Been a while

It was a busy week with travel to the usual areas and teaching in clinics and hospitals. The topic of the week was outpatient workup of breast masses. Here there is a tendency to simply hear the complaint and refer for surgical excision, something that can be rather non-cosmetic. I brought the idea of a comprehensive history, appropriate physical and fine needle aspiration/biopsy to the table as a means of more immediate diagnosis. It was well  received as the docs are generally unsatisfied with the lack of imaging and other alternatives available pre surgical intervention. The FNAB idea should help allot. 

On Friday I went to Kanye with an actual Penn med student who matched in Family Medicine, at the Ventura program no less. We were assigned a clinic at the outskirts of Kanye only to find that there wasn't an MO there so we saw about 35 pts in a three hour period, most were kids with "fever at night". It was illustrative for the student in that we prescribed only one antibiotic; for an adult with abscesses. A significant paradigm shift to be sure, and one not lost on the nurses and staff.

Yesterday I met with some FM residents through the Stellenbosch University (in SA) distance learning program. We did a unit on "how we learn" and then exchanged ideas on what it is that attracts us to FM. Interesting spectrum of reasons from "I will make more money" to "I enjoy the patient population"

Today I took a drive out to an area about 45min from Gabs on a spur away from the road to Kanye. It was an area I pass on the way out and back to Kanye and wanted to see but never had the time. It follows a valley back to the Gabs area. Glory be it was beautiful. Along the way there was a grove of what reminded me of Aspens or Tulip Poplars that were just beginning to change color (it's early Fall  here with crisp mornings bright sun that is lower lying on the horizon and warm afternoons). The grove of trees had a stream running through it not unlike Oregon, a real refreshing, quiet, reflective time. 

Location, location, location

I found this on an older blog of a friend that moved back to the states. It is a map of where we live.

http://www.wikimapia.org/#lat=-24.6520293&lon=25.9128749&z=12&l=0&m=h

Wow, all I can say is…  Wow.

 I and a Penn medicine resident, Monika, arrived in Hukuntsi on Monday afternoon after a 400km drive from Gabs. Hukuntsi is on the western frontier, literally at the end of the road. Or at least where it turns to sand and really gets out into the bush. In the town is a primary hospital that is incredible. It is staffed by about 100 people with medical, maternity, surgical, and pediatric wards and as many beds as PHRMH in Hood River. It is spread out much like a California elementary school.

 The first order of business was where we were going to stay. There is a single guest house in the town and it was full the last time we checked so we were prepared to stay in the car or on a bench in the outpatient department.  Monika is, amazingly, lower maintenance than I and game for anything, a well seasoned traveler. Well this wasn’t OK with our host, Dr. Kalenga, a 54y/o doc from DRC who has the ability to get things done like no other MO I have seen, hence his presence in Hukuntsi. The hospital was under major remodel, and he and just two other MOs both unseasoned, are the medical presence there.  So the short of it is that we stayed as his guest in his home in the staff compound of the hospital. His wife was in SA at the graduation of their son from university in Jo’burg.

 It was a rare treat to spend a day and a half in his presence and teach, learn, mentor in the in and out patient confines. What is great at these places is how the entire staff enjoys a presentation, not just the docs and the conversation is amazing. I literally had to remind myself where I was many times. The last night we went on a walk to an area about 1km outside the fence of the compound where he tried to reassure me that predators only like dark skinned prey, hilarious.

 We bade farewell on Wednesday and travelled 300km to Ghanzi, in the NW of the country to another primary hospital where the reception and for that matter the hospital design was very similar. It was run by a man, Dr. Simwanza, from Zambia with his wife also a doc. The staff there was bigger as the population was from the largest area in the country. They see patients from as far away as 250km to the NW and E.

 They also see members of the San, an ancient people that use a click dialect that requires an oropharynx that is hinged differently than mine!  A smaller and very open faced people that are genuine and loving. A mother of five brought in her fifth child, three days old, with an imperforate anus, patent urethra, and vestigial or absent vagina. At the same time we were discussing a patient that Monika tool to immediately who had new onset liver masses and needed a CT scan. Here in Bots we are good at building hospitals but haven’t yet decentralized imaging so we spend obscene amounts of money to fly or drive people to Gabs for tests that could/should be done locally. At any rate Flying Missions was called and flew in to Ghanzi that evening and took both patients back to Gabs for definitive diagnosis and hopefully therapy.

 Yesterday morning we took off at 0730 and drove 675km back here, arriving at 1530 through monstrous African rain storms. I am convinced this is for me, that this is the best way to do outreach (at least a day in the location), and that I’m a lucky guy. What a beautiful country, beautiful people, beautiful opportunity.

 

Life sans Lynne is different and difficult to be sure but with the web and Skype, real time Gmail chat and the like it is easier to stay in touch. And distance at some level seems to promote communicating in a fashion that would otherwise not occur. Conversations are deeper, addressing long suppressed stuff, stuff we thought we'd handled long ago, and just STUFF. Interesting  how that drawer, the "stuff drawer" can be so crammed with, well, stuff, and both parties can be so unaware until one is gone and the communication centers said stuff and cleaning out the drawer, or at least arranging it.

Was in Moshupa on Friday and met one of my new "mentees". You see-I are a mentor. I am a mentor for several of the family medicine registrars (residents in the US terminology) that are participating in the distance learning and residency through Stellenbosch University where I visited two weeks ago.  Moshupa is spread out along the road to Kanye from here and has numerous remote clinics there so I already like the sound of it. And I can function in two roles at once, outreach to MOs and mentoring of registrars.

I head out to the remote western part of the country on Monday so will be out of web range for a week unless I find a cafe with access in Hukuntsi or Ghanzi. It should be a hoot as I'll drive there (we actually used to fly, no more thanks to the recession and GWB) and have little plans about where to stay or visit. They know I'm coming but it might mean that I'll sleep in the outpost or clinic, maybe the primary hospital if I'm lucky in Hukuntsi. I have a place to stay in Ghanzi.

The weekend has been one of preparation; inspecting the vehicle I take, cleaning it, and packing. There is a huge amount of nothing between villages out there, guess that's why is called the Kalahari Desert. Should really be up my alley.

Thanks for all the correspondence, it's never enough of course but it is very appreciated.

Magnificent!

I just got a text from the doc in Lobatse who has been treating the woman with NMS and she is up, walking around, wondering what the big deal is. What a sweet save! She owes her life to two students from Penn who were in the  right place at the right time while their preceptor was in the john bowing to his hyperplastic prostate. I made sure they knew. 

Next week I hit the road to the far west of the central nation, a primary hospital in Hukuntsi. I'll stay there a couple of nights then head east and join the road north to Ghanzi where there is a district hospital. I'll be there teaching and mentoring two nights as well. I hope to visit some outlying and remote clinics from there.

Then a long drive back home to Gabs and a lot of discussion to be had. Lynne is enjoying herself in the US and having a wonderful time with the various outlaws and in laws. We are indeed blessed to have all of them in our lives. Aven is term and "WANTS TO HAVE A BABY!" and who can blame her. It will be a hoot when "B" makes the scene.

Tomorrow I participate in the interviewing of candidates for Dean of the new medical school here. It is very protocolized and formal, we'll see how it goes. We need to get past some of the institutional inertia and get busy.

And we're two weeks into this two month adventure of Lynnes. I sure miss her and am glad she is spreading the "Mom joy" around the corners of the MLPs.

So I found myself in Lobatse today...

Today I began the day by picking up two med students and driving to Lobatse. The drive is beautiful this time of year as everything  is green and lush. As i came across a small rise where the speed limit changes from 120 to 80km/hr I took my foot of the pedal and was slowing, but not soon enough as the local cops got me on radar at 90. So I got waved over and had to pay a fine of just P80, about $10.00. I HATE the latest toy these guys have, the video radar gun. If the enforcement was consistant, OK guilty as charged even though I was all of 6mph over the limit and was slowing. Simmer...

In Lobatse we began at the hospital, the oldest in the country with wall that are 1/2m thick and wards of 8-12 beds. Rounds there and in other hospitals are a grnad time as the nurses participate and the discussion falls to how much they are a huge help. Yesterday we saw a woman in Mochudi with Toxic Epidermal Necrolysis from anti TB medicatoin. This is a blistering desquamating skin condition that is often deadly unless the nurses and docs are all on the same page, paragraph, sentence, word. There were 10 nursing students, two docs, a med student from Penn, and your truly. It was a great time to empower the nurses and reinforce how they are the ones that get the  patient better while we just write the orders. It was a lively 30m discussion at the bedside.

This morning we discussed the next epidemic that will hit this country (diabetes 2) and then went top a local clinic where a doc, Armstrong (named after the astronaut), and the three of us spent five of the best hours to date seeing and teaching/learning. It was great. The diagnoses spanned the spectrum: VSD, dermatographism, dystonia-dysautonomia, somatization, lung neoplasm, Parkinson disease, a real full and fascinating day.

We then returned to the hospital to round in the afternoon on some of the more complex cases and WOW did we find one. We were introduced to a woman who had been on Haldol for agitation and now had a fever of 39, was rigid, comatose, and near death. The students examined her and raised something I had not seen in my career but was starring us in the face; neuroleptic malignant syndrome. We got busy. If she lives she owes her life to two fourth year students from Penn. 

More

·         Since starting Keppra I seem to have my mind back. Weird.

·          Since starting Keppra I no longer have vicious night sweats. I had some in Sudan, but nothing like the wringing wet sweats I have had over the last two years. The last one was the night before I started this stuff. Go ahead say it, I can HEAR the eye rolls. And you’re right. I just haven’t included that in my image of myself yet; a prescription pill taker.   Selfish? Yes. Stupid? Why yes it is. Annoying? Actually not as much as the fuzz of a seizing brain and the night sweats now that you mention it. So, perhaps a good thing and I should just get over it already.

·         The gay community is alive and seems to be thriving here. I see couples (mostly male) everywhere displaying affection for each other without, so it seems, fear.

·         Best to all out there……

 

Randomness again

Some random unconnected thoughts:

·         Did I mention I miss my sweetie

·         Family Medicine is alive and thriving in South Africa from where I just returned having spent the last part of the week learning about the de-centralized model of resident (called “registrar”) education. There they place a resident in a rural setting and formally educate him/her on-line thus assuring a better chance that the resident will likely stay in the rural area post training.

·         I look forward to having a role in establishing the residency here. It will be the first here in Botswana! Wow, gives me goose bumps just thinking about it.

·         “University of Botswana School of Medicine”, still a few administrative docs in a trailer, is moving along. The model they use is to employ current faculty in various and necessary departments to teach not just grad students but med students as well.

·         The referral hospital here, Princess Marina, is a monstrous, hide bound, disorganized, mess and unready for the role anticipated for it.

·         The district hospitals should do better as they transition to a teaching role.

·         Stellenbosch University School of Medicine is situated on the campus of Tyger Valley Hospital, a monstrous building that is 12+ stories high, over 200m long, two buildings side by side connected by corridors across the gap every two floors. Why? Apartheid. Now it seems ridiculous but when the place was built total separation was the rule. Less than two generations from now it (apartheid) will be a memory. Unbelievable that an entire country/culture can change that fast.

·         I will never get used to nor take for granted the shanty towns in the Cape area, each has more people in them than the entire state of Botswana.

·         In two weeks I hit the road for some rather rural areas out west of here. Places where we used to fly but with the economy and all….So the bummer is I get to drive out there and stay a few nights and teach in a little more intense environment. The things I “have” to do.

·         I’m sitting here listening to Bela Fleck, live is good. Listened to Wait Wait Don’t Tell Me earlier. It’s only mentioned because I can actually navigate make my IPod  do this stuff

·         Got up, washed and waxed the car to the great amusement of the people that live here as NOBODY does ANY work on ANYTHING that can be hired out. Then fixed my bike, mowed the lawn and tied a ball to the ceiling of the garage so I now know how far in to park the car; a productive day.

·         Oh and a fat nap.

·         Talked with Aven and Eli. Heard about TJ and the now famous apple pie massacre, I got your back big guy.

·         Having Shannon, Amber, and Olivia in my life makes we even more blessed.

·         Facebook came along at a perfect time in my life. I know sounds kinda juvenile but there you have it.