"Not eating"

Like many places including the US, someone always knows someone who knew of someone that had symptoms similar to what they are currently experiencing---and then turned up dead. Not unlike when a random test (read PSA) finds the odd cancer and soon everyone wants to buy a PSA, regardless if it has a ounce of evidence to support the idea.

We saw a gentleman in Lobatse who presented several months ago for "snoring". He was apparently wondering if this was a "problem". Well the MO at the clinic decided to 1) try a course of antibiotics that just made things worse as they selected for a resistant strain of staph (yes we have it here although thankfully very rare), 2) got a sinus series from a machine and tech that are really old and very new respectively. The films were unreadable. By now the MO was really feeling pressure to "solve" this and ordered a 3) chest X-ray.

Now I spend a fair amount of time explaining to the MO's whom I mentor that one shouldn't go on a fishing trip unless one knows what to do when one actually catches a fish, i.e. don't get a test unless you know what you'll do with the answer. A negative test doesn't necessarily rule out anything or for that matter rule something in. So low and behold the CXR came back with a large "mass" in the area between the lobes of the left lung. He has undoubtedly had this for quite a while and of course is totally fixated on it. Not unfamiliar to those of us in primary care. What to do?

So the initial, trivial complaint is lost and were pursuing not a horse but a zebra! Happens everywhere.

"Never have two Nigerians in the same room"

A week ago Friday I visited Kanye as per usual. I had a feeling the presentation for that day would be met with a lively discussion as the staff there is both bright and a not a little outspoken. Since the topic was delirium I knew that this would make for a lively conversation. At the end of the case presentation I asked if anyone had any questions or comments. And did things ever take off.

I always subscribe to the notion that there is generally more than one right way to do something in a medical context; from diagnosis to treatment the circumstances are so variable that it lends itself to anecdote over evidence. There were three excellent physicians from Nigeria in the room. One was clinic based, the other two were on the hospital staff. One offered up and idea that was a touch off the beaten therapeutic path and I offered that it might be a better idea to do "X". The outpatient doc scoffed and said how it was so obvious that what I said "was true" ,that only a bonehead would miss that. And while he was on the subject, and had a full head of steam, he began to comment on the difficulty he has/had in routine referrals. "Oh yeah, well how about the stupid referrals you send us without even a referral note or phone call?"

This was great, I smugly told myself. Before I came the two separate staffs were not interacting like this and feelings were scorched or ignored out loud. But things went south from there; to football, to "exactly where in Nigeria are you from and what medical school did you attend", to loudly discussing who was going to win the World Cup. I got a little uncomfortable and tried to intervene such that things would at least get back to medicine. Yeah, right.

Things became even louder. I raised my voice in best impatient father/attending posture and attempted to gain control. Nope, wudn't gonna happen. Finally one of the guys stopped and laughed, confessing that "Nigerians love to argue" and "never get two of us in the same room and bring up football, women, or medicine" Got it.

100% of the women on the wards that day had HIV. The concurrent and co-morbid diseases that these heroic women had were of course devastating. Yet their quiet stoicism was remarkable. Usually it's the women that make an outpatient environment so difficult as there is so much somatization and outright malingering. Without exaggeration they might have six different pains for which they want/demand "treatment". And if it is denied, rather than face the embarrassment of their peers out in the queue who did get treatment (read "tylenol") they yell to us "you want me to die!" We of course gently deny this and things often spiral down from there. Ask any outpatient doc how many of their patients truly don't or didn't need to be seen on any given day and it will be in excess of 70%. This dates back to the 40's through the early 60's when Western style doctors/evangelists came here with two agendas; treat and/or recruit. On the treatment side one of the secondary agendas was to evangelize so the path of least resistance became "treatment". And here we are.

Long time residents will say that this mind set of treatment for anything at any time pre-existed the missionary movement. And perhaps it did. What they did here was heroic in its own right. But not without consequence and the "you want me to die" paradigm might be one of them. Buy I digress...

When someone here is truly sick, one of the most telling signs is that they are very quiet, stoic, and patient. The biggest challenge is to pick them out of the queue such that they are seen more expeditiously and "treatment" is administered. As I've seen all over the world, it's the entitled ones that are the least sick but might be the most worried. The quiet ones are the most sick and might be the most entitled.

Amazing what a little sugar will do for a 4 yr. old

This won't be one of those offer-a-poor-child-a-sweet-and-have-a friend-forever kind of story. It is amazing how ADHD crosses cultures. In the States we tend to give names to many behaviors so as better to validate the parents notion that their child has special needs. And many do. And many parents are complicit in this.

Today I was asked by a colleague in Lobatse to see a 4y/o boy who was apparently having "fits" in that he would sleep so soundly that he would urinate on himself. As we (med student, resident in FM, and medical colleague in the FM residency in Stellenbosch) walked into the room the child erupted and in no time had the place torn apart, had slapped us, bit one of us, and payed no attention to the entreaties of his mother to stop until he was given some sweetened juice. Then he spit through the straw and spilled the juice all over the room.

I did the usual history and PE. It turns out that he might have been slow to breathe after birth but that of course can't be quantified here. He appeared to have a touch of microcephaly and was truly off the wall hyperactive bonkers. I said "lets see if we can gain his attention", a true diagnostic branch in the differential. I held he head in my hands, raised my index finger in the sign of the alpha male and said with a loud and firm voice, "NO!" And he melted into my arms, whimpered, put his thumb in his mouth and wuzzed my arm, hair, ear hair (needs to be trimmed along with my nose hair), and head. Quiet...

And then after about a minute resumed the bonkers part. I mentioned the prognostic benefit of being able to gain his attention and congratulated the mother on her caring of what must be a difficult child. Turns out the only reason he sleeps so soundly is that he rarely sleeps! And when he does it is the sleep of a 4y/o that is dead to the world, enuresis and all.

As he ran around the room hitting us I emphasized the need and use of consequence behavior as it provides structure and a set of guide posts for a 4y/o boy. As he hit, I would restrain him between my legs. It he hit me, he lost the privilege of using that are for a moment simply to reinforce the notion that while consequences can suck they are never the less every where and we might as well start now. As I was discussing this he got so wound up in my arms and lap that he urinated in my lap. Good thing I have Walmart pants that are basically a suit of armor; hot as hell in the summer, but shed water for some odd and helpful reason.

His mother was aghast that I could "make him behave". I pointed out to her that she indeed had her hands full but with a little planning ahead at least the inmates wouldn't be running the asylum.

He obviously needs some medication help but it continues to amaze how the path of least resistance compounds this very vexing problem. And how it crosses cultures, ethnicities, and genders.

I excused him and his mom to write the note and discuss the case with my colleagues. After doing so we walked out into the hall and noted that his mother was again bribing him with some sugar cane! Sigh....and the cycle continues. Like putting a coin in his slot, the hallway and the patients there were not enjoying it.

Please see the last title....

Eli and Amber visited here two weeks ago and did we ever have a hoot! They came to Johannesburg on a Saturday, we stayed in a hotel right at the airport and spent the evening story telling and catching up. That night we went to dinner where I enjoyed over indulging in the "dreaded buffet". More on that later.

Next day we were chatting so much on the drive home that we got a touch lost. As we pulled over to check a map, a guy in a Beemer slowed and pulled over in front of us. As he got out of his car he flashed us his "badge" from one of those classic folding wallet thingies that you see on all the detective shows. He approached us and stated that is was "against the law to stop on the side of this road" and that he'd " need to "see our passports." This is such a classic ploy, to take possession of your passports and then ransom them back to you. "OK but may I see your badge first?" say I. "What, you don't believe I'm in the South African Police?" All of the police on patrol are in uniform, in marked cars and will show their badge unless they are undercover. And wouldn't waste their time with a guy like me. By now I've had a good chance to look at his "badge" that was sticking out of his wallet thingy. It was plastic (!) like the kind you get at the toy store. A classic stand off. All the time I was thinking I would resist unless he pulls a gun (there are over 40 homicides in Jo'burg a day according to Wikipedia). No gun and he ultimately backed down stating "Thank you very much, enjoy your day, and you will be shaken down on the main road." Unbelievable.

We went back through Lobatse where my friend Roger chaperoned us around Athlone Hospital, the oldest in Bots, giving Eli and Amber a sense of health care in the rural areas of Botswana. Then home to dinner, sleep and trying to shake jet lag for E and A.

Next day I had some admin stuff to attend to and we prepared for our trip to Chobe. I think I may have summed up our trip to the Okavango the same way; WOW! We stayed a 4 star hotel, a bit of a reach from my local dive preferences in the States (where else can you make some friends and sample the local illicit crank and coke?). The hotel backed onto the Zambezi; full of hippo, crocks, birds. Beautiful. All meals were buffet style and yours truly is now 4kg heavier and much more well marbled. We went on several safaris and were impressed no only by the animal life (there are more elephants there than any other place on earth) but I was amazed at the safari clothing that everyone had. There were people from all across the planet and had all stopped into their local L.L. Bean buying the place out before they came. Eli and Amber were ultimately a bit amused that I chose shorts and the ever present grey T-shirt. But hey, at least I could be easily identified in that crowd. The best experience was a river cruise at sunset where we saw elephants playing in the water including a young one that had to be less than a month old, crocks and flood plain that were spectacular.

Also included was Victoria Falls. Now I admit that I was less than eager to go there even if it was only down the road as you have to go into Zimbabwe and I was still a touch puckered about the whole passport shake down thing (sick, I know). Eli and Amber would have none of it so Lynne booked a day and night to see it. OK so I didn't want to see one of the 7 wonders of the world. I have already said that I'm not one of the brightest bulbs in the chandelier. Again, WOW. The water over the falls is in such a huge volume that it sprays up, condenses, and rains. You can walk 2m and are in a warm Mid Western rain. Being Oregon ducks we loved it. That night the resident bachelor herd of elephants came up onto the lawn and ate, well, whatever they wanted. As did we . It might have been one of the best meals we have had; great food and company. Fantastic.

The best part of the whole experience is that we have to do it again in a month with Forrest and Shannon.

Outreach continues to reward and fascinate. I love being in the bush and teaching/relying on the instinct, reckoning, creativity that one needs out there.

I should head out to the pool. Lynne was finally able to score an entry into the UB pool. I know, not your basic "resource challenged" experience. Never the less, the 10% that one has to keep for one's self. That and I don't want to embarrass myself more than will already happen at masters nationals. Have to go work on my marbling, see ya.