"Mike, you cannot die with it!"

OK, OK, OK, OOHKAY already. The last entry wasn’t really the last. Now all you out there that have placed bets on the short can start to collect.

On my last day of outreach I was in Kanye. There the medical staff surprised me with a breakfast to say goodbye and farewell. During the meal an MO that I have mentored for the last two years was walking around the rather crowded room in hushed conversation with the others there. Now I like this guy but he can occasionally wear on me a bit as he tends to whine. I asked if he could wait for the gathering to end, he said “just a minute”. Now there is no “minute” in this culture. I was being blown off. OK, my last day, so be it. Point to him.

Shortly thereafter he stepped to the front of the room and said, “Dr. Mike do you know how many languages are represented here?” I didn’t. “Twelve.” “Do you know how many nationalities or cultures are in this room?”Mind you there were only fourteen people in the room including me,“twelve”. Interestingly none from Botswana.

And then the most moving and extraordinary thing happened; each of the MOs in turn stood then stated where they were from, their tribe and their native language… and then said “thank you” in that language. Wow-- as in lump in the back of my throat wow. That, I hope, finds its way to my hippocampus, right next to my “asymmetric amygdala” and therein imbeds itself for me to recall as often as I would like. It was just incredible and made all the time there even more extraordinary.

Then this: we were on the way to the Gabs airport to fly to the N.E. kwaZulu Natal coast. We wanted to decompress after the craziness of packing (all by Lynne) and leaving B-UP. The diving (me-six dives) and the beach (Lynne-six days) there was amazing but it was the trip to the airport where I was broad-sided by the cab driver whom we have known for almost three years.

Tendai is a religious man, a transplant from Zimbabwe, and adamant about his family and ideals. He started by saying that I was given a “gift from God himself”. It is always uncomfortable to compare myself to another who thinks of himself as of lower station. I tried to blow it off and equate him and his use with mine. He became even more animated and talked up the whole “came from the US to help us Africans” slant on things. I again tried to not let this stick. If there are any hero’s to this saga it is the patients. He finally became even more animated and stated that “you have a gift from God Mike and you cannot let it die with you!”

OK so there is was, on the head with a veritable 2x4. At some level he put simple words to an idea I have been considering for some time now: how self centered would it be if I don’t give of myself such that the “gift”, all the effort people have put into my career, is shared? Shouldn't I (we) pay it forward, share it as it were? This is no doubt a touch hokey as there is apparently a popular film out that comes at this idea. And while the benefit clearly goes both ways, it is I who has been endowed with this and need to initiate the first encounter by simply sharing and hopefully exchanging benefit It has only taken me 30yrs to get this. Maybe that is one of the lasting legacies of this adventure.

Happy New Year and compliments!

Swan song.. Or as the Brits say, done and dusted

Before you begin this read the last post. What follows will make more sense.

Parenthetically, I have found that I need to be on guard for the "multiple somatic complaint" patients when they are really just in the clinic for a refill of blood pressure meds. Yesterday evening I saw an unfortunate soul who was profoundly demented. His daughter wanted him evaluated for his dementia and I did so. Unfortunately there is no treatment that makes a difference and she was so informed. She wanted "treatment" and again I advised there was none. Off she went only to come back and indignantly demand a refill of antihypertensive meds for her father. I looked deeper into his file and found out that he had been worked up previously for dementia despite her statement that I was the first one to see him for this. He did have HTN but didn't need the meds ASAP.

I had been suckered by the last patient of the day and, well, let's just say that during the drive home I was preoccupied with introspection regarding my impatient response. Before her father we saw a desperately ill woman with HIV and fever who had been queued up for 6 freaking hours! My impatience with all of this reminded me of my old man. Geez I hope this isn't genetic. It is however a slog and one that I fear won't abate when I "get" to see chronic pain, chronic narcotic use for somatic pain, and the likes of fibromyalgia again. Wish there was a med for being so impatient and a jerk to boot (me, not my dad).

While I have no regrets about going to the States I do have mixed feelings about leaving here. I love this country; the singing (much of it acapella), the land and fauna, the smiles and laughter. It has embraced me in its most remote corners where the true heroes of the HIV epidemic reside. And yet I look at pictures of Lost Lake and Mt Hood and think "have I squandered two and a half years?"

Yet foremost and tipping the scale away from here is my family. I'm a fortunate guy to have such an amazing bunch in my life. I'd like to take credit for it but that is in Lynne's purview; I helped but is was on her lap that those monstrous teens curled up and chatted. I was the one who inspired the fun and mischief. Sorry outlaws and in-laws that will trickle down to your kids, it's simply is too much fun.

Finally I've realized what my family seemed to have known for quite some time; that I'm an "end-of-the-road, whats-around-the-next-bend" kind of guy. I find myself at an age where I don't need to persist in something that I don't enjoy and that doesn't play to my strength as a doc; simple doctoring. I am indebted to my B-UP colleagues, each of whom are brilliant, and yet I find that I don't necessarily share the same professional language or value set. Not good, bad, right, or wrong as much as it is simply true.

Shortly after the 17th we will venture to Sodwana Bay along the north eastern coast of South Africa where I can soak my head in forty feet of clear water and Lynne can read on the beach. Then to the States to harass kids and grand kids. Then to, wait for it... Hawaii. I will be with Kaiser Permanente in Honolulu and will work locums. We'll teach, swim, dive, and toss Judah, Asher, and Cora around. Forrest and therefore Shannon, et.al. will be stationed there. Then when the Northwest and Midwest are at their gloomiest, the northwesterners and hopefully the Louisvillians can come and it will Belle's, Lue's, "and countings" turn. I have a special dispensation from the extended family Pendleton to leave every 15-18 mos or so I can scratch the medical relief itch for 3 months. The University of Botswana is starting a Family Medicine program here so who knows, maybe attend in the clinics for a time, if the country will have me back.

So this will be the last blog entry. If any of you want to flee the northern hemisphere winter in February, give us a ring (you all know our contact info). We'll have a room for you and will know where you can get some killer sushi!

Cheers,

Mike

Resigned to Resignation

Early in September, a Friday, I came home from a district hospital in a lousy mood. I had been discouraged all week that the MO's, with a few notable exceptions, weren't asking the right questions and therefore not practicing up to their potential. I know, I have written about this before but my toxicity meter was in the red zone. It seemed that nothing I had done to date had made any lasting difference in care. I had had a horrific Monday, involved in something that while medically necessary, decent and appropriate really shook me like I haven't been since my MSF days. With MSF I had to look through/past events and continue; "next". Here, I have been able to let my guard down and was totally blind sided. I felt depleted and ineffective and began to seriously question the true purpose of my medical presence here.

To the extent that we, or for that matter any expat organisation , make a lasting and true difference here appears to be simply out of reach. This is a young country that is in the process of emerging from adolescence and needs to find its own value system. I find it making the same mistakes, and encountering the same struggles that a more mature country has processed through. Hell, when the US was this "age" we were fighting a war, again, (1812 wasn't it?) and for what? It is generally agreed that we are at least two generations away from true reform in medicine. Were we placating the metaphorically "young teen" country such that rather than teaching one to fix the flat tire one's his bike we instead were buying one a new bike? We'll just have to wait and see I guess.

So on that Friday I found myself thinking if the above was true, what was I doing here, really, that was making more than a temporary impact? Was this just an exercise in pure narcissism and was I just collecting stories? I love the people and the primary medicine to be sure but B-UP has slowly moved away from point-of-care medicine at a primary level. We are responsible to those that fund us and it becomes difficult to quantify relationships or for that matter reliably assure that knowledge transferred makes a difference at the doctor-patient level. I had been worrying that at some level I and my organization were, perhaps, enabling.

I found myself a bit depleted and not a little frustrated. I had struggled for a while with the notion that I am different in numerous ways from my fellow faculty members; generational, primary specialty, medical terminology and priorities, etc. Even the term "faculty" is foreign, implying separation from my primary care colleagues. I have learned alot about health care in this setting and at the same time that information rarely related to my every day teaching and, with few exceptions, had little lasting impact on my those I mentor. All too frequently I found myself saying that "we have discussed this disease and its management before" and did he/she remember that? For the most part they didn't, or didn't care.

In any case after no less than two "interventions" on the part of my family ("Papa you need to get your shit together and enjoy your grandchildren and they you") and considerable introspection on our part I submitted my resignation a week later, effective 17 December. I have 5 weeks. I know, no state secret here, but I wanted to keep it quiet as it shouldn't be about me.

Now the family reunion

Again no words can come close. We had our four (the outlaws), their four (the in-laws) and five of the following generation. Oh and us, making, what, 15?! I had no idea I was at that station in life. We were fortunate to have a huge beach house given to us to enjoy for the week. It faced the Jersey shore and was an easy walk (about 50ft!) to get to a wondrous place for exploring and Uncle Wiggly adventures.

On cold days we would laugh; at us, the screwball antics of our grandkids, and then would eat too much. I return well marbled from the following diet; hot dog with mustard and sauerkraut, then cheese steak, then Japanese food (I know, some how these don't belong in the same universe) then chew-belch-and-repeat.

We have a family of educators and docs. Weird how that happened. And they all were called upon for various situations that made us proud to see them exercise their professions. I am a proud Papa and Grandpa indeed.

All the little ones were cared for by the entire clan so they will have a time adjusting to the routine back home. Hah, the Papa and Mama's revenge. Such lovely debauchery!

First the Savuti

This area is classic African Savannah, except it isn't as a slight earth quake tilted the delta just enough such that the Okovango complex is now flowing partially through it. The Savuti used to be home to one of the largest lion prides in the world, numbering about 40. It split up when a lioness bred her family away from the pride and things went from there; a population explosion of elephants, wildebeests, eland, kudo, birds, the ever present impala (read Big Macs for predators), everything.

We went there with the intention of seeing this pride but alas it was gone, but the Savuti wasn't and it was magical. And what made it better was that friends from HR were there, Michael (alias "the DH") and MJ (alias "coach") were there. We were a party of 4 and had the guide to ourselves. Johnny was/is amazing.

He knows the area like the back of his hand and we often found ourselves away from any other tour (there aren't many) looking at a fantastic sunset with a hyena in the foreground! Yes the sunsets are as good in the eastern area of Wasco County, but when can you say you saw it from the freaking Savuti? Much less as a hyena was preparing to head out on a night patrol. Thought so.

Words simply can't do it justice. For those of you who know Michael and MJ, ask them. I'm still a bit amazed that it happened, and with them to boot. Bottom line? Have this one on your bucket list for sure. And use Johnny.

Come on Mike, connect the damn dots!

As the discerning reader will recall I have ranted about health professionals and how they (we) don't ask the appropriate questions. To whit:

I was in a remote district hospital on Tuesday where I rounded on all the patients in the hospital, about 30. We saw a child of 8 years who was anemic to the tune of a blood concentration of less than 1/3 of usual. He had been admitted on several occasions "because he eats dirt", and had no platelets (the blood cells that promote clotting). I took one look at his blood count (called "full blood count" or "FBC") and had the diagnosis. His red cells were so small and so pale that they appeared like platelets on the automated count. He was so iron deficient that he had "pica" or "geophagia" and had the uncontrollable urge to eat dirt for its iron content. "So its not that this is abnormal. It is because he has no iron stores, is HIV+, and has a diet that is deficient in iron" I desperately wanted to add "you idiots!!!!" but there was that voice in my head again...We inquired about his diet which was awful as he came from a poor family and ate just twice a day, grain at that, no meat, and little green vegetables. We gave him some iron that was to be taken three times a day for three months, no just five days that had been prescribed on previous admissions.

On to the OPD where I functioned as the visiting surgeon, dermatologist, and family doc. I saw no less than three women who had abdominal paid that was characteristic of gastro-esophgitis (2) and lateral abdominal wall pain. As all had persisted in there complaints the MOs had obtained ultrasound scans on all of them. This happens way too frequently there as the MOs are fatigued and want to fish for a diagnosis that will satisfy their "customers" as the Ministry of Health has taken to calling patients. What garbage (the MoH not the MOs)....But I digress. All three now had become fixated on needing to have their gall bladder removed as it was the seat of all that ailed them. I tried and tried to explain that they in fact had "asymptomatic chloelithiasis" and that we had learned long ago that surgery had no place in this process and causes more complications than it fixes. All left unhappy...sigh.

Then a fascinating young woman. She was seeing me because she had a spectrum of complaints that made no pathophysiologic sense otherwise known as somatization. I have been trying to get the MOs to call this symptom complex "somatization" as it is more medically descriptive than as an example, "waist ache". As I sifted through the 4cm of her chart, there it was: "raped in 9/09". She was simply trying to reconstruct her life after a vicious attack that had completely destroyed her security. We made a plan to see her frequently and who cares about the complaint, just be with her.

Then my turn. It was a classic last patient of the day. The pilots were calling me to get to the strip so we could get back to Gabs before dark. My colleagues were in the truck waiting to go to the strip and in walks a woman with" stiffness" and "dizziness"....If I had a tebe for every one of the women (classically) that had had these same complaints... I did my best to take a good history, do a perfunctory physical, and explain that while I believed that she had a problem, it wasn't serious and that it should be resolved in two weeks. She was seen the day before and wasn't better so she came see the"specialist". A bit of a misnomer in my case, but be that as it may...I basically saw her fast and sent her on her way.

Now the OPD is constructed such that the docs can leave out the back door if they need a break or need to consult on another patient, a good thing. As I was leaving I had the chance to observe her walk from behind and noted that she had a wide based gait. I caught up to her and checked a few more things, noted that she had a coarse tremor (how the hell did I miss that?), added the fact that she had a very un-animated expression and there it was starring me in the face: Parkinsonism. This of course explained her stiffness and dizziness. We started her on the appropriate medication and she should improve within the week.

The dots Mike, connect the freakin' dots.

"Who owns your life?" Part two

The next day I was in a remote district hospital and as often happens I was asked by the nurse with whom I was working if I could consult on her case. "Sure"

It's a bit of a story but after an hour I still couldn't convince her that things were "OK". I finally found myself asking her if she believed me. She said yes...and then went off again as to how she was "still sick ngaka!" I ultimately wrote what I thought was the appropriate diagnosis in her hand carried chart,"card", she read it and lit up. What is "conversion disorder?" Ever so gently I told her how she must really be frightened about what she was experiencing and that there was no medical explanation for it. This is what it should be called so other MOs coming after me would better be able to care for her. The fight was on.

Try as I might to be a "target not worth shooting", it went nowhere. She was livid that I would "un-diagnose" her and was going to report me to the ministry. "Get in line", I thought, and played the only card I had left; that I needed to get to the airstrip to fly back. I dread going back next month.

Then yesterday I had the classic "last patient on a Friday" experience. I was asked to see a 25y/o with a common problem that had been appropriately diagnosed and was resistant to "treatment". Now the last doctor in line is always the smartest because all the hard work has already been done. I gave him an "atta boy" and that" this would resolve and good luck". And again things went south. It turned out that he had visited a local church that had invoked that he was bewitched (a common metaphor here) and that there was a "snake in my abdomen", also quite common. And extremely difficult to "treat" as it were.

I tried my best and then found myself running out of patience, said some unflattering things that will send me straight to hell on my demise, and, after an hour (!) opened the door to ask him to leave.

I whined to a Motswana colleague of mine and asked why this seems to be a recurring theme; wanting to believe one is sick even when a "specialist", a bit of a misnomer in my case, spends time and makes a more benign interpretation of the symptom complex. He rolled his eyes and said that that was just the way it is. I asked a medical staff meeting earlier that day if anyone had had similar encounters to the one in the remote hospital and it was met with peels of laughter, all had.

I just don't get it. And won't, I suspect.

"Who owns your life?"

Interesting how themes seem to manifest on a given week. I had noticed that the whole school work thing had lost the allure to the SOS kids. Oh sure they would get out their books and start alright but it was always short lived or met with that far off look of a kid that would rather be somewhere else. The house where I spend the most time has 12 kids, all guys, plus one three year old girl and another that is 16. Otherwise it is can be a high charged, don't give a bleep, emerging adolescent, testosterone filled junk heap. Sure Mma Caroline does her best to keep order but these guys have taken to tuning her out and head back outside to find more mischief. "They are so naughty!" she pleads as she chases after the three year old. Time for "The Papa."

By now I had a clear idea of what wasn't working; my mere presence, reading and helping with school work. True I would play and wrestle with them all during the summer (coming up) but they are now at risk of falling off the educational bus. 'Nuff's enough. One night last week a 12 y/o boy came into the house late for dinner, got dressed down by Mma Caroline, stood there and took it, then ran off to play some more football. Missing dinner was no problem, there were many girls that we only to happy to provide him some food. He's becoming a player, and now loves to rap with his pants on the floor and liberally use the N'word. I doubt he knows how loaded that is.

As he came in for a late (very) supper he was again admonished, ignored it, THEN FED, as this seemed to be the path of least resistance for Mma. Not for moi. I asked him to apologize and he gave me a look like I was from another planet. WRONG. We had a quick talk about respect and asking forgiveness and it went south. To his credit he is a good guy with a testosterone level that is on the rise and to which he hasn't become accustomed. So onto the hard counter went his skinny butt for a long needed "time out" until he apologized. I doubt that they get the minute-to minute, guy-to-guy feedback/mentoring they need

Now believe me I get that, absent coaching, this is unfair. So while he was immobile for a period, and thankfully fuming, I coached him about asking forgiveness and to simply say "I'm sorry"." Want to practice it?" Nothing, and the power struggle was on. I had to leave. I understand that it went nowhere and he went to bed without consequence. I have routinely seen this kid, one of the smartest I have ever experienced, be "beaten" by other house mothers as he adventures into manhood. They are fed up with him and they should be. So into his life steps a guy with a stronger will than his. Might not be a pretty sight....

This week I took him, his brother (13) and another kid (14) out into the middle of the football pitch (a bare field) under the stars. We sat in a circle and I asked, "Who owns your life?" The older two said "God.", although that might have been what they thought that that was the answer that I was after. The 12y/o in question said, "Me." Good stuff to work with.

"Why does He always forgive us?" "Why, no matter what, does He forgive us?" "Because he loves us!" the older two said. The younger was by now in a fat stew. "So why should we ever ask forgiveness if He always forgives?" "Uh, so we'll know?" "Yep and so you can grow to be men." The younger was on the hook and was being reeled in. "It's just that if we don't ask for forgiveness that we will eventually drive people who love us away from us" Even I was impressed with what was coming our my mouth. "All it takes is, "I'm sorry", then it's up to the other to forgive. But in the process you learn to change your behavior, to not hurt the other person."

So we practiced. We sat in the circle under the stars and said "I'm sorry" to the one on our left. I was sitting next to the 12y/o and when it was my turn he gave a curious look. "You're old. You shouldn't have to say that." "Oh, really? I live in the same live you do, not the same place. There are cost for my actions. Try it" Nothing..."Say it man, just say it", he was admonished by his brother. He spat out the words. Then we did it again, except this time I lightly smacked him on the leg. He jumped and I said I was so sorry that I had hurt him. Tearing up, he said "It's OK". OK now smack (the 14y/o) and say your sorry. "He might beat me" "Yes he might but he for sure will do it if your don't say you're sorry. Besides if he does I'll tickle him until he can't move." He love/hates to be tickled especially in front of girls.

Smack,"I'm sorry!" he said flinching. "No problem" and he turned to the 13y/o and did the same thing, stated he was sorry and around it went. After about five rounds and squeals of laughter others came over to join the fun. Soon the circle was about 10 and, as now there were girls there, things began to deteriorate from the male side of things. But as so often happens in life they would NOT let the guys getaway without saying those two words, all the while laughing at, what? Beats me.

It's the government! (version II)

As is my habit I often will pick up hitch hikers. They are innumerable. It gives me a chance to hone some Setswana, although I still am pathetic at it. As is my habit when Lynne is over in the US, I was venturing out into the bush over the weekend. Its quiet and I get a chance to sort out the cacophony. On the way back I stopped by a district hospital to round on a patient that I had seen the previous day. I was on the side of the road answering a call as a taxi was rolled by. All taxis are private vehicles with a small sign projecting from the window so I rarely recognize them. Out of the taxi I heard "Nnaka, nnaka are you going to Gabs?!" As I was in the middle of a conversation I tried to multi-task, ignored the entreaty, and continued with the phone.

I hate these bleeping mobile phones. There are people in my life that pay so much attention to the slightest beep or buzz that rudeness has left their sphere of awareness. Ah, dopamine. But I digress.

Next thing I know the person (a house keeper at the local hospital) hops into the car and makes herself at home. Ohhhkay, where are we going? She proceeded to fill me in about how she was headed to the north of the country to organize the funeral for "the sister of my mother's mother". Funerals are very important here to honor the family member.

On the way back to Gabs, I always pass a monstrous pothole that has been under repair for, oh, about 6 months. I always count the piles of dirt and rocks and there hasn't been been a change in the number. I truly count these, I know weird. So I asked my guest how in the world this could continue and she went OFF!

"These Batswana are lazy, all the tenders (contracts) are to the Chinese and no wonder, they get it done." Not very well mind you. "I just hate this! We are so lazy!" She went on about how she, a lowly housekeeper, was the mother of three kids and all were doing great. She had a house without electricity and still was able to make a living out of her station in life. "Why not anyone else?" And on it went. Turns out she was of the same tribe as the current president, His Excellency Lieutenant Colonel Ian Khama (this is a contraction of the true title, I swear). It is about one and a half hours back to Gabs and did I ever put nickel in her slot. She slowed down when we entered traffic and actually thanked me, asking God's blessing on me. I could really use it. I took her to the bus rank (station) and again she thanked me. New in my experience.

The child I discussed (alright bragged) about last post had gained 1kg as of Wednesday. Unfortunately I was squarely in the cross hairs of the mother as I went into my usual inquisition about the environment the child would return to. The house had nine people and no income. The child has a combination of protein calorie and mass calorie malnutrition, known as marasmus-kwashiorkor, so I was a touch (alright more than a touch) reluctant to send him back into the same environment. And while I should have anticipated this, it hit the veritable fan. The end result was the mom leaving in a stew and the grandmother coming into take her role. A good if not entirely satisfactory conclusion. The child will go home after a dietitian and social worker weigh in.

Progress is slow here and won't gain momentum until the Batswana truly take charge and control of their own medical destiny; absent the infusion, intrusion, insinuation, or invitation of the ex-pat community. Sounds remotely like another area of the world from which the US just extracted/abandoned. Owning your country is so nebulous and difficult; so many variables to consider. It can't be taught. Patience, unfortunately not a component of my being. Dammit.

Calories in should equal calories out

I was in a remote hospital this week where I had been seeing a malnourished child with HIV, Tb and a mother that was overwhelmed, didn't get it, ignorant.....something. I had been there a month ago and from then to my current visit he hadn't gained a gram! To be fair the weights are to the nearest 100gms but this guy was skin on skeleton. I sent a picture to the family so if you would like to see him send me and email or contact one of them.

Again that voice..chill! Even thorough this low watt, lamictal affected brain of mine I thought well this is either a case of the nurses not getting it as he hasn't really shown distress, other than he hadn't gained a flee-flappin', racka-frackin' gram and was too weak to kick up a fuss, or his mom just was not able to participate in his care. Each thought the other was at fault and the kid just stayed at 60% weight for height, severely malnourished, all the while the HIV and Tb were wracking what was left. They are the true hyenas of the infectious world.

How to get more calories into this little irritated chum and factor the adults out of it? Aha, says I. "Please get me a neonatal NG tube, a liter bag of saline ( a smaller bag would have been better but alas), and an adult administration set." Notice I didn't say get me the damn set! Good for me huh? I was after all still hearing that voice? " Now make up some of his formula but make it 1.5 the concentration." I did the calculations for this and out came a liter of formula.

I drained the saline from the bag, cut off a corner from the top and inserted the top half of a 20cc syringe, a funnel. Love me some Miny Leatherman Tool! Than, after assuring myself that the NG was in the stomach, poured the formula into the bag and hooked up the administration set (that clear tubing that leads from the bag to the iv) to the NG. It took a little futsing but by now I was in innovative heaven. Interestingly the NG tube revealed nothing in the stomach just an hour after he was supposed to have been fed. I gave a look of "really....Really!" and each of the parties pointed to the other.

Actually things came together rather nicely and in went the formula at a calculated drip rate to equal 200cal/kg/day. And what happened? The calculus as far as I can tell is this:

one irritated, starved kid (+)

one guaranteed source of warm calories =

same kid fast asleep.

I pointed out how we no longer needed to worry about who was going to give the food. We just needed to check the drip rate as we didn't want to over fill this guys microscopic stomach and give him aspiration pneumonia. They all agreed this was a good idea. Off I went to see referrals in the out patient department.

After I finished I went back to check on him and you can guess the rest of the story. To everyone's credit the NG was in place but the formula was off as the nurses didn't to "give him diabetes". "You mean fatten him up, get him sweet, why not?" We had a lengthy discussion about this during which I congratulated them about thinking about this but that even if he did get diabetes ( he couldn't) it was still OK to proceed. They agreed and one took the lead. We'll see next month.

His ward mate was also malnourished and was ready to be discharged but was on his mothers back so much that he couldn't sit at 19 mos. I sat him in a corner of his crib and his head draped forward. Everyone naturally went to his aid but I said to just wait and see what happened. One minute later he had great head control and was reaching out for some Plumpy Nut! I tried to get his mother to allow him to be a touch more independent but she would have none of it. She is San and desperately wanted to go home to the bush and be with her family. Fair enough, he'll develop there fine what with all the tactile stimulation he'll get but it would have been a touch safer to do it under some supervision. She had done her part in that he had gained 3kg in the last month and she wanted out. She lived with 8 other members of her family way out there. Would have been fun to go with her an see it.

Today I was at another hospital and saw the same situation, same malnourished child with HIV and Tb except this kid had lost weight in the last week. In went the NG, up went the bag, in went the formula, down he went. Cool.

Day 5: “It’s the government!”

It began at Ghanzi Primary Hospital where I rounded, mentored, and then at 1530 hit the road for the 7hr journey back to Gabs. About 2hrs into the drive, one where I was in a hurry as you do better in the light where the animals are easily seen and avoided, I encountered a vehicle half out into the road, stalled and obviously broken down. I pulled up and asked how things were. “Not fine, not OK”

I hopped out and quickly diagnosed the car with a metal shavings for a gear box. The six people that the car had been transporting were in the classic group, speaking and gesticulating loudly. I asked if anyone wanted a ride, no response.

As I started the car they all noticed I was leaving and ran to the rig demanding a ride. I stated that I could take three followed by more lengthy discussion. Again I started the car, discussion ceased, and in piled three Batswana, followed again with loud discussion, smiles and laughter. We exchanged names and what it was we did. The woman in the front was a maid, one of the men in the back was a teacher, the other a brick layer. And then it started.

“I wouldn’t need to ride if the government paid better” she said. This coming from a Motswana that could avail herself of a free or near free education up through university, free health care, underwritten costs for food, and more. She was joined by all the others. I must admit that my response was less than charitable.

“Tell me what your dream is in the next five years.” This was followed by a lot of “I wants” and laughter. It then occurred to me that laughter is so much a part of the culture that not only did it cement a relationship, deflect confrontation in a relationship, but it also deferred accountability. “How will you get from here to a “huge house and a good car”” I asked. Silence, followed by more sentences that contained “the government”. I asked “who owns your life?” Again silence, laughter, no response. "How many of you have children?" Two had a single child. "Really, how old?” Silence, neither the woman nor one of the guys could answer as they were both parents in abstentia. “Why are you leaving your child and going on “vacation” without him/here?” Silence. I had had it, and regrettably erupted.

“This is so emblematic of this country, of any country with an underclass. Who here has graduated from secondary school?” The woman hadn’t with any apparent reason other than ambivalence. “OK, that makes you both unfortunate and stupid. You’re telling me that you couldn’t walk to school for a free education? Was there a problem?” She teared up and I backed off, regretting my outburst of righteousness. The others were leaning forward in the seat and the gauntlet was thrown down. Everything was someone else’s fault and but for that they’re lives would be successful, right up through parenthood. I said to try not using the word “government” for the next five minutes. Silence again. I became even more paternal.

“Let me see if I get this right; you have free education, free health care, food at underwritten cost (that to be fair is stored dry as there often is no electricity for refrigeration), 160 days of paid time if laid off, and the like.”

Others have declared that this is beginning to resemble a “nanny state”. Maybe. The Scandinavians are close but why do they seem more successful? Are we in an adolescent period that necessitates this as a natural progression to due process and prosperity for all here? I admit it is easy to say when I come from relative privilege, but "why isn’t there any entrepreneurial drive?Who owns the grocery stores?” “The Indians.” “The dry goods stores?” “The Chinese and the Indians.” ‘The auto dealerships?” “The Indians”. The contractors?” “The Chinese”, and again to be fair the bids are low-balled courtesy of the Chinese government.“Why not the Batswana?”

All the stops were off and that voice in my head was ignored. “Why not build the bricks and sell them, not build with them, have an agency for maids, get a free PhD.?” Laughter.
“What is funny, why laugh?” “We love to laugh.” “I get that, but do you have an answer?” “All looked to the floor, a sign of humility here. Jeez I was righteous and was having no effect. Damn I’d blown it. But because of the venting I felt better. I know stupid, really stupid and not at all charitable. We sat in silence.

The only way things could have been more awkward was if the dark road was smokey from desert fires set by someone out there. We crept. Soon they were again talking and one translated. “We think you have a point, Rra.” “I don’t want to be right. I would like you to think and ask yourselves some important questions beginning with: If I’m here, headed on vacation, where is my child?” “Am I truly ready to parent?” “Exactly who is in my sexual network? These are easy and necessary questions with no easy answers and in a country with an HIV prevalence of 40% in your age group YOU need to be accountable to yourself and answer it”

As I write this I’m not proud of it but for the sake of transparency, something for which I dedicated this blog in the beginning, there it is. I got home with ambivalent feelings and then recalled how fortunate I was to have spent time in the remote bush.

Day 4: “Sure we like gays.”

I awakened early and hit the dust again. I stopped and saw the dawn eating an apple and some nuts that Lynn had provided and journeyed on. This was the day I had been looking to as it took me way out into the Kalahari. The Kalahari doesn’t’ stop at some arbitrary boundary. It covers the entire country except the delta and the ancient hills in the NE section. The vistas were stunning.

I rode across hard “pans”, dried shallow round lakes that are white after they dry. In the moon light one can read from the reflected light. Looking over each of the larger pans was a settlement; each village as unique as the next, each as quiet as the next; kids everywhere, playing football with whatever, squealing toddlers on the backs of mothers, incessant talking and conversation. At last I was truly in the land of the San and Batswana.

I have always felt that Gabs, and Bots in general, was “Africa light”. Now I was out in villages that at some level were still innocent and naïve, needing preservation not intrusion. I drove quietly, didn’t get out of the rig for fear of “contaminating” the village, and drove on. The 240km to Charles Hill was the most rutted I had seen. And when it wasn’t rutted it was “wash boarded”. Not sure which is worse, the side aches from being tossed around in the ruts or the headache from the wash board. On occasion the wash board was smoothed over with rock and sand. Interestingly the sand was akin to powered cement; limestone and chalk. Once wetted it was rock hard and unforgiving; talk about your headache.

I ultimately entered Ncojane, pronounced with a click, the kind where you use your tongue in the front of your mouth to make that “tisk-tisk” sound. I picked up three people and started to head for Charles Hill. Two of them quickly announced they were gay and was “that OK?” but with a bit of a confrontational tone. No problems here say I, and then encountered some of their friends before we got underway. These guys were true flamers, multiply pierced, in skin tight pants with a sway at the hips that belied the stereotype. I wondered aloud how this went down in a small village in Botswana. “No problem”, they said. I wish we so enlightened, PFLAG member that I have been.

We made it to Charles Hill on fumes and were chagrined to find out that there wasn’t any fuel in town. We asked around and were told to head to the border with Namibia where there was gas just on the other side of the border. Only trouble was that I didn’t have a passport. No worries the passengers said we’ll get an immigration person to do it. We went there and the guys negotiated with the passport clerks to have one of them take the rig over the border and have it filled with gas. I gave the keys to him, as if I had a choice, and some pula. 20min later he returned with the car and a full tank. Wow and whew.

We rolled into Ghanzi, 250km of paved road later, shook hands and parted. I got a room at a hotel I had used in the past and had a beer. Best beer I have had in country so far.

Day 3: Four wheel drive stress test

I have always wanted to drive the “road less traveled” north across the desert to Hukuntsi. One can travel east then north then west on paved or hard pan road to get to Hukuntsi from Tsabong or one can travel straight north over, well… I was about to find out. About 10km out of town I started to think that this would be cake as the road was hard pan and I was doing an easy 80km/hr. I had seen a jackal, some endangered vultures, and paw prints that had to be lion.

Then the paved road ended and the fun began; picture driving through flour, rutted and deep, for 180km. No use steering as the ruts take you where they will. I stopped frequently and wondered at the silence and again at the subtle but now more familiar changes in flora. There were gemsbok (pronounced “hemsbok”); huge elk sized animals that were everywhere. Also long needled porcupines, impalas, and more. I went through villages that had no real reason that I could see for being where they were, except that that’s where they had been for millennia. I stopped at all the medical outposts and introduced myself and began to “network” or at least left a bunch of B-UP cards. I always encouraged them to call the referral hospital, in this case Tsabong, for assistance but if for some reason they needed different help I was always there.

I got to Hukuntsi in about 8hrs, found fuel, and then called some physician friends that I have known since I came to Bots. It is so different to drive around when basically all I have done is fly in and fly out. I promptly was invited over to see them, and for dinner. Well I didn’t want to impose…”Dr. Mike this is Africa! You are always welcome and there will always be enough.” We ate “poppa”, a staple corn based congealed porridge, with tripe in a tomato sauce, and beans, and with our hands at that. It was the first meal I had had in three days and was fantastic. Beer was brought out and as I reached into my pocket for a multi-tool with opener the hosts just used their teeth. Africans that I have seen in several countries seem to have perfect and rock hard teeth.

I took pictures of all the families and insisted that they smile, something that isn’t normal in this culture when being photographed.

I slept that night on the grounds of the hospital, again marveling at the day and the stars.

Day 2: “Your coefficient of friction…”

I have always wanted to venture to the outposts where some of the patients I treat in Tsabong come from. There is an axis, if you will, of villages and outposts from Tsabong extending east to the main highway and west to the SW corner of Botswana; by the Botswana, South Africa, and Namibia junction. an area of hundreds of thousands of square kilometers. So out to the village of Middlepits I went at the posted speed limit of 120km/hr. Just outside the village I was nailed by a speed trap on the newly paved road. As the speed limit, or so I thought, was 120km/hr and I was travelling at 110km/hr I thought that I was OK. I pulled over and was advised I was going well over the limit of 80km/hr, posted just once, about 10km back.

“Uh what’s the problem?” “You are over the speed limit.” “What’s the limit?” “80” “Huh? Why, the village is still about 5km from here?” I was speaking to a police officer that was sitting in the shade of a tree at the bottom of a hill such that a car cresting the hill would be nailed without the first hint of the presence of cops. Low hanging fruit if you’re a cop. “Why 80?” “Because the coefficient of friction on the road is too high at 120 and the road will be eaten away!”

WTF??? “The co-effi…..WHAT!? What about the trucks that sped past me and are twenty times as heavy?” “We can’t stop them. They just go on by.” “Sigh….How much?” By now I was hearing that voice that surprisingly sounds like Lynne stating “just be nice”. Nice? Jeez I hate nice when I’m being shaken down. “P500”. I get the ticket and asked where I should pay. They say “at the nearest police station.” The ticket is now in various pieces all over the landscape.

I drove out to Bokspitts, at the aforementioned corner of Botswana, through a river valley of chalk escarpments and limestone cliffs; truly beautiful and at once amazing that Tsabong served such a distant population. Bokspitts and Middlepits are old Afrikaner settlements dating back to before Botswana was “Botswana”. The journey was extraordinary in that I slowly became aware of the subtle changes I was seeing in the surrounding landscape. “Magnificent desolation”, I think is how it has been coined.

That night I stayed at a local hotel in Tsabong staffed by a UB grad who was interested in the hotel management industry, a true entrepreneur in the making and one of the very few that have independent market driven business ideals here. I was the only one at the hotel and fell asleep to the sounds of the Soweto Gospel Choir.

Shh, do you here that?

That's right you don't, because out there, there is no background white noise; no 'beemers,' 'benzes, volvos, or range rovers that are driving too fast on too narrow roads with "performance exhausts". I am in the middle of the Kalahari, sleeping, away from the light and noise, and couldn't believe my good fortune.

I took off from home on Saturday and almost made it to Tsabong. As it was getting dark it came to me that I wasn't in a rush (or "damn hurry; rush-rush-rush" as Dad would put it) so I pulled over into the bush and camped in the vehicle that I had borrowed from Matt. Picture an SUV on steroids.

Off I went, found a place to settle about 500m from the road and then stood resting against the car for two hours as I watched the sun set. The colors went through the entire spectrum of white to yellow to crimson to blue to violet to black, all within a background of pure silence interrupted by the call of evening birds. I slept in the back of the rig with knees bent the whole night (too short a bed), and freezing (-8C) and loving it. Oh and the stars! The Milky Way was a gray streak occupying about 40 degrees of arc in the sky.

The next morning I stood again for about two hours as the previous night's spectacle was spun in reverse. I moved on to a village and waited for a small tuck shop (picture a 7-11 with a gas station Botswana version in the middle of the bush on a rutted dirt road) ) to open. There was a queue outside the shop with three cold cars and guys and lots of guy talk. The pumps didn't work "because they are cold". Apparently the pumps are keyed to magnetic switches that were indeed too cold to release the pump. So being the desperate white guy that I am I breathed on the switch plate and used my watch to reflect some light onto the plate to the laughter and glee of all the guys. They were gesticulating and laughing and in general having a great time at my expense in Setswana. That is until the switch freed up and the pump worked. Well...high fives all around and more laughter. I was able to get a tank of gas for how much I have no idea. Hey I was on fumes! Then off to Tsabong.

There is a new, and the village’s first, grocery store in town where I bought some water. While I was in the checkout line I noticed that the back ground music (I know, a touch weird in a village) was gospel as I heard the work "jeso", pronounced "jayso", Jesus. As I was pulling out pula to pay, the guy behind me started to sing along with a marvelously deep base voice. Soon the rest of the store; check out girls, stock guys, everyone, joined in four part harmony with clapping and stomping, free of inhibitions and worry about what others might think. In a grocery store!

"I might have been attacked by a lion"

OK, OK, take a collective breath already! It wasn't me. I do hippos, remember?

Last week I was in a hospital on the edge of the western frontier and was rounding with an MO there. He had an "orthopedic case" and did I think I "could handle it"? Well, "I could give it a shot.""He was attacked by a lion! And now he has a bone infection and two wounds that won't heal." "And what made the lion release his grasp?", say I. "Prayer", said the patient.

Now I'd be praying all right, but for a quick death. Lions aren't known to clutch, taste a well marbled (western fat guy) or sinewy (lean Botswana guy), and spit him back out. So out came Dr. Mike's version of the Spanish Inquisition.

"Did you see the lion?" "No, I heard it." "And you're sure it was a lion?" "Yes, well maybe".

Lions aren't completely gone from this area but the guy was herding cattle. Why him and not a non-praying cow? And what about the horse he rode in on? No, seriously, he was on a horse...If I'm a lion I'm going for the low hanging fruit, the ones who have, maybe, four neurons and two synapses on a good day. Oh, and they are bigger, dumber, and don't know how to pray that the predator drops his prey (loved that sentence). In any case I had that look of extreme cynical doubt on my face, that one I got from the teacher when I thought I'd premier the "my dog ate my homework!" shtick. "Really? Really???!!"

Turns out he "might have stuck it on a thorn bush". Now things were falling into place. I half way wanted to keep the charade of the bona-fide history going as I marveled at this guys imagination and quick thinking (well, praying) to get himself out of trouble. The wound didn't match the bite of a large cat (learned that stuff in my Medical Examiner days) but was part of a large deep scratch.

The guy thought he'd try one more time, "It was were the lion scratched me!" Sigh, this was getting passed humorous and into a bit of a pain, for both of us. So like any dim watt bulb I decided to treat what I could see, feel, or touch. The history was amusing if not wholly precise. It appeared that he had two discrete areas of erosion on the affected leg with huge lymph nodes in the groin. Given that the scratch made more sense and the wound was more consistent with that, and the the wounds were multiple and grossly swollen, and erosive (graphic enough for you?) I thought that this might be the second case of sporotrichosis I had seen, the other was in the same hospital. So lion story aside I made something up about how these particular lions were known to have these particular germs and that is why he got this injury. He thought for a moment, agreed, and told me that I should learn how to pray like him so God would also protect me.

He's right. I should.

Score: 1-1 Good Guys Win!.......well maybe

This has unfortunately become the same "song and dance" at several district hospitals wherein:

1. a desperately ill patient is presented at morning report with vital signs that are
2. incompatible with life or
3. indicate life is near an end or
4. well, you know the story by now.

So there I was at morning meeting and listening as a department head nurse reviewed the patients admitted from the last evening and those that might be of interest. She mentioned a woman "with HIV, in critical condition with PCP (now called PJP) pneumonia". She had an unrecordable temp and, well, the same song and dance. I know what doesn't work by now, and since that voice in my head was as loud as the last time, I thought I'd just saunter on over to the female ward and have a look.

By now of course her vitals were worse and she was gasping. Generally in these cases simple fatigue due to the stress of breathing leads to death as a patient is so sick that they have no calories to use on respiration . I asked her nurse if her IV was working. "Yes" And how did her O2 come off her face and why is she in the far bed with the curtains drawn so no one could keep her under observation? Cue the panicked look on face and shrug. So I calmly (no, really) went and asked the charge nurse and her charges if they could please come to discuss our patient.

We assembled around the bedside and I again inquired about the vital signs, IV, 02, general condition, and why she was alone, gasping and basically circling the drain. She was an all too familiar room as of the four beds there each has hosted an unnecessary (at least unattended, missed, or otherwise ignored) septic death. We were close to batting 1.000. As I reviewed the situation I asked if some one could get a new IV, some normal saline, another 02 line and something to warm her?

Inertia. Now it may be an overstatement that there isn't a notion of accountability in this culture but this situation spoke volumes to me. So I quietly did a slow white hot fizz, got some vicious heart burn, and gathered all the equipment myself and away we went. To their credit everyone started treat her. Not sure why it took so long but there you are.

She died 3hrs later. Score: Death and frustration-1, Patients-0

I went to male ward and found a nurse who could recite the pathophysiology of each disease process we encountered and knew her patients to the nearest decimal place. No one was going to destabilize on her watch without her knowledge of it. Her patients were just as sick yet they were in much better hands. Just like every place I have been, the culture of a particular ward can vary widely within an inpatient environment. In this case: Death-1, Patients-1. Tie goes to the home team. Good guys win. We'll take it.

Today Lynne and I went for a drive into the bush. I doubt most expats realize how near the bush is to Gabs. When I fly to outlying areas I can see it as close as a km from the airport. What I love about it is the quiet, the smiles, giving people on the road or trail a ride and taking them to their home. Many think this experience can only be had in the middle of nowhere and yet these people live and thrive so close to here. We wound around and saw some amazing homes, huts, cattle posts and giggling kids. The bush in winter is thinner and therefore easier to see through. The vistas will be only one of the amazing things I will always remember about Botswana.

"A febrile seizure".....

for no less than thirty minutes! (Insert frowning face with teeth clenched and hands to head in disbelief here). I felt like flopping and pulling a tantrum like the futbol players, but it wouldn't get me or the kid anywhere.

An MO at a district hospital asked me to review a patient on peds. He introduced him as a 6mo old boy who had had a "febrile seizure" but who hadn't "awakened". He apparently had a fever of (40.5C (>104F) and started to seize. I asked the mother how long he had seized and she said 15 minutes, then during the ride in the taxi for another 20minutes, then in the ED for another several before he got some anti-seizure meds. On exam he was somnolent and still stiff in his arms and legs. I wondered about cerebral palsy and asked about his birth--"fine", and how he was before he seized--"laughing and normal". OK, so I might not the brightest bulb in the chandelier but this ain't no "febrile seizure" as these are usually less than 5min and kids awaken without trouble. To be sure, it is a "seizure with fever" which is more deadly if unrecognized. I responded internally with...well, those that know me can fill in the blanks.

It occurred to me that he might still be in status so we gave him another hit of diazepam, just his second in TWELVE HOURS ( way too infrequently) and he softened into a deep sleep...with a stiff neck and an encephalopathic mental status. There were so many areas where this child had fallen through the cracks and where we had let him down that I couldn't begin to count. The MO was a touch chagrined and at my behest transfered him to a higher level of care to be CT'd and tapped. At least he was on antibiotics.

My left hemisphere desperately wanted to scream obscenities. But my right hemisphere, and this voice in my head that sounded remarkably like Lynne, held me back and instead I got a doozy of a headache. I got home, found the beer and, again, those that know me can fill in the blanks from there. This morning? Another headache but for a wholly different (and admittedly stupid) reason. More existential angst to chew on...... The good news is that "living color" are still there and thriving as they await adoption.

I went to Lobatse on Thursday this week , a national holiday and therefore quiet, to see a woman with a chronic condition. During our discussion I asked her about what it was like growing up in the area before paved roads, piped water, reliable schools and the like. What did she enjoy then, what was it like? She misted up and got a far away look in her eyes as she described a pastoral life that was as fun as it was dusty and muddy. Her parents were members of the ANC so they had to be careful of assassination by the Afrikaners from just over the border, 15km away. An amazing life.

We are in the dry season where everything is covered with a fine layer of dust. Interesting that the high end cars, of which there are more here per capita than any other place I have been, are all dust free. They are cleaned daily by the "help".

And to think that the people that have made it to 90 y/o have lived more that twice their life expectancy at birth. They have endured amazing hardship and don't view it that way at all. They have had a rich life and are rock hard. Incredible.

Somethimes you eat the bear...

Sometimes the bear eats you....chews you up into little bite size pieces, sucks the marrow out of your bones, and spits out,...well, you get point. This was one of those weeks where I truly wondered whether I was making a difference that was worth more than a bucket of warm spit. Was I truly "capacity building" or just thinking so.

I began the usual road trips to the usual district hospitals and basically heard the same song and dance at each one. Now Matt and I have emphasized the early diagnosis and emergency treatment of sepsis at least twice a month. It is rampant here what with a huge HIV prevalence and other impediments to care. Given the nature of some hospitals here one is at more risk in one than out. So Wednesday we heard about a man admitted with an unrecordable temperature (that means under 35.5C), an unrecordable blood pressure, and pulse of >110. I exchanged a look with Matt, one of "are you effing kidding me??!!" After everything we have tried to emphasize about this disease?! And here we are listening to the vital signs of a patient circling the drain, from three hours ago?! I have made some sweet saves from this disease, mostly in kids. Adults are easier. And no one got up and went to this guy's aid. It was cold outside about -5C, the rooms are unheated and after the ABC's come warmth! There is no way this guy could have warmed himself up with a blanket.

I went off to round in peds as I thought I'd just go ballistic if I went to the ward of this guy. Matt went and started the requisite lines and meds on this guy He even sent me an SMS to let me know he was on it. Regrettably is was probably too late. That steam from peds? Me.

Then yesterday I heard the same song and dance at another district hospital and found the same mess, except I had the privilege of watching him take his last breath. We had a nurse come into the docs room asking for help with an emergency in the OPD. No one moved, including me as I wanted to see if ANYONE was interested in the entreaty of this triage nurse. Nope. And this happens everywhere; the US, some of the-off-the-grid places I've been, everywhere. So I stepped outside and went down to the OPD. I had given a presentation on status

epilepticus (seizures that don't stop) that morning, just 20m prior, and low and behold the guy there was in status! A great teaching case but for the fact that there weren't any other docs there.

The nurses had done a fantastic job with this guy, had assessed that he was in status, and had given him first line therapy. They even had performed a rectal and found a worm which in essence made the diagnosis . I congratulated them and they sighed that they could really use a cup of hot tea. I told them I had some hot coffee (can't have caffeine dysregulation doncha know) and they drank it with relish.

Then today another place another patient with the same HIV and same unnecessary sepsis. She, a beautiful 16y/o with HIV, will die. That coupled with a Monday wherein I was a small part of one of the worst medical experiences I have had (I simply won't/can't bear to get into it) and a Tuesday that was equally awful, and the bear had me good. Hope the bastard enjoyed every bite. Maybe he'll get septic, wouldn't that be justice.

" Mike, do you believe in God?"

Again first things first. I had a gas in Atlanta. Swam lousy but really loved seeing my swimming friends and community. And getting away from medicine is always healthy in a weird sort of way.

There are some certifiably FAST master swimmers out there. The so called fast suits are tight girdles from which oozes well marbled flesh causing, as Bill so aptly puts it, wives to laugh themselves silly and children to run into the night. And they really don't make a difference. I, again, got vertical in the 100fly, a big no-no, and was headed to the light. My teammates were all lined up to cheer/groan as I dropped my by now leadened legs and couldn't get my arms, or for that matter brain, to cooperate.

Bill, MJ and I finished up the experience with a great carnivorous meal at "Fat Matt's" rib place. Picture a shoe box shaped building you can smell before you can see. You get in line and order, and enjoy some live blues from one end of the place. You see two guys enter the back door each with 12 loaves of Wonder Bread; truly authentic. Bill and MJ ordered big meals o' meat and I ordered my favorite, a pork sandwich. It tasted fantastic and I was having a great time, until my manhood was questioned, again, by my "friends" and for that matter the staff. It seems I only ordered a "small" sandwich. The woman behind the counter shot me a "you'll be back honey" look. And I was. Conversation stopped as I dove into some amazing ribs. That and beer. Did I mention the beer? So much better than here, and there you have it.

Seeing Eli, Amber, Aven , Beth, and Belle was fantastic as well. Watching Belle, 15 mos (I think and hope), entertain herself with a basin of water and have Uncle Eli encourage her to "wash your bachachas" was hilarious. Beats any digital toy out there.

Then the long flight home and to SOS that week. I sometimes walk out onto the dirt field to see the starry ski and did so this night as I was hitting the jet lag wall. Out there I met Thabong, a 13yr old guy with whom we have taken a mutual shine. He was staring into the night and came over to me. I could see this might be an interesting time as he truly had a look about him that I hadn't seen.

With inquisitive and.......what, a very disarming facial expression, he asked 'Mike, do you believe in God" I did the shake and bake as I didn't want to answer before we fleshed out where this came from. He attends a private evangelical school on a very generous scholarship, one for gifted kids. So I put it back to him. "Do you?"

"I don't know." "Why?" "I can't see him." A perfect place for a thirteen year old wrestling with the angst of youth to be in my opinion. "Do you need to SEE him?", say I. And on went the conversation. He wanting proof. So I stepped behind him on this absolutely beautiful night and said, "Do you see me?" "No." "Then how do you know I'm here?" "Do you feel me close to you?" I said as I was stepping away from his turned back. "Yes." "Even now?" "Well I think so." "So you know I'm here but can't see me..." He laughed and said to the effect that he knew where this was going. And we became silent, in the cold night air, he enjoying the company of an old man. And the old man enjoying and marveling at the emergence of a young one.

Living Color

Yesterday I was at a district hospital attending morning report. The report included a child who was abandoned on the side of the road and was admitted pending placement. The child, a boy, was thought to be of Zimbabwean decent as "he is very dark". He was placed in peds to the consternation of the ward nurses there as they were worried that he might catch one of the ever present bugs looming in any ward.

I mentioned that these kids are often abandoned because the mother is overwhelmed, but also because the child might have some condition that confers high needs on him/her. So indeed we should do a careful exam to find any evidence of a congenital disease.

As we were rounding there, we went into a remote office where there was a child in a bassinet, in the corner. As I approached her I stepped over a mattress in the floor underneath the bassinet that had, I thought, a pile of blankets on it for the child above. I was getting ready to move the mattress aside with my foot, as it was clearly in the way. You can tell where this is going...The blankets moved and gave a little baby noise and I realized that this was the second child brought in last night! As always the tension was defused with laughter that a peds doc like me was going to "kick" the other child and "what, what, what".

So I put both kids in the bassinet head to toe, lying in opposite directions. The kids were children of color to be sure, African in conformation, and very different in pigmentation. One was the color of a double shot of espresso and the other a vente latte with lots of milk (or is it skinny?).

A nurse in the room remarked that these kids represented "black and white television" and then corrected himself and stated that they really were in "living color"! The laughter went on and on.

I needed that.

Kernicterus and opisthotonus (#2)

Was in a district hospital today and rounded in the peds ward. Now, as a doc, there exists a side of me that has a "life list" of pathology as it were. I see people with diagnoses that would rarely be seen in the US and "collect" them on my list. I know, sick and wrong. But there you have it, all in the name of transparency. So today we were in peds and the pathology was waist deep.

There were two kids with malnutrition and other co-existing diseases. Often they have been admitted many times with the same co-morbid diagnoses and nobody asks why. I may have mentioned that the kids here are compared to growth curves that are weight and height for age, not weight for length. So they can be happily tracking along at a low percentile, not raising suspicions and still be quite malnourished by w/l measurements. We saw both of the major kinds of malnutrition and had a long discussion about what the nutritional requirements are in theses variants of disease and why they are somewhat altogether different, not unlike diabetes type 1 and 2. Both are wasting illnesses with different manifestations and nutritional therapies.

Then we saw a child with a constellation of symptoms that medical types in the States spend a lot of time worrying about but rarely if ever see. This child was admitted with "pneumonia", an all too common diagnosis, one I/we frequently "undiagnose". In the process of discussing the situation, the mother volunteered that she had taken the child to an ophthalmologist for an eye exam and had been told the eyes "were just OK". As we looked at the child I noticed some slow grimacing and posturing called choreo-athetoid movements. His eyes were averse to upward gaze to the extent that he looked so far downward his pupils were buried in the lower lids. And his mother reported that it seemed as though he couldn't hear. She then volunteered that he was admitted with a post birth bilirubin that was 36 times normal. He had all the cardinal signs of kernicterus. This is also a true bastard; his fate is sealed. In the States there is a lot of preoccupation about this very rare ( in the Western World) complication of bilirubin metabolism. But this is the first case I have seen.

Then it was opithotonus, again. A child that was in the ward a week ago with this was now on ATT but was still in great pain and distress. I asked to take a picture as this was on the list but I now have seen enough that the novelty has worn off.

Then a young boy with monstrous neck nodes that, I think, were misdiagnosed as extra pulmonary Tb. We wanted to take him to the OR ("theatre") but the anesthetist was resistant. There was a bit of gesticulating and animated conversation following and she called PMH (now called the "Hospital of Death" in the local media, well deserved in my opinion) and they accepted the child in transfer to undergo anesthesia by an anesthesiologist. The nodes should explode and reduce in size significantly. I'll really be surprised of this is Tb.

More for the list.

Ntlantle and a caboose

For some reason we seem to see a fair number of malnourished kids from this village. The discerning reader will recall that this was the place where I and a nurse resuscitated a child with sepsis. He and his grandfather showed up on the doorstep of the outpost there with initially, no one but moi to get started. And it went (well) from there.

This morning I was again in Lobatse and was asked to do business rounds wherein one rounds on those that need it only as Thursday is a day for the staff to pursue other areas of medicine. The staff there has been reduced to four from ten earlier in the year so they are beat and desperate. I saw a bunch of difficult cases in the male and female wards, maternity, and Tb. We saw a critically ill woman with cryptococcal meningitis (a real bastard when your immunity is wracked by HIV) who was not responding to therapy. When it has been longer than two weeks and the patient is getting worse one needs to think about Tb meningitis. So we started her on ATT and moved on. In the States she would have had a zillion tests and, cynically, the end result would have been the same.

In the process of rounding on her there were about 10 nurses and students watching me (old white dude that I am) and I thought I'd engage them in a conversation about withdrawing care. Well didn't THAT just put a nickel in their collective slots. Away we went; murder, euthanasia, cruelty, and even felony. It is unlawful to withdraw care here, I knew that, but wanted to discuss not adding any additional care. A big time clash of cultures. Most would "do anything" until the patient is "late", satswana for death. It was a great 30min.

Then on to peds. There is a little newborn boy there who was no sooner born then his mother "absconded", leaving the child at the hospital. Every time I'm there I play with him and he, just like Empho, is thriving thanks to the excellence of the nurses. They call him my "son" and are always asking why I don't adopt him. I confess that Lynne would in a blink, not a good idea at our age but never the less a temptation. And it is not only unfair to the child but as I understand it, against the law for a non-Batswana to adopt in this country. And it should be.

While there I was asked to see a 4mo old girl who was from Ntlantle. Her mother was dutifully with her at crib-side. One look and I knew that whatever the admitting diagnosis was, this child was severely malnourished.

It is very important to take an accurate history about food security with each mother or parent equivalent (often the grandmother) of a malnourished child. This child was the caboose in a family of five kids. It is always the caboose that is the most vulnerable in a family with an insecure source of food. After starting our inquiry the mother responded that she ate three times a day and cited what food she ate and when. She described what her kids ate and that they all ate a meal at school. Time for the true art of medicine.

I gently inquired if there were times when she didn't eat because of food shortage. Yes for two days at a time. You could begin to read her body language; despair for herself and her beloved children, fear that her child would be taken from her, and all these conflicting emotions in the context of her own huge protein calorie malnutrition. Makes me tear up just writing this. As she turned away and started to cry, we ever so gently continued. Her mother lived with the family and it was she who got a monthly pension, the only income the family had. The food gaps were two weeks long and she simply felt horrible about it. The nurses took a weight for height (a true coup as this has been a subject of conversation for months) and we found that she was 70% of normal weight for her length, severe malnutrition. More to the point; acute on severe malnutrition.

Now the only way to get to a child, loved and cherished by the mother, is indeed through the mother. We explained to her that she was a good mother, if not overwhelmed, and that her custody wasn't at risk. To which she burst into tears. Man I was shook and still am. A great moment to remind me why I do this. We will feed the mother along with the child and will make sure that food is more available in a better balance. In Sudan the mothers were as beat as the kids so we always fed them up as well and gave them a months supply of food on discharge.

On the way home I was able to reflect on the moment. I am a point of care doc, perhaps not a programmatic one, as intimate care of people is what I enjoy most. The stories, the excitement, the rewards, the victories, the fall flat on your face losses. Gotta get back into MSF again. When?

I "might" have been chased by a hippo

But more on that later...

First things first. Forrest and Shannon left last Tuesday and it seems so long ago. As with Eli and Amber, I found myself asking "did that really happen?" They came on a Sunday and Monday was a rest day. These guys have been sleep deprived for, oh, the last two years. And if anyone needs sleep it's those two. So Lynne's instructions were something to effect of "listen you early riser, if you wake them up as you slam around out there...." She didn't finish her warning and didn't need to. I got it loud and clear. At first they were up around the time I was (0530) due to jet lag, then they progressed to sleeping the clock around.

On Tuesday we went back to Chobe and "had" to duplicate the trip we had with E&A. The weather was rough the week before as it is Fall here. We had the first crystal clear days in weeks for our visit. Picture a gorgeous October day in Hood River, you get the point. We had a game drive in the morning where we were effectively skunked. F&S were good guests and said that it didn't matter. It did to me.

That afternoon we saw a mother hippo and her adolescent calf in the creek that runs through the hotel area. She would snort and sink, snort and roar, and sink. Her calf was hidden in the bushes near her but was almost invisible. We then went on the most amazing river cruise. As before we all hopped in a boat with dozens of others from around the world (is there a LL Bean in every country?) and went up the river to see the sights and any animals that were on shore. It had been hot but now the sun was setting and it was turning cool. We saw many crocks on the shore cooling off, a gillion hippos and too many to count elephants. Cape buffalo, impala, kudo, gemsbok, baboon, more elephants, and more hippo, fish eagles, beautiful birds. The sun set and it was just magic.

That night I was able to resist the dreaded buffet monster. Tempting to be sure but with just two weeks 'til nats I just couldn't become well marbled again. We went for a short walk to view and photo some extraordinary spiders and see some stars. As we were on our way I noticed a group of twelve or so people off in the distance, all of them excited and pointing. Well I just had to see what all the commotion was all about so I sauntered over to see for myself. Off in the distance was a grazing hippo, on the lawn, probably the mother we had seen earlier.

As I'm sure most of you know, hippos are a cranky and contrary lot. They are responsible for more animal attacks than any other in this part of the world. And some idiot was taking flash photographs...begging to be skewered. So of course the hippo snorted add made a mock charge. Now these guys can go from 0-60km/hr in a blink. We all backed up and I found myself next to the same idiot who again took some flash pics. Real dumb. And I found myself standing beside him, also reeaal dumb. Still I thought all I have to do is keep the flasher between me and the hippo and I'm safe. Darwinian selection at work doncha know.

Well this time the hippo was appropriately upset and charged again, but we couldn't tell if it was a mock charge or the real deal. I thought it was probably of the mock variety so I was a touch slow on the uptake. When she didn't stop, and was about 10m from us, I took off up between some buildings with idiot close on my heals. The space between hotel buildings was a tight fit and wouldn't admit a hippo, or so I hoped. I ran out of my sandals and might have sprained my ankle. My first thought? Not "that was close", it wasn't. Not "that was so cool", it was! It was "this is really going to eff up my nats!"

Forrest came to my "rescue" and was amused until we got back to our respective wives tapping their feet, arms crossed, glaring. Then he was on their side! Safe to say there weren't any couches in the rooms or I would have had to cram myself onto one for the night. The alpha female was upset.

Next it was off to Victoria Falls. As it had been raining for the previous week, and the river was way up we had a difficult time seeing all of the falls for the spray. But could we ever feel them. Not unlike the feeling you get when a crack of lightning is followed by thunder that seems a touch too close. What power and sound. We of course got soaking wet and then mutually (OK, Forrest and I did) decided to cross the "Amber Line" at one of the lookouts. But just by a meter, I swear Amber.

We went home to have the most rain and cold in a given week that Bots has had in quite some time. THAT really messed with my training. On went the farmer john and out went the sea anchor. I was reminded of the t-shirt at masters meets that says "I'm old, but I'm slow". I also like the one, "The older I get the faster I was". True that. My pace was more appropriately timed by a calender. I had to add at least 10s per hundred to even stay within a set.

This week has been great medically. I was in a primary hospital and was rounding on a woman who was having seizures that we not well controlled by medication. Interestingly she was fine after the seizure which is a touch unusual when they are major motor type; no loss of consciousness, no post seizure disorientation or lethargy. In the process of examining her I noticed her face was without expression and she had some cog wheeling rigidity. We got her to stand an she had a wide based, tremulous gait; Parkinsons disease. That explained her "seizures" and her level of consciousness after.

Every once in a while I can overcome my lamictal brain and make a clean diagnosis. And she had been in the hospital for two weeks! The third doctor to round on a patient is always the smartest as s/he knows what the diagnosis, or treatment, ain't or ain't working. This time I got to be the third.