It's been a week!

Well it’s been a week of attending on the wards and-so far-no clean kills. I’ve had a great team; Mike, a 3rd year Penn med student, Emily, a third year Penn med resident, and Christine, a Medical Officer who is in her fourth post graduate year having had a rotating internship here at “Marina” (as Princess Marina Hospital is called). Each is wicked smart, able to evolve a differential diagnosis way faster and much more completely than me, and has a delightful manner and sense of humor. Having spent the last 25 yrs as a rural family doc my approach has been one of selecting what the pathology is vs. what it might also be. Now that I’m back in an academic environment this will be one of my bigger challenges; outlining and guiding a student/house officer through a comprehensive differential diagnosis.

Christine is simply extraordinary. She is Batswana, living with her parents and family here in Gabs. She went to med school in Russia (!) and learned the language as she attending school!!! She is a fantastic healer and has that ability to walk onto the ward and have a quick and comprehensive sense of not only the patients’ status but the staff as well. They and we love her. She is a huge asset to this nation.

Death here is a lot like Sudan, with a measure if dignity and resignation that I find hugely refreshing. We can quickly run out the string on the options we have for our patients here as they come in with devastating neurologic, cardiologic, respiratory, and infectious injuries. We do what we can, and do it very well, but death here is not as much of a defeat as it is a part of life. Trite I know, but also liberating; almost as if I can breathe again.

We had a great episode yesterday. We were rounding on the ward where we try to begin with the most ill finishing with the most stable. The ward is so chaotic with nurses who seem ambivalent on occasion that it makes for many distractions when I’m trying to “lead, follow, or get out of the way” of my team. As we were just about finished (isn’t this when these stories always happen?) we encountered a newly admitted young man, HIV+, with a level of consciousness that was all over the scale. Mike joked that his Glasgow Coma Scale was 4-12 (on a scale of 4-15), meaning from operating on the lowest parts of the brain to like me on a good day. We exchanged that knowing look and muttered,”crypto”, as we set about to do an LP. Even I after just five days on the ward I was up to speed with the team on this one. Crypto is medspeak for cryptococcal meningitis, an infection of the brain and central nervous system that raises the pressure around the brain and causes a picture of inebriation-somnolence-ambivalence.

He was moved to the procedure area and Emily did his LP as I gave her the only tips I can, which have more to do with the logistics of performing procedures i.e. never with a full bladder or an empty stomach, always be comfortable as you might be here a while, talk to not down to your patient (something she would never do), etc. We use a hollow tube (a monometer) to measure the pressure of the CSF. The fluid was under so much pressure that it went out the top of the tube like a fountain! After the LP where we took off about 40cc of spinal fluid I excused myself to go across the corridor to the woman’s side for a quick conversation, only to find Mike rushing over saying “You gotta see this guy!” Thinking the worst I raced over only to find that with the decrease in fluid and consequent decrease in pressure he was awake, lucent, and wondering what the big deal was. Oh, and why did his back hurt! A great career making experience for the team. I had seen this in Sudan several times and had forgotten just how dramatic it can be. The treatment is medication and therapeutic taps as needed until the pressure is reduced reliably.

We continue to count our blessings as we stay in this house. We’re (OK I am) old and grumpy enough that having one domicile to return to at night is wonderful as opposed to moving from one flat to another. We are developing friends, I seem to be navigating this left hand driving thing better and better, and am enjoying my colleagues very much. This weekend is for nesting and reading. I/we need it and are relaxing into the Africa that is called Botswana.