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.