"Mike, you cannot die with it!"

OK, OK, OK, OOHKAY already. The last entry wasn’t really the last. Now all you out there that have placed bets on the short can start to collect.

On my last day of outreach I was in Kanye. There the medical staff surprised me with a breakfast to say goodbye and farewell. During the meal an MO that I have mentored for the last two years was walking around the rather crowded room in hushed conversation with the others there. Now I like this guy but he can occasionally wear on me a bit as he tends to whine. I asked if he could wait for the gathering to end, he said “just a minute”. Now there is no “minute” in this culture. I was being blown off. OK, my last day, so be it. Point to him.

Shortly thereafter he stepped to the front of the room and said, “Dr. Mike do you know how many languages are represented here?” I didn’t. “Twelve.” “Do you know how many nationalities or cultures are in this room?”Mind you there were only fourteen people in the room including me,“twelve”. Interestingly none from Botswana.

And then the most moving and extraordinary thing happened; each of the MOs in turn stood then stated where they were from, their tribe and their native language… and then said “thank you” in that language. Wow-- as in lump in the back of my throat wow. That, I hope, finds its way to my hippocampus, right next to my “asymmetric amygdala” and therein imbeds itself for me to recall as often as I would like. It was just incredible and made all the time there even more extraordinary.

Then this: we were on the way to the Gabs airport to fly to the N.E. kwaZulu Natal coast. We wanted to decompress after the craziness of packing (all by Lynne) and leaving B-UP. The diving (me-six dives) and the beach (Lynne-six days) there was amazing but it was the trip to the airport where I was broad-sided by the cab driver whom we have known for almost three years.

Tendai is a religious man, a transplant from Zimbabwe, and adamant about his family and ideals. He started by saying that I was given a “gift from God himself”. It is always uncomfortable to compare myself to another who thinks of himself as of lower station. I tried to blow it off and equate him and his use with mine. He became even more animated and talked up the whole “came from the US to help us Africans” slant on things. I again tried to not let this stick. If there are any hero’s to this saga it is the patients. He finally became even more animated and stated that “you have a gift from God Mike and you cannot let it die with you!”

OK so there is was, on the head with a veritable 2x4. At some level he put simple words to an idea I have been considering for some time now: how self centered would it be if I don’t give of myself such that the “gift”, all the effort people have put into my career, is shared? Shouldn't I (we) pay it forward, share it as it were? This is no doubt a touch hokey as there is apparently a popular film out that comes at this idea. And while the benefit clearly goes both ways, it is I who has been endowed with this and need to initiate the first encounter by simply sharing and hopefully exchanging benefit It has only taken me 30yrs to get this. Maybe that is one of the lasting legacies of this adventure.

Happy New Year and compliments!

Swan song.. Or as the Brits say, done and dusted

Before you begin this read the last post. What follows will make more sense.

Parenthetically, I have found that I need to be on guard for the "multiple somatic complaint" patients when they are really just in the clinic for a refill of blood pressure meds. Yesterday evening I saw an unfortunate soul who was profoundly demented. His daughter wanted him evaluated for his dementia and I did so. Unfortunately there is no treatment that makes a difference and she was so informed. She wanted "treatment" and again I advised there was none. Off she went only to come back and indignantly demand a refill of antihypertensive meds for her father. I looked deeper into his file and found out that he had been worked up previously for dementia despite her statement that I was the first one to see him for this. He did have HTN but didn't need the meds ASAP.

I had been suckered by the last patient of the day and, well, let's just say that during the drive home I was preoccupied with introspection regarding my impatient response. Before her father we saw a desperately ill woman with HIV and fever who had been queued up for 6 freaking hours! My impatience with all of this reminded me of my old man. Geez I hope this isn't genetic. It is however a slog and one that I fear won't abate when I "get" to see chronic pain, chronic narcotic use for somatic pain, and the likes of fibromyalgia again. Wish there was a med for being so impatient and a jerk to boot (me, not my dad).

While I have no regrets about going to the States I do have mixed feelings about leaving here. I love this country; the singing (much of it acapella), the land and fauna, the smiles and laughter. It has embraced me in its most remote corners where the true heroes of the HIV epidemic reside. And yet I look at pictures of Lost Lake and Mt Hood and think "have I squandered two and a half years?"

Yet foremost and tipping the scale away from here is my family. I'm a fortunate guy to have such an amazing bunch in my life. I'd like to take credit for it but that is in Lynne's purview; I helped but is was on her lap that those monstrous teens curled up and chatted. I was the one who inspired the fun and mischief. Sorry outlaws and in-laws that will trickle down to your kids, it's simply is too much fun.

Finally I've realized what my family seemed to have known for quite some time; that I'm an "end-of-the-road, whats-around-the-next-bend" kind of guy. I find myself at an age where I don't need to persist in something that I don't enjoy and that doesn't play to my strength as a doc; simple doctoring. I am indebted to my B-UP colleagues, each of whom are brilliant, and yet I find that I don't necessarily share the same professional language or value set. Not good, bad, right, or wrong as much as it is simply true.

Shortly after the 17th we will venture to Sodwana Bay along the north eastern coast of South Africa where I can soak my head in forty feet of clear water and Lynne can read on the beach. Then to the States to harass kids and grand kids. Then to, wait for it... Hawaii. I will be with Kaiser Permanente in Honolulu and will work locums. We'll teach, swim, dive, and toss Judah, Asher, and Cora around. Forrest and therefore Shannon, et.al. will be stationed there. Then when the Northwest and Midwest are at their gloomiest, the northwesterners and hopefully the Louisvillians can come and it will Belle's, Lue's, "and countings" turn. I have a special dispensation from the extended family Pendleton to leave every 15-18 mos or so I can scratch the medical relief itch for 3 months. The University of Botswana is starting a Family Medicine program here so who knows, maybe attend in the clinics for a time, if the country will have me back.

So this will be the last blog entry. If any of you want to flee the northern hemisphere winter in February, give us a ring (you all know our contact info). We'll have a room for you and will know where you can get some killer sushi!

Cheers,

Mike

Resigned to Resignation

Early in September, a Friday, I came home from a district hospital in a lousy mood. I had been discouraged all week that the MO's, with a few notable exceptions, weren't asking the right questions and therefore not practicing up to their potential. I know, I have written about this before but my toxicity meter was in the red zone. It seemed that nothing I had done to date had made any lasting difference in care. I had had a horrific Monday, involved in something that while medically necessary, decent and appropriate really shook me like I haven't been since my MSF days. With MSF I had to look through/past events and continue; "next". Here, I have been able to let my guard down and was totally blind sided. I felt depleted and ineffective and began to seriously question the true purpose of my medical presence here.

To the extent that we, or for that matter any expat organisation , make a lasting and true difference here appears to be simply out of reach. This is a young country that is in the process of emerging from adolescence and needs to find its own value system. I find it making the same mistakes, and encountering the same struggles that a more mature country has processed through. Hell, when the US was this "age" we were fighting a war, again, (1812 wasn't it?) and for what? It is generally agreed that we are at least two generations away from true reform in medicine. Were we placating the metaphorically "young teen" country such that rather than teaching one to fix the flat tire one's his bike we instead were buying one a new bike? We'll just have to wait and see I guess.

So on that Friday I found myself thinking if the above was true, what was I doing here, really, that was making more than a temporary impact? Was this just an exercise in pure narcissism and was I just collecting stories? I love the people and the primary medicine to be sure but B-UP has slowly moved away from point-of-care medicine at a primary level. We are responsible to those that fund us and it becomes difficult to quantify relationships or for that matter reliably assure that knowledge transferred makes a difference at the doctor-patient level. I had been worrying that at some level I and my organization were, perhaps, enabling.

I found myself a bit depleted and not a little frustrated. I had struggled for a while with the notion that I am different in numerous ways from my fellow faculty members; generational, primary specialty, medical terminology and priorities, etc. Even the term "faculty" is foreign, implying separation from my primary care colleagues. I have learned alot about health care in this setting and at the same time that information rarely related to my every day teaching and, with few exceptions, had little lasting impact on my those I mentor. All too frequently I found myself saying that "we have discussed this disease and its management before" and did he/she remember that? For the most part they didn't, or didn't care.

In any case after no less than two "interventions" on the part of my family ("Papa you need to get your shit together and enjoy your grandchildren and they you") and considerable introspection on our part I submitted my resignation a week later, effective 17 December. I have 5 weeks. I know, no state secret here, but I wanted to keep it quiet as it shouldn't be about me.

Now the family reunion

Again no words can come close. We had our four (the outlaws), their four (the in-laws) and five of the following generation. Oh and us, making, what, 15?! I had no idea I was at that station in life. We were fortunate to have a huge beach house given to us to enjoy for the week. It faced the Jersey shore and was an easy walk (about 50ft!) to get to a wondrous place for exploring and Uncle Wiggly adventures.

On cold days we would laugh; at us, the screwball antics of our grandkids, and then would eat too much. I return well marbled from the following diet; hot dog with mustard and sauerkraut, then cheese steak, then Japanese food (I know, some how these don't belong in the same universe) then chew-belch-and-repeat.

We have a family of educators and docs. Weird how that happened. And they all were called upon for various situations that made us proud to see them exercise their professions. I am a proud Papa and Grandpa indeed.

All the little ones were cared for by the entire clan so they will have a time adjusting to the routine back home. Hah, the Papa and Mama's revenge. Such lovely debauchery!

First the Savuti

This area is classic African Savannah, except it isn't as a slight earth quake tilted the delta just enough such that the Okovango complex is now flowing partially through it. The Savuti used to be home to one of the largest lion prides in the world, numbering about 40. It split up when a lioness bred her family away from the pride and things went from there; a population explosion of elephants, wildebeests, eland, kudo, birds, the ever present impala (read Big Macs for predators), everything.

We went there with the intention of seeing this pride but alas it was gone, but the Savuti wasn't and it was magical. And what made it better was that friends from HR were there, Michael (alias "the DH") and MJ (alias "coach") were there. We were a party of 4 and had the guide to ourselves. Johnny was/is amazing.

He knows the area like the back of his hand and we often found ourselves away from any other tour (there aren't many) looking at a fantastic sunset with a hyena in the foreground! Yes the sunsets are as good in the eastern area of Wasco County, but when can you say you saw it from the freaking Savuti? Much less as a hyena was preparing to head out on a night patrol. Thought so.

Words simply can't do it justice. For those of you who know Michael and MJ, ask them. I'm still a bit amazed that it happened, and with them to boot. Bottom line? Have this one on your bucket list for sure. And use Johnny.

Come on Mike, connect the damn dots!

As the discerning reader will recall I have ranted about health professionals and how they (we) don't ask the appropriate questions. To whit:

I was in a remote district hospital on Tuesday where I rounded on all the patients in the hospital, about 30. We saw a child of 8 years who was anemic to the tune of a blood concentration of less than 1/3 of usual. He had been admitted on several occasions "because he eats dirt", and had no platelets (the blood cells that promote clotting). I took one look at his blood count (called "full blood count" or "FBC") and had the diagnosis. His red cells were so small and so pale that they appeared like platelets on the automated count. He was so iron deficient that he had "pica" or "geophagia" and had the uncontrollable urge to eat dirt for its iron content. "So its not that this is abnormal. It is because he has no iron stores, is HIV+, and has a diet that is deficient in iron" I desperately wanted to add "you idiots!!!!" but there was that voice in my head again...We inquired about his diet which was awful as he came from a poor family and ate just twice a day, grain at that, no meat, and little green vegetables. We gave him some iron that was to be taken three times a day for three months, no just five days that had been prescribed on previous admissions.

On to the OPD where I functioned as the visiting surgeon, dermatologist, and family doc. I saw no less than three women who had abdominal paid that was characteristic of gastro-esophgitis (2) and lateral abdominal wall pain. As all had persisted in there complaints the MOs had obtained ultrasound scans on all of them. This happens way too frequently there as the MOs are fatigued and want to fish for a diagnosis that will satisfy their "customers" as the Ministry of Health has taken to calling patients. What garbage (the MoH not the MOs)....But I digress. All three now had become fixated on needing to have their gall bladder removed as it was the seat of all that ailed them. I tried and tried to explain that they in fact had "asymptomatic chloelithiasis" and that we had learned long ago that surgery had no place in this process and causes more complications than it fixes. All left unhappy...sigh.

Then a fascinating young woman. She was seeing me because she had a spectrum of complaints that made no pathophysiologic sense otherwise known as somatization. I have been trying to get the MOs to call this symptom complex "somatization" as it is more medically descriptive than as an example, "waist ache". As I sifted through the 4cm of her chart, there it was: "raped in 9/09". She was simply trying to reconstruct her life after a vicious attack that had completely destroyed her security. We made a plan to see her frequently and who cares about the complaint, just be with her.

Then my turn. It was a classic last patient of the day. The pilots were calling me to get to the strip so we could get back to Gabs before dark. My colleagues were in the truck waiting to go to the strip and in walks a woman with" stiffness" and "dizziness"....If I had a tebe for every one of the women (classically) that had had these same complaints... I did my best to take a good history, do a perfunctory physical, and explain that while I believed that she had a problem, it wasn't serious and that it should be resolved in two weeks. She was seen the day before and wasn't better so she came see the"specialist". A bit of a misnomer in my case, but be that as it may...I basically saw her fast and sent her on her way.

Now the OPD is constructed such that the docs can leave out the back door if they need a break or need to consult on another patient, a good thing. As I was leaving I had the chance to observe her walk from behind and noted that she had a wide based gait. I caught up to her and checked a few more things, noted that she had a coarse tremor (how the hell did I miss that?), added the fact that she had a very un-animated expression and there it was starring me in the face: Parkinsonism. This of course explained her stiffness and dizziness. We started her on the appropriate medication and she should improve within the week.

The dots Mike, connect the freakin' dots.

"Who owns your life?" Part two

The next day I was in a remote district hospital and as often happens I was asked by the nurse with whom I was working if I could consult on her case. "Sure"

It's a bit of a story but after an hour I still couldn't convince her that things were "OK". I finally found myself asking her if she believed me. She said yes...and then went off again as to how she was "still sick ngaka!" I ultimately wrote what I thought was the appropriate diagnosis in her hand carried chart,"card", she read it and lit up. What is "conversion disorder?" Ever so gently I told her how she must really be frightened about what she was experiencing and that there was no medical explanation for it. This is what it should be called so other MOs coming after me would better be able to care for her. The fight was on.

Try as I might to be a "target not worth shooting", it went nowhere. She was livid that I would "un-diagnose" her and was going to report me to the ministry. "Get in line", I thought, and played the only card I had left; that I needed to get to the airstrip to fly back. I dread going back next month.

Then yesterday I had the classic "last patient on a Friday" experience. I was asked to see a 25y/o with a common problem that had been appropriately diagnosed and was resistant to "treatment". Now the last doctor in line is always the smartest because all the hard work has already been done. I gave him an "atta boy" and that" this would resolve and good luck". And again things went south. It turned out that he had visited a local church that had invoked that he was bewitched (a common metaphor here) and that there was a "snake in my abdomen", also quite common. And extremely difficult to "treat" as it were.

I tried my best and then found myself running out of patience, said some unflattering things that will send me straight to hell on my demise, and, after an hour (!) opened the door to ask him to leave.

I whined to a Motswana colleague of mine and asked why this seems to be a recurring theme; wanting to believe one is sick even when a "specialist", a bit of a misnomer in my case, spends time and makes a more benign interpretation of the symptom complex. He rolled his eyes and said that that was just the way it is. I asked a medical staff meeting earlier that day if anyone had had similar encounters to the one in the remote hospital and it was met with peels of laughter, all had.

I just don't get it. And won't, I suspect.