Worms!!!!

I was in Lobatse today and spent some time in a local clinic with an MO from Nigeria. That the majority of out-patients we see have so-called “medically unexplained symptoms” is a source of both fascination and aggravation. Yesterday I was in a rural area of a district north of here where a Penn medicine resident and I saw about 40 pts in 2 ½ hrs, ALL of whom save one had the above MUS. I’ve ranted about this in the past but yesterday took the cake. To make a point with the staff of the outpost I resisted giving out meds and wound up Rx’ing just one antibiotic for impetigo.

 The MOs here see all the hypertensive patients every month for refills of their meds. Because this is a relationship based society the patients will say anything necessary to get the attention of the MO and get what has become the currency of medicine here and in all developing countries; medication. So virtually all patients leave with paracetomol (acetaminophen), and some Vit D tabs, Wintergreen oint for application to whatever hurts, iron supplements (see “Geritol”), and folic acid. Which of course reinforces the  behavior in the first place. So I had a woman (it would seem the average patient with this schema is 25-55 and female) return three times for meds when she was asked to refill her BP meds and informed that her (no less than) SEVEN somatic pains would go away in time, and without any other medical intervention. That we are told nothing resembling the truth is something I have become used to and have learned to rely on instinct and physical, and treat nothing I can’t see, feel, touch, or test. So the currency of medicine here is just that, medicine, not information by way of reassurance. And the truth is not a part of the equation. It was this way in Sudan but the patients may have walked for three days to see us and the trip alone had exhausted them, necessitating some form of medical intervention. Some days are more frustrating than others and today was that kind of day.

 I went back to the hospital at about 1230 and met a good friend of mine, Roger, who has been assigned to A&E and maternity. We discussed cases and as we were ready to head off for a mid-day meal he invited me to his home for lunch. We got there and were surrounded by elementary aged girlies playing with dolls, running around playing hide and seek, and women fixing a huge meal for us. Part of it was a dish of mopane worms. These are caterpillars that are harvested in the late Spring/early summer (read November and December) and dried for eating later. They are sold in bags at all local markets and stands. The Zambians (Roger’s nationality) are also famous for enjoying them and now a bald headed guy from Oregon is too. They are chewy, salty, gritty, and loaded with protein. We ought to give these out for all the somatisizers that plague our clinics. At least that way they would get something of value true proteinaceous value. So I get to check that one off my culinary list….

 Best of luck to our friends that are headed to masters nationals in Clovis, CA!  Just remember, it ain’t Fresno, it’s Clovis, so it could be worse. Seriously good luck, good times, good fun!

Gun violence

It's only when I have lived in a country where even the police don't carry a gun that I realize how ridiculous the 2nd amendment controversy is. Each week I read on CNN or somewhere else about how, but for a gun, some individual would not have massacred his family or friends or acquaintances or strangers. Even if he had a baseball bat most would be alive.

Interesting how mostly in the US does one read about these things. I’m confident the advocates for guns in the home have considerable data to support their view but try living here in a nation where owning an unregistered gun will land you in jail for 20 yrs, TOMORROW, where arguments are rare and solved with  shouting or, rarely, knives and you’ll see my point.

 I asked the emergency room staff in Kanye the last someone had been seen there as a result of gun violence and no one could recall ANY time, EVER, that that had occurred.

When we were robbed of our computer in our bedroom, had I a gun, he would be dead (if I hadn't shot Lynne by mistake who was between me and the kid cussing him out) and I would still have our computer. Let's see dead guy on my conscience vs laptop.....doesn't pencil out for me.

It’s a cool crisp Fall morning, great day for birding.

 

 

 

 

 

One for the books

What an extraordinary day! Friday is Kanye, my favorite drive through the back country of the southwestern part of the country. It is about 120km from here. The medical staff is largely Moslem or very evangelically Christian with five countries represented on a staff of eight docs, including Ethiopia, DRC, Zimbabwe, Argentina, and Philippines.

 I led a discussion about chest pain and how all you really need is a good history and physical, but that you really NEED a good H&P and can’t short cut around it. After that an EKG and chest X-ray would be nice but not absolutely essential. Then it was down the hill to the civic center (read district offices) for a two hour discussion with the outpatient MOs about medically unexplained symptoms, chest pain, and the like. 

Here all hypertensive patients are seen every month.  Because this is a relationship based society and because health care is free all the returning hypertension patients have virtually the same 6 complaints of somatic pain. All in order to get your attention and some medication which indicates to them that you; a) care, b) take them seriously, and c) that they got the currency of health care in a developing nation- meds.  Whether they truly need it or not. So we discussed how to ask, “How are you feeling?” instead of “What is the matter?” and how seeing returning hypertension patients with stable blood pressure can be done every 6 mos rather than more frequently and thence clogging up the queue.

 I then returned to the hospital to join a dear friend and colleague, Mohamed from Ethiopia, for Friday prayers in the mosque and lunch at his home. He has three kids, an 8mo old, a 3yr old, both girls, and a 5yr old son with birth associate brain injury. His wife is a gem and an amazing cook. We had the usual staple of rice with potatoes and lentils, and chicken. Wow….

 The drive home was beautiful and Fall-like, and culminated in the best part of the week/2months in that Lynne is home!!!!! She came in on Wednesday and has been getting her feet under her and looking forward to some adventures out there with yours truly. Man did I ever miss her.

 So a great couple of talks, a moving prayer service shared with men who I am convinced worship the same God as I do, a magnificent meal, and, best of all, my wife of going on 35yrs is  home….a great day indeed.

 

Easter Weekend

There is a local hill near here that overlooks Gabs and the surrounding Botswanan and South African area. It on occasion is the site of robbery and muggings by local thugs and so is on “the list” of the US Embassy as place one shouldn’t go. So I got up this morning early and went. But first a bit about yesterday…

It began with meeting an MO friend of mine from Zambia who works in Lobatse. We met at a local amusement park that is just of the main road in the bush. His kids are 2 and 8 and gorgeous. I was great to see his family and to watch every flavor and color of people there. Teens are teens anywhere; girls giggling and grooming with an eye on the boys and boys playing football with an eye on the girls. Parents over indulging their kids and general fun and laughter as the kids ride some rides that remind me of a county fair. I have vowed to get out of the white expat culture and this was a good first start.

Nicola and Chawa, both valued friends and colleagues invited me to their flat for an evening of high protein intake (I’m a touch underweight apparently) and hepatic stress testing. Nicola is from Peru and brilliant. He somehow hit the jackpot and is in relationship with Chawa, an equally brilliant Batswana who is as beautiful as she is brilliant. We sat down to some whiskey, he and I smoked pipes, ate some meat, drank some more whiskey, more meat, more miskey and more weat…..Made it home in one piece but had to bargain with my GI tract and liver that I’d go easy from now on. It was delightful and peaceful to sit, laugh, eat, laugh, and relax. I even took several naps yesterday.

This AM I climbed Kaghle Hill to watch the sunrise and again saw all flavors of people up there. There were Africans from all over sub-Saharan Africa, South Asians, East Asians, and one bald white guy from Gabs by way of Hood River. It was a great way to greet Easter and feel a citizen of the world at once. It would be tough to be a mugger with all the folks around. Some younger people regularly run up and down the trail, a hill like one in the middle of the Hood River Valley, only taller and rockier, and oh-my-gosh I can’t recall its name.

So today its more naps and lazing around. I will write a talk about anemia this afternoon for Tuesday which should be easy and then an easy evening on the ol’ liver. Happy Easter to those who celebrate it. Hope all is well for all of you and those you love.

Some of the places I've been

I was in Artesia this Wednesday and thought I'd try to post some of the places I've been or go to each week:

 

Artesia: 

http://www.wikimapia.org/#lat=-24.0149506&lon=26.319809&z=16&l=0&m=h

 Kanye:

http://www.wikimapia.org/#lat=-24.9723843&lon=25.3414679&z=17&l=0&m=a&v=2

 

Lobatse:

http://www.wikimapia.org/#lat=-25.206339&lon=25.67433&z=17&l=0&m=a&v=2&show=/12185067/

 

Mochudi:

http://www.wikimapia.org/#lat=-24.3828668&lon=26.147697&z=16&l=0&m=a&v=2&search=mochudi%2C%20botswana

 

Hukuntsi:

http://www.wikimapia.org/#lat=-23.9960938&lon=21.7966604&z=15&l=0&m=a&v=2&search=hukuntsi%2C%20botswana

 

Ghanzi:

http://www.wikimapia.org/#lat=-21.7101077&lon=21.630578&z=16&l=0&m=a&v=2 

(before it was built apparently)

 

Dufus take two

So after meeting with the tech guys three times on Monday and getting nowhere, and then with the customer service folks today I have been able to return my iPhone for a refund minus P999 which I chalk up to being a dufus and a total nimrod. Back to four separate components. Good thing my back pack is big enough. For being an idiot it'll cost me $132.00 US which is probably appropriate. I was informed that this is the first time they have ever given a refund....Sure.

I have been trying my best to give accurate data for the funders of our program (read PEPFAR) but it is such a massage of data that I find it annoying. Sure it  is necessary as they want to be sure that they are funding the proper agency (us) but is really has little to do with the day-to-day stuff that I do. Frustrating to say the least. 

I feel at low ebb, the case of the ass is better but this stuff is distracting and preoccupying from what is truly important. And I  guess it's necessary. 

Musings on a Sunday

Lately I’ve had what my dad would call, with an infectious twinkle in his eye, a “case of the ass”. Except I’ve lost the twinkle. I really can’t attribute it to any one thing, more like a host of annoyances coming to fruition at once, or so it seems. While I really miss Lynne which I’m sure is the major part of it, in truth I’m fortunate to be here, at this time in my life, doing what I’m doing, where I get to do it. And there is still the possibility of starting a Family Medicine residency here, at once and an honor and a pain. Maybe that’s it; I got the trees in sight, just not the forest. So I am exercising fool, swimming on the weekend and running during the week, becoming an endorphin junky. There is apparently a family bet that I have lost some weight and things are hanging a little loose on me. So my default meal of oats-yogurt-fruit-milk is apparently a touch lite although not yet boring.

 This am I took off to explore an area off the main road on the way to Kanye and to get behind my eyes to sort things out. There is a grove of cotton-wood like trees, in a river bottom, that are changing color as it is fall here. The rustle of the leaves as the crisp wind moves through is like sweet music. It’s only 40km from here and is very renewing. I’m slowly coming around to the idea that I am in the southern hemisphere and that this is both April and Fall. The days are crisp and clear with warm afternoons and cool nights.

 Yesterday I got an iPhone in an attempt to consolidate phone, PDA, iPod, and camera. I must admit that I do not find it the least bit intuitive and am struggling to get it sorted out. I think the PDA part works only if I am near a WiFi area and that is rare. I’m not sure how to load UpToDate on it and it may be impossible despite what the people at Orange (a French company of course) assured me of when I thought and thought and inquired about it. So the SIM card travels back and forth between my cheap cell phone and this expensive, and thus far suboptimal, gadget that I’m embarrassed to admit I bought without figuring the whole thing out.

 The UTD comes on a “DVD” and I can get to my desk top, but from there I’m not sure how to load it into the iPhone, and then if I can how to easily get to it from there. Jeez I’m so 60’s and yesterday!

 Course it would help if I wasn’t such a cheap bastard. I mentioned a while ago that I got a great deal on a bike called a Supa Hamba. It’s a touring config and cheap, as opposed to inexpensive. I broke the rear coaster hub such that I could neither peddle nor stop and took it apart and immediately saw why it was so cheap, because it was build cheap. Note to self; quality might cost a touch more. So I took the hub to the local bike shop that actually has a mechanic who took one glance at it and said, “Ah I see you have a Supa Hamba!” I now will have more money into it than had I got a true Hamba as I’ll have the frame of a Supa and the hub of a Hamba, so it truly will be a Supa Supa Hamba. Ah life, it happens doesn’t it. The forest is in sight, I just need to take off the blinkers and enjoy the wider view.

 

 

 

Been a while, 2nd edition

Well it's safe to say I had a regular week! It began in the clinics here in Gabs where I mentored a very capable, and lonely, doc from DRC who staffs a busy clinic in a central neighborhood. One of the interesting things about this area is that compared to a generation ago when there literally was no health care, now any access is generally considered of good quality, which of course is hooey. Suffice it to say that the Gabs MO's run the gamut from caring and compassionate to abrupt and arrogant. Sound familiar? This guy was a member of the former.

The que at the clinic on Monday and Tuesday was literally spilling out the door. Some of the crowding is self inflicted as the MO's want to see all hypertensives back each month. The data shows that we typically need to treat 100 patients for 5 yrs to prevent 3 complications from this disease. So slowly I am convincing them that once every 3-6 months is plenty and will reduce the daily patient load by up to 15%. They are typical of docs with the same level of training in that they over treat from a sense of insecurity and over diagnose just in case they might be missing something. This adds to their fatigue and length of work day. So in there is a compromise that works for all. Added to that is the reliable fact that all patients returning for a blood pressure evaluation ALWAYS have some variety of somatic pain so these visits take a toll on concentration and quality as the path of least resistance is false diagnosis and treatment that once begun is difficult if not impossible to discontinue.

And it gets in the way of emergent care. We had an 8 y/o child with HIV on HAART who had a twoday history of bad impetigo and was septic. He showed up with his grandmother to the clinic. Thankfully he was appropriately triaged and we saw him in a timely fashion. His pressure was down and he was somnolent. We started an IV and gave him a gram of ceftriaxone and then tried to achieve disposition such that he could be admitted without going through the land of no return known as the Princess Marina A&E (emergency room). 

Since he already had a diagnosis and treatment had started all he needed was a peds bed and a doc. I was able to achieve said objective with a few phone calls and had to ride the ambulance (a covered pickup bed) with him to continue treatment. We parked in a different lot much to the consternation of the driver who knew we were breaking protocol, and I carried our boy to the peds ward to be met with a lot of eye rolling and not a little passive aggression. A small nuclear event later said child had a bed and the doc I had called showed up to assume care. MUCH FASTER than going through the A&E, and he is better at this writing.

Two observations. Many children here are raised by grandparents as their parents are living in a different town, dead from HIV, or too young and that's the way they were raised themselves. This of course is not unique to Bots, just interesting in passing. Also, PMH recently underwent an extensive evaluation by a South African firm and was found to be in compliance with the international standards of care (apparently as enunciated by WHO among others) all of 3% of the time(!). THAT is no surprise and just might motivate officials but I'm betting that it won't see the light of day. It will instead be a small change, a bit at a time, dripping with politics.

But I am so very fortunate to be here at this time in my life and career. I love what I get to do, love to teach family medicine and introduce it to the Penn students from my perspective, love to treat. It may not get much better....