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.