Last night was the final night of call for me for the next 9 mos. Silly me, I mistakenly thought the Great Call God in the Sky would take pity on me and make it a routine (read QUIET) night, nope. I was awakened at 2400 by a call from the A&E doc stating that they had a patient known to our service with a blocked PD catheter. Peritoneal dialysis, as opposed to hemodialysis that is used in developed nations, is the preferred (read only) mode of therapy for renal failure here. A catheter (tube) is inserted into the abdominal cavity and fluid is infused that acts to exchange toxins across the membrane lining the cavity. It prolongs life but is VERY preoccupying and difficult, and life becomes all about PD in that has to happen 5x/day, each taking about 2 hrs.
Traditionally a blocked PD catheter is admitted to the medical ward whereupon we try, usually in vain, to contact urology to come and unplug it. This of course is nuts as we have nothing to offer the patient and because the passive aggression of the urology service is legion; they never answer their pages on the first page, preferring to use the common and hackneyed excuse that they are in the theatre (read OR) which of course is patent BS.
So I was called by a particularly sympathetic A&E doc last night asking if I would admit this guy, I declined and said it was a urologic problem and they should clean up after themselves. He agreed (!!!). I should not have been so naïve, silly me. I got a call about one hour later from the urologist on call that actually came in (!) and saw the patient and wanted me to admit him until he got around to fixing the catheter. That would have been mid next week. I stated so and then went to the hospital where the fight began. We had a rather animated conversation during which I pointed out the logic of admitting a guy to medicine that needed a new surgical appliance. Ultimately this guy admitted our patient to undergo placement of a new peritoneal dialysis tube for renal failure. If for some reason this doesn’t work he will need hemodialysis and this will be his death knell.
The urologist was so frustrated with my reluctance to admit him to an irrelevant service (medicine) and my insistence that he be cared for on the urology service, with our consultative input as needed, that he threatened to return to China (!?). Oh really and when might that be? Ooooohkaay, but don’t blame me.
Later this morning (about 0400) my MO got a call from the head admin guy for the hospital demanding he admit the above patient, as the urologist thought that he could make an end run around me. The MO was in on the situation and refused. This morning our patient was waiting for the urologist to act like one and take him to the OR to install another permanent catheter or concede that he can't tolerate another PD catheter (this might actually be the case) and we'll move from there.
This morning I climbed the tallest hill above Gabs and looked out over the city for about half an hour before I followed a secondary school class down the hill another way to a local mall where I met up with Lynne and then went to lunch. The vistas were breath taking and at the same time familiar…odd. Best to all, Mike.
Saturday, November 29, 2008
Friday, November 28, 2008
The day after Thanksgiving
It’s been a week of outreach and fun. It will come as no surprise to my family and those that know me when I say I finally felt like I was in my element. I had the pleasure of sharing three sites with Daniel this week as he is signing off and moving back to Oz where he is to do some locums in N. Queensland and at some point begin a fellowship in Infectious Disease. His input and hand holding have proved invaluable.
On Tuesday we were in Kanye, a town of about 50,000 NW of here by about 100km. The hospital sits on a bluff overlooking the town. The staff there is well trained and dedicated and eager to have discussions about alternative ideas for care of their inpatients. Like many places at the district level and below, they over treat and do so out of fear of missing something. It is always a pleasure to reassure them that they are treating the patient appropriately and that what I have to offer is simply one more right way to care for their patient. Generally they are relieved to hear that they can use fewer meds and have as good a therapeutic effect.
Wednesday we were in Lobatse, about 100km WSW of here and had a large outpatient clinic waiting for us. The frustration is that the medical staff, while quite strong, view me not as a teacher but as another provider so they can go about their hurried and harried professional lives without my teaching component, which after all is the purpose for outreach. I’ll need to slowly work on them. I spent a fair amount of time undiagnosing and withdrawing meds from patients, spending LOTS of time reassuring them that their doctor is quite intelligent and that mine is simply another idea based on more experience/mistakes, that’s all.
Yesterday we were in Mochudi, about 60km NE of hear where I finally, after three months, had a chance to round on some (lots of) sick kids. I of course loved it and discovered I was actually able to teach more about this aspect of care than adult medicine. We were again able to reassure the care providers and basically clear off the service for the weekend. There were toddlers everywhere with scalding burns, febrile seizures, asthma/bronchiolitis, marasmus (malnutrition; really took me back to South Sudan), cellulitis, pneumonia, and the like. We saw some clinic patients in the afternoon that were very reminiscent of the US. One was a man, with his wife of 35 years, who was becoming progressively demented. Her care for him and the discomfort that each had for the current status quo was exquisitely touching.
Then is was home for a traditional Thanksgiving dinner at Mallach House with all the Penn folks and students/housestaff. It was a hoot. And I ate like one would back in the US, waaaaay too much, delightful.
Tomorrow I’ll climb a local hill early in the morning before the bad guys who rob and harass you are up. It should provide some beautiful vistas. Then Lynne and I will drive some of the back roads around here out into the desert and enjoy the green wide open spaces, and rest for the coming week. It’s my intention to get farther out into the sticks and visit the primary hospitals as well as the nurse run clinics and get a sense of how things are done here. I only hope I have something to offer in return for the privilege of doing so.
On Tuesday we were in Kanye, a town of about 50,000 NW of here by about 100km. The hospital sits on a bluff overlooking the town. The staff there is well trained and dedicated and eager to have discussions about alternative ideas for care of their inpatients. Like many places at the district level and below, they over treat and do so out of fear of missing something. It is always a pleasure to reassure them that they are treating the patient appropriately and that what I have to offer is simply one more right way to care for their patient. Generally they are relieved to hear that they can use fewer meds and have as good a therapeutic effect.
Wednesday we were in Lobatse, about 100km WSW of here and had a large outpatient clinic waiting for us. The frustration is that the medical staff, while quite strong, view me not as a teacher but as another provider so they can go about their hurried and harried professional lives without my teaching component, which after all is the purpose for outreach. I’ll need to slowly work on them. I spent a fair amount of time undiagnosing and withdrawing meds from patients, spending LOTS of time reassuring them that their doctor is quite intelligent and that mine is simply another idea based on more experience/mistakes, that’s all.
Yesterday we were in Mochudi, about 60km NE of hear where I finally, after three months, had a chance to round on some (lots of) sick kids. I of course loved it and discovered I was actually able to teach more about this aspect of care than adult medicine. We were again able to reassure the care providers and basically clear off the service for the weekend. There were toddlers everywhere with scalding burns, febrile seizures, asthma/bronchiolitis, marasmus (malnutrition; really took me back to South Sudan), cellulitis, pneumonia, and the like. We saw some clinic patients in the afternoon that were very reminiscent of the US. One was a man, with his wife of 35 years, who was becoming progressively demented. Her care for him and the discomfort that each had for the current status quo was exquisitely touching.
Then is was home for a traditional Thanksgiving dinner at Mallach House with all the Penn folks and students/housestaff. It was a hoot. And I ate like one would back in the US, waaaaay too much, delightful.
Tomorrow I’ll climb a local hill early in the morning before the bad guys who rob and harass you are up. It should provide some beautiful vistas. Then Lynne and I will drive some of the back roads around here out into the desert and enjoy the green wide open spaces, and rest for the coming week. It’s my intention to get farther out into the sticks and visit the primary hospitals as well as the nurse run clinics and get a sense of how things are done here. I only hope I have something to offer in return for the privilege of doing so.
Sunday, November 23, 2008
Sunday on call
I’ve been on call today and have had the usual frustrations marked by some truly remarkable stuff. The ICU is a bastion of, what, a system that is such that one can’t admit there without the expressed permission of one of the anesthetists who are conveniently “preoccupied” such that they are impossible to contact or otherwise choose not to return their page. Thus one talks with nurses of various cultures and ethnicities all of whom are intimidated by these bastards and do as they say. I got a call today to start somebody on anti-HIV meds (HAART) as he was on it on the outside, had it at his bedside and needed a medical consultant to write the orders, unbelievable. When I informed the nurse that it a) could be started tomorrow, b) was best done through the clinic that is set up to do so (the infectious disease care clinic here at the hospital), and c) could be done by anyone there- I was rudely admonished to come in and hung up upon. OK, those that know me can fill in the blanks from here. Suffice it to say that he’s on HAART and the head dude and I are going to have a conversation about this tripe tomorrow.
We admitted a woman who is truly the face of HIV in Botswana. She has had HIV for an undetermined period of time, is wasted, has TB and goodness knows what else. She came in because of intractable vomiting and abdominal pain and was found to have decreased breath sounds on the left. A chest X-ray showed the most beat up (L) hemi-thorax I have seen. She had a tension pneumothorax with numerous huge fist sized cavities from TB and lung that was tightly collapsed in very bizarre areas. She was not in respiratory distress so we chose to go slowly with this and will CT the chest to best decide how to decompress this. The chest findings on CXR here are unbelievable. Easily 80% of the exams are grossly abnormal with findings that are present because of prolonged processes that precede admission, something I simply never saw in the States.
Steve Gluckman, my colleague and friend from Penn, and I climbed a hill that overlooks Gabs today. The similarities to Eastern Oregon were striking and beautiful as green is now the dominant color here.
Outreach for good this week, wow. How lucky can a guy like me get?
We admitted a woman who is truly the face of HIV in Botswana. She has had HIV for an undetermined period of time, is wasted, has TB and goodness knows what else. She came in because of intractable vomiting and abdominal pain and was found to have decreased breath sounds on the left. A chest X-ray showed the most beat up (L) hemi-thorax I have seen. She had a tension pneumothorax with numerous huge fist sized cavities from TB and lung that was tightly collapsed in very bizarre areas. She was not in respiratory distress so we chose to go slowly with this and will CT the chest to best decide how to decompress this. The chest findings on CXR here are unbelievable. Easily 80% of the exams are grossly abnormal with findings that are present because of prolonged processes that precede admission, something I simply never saw in the States.
Steve Gluckman, my colleague and friend from Penn, and I climbed a hill that overlooks Gabs today. The similarities to Eastern Oregon were striking and beautiful as green is now the dominant color here.
Outreach for good this week, wow. How lucky can a guy like me get?
Saturday, November 22, 2008
Musings for a Saturday morning
It‘s been a week! Outreach this week was to Mahalapye, at about half the distance to Francistown (200km) from here. The hospital is new, as in opened in the last year and rather out of place. It is beautiful with huge atria, tall ceilings, very wide corridors and large wards. It is a district level hospital that is staffed by M.O.s of various capability and motivation, not unlike any hospital in similar circumstanced in the US. It is this hospital that is slated to become the home of a family medicine residency in the next two years or so. The chair of the department is a Scot but isn’t in the country as yet. The first class of students at the med school has been accepted as of August ’09; lots to do between then and now.
Things are GREEN. In just a three week period things have greened up amazingly. Where everything was brown, or a shade of it, now is brilliant green and oh so refreshing. The travelling to outreach sites will be interesting in and of itself but with the green vistas it should be breath taking.
Our weavers are nesting and we are expecting in the next month!
As expats in the capital city it is easy to shop, eat, socialize with our like and more difficult than I anticipated to become true friends with nationals. Some of the barriers include ethnicity (read color) where assumptions are made in both directions, class where the national people that are sitting in the same eating establishment are of an income bracket that is elevated but still associate with similarly cultured friends as they are served by members of a similar ethnicity, and the like. Virtually all kids here are educated through secondary school (high school) and many attend college. I hope I can find us in an environment where this intercourse is easier or am I being too naïve?
The wards are full of challenging cases that have been handled with extraordinary skill by our current team: a national (actually Tanzanian)MO, Christine, national intern, Maposa, Penn student, Kate, and Penn residident, Keith. We had a gentleman that we thought had LP negative cryptococcal meningitis and wasn’t rallying after about 10 days so Keith looks at him and decides this just might be Listeria, starts him on appropriate medication and now our patient is laughing with us. A great save.
Another was a woman who had heard some bad news and began to have bonafide heart failure. Turns out the really IS a diagnosis of ‘broken heart syndrome” of which I was completely unaware (add it to a huge and lengthening list) where in the adrenaline (catecholamine) surge in the blood from stress causes the heart to “fail” and pump inefficiently, as the muscle is stunned but not damaged. Whodathought? We have a young guy on the service that has was started on TB meds two months ago and presented with a probable hypersensitivity reaction to INH with a significant rash, mental status changes, liver injury, renal failure and the like. We started him on steroids (dexamethasone in high doses) to combat the inflammatory component only to find out that he didn’t get any for 36 hours as we were “out” (read the ward was out but no one had gone to central supply to get more). The fact was dutifully recorded but no one outside of the nurse who did so was notified and the patient quietly slipped deeper into his symptomatology.
I found my response to this interesting in that I didn’t light up as much as was simply resigned to the status quo; making a mental note to, what…., talk with , who…., about how to fix, what…..Sometimes the energy is there but zeal is required. Frustrating to be sure, but the next patient awaits.
Things are GREEN. In just a three week period things have greened up amazingly. Where everything was brown, or a shade of it, now is brilliant green and oh so refreshing. The travelling to outreach sites will be interesting in and of itself but with the green vistas it should be breath taking.
Our weavers are nesting and we are expecting in the next month!
As expats in the capital city it is easy to shop, eat, socialize with our like and more difficult than I anticipated to become true friends with nationals. Some of the barriers include ethnicity (read color) where assumptions are made in both directions, class where the national people that are sitting in the same eating establishment are of an income bracket that is elevated but still associate with similarly cultured friends as they are served by members of a similar ethnicity, and the like. Virtually all kids here are educated through secondary school (high school) and many attend college. I hope I can find us in an environment where this intercourse is easier or am I being too naïve?
The wards are full of challenging cases that have been handled with extraordinary skill by our current team: a national (actually Tanzanian)MO, Christine, national intern, Maposa, Penn student, Kate, and Penn residident, Keith. We had a gentleman that we thought had LP negative cryptococcal meningitis and wasn’t rallying after about 10 days so Keith looks at him and decides this just might be Listeria, starts him on appropriate medication and now our patient is laughing with us. A great save.
Another was a woman who had heard some bad news and began to have bonafide heart failure. Turns out the really IS a diagnosis of ‘broken heart syndrome” of which I was completely unaware (add it to a huge and lengthening list) where in the adrenaline (catecholamine) surge in the blood from stress causes the heart to “fail” and pump inefficiently, as the muscle is stunned but not damaged. Whodathought? We have a young guy on the service that has was started on TB meds two months ago and presented with a probable hypersensitivity reaction to INH with a significant rash, mental status changes, liver injury, renal failure and the like. We started him on steroids (dexamethasone in high doses) to combat the inflammatory component only to find out that he didn’t get any for 36 hours as we were “out” (read the ward was out but no one had gone to central supply to get more). The fact was dutifully recorded but no one outside of the nurse who did so was notified and the patient quietly slipped deeper into his symptomatology.
I found my response to this interesting in that I didn’t light up as much as was simply resigned to the status quo; making a mental note to, what…., talk with , who…., about how to fix, what…..Sometimes the energy is there but zeal is required. Frustrating to be sure, but the next patient awaits.
Sunday, November 16, 2008
Day to day
Well for starters the refrigerator is smaller, more narrow than in the US and powered by 220v. Milk is expensive, better preserved and in boxes of 1L. So we pay P11-16.00 for a liter or about $1.60-$2.30/liter or roughly twice that for a half gallon. We have fruit that is grown in this hemisphere, typically in S.A., grapes, apples, pears, guava, kiwi, papaya (called papa here), small but delicious pineapples, and the like. We of course pay a large sum so I eat less fruit but hey, here I am in Bots having fruit on some morning oats.
The oats are from SA as well, as are many cereal products. The favorite grain here is sorghum (mealie meal), samp (coarse ground white corn), pap (finely ground sorghum, I think) are all served at meals here. One eats with ones hands in the home. It’s only us expats from the west that use utensils. Although the hands thing sounds inviting.
One can have any variety of manufactured drinks here. The soft drink area is reminiscent of Menifee County, occupying a huge area in the grocery store with pastel colors of drinks that are sure to dye ones insides. Coke is huge here, not Pepsi. One can get Tab as Bots apparently is less worried than the US about phenylalanine. Fanta is generic for any non-Coke, non-Sprite drink in a can again in a variety of technicolor displays.
Beer is local, meaning both Bots and SA, and light lager in variety. All the liquor stores have the same varieties like in Pennsylvania. The only non local brand that I have found thus far is Black Label, from Philly(!), source of a great hangover after first semester finals in med school, courtesy of Mad Dog John Mallili.
Meat (beef) is a source of national pride and is raised rurally in numbers that far exceed the 1.6 million human population. It is uniformly good and I enjoy it about once a month in some form or fashion as we try to remain vegetarian.
This afternoon we went to Mokolodi, a local game reserve, travelling throughout the park, seeing the usual assortment of bush wildlife. Interesting that I have become so casual about the fact that we can see these animals so readily. The trip also included an opportunity for the Penn folks to pet a domesticated cheetah, accompanied by pictures and poses; odd and a little over the top for my tastes.
Then tonight a brai (barbecue) to celebrate the tenure of one of the best and most regular neurology residents I have met. Good food, lots of it and now home to bed. Not a bad weekend, indeed.
The oats are from SA as well, as are many cereal products. The favorite grain here is sorghum (mealie meal), samp (coarse ground white corn), pap (finely ground sorghum, I think) are all served at meals here. One eats with ones hands in the home. It’s only us expats from the west that use utensils. Although the hands thing sounds inviting.
One can have any variety of manufactured drinks here. The soft drink area is reminiscent of Menifee County, occupying a huge area in the grocery store with pastel colors of drinks that are sure to dye ones insides. Coke is huge here, not Pepsi. One can get Tab as Bots apparently is less worried than the US about phenylalanine. Fanta is generic for any non-Coke, non-Sprite drink in a can again in a variety of technicolor displays.
Beer is local, meaning both Bots and SA, and light lager in variety. All the liquor stores have the same varieties like in Pennsylvania. The only non local brand that I have found thus far is Black Label, from Philly(!), source of a great hangover after first semester finals in med school, courtesy of Mad Dog John Mallili.
Meat (beef) is a source of national pride and is raised rurally in numbers that far exceed the 1.6 million human population. It is uniformly good and I enjoy it about once a month in some form or fashion as we try to remain vegetarian.
This afternoon we went to Mokolodi, a local game reserve, travelling throughout the park, seeing the usual assortment of bush wildlife. Interesting that I have become so casual about the fact that we can see these animals so readily. The trip also included an opportunity for the Penn folks to pet a domesticated cheetah, accompanied by pictures and poses; odd and a little over the top for my tastes.
Then tonight a brai (barbecue) to celebrate the tenure of one of the best and most regular neurology residents I have met. Good food, lots of it and now home to bed. Not a bad weekend, indeed.
Saturday, November 15, 2008
Hail yes!
I went on outreach to Mochudi yesterday, a town the size of The Dalles in area but with probably 1.5x the population, that has a hospital and a well established medical community. It's only about 45 km from here to the north. They have a nursing school where the female students wear hats and dresses while the male students wear white coats. All are beautiful and eager to learn. We held bedside rounds on numerous patients on the wards that were a true delight. Many nurses, students and staff along with the M.O.s who were caring for the patients were there and entered into the discussion.
For the medically inclined, we saw another case of Progressive Multifocal Leukoencephalopathy (referred to as PML mercifully) a rare neuro-degenerative disorder that is much more prevalent in HIV+ individuals. The prognosis is horrible but the dignity with which the patients here endure is moving to the core. I also "undiagnosed" a series of worrisome problems that, as is sometimes the case with the MOs, are generally over worked up. In medicine the danger in trolling through the lab is that an abnormality even if trivial will lead away from the proper diagnosis. The MOs, afraid of missing a diagnosis, do what we all so often do, compensate for their insecurity about the disease process they are witnessing by generating lots of data and trying lots of remedies. I find I spend a lot of time teaching about “other right ways” of reaching a diagnosis and treating illness.
We had lunch in a chicken place in the downtown area that was interrupted by a HUGE hail storm, stones the size of 3cm. It tore apart the roof of the lunch place and water cascaded in all directions. In all we must have had 5cm of ice and rain in 20min.
The quiet dignity of our patients and attendant families continues to impress me. We are caring for a 16 yr old boy with AIDS from birth (mother had it) who has cryptococcal meningitis. If you make it to your teens with HIV here you are usually cared for by relatives as your father may be dead or never was in the picture, your mother is dead and you are bounced from pillar to post by generally well meaning relatives. By now in your life you look different; quite small for your age, are thin and chronically ill, have a different circle of friends and experiences (the staff at Baylor, other HIV kids, the hospital staff that is indifferent on a good day) and need to take meds daily. And even if you do everything right you still get sick, REALLY sick, with increasing regularity. This boy wears a plastic bracelet with the national football team logo, the Zebras, on it. I wrote a note to the team, conveniently based here in Gabs, to see if one of them could visit with a jersey for our young fan.
My current team has a third year medicine resident, a fourth year student headed into Peds, an outstanding Batswana intern, another outstanding MO, and me. The team is bigger than I’ve experienced and makes for some lively discussions. We (actually they as I was away yesterday) got slammed with 12 admissions over night and to their credit they did fantastic. The Penn people were the only ones there as our intern had a death in the family and was on the road home, our MO is on a two week leave, and I was in Mochudi. So here’s to Keith and Kate, great work by two excellent examples of bright dedicated physicians in training.
And here’s to you all for your support. The comments, letters, chat, Skype are most welcomed and help us more than you can know. We blessed to have you in our lives. Thanks…..
For the medically inclined, we saw another case of Progressive Multifocal Leukoencephalopathy (referred to as PML mercifully) a rare neuro-degenerative disorder that is much more prevalent in HIV+ individuals. The prognosis is horrible but the dignity with which the patients here endure is moving to the core. I also "undiagnosed" a series of worrisome problems that, as is sometimes the case with the MOs, are generally over worked up. In medicine the danger in trolling through the lab is that an abnormality even if trivial will lead away from the proper diagnosis. The MOs, afraid of missing a diagnosis, do what we all so often do, compensate for their insecurity about the disease process they are witnessing by generating lots of data and trying lots of remedies. I find I spend a lot of time teaching about “other right ways” of reaching a diagnosis and treating illness.
We had lunch in a chicken place in the downtown area that was interrupted by a HUGE hail storm, stones the size of 3cm. It tore apart the roof of the lunch place and water cascaded in all directions. In all we must have had 5cm of ice and rain in 20min.
The quiet dignity of our patients and attendant families continues to impress me. We are caring for a 16 yr old boy with AIDS from birth (mother had it) who has cryptococcal meningitis. If you make it to your teens with HIV here you are usually cared for by relatives as your father may be dead or never was in the picture, your mother is dead and you are bounced from pillar to post by generally well meaning relatives. By now in your life you look different; quite small for your age, are thin and chronically ill, have a different circle of friends and experiences (the staff at Baylor, other HIV kids, the hospital staff that is indifferent on a good day) and need to take meds daily. And even if you do everything right you still get sick, REALLY sick, with increasing regularity. This boy wears a plastic bracelet with the national football team logo, the Zebras, on it. I wrote a note to the team, conveniently based here in Gabs, to see if one of them could visit with a jersey for our young fan.
My current team has a third year medicine resident, a fourth year student headed into Peds, an outstanding Batswana intern, another outstanding MO, and me. The team is bigger than I’ve experienced and makes for some lively discussions. We (actually they as I was away yesterday) got slammed with 12 admissions over night and to their credit they did fantastic. The Penn people were the only ones there as our intern had a death in the family and was on the road home, our MO is on a two week leave, and I was in Mochudi. So here’s to Keith and Kate, great work by two excellent examples of bright dedicated physicians in training.
And here’s to you all for your support. The comments, letters, chat, Skype are most welcomed and help us more than you can know. We blessed to have you in our lives. Thanks…..
Wednesday, November 12, 2008
More randomness
The weather has been truly Northwestern; heavy low overcast with rain, only warmer/hotter in between. We’re taking Setswana classes at UB and it is interesting to be on campus. It is full of the same spectrum of students found on any campus; jocks, chatty groups of coeds, metro-sexuals, rural based kids that dress as such, openly effeminate men dressed in makeup and pressed denim, and Jane and Joe Average. The professors are busy teaching evening classes and the corridors (all outside) are buzzing.
Setswana class is tough but if a Batswana can learn to speak English the least we can do is learn the national language here. On the wards is a perfect place to practice and it adds humor to the day for many of the patients.
I’m still impressed with the number of Batswana that ask me on a daily basis about the election result and my opinion of it. Uniformly and without exception they are excited about the new administration. They see Obama less as a black man that I suspect the average American does (after all in the US you are white or you’re not, even if a parent was white). To them he is an inspiration but as a person of color, in this case mixed race, he lends validity to the US in areas of the world like this.
Things are greening up at an accelerated pace, three weeks from now it will be so different. The weaver birds are all bedded down in their nests so there is much less courting than a week ago. Next up, baby weavers!
The staff people at the hospital get a huge kick out of the fact that I ride a single speed bike to work. The good news about that is that virtually everyone knows it’s mine. Security in familiarity doncha know. Time to sign out, thanks so much for your comments and letters, I sure enjoy them.
Setswana class is tough but if a Batswana can learn to speak English the least we can do is learn the national language here. On the wards is a perfect place to practice and it adds humor to the day for many of the patients.
I’m still impressed with the number of Batswana that ask me on a daily basis about the election result and my opinion of it. Uniformly and without exception they are excited about the new administration. They see Obama less as a black man that I suspect the average American does (after all in the US you are white or you’re not, even if a parent was white). To them he is an inspiration but as a person of color, in this case mixed race, he lends validity to the US in areas of the world like this.
Things are greening up at an accelerated pace, three weeks from now it will be so different. The weaver birds are all bedded down in their nests so there is much less courting than a week ago. Next up, baby weavers!
The staff people at the hospital get a huge kick out of the fact that I ride a single speed bike to work. The good news about that is that virtually everyone knows it’s mine. Security in familiarity doncha know. Time to sign out, thanks so much for your comments and letters, I sure enjoy them.
Monday, November 10, 2008
Monday
I can't remember, and am too busy to review, all the previous posts and whether I related in this space about a guy who has been on the service since 4 July. He was a disagreeable type before he was admitted as he was a prideful alcoholic, HIV+ and just generally a parasite to those around him. I had tried to discharge him before only to have him bounce back because even though we would afford a cab ride for him he never could quite remember where he lived.
He embodies that blurry, poorly demarcated region between passive aggression-alcoholic dementia-personality disorder and the like. All who cared for him thought he was alone in the world as he was from Zimbabwe and was never visited. Well don't ya know today he was visited by five of the nicest women on the face of the planet. No they absolutely would NOT take him into their home, he was and is a jerk. But the were genuinely concerned for his welfare and wondered if they could pay for his mounting hospital bill, P10,000 and counting, and afford his ARVs. Since he is from Zim he will be billed, as if that will do any good, but to the credit of the hospital they haven't tossed him out on his ear.
After a long conversation at which time they were informed that he was deteriorating and that the most compassionate thing to do for him was to simply make him pain free and withdraw him from all meds aimed at Tb, AIDS, co-morbidities and the like, they concurred and we'll see how this goes.
It was admittedly refreshing to be able to do this, realizing the gravity with which we collectively made the decision, without the attendant fear of suit, legal reprisal, need for 2nd-3rd-4th opinion and so on. He will be free, and so will we; a break even day if there ever was one.
He embodies that blurry, poorly demarcated region between passive aggression-alcoholic dementia-personality disorder and the like. All who cared for him thought he was alone in the world as he was from Zimbabwe and was never visited. Well don't ya know today he was visited by five of the nicest women on the face of the planet. No they absolutely would NOT take him into their home, he was and is a jerk. But the were genuinely concerned for his welfare and wondered if they could pay for his mounting hospital bill, P10,000 and counting, and afford his ARVs. Since he is from Zim he will be billed, as if that will do any good, but to the credit of the hospital they haven't tossed him out on his ear.
After a long conversation at which time they were informed that he was deteriorating and that the most compassionate thing to do for him was to simply make him pain free and withdraw him from all meds aimed at Tb, AIDS, co-morbidities and the like, they concurred and we'll see how this goes.
It was admittedly refreshing to be able to do this, realizing the gravity with which we collectively made the decision, without the attendant fear of suit, legal reprisal, need for 2nd-3rd-4th opinion and so on. He will be free, and so will we; a break even day if there ever was one.
Sunday, November 9, 2008
Down time
We finally got the heck out of Dodge this weekend, our first sojourn into travelling as it were. We headed south to the northwestern area of South Africa to Groot Marico a small town very reminiscent of Mosier, or Boulder Creek 20y ago, or Hood River 30y ago; small and very quaint with several art studios, a restaurant that is open on the weekends only and such. We spent the night at a “guest house” (read B%B) of which there are numerous about the area. It was all of 200km from home and was a delightful time away. We had a room away from the main home, spent time communing on a beautiful river, and started today with a great breakfast.
We had heard about the source of the river being a huge spring about 30km from where we were so this mornig took off on back roads (unpaved) through some terrain very much like the high desert from Prineville east. There were farms, ranches and lots of stratigraphy much like KY. The source of the Marico River, it turns out, is on a farm at the top of a ridge and is a huge, deep spring about 30m across and about 40-60m deep (http://www.dive4life.co.za/marico-oog). Then out to the west to return to Gabs via Lobatse so Lynne could see one of the sites I visit. And now home to some down time before we start the week again. Loved it!
The ward has been quiet and the cases are rather routine, not to say they aren’t challenging, I seem to have hit cruising altitude and have a better handle on the pathology.
It was fun to hit the road as a couple and explore. Lynne was fantastic, course I knew she would be, and that made the adventure even more of one. I chatted with some of my CGFM buddies and caught up on the stuff. I honestly miss the personalities, Hood River, the efficiencies of the US, just not the medicine. I/we are where we’re supposed to be for the time being and that makes us truly fortunate.
We had heard about the source of the river being a huge spring about 30km from where we were so this mornig took off on back roads (unpaved) through some terrain very much like the high desert from Prineville east. There were farms, ranches and lots of stratigraphy much like KY. The source of the Marico River, it turns out, is on a farm at the top of a ridge and is a huge, deep spring about 30m across and about 40-60m deep (http://www.dive4life.co.za/marico-oog). Then out to the west to return to Gabs via Lobatse so Lynne could see one of the sites I visit. And now home to some down time before we start the week again. Loved it!
The ward has been quiet and the cases are rather routine, not to say they aren’t challenging, I seem to have hit cruising altitude and have a better handle on the pathology.
It was fun to hit the road as a couple and explore. Lynne was fantastic, course I knew she would be, and that made the adventure even more of one. I chatted with some of my CGFM buddies and caught up on the stuff. I honestly miss the personalities, Hood River, the efficiencies of the US, just not the medicine. I/we are where we’re supposed to be for the time being and that makes us truly fortunate.
Thursday, November 6, 2008
Today in Ghanzi
This morning I flew to Ghanzi. along the Western frontier of the country where we taught and rounded with the M.O.'s there. The level of enthusiasm was eager and earnest and the level of medicine was of the standard one might expect in a rural hospital. The building was new and very spread out, a lot like a new elementary school in some sunny clime in the States. The nurses are enthusiastic which separates them from the staff at Marina. The patients represented a spectrum of rural problems: an elderly woman with a hemoglobin of 1(!!, normal is 13-15) who probably was losing blood slowly over time so she could actually stand upright, a child with probable slipped capital femoral epiphysis (a problem with the thigh bone), a woman with dysfunctional uterine bleeding, and the like. Truly bread and butter family medicine.
And one of the most amazing things about this place (800km from Gabs) is that the staff was just giddy about the Obama victory! It really is infectious and kept things light and fun. He'll need time to be sure but to have that level of enthusiasm at that place at this moment is time is incredible.
Thanks for the comments and letters, they make my day.
And one of the most amazing things about this place (800km from Gabs) is that the staff was just giddy about the Obama victory! It really is infectious and kept things light and fun. He'll need time to be sure but to have that level of enthusiasm at that place at this moment is time is incredible.
Thanks for the comments and letters, they make my day.
Wednesday, November 5, 2008
Historic
On my way into the hospital this morning, riding my bike, I was hailed twice by national Batswana:
"Are you American?"
"Yes."
"Congratulations!!!"
Truly historic for the US and the rest of the world.
All the hospital staff were already up to speed about the results and were talking about it incessantly.
Amazing.
"Are you American?"
"Yes."
"Congratulations!!!"
Truly historic for the US and the rest of the world.
All the hospital staff were already up to speed about the results and were talking about it incessantly.
Amazing.
Saturday, November 1, 2008
Outreaching
I went on my first outreach yesterday to a community WSW of here about 75km. Lobotse is one of the older settlements of Botswana. The hospital is old, built in the 1920’s with walls that are half a meter thick so the inside temp can be 10-15 degrees C cooler than the outside. The drive is very reminiscent of eastern Oregon and the high desert around Jordan Valley. The flora and fauna are strikingly different (beginning with troops of monkeys and baboons!) but the geology and relatively dry climate are very familiar.
Once there, my partner, Daniel, gave a great and quick talk on the treatment of epilepsy and we adjourned to the wards to consult on inpatients. The pace there is refreshing, a more deliberate rhythm. We saw a deeply comatose man who had not received treatment or substantial workup since his admission two days previously in anticipation of our consultation. As diplomatically as possible I offered that this was guy on whom one could damn the workup and start treating for Tb, to encephalitis, to jock itch without our input and offered up some contact information so they could consult me over the phone. The workup and treatment were initiated but too late and he died that afternoon. We then saw a woman who was discharged from Princess Marina Hospital and was promptly driven home to Lobatse where she was admitted again with what amounts to significant psychosomesis (she’s nuts, but isn't malingering). She was in bed and the closer I got the longer her stare grew. She looked as though she had suffered a significant psychological insult and most probably had. I was able to walk the staff through some tricks to determine this and expand their comfort zone about how to best care for her.
We saw some outpatient consultations that were just bread and butter family medicine, and I of course was in my element. Then lunch at a local hotel with a fairly famous buffet and back to the IDCC (euphemism for HIV clinic) for some more consults. I loved every minute of it; the interaction with the MO’s, staff, patients, the rural nature of the experience and the drive, all great.
Today I’m on call for the hospital and as such get to round without all the attendant teaching. It is faster and much more efficient, just not anywhere near as fun. We currently have a 15y/o boy with HIV in end stage who doesn’t take his meds, making him no different than any other 15y/o with a chronic disease. Unfortunately this has lead him to have MDR Tb and end stage HIV, an incredible story of bravery and just plain guts. May I and the ones I love never have to show half that much courage in the face of such daunting odds. Many of these kids are orphaned on top of that so reliable adult input is at a premium and often is provided by the staff of the hospital, Baylor, or us.
As most of you know our home has been stood on its ear with tile floors being replaced. The process has left the place a dust heap. Lynne felt uncomfortable leaving the place while they were here so she was trapped as it were for four days and now is cleaning up with my help when I’m not at the hospital today. As she so aptly points out, “this too shall pass”. True, a home on its ear is no big deal in the context of why we're here. Still we're both running a little too close to empty (at least I am) and this "one more thing" is an unwelcome challenge. I think of Lynne and am struck by her courage and grace, and am eager to see how this chapter of her life unfolds. I’m a lucky guy to be sure.
Once there, my partner, Daniel, gave a great and quick talk on the treatment of epilepsy and we adjourned to the wards to consult on inpatients. The pace there is refreshing, a more deliberate rhythm. We saw a deeply comatose man who had not received treatment or substantial workup since his admission two days previously in anticipation of our consultation. As diplomatically as possible I offered that this was guy on whom one could damn the workup and start treating for Tb, to encephalitis, to jock itch without our input and offered up some contact information so they could consult me over the phone. The workup and treatment were initiated but too late and he died that afternoon. We then saw a woman who was discharged from Princess Marina Hospital and was promptly driven home to Lobatse where she was admitted again with what amounts to significant psychosomesis (she’s nuts, but isn't malingering). She was in bed and the closer I got the longer her stare grew. She looked as though she had suffered a significant psychological insult and most probably had. I was able to walk the staff through some tricks to determine this and expand their comfort zone about how to best care for her.
We saw some outpatient consultations that were just bread and butter family medicine, and I of course was in my element. Then lunch at a local hotel with a fairly famous buffet and back to the IDCC (euphemism for HIV clinic) for some more consults. I loved every minute of it; the interaction with the MO’s, staff, patients, the rural nature of the experience and the drive, all great.
Today I’m on call for the hospital and as such get to round without all the attendant teaching. It is faster and much more efficient, just not anywhere near as fun. We currently have a 15y/o boy with HIV in end stage who doesn’t take his meds, making him no different than any other 15y/o with a chronic disease. Unfortunately this has lead him to have MDR Tb and end stage HIV, an incredible story of bravery and just plain guts. May I and the ones I love never have to show half that much courage in the face of such daunting odds. Many of these kids are orphaned on top of that so reliable adult input is at a premium and often is provided by the staff of the hospital, Baylor, or us.
As most of you know our home has been stood on its ear with tile floors being replaced. The process has left the place a dust heap. Lynne felt uncomfortable leaving the place while they were here so she was trapped as it were for four days and now is cleaning up with my help when I’m not at the hospital today. As she so aptly points out, “this too shall pass”. True, a home on its ear is no big deal in the context of why we're here. Still we're both running a little too close to empty (at least I am) and this "one more thing" is an unwelcome challenge. I think of Lynne and am struck by her courage and grace, and am eager to see how this chapter of her life unfolds. I’m a lucky guy to be sure.
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