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.

A Sunday

Today I washed the car. Not a big deal but to me it's a little like working in the garden or mowing the lawn....after you've done it you can look at it with a sense of accomplishment. Achievement in medicine is so often undefined and slow such that at the end of the day it is difficult to look back and assess what you have truly accomplished. Hence the seduction of washing the car.

No one in my skin or at my "station" washes their own vehicle here. It is viewed as beneath one. And it represents a chance for someone else to earn a token amount of money. Lynne and I actually got into a bit of an animated conversation about that; I was taking money away from someone else by washing my own vehicle. Nope I was simply trying to achieve where I had not in a more immediate time frame. I enjoyed it and the car is clean.

Things here are clean in general. There are no true heaps on the road, little if any litter as the govt employs people to cut grass, sweep streets, scavenge litter, and in general keep the place neat and tidy. In Sudan the litter was so ever present that I was surprised to see it in the pictures I took, so used to it was I.

A quiet Sunday beginning with a great birding adventure at the local game reserve where we saw at least 20 different and exotic species, wart hogs, impala, and huge monitor lizards basking in the sun on a pond bank near their nests. Then a fat breakfast, now a nap. Hardly the rough life to be sure. Difficult to reconcile that at times but the occasional car wash helps if only temporarily.

A new favorite place

Last Sunday, a week ago, Lynne and I drove the 200K to Mahalapye to have a look at the hospital that might house a Family Medicine residency and the town. It is more dry there as it is closer to the Kalahari and has less topography than Gabs. And yet it is familiar, like our old home town of Hood River; quiet, kids everywhere, fewer fences topped by electric wire, fewer guards of property. 

The hospital is huge, over-built, understaffed, and under-maintained like so many new things here. It has huge corridors, wide atria, and wards that are separated by empty space. Some doors are afar because they can't close, some have liquid leaking out from under them. I know the nursing staff to be dedicated and caring, and the administration to be very capable. We looked at each other and acknowledged "we could do this" principally because we would be some of the very few expats in the area. The FM program is not well defined as yet so we'll wait and see.

The week was punctuated by a national holiday, Thursday was Ascension Day, so we climbed the local hill and watched the sunrising above the Gabs floor. Then Nicola and I travelled to Lobatse to round on a child I have been following with Marasmus (malnutritition) while Lynne and Chawa had breakfast with other women of the profect. Lobatse is the oldest city of the country and had the only paved road  when independance was granted in the mid 60's.

Friday I mentored at an outpost in Manyana a town of 1500 at the end of the road, SW of here. There I walked into the medical outpost (an outpost is staffed by a nurse with a once weekly visit by a doctor) to find a misplaced shipment of 12 huge cartons of condoms (!). Everyone was in stitches and when the Batswana laugh it is infectious. I was laughing in seconds and had no idea why until someone explained it. See, there are condom dispensers in every male toilet in every clinic, upscale restaurant, government building, everywhere. ALL are empty. For that matter so is the soap, toilet paper, and paper towel. Only the staff has access to these items and they are guarded with lock and key. It has become a hot political item here as the ministry feigns ignorance of the problem and the staff blames the ministry, and so it goes. So to have a shipment of more condoms than can be used by a town of 1500 oversexed men in a year arrive in Manyana was as hilarious as it was ironic. 

The pace is slow and careful, the nurse is excellent and lives in a house under the only baobab tree in the south part of the country. We saw a man with MDR (multiple drug resistant) Tb and paid a home visit to inject him with his daily dose of med under the directly observed treatment program. 

Leaving in the afternoon I realized I still have vestiges of this blamed ATF in me and was rather wiped for the week. Still, I'm a lucky guy AND we are coming back to the States, and the Great Northwest in 5 weeks!

Its been a week

I, finally, feel well. And found out that I wasn't, by far, the only expat with this annoying African Tic Fever. Thanks to Rickettsia africae I felt a touch beat up for a week. And the interaction of the doxycycline and Keppra lead to some rather hairy dreams and, (&%$@!!!!), an episode of seizure activity lasting about 5secs.

 

Friday I was in Moshupa with a favorite MO/mentee/Stellenbosch resident of mine, Cathy. She had some patients come to the clinic there about whom she had questions and we we able to take some time to go over them and review. We saw a post op "Caesar" ("Brit speak" for C/section) with some oozing at the site of the abdominal wound. Cathy did a great job of reassuring the patient and removing the sutures. And then we had a great "last patient of the day".

As we were preparing to leave the clinic there in walked a teenage mother with her 3 month old daughter who had a fever. I had given a talk on "fever in a child three months of age or younger" to the residents the previous week and had given the talk to all the hospital staffs I had visited the previous week.  So all we knew was she "had a fever of 38.5C" taken axillary, a great teaching moment if there ever was one.  The timing was sweet!

So we did something we rarely do in the clinics which is take a bonafide rectal temp. The axillary temps are a great way to screen but are really too peripheral for my comfort zone. The rectal temp was met with a little eye rolling but was 39.5C (103+F), so another teaching moment....What next? As I was visiting Cathy that day with a real and genuine UPenn FP resident, also a Kathy, we had a great cross cultural moment about what is appropriate, reassuring, and how to get there from here. 

We (well...me, because I love to care for sick kids) unclothed the child and began to assess whether her behavior and exam were reassuring or non-reassuring and discuss where our comfort zone was and what was evidence based.  Ultimately she had a non focal, reassuring exam and the result of our 2 1/2 heads being put together was to send her to the Kanye hospital to have some blood drawn (an FBC, equiv to a CBC) while she was re-examined there. One of my pet peeves is the lack of conversation between outlying clinics and hospital staffs.  I demonstrated how to do this and why it was so necessary. So off she went, and so did we about 40m after we had originally headed for the door.

Tomorrow Lynne and I head to Mahalapye, a town about 200k north of here to see if we could live there as this is a great place to establish a FM residency. If the answer is "no" then no sense in continuing the conversation about having a role in the new FM residency. 

I have my sweetie back, my health (such as it is with a bleepin' seizure disorder) back, and have a bright future. I'm a lucky guy.

One other(x3) thing

Still febrile today so I saw Nicola and he of course asked to see the lesion..which it turns out has an escar in the center. Since I couldn't see my own fanny and Lynne wasn't advised of the difference it simply was overlooked and, well, when was the last time I had staph and felt this crummy. The adenopathy is still regional but unchanged and I'm still flippin febrile. 

So off to the pharmacy I go for some doxycycline and here's hoping that this does the trick. African tic fever. I certainly was in plenty of places I could have been exposed.  It's a better idea than mine to be sure. No spots yet and the doxy is a bit broader spectrum and ultimately a better choice than the clox I was taking.

One other other thing

Turns out that that fever is from a bug bite that I got sleeping at the lodge the night of the storm. I, being me, scratched the blazes out of it in my sleep and now have a consequent staph infection on my back side. I had thought that the adenopathy in my right inguinum was...what, well who cares I was sick dammit. Then last night Lynne saw me in the shower and noticed a bright red beacon of infection on my right lily white butt cheek with streaking around to....yup the same adenopathy. So today is the third day of the "feel bads", first day of antibiotics and hopefully one of the last days of febrility.

It's interesting how you can walk into a pharmacy here and ask "got any cloxacillin?", and they will simply ask how many you want.  Good thing the UPenn Division of Infectious Disease signs my check and I have two close in-country friends who are ID docs. Now if they just had a magic wand they could wave over me....

In the grand scheme of things I'm a wuss. The hospital is full of very sick people. I have NOT seen a normal chest x-ray since resuming morning report two weeks ago. The stoicism of the Batswana can be incredible.

Go OMS!! 

One other thing

I forgot to mention that at about 0100 I awoke to a calm between the storms. Lynne stirred and we went outside into the night to see what I really love about the African bush; the night sky. 

I remember marvelling at the Milky Way in the Sierras when I was a scout on a fifty miler or at Philmont in NM. But I appreciate them so much more now. The night sky was just  loaded, nothing recognizable as it was early in the am and in the southern hemisphere but the Milky Way was about 30 degrees of arc across the night sky, extending horizon to horizon. Incredible.

Today I'm sick with a fever and fatigue, perhaps a hangover from the weekend's adventure 

Oh, Beth got a job! She starts as an ED nurse at SW Washington Medical Center in Vancouver. She will be fantastic and they won't have any idea what hit 'em. So proud of the outlaws and inlaws in the fam. 

Go Oregon Masters!!!!

One for the books

So there we were on the Kalahari Desert in central Botswana, the Khustse Game reserve to be specific, when…..but first let me set this up better. 

Lynne and I have vowed to see Botswana more that we have to date, which is essentially nil. This was a huge oversight on our parts as we were so busy setting up a home and career path that we neglected to actually “see” this extraordinary country.  So beginning this Friday we started to do a better job. Friday was May Day, a national holiday in most of the world except the US. I decided to work it and took Lynne to Kanye to meet a favorite MO friend of mine, Abdosh, and his family where she would stay and visit with his wife Hanan, their 8mo old and two yr old daughters and 5yr old son. I took along a Penn resident and we worked the A&E as well as rounded on the wards with the MO on call .

After Abdosh and I worshipped in his mosque we all sat down and had a monstrous Ethiopian meal. His wife is the age of our kids and they have a beautiful family.  After our goodbyes, I was able to drive part of the way home before the meal caught up to me and I had to pull over for a quick nap. That night we had dinner with the new dean of the University of Botswana School Of Medicine and discussed how family medicine and I might fit into the short and long term picture.

Saturday we, another couple from Penn and two other Penn folks, a resident and a NICU nurse, loaded up into a safari truck (read open sided with three rows of stadium like seating) and headed off to the Kalahari for a couple of days of game drives and camping. The weather has definitely turned here and is colder, heavier, with shorter days and cool nights. The work week was clear and bright with gorgeous days and starlit nights. And you knew it just had to turn…

We arrived in the park after a 4hr drive north of here into the Khutse Game Reserve, one of the two large central Botswana game parks. After setting up camp in an area that was very reminiscent of Eastern Oregon's Christmas Valley, we went out on a game drive and saw wildebeest, hartebeest, springbok, gemsbok (oryx), bird life of all colors and hues, huge kori bustards (largest birds of flight)…..and then noticed an anvil cloud on the leading edge of a huge, dark, weather front. 

We thought we might get lucky and have it blow north of us but were disabused of that idea as it bore down on us.... and the whole time I was thinking, "come on, this is a freaking desert!"  But no, we were clobbered by a monstrously powerful thunder-storm with hail and a funnel cloud!  Did I mention we were on a desert? We raced back to camp, got caught out in the open and had to back the truck into the wind and rain so we could at least try to stay warm under some wool blankets while we hunkered down like a Texas jackrabbit. Man we got soaked. The only thing worse than wet is cold and wet, which of course we were as well. Did I mention we were on a desert where the annual rainfall is measured in millimeters? We were later informed at the office that the storm dumped 44mm (about 1.75 inches) of rain in 20min.

After the huge storm; lightning, hail, rain, wind, cold, and funnel cloud passed over us we beat it back to camp in the dark and rain to find our tents which were the classic square igloo-type with external bendable poles had blown into the next district along with the table and service items.  So off to a local, and the only, B&B we went in the dark, in the rain. We stopped at the gate of the park and found a San kid who had become so disoriented from the storm (it being so rare and all) that he was headed the wrong direction back to his village. This NEVER happens with the San, the original Bushmen. We gave him a ride.

We spent the night in dry warmth and went to clean up the carnage this morning finding the tents in some cases 30m from the camp. We dried everything out as best we could and headed home, laughing at our situation and marveling at the specter of the Kalahari. No lions, but lots of great non-carnivores and birds and the storm of a life time. A great weekend.