into current textbooks. On the other side we have the suave publishers. Toting degrees from posh institutions that inculcate snobbery they fly around collecting data and creating analysis that serves them well. However they act like they never met a poor, dying man ever. Never shared his pain.

I realize that my previous paragraph is harsh. I am in danger of putting myself on a pedestal. But I write because of frustration. Because I lack good teachers. Because my textbooks are nothing like the real world. The chapters on renal failure make no sense because they don't talk about patients. I know how to manage a rising blood urea level better than I know how to manage people dying. I cant prevent death because of the silence maintained on the people causing renal failure. By selling dangerous medicines and by their failure to create a working system people of my community cause people to die stupid deaths.

Its time we saw a chapter on renal failure that reflects reality.


Carolyn said...

It's true. Reading your words gives me a painfully real picture of the whole scene, and I too have sat there on the bed with someone dying in front of me - completely helpless both of us.

I don't know if you - we - lack good teachers. I don't know if anyone knows anything useful to teach, actually. It's much easier to concentrate on the things people can spout knowledge and information about and ignore those other difficult bits that just don't work. Such as gasping and suffocating to death with no space in your lungs.

Lalit Narayan said...

It takes a great teacher to acknowledge that there isn't anything useful you can say about certain topics within the confines of a classroom. And then take the class on a journey from there.

The second one of my patients with renal failure who I had said would 'come back to die another day' passed away two days ago.