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.