3-2-1 Discharge!

I was out in Lobatse today and discharged Empho. But before that I gave her some Crayon-like markers with which she colored the accompanying paper, then the floor of the ward, then ate one. Surprised....me? It was hilarious and we were all holding ourselves with laughter. Here come blue poops!

The ward was a touch crowded with kids who have measles, chicken pox, and dehydrating gastroenteritis. As she has free reign of the place, she frequently crawls into the rooms to see what is happening and in the process is exposed. An infectious swamp to be sure. So....for the sake of preventing a nosocomial infection, out she went. It was far from clean and neat as she is to be cared for by the "grandmother of her uncle". Since she will live near a rather remote clinic we indoctrinated the nurse there about how often she should be weighed and seen for follow up. I don't think this will be entirely satisfactory as rumor has it that her brother, 7 y/o, was seen on the street begging for food the other day. So the head matron has her radar on and will yank Empho at the first sign that her grandmother can't keep up with a now willful 2 year old. Who can???

Then it just might be SOS for her and her brother. Who knows. I would have preferred to send her there as she meets two of three criteria for admission; abandonment and abuse. It's unknown if her mother is alive or had HIV. Empho does not. Anyway, ain't my country and this is way above my pay grade. Hope things work out.

Was at SOS the other night and an adolescent girl walked up to me and asked "what is your name?" I replied "Mike" and she immediately scoffed. "You need a proper Satswana name". "OK how about silly goose". She glared. "Well, how about water?". Glared again; you know that thirteen year old girl, eye rolling, "I can't believe this white guy from America is such a doofus" look? "How about earth?" say I. Finger to chin she ponders and then says, "We will call you Empho!" I stifled a rather knowing grin and accepted her moniker. She then used it enough that it became rather un-unique and hilarious at the same time. Adolescents are the same everywhere...... "boundaries, what are boundaries?!

Still can't get used to 40 degree heat here at Christmas time. And yet it's rather festive to be sure. When on the road by myself I usually contemplate what I'll miss about Botswana if and when we leave here. Without a doubt it will the kind and gentle people, the smiles, the laughter, the genuine lightness of heart. There is definitely a widening economic dualism that is expanding with a burgeoning middle class, more concerned with the usual stuff (career, family, cars) than that of their countrymen. I swear I have not seen so many 'Benzes, 'Beemers, Audis, and Range Rovers as here. It makes for rare episodes of envy and self righteousness but the smiles seem to ameliorate it.

I had to be the primary physician the other day in a town that is famous for abusing the doc there. On any given morning about a fifth of the population is queued up and expect "treatment" or sick leave. As I had worked with a strong willed Motswana doc earlier that week who announces each morning that she will be the one that decides about meds and leave and that she rarely gives either, I thought I'd give it a shot. I stood beside a scared nurse who announced that there would be no leave given out that day and that meds would be given only if needed, and that didn't include your desire to have them. The hue and cry was deafening. And after that about half of the assembled crowd stomped off! The day was full of difficult cases that truly needed a doc and not more of the usual somatization and malingering. I don't get that about this culture but again; above my pay grade.

The topography here would remind anyone of the arid west or high Midwest. The flora and fauna are different to be sure. The birds are fantastic. Monkeys, baboons, warthogs, and the ever present cattle-donkeys-goats, can be seen on a trip from Gabs to an outlying area. So on these trips I get to get behind my eyeballs and realize that I have a loving wife of 35 years, a great and grown family that pays it forward, and a great job in an amazing part of the world. I am indeed blessed. Best wishes for Christmas, and Peace.

Who'd a thunk it...

This has been a week to be sure. It began with the usual in the clinics here in Gabs where I do some mentoring and teaching. I had an opportunity to work alongside a great Ethiopian doc who is one of my favorites; inquisitive, sensitive, compassionate. As things wind down toward Christmas, (I must have been the last one to find out that it is now called the "festive season"), indeed this is a predominantly Christian area intermixed with North African Muslims and Indian Hindi, the docs thin out and we are generally under staffed. Even the streets have about half as many cars. Next week and the week after they will become deserted.

I was informed that I can be, or am, too "paternalistic" and that that puts distance between me and some of the MO's in training and some of the BUP docs. It is difficult to know where the line is. I think this dates back to a Monday morning report where we had had 9 deaths over the weekend with 17 admissions. Many of the deaths were reported off handedly and were certified when the patient was "cold and stiff". I looked around and was disappointed that this wasn't bothering anyone or that they weren't speaking up about it. I pointedly raised the notion that this can never be OK. Some of the patients would have died anyway to be sure, but they deserved a physician at the bedside and some could have been saved had they had a doc earlier on in the process. And that the leadership in this had to come from "us" (I was sure to use this term) as it would not come from the nursing service.

But first we had to care. After I finished this rant there was silence. And then the finger pointing began. It was the nurses, the docs, etc. The nurses are used to not having their pages answered so don't call, and the docs claim they are busy in the A and E so they can't respond or that they aren't paged in the first place; a monstrous and emblematic mess. In any case as this came across from a guy my age and since it was pointed it was apparently interpreted as paternalistic. Hell yes I was angry and dumbfounded. Why wasn't anyone else? So deniability is automatically built in if it comes from a "paternalistic old, angry man". I'm still not sure what that means except that I am old enough to be the uncle or father of all the trainees and younger MO's in the health care system, or at PMH, or at BUP for that matter. And dysfunction continues to reign supreme. There are providers and colleagues that are gifted and highly capable to be sure, yet I have found the delivery systems to be increasingly burdensome.

I fear we aren't building capacity (read rehabilitating) here as much as participating in a westernized agenda of rescuing. At this point I have a better idea of what doesn't work that what does. Building relationships is difficult to quantify and yet that is what I do most of time. Never the less in a grant based program it is important to quantify what it is we do. I haven't found the appropriate way to do this and it becomes frustrating to slowly realize that this might not be what I originally signed on for. I have no problem with those that do enjoy this and have a passion for it; it just isn't this aged doc's idea of practice.

And moving back to the States isn't as easy as it might seem. I love and miss my family to be sure. And I love clinical medicine, especially the creative, working without a net part. Things in the US were dysfunctional enough that I felt suffocated. And the pathology often bypasses me or the etiology is based in overindulgence (witness metabolic syndrome). Add that to entitlement and things rapidly stopped being fun and engaging. Here and other places I at least get to do the following:

I was at a district hospital this week and heard about an 18m/o that came in very dehydrated and probably septic. The resuscitation was great; fluids and meds by IO, somehow including D50W in small boluses. I was asked to review the patient and did so. All the MO's dropped by peds and remarked how much better he looked. I thought great until I noticed that he was still breathing rapidly and deeply. By now he should have been back to base line respirations with a pulse that was normal for age. I started to connect the dots in this aged, Lamictal affected brain of mine and asked for a finger stick blood sugar. It came back at 5x normal.

Ohhhhkay now we have a better idea of the what and why. Let's get a quick UA as we can't get a bicarb level, let alone an ABG. The UA indicated a pH of 5 (acidotic) and ketones were 1+ with glucose of 3+; a slam dunk; DKA. So I shipped him to PMH as they have pediatricians and better lab support. Nowhere in the US world of primary care would I have that chance to diagnose DKA with a minimal amount of, or no, lab support. We could have treated it but I had to leave that afternoon and I/we would have needed to check on him q30m. It was a great teaching opportunity, and exactly how can that be quantified? Or, perhaps more to the point, where in the US could I duplicate that?

Time here is flying by as I get to live in the present. I am working with some truly brilliant and gifted docs, for many of whom this represents their first career move or they are in the first 5-10 yrs of their career. I'm not and this is becoming a bit of an issue I fear. Time to wait and see I guess.

Best to all for a festive season!

GREEN

Everything is green! We have had some sustained rains and some hard hail, the size of marbles that dimple a car roof or hood. As a result things are green, damp, and humid. What once was brown is green and all Botswana is glad for it.

One of the interesting things about this place is that it in some way is held hostage to its own lack of food production. Some say that 80% of the food stuffs here are imported. Much of the cereal processing occurs here, much of it in Gabs, but most of the grains are grown elsewhere. The farms that I can see from the air are all subsistence type. We can sustain our own eggs and beef, a LOT of goats, but no significant and sustainable fruits and vegetables. Currently it is kale and cabbage season so much is bought from road side stands (called tuck shops) or harvested at various prisons where it is grown to keep the prisoners occupied.

Yesterday I was rounding on the peds ward at Lobatse (Athlone Hospital), one of my favorite. Recall that this was the place where we had a septic man on the ward and it was met with a touch too much ambivalence to suit me. I had just given a presentation on it and I thought we had this diagnosis well worked out. So onto peds I go to spell the CMO who is up to his "waist" in alligators. First thing I see is an infant with sunken eyes and panting, admitted two and a half days ago with gastroenteritis. She was in deep yogurt to be sure.

We weighed her only to find that she had lost weight since her routine weight 2 wks ago. Starting to sound familiar? She had a temp of 39C, a pulse of >140, and R's of 40. Dehydrated to be sure but truly this was sepsis. She was being hydrated with half strength solution, not the right stuff, and not doing well. I switched out the IV to saline and promptly discovered that her IV site was toast. I tell you I cannot devine how the staff can start IV's on these hypotensive, chubby, African kids. They have the touch and I don't that's for sure. So the nurses brought everything needed for another "cannula" and gave me that "you don't think I'M going to start it do you"? I proceeded to turn this little girl into a pin cushion, finally getting one in her foot.

By now you know the rest of the story; in goes 20ml/kg in a bolus than a flow rate to account for her at least 10% dehydration and baseline fluid needs, and a quick change in antibiotics to get after the things that cause sepsis in kids under 1 y/o. She did her part and promptly fell fast asleep and awoke cooing and hungry. Was a great teaching case in that it so very important to track a daily weight and take accurate intake and output. Oh and diagnose sepsis early and come after it with fluids. A sweet save none the less.

The little girl with marasmus-kwashiorkor is thriving. She is stimulated no end at the nursing station. She is 2 and learning to walk for the first time; and having hissy fits when she doesn't get her way. All of this is to the delight and squeals of laughter from all the adults. She no longer has the "1000m stare" and is engaging with everyone. I held her and she promptly inspected my goatee and arm hair, again to the delight of amusement of the nurses. She might wind up at SOS which is cool in and of itself. Her name by the way is Npo, "gift". Truly.

Rumor has it that she'll be around at Christmas. I probably'll go up there and play with her, show her how to use, hopefully not eat, crayons and generally carry on. Then it'll be over to Mochudi to work in the OPD with the MO on call as the pathology there is always thick and fascinating. And then the next day, I to head to the US!

The two steps back part...

Admission

There is a little girl that has been on the Athlone (Lobatse) peds ward for a month with both kwashiorkor (protein calorie malnutrition) and marasmus (all calorie malnutrition). These kids are a nursing challenge but as each is a mother or a sister they have done a magnificent job. She has done wonderfully and the nurses are teaching her to walk in a walker, eat, and coo. Her hair is coming in black underneath white now which is why the nurses shaved her head! She is a hoot and has recovered nicely. And can really chow down. And I finally learned how to upload pics so here she is.....

Today was Lobatse day, a day where we usually begin with morning report. As I was reading our handout trying to ready myself for the presentation to the medical staff I heard out of the corner of my ear that there was an HIV+ man who had been admitted for suspected pulmonary Tb. This morning he was reported by the nurse with the softest, rather ambivalent of voices to have "no measurable temperature and no measurable blood pressure." Yet he had respirations of 20, and then went on to the next case...

This got me to look up and inquire again about the guy as I couldn't believe my ears. She reviewed the patient and I unfortunately lit up. Uh, sports fans whatever he was admitted for is mute, HE'S SEPTIC. They acknowledged that, well, that could be why he was hypotensive and hypothermic..and presented the next patient. I blew a gasket as I had just presented sepsis as a topic for discussion within the month. "He could be dead by now". No movement to the door. "Why isn't some one going to check on him right now?" Again shuffling but no movement to the door. I guess this is the "one step forward...two steps back" part.

I picked up my stuff and headed for the door. By now I had raised enough of a point that another MO came with me. We first checked the VS again and they were worse. Then started two iv's and poured in 4L of saline from which he began to recover and had a measurable blood pressure. I spoke to the Matron (nurse in charge) who expressed frustration that the docs often don't come so the nurses don't call...and hence the nurses are less likely to do so. We'll just add it to the list.

I "MacGyvered" a tool this week to pull a faux pearl from the nose of a two year old. Well what else do you do with one of those things if you're two and wonder what happens when? Normally the child is sent to the ED to be consulted by ENT and then with a lot of fanfare the foreign body is removed. Well why go the fetid hole that is PMH, although the ED is good, when one can remove it here? Out comes the Gerber Tool and a paper clip. In a minute we had a curette and in less than that out came the pearl, sweet.

The rhythm of the place is becoming familiar. Many Batswana speak at the same time and loudly. If the cadence is from LOUD to soft with a descending tone it is generally an important point. If the last word is higher pitched than the one before it, than the speaker is serious. Better than "upspeak", if you ask me? Enough, got to roast some veggies for a dinner tonight. Happy Thanksgiving!

Random randomness II

Mondays can be rather long (a schlep as Matt would call it) but they finish at SOS; a good thing. Last Monday I brought two hula-hoops, two jump ropes, a soccer ball, a whiffle ball and bat, and assorted other out door things for the kids to play with before it got too dark. They'll play way after dark but we try to have some simmer down time before they head to bed.

On occasion I'll wander to the side of the playing field (read large dirt football field) and enjoy the sight of the kids playing and laughing. Everyone here laughs even if it is a difficult situation. The usual response is not to get exercised about it but to laugh. As I was enjoying the sunset and the moon rise two kids came over to me, each about 8-10y/o sat down with me and proceeded to "inspect" me. I have taken to shaving my hair, what there is of it, very short and they love to run their fingers through it and feel the texture of short European hair. 'Course they won't hear me complain as it feels wonderful and truly is a "bucket filler". Then they examine my arms and runs their hands up and down them to feel all the arm hair, something that most Motswana don't have. THAT feels fantastic. Then lift my shirt to look at my graying chest hair all with the most innocent of intentions.

I banged up my leg (getting out of the pool-pond no less) and have a bit of an abscess that I finally treated with antibiotics after draining it three times. Man that hurts but it's easier than finding a doc that can do it for me and maybe just a touch cleaner. Anyway after draining it I rap it in a tight bandage to avoid accumulation of goo and hope the goo won't return. As I had the bandage on they were interested in what was under it.

Well, OK, so I took it off and showed them. They were genuinely saddened that their friend had this and expressed that I "should see a doctor". I told them I was one but that wasn't satisfactory and they told me again. Something tells me that they had somehow been in communication with my family!

I was out of the pool for a week and resumed yesterday. I am definitely a nicer guy if I swim. There is talk about using drivers and state vehicles to deliver us to our sites. This will really cramp my style so I have been more that a little hyped up lately, I feel like a I'm a touch "toxic" and in need of a break. I'll wait until 26 Dec for that. Maybe drive some back roads to out of the way places 'til then.

Things have changed here in the office, generally for the better. We have a huge staff, many of whom are Motswana. We now have a large document that outlines the conditions of employment. It's seems interesting that we spend so much time protecting the entity that is BUP when I'd much rather spend that time protecting and treating their countrymen.

The currency of visits to the doctor is still pain and the currency of treatment is still acetaminophen. People will complain of six kinds of pain to get 7 paracetamol (Tylenol to the US). I gave a talk on malingering, somatization, and conversion disorder and it was well received so maybe we'll start to call it what it is, not the symptom.

That's enough for now, best to all who read this and celebrate Thanksgiving. And to those that don't!

3 grand!

Made it over the hump! Weren't pretty, weren't fast but there you are.

Oh, and that 7 mo old septic boy from a week ago Friday? Went home from Athlone Hospital in Lobatse on Wednesday wondering what the big deal was all about. Nothing makes me feel better as a doc.

Made it to 2800m!

The week began with yet another case of sepsis and, well, you've already heard way too much about this.

Tuesday we flew to Hukuntsi, worked in the OPD and saw some cool peds cases.

Wednesday we went on outreach to a remote clinic in the Mochudi area and, thankfully, it was slow. I had a chance to discuss the future with our boss, Harvey.

Thursday was Lobatse where I transfered a child with what had to be a brain abscess to PMH. I round on peds there as they are so understaffed. Some of the kids aren't seen for three days.

Today was outreach with one of the residents I mentor who is also an MO so I can serve two masters at once. It was great fun as it was, of course, off the beaten track.

Then today I took on a swim set written by my old (well not "old"old) lane buddy at CGMS, the marquis de swimming, Bill. Kicked my sorry arse into next week. I think I just now have a pulse under 100.

Gotta eat some apple cake, I deserve it. I think I'll eat it out of the pan with a fork, less effort.

Cheers

Scratching that creative itch..

One of the fun things about outreach is that I get to be more creative than in the US. We were unable to open the top of the antibiotic so out comes the mini-Leatherman and off goes the top. No scissors to cut the tape (there never are) so the Leatherman again. When the ambulance didn't have an IV hook (they never do as they are generally stripped of all equipment) out comes the Gerber tool. I cut off a strip of metal fence and a minute later there was the hook.

Fun and (it's not really an over statement) life saving. And a hoot!

Batting 1.000! Well make that .750 if we include Lorolwane

Three up, three still up! Let’s begin from the end.

Just so I’m clear; there is nothing as fun and rewarding in my profession as pulling a child back from the ragged edge. Today, Friday, I had a little time on my hands to explore some clinics that I might visit in the Kanye District. On the way out to Kanye I always pass a cool little town named Nthlanthle, pronounced with clicks. Kinda like your tongue is disarticulated at both ends. It has a clinic outpost staffed by a nurse. I found it and parked outside the now empty clinic and walked in, saying the Setswana greeting for “hello”, and no one was around. This is usual on a Friday afternoon as the nurse who works at these outposts generally sees patients in the morning and they thin out by 1:00pm. I showed up at 1:30 to an empty clinic and nosed around into various rooms seeing what they had to offer and how I might help them.

After the tour I walked outside to see a grandfather cradling a young child who looked big sick. Now I always emphasize to the staffs at the various places I visit that “sick kids look sick” and this child was going to the light. I thought ‘how the bleep am I going to do a resuscitation on this little guy here if I have no idea of where things are kept?’

The nurse came along (they usually live on site), I introduced myself, and we got busy. Let’s see, two day temp of 40, respiratory rate of 60 with paroxysmal movement, pulse of 130…Now I’m definitely not the brightest bulb in the box but even I know this represents sepsis.

So we weighed him and found him to be 1.2kg less than last week, presumably from the diarrhea and vomiting he had had for that time. As we were doing this he coughed a deep cough and the problem became clearer. Just from the vital signs he had pneumonia, but this cinched it. We took him back to an exam room and Diziro, the nurse, got things ready as I prayed to find a vein. This kid was precisely the wrong age and race; a chubby African, 7mos of age, dehydrated and septic, with no veins. We must have stuck him 15 times. I was thinking if an intra-osseous but thought I’d give it another shot. I said a quiet prayer (I’ll cut back on the swearing, see “bleep” above, if only I could get the Big Guy on the side of this child and his aged doc) and slipped in a line into a scalp vein as sweet as you please. In went fluid (LR, it was the only thing we had Amber, sorry) at 20cc/kg x3. At this point the child fell into a deep sleep but not without me checking his vitals every five minutes. By now my back was up and if Death wanted this child he’d have to go through me.

Next was an antibiotic (Ceftriaxone) at 100mg/kg. Then I wound this kid’s head with anything I could find to secure the IV, looked like he had a turban. He awoke about half an hour later and started to coo and chat! Man this stuff works great. The ambulance came from Kanye, about 40km from Ntlanthle. and we loaded him on to send him to Lobatse. I called my friend Roger there who got things set up at the hospital. He should make it. I was able to congratulate Diziro about the clean save and shed a little mist. Man that was three hours of intense work but what a thrill. If I had been in Sudan I would have had no time to reflect on it as it would be on to the next patient. Here it was driving home to the Gypsy Kings.

Wednesday we were in Malwane, a clinic in the Mochudi district, way out there. In other words, my kind of place. I was discussing with the MO there how taking time to treat patients with four types of pain (literally) was a waste of his time, and was at some level co-dependent, and that the “sickest patient is always in the queue” Sure enough half an hour later and many somatising and malingering patients later, in walks (barely) an HIV+ woman with a BP of 80/palp, pulse of 170, and R’s of 32. Sepsis, it hits you over the head sometimes. In went an IV, three liters of saline, some antibiotics, and she was transferred to Mochudi. The receiving doc was unimpressed with her sepsis (that because we already gave her FOUR LITERS) and treated her as a simple case of pneumonia in an HIV+ woman, like THAT is ever simple.
Never the less, it was clean save number two. This time I was able to congratulate the med student accompanying me as he rode in the back of the ambulance securing the IV’s. Sweet save!

In Tsabong (we fly there as it is WAY out there, I know--cool) on Tuesday I was rounding on the wards with Julien, a doc from DRC who was confused about an obtunded HIV+ woman with low blood pressure. “That’s because she’s septic” says I. We got busy, he started an external jugular and five liters and some antibiotics later she was back from the brink. Save numero uno.

These were all great teaching case especially because they lived (!). It DOES happen in threes just not always this good….

They say that these things occur in threes...

It's been a week. I know, I say that a lot.

On Tuesday we flew to the NW part of Bots and I went to New Xade (pronounced with a click), a San village 100 km out on a dirt road, incredible. The health care is episodic and interestingly full of HIV, but performed with great expertise by the MO who visits there once a month.

On Thursday we were in Lobatse where we work in the secondary hospital and clinics; first leading a discussion with the medical staff in the hospital then, while one of us stays and completes rounds, the other ventures out to the clinics and mentors there. Since the hospital is so understaffed due to people on leave and reassignment, we routinely take on a much bigger treating role there than in at any other facility.

During our discussion of thrombosis and HIV, an exhausted doc who was just coming off night call received a phone call and motioned to me to come with him. One of his patients was decompensating (read dying). We went to the ward and found a 45 yr old man, HIV negative which becomes important later, with massive hematemesis (vomiting up blood) and with a huge amount of blood in his stool. It turned out that he had liver failure and as a result had varicose veins of his esophagus and stomach, which were briskly bleeding. He was encephalopathic (read comatose) and we, Matt and I, got busy. Normally we try to stand back and use the opportunity to mentor but this guy was "heading for the light" and the doc coming off call had that "what should I do?" look.

Long story short, I have a tendency to concentrate with my mouth open. This has resulted in infant boys peeing into the back of my throat as I attempt to circumcise them, tasting engine oil if I can't get out of the way fast enough while I change it, etc. So there I was attempting intubation on this guy with of course an open mouth when he roops up some more blood, which unknowingly (I know, I know already) apparently splashed into the back of my mouth. I wondered why I suddenly had a salty taste in the back of my mouth and dismissed it to the meds I am taking (moth eaten brain and all...). We were unsuccessful in the attempt so, what with a prostate the size if an apple and a small bladder, I excused myself to "the toilet" as we say here. I glanced in a window for some reason on the way to the loo and there it was, some blood on my lip. At first I actually asked myself "how the hell did that happen" then it dawned on me....bleep, so THAT was the salty taste (definitely NOT the brightest bulb in the box).

I pee'd (not quickly, see reference to prostate) and hustled back to to check the guy's HIV status, which was negative within the last two days. He was close to buying the farm. And had had a recent (-)HIV test, which is not particularly reassuring as he could have acute HIV disease and not yet converted to positive. I theoretically could have been in a touch of deep doo-doo.

I called Michelle, our third new partner who is fortunately an Infectious Disease specialist, and she was very understanding if not a little bit amused. "Intubating with your mouth open, huh?" She told me what I already suspected, that my risk was infinitesimal, so I'm not on post exposure prophylaxsis as the risk of me auguring in on the drive home was much higher that the risk of HIV. Any other annoying thing I would have been exposed to was something against which I was either immunized or wherein any self respecting virus would retreat to infect another day.

I wisely, to my credit, called Lynne who got a good laugh out of it at my expense and then promptly informed the kids (cue the collective eye roll and gut laugh)for which I'm sure I will suffer mightily.

Matt and I disagreed about transfer, he for it and me against it, and we held this discussion in front of the nurses. It was a great teaching moment as they had a chance to see two docs who admire and respect each other have a conversation about which would be best; transfer or allow the guy to die in Lobatse as his prognosis was in negative numbers. He ultimately was transfered as the doc coming off call finally got to point where he just wanted to go home and rest and had had enough. We acknowledged his wishes and transferred. I then rounded on peds and had a much needed series of hugs, and laughter.

Yesterday we were out in Lorolwane, a VERY remote, and therefore way cool village I have described before. The first patient of the day was a woman in distress who was carried off a donkey cart. She had "collapsed" at home... Now I can't count the number of times I have seen this type of attention seeking behavior so my cynicism was in the red zone; heavy sigh... We examined her only to find that she had nystagmus (quick uncoordinated movement of her eyes) and since this can't be done voluntarily she was indeed in deep yogurt. She was HIV positive and our resident expert on ID, Michelle, thought it represented pneumoccocal sepsis. So there we were; 85km from the nearest paved road (I've been in tighter jams), with no ambulance(all of these outposts have one but they typically have been stripped of equipment and in any case there is no pre-hospital care as the nurse traditionally rides up front), no cell service (most these little villages have a cell tower, a good thing, but they are rarely maintained, an extremely frustrating thing. Don't get me started), no running water (sinks with pipes to them but no water, an all too common thing. See above about frustration,) an outstanding MO (Cathy), with Matt, Michelle and a dumb family doc.

We valiantly tried everything we could think of and Cathy made some tough decisions with an expertise that belies her level of training. And as the patient was loaded into the district truck that brought Cathy to the site, she breathed her last and died. It was at some level a privilege to witness that and realize her release and, again, teach Cathy about the diagnosis and dismal prognosis of sepsis. But we all felt empty.

The evening was finished with watching Matt play sax with an outstanding African jazz band (that guy amazes me) and then passing out in bed. It's rare anymore that I sleep and awake without being aware I'm in bed but it's been a week. This has been a touch longer than the average screed but it has been therapeutic to externalize it. And at some level I always finish the week feeling most fortunate and loving it.

The Big Five

Ho-ly cow, or water buffalo, or lion. The "Big Five" in two weeks. Incredible! Here are some of the pics:

http://picasaweb.google.com/pendletonmd/MoremiOkavangoDelta#

Cynicism=Death II

Another episode: A woman came into the OPD in Mochudi and complained of nausea and vomiting. We were stealing glances at each and rolling our eyes when her husband produced a jar full of what came up and it looked like wide white spaghetti, only it was segmented. Oh reeeaaaly. So we took a closer look and were surprised to see the segmented remnants of a tape worm! We put her on meds, and the pharmacy had them which was surprising and a relief.

Today I swam again. The pool is dirty, a little like swimming in a pond, but it’s all that I have. I did a 4-4-4 warm up then 4x200 on the 3:20, then 4x100 on 1:40. Slow intervals I know but the best I can hold for the moment. I might get better although it’s raining tonight and the pool, like all pools in the area, is unheated. It always takes a 50-75 to get used to the water. But tomorrow it might be impossible to swim because of the temperature.

Love the rain. Things might green up around here. The trees are in full bloom but the grasses and shrubs will stay brown until after Christmas. Very different from last year.

Best to all…

Cynicism=Death

So there I was minding my own business and that of the MO whom I was mentoring in a local clinic, when yet another woman (they often are women to the extent that if a man comes through the door he is met with a quizzical look) enters the exam room. In any case, in walks a woman with “a cough” as in “yet another patient, a woman, with a cough”. This cynicism is of course dangerous as something can be easily missed. So I always insist on listening to the patient's chest if the history is compelling. And, in short, it was.

I continually emphasize to the MOs when we lead discussions that “the second question out of your mouth after: “How can I help you?” should always be: “What is your HIV status?” So she was asked and she was indeed positive. The incidence of Tb with HIV here can be 60% or greater. In other words if one lives long enough with HIV one will have a positive skin test at the very least, if not active pulmonary or extra-pulmonary Tb.

So, stethoscope to chest, we noted that the breath sounds were uneven. I took her blood pressure again (figuratively rolling my eyes) and lo and behold she had a pulsus paradoxus; a bit of a long winded explanation to the non medical types that deign to read this rag. The first thing you think about here in Bots is pericardial effusion and tamponade. So off she went for a chest x-ray at PMH where she was met by ambivalent techs in a crowded waiting area, coughing all over the place and exposing other patients, I’m sure, to Tb! We have a terrible track record at PMH of segregating the Tb positive, or suspected Tb positive, people away from the rest of the patients. It truly is scandalous.

Because it was early in the day and because she had transport (the clinic ambulance) she arrived back with the x-ray in hand. We read it and saw a huge cardiac shadow, boot shaped, indicative of a monstrous pericardial effusion that was constricting her heart just as if a hand was squeezing it. No doubt from Tb! Bleep, and to think our collective cynicism nearly missed this.

So back she went to the A&E (read E.D.) at PMH for evaluation and pericardiocentesis (wherein a needle is place under the xyphoid, that little bone thingy at bottom of the sternum, aimed at the left shoulder) and a massive amount of fluid was drained from the sack surrounding her heart (we’re talking liters here). She immediately started to perfuse her body more efficiently, and we saved her! All because we listened to her chest when what we truly wanted to do was send her out with assurance that she would be fine. Jeez and whew!

We head to the Okavango this next week for some R&R. This is one of the true and unique gems of Botswana where an entire river empties onto a plain that was an ancient lake. The watershed that is created has all matter of wild life including some big crocs. It should be a memorable experience to be sure.

The friendly skies

We’re flying! Or did I already say that? We have resumed the flights to outlying primary hospitals and clinics so the travel time is reduced from 7 ½ hrs over rough and straight-as-an-arrow road, to 1hr 15min and we arrive refreshed. We only get to spend about 7 hrs on the ground but we go weekly now and not every three months. To think….

Tuesdays of each week we meet at the airport, make that Sir Seretse Khama International Airport, and leave at 0730 for one of three destinations. This month we have visited Tsabong in the far southwest, Hukuntsi in the far west, and Ghanzi in the northwest. Like I’ve said, Tsabong is reminiscent of the old HRMH with a ward of 30+ beds, an OR, Maternity, and a large OPD. All of the staffs are friendly and seem eager to hear our presentations.

While in Ghanzi (pronounced “hanzi”) I was leaving the OPD when a guy ran up to me and chewed me out for not seeing him and his prisoner in a timely fashion. NO ONE is seen in a timely fashion. Indeed you arrive to queue up at 0730 or earlier and then wait, a long time, wait some more, wait, watch the MO come and go for emergencies or simply to relive him/herself, one doesn’t eat including the MOs, did I mention wait?, and then are seen sometimes 4-5 hours after queuing.

So this guy was reasonably puckered. I glanced at his chart, they are all patient carried “cards”, and it looked like he was referred for “narcolepsy”. Ohhhhkay. I told him I would be back shortly as I was headed to the TB ward and would see him in ten minutes. He, perhaps rightfully so, scoffed and snorted. I told him that if he thought I was lying he should just leave but if he believed me I’d see him in 10, which is what happened.

Turns out he had fallen asleep on the job and was looking for some medical problem to legitimize this episode such that he wouldn’t be disciplined. He didn’t have narcolepsy and had simply had difficulty adjusting to night shift. “Sorry but there isn’t a disease process here.” He lit up and refused to leave until I signed a leave form.

This happens WAY too much here. It has been enfranchised so much so that on Mondays the waiting areas of local clinics here in Gabs are full of people who are hung over or have minor complaints and want “leave.” For a day--- “to rest”. Many if not all of the employers here have abdicated responsibility and have successfully placed the physician between the employer and the employee for certification of leave. As all the MOs are foreign nationals and the employers are political heavyweights, the docs feel that their jobs are threatened if they don’t give useless meds, grant medical leave, certify medical pathology when there is none, and the like. Shades of workers comp in OR. I’d almost, almost rather care for chronic pain, fibromyalgia, or chronic fatigue syndrome. Anyway this guy wouldn’t leave so I simply asked if he wouldn’t mind standing while I invited the next patient in. I ignored him out loud so he finally left threatening to see “a private doctor as he’ll give me what I need”.

And he is right. The parallel private system here is no better than the publically accessed one but as it’s private and fee-for-service, and as one has to keep ones customers happy, the private docs over prescribe, over diagnose, and over utilize. Sound familiar? God help you if you point out that the diagnosis, let alone the treatment, is bogus as it isn’t about quality as much as availability and convenience. In general you can access as capable care in the public sector the difference being you can get an appointment with the private docs and don’t have to queue with us. And by the time you see us we’re often times tired and hungry. Hell, I’d go private if I had the cash just to get out of the damn queue.

For us life continues apace. The trees are in full bloom, we’ve had relief from the dry season with some booming thunder storms (nothing worse than the Midwest in the US), and it has been a quick year. And a truly incredible and rewarding one at that.

Random randomness

Some random thoughts and observations:

-Having Matt here is GREAT. He is a natural teacher and mentor, and a great partner with whom to discuss medicine and life.

-I went out to Kanye to teach my Family Medicine residents from Stellenbosch (did I mention I PASSED the boards?). They are all bright and gifted docs. Three are national Botswana, two are from DRC and one from Uganda. I spent the next day with one of them where she was working in what is known as the IDCC (Infectious Disease Care Clinic). The euphemism breaks down in that everyone who is there is aware that they are in the queue because they have HIV and are getting their monthly clinic appt. We saw a 50'ish woman with a year long history of post menopausal bleeding, and she was a classic "last patient of the day" story. She was bleeding enough that she was concerned and mentioned that she had to wear a pad. My MO was close to blowing all this off as she needed the time to study and for other things. I recalled to her that a wiser attending than me had once said that I should never miss the opportunity to place my finger in a bleeding orifice. So after an appropriate eye roll she went to the clinic next door and found a speculum, brought it back and inserted it. She is really good but I I had to get a touch testy saying that this is what I, as her mentor, expected from her.

We couldn't visualize the cervix easily for all the blood. So recalling that adage from an attending smarter than I, we did a manual exam; the first in a year as this was always temporized by other MOs in the out-patient settings. She had had an ultrasound of her pelvis and a PAP smear but no true exam. The PAPs are done under dim light often without a manual exam and then they become important only because we finally did one and found a fungating squamous cell carcinoma involving the cervix and vaginal side wall.

Blast and damn, this should have been picked up months ago and wasn't. It occurs much more frequently in HIV and should have been expected.

-These talks we give are all patient based and have apparently become quite popular. There was discussion about substituting another speaker for us on a Wednesday in Mochudi and the hue and cry was flatteringly great enough that they scheduled around us, WOW!

-We flew! Yeah, out to Tsabong where I felt so at home it was a touch spooky. It is a town in the far west of the country that takes 6-7hrs to drive to or 56min to fly. We took off with me in the right seat (thanks for the suggestion For') and had a gas out there. Very reminiscent of Hood River and the old Hood River Memorial Hospital; small number of beds, small staff, everyone knows everyone, and great comprehensive general care.

We spent a fair amount of time dissuading them from transferring patients to Gabs as the care here offers little more than what they get there except some more comprehensive testing. Specialist consultation can be obtained over the phone and is often sketchy depending on the motivation of the specialist. I swear some of these guys (all expats from various backgrounds, training, and medical cultures) look for reasons NOT to intervene when it stares them right in the face. They embody an arrogance and indifference that is the ugly side of medicine. The only indication for transfer to the ICU here is imminent death (i.e. an 02 sat of less than 60!), and one has to get on bent knee to plead with an anesthetist(!) for transfer. We tend not to look for quality as much as to fill the specialist slot with a widget. As long as the slot is filled....

Hope all are well. Now that the boards are over I can try to learn Setswana. Ke a leboga! (Thank you)

Lynne's Home, and I Passed!

Lynne’s here and life is good, or did I mention that? She was happily up to her neck in twins and now is home, soon to be up to her neck at SOS. She got home on Monday and is slowly recovering from jet lag. The fare has definitely picked up and I have filled out. Last night we had roasted vegetables; delicious. Apparently I had forgotten about that whole category of the food pyramid.

P=MD(BC). Make that Pass=MD(Board Certified). And I’m old enough, yep I’m 57, that I think this is the last time I have to/get to/have the privilege of sitting in front of a computer screen for the better part of a day, sweating. The medicine here is so very different. I have definitely lost the edge to practice in the US and the style of family medicine that I left there. And I’m old, or did I mention that?

Yesterday we were in Kanye where I had Matt, the newly minted and gifted Internal Medicine outreach dude, and married to Premal (see below), Jessie; a third time visitor and this time as a Infectious Disease Fellow, Premal; a newly minted IM doc working for Baylor and married to Matt, and me, an aging and aged family medicine doc with a seizure disorder (that, by-the-way, is under better control with a new med). Matt drove and led the discussion on TB, that I had led at other venues, to try on his chops and did fantastic. We then rounded on a patient with Multiple Drug Resistant TB (MDR-TB) who was being managed admirably by the docs at Kanye SDAH. ID is not my strong point, and TB is the weakest link in that chain thus far. Actually based on my score on the board exam it would seem I no longer have a strong point (P=MD(BC), I just gotta keep saying that to myself). The Kanye docs were doing great.

We then went to a local clinic where we saw some amazing infectious disease. This is not even close to the stuff I saw in South Sudan but we shouldn’t be seeing that in this nation, as often or severe. What we see here is HIV/TB co-infection and it complications with a little medication side effect (mostly hepatitis) thrown in. The disease spectrum here is more narrow but deeper. And for a mono-neuronal family doc it is a touch easier to get a purchase on so as to move the patient towards health.

We of course had to weed out the truly sick from the “wanna-be-sick-so-as-to-get-sick-leave-on- a-Friday” folks. I came across a way to cynical to these guys I fear but I wanted to demonstrate the MOs that you need to dissuade patients with multiple somatic pains and an agenda from taking up your time so you can attend to the truly sick and needy. The sick leave situation here is a great exercise in abdication of employer responsibility. All the waiting rooms from the smallest outpost to the downtown clinics are crammed with anyone from the truly sick to the majority “wanna be’s” all wanting medically sanctioned time off on a Monday or Friday, absurd and a total waste of time. Yet we give them meds, sometimes five of them (acetaminophen, and four types of vitamins and a mineral or two) so they truly think they are sick and show their friends on the way out how they were treated so well that they got all these meds. We have created this monster and only we can fix it.

Did I mention Lynne is home? Wahoo!!!!

Restoration of the soul...

Something about a couple of kids on your lap after their dinner, snuggled in tight, as you read to them that fills and repairs the spirit.

I went to SOS last night and it began with the marimba band practice, still fantastic. They are amazing, have innate rhythm, and play faster than my tired eyes could follow. We were oriented by the head the orphanage, Bikia, a man in his thirties. There are 24 “homes” staffed by “aunties” and housing 8-12 kids. The adolescents live autonomously within a budget and learn to purchase food and necessities, cook, and clean their home. Their home is a happy mess but they are well fed and fantastically well socialized. Other younger kids live two or more to a room and are cared for by the auntie. The campus is home to kids who are orphaned from HIV, destitution, or abandonment. Once there, they are rarely adopted out and frankly that’s a good thing. The extended “family” they have and the life skills they are taught are extraordinary.

So I was sitting down with a child on each side and one on my lap reading nursery rhymes, something we rarely read to our own kids as they are dated and not a little racist and sexist. The kids lapped it up. I have cut my hair very short so the boy on my lap sucked his thumb and wuzzed my hair because he liked the texture. It was a dead heat as to who would fall asleep first. The other boys felt the hair on my arms as I have become rather hairy now that I’m not in the pool.

We read then wrestled then read some more. Then time to go home with hugs all around and “when are you coming back?” Each week for sure. This is where the Penn students should spend more time. I was introduced to there by Caitlin, a student headed for family medicine and I think they’d all love it. I know the kids would.

As sweet a save as you'll find....

And not by me. By our eldest son, Eli, and a rural Charlottesville family!

So there he was, minding his own business, while on an organized run outside Charlottesville, VA. He is training for a marathon and a group of runners of like mind (there really is "a group" that want to do this?) were running through the rural farmland when he came upon a runner who was walking with an odd posture. She had her arms away from her side, stuck out at a 45 degree angle and, well, looked curious. So he stopped and asked if she was OK.

He recognized her from his work at UVA where he is a family doc. Seems she'd been stung behind her ear by a wasp and was a little rattled for the experience. That and she had urticaria (hives) from head to toe(!), hence the posture.

"Gee, you OK?"

"I think so, I'll just walk a bit and see how things go", she says.

"Breathing OK?"

"I'm a little wheezy....." Wrong answer.

Thinking fast he decides to stop a home up ahead and see if, perhaps, they might just have some Benadryl, an antihistamine. They knock, he identifies himself as a doc with a concern about this runner and do they by any chance have some Benadryl? Why yes, in fact they do. So down goes 50mg. But by know she is really wheezing and getting a touch light headed. Bleep.

So he calls 911, then asks, knowing its against all odds, "You don't by any chance have an "Epi-pen" do you?" As a matter of fact they do!!!! He administers the epinephrine injection.

A few minutes later the rural first resp0nders show. They take her blood pressure and its below 80mmHg systolic; full on anaphylaxis. By now she is a little the worse for wear but hanging in there and all are thanking their lucky stars. An ambulance shows up. They take her pressure again as they load her for the ride to the UVA emergency department, and it's unchanged. She goes on O2, and is taken to the ED.

As clean a save as you'll ever find thanks to a runner-physician who had his antennae out and a welcoming home that, unbelievably, had the appropriate meds. Incredible.

This week has been a little bit of a watershed for me and the program.

Tuesday- It began in a local clinic where I was to mentor an MO there but beat him to the office. I was in the exam room, door closed, to await the MO when a nurse stuck her head in and said she needed me next door.

“Ohhhhkay, why?”

“A little girl is in status”

“Uh, status what?” Hoping she meant asthmaticus.

“Epilepticus, she’s fitting Naka!”

“Bleep!”

So in I walk only to be handed a premeasured syringe with diazepam for rectal administration! She is a chubby three year old with epilepsy since birth secondary to birth injury fitting away for the last hour with no IV sites. In went the diazepam and in five minutes off went the seizures. We piled her into a car and off she went to PMH. The nurse was exceptional and acted like having things THIS much under control was no big deal. Would love to clone her!

Wednesday-I have been giving talks at Deborah Retief Memorial Hospital in Mochudi to the entire staff (about 30 professional from across the spectrum) and have made an annoying arss of myself trying to get the outpatient docs to join. Yesterday 6 showed up and stayed for an hour as we discussed innumerable issues that were shared and at times contentious. A great episode in medical staff intercourse and huge for quality of patient care. A true first.

Today-For the last several months I have struggled with the outpatient medical staff in Lobatse. They and I worked to come to some agreement about how best to participate with them. One of them lined up a bunch of patients about whom he had questions and away we went. Then I gave the same talk in the afternoon to them and it was received well. I, again, gave them my info and encouraged them to call anytime, and was before I had left town.

Its freaking cold here, just like you might expect from a high desert in the early spring. But the wards aren't heated so all the kids in peds are under 50 blankets and are just bumps on the bed. We have a diabetic in DKA here at Athlone Hospital in Lobatse. I swear that adolescents are the same the world over. He is sweet, too sweet literally, but is experimenting with controlling his own life, disease, meds, and, like all of us, his first foray into this arena was a little rough. We discussed how to treat this without lab back up, just with a glucometer and urine dipsticks. It was all very reminiscent of Frenchburg in the winter when I would treat two brothers with DKA, at the clinic as outpatients, as their mother was afraid of travel in the snow and ice.

Last night I did some more volunteering at the SOS village,

http://archive.soschildrensvillages.org.uk/sponsor-child/botswana_select_a_village.html

a large and well established "orphanage" here in the area, one of dozens. It sits on a campus the size of a small secondary school with houses numbering in the teens and kids numbering in the hundreds. Each house has a resident "auntie"/mother and a relatively static group of kids of similar age and development. No outside adoption is allowed as it is too stressful on the kids and siblings are housed together.

All the kids are incredibly well socialized as they have literally hundreds of brother, sisters, adult mentors and care providers. It is located in an area of greater Gabs where all the people are national Batswana, no expats.

I usually stop at the teenage girls area first and help with homework. Last night is was quadratic equations, a real blast out of the past. Then it's over to the home of younger kids where there are is a toddler who can't get enough lap time, and brothers who love to read and be read to. In particular they love to sit close and gets hugs, have their heads rubbed, wrestle and giggle. I usually read from their favorite book of old fairy tales and have them read with me. It's amazingly racist and they couldn't care less, it's the story they love even if I try to modify it to be a touch less British Empire-like.

As we about to leave we were asked if we would like to hear some marimbas. Uh...sure. We walked out to the back only to see a room full of marimbas and kids of every size and flavor playing their hearts out, and GOOD. They are invited all over the place. The shortest kid plays the largest bass, the most outgoing plays tenor as fast as I've seen it. Incredible. A great time.

These things tend to occur in threes...

Shit….it does happen in medicine, and in "threes" if I’m not mistaken. Yesterday morning I was solo, something that is rare these days but welcomed on occasion. I made the drive to Kanye and was just sitting down to morning report by the staff at the hospital when a call came in from OB for newborn resuscitation. A child has been born over a prolapsed cord and wasn’t breathing.

These situations are true buggers in any country. The child (read brain) has been deprived of blood (read oxygen) due to compression of the cord between the side wall of the pelvis and the infant's body. Any attempt at resuscitation is mis-named. Instead of cardio-pulmonary resuscitation it should be called brain resuscitation.

In newborns the cardio-pulmonary tree is so pristine it usually “starts” without a lot of carrying on. It’s the brain….that jello-like mass of goo that needs the 02 more than the other organs. It can shut down so completely such that blood doesn’t even make it past the neck. Now if you’re a dumb family doc like me with a moth eaten brain in the first place, maybe no big deal. In a child it isn’t compatible with life.

So the flail was on. It was truly other-worldly in that it was conducted in room where there were no less than six deliveries on two beds by three midwives. While we proceeded people casually were moved about accompanied by all the sounds of women in labor, and cleaning ladies mopping floors in between deliveries. Like other hospitals, they had a warmer but no one knew how to use it. They did have neonatal intubation ability and my colleague did admirably in establishing an airway. We had 02, and an ambu-bag, now full of meconium, that I washed out and then used to provide ventilation.

So; “Airway”-got that covered, “Breathing”-yup breathing OK, “Cardiac”-seems to be perfusing well, below the head at least, “Drugs” need bicarb and D-10 or at least D-“something”. As I asked for bicarb I was informed that we were “out of stock”. “Of @#$%#ing bicarb?!” I lit up like a damn cruise liner at night. My colleague shrugged. I fumed and called the pharmacist to the room asking how in the name of all that makes sense we could be out of bicarb, ...today, ...now,... here?!? She shrugged. I asked that she check everywhere as I felt this child’s brain leak through my hands. She left.

We attempted au umbilical line but to no avail as the iv cannulas were too stiff and the feeding tubes too big, so my colleague got a line in the foot; in the foot of a clamped down, meconium stained, non-perfusing deeply pigmented neonate! These guys are amazing. We found some D-50, diluted it up and gave it, some very old bicarb appeared from surgery where it had been used many times from the same bag (no clue about how that made sense), and tried to figure out the difference between milligrams, milli-equivalents, and millimoles as all three were cited on the bag, and we had no idea if it had any bicarb in it in the first place.

By now every baby doc's fear was being realized; we were saving the heart and lungs but the brain was dying or dead. We gave some of the supposed "bicarb", she started to breathe on her own, … and then the seizures started. Well shit again.

We called PMH and were told that since she didn’t need ventilation she didn’t need transfer. We all exchanged looks, calculated doses and rates and put her next to her mother. We couldn’t get her warm so adhering to the adage that “you aren’t dead ‘til your warm and dead and sweet and dead” we heated two liter bags of iv solution, placed them along side of her and gave more D-10 (or D-something).

Blessedly she quietly died last night at 1830.

A new angel

Today was one of those days you just know is out there but dread. I was past due for this....a child died in my care. We, two dermatology residents and I, were in Lobatse today. They had given a great talk about the latest ideas regarding care for a perfectly miserable spectrum of skin diseases characterized by anything from rash to blistered lips to burn-like wounds across the entire surface area of the body. It's called TEN (toxic epidermal necrolysis) for short and is a true bitch.

It is quite prevalent in HIV prone areas because one of the anti-retrovirals used early in the care of HIV is frequently associated with it. It's interesting in that the care for TEN in western countries involves intense intensive care with a mortality rate of 50-70%. I've cared for it in remote Sudan with a perfectly lousy outcome as well. In South Africa they are as diligent but use less invasive techniques and have a rate of generally <10%.

In the middle of the talk a nurse came into the room and asked for Roger, a good friend of mine and excellent doc. We casually finished the discussion and went out to see if the residents could shadow him in the A&E (the emergency area; "Accident and Emergency"). I walked into the room and found him bagging (breathing for) a 3mo old boy.

Apparently the child had gastroenteritis for three days and had visited a "traditional healer" at least once. He was brought by his parents and grandparents who were arguing about whether to let us treat him. By now he was obviously dry and in shock. When the powers that be relented or won, depending on one's point of view, Roger got busy. He had started an IV in the external jugular (the guy can canulate a capillary!) but didn't have normal saline, the mask didn't fit, the 02 wasn't reliable and the tubing the wrong size. In short it was like a lot of pediatric codes in western hospitals that haven't had one in a while.

So I got in the middle of the flail and started to rehydrate, establish and airway, decompress the stomach, and initiate CPR. Now if a three month old's heart stops it has to be from electrolyte abnormality, profound sepsis and shock, or.....well that's about it if it was previously working fine. So we suspected the traditional remedy but who knows. He was terribly ill and appeared to be caught in a power struggle that relented too late. For that matter it could have been a clean kill from traditional medication. We'll never know and that is so damn maddening. Nothing to learn about the cause of death, just an opportunity to review pediatric resuscitation in a secondary hospital. Maybe that can be his legacy. God I feel empty..

The rest of the July story

And what a wedding indeed. It was at the home of Olivia’s sister in east Portland. She, her boyfriend, and anyone walking down the street worked tirelessly to turn the back yard of their home from a patch of blackberries into something out of Sunset Magazine, simply beautiful.

Olivia and Beth exchanged vows in the side yard with Eli officiating. There was enough humor in addition to the vows exchanged to keep it light but very devotional; a truly wonderful and moving memory.

We then moved to the back yard where those in attendance offered blessings on the marriage and laughed, cried, loved. Then the party. We rented an old Masonic Temple in North Portland and had DJ Eli plug his iPhone into a great sound system and danced the floor around. It was wonderful to see family and friends at this celebration.

We flew to Philly where we saw the KA’s and I went to UPenn to have my head examined yet again. I’m still screwed up enough that another med is warranted. I tried to get another MR scan of my gourd but ran head long into the underbelly of US health care. I didn’t need a prior authorization for the MR scan but because Penn had contracted out the process to a third party, that has the huge and necessary data base, I still had to go through them to the tune of waiting “just 24-36h” for an authorization I didn’t need but without the OK from then would be on the hook for paying for an MR scan, HUNGH???!! So needless to say, no MR scan as I had to get to NYC and over the pond.

We had two fantastic farewell dinners with family and then Walt took me to Trenton to board a train to Grand Central in NYC. I arrived there on a Friday afternoon with two large bags and a backpack, navigated my way around and through to the subway and made it out to the hotel at JFK without losing anything other than my mind and dignity. Not sure what I was thinking when this struck me as a good idea and doable. Doable yes, a good idea……

Lynne has stayed in the States to offer much needed and appreciated help with the twin grandbabies in JAX. Forrest and Shannon are doing admirably but like any couple with three kids under two, well, you can fill in the blanks….

And I’m back at it. We are in the middle of Influenza H1N1 here as if things weren’t tough enough already. I was advised that each hospital has been allocated 10 (that’s ten) dosing regimens of the antiviral indicated for this flu. We are in deep yogurt if this truly becomes epidemic here in a country with a HIV prevalence rate of 13-60%, depending on region.

Best to all that we saw in the States, friends and family in Hood River, CGM, CGFM, the BA relatives and friends, and the UPenn crew. Thanks so much.

July!

And here we are in PDX, in the PDT time zone! Lynne has acclimated to the 16hr plane ride from Jo’burg to NYC quicker and better than my slow burn as she is more accomplished at this point. I run out of things to do and my neck starts to bend in new and different ways thanks to being too tall for the seats to sleep comfortably. Hmmm, “sleep comfortably”....on a plane...... in coach; a true oxymoron if there ever was one.

We arrived in New York early in the morning, left our stuff at the hotel and went to Manhattan via the subway to see Central Park. It was amazing; clean, safe, HUGE, friendly. Something, in my ignorance, I didn’t expect. We were caught by a rain storm and delighted in the familiar odor of “east coast wet”. We walked to Times Square where we were overcome with and by the people/tourists and fatigue, ultimately fleeing back to the hotel to sleep then leave for the NW the next morning.

It was delightful to be met at the airport by Aven, TJ, Belle, Bethany, and Olivia. Hugs and greetings of longing all around, a night’s sleep and then, on the 4^th, a trip to Hood River. It’s fair to say that I was floored about how unprepared I was for my reaction as we drove up the Gorge. Call me naïve, but I was overcome with a sense of déjà vu, a sense of “what was I thinking?!!”, as we drove past Multnomah Falls, the Osprey nests, through Cascade Locks and into our old home town of 22 yrs. We parked at my old office and met up with friend after friend as we watched the famous Hood River 4^th of July Parade wherein half of the population is in it as the other half watches. Every kid on roller-skates, every jacked up pickup, every swim club, ball team, politico, and anyone who wanted to advertise their business was in it. We finished the day in our old neighborhood with a classic barbecue; too much of everything including nostalgia, food, and laughter. It was great.

We returned to HR later that week to see old friends and haunts. We spent the evenings at MJ and Michael’s home above Mosier where we had an apartment and could try to catch up to ourselves. They are great friends and fellow swimmers from our previous lives, so generous and kind. Monday we “swam” with the team, ate huge breakfasts, and had a chance to see eagles, The Hook, drink too much good coffee, and read "The Oregonian". I had my eyes and teeth examined and get to return to have a ‘drill and fill” on one of my teeth. It would seem that in addition to having an asymmetric head I also have an asymmetric jaw that causes stress on my teeth. Jeez I just can’t get enough mileage from those guys.

The past weeks have been filled with grandchildren as Forrest and Shannon have adopted twin newborns; Asher and Cora and now have three kids less than 21 months of age. It was a difficult week as they struggled to seek out a space where they could anticipate the additions to their family and care for the mother who was placing them; amazingly moving and courageous on all parties’ parts. Judah is a great brother and is getting that role figured out. Belle is four months, long and tall, and filling out. She loves to seek stimulus and enjoys motion. But to her credit is sleeping well and working on her fourth chin.

Eli and Amber, our son and daughter in law, have arrived. Yesterday we had our first Family Council Meeting. We’ll have more but this one gave us each an opportunity to acknowledge and explore. Forrest and Shannon were present by speaker phone as were the g’kids. Our family is changing and sentiment runs the spectrum but several things remain and persist, our love and devotion to our (nearly) spouses, the extended family Pendleton, and working out how we can be in each other’s lives. Tomorrow we “swim” with the team, have some medical appointments and lunch in HR. Thursday I have another, and last, chance to swim with the team, then a radio show, a real homage to simpler times and a true treat, and finally a noon presentation with the medical staff at my old hospital.

Now on to the wedding!

Its been a a while

Two weeks ago Lynne and I finally took a break and went to an animal reserve south of here, just over the SA border, to a game lodge called Tau ("lion"). It turned out to be one of those all inclusive resorts where you are greeted at the front door and your car is driven away as you settle into a routine of being pampered, not unlike what I imagine a cruise would be, with too much food, drink and the like. We skipped a meal and were called by the desk to check on us! The game drives were amazing with all the usual just not in abundance as the late rains had made it less easy to access the water holes and areas where some of the popular game congregate. It was very relaxing and long overdue.

That Monday I was on the road with two med students, Kandace from UPenn in her fourth year and Kea, a Motswana, schooling in Australia, in her last year. We headed out to Tsabong in the SW of the western frontier to a primary hospital there. I no sooner got out of the car than I assisted the CMO with a C/Section ( a "Cesar" as it is known throughout the area). We discussed the numerous ways to perform this procedure and the benefits of each as we saw them. We then rounded in the small general purpose ward and the next day I taught a class on CHF and HIV. It amazed me that HIV has such a presence even at the "end of the road". All you need is a trucking industry that is "serviced" as it were and spread of STDs is assured.

Tuesday we headed back east then north then west again to Hukuntsi where we met the new CMO, rounded, taught, learned, laughed. We stayed there for two nights, me in a suite with two other guys that enjoyed ladies of the night well into the morning so sleep was with medical aid and ear plugs crammed deep into my EACs. Doubt "protection" was high on the agenda as it was all very alcohol fueled.

Thursday we again headed east, north, then northwest to Ghanzi for five nights. We worked with the local district hospital team on the inpatient services, then in the clinics of Ghanzi with the only MO for the district.

Saturday night we went to a village, D'Kar, about 45km to the east and witnessed a "healing dance" by the San, an ancient ethnicity of the area who use some 20 different clicks in their language. It is impossible to comprehend and I found myself staring into their mouths as they discussed the day, much to their amusement and glee. On the way out we stopped off the road and witnessed what I hadn't seen since Afghanistan, a Milky Way so huge and bright that you could read by it!

There is a school in the same town that houses San kids as they live very remotely. They are a group of people that are very small featured, almost orange in color, broad open faces, always laughing.

I saw the worst case of AIDS I have seen thus far; a 23 yr old woman with wasting, advanced TB, genital condyloma, Kaposi's sarcoma, and a huge fist sized, pendulous, papilloma of the vulva. One of my lasting memories of the hospital will be Kandace and Kea, both of whom thought they might go into a more tertiary specialty, sitting on the floor in peds laughing and giggling with the kids there, then telling me that they just might go into primary care. Nothing like a 9 day adventure into key primary care areas to open one's mind. That and some giggling kids in a peds ward in the middle of nowhere.

Sunday we went to my new favorite town, Charles Hill on the Namibian border, and saw the local and lonely doc there. My lasting memory of the trip will be sitting in the bed of the small pickup truck we were driving, sipping a Coke of all things, taking in the surrounding culture of the town center as Herero women walked around with their characteristic headdress, kids laughed and played, and the rival political parties blared sound trucks at each other across the dusty expanse. Man was that cool or what?

We drove home on Tuesday and spent the rest of the week in the usual outreach routine. Now it appears that the students from Penn might get to spend their time in Mochudi, a huge benefit for them as the experience becomes more truly "global", integrative, and assimilating.

See those of you in the PDT time zone in less than a week!

OK, way, way out there....

This week was amazing:

Monday we began in Moshupa with one of my Stellenbosch mentees, Cathy, a great doc from DRC. There we saw a full slate of illnesses and a pre-septic child or two. We have yet to have any confirmed cases of HINI flu here but we are all confident it is on the continent and headed this way if not here and under-reported already. It will make life very difficult as it overwhelms our health care system. It will make for a tough spring and early summer (read August through November).

Tuesday Cathy and I hit the road to a tiny village outside of Moshupa; about 10km from where she lives called Lotlakane. It rained all night the night before and the road was like grease. On arrival we were surrounded by very familiar sites, sights, smells, spells, and sounds. I discussed this in the entry just previous to this one. It became my new favorite place. I want Cathy’s job.

Wednesday was Mochudi and a rural clinic that has one of my favorite MOs there, a woman about fifty-ish who is very capable. No meds if you don’t need them and you had better have a good reason for not using or “forgetting” why you didn’t use the last ones she gave you. We again saw a wide range of pathology and in general had a great time.

Thursday in Lobatse we saw a wide variety of the sick and those that were just sure they deathly ill with all of five somatic pains and counting if we didn’t act impressed. I have come to recognize a characteristic facial expression on these people (mostly women) that is a dead give away for so called medically unexplained symptoms (now called MUS in the literature instead of somatization or just plain nuts)) from the first breath. We finished the clinic at 1:00pm, got some lunch at the local grocery store, and went back to the hospital to see what trouble we could get into…..quite a bit as it turned out.

There in the A&E was a 9mo old who had been given a “traditional medicine” for vomiting and now was septic, seizing, comatose, “fill-in-the–blank”. The MO was appropriately trying to start an IV in a child with fat hands, no BP and having no luck. I mentioned an intra-osseous line as I have been in his shoes countless times and learned, at the cost of numerous kids’ lives, that one can futz with an IV for an hour or get down to the business of saving her little butt. He didn’t know how so we took her to the peds ward and on the third attempt (it took a minute to have it all come back to me) in it went as sweet as you please and we went about the business of reeling this kid back. Only later did it dawn on me that with the salivation, lacrimation, seizures, coma, and vomiting that we were probably witnessing cholinergic intoxication either from accidental poisoning or the traditional medication. She bounced a little with a fluid challenge and some antibiotics. Hope she makes it; a great teaching case for the students, MOs, staff and an aging family doc.

Friday we were “way out there” as in 100km off the road on a dirt road in the middle of the western Kalahari in my new favorite place. The village is Lolowane. To pronounce it one needs to disarticulate one’s tongue from the back of one’s mouth, allow air to pass around the back it as you try to pronounce the sound of “L”, then immediately roll our tongue to pronounce the “wane”, sounding like “wannae”. I tried to the glee of the people there and their shrill laughter was simply infectious.

There we few enough patients that the students could do the clinic with the supervision of Cathy and I. Each saw a wide array of cases that you see in remote places. We even saw a case of what I last saw in Sudan, Iraq before that, Afghanistan before that, and Turkey before that; Limb Girdle Muscular Dystrophy. This time I think it was complicated and accelerated by HIV but who knows and we'll get some more info with some blood work she gave us in a month. We took pictures all around, laughed likes little kids, and drove back across the Kalahari to Kanye. I’m a touch the worse for wear but man was that a gas. What a great week.

Way out there

Well I’m getting farther off the beaten track these days and it will come as no surprise to those that know me that I’m having the time of my professional life. Yesterday I found myself with one of my mentees, Cathy, in a town very reminiscent of the way Hood River must have been at the turn of the last century; small, familiar, with the onsite health care provider (a male nurse) firmly in charge of who got seen for what and when.

There we were way off the beaten track, in the winter rain, at the medical-cultural-commercial center of a village; its health outpost. The onsite nurse knew everyone and was drawing blood on kids with HIV for CD-4 counts, dispensing meds, chiding patients for not taking their meds properly, flirting with the ladies, and sending us the truly sick that he had triaged. The clinic was very……. what, “guy”. Things were generally neat, but sloppy and might have been underneath stacks of stuff. He knew where everything was just that it might be under something. And he could draw blood out of a mosquito.

We saw all manner of rural HIV and co-morbidities, still saw lots of somatic stuff, and in general had a gas. The school was next to the clinic, across from the rural Botswanan equivalent of a 7- eleven, down the path from the town admin building. We left cold and a little wet as the clinic leaked, but warmed from the adventure and the medicine.

Friday I and Cathy go waaaaay off the road into rural southern Botswana to a remote health outpost. The medicine is as fun and challenging, as are these destinations. This weekend Lynne and I are off to SA to stay at a game reserve and see some larger game (lions, elephants, and the like), then Monday I hit the road for another tour of the western frontier hospitals. Then we head for the US and Oregon. Hard to believe that I’m coming up on a year away from CGFM. I must say I miss the people in my previous life deeply but have no regrets to be doing this at this time in my career. I'm truly fotunate and indeed blessed.

Neat and clean

The Batswana are very fastidious. You never see a dirty car or a piece of litter...they have two people walk the roads wearing bright orange jump suits spearing litter, what there is of it, and in general keep the place quite tidy. They even sweep the dirt free of leaves. 

Now that it is Fall, they are out in force sweeping the area, keeping things in order and orderly. This separates them from the Sudanese where there was so much litter that you soon became quite used to it.  It was surprising to see it in the photos I took.

The women here dress very proper, very British if you will, and will walk for km's in shoes with 4 cm heels along dirt roads, across fields, and the like. 

Every town/village/city has at least one large area that is all dirt and used for football (soccer). There is a local interest in fast pitch softball with teams from all over this area competing on the weekend. All sorts of alcoholic beverages are sold at the games so things can be either animated or quite sedate depending on the average alcohol level of the fans. Beer is sold at all events, even in the local amusement parks.

In have returned to attending at PMH for one day a week under a new paradigm wherein I teach, and write very few notes. This seems to be workable as rounds are better, faster, and more efficient. One of the UPenn students has fashioned a non re-breather O2 delivery mask and it has  made a huge impact on the hypoxia of the PCP pts, taking their o2 saturation from the mid 50's to >95%!  The dysfunction is just the same, especially in contradistinction to the secondary hospitals. 

 The med school has a new founding dean and my role there is still to be defined. In the mean time I love what I get to do each day so I can't go wrong. Fortune has indeed blessed me.

Now that I know my way around this part of the country it is beginning to feel more like "home".  This weekend I meet with my mentees in the FP residency. Next weekend is a getaway with Lynne to Tau, a SA game reserve . Then I hit the road for 10 days to make a circuit to Tsabong, Hukuntsi, and Ghanzi. Find them on the Google maps and you'll get a taste of why this is such a sweet gig. All my best.

The week in review

The past week has been event filled. Monday and Tuesday I followed a favorite and highly skilled MO who is also a mentee of mine through the Stellenbosch University program in SA. We worked in some rather slow paced clinics leaving time for discussion between cases and review ideas and other “right choices”. On Tuesday A.M. I also lost three hours I’ll never get back standing in line to get a Bots driver’s license. It actually came in quite handy---see below.

Wednesday we went to Mochudi where I gave a talk on HIV and dermatology, and then went to a remote clinic only to find that the MO was at a course in the Gabs area. As it is near the Zim border, and therefore a BNDF (Botswana National Defense Force) outpost, there were several guys waiting for a doc to show. One wasn’t.

 It’s only in these situations that I step in to fill the void, without a MO to mentor. I do so mostly to generate good will and to help the overwhelmed nurses. The first guy had a long course of abdominal complaints with bloating, pain, passage of mucous (pus) and blood and a VERY painful rectal exam. He had had two previous surgeries for hemorrhoids and fistulas.  I’d seen this several times in the states and as he had lost about 10kg in the last year thought he might have inflammatory bowel disease. We only have one med for this here and I started him on it with all the usual discussion and warnings. I made the mistake of giving him my card (I now have one) and telling him to call me with any problems. He proceeded to give it around back at the barracks and I have been screening calls from the outpost all week. It seems an old, western doc is valued more than a new doc from DRC (the one assigned to that clinic). Blast. So now I’ve heard about everything from drips to jock itch from these guys and each time refer them to the remote clinic on the border.

Thursday the new license came in handy as I was stopped twice. Once was just after I had picked up some passengers from a rural bus stop along the way to Lobatse. As I was accelerating away from the stop and listening how no white guy EVER stops for black people and what was the matter with me, I got jerked over for going 90 in an 80km zone. I WAS slowing down but there I was. The cop wanted P460 for the infraction which I didn’t have and let me go with a dismissive wave of his hand. In Lobatse I again went to a clinic without a doc for the day and saw patients for the morning. I was late getting back to the hospital and called there to let them know I was on the way...and got pulled over for using a cell phone as I entered the hospital grounds! Again a quick apology for being stupid and no fine. I have no luck, good karma, angelic presence left around me I’m sure. The bucket of good will is dry to be sure.

Friday I and a cardiologist from Penn who has been in practice longer than I have been alive went to Kanye, gave the same talk and then rounded on peds where we saw two kids with opisthotonus and meningitis. We transferred both here for pediatric intensive care. The prognosis is grim for both.

 Then we went to my new favorite village, Manyana. It is literally at the end of the road. There we saw a raw but very good MO who had accumulated some cases for us; peripartum cardiomyopathy, pregnancy and DVT, complex derm cases, sick kids, bad hypertension…the place was thick with pathology. We had a gas; great teaching and learning, great staff input, great people.