Pendlehome Botswana

"Mike, you cannot die with it!"

2010-12-27T17:17:00.001+02:00

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

2010-11-13T16:42:00.008+02:00

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

2010-11-13T10:54:00.007+02:00

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

2010-10-25T17:07:00.002+02:00

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

2010-10-25T16:48:00.002+02:00

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!

2010-09-22T19:06:00.003+02:00

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

2010-09-11T11:49:00.004+02:00

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?"

2010-09-11T10:37:00.002+02:00

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)

2010-09-05T09:37:00.002+02:00

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

2010-08-19T18:32:00.004+02:00

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!”

2010-07-25T11:48:00.007+02:00

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.”

2010-07-25T11:46:00.001+02:00

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

2010-07-25T11:45:00.001+02:00

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…”

2010-07-25T11:44:00.001+02:00

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?

2010-07-24T08:34:00.004+02:00

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"

2010-07-16T20:25:00.007+02:00

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

2010-07-11T19:54:00.005+02:00

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

a desperately ill patient is presented at morning report with vital signs that are
incompatible with life or
indicate life is near an end or
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".....

2010-07-03T19:17:00.005+02:00

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...

2010-06-18T15:13:00.004+02:00

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?"

2010-06-08T17:02:00.005+02:00

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

2010-05-15T08:14:00.004+02:00

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)

2010-05-12T18:18:00.005+02:00

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

2010-05-06T18:41:00.006+02:00

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

2010-05-02T18:23:00.002+02:00

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.

A better week

2010-04-16T17:48:00.003+02:00

I visited Kanye today and saw the little guy with ANUG, who was looking much better! His cheek had gone down and while his mouth was still a fetid hole he is indeed better, but a long way from "good". No x-rays had yet been taken so I encouraged that idea and we'll see.

There has been an outbreak of Rift Valley Fever in all of the countries with which we have a border, not us. Which makes me wonder if we aren't looking hard enough or if the disease just isn't recognized here yet. It is one of the hemorrhagic fevers but is typically transmitted via handling of infected beef. It isn't Ebola or Marburg thankfully, but gives one pause to consider the situation over in this part of the world. Typically it behaves itself and looks like the flu. On rare occasion the disease can become quite virulent nasty and difficult. Rare meaning <1%.

The week has been full and rewarding. We had a chance to teach 4 students at Kanye (KSADH), two from Loma Linda in CA and two from Zambia. There were some unexpected cases of malnutrition that we discovered by actually looking for it. It made for some interesting conversation as I have been harping on this for quite some time to wit: if we don't ask the question we won't detect it early enough to interrupt it.

And Sunday Forrest and Shannon arrive! Should be a great week next. We are all due for one. Now if I can just stay away from the dreaded "BUFFET BEAST" and peck away at something only a bird would eat I can stay in training form. Like THAT'S gonna happen. Here's to you in gluttony.

Opisthotonus and ANUG

2010-04-10T14:35:00.003+02:00

The week began in Lobatse where I saw a child, one of several times in the peds ward, that had been horribly attacked by HIV and Tb. She had Tb meningitis and had an opisthotonic posture; back arched in a painful ark and unable to easily breathe or eat. She was not yet on anti-AIDS medication (HAART) as, while she was born here, her mother was from SA and therefore needed documentation that her daughter was born in Botswana, and therefore eligible. Never mind that she was born at that same hospital and this was one of many admissions. She was mal/undernourished and couldn't swallow, so afflicted was her brain and musculature by the combination of these two diseases. I placed an NG tube to start feeds while we waited for documentation that she could get HAART. I know, I didn't understand it either. And in the long run it wouldn't have made a difference.

That afternoon her father showed up to see her. The same that had dropped her off at the police station so THEY could take to the hospital. We informed him of her condition and his ambivalence was deafening. I had to leave. She died that night. Shit.

Acute Necrotizing Ulcerative Gingivostomatitis, a name that sounds as ugly as the disease. Factor in HIV and it is a true bastard. I was in Kanye yesterday and a 2y/o child was presented at morning report. We usually try to attend this before we give our presentation for the week at each outlying hospital. During the report a child was presented that had "an abscess" of the right cheek and was HIV unknown. His mother however was "late" (dead) most probably due to HIV. He, the patient, had been tested for HIV and was found to be "positive" only to have it whited out in his chart, or "card" (who the hell has white out around here other than Lynne?). In its place was "negative". Right....

In any case he looked like he was one year old, malnourished, and deathly ill. He had a right cheek that was immensely swollen and he appeared toxic as could be imagined. The culprit? Looking in his mouth I recognized the cardinal signs of ANUG; erythematous and exudative gingivae, blunting of the papillae, necrotic matter on the margin of the teeth (picture a kid who has just eaten pancakes and hasn't brushed his teeth), and teeth that are carioius to a fair-thee-well. Oh, and an odor of sewage.

I have yet to find a disease that isn't made worse by HIV and this unfortunately was no exception. I gloved up and palpated his right maxillary teeth only to have one float off in my finger. God I almost lost it. My voice cracked and I found myself tearing up as a wave of dismay, empathy, revulsion, and rage washed over me. I palpated his cheek and was greeted by the "ulcerative" component of the name, and things just got worse. He had eroded into his maxillary sinus and was a tissue paper thin bone away from his brain. All of his deciduous teeth on that side were loose, eroded or gone and I could see bone under them.

I have seen much worse but, perhaps to my credit, the immensity of that situation, now years ago, has dimmed and I wasn't prepared for how much I was affected by this child. By that morning he had been tested for HIV and to no one's surprise he was indeed positive. He was on the appropriate antibiotics and needed some x-rays to investigate whether he had infection of the bones of his face (an easy call) and how long to give him IV antibiotics (months). Not a good Friday.

And today I find myself a touch the worse for wear. So how did I handle it? I went to the pool (weird how it feels to say that we have one here), warmed up and swam a 400IM. Now I'm so baked that all I need is fork to finish me. Off for a big fat nap.

Some Vignettes

2010-04-02T21:17:00.002+02:00

Yesterday I was in Lobatse where I usually round on the pediatric ward. I feel I have something to teach and the kids are sometimes not seen for several days as the MOs are swamped. As I was seeing a particularly sick child I heard some kid-chirping from the ward next door. I turned around and saw three toddler boys, in for malnutrition and recovering well, who had all discovered their reflection in the glass that separates the two wards. Well....wasn't this just more fun than a two year old should be allowed to have! They were all giggling and laughing that infectious toddler laugh that immediately had the rest of the adults howling. Soon we were all a puddle of laughter and tears. What made in more fun is that I could see it from the "other side" of the mirror/window. The look of absolute joy that was shared between these guys was priceless.

After I rounded, I connected with my friend Roger and we worked the "casualty" (ER) together. Soon after we arrived we were alerted by a nurse that a child was "looking poorly" and could we take a look. Out into the hallway (isn't there always one in every ER, in every country?) we ventured only to find what turned out to be another in what is becoming a long line of septic kids. This one apparently had a seizure disorder and had been doing so more frequently the last three days, probably leading to aspiration pneumonia. He looked the usual for this disease; pallid, sunken eyes, temp of 35C (!), very irregular respirations, in short circling the drain.

It is always tough to get a line in these kids but after too much poking, including two IOs we (well Roger) finally got in an e.j. and I poured in fluids, gave him some antibiotics, and was reassured when his breathing became more regular. Then he fell asleep.

Today I returned to Lobatse. It is a national holiday and I really enjoy teaching/working along side of the MOs without all of the background buzz that is any hospital on a common work day. I rounded with another close friend of mine, Asumani. We first saw a horribly affected man with HIV and Tb. He had started anit-Tb (ATT) meds and had had a terrible reaction to one. The medical term for it is Toxic Epidermal Necrolysis, a term that sounds as bad as it is. Picture a man who is loosing his skin to the depth of a partial-full thickness burn all over his body including the mouth and esophagus and you get the picture. The nurses wanted to transfer to Gaborone. I assured them that the care he was receiving in Lobatse was on a par or better than in Gabs and we started to address his needs. I put in a feeding tube as he is profoundly protein calorie malnourished and simply can't eat the 3500 cal he needs per day. We changed the ointment to be applied to his skin and eyes and now hope for the best.

I went back to peds to find the child from the day before walking around and acting the willful two year old! Whew....

Another guy who was admitted with chest pain yesterday was all over the ward, with, as it turned out, nothing other than malingering. Something seen frequently surrounding a holiday.

Then a five week old with gastroenteritis and dehydration: iv-fluid-meds-ward.

I bid Lobatse farewell and went to Kanye where we had a hugely busy afternoon with a great MO there, Samuel. In came a guy with his head split open, BY HIS SON. The son had been beaten about the head and both were still yelling at each other. One of the med students asked in horror if they had been drinking to which a knowing nurse replied, "Of course they have been drinking!"

The local "beer" is a very irregular swill that is made from fermented sorghum; lumpy, and tastes like the after taste when one roops! Yes, I can say I've tried it. You can smell it from across town and on the breath (if your are brave/stupid enough).

Then off to home.

One of the true delights as I drive home from Kanye is the rural areas on the way to Gabs. I try to pick up as many hitch hikers as is prudent (the roads are full of them on a holiday weekend) and take them to their door, to their great surprise and pleasure. This of course happens only in our vehicle, not UP's ( insert insipid smiley face here). It's a fantastic way to embrace the people and culture.

I stay fortunate in all these roles; with Lynne, our kids, and here.

"Not eating"

2010-03-29T15:11:00.003+02:00

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"

2010-03-28T20:44:00.002+02:00

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

2010-03-25T17:44:00.002+02:00

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....

2010-03-20T13:34:00.006+02:00

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.

Been a while

2010-02-21T17:28:00.003+02:00

Oh wait I tried that excuse already...

I got into a bit of deep yogurt from the story, name identification, and pics I posted of "that little child in a peds unit with Marasmus" Seems that people sue for that here and that puckers some of the admin folks. Never mind that:

a) her mother died from HIV or abandoned her,

b) so did her father,

c) her brother allegedly has been seen on the streets begging,

d) she now lives in the middle of nowhere and the pics were to celebrate the fact that nurses here are amazing and that she is alive today because of them.

And of course I hear all of this second hand which is typical in our organization if not the culture at large. Nothing about how the blog praises this amazing country, just how I may have screwed up, again. OK vent over.

I have been in the pool a lot lately and have decided to represent Oregon Masters at the national meet in Atlanta. There I said it. In point of fact the pool is less a pond now that we are on the same page about chlorine. So I have run out of excuses other than I have no training partner....I know stop the whining. MJ and Bill have been great motivators and hilarious at the same time; sending me workouts with tongue in cheek commentary. I need to do more fly and IMs. I think I'll enter the 1650 and 400IM as that is where I stand to score the most points for OR. Which is another way of saying that few people in my age group are as dumb and stupid as to enter both. I did a 1650 on Friday and actually did legal turns with a pull out on every turn, all 65 of 'em. Sometimes I do more than a 1650 as I get lost somewhere around the 900 and do an extra 100 just be on the safe side. Ain't hypoxia great?

Last week I went to a remote outpost with one of my Family Medicine mentees only to find that there was no nurse for translation. So we re-traiged and discovered that most of the patients were there for the usual, "altered comfort state" and were after the African equivalent of Tylenol. They all went to the back of the queue and were furious! We triaged to the front any kid with a fever, any HIV+ patient with a fever or change in status quo, and the like. A woman who worked there was kind enough to translate.

In the first three patients we saw a young boy with peri-orbital cellulitis, an infection that can be devastating as the blood from the orbits drains through the brain and the bone there is very thin making meningitis a real threat. Then we saw a 1wk old with pneumonia, then a family with neurofibromatosis. The mother was intact but her kids were either cognitively injured of psychiatrically so. One was in status epilepticus (constant seizure), one with schizophrenia, and one who would go up to anyone and start up a conversation (something that even in this country is considered inappropriate). All had the tell tale fibromas of the face and body. These are small mole-like protrusions from the skin and they cover the body. This is of course bad enough except they can grow as tumors in the central nervous system. It is a genetic disorder that carries a risk of 50% transmission with each pregnancy and unfortunately they all lost the toss.

Never the less, a great teaching moment to reinforce getting control of ones queue. And some great teaching surrounding these disease entities.

Eli and Amber are two weeks away and we can't wait. We'll greet them, let them settle in, and then head to the north to see some amazing vistas and animals in a huge panorama. Lately the birds have been migrating and we are seeing some interesting flights of long legged cranes and others; hornbills, eagles, kites, ducks and geese.

I have been asked to present an interpretation of the effect of HIV on rural Botswana. Somewhere I got a reputation for this and will be giving it to the HIV folks at UB and anyone else that might to wander in. I'll review the history of HIV here than narrow it down to the rural impact. The real story is how HIV is affecting those that live with it and their care givers in rural Bots. These people must travel many km for care, have less reliable access to it, meds, and food. They, and their urban compatriots, are the true heroes in this saga.

Enough already. Will try to keep more up to date. Cheers!

Been a while

2010-01-21T17:42:00.002+02:00

First things first: Empho is thriving. Her "grandmother" is faithfully bringing her in for weekly weights. She is walking better and has truly transitioned into a head strong 2 year old; way cool. All the "nurse mothers" are so matter of fact about how they brought her back from the brink it amazes me, they are truly extraordinary.

Christmas Day found me in Mochudi where I mentored on the wards and then the OPD. The doc on call was very strong and the queue was out the door and down the street. I'm not sure why it was like that but maybe people thought that it would be a good day to get some attention. Once again the OPD was crowded with somatization, malingering, and the like. The bona fide pathology is usually quite thick and this day was no different with fractures, death and dying, and the like. One that sticks out is a woman who was "hit by a car" and was apparently brought in the night before wailing. The original doc the night before sent her to PMH for x-rays as she was protesting so much. She was seen by the OPD doc down there, had films that we negative and sent home. On the way she again stopped by our hospital demanding admission as she "couldn't walk". Well let's see....Can you lift your legs? Yep, flex your ankles? Yep. Any bruises? Nope. OK let's see if you can stand. And let the wailing begin. The short of the next 20 minutes was that she could in fact walk but was so deep in conversion disorder that she flopped on the floor kicking around and yelling that "you want me to die", a common declaration.

I took a break and gave myself a treat by investigating a clinic in an area north of there named Oliphants Drift. It is next to the RSA border and quite remote. I saw the clinic and the nurse that staffed it and it reminded me of how remote villages still get care that many nationalities would love to have.

Then the next day off to the States. I made to DC without a hitch was reunited with Lynne in the departure area to the tune of lots of mutual tears. Her beloved sister Terry had finally made the transition and we were/are still in bereavement. Then we had the classic situation where we boarded the plane for JAX were on the flight line only to find that the flaps didn't work, returned to the gate, and waited only to find out that the flight was cancelled. Several hours in line later we were given accommodations at a local hotel, and quite a hotel it was. Full of upper middle class people, an outdoor mall in the back street with an ice rink, and every national brand establishment (save Walmart) in the 4 block area. Every little yuppie named child was there, skating and having a great time as a parent would call out to them. Well and good, but I was reaching toxicity. So naturally I ducked into a Starbucks much to Lynne's amusement and while the coffee was welcomed and good, the toxicity went into the red zone. Not sure what I was expecting.....Called Eli and we laughed at how much of a third world hick I have become.

Next off to Jacksonville to see Forrest, Shannon, Judah, and the twins! And then we were joined by Eli and Amber! It was great. Now, I am blessed with strong willed kids who have in turn married women of equally strong will. The topic of the time was why I had "checked out" and what the hell was I going to do after my contract was completed, assuming Penn keeps me that long. Again the short of it is I GOT IT. Have no idea where the future will take us yet but the options including staying are being heavily considered. Anyone know of a town that has four seasons, is near an ocean, with an NPR radio station, great remote roads for cycling and motorcycling? Oh and has an opportunity to doctor with an under served population that would be happy for me to boogie off about every 12-18 mos to the wilds of some truly under resourced place for three to six months?

We went to Portland where we saw OUR twins and their spice. Oh and I best include yet another grand child (4 for those that are counting) where we engaged in the life of too much; food, sleep, treats, and the like. I had a chance to swim with my old masters teams in Portland and Hood River. My old lane mates put me to shame.....I saw my close friend and former partner for a cup of joe and then sank myself into my favorite breakfast at Egg Harbor. I really miss Hood River, much more than I anticipated; friends, masters swimming, the Columbia, having my choice of two national forests to see, cycle and hike. Jeez did I do the right thing?

Now it's back to what floats my medical boat and yet with a more concerted glance over my shoulder. I love the people of this great country and continue to make friends in the national population. I enjoy and hold dear our ex-pat friends to be sure but I want to miss the national Batswana. I'll be truly fortunate if I can achieve that.

3-2-1 Discharge!

2009-12-24T18:15:00.002+02:00

I was out in Lobatse today and discharged Empho. But before that I gave her some Crayon-like markers with which she colored the accompanying paper, then the floor of the ward, then ate one. Surprised....me? It was hilarious and we were all holding ourselves with laughter. Here come blue poops!

The ward was a touch crowded with kids who have measles, chicken pox, and dehydrating gastroenteritis. As she has free reign of the place, she frequently crawls into the rooms to see what is happening and in the process is exposed. An infectious swamp to be sure. So....for the sake of preventing a nosocomial infection, out she went. It was far from clean and neat as she is to be cared for by the "grandmother of her uncle". Since she will live near a rather remote clinic we indoctrinated the nurse there about how often she should be weighed and seen for follow up. I don't think this will be entirely satisfactory as rumor has it that her brother, 7 y/o, was seen on the street begging for food the other day. So the head matron has her radar on and will yank Empho at the first sign that her grandmother can't keep up with a now willful 2 year old. Who can???

Then it just might be SOS for her and her brother. Who knows. I would have preferred to send her there as she meets two of three criteria for admission; abandonment and abuse. It's unknown if her mother is alive or had HIV. Empho does not. Anyway, ain't my country and this is way above my pay grade. Hope things work out.

Was at SOS the other night and an adolescent girl walked up to me and asked "what is your name?" I replied "Mike" and she immediately scoffed. "You need a proper Satswana name". "OK how about silly goose". She glared. "Well, how about water?". Glared again; you know that thirteen year old girl, eye rolling, "I can't believe this white guy from America is such a doofus" look? "How about earth?" say I. Finger to chin she ponders and then says, "We will call you Empho!" I stifled a rather knowing grin and accepted her moniker. She then used it enough that it became rather un-unique and hilarious at the same time. Adolescents are the same everywhere...... "boundaries, what are boundaries?!

Still can't get used to 40 degree heat here at Christmas time. And yet it's rather festive to be sure. When on the road by myself I usually contemplate what I'll miss about Botswana if and when we leave here. Without a doubt it will the kind and gentle people, the smiles, the laughter, the genuine lightness of heart. There is definitely a widening economic dualism that is expanding with a burgeoning middle class, more concerned with the usual stuff (career, family, cars) than that of their countrymen. I swear I have not seen so many 'Benzes, 'Beemers, Audis, and Range Rovers as here. It makes for rare episodes of envy and self righteousness but the smiles seem to ameliorate it.

I had to be the primary physician the other day in a town that is famous for abusing the doc there. On any given morning about a fifth of the population is queued up and expect "treatment" or sick leave. As I had worked with a strong willed Motswana doc earlier that week who announces each morning that she will be the one that decides about meds and leave and that she rarely gives either, I thought I'd give it a shot. I stood beside a scared nurse who announced that there would be no leave given out that day and that meds would be given only if needed, and that didn't include your desire to have them. The hue and cry was deafening. And after that about half of the assembled crowd stomped off! The day was full of difficult cases that truly needed a doc and not more of the usual somatization and malingering. I don't get that about this culture but again; above my pay grade.

The topography here would remind anyone of the arid west or high Midwest. The flora and fauna are different to be sure. The birds are fantastic. Monkeys, baboons, warthogs, and the ever present cattle-donkeys-goats, can be seen on a trip from Gabs to an outlying area. So on these trips I get to get behind my eyeballs and realize that I have a loving wife of 35 years, a great and grown family that pays it forward, and a great job in an amazing part of the world. I am indeed blessed. Best wishes for Christmas, and Peace.

Who'd a thunk it...

2009-12-20T11:29:00.003+02:00

This has been a week to be sure. It began with the usual in the clinics here in Gabs where I do some mentoring and teaching. I had an opportunity to work alongside a great Ethiopian doc who is one of my favorites; inquisitive, sensitive, compassionate. As things wind down toward Christmas, (I must have been the last one to find out that it is now called the "festive season"), indeed this is a predominantly Christian area intermixed with North African Muslims and Indian Hindi, the docs thin out and we are generally under staffed. Even the streets have about half as many cars. Next week and the week after they will become deserted.

I was informed that I can be, or am, too "paternalistic" and that that puts distance between me and some of the MO's in training and some of the BUP docs. It is difficult to know where the line is. I think this dates back to a Monday morning report where we had had 9 deaths over the weekend with 17 admissions. Many of the deaths were reported off handedly and were certified when the patient was "cold and stiff". I looked around and was disappointed that this wasn't bothering anyone or that they weren't speaking up about it. I pointedly raised the notion that this can never be OK. Some of the patients would have died anyway to be sure, but they deserved a physician at the bedside and some could have been saved had they had a doc earlier on in the process. And that the leadership in this had to come from "us" (I was sure to use this term) as it would not come from the nursing service.

But first we had to care. After I finished this rant there was silence. And then the finger pointing began. It was the nurses, the docs, etc. The nurses are used to not having their pages answered so don't call, and the docs claim they are busy in the A and E so they can't respond or that they aren't paged in the first place; a monstrous and emblematic mess. In any case as this came across from a guy my age and since it was pointed it was apparently interpreted as paternalistic. Hell yes I was angry and dumbfounded. Why wasn't anyone else? So deniability is automatically built in if it comes from a "paternalistic old, angry man". I'm still not sure what that means except that I am old enough to be the uncle or father of all the trainees and younger MO's in the health care system, or at PMH, or at BUP for that matter. And dysfunction continues to reign supreme. There are providers and colleagues that are gifted and highly capable to be sure, yet I have found the delivery systems to be increasingly burdensome.

I fear we aren't building capacity (read rehabilitating) here as much as participating in a westernized agenda of rescuing. At this point I have a better idea of what doesn't work that what does. Building relationships is difficult to quantify and yet that is what I do most of time. Never the less in a grant based program it is important to quantify what it is we do. I haven't found the appropriate way to do this and it becomes frustrating to slowly realize that this might not be what I originally signed on for. I have no problem with those that do enjoy this and have a passion for it; it just isn't this aged doc's idea of practice.

And moving back to the States isn't as easy as it might seem. I love and miss my family to be sure. And I love clinical medicine, especially the creative, working without a net part. Things in the US were dysfunctional enough that I felt suffocated. And the pathology often bypasses me or the etiology is based in overindulgence (witness metabolic syndrome). Add that to entitlement and things rapidly stopped being fun and engaging. Here and other places I at least get to do the following:

I was at a district hospital this week and heard about an 18m/o that came in very dehydrated and probably septic. The resuscitation was great; fluids and meds by IO, somehow including D50W in small boluses. I was asked to review the patient and did so. All the MO's dropped by peds and remarked how much better he looked. I thought great until I noticed that he was still breathing rapidly and deeply. By now he should have been back to base line respirations with a pulse that was normal for age. I started to connect the dots in this aged, Lamictal affected brain of mine and asked for a finger stick blood sugar. It came back at 5x normal.

Ohhhhkay now we have a better idea of the what and why. Let's get a quick UA as we can't get a bicarb level, let alone an ABG. The UA indicated a pH of 5 (acidotic) and ketones were 1+ with glucose of 3+; a slam dunk; DKA. So I shipped him to PMH as they have pediatricians and better lab support. Nowhere in the US world of primary care would I have that chance to diagnose DKA with a minimal amount of, or no, lab support. We could have treated it but I had to leave that afternoon and I/we would have needed to check on him q30m. It was a great teaching opportunity, and exactly how can that be quantified? Or, perhaps more to the point, where in the US could I duplicate that?

Time here is flying by as I get to live in the present. I am working with some truly brilliant and gifted docs, for many of whom this represents their first career move or they are in the first 5-10 yrs of their career. I'm not and this is becoming a bit of an issue I fear. Time to wait and see I guess.

Best to all for a festive season!

GREEN

2009-12-04T20:54:00.004+02:00

Everything is green! We have had some sustained rains and some hard hail, the size of marbles that dimple a car roof or hood. As a result things are green, damp, and humid. What once was brown is green and all Botswana is glad for it.

One of the interesting things about this place is that it in some way is held hostage to its own lack of food production. Some say that 80% of the food stuffs here are imported. Much of the cereal processing occurs here, much of it in Gabs, but most of the grains are grown elsewhere. The farms that I can see from the air are all subsistence type. We can sustain our own eggs and beef, a LOT of goats, but no significant and sustainable fruits and vegetables. Currently it is kale and cabbage season so much is bought from road side stands (called tuck shops) or harvested at various prisons where it is grown to keep the prisoners occupied.

Yesterday I was rounding on the peds ward at Lobatse (Athlone Hospital), one of my favorite. Recall that this was the place where we had a septic man on the ward and it was met with a touch too much ambivalence to suit me. I had just given a presentation on it and I thought we had this diagnosis well worked out. So onto peds I go to spell the CMO who is up to his "waist" in alligators. First thing I see is an infant with sunken eyes and panting, admitted two and a half days ago with gastroenteritis. She was in deep yogurt to be sure.

We weighed her only to find that she had lost weight since her routine weight 2 wks ago. Starting to sound familiar? She had a temp of 39C, a pulse of >140, and R's of 40. Dehydrated to be sure but truly this was sepsis. She was being hydrated with half strength solution, not the right stuff, and not doing well. I switched out the IV to saline and promptly discovered that her IV site was toast. I tell you I cannot devine how the staff can start IV's on these hypotensive, chubby, African kids. They have the touch and I don't that's for sure. So the nurses brought everything needed for another "cannula" and gave me that "you don't think I'M going to start it do you"? I proceeded to turn this little girl into a pin cushion, finally getting one in her foot.

By now you know the rest of the story; in goes 20ml/kg in a bolus than a flow rate to account for her at least 10% dehydration and baseline fluid needs, and a quick change in antibiotics to get after the things that cause sepsis in kids under 1 y/o. She did her part and promptly fell fast asleep and awoke cooing and hungry. Was a great teaching case in that it so very important to track a daily weight and take accurate intake and output. Oh and diagnose sepsis early and come after it with fluids. A sweet save none the less.

The little girl with marasmus-kwashiorkor is thriving. She is stimulated no end at the nursing station. She is 2 and learning to walk for the first time; and having hissy fits when she doesn't get her way. All of this is to the delight and squeals of laughter from all the adults. She no longer has the "1000m stare" and is engaging with everyone. I held her and she promptly inspected my goatee and arm hair, again to the delight of amusement of the nurses. She might wind up at SOS which is cool in and of itself. Her name by the way is Npo, "gift". Truly.

Rumor has it that she'll be around at Christmas. I probably'll go up there and play with her, show her how to use, hopefully not eat, crayons and generally carry on. Then it'll be over to Mochudi to work in the OPD with the MO on call as the pathology there is always thick and fascinating. And then the next day, I to head to the US!

The two steps back part...

2009-11-26T14:48:00.012+02:00

Admission

There is a little girl that has been on the Athlone (Lobatse) peds ward for a month with both kwashiorkor (protein calorie malnutrition) and marasmus (all calorie malnutrition). These kids are a nursing challenge but as each is a mother or a sister they have done a magnificent job. She has done wonderfully and the nurses are teaching her to walk in a walker, eat, and coo. Her hair is coming in black underneath white now which is why the nurses shaved her head! She is a hoot and has recovered nicely. And can really chow down. And I finally learned how to upload pics so here she is.....

Today was Lobatse day, a day where we usually begin with morning report. As I was reading our handout trying to ready myself for the presentation to the medical staff I heard out of the corner of my ear that there was an HIV+ man who had been admitted for suspected pulmonary Tb. This morning he was reported by the nurse with the softest, rather ambivalent of voices to have "no measurable temperature and no measurable blood pressure." Yet he had respirations of 20, and then went on to the next case...

This got me to look up and inquire again about the guy as I couldn't believe my ears. She reviewed the patient and I unfortunately lit up. Uh, sports fans whatever he was admitted for is mute, HE'S SEPTIC. They acknowledged that, well, that could be why he was hypotensive and hypothermic..and presented the next patient. I blew a gasket as I had just presented sepsis as a topic for discussion within the month. "He could be dead by now". No movement to the door. "Why isn't some one going to check on him right now?" Again shuffling but no movement to the door. I guess this is the "one step forward...two steps back" part.

I picked up my stuff and headed for the door. By now I had raised enough of a point that another MO came with me. We first checked the VS again and they were worse. Then started two iv's and poured in 4L of saline from which he began to recover and had a measurable blood pressure. I spoke to the Matron (nurse in charge) who expressed frustration that the docs often don't come so the nurses don't call...and hence the nurses are less likely to do so. We'll just add it to the list.

I "MacGyvered" a tool this week to pull a faux pearl from the nose of a two year old. Well what else do you do with one of those things if you're two and wonder what happens when? Normally the child is sent to the ED to be consulted by ENT and then with a lot of fanfare the foreign body is removed. Well why go the fetid hole that is PMH, although the ED is good, when one can remove it here? Out comes the Gerber Tool and a paper clip. In a minute we had a curette and in less than that out came the pearl, sweet.

The rhythm of the place is becoming familiar. Many Batswana speak at the same time and loudly. If the cadence is from LOUD to soft with a descending tone it is generally an important point. If the last word is higher pitched than the one before it, than the speaker is serious. Better than "upspeak", if you ask me? Enough, got to roast some veggies for a dinner tonight. Happy Thanksgiving!

Random randomness II

2009-11-25T16:31:00.004+02:00

Mondays can be rather long (a schlep as Matt would call it) but they finish at SOS; a good thing. Last Monday I brought two hula-hoops, two jump ropes, a soccer ball, a whiffle ball and bat, and assorted other out door things for the kids to play with before it got too dark. They'll play way after dark but we try to have some simmer down time before they head to bed.

On occasion I'll wander to the side of the playing field (read large dirt football field) and enjoy the sight of the kids playing and laughing. Everyone here laughs even if it is a difficult situation. The usual response is not to get exercised about it but to laugh. As I was enjoying the sunset and the moon rise two kids came over to me, each about 8-10y/o sat down with me and proceeded to "inspect" me. I have taken to shaving my hair, what there is of it, very short and they love to run their fingers through it and feel the texture of short European hair. 'Course they won't hear me complain as it feels wonderful and truly is a "bucket filler". Then they examine my arms and runs their hands up and down them to feel all the arm hair, something that most Motswana don't have. THAT feels fantastic. Then lift my shirt to look at my graying chest hair all with the most innocent of intentions.

I banged up my leg (getting out of the pool-pond no less) and have a bit of an abscess that I finally treated with antibiotics after draining it three times. Man that hurts but it's easier than finding a doc that can do it for me and maybe just a touch cleaner. Anyway after draining it I rap it in a tight bandage to avoid accumulation of goo and hope the goo won't return. As I had the bandage on they were interested in what was under it.

Well, OK, so I took it off and showed them. They were genuinely saddened that their friend had this and expressed that I "should see a doctor". I told them I was one but that wasn't satisfactory and they told me again. Something tells me that they had somehow been in communication with my family!

I was out of the pool for a week and resumed yesterday. I am definitely a nicer guy if I swim. There is talk about using drivers and state vehicles to deliver us to our sites. This will really cramp my style so I have been more that a little hyped up lately, I feel like a I'm a touch "toxic" and in need of a break. I'll wait until 26 Dec for that. Maybe drive some back roads to out of the way places 'til then.

Things have changed here in the office, generally for the better. We have a huge staff, many of whom are Motswana. We now have a large document that outlines the conditions of employment. It's seems interesting that we spend so much time protecting the entity that is BUP when I'd much rather spend that time protecting and treating their countrymen.

The currency of visits to the doctor is still pain and the currency of treatment is still acetaminophen. People will complain of six kinds of pain to get 7 paracetamol (Tylenol to the US). I gave a talk on malingering, somatization, and conversion disorder and it was well received so maybe we'll start to call it what it is, not the symptom.

That's enough for now, best to all who read this and celebrate Thanksgiving. And to those that don't!

3 grand!

2009-11-14T15:05:00.002+02:00

Made it over the hump! Weren't pretty, weren't fast but there you are.

Oh, and that 7 mo old septic boy from a week ago Friday? Went home from Athlone Hospital in Lobatse on Wednesday wondering what the big deal was all about. Nothing makes me feel better as a doc.

Made it to 2800m!

2009-11-13T20:52:00.002+02:00

The week began with yet another case of sepsis and, well, you've already heard way too much about this.

Tuesday we flew to Hukuntsi, worked in the OPD and saw some cool peds cases.

Wednesday we went on outreach to a remote clinic in the Mochudi area and, thankfully, it was slow. I had a chance to discuss the future with our boss, Harvey.

Thursday was Lobatse where I transfered a child with what had to be a brain abscess to PMH. I round on peds there as they are so understaffed. Some of the kids aren't seen for three days.

Today was outreach with one of the residents I mentor who is also an MO so I can serve two masters at once. It was great fun as it was, of course, off the beaten track.

Then today I took on a swim set written by my old (well not "old"old) lane buddy at CGMS, the marquis de swimming, Bill. Kicked my sorry arse into next week. I think I just now have a pulse under 100.

Gotta eat some apple cake, I deserve it. I think I'll eat it out of the pan with a fork, less effort.

Cheers

Scratching that creative itch..

2009-11-07T10:10:00.003+02:00

One of the fun things about outreach is that I get to be more creative than in the US. We were unable to open the top of the antibiotic so out comes the mini-Leatherman and off goes the top. No scissors to cut the tape (there never are) so the Leatherman again. When the ambulance didn't have an IV hook (they never do as they are generally stripped of all equipment) out comes the Gerber tool. I cut off a strip of metal fence and a minute later there was the hook.

Fun and (it's not really an over statement) life saving. And a hoot!

Batting 1.000! Well make that .750 if we include Lorolwane

2009-11-06T21:48:00.002+02:00

Three up, three still up! Let’s begin from the end.

Just so I’m clear; there is nothing as fun and rewarding in my profession as pulling a child back from the ragged edge. Today, Friday, I had a little time on my hands to explore some clinics that I might visit in the Kanye District. On the way out to Kanye I always pass a cool little town named Nthlanthle, pronounced with clicks. Kinda like your tongue is disarticulated at both ends. It has a clinic outpost staffed by a nurse. I found it and parked outside the now empty clinic and walked in, saying the Setswana greeting for “hello”, and no one was around. This is usual on a Friday afternoon as the nurse who works at these outposts generally sees patients in the morning and they thin out by 1:00pm. I showed up at 1:30 to an empty clinic and nosed around into various rooms seeing what they had to offer and how I might help them.

After the tour I walked outside to see a grandfather cradling a young child who looked big sick. Now I always emphasize to the staffs at the various places I visit that “sick kids look sick” and this child was going to the light. I thought ‘how the bleep am I going to do a resuscitation on this little guy here if I have no idea of where things are kept?’

The nurse came along (they usually live on site), I introduced myself, and we got busy. Let’s see, two day temp of 40, respiratory rate of 60 with paroxysmal movement, pulse of 130…Now I’m definitely not the brightest bulb in the box but even I know this represents sepsis.

So we weighed him and found him to be 1.2kg less than last week, presumably from the diarrhea and vomiting he had had for that time. As we were doing this he coughed a deep cough and the problem became clearer. Just from the vital signs he had pneumonia, but this cinched it. We took him back to an exam room and Diziro, the nurse, got things ready as I prayed to find a vein. This kid was precisely the wrong age and race; a chubby African, 7mos of age, dehydrated and septic, with no veins. We must have stuck him 15 times. I was thinking if an intra-osseous but thought I’d give it another shot. I said a quiet prayer (I’ll cut back on the swearing, see “bleep” above, if only I could get the Big Guy on the side of this child and his aged doc) and slipped in a line into a scalp vein as sweet as you please. In went fluid (LR, it was the only thing we had Amber, sorry) at 20cc/kg x3. At this point the child fell into a deep sleep but not without me checking his vitals every five minutes. By now my back was up and if Death wanted this child he’d have to go through me.

Next was an antibiotic (Ceftriaxone) at 100mg/kg. Then I wound this kid’s head with anything I could find to secure the IV, looked like he had a turban. He awoke about half an hour later and started to coo and chat! Man this stuff works great. The ambulance came from Kanye, about 40km from Ntlanthle. and we loaded him on to send him to Lobatse. I called my friend Roger there who got things set up at the hospital. He should make it. I was able to congratulate Diziro about the clean save and shed a little mist. Man that was three hours of intense work but what a thrill. If I had been in Sudan I would have had no time to reflect on it as it would be on to the next patient. Here it was driving home to the Gypsy Kings.

Wednesday we were in Malwane, a clinic in the Mochudi district, way out there. In other words, my kind of place. I was discussing with the MO there how taking time to treat patients with four types of pain (literally) was a waste of his time, and was at some level co-dependent, and that the “sickest patient is always in the queue” Sure enough half an hour later and many somatising and malingering patients later, in walks (barely) an HIV+ woman with a BP of 80/palp, pulse of 170, and R’s of 32. Sepsis, it hits you over the head sometimes. In went an IV, three liters of saline, some antibiotics, and she was transferred to Mochudi. The receiving doc was unimpressed with her sepsis (that because we already gave her FOUR LITERS) and treated her as a simple case of pneumonia in an HIV+ woman, like THAT is ever simple.
Never the less, it was clean save number two. This time I was able to congratulate the med student accompanying me as he rode in the back of the ambulance securing the IV’s. Sweet save!

In Tsabong (we fly there as it is WAY out there, I know--cool) on Tuesday I was rounding on the wards with Julien, a doc from DRC who was confused about an obtunded HIV+ woman with low blood pressure. “That’s because she’s septic” says I. We got busy, he started an external jugular and five liters and some antibiotics later she was back from the brink. Save numero uno.

These were all great teaching case especially because they lived (!). It DOES happen in threes just not always this good….

They say that these things occur in threes...

2009-10-24T07:22:00.004+02:00

It's been a week. I know, I say that a lot.

On Tuesday we flew to the NW part of Bots and I went to New Xade (pronounced with a click), a San village 100 km out on a dirt road, incredible. The health care is episodic and interestingly full of HIV, but performed with great expertise by the MO who visits there once a month.

On Thursday we were in Lobatse where we work in the secondary hospital and clinics; first leading a discussion with the medical staff in the hospital then, while one of us stays and completes rounds, the other ventures out to the clinics and mentors there. Since the hospital is so understaffed due to people on leave and reassignment, we routinely take on a much bigger treating role there than in at any other facility.

During our discussion of thrombosis and HIV, an exhausted doc who was just coming off night call received a phone call and motioned to me to come with him. One of his patients was decompensating (read dying). We went to the ward and found a 45 yr old man, HIV negative which becomes important later, with massive hematemesis (vomiting up blood) and with a huge amount of blood in his stool. It turned out that he had liver failure and as a result had varicose veins of his esophagus and stomach, which were briskly bleeding. He was encephalopathic (read comatose) and we, Matt and I, got busy. Normally we try to stand back and use the opportunity to mentor but this guy was "heading for the light" and the doc coming off call had that "what should I do?" look.

Long story short, I have a tendency to concentrate with my mouth open. This has resulted in infant boys peeing into the back of my throat as I attempt to circumcise them, tasting engine oil if I can't get out of the way fast enough while I change it, etc. So there I was attempting intubation on this guy with of course an open mouth when he roops up some more blood, which unknowingly (I know, I know already) apparently splashed into the back of my mouth. I wondered why I suddenly had a salty taste in the back of my mouth and dismissed it to the meds I am taking (moth eaten brain and all...). We were unsuccessful in the attempt so, what with a prostate the size if an apple and a small bladder, I excused myself to "the toilet" as we say here. I glanced in a window for some reason on the way to the loo and there it was, some blood on my lip. At first I actually asked myself "how the hell did that happen" then it dawned on me....bleep, so THAT was the salty taste (definitely NOT the brightest bulb in the box).

I pee'd (not quickly, see reference to prostate) and hustled back to to check the guy's HIV status, which was negative within the last two days. He was close to buying the farm. And had had a recent (-)HIV test, which is not particularly reassuring as he could have acute HIV disease and not yet converted to positive. I theoretically could have been in a touch of deep doo-doo.

I called Michelle, our third new partner who is fortunately an Infectious Disease specialist, and she was very understanding if not a little bit amused. "Intubating with your mouth open, huh?" She told me what I already suspected, that my risk was infinitesimal, so I'm not on post exposure prophylaxsis as the risk of me auguring in on the drive home was much higher that the risk of HIV. Any other annoying thing I would have been exposed to was something against which I was either immunized or wherein any self respecting virus would retreat to infect another day.

I wisely, to my credit, called Lynne who got a good laugh out of it at my expense and then promptly informed the kids (cue the collective eye roll and gut laugh)for which I'm sure I will suffer mightily.

Matt and I disagreed about transfer, he for it and me against it, and we held this discussion in front of the nurses. It was a great teaching moment as they had a chance to see two docs who admire and respect each other have a conversation about which would be best; transfer or allow the guy to die in Lobatse as his prognosis was in negative numbers. He ultimately was transfered as the doc coming off call finally got to point where he just wanted to go home and rest and had had enough. We acknowledged his wishes and transferred. I then rounded on peds and had a much needed series of hugs, and laughter.

Yesterday we were out in Lorolwane, a VERY remote, and therefore way cool village I have described before. The first patient of the day was a woman in distress who was carried off a donkey cart. She had "collapsed" at home... Now I can't count the number of times I have seen this type of attention seeking behavior so my cynicism was in the red zone; heavy sigh... We examined her only to find that she had nystagmus (quick uncoordinated movement of her eyes) and since this can't be done voluntarily she was indeed in deep yogurt. She was HIV positive and our resident expert on ID, Michelle, thought it represented pneumoccocal sepsis. So there we were; 85km from the nearest paved road (I've been in tighter jams), with no ambulance(all of these outposts have one but they typically have been stripped of equipment and in any case there is no pre-hospital care as the nurse traditionally rides up front), no cell service (most these little villages have a cell tower, a good thing, but they are rarely maintained, an extremely frustrating thing. Don't get me started), no running water (sinks with pipes to them but no water, an all too common thing. See above about frustration,) an outstanding MO (Cathy), with Matt, Michelle and a dumb family doc.

We valiantly tried everything we could think of and Cathy made some tough decisions with an expertise that belies her level of training. And as the patient was loaded into the district truck that brought Cathy to the site, she breathed her last and died. It was at some level a privilege to witness that and realize her release and, again, teach Cathy about the diagnosis and dismal prognosis of sepsis. But we all felt empty.

The evening was finished with watching Matt play sax with an outstanding African jazz band (that guy amazes me) and then passing out in bed. It's rare anymore that I sleep and awake without being aware I'm in bed but it's been a week. This has been a touch longer than the average screed but it has been therapeutic to externalize it. And at some level I always finish the week feeling most fortunate and loving it.

The Big Five

2009-10-13T22:12:00.002+02:00

Ho-ly cow, or water buffalo, or lion. The "Big Five" in two weeks. Incredible! Here are some of the pics:

http://picasaweb.google.com/pendletonmd/MoremiOkavangoDelta#

Cynicism=Death II

2009-10-03T22:32:00.003+02:00

Another episode: A woman came into the OPD in Mochudi and complained of nausea and vomiting. We were stealing glances at each and rolling our eyes when her husband produced a jar full of what came up and it looked like wide white spaghetti, only it was segmented. Oh reeeaaaly. So we took a closer look and were surprised to see the segmented remnants of a tape worm! We put her on meds, and the pharmacy had them which was surprising and a relief.

Today I swam again. The pool is dirty, a little like swimming in a pond, but it’s all that I have. I did a 4-4-4 warm up then 4x200 on the 3:20, then 4x100 on 1:40. Slow intervals I know but the best I can hold for the moment. I might get better although it’s raining tonight and the pool, like all pools in the area, is unheated. It always takes a 50-75 to get used to the water. But tomorrow it might be impossible to swim because of the temperature.

Love the rain. Things might green up around here. The trees are in full bloom but the grasses and shrubs will stay brown until after Christmas. Very different from last year.

Best to all…

Cynicism=Death

2009-10-03T07:48:00.002+02:00

So there I was minding my own business and that of the MO whom I was mentoring in a local clinic, when yet another woman (they often are women to the extent that if a man comes through the door he is met with a quizzical look) enters the exam room. In any case, in walks a woman with “a cough” as in “yet another patient, a woman, with a cough”. This cynicism is of course dangerous as something can be easily missed. So I always insist on listening to the patient's chest if the history is compelling. And, in short, it was.

I continually emphasize to the MOs when we lead discussions that “the second question out of your mouth after: “How can I help you?” should always be: “What is your HIV status?” So she was asked and she was indeed positive. The incidence of Tb with HIV here can be 60% or greater. In other words if one lives long enough with HIV one will have a positive skin test at the very least, if not active pulmonary or extra-pulmonary Tb.

So, stethoscope to chest, we noted that the breath sounds were uneven. I took her blood pressure again (figuratively rolling my eyes) and lo and behold she had a pulsus paradoxus; a bit of a long winded explanation to the non medical types that deign to read this rag. The first thing you think about here in Bots is pericardial effusion and tamponade. So off she went for a chest x-ray at PMH where she was met by ambivalent techs in a crowded waiting area, coughing all over the place and exposing other patients, I’m sure, to Tb! We have a terrible track record at PMH of segregating the Tb positive, or suspected Tb positive, people away from the rest of the patients. It truly is scandalous.

Because it was early in the day and because she had transport (the clinic ambulance) she arrived back with the x-ray in hand. We read it and saw a huge cardiac shadow, boot shaped, indicative of a monstrous pericardial effusion that was constricting her heart just as if a hand was squeezing it. No doubt from Tb! Bleep, and to think our collective cynicism nearly missed this.

So back she went to the A&E (read E.D.) at PMH for evaluation and pericardiocentesis (wherein a needle is place under the xyphoid, that little bone thingy at bottom of the sternum, aimed at the left shoulder) and a massive amount of fluid was drained from the sack surrounding her heart (we’re talking liters here). She immediately started to perfuse her body more efficiently, and we saved her! All because we listened to her chest when what we truly wanted to do was send her out with assurance that she would be fine. Jeez and whew!

We head to the Okavango this next week for some R&R. This is one of the true and unique gems of Botswana where an entire river empties onto a plain that was an ancient lake. The watershed that is created has all matter of wild life including some big crocs. It should be a memorable experience to be sure.

The friendly skies

2009-09-26T09:10:00.002+02:00

We’re flying! Or did I already say that? We have resumed the flights to outlying primary hospitals and clinics so the travel time is reduced from 7 ½ hrs over rough and straight-as-an-arrow road, to 1hr 15min and we arrive refreshed. We only get to spend about 7 hrs on the ground but we go weekly now and not every three months. To think….

Tuesdays of each week we meet at the airport, make that Sir Seretse Khama International Airport, and leave at 0730 for one of three destinations. This month we have visited Tsabong in the far southwest, Hukuntsi in the far west, and Ghanzi in the northwest. Like I’ve said, Tsabong is reminiscent of the old HRMH with a ward of 30+ beds, an OR, Maternity, and a large OPD. All of the staffs are friendly and seem eager to hear our presentations.

While in Ghanzi (pronounced “hanzi”) I was leaving the OPD when a guy ran up to me and chewed me out for not seeing him and his prisoner in a timely fashion. NO ONE is seen in a timely fashion. Indeed you arrive to queue up at 0730 or earlier and then wait, a long time, wait some more, wait, watch the MO come and go for emergencies or simply to relive him/herself, one doesn’t eat including the MOs, did I mention wait?, and then are seen sometimes 4-5 hours after queuing.

So this guy was reasonably puckered. I glanced at his chart, they are all patient carried “cards”, and it looked like he was referred for “narcolepsy”. Ohhhhkay. I told him I would be back shortly as I was headed to the TB ward and would see him in ten minutes. He, perhaps rightfully so, scoffed and snorted. I told him that if he thought I was lying he should just leave but if he believed me I’d see him in 10, which is what happened.

Turns out he had fallen asleep on the job and was looking for some medical problem to legitimize this episode such that he wouldn’t be disciplined. He didn’t have narcolepsy and had simply had difficulty adjusting to night shift. “Sorry but there isn’t a disease process here.” He lit up and refused to leave until I signed a leave form.

This happens WAY too much here. It has been enfranchised so much so that on Mondays the waiting areas of local clinics here in Gabs are full of people who are hung over or have minor complaints and want “leave.” For a day--- “to rest”. Many if not all of the employers here have abdicated responsibility and have successfully placed the physician between the employer and the employee for certification of leave. As all the MOs are foreign nationals and the employers are political heavyweights, the docs feel that their jobs are threatened if they don’t give useless meds, grant medical leave, certify medical pathology when there is none, and the like. Shades of workers comp in OR. I’d almost, almost rather care for chronic pain, fibromyalgia, or chronic fatigue syndrome. Anyway this guy wouldn’t leave so I simply asked if he wouldn’t mind standing while I invited the next patient in. I ignored him out loud so he finally left threatening to see “a private doctor as he’ll give me what I need”.

And he is right. The parallel private system here is no better than the publically accessed one but as it’s private and fee-for-service, and as one has to keep ones customers happy, the private docs over prescribe, over diagnose, and over utilize. Sound familiar? God help you if you point out that the diagnosis, let alone the treatment, is bogus as it isn’t about quality as much as availability and convenience. In general you can access as capable care in the public sector the difference being you can get an appointment with the private docs and don’t have to queue with us. And by the time you see us we’re often times tired and hungry. Hell, I’d go private if I had the cash just to get out of the damn queue.

For us life continues apace. The trees are in full bloom, we’ve had relief from the dry season with some booming thunder storms (nothing worse than the Midwest in the US), and it has been a quick year. And a truly incredible and rewarding one at that.

Random randomness

2009-09-10T17:33:00.004+02:00

Some random thoughts and observations:

-Having Matt here is GREAT. He is a natural teacher and mentor, and a great partner with whom to discuss medicine and life.

-I went out to Kanye to teach my Family Medicine residents from Stellenbosch (did I mention I PASSED the boards?). They are all bright and gifted docs. Three are national Botswana, two are from DRC and one from Uganda. I spent the next day with one of them where she was working in what is known as the IDCC (Infectious Disease Care Clinic). The euphemism breaks down in that everyone who is there is aware that they are in the queue because they have HIV and are getting their monthly clinic appt. We saw a 50'ish woman with a year long history of post menopausal bleeding, and she was a classic "last patient of the day" story. She was bleeding enough that she was concerned and mentioned that she had to wear a pad. My MO was close to blowing all this off as she needed the time to study and for other things. I recalled to her that a wiser attending than me had once said that I should never miss the opportunity to place my finger in a bleeding orifice. So after an appropriate eye roll she went to the clinic next door and found a speculum, brought it back and inserted it. She is really good but I I had to get a touch testy saying that this is what I, as her mentor, expected from her.

We couldn't visualize the cervix easily for all the blood. So recalling that adage from an attending smarter than I, we did a manual exam; the first in a year as this was always temporized by other MOs in the out-patient settings. She had had an ultrasound of her pelvis and a PAP smear but no true exam. The PAPs are done under dim light often without a manual exam and then they become important only because we finally did one and found a fungating squamous cell carcinoma involving the cervix and vaginal side wall.

Blast and damn, this should have been picked up months ago and wasn't. It occurs much more frequently in HIV and should have been expected.

-These talks we give are all patient based and have apparently become quite popular. There was discussion about substituting another speaker for us on a Wednesday in Mochudi and the hue and cry was flatteringly great enough that they scheduled around us, WOW!

-We flew! Yeah, out to Tsabong where I felt so at home it was a touch spooky. It is a town in the far west of the country that takes 6-7hrs to drive to or 56min to fly. We took off with me in the right seat (thanks for the suggestion For') and had a gas out there. Very reminiscent of Hood River and the old Hood River Memorial Hospital; small number of beds, small staff, everyone knows everyone, and great comprehensive general care.

We spent a fair amount of time dissuading them from transferring patients to Gabs as the care here offers little more than what they get there except some more comprehensive testing. Specialist consultation can be obtained over the phone and is often sketchy depending on the motivation of the specialist. I swear some of these guys (all expats from various backgrounds, training, and medical cultures) look for reasons NOT to intervene when it stares them right in the face. They embody an arrogance and indifference that is the ugly side of medicine. The only indication for transfer to the ICU here is imminent death (i.e. an 02 sat of less than 60!), and one has to get on bent knee to plead with an anesthetist(!) for transfer. We tend not to look for quality as much as to fill the specialist slot with a widget. As long as the slot is filled....

Hope all are well. Now that the boards are over I can try to learn Setswana. Ke a leboga! (Thank you)

Lynne's Home, and I Passed!

2009-09-05T06:27:00.001+02:00

Lynne’s here and life is good, or did I mention that? She was happily up to her neck in twins and now is home, soon to be up to her neck at SOS. She got home on Monday and is slowly recovering from jet lag. The fare has definitely picked up and I have filled out. Last night we had roasted vegetables; delicious. Apparently I had forgotten about that whole category of the food pyramid.

P=MD(BC). Make that Pass=MD(Board Certified). And I’m old enough, yep I’m 57, that I think this is the last time I have to/get to/have the privilege of sitting in front of a computer screen for the better part of a day, sweating. The medicine here is so very different. I have definitely lost the edge to practice in the US and the style of family medicine that I left there. And I’m old, or did I mention that?

Yesterday we were in Kanye where I had Matt, the newly minted and gifted Internal Medicine outreach dude, and married to Premal (see below), Jessie; a third time visitor and this time as a Infectious Disease Fellow, Premal; a newly minted IM doc working for Baylor and married to Matt, and me, an aging and aged family medicine doc with a seizure disorder (that, by-the-way, is under better control with a new med). Matt drove and led the discussion on TB, that I had led at other venues, to try on his chops and did fantastic. We then rounded on a patient with Multiple Drug Resistant TB (MDR-TB) who was being managed admirably by the docs at Kanye SDAH. ID is not my strong point, and TB is the weakest link in that chain thus far. Actually based on my score on the board exam it would seem I no longer have a strong point (P=MD(BC), I just gotta keep saying that to myself). The Kanye docs were doing great.

We then went to a local clinic where we saw some amazing infectious disease. This is not even close to the stuff I saw in South Sudan but we shouldn’t be seeing that in this nation, as often or severe. What we see here is HIV/TB co-infection and it complications with a little medication side effect (mostly hepatitis) thrown in. The disease spectrum here is more narrow but deeper. And for a mono-neuronal family doc it is a touch easier to get a purchase on so as to move the patient towards health.

We of course had to weed out the truly sick from the “wanna-be-sick-so-as-to-get-sick-leave-on- a-Friday” folks. I came across a way to cynical to these guys I fear but I wanted to demonstrate the MOs that you need to dissuade patients with multiple somatic pains and an agenda from taking up your time so you can attend to the truly sick and needy. The sick leave situation here is a great exercise in abdication of employer responsibility. All the waiting rooms from the smallest outpost to the downtown clinics are crammed with anyone from the truly sick to the majority “wanna be’s” all wanting medically sanctioned time off on a Monday or Friday, absurd and a total waste of time. Yet we give them meds, sometimes five of them (acetaminophen, and four types of vitamins and a mineral or two) so they truly think they are sick and show their friends on the way out how they were treated so well that they got all these meds. We have created this monster and only we can fix it.

Did I mention Lynne is home? Wahoo!!!!

Restoration of the soul...

2009-08-25T18:59:00.002+02:00

Something about a couple of kids on your lap after their dinner, snuggled in tight, as you read to them that fills and repairs the spirit.

I went to SOS last night and it began with the marimba band practice, still fantastic. They are amazing, have innate rhythm, and play faster than my tired eyes could follow. We were oriented by the head the orphanage, Bikia, a man in his thirties. There are 24 “homes” staffed by “aunties” and housing 8-12 kids. The adolescents live autonomously within a budget and learn to purchase food and necessities, cook, and clean their home. Their home is a happy mess but they are well fed and fantastically well socialized. Other younger kids live two or more to a room and are cared for by the auntie. The campus is home to kids who are orphaned from HIV, destitution, or abandonment. Once there, they are rarely adopted out and frankly that’s a good thing. The extended “family” they have and the life skills they are taught are extraordinary.

So I was sitting down with a child on each side and one on my lap reading nursery rhymes, something we rarely read to our own kids as they are dated and not a little racist and sexist. The kids lapped it up. I have cut my hair very short so the boy on my lap sucked his thumb and wuzzed my hair because he liked the texture. It was a dead heat as to who would fall asleep first. The other boys felt the hair on my arms as I have become rather hairy now that I’m not in the pool.

We read then wrestled then read some more. Then time to go home with hugs all around and “when are you coming back?” Each week for sure. This is where the Penn students should spend more time. I was introduced to there by Caitlin, a student headed for family medicine and I think they’d all love it. I know the kids would.

As sweet a save as you'll find....

2009-08-23T06:08:00.003+02:00

And not by me. By our eldest son, Eli, and a rural Charlottesville family!

So there he was, minding his own business, while on an organized run outside Charlottesville, VA. He is training for a marathon and a group of runners of like mind (there really is "a group" that want to do this?) were running through the rural farmland when he came upon a runner who was walking with an odd posture. She had her arms away from her side, stuck out at a 45 degree angle and, well, looked curious. So he stopped and asked if she was OK.

He recognized her from his work at UVA where he is a family doc. Seems she'd been stung behind her ear by a wasp and was a little rattled for the experience. That and she had urticaria (hives) from head to toe(!), hence the posture.

"Gee, you OK?"

"I think so, I'll just walk a bit and see how things go", she says.

"Breathing OK?"

"I'm a little wheezy....." Wrong answer.

Thinking fast he decides to stop a home up ahead and see if, perhaps, they might just have some Benadryl, an antihistamine. They knock, he identifies himself as a doc with a concern about this runner and do they by any chance have some Benadryl? Why yes, in fact they do. So down goes 50mg. But by know she is really wheezing and getting a touch light headed. Bleep.

So he calls 911, then asks, knowing its against all odds, "You don't by any chance have an "Epi-pen" do you?" As a matter of fact they do!!!! He administers the epinephrine injection.

A few minutes later the rural first resp0nders show. They take her blood pressure and its below 80mmHg systolic; full on anaphylaxis. By now she is a little the worse for wear but hanging in there and all are thanking their lucky stars. An ambulance shows up. They take her pressure again as they load her for the ride to the UVA emergency department, and it's unchanged. She goes on O2, and is taken to the ED.

As clean a save as you'll ever find thanks to a runner-physician who had his antennae out and a welcoming home that, unbelievably, had the appropriate meds. Incredible.

2009-08-20T20:08:00.002+02:00

This week has been a little bit of a watershed for me and the program.

Tuesday- It began in a local clinic where I was to mentor an MO there but beat him to the office. I was in the exam room, door closed, to await the MO when a nurse stuck her head in and said she needed me next door.

“Ohhhhkay, why?”

“A little girl is in status”

“Uh, status what?” Hoping she meant asthmaticus.

“Epilepticus, she’s fitting Naka!”

“Bleep!”

So in I walk only to be handed a premeasured syringe with diazepam for rectal administration! She is a chubby three year old with epilepsy since birth secondary to birth injury fitting away for the last hour with no IV sites. In went the diazepam and in five minutes off went the seizures. We piled her into a car and off she went to PMH. The nurse was exceptional and acted like having things THIS much under control was no big deal. Would love to clone her!

Wednesday-I have been giving talks at Deborah Retief Memorial Hospital in Mochudi to the entire staff (about 30 professional from across the spectrum) and have made an annoying arss of myself trying to get the outpatient docs to join. Yesterday 6 showed up and stayed for an hour as we discussed innumerable issues that were shared and at times contentious. A great episode in medical staff intercourse and huge for quality of patient care. A true first.

Today-For the last several months I have struggled with the outpatient medical staff in Lobatse. They and I worked to come to some agreement about how best to participate with them. One of them lined up a bunch of patients about whom he had questions and away we went. Then I gave the same talk in the afternoon to them and it was received well. I, again, gave them my info and encouraged them to call anytime, and was before I had left town.

Its freaking cold here, just like you might expect from a high desert in the early spring. But the wards aren't heated so all the kids in peds are under 50 blankets and are just bumps on the bed. We have a diabetic in DKA here at Athlone Hospital in Lobatse. I swear that adolescents are the same the world over. He is sweet, too sweet literally, but is experimenting with controlling his own life, disease, meds, and, like all of us, his first foray into this arena was a little rough. We discussed how to treat this without lab back up, just with a glucometer and urine dipsticks. It was all very reminiscent of Frenchburg in the winter when I would treat two brothers with DKA, at the clinic as outpatients, as their mother was afraid of travel in the snow and ice.

2009-08-18T13:10:00.002+02:00

Last night I did some more volunteering at the SOS village,

http://archive.soschildrensvillages.org.uk/sponsor-child/botswana_select_a_village.html

a large and well established "orphanage" here in the area, one of dozens. It sits on a campus the size of a small secondary school with houses numbering in the teens and kids numbering in the hundreds. Each house has a resident "auntie"/mother and a relatively static group of kids of similar age and development. No outside adoption is allowed as it is too stressful on the kids and siblings are housed together.

All the kids are incredibly well socialized as they have literally hundreds of brother, sisters, adult mentors and care providers. It is located in an area of greater Gabs where all the people are national Batswana, no expats.

I usually stop at the teenage girls area first and help with homework. Last night is was quadratic equations, a real blast out of the past. Then it's over to the home of younger kids where there are is a toddler who can't get enough lap time, and brothers who love to read and be read to. In particular they love to sit close and gets hugs, have their heads rubbed, wrestle and giggle. I usually read from their favorite book of old fairy tales and have them read with me. It's amazingly racist and they couldn't care less, it's the story they love even if I try to modify it to be a touch less British Empire-like.

As we about to leave we were asked if we would like to hear some marimbas. Uh...sure. We walked out to the back only to see a room full of marimbas and kids of every size and flavor playing their hearts out, and GOOD. They are invited all over the place. The shortest kid plays the largest bass, the most outgoing plays tenor as fast as I've seen it. Incredible. A great time.

These things tend to occur in threes...

2009-08-15T07:03:00.004+02:00

Shit….it does happen in medicine, and in "threes" if I’m not mistaken. Yesterday morning I was solo, something that is rare these days but welcomed on occasion. I made the drive to Kanye and was just sitting down to morning report by the staff at the hospital when a call came in from OB for newborn resuscitation. A child has been born over a prolapsed cord and wasn’t breathing.

These situations are true buggers in any country. The child (read brain) has been deprived of blood (read oxygen) due to compression of the cord between the side wall of the pelvis and the infant's body. Any attempt at resuscitation is mis-named. Instead of cardio-pulmonary resuscitation it should be called brain resuscitation.

In newborns the cardio-pulmonary tree is so pristine it usually “starts” without a lot of carrying on. It’s the brain….that jello-like mass of goo that needs the 02 more than the other organs. It can shut down so completely such that blood doesn’t even make it past the neck. Now if you’re a dumb family doc like me with a moth eaten brain in the first place, maybe no big deal. In a child it isn’t compatible with life.

So the flail was on. It was truly other-worldly in that it was conducted in room where there were no less than six deliveries on two beds by three midwives. While we proceeded people casually were moved about accompanied by all the sounds of women in labor, and cleaning ladies mopping floors in between deliveries. Like other hospitals, they had a warmer but no one knew how to use it. They did have neonatal intubation ability and my colleague did admirably in establishing an airway. We had 02, and an ambu-bag, now full of meconium, that I washed out and then used to provide ventilation.

So; “Airway”-got that covered, “Breathing”-yup breathing OK, “Cardiac”-seems to be perfusing well, below the head at least, “Drugs” need bicarb and D-10 or at least D-“something”. As I asked for bicarb I was informed that we were “out of stock”. “Of @#$%#ing bicarb?!” I lit up like a damn cruise liner at night. My colleague shrugged. I fumed and called the pharmacist to the room asking how in the name of all that makes sense we could be out of bicarb, ...today, ...now,... here?!? She shrugged. I asked that she check everywhere as I felt this child’s brain leak through my hands. She left.

We attempted au umbilical line but to no avail as the iv cannulas were too stiff and the feeding tubes too big, so my colleague got a line in the foot; in the foot of a clamped down, meconium stained, non-perfusing deeply pigmented neonate! These guys are amazing. We found some D-50, diluted it up and gave it, some very old bicarb appeared from surgery where it had been used many times from the same bag (no clue about how that made sense), and tried to figure out the difference between milligrams, milli-equivalents, and millimoles as all three were cited on the bag, and we had no idea if it had any bicarb in it in the first place.

By now every baby doc's fear was being realized; we were saving the heart and lungs but the brain was dying or dead. We gave some of the supposed "bicarb", she started to breathe on her own, … and then the seizures started. Well shit again.

We called PMH and were told that since she didn’t need ventilation she didn’t need transfer. We all exchanged looks, calculated doses and rates and put her next to her mother. We couldn’t get her warm so adhering to the adage that “you aren’t dead ‘til your warm and dead and sweet and dead” we heated two liter bags of iv solution, placed them along side of her and gave more D-10 (or D-something).

Blessedly she quietly died last night at 1830.

A new angel

2009-08-13T19:09:00.005+02:00

Today was one of those days you just know is out there but dread. I was past due for this....a child died in my care. We, two dermatology residents and I, were in Lobatse today. They had given a great talk about the latest ideas regarding care for a perfectly miserable spectrum of skin diseases characterized by anything from rash to blistered lips to burn-like wounds across the entire surface area of the body. It's called TEN (toxic epidermal necrolysis) for short and is a true bitch.

It is quite prevalent in HIV prone areas because one of the anti-retrovirals used early in the care of HIV is frequently associated with it. It's interesting in that the care for TEN in western countries involves intense intensive care with a mortality rate of 50-70%. I've cared for it in remote Sudan with a perfectly lousy outcome as well. In South Africa they are as diligent but use less invasive techniques and have a rate of generally <10%.

In the middle of the talk a nurse came into the room and asked for Roger, a good friend of mine and excellent doc. We casually finished the discussion and went out to see if the residents could shadow him in the A&E (the emergency area; "Accident and Emergency"). I walked into the room and found him bagging (breathing for) a 3mo old boy.

Apparently the child had gastroenteritis for three days and had visited a "traditional healer" at least once. He was brought by his parents and grandparents who were arguing about whether to let us treat him. By now he was obviously dry and in shock. When the powers that be relented or won, depending on one's point of view, Roger got busy. He had started an IV in the external jugular (the guy can canulate a capillary!) but didn't have normal saline, the mask didn't fit, the 02 wasn't reliable and the tubing the wrong size. In short it was like a lot of pediatric codes in western hospitals that haven't had one in a while.

So I got in the middle of the flail and started to rehydrate, establish and airway, decompress the stomach, and initiate CPR. Now if a three month old's heart stops it has to be from electrolyte abnormality, profound sepsis and shock, or.....well that's about it if it was previously working fine. So we suspected the traditional remedy but who knows. He was terribly ill and appeared to be caught in a power struggle that relented too late. For that matter it could have been a clean kill from traditional medication. We'll never know and that is so damn maddening. Nothing to learn about the cause of death, just an opportunity to review pediatric resuscitation in a secondary hospital. Maybe that can be his legacy. God I feel empty..

The rest of the July story

2009-08-06T18:26:00.001+02:00

And what a wedding indeed. It was at the home of Olivia’s sister in east Portland. She, her boyfriend, and anyone walking down the street worked tirelessly to turn the back yard of their home from a patch of blackberries into something out of Sunset Magazine, simply beautiful.

Olivia and Beth exchanged vows in the side yard with Eli officiating. There was enough humor in addition to the vows exchanged to keep it light but very devotional; a truly wonderful and moving memory.

We then moved to the back yard where those in attendance offered blessings on the marriage and laughed, cried, loved. Then the party. We rented an old Masonic Temple in North Portland and had DJ Eli plug his iPhone into a great sound system and danced the floor around. It was wonderful to see family and friends at this celebration.

We flew to Philly where we saw the KA’s and I went to UPenn to have my head examined yet again. I’m still screwed up enough that another med is warranted. I tried to get another MR scan of my gourd but ran head long into the underbelly of US health care. I didn’t need a prior authorization for the MR scan but because Penn had contracted out the process to a third party, that has the huge and necessary data base, I still had to go through them to the tune of waiting “just 24-36h” for an authorization I didn’t need but without the OK from then would be on the hook for paying for an MR scan, HUNGH???!! So needless to say, no MR scan as I had to get to NYC and over the pond.

We had two fantastic farewell dinners with family and then Walt took me to Trenton to board a train to Grand Central in NYC. I arrived there on a Friday afternoon with two large bags and a backpack, navigated my way around and through to the subway and made it out to the hotel at JFK without losing anything other than my mind and dignity. Not sure what I was thinking when this struck me as a good idea and doable. Doable yes, a good idea……

Lynne has stayed in the States to offer much needed and appreciated help with the twin grandbabies in JAX. Forrest and Shannon are doing admirably but like any couple with three kids under two, well, you can fill in the blanks….

And I’m back at it. We are in the middle of Influenza H1N1 here as if things weren’t tough enough already. I was advised that each hospital has been allocated 10 (that’s ten) dosing regimens of the antiviral indicated for this flu. We are in deep yogurt if this truly becomes epidemic here in a country with a HIV prevalence rate of 13-60%, depending on region.

Best to all that we saw in the States, friends and family in Hood River, CGM, CGFM, the BA relatives and friends, and the UPenn crew. Thanks so much.

July!

2009-07-20T20:25:00.003+02:00

And here we are in PDX, in the PDT time zone! Lynne has acclimated to the 16hr plane ride from Jo’burg to NYC quicker and better than my slow burn as she is more accomplished at this point. I run out of things to do and my neck starts to bend in new and different ways thanks to being too tall for the seats to sleep comfortably. Hmmm, “sleep comfortably”....on a plane...... in coach; a true oxymoron if there ever was one.

We arrived in New York early in the morning, left our stuff at the hotel and went to Manhattan via the subway to see Central Park. It was amazing; clean, safe, HUGE, friendly. Something, in my ignorance, I didn’t expect. We were caught by a rain storm and delighted in the familiar odor of “east coast wet”. We walked to Times Square where we were overcome with and by the people/tourists and fatigue, ultimately fleeing back to the hotel to sleep then leave for the NW the next morning.

It was delightful to be met at the airport by Aven, TJ, Belle, Bethany, and Olivia. Hugs and greetings of longing all around, a night’s sleep and then, on the 4^th, a trip to Hood River. It’s fair to say that I was floored about how unprepared I was for my reaction as we drove up the Gorge. Call me naïve, but I was overcome with a sense of déjà vu, a sense of “what was I thinking?!!”, as we drove past Multnomah Falls, the Osprey nests, through Cascade Locks and into our old home town of 22 yrs. We parked at my old office and met up with friend after friend as we watched the famous Hood River 4^th of July Parade wherein half of the population is in it as the other half watches. Every kid on roller-skates, every jacked up pickup, every swim club, ball team, politico, and anyone who wanted to advertise their business was in it. We finished the day in our old neighborhood with a classic barbecue; too much of everything including nostalgia, food, and laughter. It was great.

We returned to HR later that week to see old friends and haunts. We spent the evenings at MJ and Michael’s home above Mosier where we had an apartment and could try to catch up to ourselves. They are great friends and fellow swimmers from our previous lives, so generous and kind. Monday we “swam” with the team, ate huge breakfasts, and had a chance to see eagles, The Hook, drink too much good coffee, and read "The Oregonian". I had my eyes and teeth examined and get to return to have a ‘drill and fill” on one of my teeth. It would seem that in addition to having an asymmetric head I also have an asymmetric jaw that causes stress on my teeth. Jeez I just can’t get enough mileage from those guys.

The past weeks have been filled with grandchildren as Forrest and Shannon have adopted twin newborns; Asher and Cora and now have three kids less than 21 months of age. It was a difficult week as they struggled to seek out a space where they could anticipate the additions to their family and care for the mother who was placing them; amazingly moving and courageous on all parties’ parts. Judah is a great brother and is getting that role figured out. Belle is four months, long and tall, and filling out. She loves to seek stimulus and enjoys motion. But to her credit is sleeping well and working on her fourth chin.

Eli and Amber, our son and daughter in law, have arrived. Yesterday we had our first Family Council Meeting. We’ll have more but this one gave us each an opportunity to acknowledge and explore. Forrest and Shannon were present by speaker phone as were the g’kids. Our family is changing and sentiment runs the spectrum but several things remain and persist, our love and devotion to our (nearly) spouses, the extended family Pendleton, and working out how we can be in each other’s lives. Tomorrow we “swim” with the team, have some medical appointments and lunch in HR. Thursday I have another, and last, chance to swim with the team, then a radio show, a real homage to simpler times and a true treat, and finally a noon presentation with the medical staff at my old hospital.

Now on to the wedding!

Its been a a while

2009-06-27T06:58:00.006+02:00

Two weeks ago Lynne and I finally took a break and went to an animal reserve south of here, just over the SA border, to a game lodge called Tau ("lion"). It turned out to be one of those all inclusive resorts where you are greeted at the front door and your car is driven away as you settle into a routine of being pampered, not unlike what I imagine a cruise would be, with too much food, drink and the like. We skipped a meal and were called by the desk to check on us! The game drives were amazing with all the usual just not in abundance as the late rains had made it less easy to access the water holes and areas where some of the popular game congregate. It was very relaxing and long overdue.

That Monday I was on the road with two med students, Kandace from UPenn in her fourth year and Kea, a Motswana, schooling in Australia, in her last year. We headed out to Tsabong in the SW of the western frontier to a primary hospital there. I no sooner got out of the car than I assisted the CMO with a C/Section ( a "Cesar" as it is known throughout the area). We discussed the numerous ways to perform this procedure and the benefits of each as we saw them. We then rounded in the small general purpose ward and the next day I taught a class on CHF and HIV. It amazed me that HIV has such a presence even at the "end of the road". All you need is a trucking industry that is "serviced" as it were and spread of STDs is assured.

Tuesday we headed back east then north then west again to Hukuntsi where we met the new CMO, rounded, taught, learned, laughed. We stayed there for two nights, me in a suite with two other guys that enjoyed ladies of the night well into the morning so sleep was with medical aid and ear plugs crammed deep into my EACs. Doubt "protection" was high on the agenda as it was all very alcohol fueled.

Thursday we again headed east, north, then northwest to Ghanzi for five nights. We worked with the local district hospital team on the inpatient services, then in the clinics of Ghanzi with the only MO for the district.

Saturday night we went to a village, D'Kar, about 45km to the east and witnessed a "healing dance" by the San, an ancient ethnicity of the area who use some 20 different clicks in their language. It is impossible to comprehend and I found myself staring into their mouths as they discussed the day, much to their amusement and glee. On the way out we stopped off the road and witnessed what I hadn't seen since Afghanistan, a Milky Way so huge and bright that you could read by it!

There is a school in the same town that houses San kids as they live very remotely. They are a group of people that are very small featured, almost orange in color, broad open faces, always laughing.

I saw the worst case of AIDS I have seen thus far; a 23 yr old woman with wasting, advanced TB, genital condyloma, Kaposi's sarcoma, and a huge fist sized, pendulous, papilloma of the vulva. One of my lasting memories of the hospital will be Kandace and Kea, both of whom thought they might go into a more tertiary specialty, sitting on the floor in peds laughing and giggling with the kids there, then telling me that they just might go into primary care. Nothing like a 9 day adventure into key primary care areas to open one's mind. That and some giggling kids in a peds ward in the middle of nowhere.

Sunday we went to my new favorite town, Charles Hill on the Namibian border, and saw the local and lonely doc there. My lasting memory of the trip will be sitting in the bed of the small pickup truck we were driving, sipping a Coke of all things, taking in the surrounding culture of the town center as Herero women walked around with their characteristic headdress, kids laughed and played, and the rival political parties blared sound trucks at each other across the dusty expanse. Man was that cool or what?

We drove home on Tuesday and spent the rest of the week in the usual outreach routine. Now it appears that the students from Penn might get to spend their time in Mochudi, a huge benefit for them as the experience becomes more truly "global", integrative, and assimilating.

See those of you in the PDT time zone in less than a week!

OK, way, way out there....

2009-06-13T07:51:00.002+02:00

This week was amazing:

Monday we began in Moshupa with one of my Stellenbosch mentees, Cathy, a great doc from DRC. There we saw a full slate of illnesses and a pre-septic child or two. We have yet to have any confirmed cases of HINI flu here but we are all confident it is on the continent and headed this way if not here and under-reported already. It will make life very difficult as it overwhelms our health care system. It will make for a tough spring and early summer (read August through November).

Tuesday Cathy and I hit the road to a tiny village outside of Moshupa; about 10km from where she lives called Lotlakane. It rained all night the night before and the road was like grease. On arrival we were surrounded by very familiar sites, sights, smells, spells, and sounds. I discussed this in the entry just previous to this one. It became my new favorite place. I want Cathy’s job.

Wednesday was Mochudi and a rural clinic that has one of my favorite MOs there, a woman about fifty-ish who is very capable. No meds if you don’t need them and you had better have a good reason for not using or “forgetting” why you didn’t use the last ones she gave you. We again saw a wide range of pathology and in general had a great time.

Thursday in Lobatse we saw a wide variety of the sick and those that were just sure they deathly ill with all of five somatic pains and counting if we didn’t act impressed. I have come to recognize a characteristic facial expression on these people (mostly women) that is a dead give away for so called medically unexplained symptoms (now called MUS in the literature instead of somatization or just plain nuts)) from the first breath. We finished the clinic at 1:00pm, got some lunch at the local grocery store, and went back to the hospital to see what trouble we could get into…..quite a bit as it turned out.

There in the A&E was a 9mo old who had been given a “traditional medicine” for vomiting and now was septic, seizing, comatose, “fill-in-the–blank”. The MO was appropriately trying to start an IV in a child with fat hands, no BP and having no luck. I mentioned an intra-osseous line as I have been in his shoes countless times and learned, at the cost of numerous kids’ lives, that one can futz with an IV for an hour or get down to the business of saving her little butt. He didn’t know how so we took her to the peds ward and on the third attempt (it took a minute to have it all come back to me) in it went as sweet as you please and we went about the business of reeling this kid back. Only later did it dawn on me that with the salivation, lacrimation, seizures, coma, and vomiting that we were probably witnessing cholinergic intoxication either from accidental poisoning or the traditional medication. She bounced a little with a fluid challenge and some antibiotics. Hope she makes it; a great teaching case for the students, MOs, staff and an aging family doc.

Friday we were “way out there” as in 100km off the road on a dirt road in the middle of the western Kalahari in my new favorite place. The village is Lolowane. To pronounce it one needs to disarticulate one’s tongue from the back of one’s mouth, allow air to pass around the back it as you try to pronounce the sound of “L”, then immediately roll our tongue to pronounce the “wane”, sounding like “wannae”. I tried to the glee of the people there and their shrill laughter was simply infectious.

There we few enough patients that the students could do the clinic with the supervision of Cathy and I. Each saw a wide array of cases that you see in remote places. We even saw a case of what I last saw in Sudan, Iraq before that, Afghanistan before that, and Turkey before that; Limb Girdle Muscular Dystrophy. This time I think it was complicated and accelerated by HIV but who knows and we'll get some more info with some blood work she gave us in a month. We took pictures all around, laughed likes little kids, and drove back across the Kalahari to Kanye. I’m a touch the worse for wear but man was that a gas. What a great week.

Way out there

2009-06-10T15:58:00.002+02:00

Well I’m getting farther off the beaten track these days and it will come as no surprise to those that know me that I’m having the time of my professional life. Yesterday I found myself with one of my mentees, Cathy, in a town very reminiscent of the way Hood River must have been at the turn of the last century; small, familiar, with the onsite health care provider (a male nurse) firmly in charge of who got seen for what and when.

There we were way off the beaten track, in the winter rain, at the medical-cultural-commercial center of a village; its health outpost. The onsite nurse knew everyone and was drawing blood on kids with HIV for CD-4 counts, dispensing meds, chiding patients for not taking their meds properly, flirting with the ladies, and sending us the truly sick that he had triaged. The clinic was very……. what, “guy”. Things were generally neat, but sloppy and might have been underneath stacks of stuff. He knew where everything was just that it might be under something. And he could draw blood out of a mosquito.

We saw all manner of rural HIV and co-morbidities, still saw lots of somatic stuff, and in general had a gas. The school was next to the clinic, across from the rural Botswanan equivalent of a 7- eleven, down the path from the town admin building. We left cold and a little wet as the clinic leaked, but warmed from the adventure and the medicine.

Friday I and Cathy go waaaaay off the road into rural southern Botswana to a remote health outpost. The medicine is as fun and challenging, as are these destinations. This weekend Lynne and I are off to SA to stay at a game reserve and see some larger game (lions, elephants, and the like), then Monday I hit the road for another tour of the western frontier hospitals. Then we head for the US and Oregon. Hard to believe that I’m coming up on a year away from CGFM. I must say I miss the people in my previous life deeply but have no regrets to be doing this at this time in my career. I'm truly fotunate and indeed blessed.

Neat and clean

2009-06-02T19:27:00.003+02:00

The Batswana are very fastidious. You never see a dirty car or a piece of litter...they have two people walk the roads wearing bright orange jump suits spearing litter, what there is of it, and in general keep the place quite tidy. They even sweep the dirt free of leaves.

Now that it is Fall, they are out in force sweeping the area, keeping things in order and orderly. This separates them from the Sudanese where there was so much litter that you soon became quite used to it. It was surprising to see it in the photos I took.

The women here dress very proper, very British if you will, and will walk for km's in shoes with 4 cm heels along dirt roads, across fields, and the like.

Every town/village/city has at least one large area that is all dirt and used for football (soccer). There is a local interest in fast pitch softball with teams from all over this area competing on the weekend. All sorts of alcoholic beverages are sold at the games so things can be either animated or quite sedate depending on the average alcohol level of the fans. Beer is sold at all events, even in the local amusement parks.

In have returned to attending at PMH for one day a week under a new paradigm wherein I teach, and write very few notes. This seems to be workable as rounds are better, faster, and more efficient. One of the UPenn students has fashioned a non re-breather O2 delivery mask and it has made a huge impact on the hypoxia of the PCP pts, taking their o2 saturation from the mid 50's to >95%! The dysfunction is just the same, especially in contradistinction to the secondary hospitals.

The med school has a new founding dean and my role there is still to be defined. In the mean time I love what I get to do each day so I can't go wrong. Fortune has indeed blessed me.

Now that I know my way around this part of the country it is beginning to feel more like "home". This weekend I meet with my mentees in the FP residency. Next weekend is a getaway with Lynne to Tau, a SA game reserve . Then I hit the road for 10 days to make a circuit to Tsabong, Hukuntsi, and Ghanzi. Find them on the Google maps and you'll get a taste of why this is such a sweet gig. All my best.

The week in review

2009-05-31T09:53:00.001+02:00

The past week has been event filled. Monday and Tuesday I followed a favorite and highly skilled MO who is also a mentee of mine through the Stellenbosch University program in SA. We worked in some rather slow paced clinics leaving time for discussion between cases and review ideas and other “right choices”. On Tuesday A.M. I also lost three hours I’ll never get back standing in line to get a Bots driver’s license. It actually came in quite handy---see below.

Wednesday we went to Mochudi where I gave a talk on HIV and dermatology, and then went to a remote clinic only to find that the MO was at a course in the Gabs area. As it is near the Zim border, and therefore a BNDF (Botswana National Defense Force) outpost, there were several guys waiting for a doc to show. One wasn’t.

It’s only in these situations that I step in to fill the void, without a MO to mentor. I do so mostly to generate good will and to help the overwhelmed nurses. The first guy had a long course of abdominal complaints with bloating, pain, passage of mucous (pus) and blood and a VERY painful rectal exam. He had had two previous surgeries for hemorrhoids and fistulas. I’d seen this several times in the states and as he had lost about 10kg in the last year thought he might have inflammatory bowel disease. We only have one med for this here and I started him on it with all the usual discussion and warnings. I made the mistake of giving him my card (I now have one) and telling him to call me with any problems. He proceeded to give it around back at the barracks and I have been screening calls from the outpost all week. It seems an old, western doc is valued more than a new doc from DRC (the one assigned to that clinic). Blast. So now I’ve heard about everything from drips to jock itch from these guys and each time refer them to the remote clinic on the border.

Thursday the new license came in handy as I was stopped twice. Once was just after I had picked up some passengers from a rural bus stop along the way to Lobatse. As I was accelerating away from the stop and listening how no white guy EVER stops for black people and what was the matter with me, I got jerked over for going 90 in an 80km zone. I WAS slowing down but there I was. The cop wanted P460 for the infraction which I didn’t have and let me go with a dismissive wave of his hand. In Lobatse I again went to a clinic without a doc for the day and saw patients for the morning. I was late getting back to the hospital and called there to let them know I was on the way...and got pulled over for using a cell phone as I entered the hospital grounds! Again a quick apology for being stupid and no fine. I have no luck, good karma, angelic presence left around me I’m sure. The bucket of good will is dry to be sure.

Friday I and a cardiologist from Penn who has been in practice longer than I have been alive went to Kanye, gave the same talk and then rounded on peds where we saw two kids with opisthotonus and meningitis. We transferred both here for pediatric intensive care. The prognosis is grim for both.

Then we went to my new favorite village, Manyana. It is literally at the end of the road. There we saw a raw but very good MO who had accumulated some cases for us; peripartum cardiomyopathy, pregnancy and DVT, complex derm cases, sick kids, bad hypertension…the place was thick with pathology. We had a gas; great teaching and learning, great staff input, great people.

A Sunday

2009-05-24T14:53:00.002+02:00

Today I washed the car. Not a big deal but to me it's a little like working in the garden or mowing the lawn....after you've done it you can look at it with a sense of accomplishment. Achievement in medicine is so often undefined and slow such that at the end of the day it is difficult to look back and assess what you have truly accomplished. Hence the seduction of washing the car.

No one in my skin or at my "station" washes their own vehicle here. It is viewed as beneath one. And it represents a chance for someone else to earn a token amount of money. Lynne and I actually got into a bit of an animated conversation about that; I was taking money away from someone else by washing my own vehicle. Nope I was simply trying to achieve where I had not in a more immediate time frame. I enjoyed it and the car is clean.

Things here are clean in general. There are no true heaps on the road, little if any litter as the govt employs people to cut grass, sweep streets, scavenge litter, and in general keep the place neat and tidy. In Sudan the litter was so ever present that I was surprised to see it in the pictures I took, so used to it was I.

A quiet Sunday beginning with a great birding adventure at the local game reserve where we saw at least 20 different and exotic species, wart hogs, impala, and huge monitor lizards basking in the sun on a pond bank near their nests. Then a fat breakfast, now a nap. Hardly the rough life to be sure. Difficult to reconcile that at times but the occasional car wash helps if only temporarily.

A new favorite place

2009-05-24T06:48:00.002+02:00

Last Sunday, a week ago, Lynne and I drove the 200K to Mahalapye to have a look at the hospital that might house a Family Medicine residency and the town. It is more dry there as it is closer to the Kalahari and has less topography than Gabs. And yet it is familiar, like our old home town of Hood River; quiet, kids everywhere, fewer fences topped by electric wire, fewer guards of property.

The hospital is huge, over-built, understaffed, and under-maintained like so many new things here. It has huge corridors, wide atria, and wards that are separated by empty space. Some doors are afar because they can't close, some have liquid leaking out from under them. I know the nursing staff to be dedicated and caring, and the administration to be very capable. We looked at each other and acknowledged "we could do this" principally because we would be some of the very few expats in the area. The FM program is not well defined as yet so we'll wait and see.

The week was punctuated by a national holiday, Thursday was Ascension Day, so we climbed the local hill and watched the sunrising above the Gabs floor. Then Nicola and I travelled to Lobatse to round on a child I have been following with Marasmus (malnutritition) while Lynne and Chawa had breakfast with other women of the profect. Lobatse is the oldest city of the country and had the only paved road when independance was granted in the mid 60's.

Friday I mentored at an outpost in Manyana a town of 1500 at the end of the road, SW of here. There I walked into the medical outpost (an outpost is staffed by a nurse with a once weekly visit by a doctor) to find a misplaced shipment of 12 huge cartons of condoms (!). Everyone was in stitches and when the Batswana laugh it is infectious. I was laughing in seconds and had no idea why until someone explained it. See, there are condom dispensers in every male toilet in every clinic, upscale restaurant, government building, everywhere. ALL are empty. For that matter so is the soap, toilet paper, and paper towel. Only the staff has access to these items and they are guarded with lock and key. It has become a hot political item here as the ministry feigns ignorance of the problem and the staff blames the ministry, and so it goes. So to have a shipment of more condoms than can be used by a town of 1500 oversexed men in a year arrive in Manyana was as hilarious as it was ironic.

The pace is slow and careful, the nurse is excellent and lives in a house under the only baobab tree in the south part of the country. We saw a man with MDR (multiple drug resistant) Tb and paid a home visit to inject him with his daily dose of med under the directly observed treatment program.

Leaving in the afternoon I realized I still have vestiges of this blamed ATF in me and was rather wiped for the week. Still, I'm a lucky guy AND we are coming back to the States, and the Great Northwest in 5 weeks!

Its been a week

2009-05-16T16:41:00.002+02:00

I, finally, feel well. And found out that I wasn't, by far, the only expat with this annoying African Tic Fever. Thanks to Rickettsia africae I felt a touch beat up for a week. And the interaction of the doxycycline and Keppra lead to some rather hairy dreams and, (&%$@!!!!), an episode of seizure activity lasting about 5secs.

Friday I was in Moshupa with a favorite MO/mentee/Stellenbosch resident of mine, Cathy. She had some patients come to the clinic there about whom she had questions and we we able to take some time to go over them and review. We saw a post op "Caesar" ("Brit speak" for C/section) with some oozing at the site of the abdominal wound. Cathy did a great job of reassuring the patient and removing the sutures. And then we had a great "last patient of the day".

As we were preparing to leave the clinic there in walked a teenage mother with her 3 month old daughter who had a fever. I had given a talk on "fever in a child three months of age or younger" to the residents the previous week and had given the talk to all the hospital staffs I had visited the previous week. So all we knew was she "had a fever of 38.5C" taken axillary, a great teaching moment if there ever was one. The timing was sweet!

So we did something we rarely do in the clinics which is take a bonafide rectal temp. The axillary temps are a great way to screen but are really too peripheral for my comfort zone. The rectal temp was met with a little eye rolling but was 39.5C (103+F), so another teaching moment....What next? As I was visiting Cathy that day with a real and genuine UPenn FP resident, also a Kathy, we had a great cross cultural moment about what is appropriate, reassuring, and how to get there from here.

We (well...me, because I love to care for sick kids) unclothed the child and began to assess whether her behavior and exam were reassuring or non-reassuring and discuss where our comfort zone was and what was evidence based. Ultimately she had a non focal, reassuring exam and the result of our 2 1/2 heads being put together was to send her to the Kanye hospital to have some blood drawn (an FBC, equiv to a CBC) while she was re-examined there. One of my pet peeves is the lack of conversation between outlying clinics and hospital staffs. I demonstrated how to do this and why it was so necessary. So off she went, and so did we about 40m after we had originally headed for the door.

Tomorrow Lynne and I head to Mahalapye, a town about 200k north of here to see if we could live there as this is a great place to establish a FM residency. If the answer is "no" then no sense in continuing the conversation about having a role in the new FM residency.

I have my sweetie back, my health (such as it is with a bleepin' seizure disorder) back, and have a bright future. I'm a lucky guy.

One other(x3) thing

2009-05-08T18:24:00.003+02:00

Still febrile today so I saw Nicola and he of course asked to see the lesion..which it turns out has an escar in the center. Since I couldn't see my own fanny and Lynne wasn't advised of the difference it simply was overlooked and, well, when was the last time I had staph and felt this crummy. The adenopathy is still regional but unchanged and I'm still flippin febrile.

So off to the pharmacy I go for some doxycycline and here's hoping that this does the trick. African tic fever. I certainly was in plenty of places I could have been exposed. It's a better idea than mine to be sure. No spots yet and the doxy is a bit broader spectrum and ultimately a better choice than the clox I was taking.

One other other thing

2009-05-07T19:52:00.005+02:00

Turns out that that fever is from a bug bite that I got sleeping at the lodge the night of the storm. I, being me, scratched the blazes out of it in my sleep and now have a consequent staph infection on my back side. I had thought that the adenopathy in my right inguinum was...what, well who cares I was sick dammit. Then last night Lynne saw me in the shower and noticed a bright red beacon of infection on my right lily white butt cheek with streaking around to....yup the same adenopathy. So today is the third day of the "feel bads", first day of antibiotics and hopefully one of the last days of febrility.

It's interesting how you can walk into a pharmacy here and ask "got any cloxacillin?", and they will simply ask how many you want. Good thing the UPenn Division of Infectious Disease signs my check and I have two close in-country friends who are ID docs. Now if they just had a magic wand they could wave over me....

In the grand scheme of things I'm a wuss. The hospital is full of very sick people. I have NOT seen a normal chest x-ray since resuming morning report two weeks ago. The stoicism of the Batswana can be incredible.

Go OMS!!

One other thing

2009-05-05T09:03:00.003+02:00

I forgot to mention that at about 0100 I awoke to a calm between the storms. Lynne stirred and we went outside into the night to see what I really love about the African bush; the night sky.

I remember marvelling at the Milky Way in the Sierras when I was a scout on a fifty miler or at Philmont in NM. But I appreciate them so much more now. The night sky was just loaded, nothing recognizable as it was early in the am and in the southern hemisphere but the Milky Way was about 30 degrees of arc across the night sky, extending horizon to horizon. Incredible.

Today I'm sick with a fever and fatigue, perhaps a hangover from the weekend's adventure

Oh, Beth got a job! She starts as an ED nurse at SW Washington Medical Center in Vancouver. She will be fantastic and they won't have any idea what hit 'em. So proud of the outlaws and inlaws in the fam.

Go Oregon Masters!!!!

One for the books

2009-05-03T20:50:00.005+02:00

So there we were on the Kalahari Desert in central Botswana, the Khustse Game reserve to be specific, when…..but first let me set this up better.

Lynne and I have vowed to see Botswana more that we have to date, which is essentially nil. This was a huge oversight on our parts as we were so busy setting up a home and career path that we neglected to actually “see” this extraordinary country. So beginning this Friday we started to do a better job. Friday was May Day, a national holiday in most of the world except the US. I decided to work it and took Lynne to Kanye to meet a favorite MO friend of mine, Abdosh, and his family where she would stay and visit with his wife Hanan, their 8mo old and two yr old daughters and 5yr old son. I took along a Penn resident and we worked the A&E as well as rounded on the wards with the MO on call .

After Abdosh and I worshipped in his mosque we all sat down and had a monstrous Ethiopian meal. His wife is the age of our kids and they have a beautiful family. After our goodbyes, I was able to drive part of the way home before the meal caught up to me and I had to pull over for a quick nap. That night we had dinner with the new dean of the University of Botswana School Of Medicine and discussed how family medicine and I might fit into the short and long term picture.

Saturday we, another couple from Penn and two other Penn folks, a resident and a NICU nurse, loaded up into a safari truck (read open sided with three rows of stadium like seating) and headed off to the Kalahari for a couple of days of game drives and camping. The weather has definitely turned here and is colder, heavier, with shorter days and cool nights. The work week was clear and bright with gorgeous days and starlit nights. And you knew it just had to turn…

We arrived in the park after a 4hr drive north of here into the Khutse Game Reserve, one of the two large central Botswana game parks. After setting up camp in an area that was very reminiscent of Eastern Oregon's Christmas Valley, we went out on a game drive and saw wildebeest, hartebeest, springbok, gemsbok (oryx), bird life of all colors and hues, huge kori bustards (largest birds of flight)…..and then noticed an anvil cloud on the leading edge of a huge, dark, weather front.

We thought we might get lucky and have it blow north of us but were disabused of that idea as it bore down on us.... and the whole time I was thinking, "come on, this is a freaking desert!" But no, we were clobbered by a monstrously powerful thunder-storm with hail and a funnel cloud! Did I mention we were on a desert? We raced back to camp, got caught out in the open and had to back the truck into the wind and rain so we could at least try to stay warm under some wool blankets while we hunkered down like a Texas jackrabbit. Man we got soaked. The only thing worse than wet is cold and wet, which of course we were as well. Did I mention we were on a desert where the annual rainfall is measured in millimeters? We were later informed at the office that the storm dumped 44mm (about 1.75 inches) of rain in 20min.

After the huge storm; lightning, hail, rain, wind, cold, and funnel cloud passed over us we beat it back to camp in the dark and rain to find our tents which were the classic square igloo-type with external bendable poles had blown into the next district along with the table and service items. So off to a local, and the only, B&B we went in the dark, in the rain. We stopped at the gate of the park and found a San kid who had become so disoriented from the storm (it being so rare and all) that he was headed the wrong direction back to his village. This NEVER happens with the San, the original Bushmen. We gave him a ride.

We spent the night in dry warmth and went to clean up the carnage this morning finding the tents in some cases 30m from the camp. We dried everything out as best we could and headed home, laughing at our situation and marveling at the specter of the Kalahari. No lions, but lots of great non-carnivores and birds and the storm of a life time. A great weekend.

Worms!!!!

2009-04-30T18:28:00.002+02:00

I was in Lobatse today and spent some time in a local clinic with an MO from Nigeria. That the majority of out-patients we see have so-called “medically unexplained symptoms” is a source of both fascination and aggravation. Yesterday I was in a rural area of a district north of here where a Penn medicine resident and I saw about 40 pts in 2 ½ hrs, ALL of whom save one had the above MUS. I’ve ranted about this in the past but yesterday took the cake. To make a point with the staff of the outpost I resisted giving out meds and wound up Rx’ing just one antibiotic for impetigo.

The MOs here see all the hypertensive patients every month for refills of their meds. Because this is a relationship based society the patients will say anything necessary to get the attention of the MO and get what has become the currency of medicine here and in all developing countries; medication. So virtually all patients leave with paracetomol (acetaminophen), and some Vit D tabs, Wintergreen oint for application to whatever hurts, iron supplements (see “Geritol”), and folic acid. Which of course reinforces the behavior in the first place. So I had a woman (it would seem the average patient with this schema is 25-55 and female) return three times for meds when she was asked to refill her BP meds and informed that her (no less than) SEVEN somatic pains would go away in time, and without any other medical intervention. That we are told nothing resembling the truth is something I have become used to and have learned to rely on instinct and physical, and treat nothing I can’t see, feel, touch, or test. So the currency of medicine here is just that, medicine, not information by way of reassurance. And the truth is not a part of the equation. It was this way in Sudan but the patients may have walked for three days to see us and the trip alone had exhausted them, necessitating some form of medical intervention. Some days are more frustrating than others and today was that kind of day.

I went back to the hospital at about 1230 and met a good friend of mine, Roger, who has been assigned to A&E and maternity. We discussed cases and as we were ready to head off for a mid-day meal he invited me to his home for lunch. We got there and were surrounded by elementary aged girlies playing with dolls, running around playing hide and seek, and women fixing a huge meal for us. Part of it was a dish of mopane worms. These are caterpillars that are harvested in the late Spring/early summer (read November and December) and dried for eating later. They are sold in bags at all local markets and stands. The Zambians (Roger’s nationality) are also famous for enjoying them and now a bald headed guy from Oregon is too. They are chewy, salty, gritty, and loaded with protein. We ought to give these out for all the somatisizers that plague our clinics. At least that way they would get something of value true proteinaceous value. So I get to check that one off my culinary list….

Best of luck to our friends that are headed to masters nationals in Clovis, CA! Just remember, it ain’t Fresno, it’s Clovis, so it could be worse. Seriously good luck, good times, good fun!

Gun violence

2009-04-26T06:45:00.004+02:00

It's only when I have lived in a country where even the police don't carry a gun that I realize how ridiculous the 2nd amendment controversy is. Each week I read on CNN or somewhere else about how, but for a gun, some individual would not have massacred his family or friends or acquaintances or strangers. Even if he had a baseball bat most would be alive.

Interesting how mostly in the US does one read about these things. I’m confident the advocates for guns in the home have considerable data to support their view but try living here in a nation where owning an unregistered gun will land you in jail for 20 yrs, TOMORROW, where arguments are rare and solved with shouting or, rarely, knives and you’ll see my point.

I asked the emergency room staff in Kanye the last someone had been seen there as a result of gun violence and no one could recall ANY time, EVER, that that had occurred.

When we were robbed of our computer in our bedroom, had I a gun, he would be dead (if I hadn't shot Lynne by mistake who was between me and the kid cussing him out) and I would still have our computer. Let's see dead guy on my conscience vs laptop.....doesn't pencil out for me.

It’s a cool crisp Fall morning, great day for birding.

One for the books

2009-04-24T17:22:00.002+02:00

What an extraordinary day! Friday is Kanye, my favorite drive through the back country of the southwestern part of the country. It is about 120km from here. The medical staff is largely Moslem or very evangelically Christian with five countries represented on a staff of eight docs, including Ethiopia, DRC, Zimbabwe, Argentina, and Philippines.

I led a discussion about chest pain and how all you really need is a good history and physical, but that you really NEED a good H&P and can’t short cut around it. After that an EKG and chest X-ray would be nice but not absolutely essential. Then it was down the hill to the civic center (read district offices) for a two hour discussion with the outpatient MOs about medically unexplained symptoms, chest pain, and the like.

Here all hypertensive patients are seen every month. Because this is a relationship based society and because health care is free all the returning hypertension patients have virtually the same 6 complaints of somatic pain. All in order to get your attention and some medication which indicates to them that you; a) care, b) take them seriously, and c) that they got the currency of health care in a developing nation- meds. Whether they truly need it or not. So we discussed how to ask, “How are you feeling?” instead of “What is the matter?” and how seeing returning hypertension patients with stable blood pressure can be done every 6 mos rather than more frequently and thence clogging up the queue.

I then returned to the hospital to join a dear friend and colleague, Mohamed from Ethiopia, for Friday prayers in the mosque and lunch at his home. He has three kids, an 8mo old, a 3yr old, both girls, and a 5yr old son with birth associate brain injury. His wife is a gem and an amazing cook. We had the usual staple of rice with potatoes and lentils, and chicken. Wow….

The drive home was beautiful and Fall-like, and culminated in the best part of the week/2months in that Lynne is home!!!!! She came in on Wednesday and has been getting her feet under her and looking forward to some adventures out there with yours truly. Man did I ever miss her.

So a great couple of talks, a moving prayer service shared with men who I am convinced worship the same God as I do, a magnificent meal, and, best of all, my wife of going on 35yrs is home….a great day indeed.

Easter Weekend

2009-04-12T12:14:00.001+02:00

There is a local hill near here that overlooks Gabs and the surrounding Botswanan and South African area. It on occasion is the site of robbery and muggings by local thugs and so is on “the list” of the US Embassy as place one shouldn’t go. So I got up this morning early and went. But first a bit about yesterday…

It began with meeting an MO friend of mine from Zambia who works in Lobatse. We met at a local amusement park that is just of the main road in the bush. His kids are 2 and 8 and gorgeous. I was great to see his family and to watch every flavor and color of people there. Teens are teens anywhere; girls giggling and grooming with an eye on the boys and boys playing football with an eye on the girls. Parents over indulging their kids and general fun and laughter as the kids ride some rides that remind me of a county fair. I have vowed to get out of the white expat culture and this was a good first start.

Nicola and Chawa, both valued friends and colleagues invited me to their flat for an evening of high protein intake (I’m a touch underweight apparently) and hepatic stress testing. Nicola is from Peru and brilliant. He somehow hit the jackpot and is in relationship with Chawa, an equally brilliant Batswana who is as beautiful as she is brilliant. We sat down to some whiskey, he and I smoked pipes, ate some meat, drank some more whiskey, more meat, more miskey and more weat…..Made it home in one piece but had to bargain with my GI tract and liver that I’d go easy from now on. It was delightful and peaceful to sit, laugh, eat, laugh, and relax. I even took several naps yesterday.

This AM I climbed Kaghle Hill to watch the sunrise and again saw all flavors of people up there. There were Africans from all over sub-Saharan Africa, South Asians, East Asians, and one bald white guy from Gabs by way of Hood River. It was a great way to greet Easter and feel a citizen of the world at once. It would be tough to be a mugger with all the folks around. Some younger people regularly run up and down the trail, a hill like one in the middle of the Hood River Valley, only taller and rockier, and oh-my-gosh I can’t recall its name.

So today its more naps and lazing around. I will write a talk about anemia this afternoon for Tuesday which should be easy and then an easy evening on the ol’ liver. Happy Easter to those who celebrate it. Hope all is well for all of you and those you love.

Some of the places I've been

2009-04-10T16:28:00.002+02:00

I was in Artesia this Wednesday and thought I'd try to post some of the places I've been or go to each week:

Artesia:

http://www.wikimapia.org/#lat=-24.0149506&lon=26.319809&z=16&l=0&m=h

Kanye:

http://www.wikimapia.org/#lat=-24.9723843&lon=25.3414679&z=17&l=0&m=a&v=2

Lobatse:

http://www.wikimapia.org/#lat=-25.206339&lon=25.67433&z=17&l=0&m=a&v=2&show=/12185067/

Mochudi:

http://www.wikimapia.org/#lat=-24.3828668&lon=26.147697&z=16&l=0&m=a&v=2&search=mochudi%2C%20botswana

Hukuntsi:

http://www.wikimapia.org/#lat=-23.9960938&lon=21.7966604&z=15&l=0&m=a&v=2&search=hukuntsi%2C%20botswana

Ghanzi:

http://www.wikimapia.org/#lat=-21.7101077&lon=21.630578&z=16&l=0&m=a&v=2

(before it was built apparently)

Dufus take two

2009-04-07T18:32:00.002+02:00

So after meeting with the tech guys three times on Monday and getting nowhere, and then with the customer service folks today I have been able to return my iPhone for a refund minus P999 which I chalk up to being a dufus and a total nimrod. Back to four separate components. Good thing my back pack is big enough. For being an idiot it'll cost me $132.00 US which is probably appropriate. I was informed that this is the first time they have ever given a refund....Sure.

I have been trying my best to give accurate data for the funders of our program (read PEPFAR) but it is such a massage of data that I find it annoying. Sure it is necessary as they want to be sure that they are funding the proper agency (us) but is really has little to do with the day-to-day stuff that I do. Frustrating to say the least.

I feel at low ebb, the case of the ass is better but this stuff is distracting and preoccupying from what is truly important. And I guess it's necessary.

Musings on a Sunday

2009-04-05T15:56:00.000+02:00

Lately I’ve had what my dad would call, with an infectious twinkle in his eye, a “case of the ass”. Except I’ve lost the twinkle. I really can’t attribute it to any one thing, more like a host of annoyances coming to fruition at once, or so it seems. While I really miss Lynne which I’m sure is the major part of it, in truth I’m fortunate to be here, at this time in my life, doing what I’m doing, where I get to do it. And there is still the possibility of starting a Family Medicine residency here, at once and an honor and a pain. Maybe that’s it; I got the trees in sight, just not the forest. So I am exercising fool, swimming on the weekend and running during the week, becoming an endorphin junky. There is apparently a family bet that I have lost some weight and things are hanging a little loose on me. So my default meal of oats-yogurt-fruit-milk is apparently a touch lite although not yet boring.

This am I took off to explore an area off the main road on the way to Kanye and to get behind my eyes to sort things out. There is a grove of cotton-wood like trees, in a river bottom, that are changing color as it is fall here. The rustle of the leaves as the crisp wind moves through is like sweet music. It’s only 40km from here and is very renewing. I’m slowly coming around to the idea that I am in the southern hemisphere and that this is both April and Fall. The days are crisp and clear with warm afternoons and cool nights.

Yesterday I got an iPhone in an attempt to consolidate phone, PDA, iPod, and camera. I must admit that I do not find it the least bit intuitive and am struggling to get it sorted out. I think the PDA part works only if I am near a WiFi area and that is rare. I’m not sure how to load UpToDate on it and it may be impossible despite what the people at Orange (a French company of course) assured me of when I thought and thought and inquired about it. So the SIM card travels back and forth between my cheap cell phone and this expensive, and thus far suboptimal, gadget that I’m embarrassed to admit I bought without figuring the whole thing out.

The UTD comes on a “DVD” and I can get to my desk top, but from there I’m not sure how to load it into the iPhone, and then if I can how to easily get to it from there. Jeez I’m so 60’s and yesterday!

Course it would help if I wasn’t such a cheap bastard. I mentioned a while ago that I got a great deal on a bike called a Supa Hamba. It’s a touring config and cheap, as opposed to inexpensive. I broke the rear coaster hub such that I could neither peddle nor stop and took it apart and immediately saw why it was so cheap, because it was build cheap. Note to self; quality might cost a touch more. So I took the hub to the local bike shop that actually has a mechanic who took one glance at it and said, “Ah I see you have a Supa Hamba!” I now will have more money into it than had I got a true Hamba as I’ll have the frame of a Supa and the hub of a Hamba, so it truly will be a Supa Supa Hamba. Ah life, it happens doesn’t it. The forest is in sight, I just need to take off the blinkers and enjoy the wider view.

Been a while, 2nd edition

2009-04-03T18:31:00.003+02:00

Well it's safe to say I had a regular week! It began in the clinics here in Gabs where I mentored a very capable, and lonely, doc from DRC who staffs a busy clinic in a central neighborhood. One of the interesting things about this area is that compared to a generation ago when there literally was no health care, now any access is generally considered of good quality, which of course is hooey. Suffice it to say that the Gabs MO's run the gamut from caring and compassionate to abrupt and arrogant. Sound familiar? This guy was a member of the former.

The que at the clinic on Monday and Tuesday was literally spilling out the door. Some of the crowding is self inflicted as the MO's want to see all hypertensives back each month. The data shows that we typically need to treat 100 patients for 5 yrs to prevent 3 complications from this disease. So slowly I am convincing them that once every 3-6 months is plenty and will reduce the daily patient load by up to 15%. They are typical of docs with the same level of training in that they over treat from a sense of insecurity and over diagnose just in case they might be missing something. This adds to their fatigue and length of work day. So in there is a compromise that works for all. Added to that is the reliable fact that all patients returning for a blood pressure evaluation ALWAYS have some variety of somatic pain so these visits take a toll on concentration and quality as the path of least resistance is false diagnosis and treatment that once begun is difficult if not impossible to discontinue.

And it gets in the way of emergent care. We had an 8 y/o child with HIV on HAART who had a twoday history of bad impetigo and was septic. He showed up with his grandmother to the clinic. Thankfully he was appropriately triaged and we saw him in a timely fashion. His pressure was down and he was somnolent. We started an IV and gave him a gram of ceftriaxone and then tried to achieve disposition such that he could be admitted without going through the land of no return known as the Princess Marina A&E (emergency room).

Since he already had a diagnosis and treatment had started all he needed was a peds bed and a doc. I was able to achieve said objective with a few phone calls and had to ride the ambulance (a covered pickup bed) with him to continue treatment. We parked in a different lot much to the consternation of the driver who knew we were breaking protocol, and I carried our boy to the peds ward to be met with a lot of eye rolling and not a little passive aggression. A small nuclear event later said child had a bed and the doc I had called showed up to assume care. MUCH FASTER than going through the A&E, and he is better at this writing.

Two observations. Many children here are raised by grandparents as their parents are living in a different town, dead from HIV, or too young and that's the way they were raised themselves. This of course is not unique to Bots, just interesting in passing. Also, PMH recently underwent an extensive evaluation by a South African firm and was found to be in compliance with the international standards of care (apparently as enunciated by WHO among others) all of 3% of the time(!). THAT is no surprise and just might motivate officials but I'm betting that it won't see the light of day. It will instead be a small change, a bit at a time, dripping with politics.

But I am so very fortunate to be here at this time in my life and career. I love what I get to do, love to teach family medicine and introduce it to the Penn students from my perspective, love to treat. It may not get much better....

Been a while

2009-03-29T17:46:00.002+02:00

It was a busy week with travel to the usual areas and teaching in clinics and hospitals. The topic of the week was outpatient workup of breast masses. Here there is a tendency to simply hear the complaint and refer for surgical excision, something that can be rather non-cosmetic. I brought the idea of a comprehensive history, appropriate physical and fine needle aspiration/biopsy to the table as a means of more immediate diagnosis. It was well received as the docs are generally unsatisfied with the lack of imaging and other alternatives available pre surgical intervention. The FNAB idea should help allot.

On Friday I went to Kanye with an actual Penn med student who matched in Family Medicine, at the Ventura program no less. We were assigned a clinic at the outskirts of Kanye only to find that there wasn't an MO there so we saw about 35 pts in a three hour period, most were kids with "fever at night". It was illustrative for the student in that we prescribed only one antibiotic; for an adult with abscesses. A significant paradigm shift to be sure, and one not lost on the nurses and staff.

Yesterday I met with some FM residents through the Stellenbosch University (in SA) distance learning program. We did a unit on "how we learn" and then exchanged ideas on what it is that attracts us to FM. Interesting spectrum of reasons from "I will make more money" to "I enjoy the patient population"

Today I took a drive out to an area about 45min from Gabs on a spur away from the road to Kanye. It was an area I pass on the way out and back to Kanye and wanted to see but never had the time. It follows a valley back to the Gabs area. Glory be it was beautiful. Along the way there was a grove of what reminded me of Aspens or Tulip Poplars that were just beginning to change color (it's early Fall here with crisp mornings bright sun that is lower lying on the horizon and warm afternoons). The grove of trees had a stream running through it not unlike Oregon, a real refreshing, quiet, reflective time.

Location, location, location

2009-03-22T13:13:00.002+02:00

I found this on an older blog of a friend that moved back to the states. It is a map of where we live.

http://www.wikimapia.org/#lat=-24.6520293&lon=25.9128749&z=12&l=0&m=h

2009-03-21T09:45:00.000+02:00

Wow, all I can say is… Wow.

I and a Penn medicine resident, Monika, arrived in Hukuntsi on Monday afternoon after a 400km drive from Gabs. Hukuntsi is on the western frontier, literally at the end of the road. Or at least where it turns to sand and really gets out into the bush. In the town is a primary hospital that is incredible. It is staffed by about 100 people with medical, maternity, surgical, and pediatric wards and as many beds as PHRMH in Hood River. It is spread out much like a California elementary school.

The first order of business was where we were going to stay. There is a single guest house in the town and it was full the last time we checked so we were prepared to stay in the car or on a bench in the outpatient department. Monika is, amazingly, lower maintenance than I and game for anything, a well seasoned traveler. Well this wasn’t OK with our host, Dr. Kalenga, a 54y/o doc from DRC who has the ability to get things done like no other MO I have seen, hence his presence in Hukuntsi. The hospital was under major remodel, and he and just two other MOs both unseasoned, are the medical presence there. So the short of it is that we stayed as his guest in his home in the staff compound of the hospital. His wife was in SA at the graduation of their son from university in Jo’burg.

It was a rare treat to spend a day and a half in his presence and teach, learn, mentor in the in and out patient confines. What is great at these places is how the entire staff enjoys a presentation, not just the docs and the conversation is amazing. I literally had to remind myself where I was many times. The last night we went on a walk to an area about 1km outside the fence of the compound where he tried to reassure me that predators only like dark skinned prey, hilarious.

We bade farewell on Wednesday and travelled 300km to Ghanzi, in the NW of the country to another primary hospital where the reception and for that matter the hospital design was very similar. It was run by a man, Dr. Simwanza, from Zambia with his wife also a doc. The staff there was bigger as the population was from the largest area in the country. They see patients from as far away as 250km to the NW and E.

They also see members of the San, an ancient people that use a click dialect that requires an oropharynx that is hinged differently than mine! A smaller and very open faced people that are genuine and loving. A mother of five brought in her fifth child, three days old, with an imperforate anus, patent urethra, and vestigial or absent vagina. At the same time we were discussing a patient that Monika tool to immediately who had new onset liver masses and needed a CT scan. Here in Bots we are good at building hospitals but haven’t yet decentralized imaging so we spend obscene amounts of money to fly or drive people to Gabs for tests that could/should be done locally. At any rate Flying Missions was called and flew in to Ghanzi that evening and took both patients back to Gabs for definitive diagnosis and hopefully therapy.

Yesterday morning we took off at 0730 and drove 675km back here, arriving at 1530 through monstrous African rain storms. I am convinced this is for me, that this is the best way to do outreach (at least a day in the location), and that I’m a lucky guy. What a beautiful country, beautiful people, beautiful opportunity.

2009-03-14T18:42:00.003+02:00

Life sans Lynne is different and difficult to be sure but with the web and Skype, real time Gmail chat and the like it is easier to stay in touch. And distance at some level seems to promote communicating in a fashion that would otherwise not occur. Conversations are deeper, addressing long suppressed stuff, stuff we thought we'd handled long ago, and just STUFF. Interesting how that drawer, the "stuff drawer" can be so crammed with, well, stuff, and both parties can be so unaware until one is gone and the communication centers said stuff and cleaning out the drawer, or at least arranging it.

Was in Moshupa on Friday and met one of my new "mentees". You see-I are a mentor. I am a mentor for several of the family medicine registrars (residents in the US terminology) that are participating in the distance learning and residency through Stellenbosch University where I visited two weeks ago. Moshupa is spread out along the road to Kanye from here and has numerous remote clinics there so I already like the sound of it. And I can function in two roles at once, outreach to MOs and mentoring of registrars.

I head out to the remote western part of the country on Monday so will be out of web range for a week unless I find a cafe with access in Hukuntsi or Ghanzi. It should be a hoot as I'll drive there (we actually used to fly, no more thanks to the recession and GWB) and have little plans about where to stay or visit. They know I'm coming but it might mean that I'll sleep in the outpost or clinic, maybe the primary hospital if I'm lucky in Hukuntsi. I have a place to stay in Ghanzi.

The weekend has been one of preparation; inspecting the vehicle I take, cleaning it, and packing. There is a huge amount of nothing between villages out there, guess that's why is called the Kalahari Desert. Should really be up my alley.

Thanks for all the correspondence, it's never enough of course but it is very appreciated.

Magnificent!

2009-03-10T17:53:00.002+02:00

I just got a text from the doc in Lobatse who has been treating the woman with NMS and she is up, walking around, wondering what the big deal is. What a sweet save! She owes her life to two students from Penn who were in the right place at the right time while their preceptor was in the john bowing to his hyperplastic prostate. I made sure they knew.

Next week I hit the road to the far west of the central nation, a primary hospital in Hukuntsi. I'll stay there a couple of nights then head east and join the road north to Ghanzi where there is a district hospital. I'll be there teaching and mentoring two nights as well. I hope to visit some outlying and remote clinics from there.

Then a long drive back home to Gabs and a lot of discussion to be had. Lynne is enjoying herself in the US and having a wonderful time with the various outlaws and in laws. We are indeed blessed to have all of them in our lives. Aven is term and "WANTS TO HAVE A BABY!" and who can blame her. It will be a hoot when "B" makes the scene.

Tomorrow I participate in the interviewing of candidates for Dean of the new medical school here. It is very protocolized and formal, we'll see how it goes. We need to get past some of the institutional inertia and get busy.

And we're two weeks into this two month adventure of Lynnes. I sure miss her and am glad she is spreading the "Mom joy" around the corners of the MLPs.

So I found myself in Lobatse today...

2009-03-05T18:44:00.002+02:00

Today I began the day by picking up two med students and driving to Lobatse. The drive is beautiful this time of year as everything is green and lush. As i came across a small rise where the speed limit changes from 120 to 80km/hr I took my foot of the pedal and was slowing, but not soon enough as the local cops got me on radar at 90. So I got waved over and had to pay a fine of just P80, about $10.00. I HATE the latest toy these guys have, the video radar gun. If the enforcement was consistant, OK guilty as charged even though I was all of 6mph over the limit and was slowing. Simmer...

In Lobatse we began at the hospital, the oldest in the country with wall that are 1/2m thick and wards of 8-12 beds. Rounds there and in other hospitals are a grnad time as the nurses participate and the discussion falls to how much they are a huge help. Yesterday we saw a woman in Mochudi with Toxic Epidermal Necrolysis from anti TB medicatoin. This is a blistering desquamating skin condition that is often deadly unless the nurses and docs are all on the same page, paragraph, sentence, word. There were 10 nursing students, two docs, a med student from Penn, and your truly. It was a great time to empower the nurses and reinforce how they are the ones that get the patient better while we just write the orders. It was a lively 30m discussion at the bedside.

This morning we discussed the next epidemic that will hit this country (diabetes 2) and then went top a local clinic where a doc, Armstrong (named after the astronaut), and the three of us spent five of the best hours to date seeing and teaching/learning. It was great. The diagnoses spanned the spectrum: VSD, dermatographism, dystonia-dysautonomia, somatization, lung neoplasm, Parkinson disease, a real full and fascinating day.

We then returned to the hospital to round in the afternoon on some of the more complex cases and WOW did we find one. We were introduced to a woman who had been on Haldol for agitation and now had a fever of 39, was rigid, comatose, and near death. The students examined her and raised something I had not seen in my career but was starring us in the face; neuroleptic malignant syndrome. We got busy. If she lives she owes her life to two fourth year students from Penn.

2009-03-01T18:22:00.000+02:00

· Since starting Keppra I seem to have my mind back. Weird.

· Since starting Keppra I no longer have vicious night sweats. I had some in Sudan, but nothing like the wringing wet sweats I have had over the last two years. The last one was the night before I started this stuff. Go ahead say it, I can HEAR the eye rolls. And you’re right. I just haven’t included that in my image of myself yet; a prescription pill taker. Selfish? Yes. Stupid? Why yes it is. Annoying? Actually not as much as the fuzz of a seizing brain and the night sweats now that you mention it. So, perhaps a good thing and I should just get over it already.

· The gay community is alive and seems to be thriving here. I see couples (mostly male) everywhere displaying affection for each other without, so it seems, fear.

· Best to all out there……

Randomness again

2009-03-01T14:27:00.006+02:00

Some random unconnected thoughts:

· Did I mention I miss my sweetie

· Family Medicine is alive and thriving in South Africa from where I just returned having spent the last part of the week learning about the de-centralized model of resident (called “registrar”) education. There they place a resident in a rural setting and formally educate him/her on-line thus assuring a better chance that the resident will likely stay in the rural area post training.

· I look forward to having a role in establishing the residency here. It will be the first here in Botswana! Wow, gives me goose bumps just thinking about it.

· “University of Botswana School of Medicine”, still a few administrative docs in a trailer, is moving along. The model they use is to employ current faculty in various and necessary departments to teach not just grad students but med students as well.

· The referral hospital here, Princess Marina, is a monstrous, hide bound, disorganized, mess and unready for the role anticipated for it.

· The district hospitals should do better as they transition to a teaching role.

· Stellenbosch University School of Medicine is situated on the campus of Tyger Valley Hospital, a monstrous building that is 12+ stories high, over 200m long, two buildings side by side connected by corridors across the gap every two floors. Why? Apartheid. Now it seems ridiculous but when the place was built total separation was the rule. Less than two generations from now it (apartheid) will be a memory. Unbelievable that an entire country/culture can change that fast.

· I will never get used to nor take for granted the shanty towns in the Cape area, each has more people in them than the entire state of Botswana.

· In two weeks I hit the road for some rather rural areas out west of here. Places where we used to fly but with the economy and all….So the bummer is I get to drive out there and stay a few nights and teach in a little more intense environment. The things I “have” to do.

· I’m sitting here listening to Bela Fleck, live is good. Listened to Wait Wait Don’t Tell Me earlier. It’s only mentioned because I can actually navigate make my IPod do this stuff

· Got up, washed and waxed the car to the great amusement of the people that live here as NOBODY does ANY work on ANYTHING that can be hired out. Then fixed my bike, mowed the lawn and tied a ball to the ceiling of the garage so I now know how far in to park the car; a productive day.

· Oh and a fat nap.

· Talked with Aven and Eli. Heard about TJ and the now famous apple pie massacre, I got your back big guy.

· Having Shannon, Amber, and Olivia in my life makes we even more blessed.

· Facebook came along at a perfect time in my life. I know sounds kinda juvenile but there you have it.

2009-02-24T18:12:00.002+02:00

Well I kissed my sweetie goodbye today, leaked a little as I walked out to the parking lot at the airport and began a two month period of bachelorhood. Did I mention I miss her? I’ll be fine but did I mention how much I miss her? Sure things will be different, not worse, just different but did I forget to say how much I love this woman and miss her. She’s off to visit her sister and walk on the beach sorting out their relationship and other pressing issues.

Then it’s off to VA then FLA to visit sons and some truly extraordinary daughters in law. I truly have been blessed with the presence of some extraordinary women in my life, including my daughter in law to be. Finally she will arrive sometime near (we hope) the delivery of our second grandchild, first granddaughter and first child to TJ and Aven. Yes Aven is the one who’s pregnant but they both have symptoms and both deserve lots of love and support. The fam was out there this past weekend to “shower” the expectant Middlesworths with stuff. They hung out and laughed the weekend away, which at a most basic level validates my/our parenting as it is truly delightful that they enjoy each other’s company.

Today was one of sadness and reflection for me as I don’t enjoy being separated for great periods of time even if there is adventure involved, contrary to popular myth. I worked a local clinic and saw more of the same. It is the MOs that I enjoy as I seem to have something to offer on each case. I gave a talk this afternoon on hypertension; how it’s not a number were treating but a patient associated with the number, maximizing one med before adding another, when to switch, which to use based on race and ethnicity, and who not to treat. It was a hoot, very stimulating conversation, and I hope worthwhile.

Tomorrow it’s off to Cape Town for a class from Stellenbosch University from SA on decentralized post graduate training of family docs. The paradigm they use is to place a resident in a small community where the need is great then teach over the web. This way the resident has a local mentor who also benefits, bonds with the community, and generally stays there after residency is completed.

Jeez I miss her.

Then the third week in March I take to the road for a trial run out into the wilds of Western Bots to visit some remote hospitals and clinics so I can assess need and desire for assistance. That should be a true adventure. Love to hear from anyone out there,

Mike

2009-02-21T15:59:00.001+02:00

This has been the week to confirm in my mind why we are here. Wednesday thru Friday I had a chance to teach in clinics that were way off the grid. Wednesday I arrived in a clinic associated with Mochudi district, north of here. The clinic is on the SA border and way off the beaten track.

As in many places in this part of the world, women here are worked to the bone, especially in rural areas. As a result one of the few ways they can take a break is if they are “sick”. So they come to the clinic and are in exaggerated extremis with hand to forehead fainting, general body failure and “altered state of consciousness”. The nurse or physician (if indeed he is there that day) will receive the woman and designate a family member to be her advocate as she rests. She gets an IV as that is what is used to treat this. When you think about it, it makes sense in that she is “forced” to rest for about 3-4 hours as the iv goes in, “recovers’, and goes home to her multiroled and exhausting life.

So as we entered the clinic two nurse practitioners were in the middle of treating a couple of women in this modality. We were invited to evaluate them mostly as a courtesy to us in recognition of our station. The problem was that both were septic. Sick to be sure but getting as IV wasn’t about to address the problem. So this was a great opportunity to reinforce the clinical skills the nurses were demonstrating and at the same time discuss what represents infectious disease in an HIV/Tb infected woman who appears ill, why to take vital signs more frequently and when to transfer. Interestingly each of these clinics has an ambulance on standby for that very reason. We are a touch dollar (Pula) foolish over here: huge new hospitals in many districts that are empty when what we need are more providers and decentralized imaging/lab. Oops, sorry, rant over…So off they went on a 60km odyssey to DRM Hospital in Mochudi, hope they made it.

Yesterday I was at the central clinic in Kanye where there wasn’t a doc as he was “at a conference” so a nurse practitioner and I saw about 50 pts with lots of teaching opportunities involved.

The weather is like late August/ early September back in the Pacific NW, hot and dry. All the grass is seeding out so allergies are at a max and many people come in plugged to the gills. For some reason the grass along the roads is whipped down with a curved machete like tool. It keeps people employed but is unbelievably difficult work. All the vehicles are covered with a fine layer of pollen.

Speaking of which; there are no junkers here, no shanty towns, no homes with cars on blocks in the yard, litter in the street. It is a very fastidious society that is predominantly middle-working class, educated (at government expense), and one used to a tradition of due process. They/we have the usual weird circumstances inherent in an emerging nation with deep pockets (see above and previous rants).

So why am I here and not trying to “make a difference” in, say, Appalachia, the depressed Mid-West, inner city Gulf coast? Well, I only have so much time left in my career and with 1.8 million people here in a country the size of Texas I can find the handle and begin to manipulate health care here as this nation gets its first med school, FM residency, and residencies in peds and medicine. And I am a citizen of the world.

2009-02-13T19:30:00.000+02:00

Today was one of those days that confirmed for me why I/we came here. Outreach can be a bit of a crap shoot in that I never know what will be out there and if there is anything I know well enough about which to teach. Not unlike an average day in the clinic back in Hood River in that each day was a new one and represented a challenge in and of itself. That is what makes family medicine so fascinating to me.

Today I visited outlying clinics and outposts in the Kanye district that is SW of here. I introduced myself and then was promptly enveloped in the patient sitting in front of the health care provider and actually had something to offer all of them at each clinic. I saw acute on chronic pediatric malnutrition for the first time and was able to invent a way to save the child an IV and a referral. The nurse provider and I had a great conversation about how to detect dehydration in a child who already has a quasi-positive tent sign from lack of calories, let alone fluids. I demonstrated how weights were essential in the evaluation of a child especially one on whom you have previous measurements; all this in the middle of nowhere. It was all very reminiscent of, dare I say it, “MSF”. The TFC kids taught this old family doc so much and some of it actually stuck, imagine. And now that I’m on anti-seizure meds things are recallable so much more efficiently, as much as I hate to acknowledge it.

I came home through Molepolole, a town the size of The Dalles, with three times the population and a spanking new hospital. The building is so very out of place with corridors that are 200m long, empty wards, no specialists (at least a radiologist would be nice), and now CT scanner. We’re learning slowly here and in the process make many of the same mistakes well endowed developing nations make; equating physical plant with quality care.

The drive was amazing; the African sky extending on forever with clouds and sun, brisk wind and green everywhere. We are at the equivalent of late August with the nights getting longer and days brighter and shorter. Fall, like back in OR, is more of an acknowledgement than a date.

Lynne leaves in 10 days for a tour of the kids and then the advent of our second grandchild. That would be Aven and TJ’s first, a much anticipated daughter.

While she’s gone I intend to hit the road and visit some very remote clinics that will take a couple of weeks to really see and evaluate. Should be a hoot.

Back at it

2009-02-12T18:38:00.003+02:00

We’re home and in one piece. I dove back into my work here and find myself seriously jet- lagged at this writing: I’m grouchy (to our kids: NO EYE ROLLING) and when I get a chance to nap I awaken from what feels like an unconscious state.

I find myself day dreaming on the road about how weird and other worldly the last month has been. A delightful trip to the Cape of Good Hope area followed by an out of body experience wherein I became a patient, was with the ones we love, was fairly sure I had a brain tumor (a low grade glioma to be specific), then reassured that my brain was not tumorous, just asymmetric and in a weird shaped vessel (my skull). Oooohkaay, how the hell do I put all THAT in perspective? How does a guy who has pursued health his whole life, not unlike a lot of my generation, process this bleep? Just God’s way of introducing some humility in my life I suppose, and never a bad thing as painful and annoying as it might be.

So thanks to all of you for being there for me/us. Interaction at that level, at any level, doesn’t come easy to me, just ask my sibs. Never the less I am at once humbled and blessed, and grateful.

I continue to be amazed that I have anything to offer the medical officers at the neighboring hospitals here. They are just like the FP’s familiar to me who see a patient in the out- patient setting, admit them to the hospital, treat them, discharge them, and see them in follow-up. Today I saw a woman with HIV, on HAART (highly active anti-retroviral therapy) with a month long history of fever on at least five different antibiotics and still febrile. What did I suggest they do? Well, harkening back to my training a million years ago, I said lets stop all meds and see what develops!

The nurses who always accompany me and the doc on rounds immediately chimed in that that was abandoning the patient, a 30+ year old woman with a family to care for. We had an animated conversation during which I invoked all the ID docs I know/knew and assured them that they would agree with me (I deeply hoped) and since we had a good idea of what DOESN’T work, let’s start from the beginning. The harried MO, a guy becoming a close friend, was post call and NOT the least bit interested in another lengthy workup. I demonstrated how it took less than 5 minutes to reinvestigate, via history and physical, what to test and treat, and how, and with what. He was grateful, the patient was grateful, the nurses were convinced, now if the patient’s immune system would just cooperate and improve.…

The drive out and back to these areas continues to amaze; troops of baboons and monkeys, wild jackasses (I know, I know me included), goats, and cattle. Everything is green now and the temp is now humane. I feel like we are where we’re supposed to be for the foreseeable future. We are expats successfully living in Botswana! A new med school, a new family medicine residency, and I get to go way off the beaten track top some remote clinics to teach. All in all, seizure disorder aside, I’m a lucky dude.

Life's little curve ball....is hit outta the park!

2009-02-05T16:43:00.006+02:00

Just got off the phone with "my neuro-oncologist" (that term again) who reviewed the data with all her colleagues and the consensus is this: I have an asymmetric brain with a particular septum structure that is missing, a mid brain structure that is larger on one side than the other (hence the concern about a tumor), NO hole as the area referred to was from a slight asymmetry in the "cut" of the previous MR scan, but so significant change from the MR scan of last Spring.

Bottom line: no evident tumor.

So WHEW! Bullet dodged and I'm back in the saddle with a malformed brain but one that most likely DOES NOT have a tumor and apparently doesn't have a hole! The congenital abnormalities can last a lifetime without causing symptoms or can manifest as seizures. So here I is and I haven't had a seizure for the last 5 days.

Now it's back to Bots to continue the exciting work begun there with a new perspective on things.

The last week has been a growing, painful, disorienting, and yet worthwhile experience to say the least. I just hope I prove worthy of the lessons contained therein.

Thanks for all the support.

Mike

Life's little curve ball

2009-01-30T21:09:00.003+02:00

So there I was minding my own business after having appointments with specialists in infectious disease and neurology Monday of last week, lots of lab drawn, an EEG and MR scan on Wednesday of this week and then “the phone call” came on Thursday. My neurologist (weird how that sounds to me) had seen the new MR scan, comparing it with the old one, and found a “new finding” this time in the L temporal lobe. Those that follow this remember that I have a “hole in my head”, actually an area of unexplained encephalomalacia about 3mm wide in my R temporal lobe. That finding is unchanged and stable, whatever the hell that means. No new holes this time around but there is “a subtle area of inflammation on the cortical surface of the L temporal lobe", the significance of which is cause a fare amount of debate in several departments at Penn.

The end result of all this is that I/we were asked to delay our return to Bots for another week to sort this out with a PET scan and an evaluation by a neuro-oncologist. The differential is tumor vs. infection vs. who-the-hell-knows. All are treatable and the anti-seizure meds are really making a noticeable difference. Both of those evals are on Monday of next week, then who knows…

This feels a little like what I often referred to with my patients as “specialist hell”. The risk of visiting a high powered place like Penn is that, while I have received nothing but very kind and solicitous care, I may get tested to a fare-thee-well only to find out what it ain’t or, worse, “could be” without any definitive sense of what this is or where it's headed. While I’m prepared for that I honestly never thought I’d find myself in this fix. I know, who does, right?

So I’m amused that I seem to be experiencing the classic and well defined grief reaction: denial, anger, bargaining, depression, and acceptance. And I’m slamming around between poles of these stages with a rapidity that is as annoying as it is fatiguing. The truth is that these episodes had been a relatively minor but persistent pain in the ass and had reached a place in my life where some answers were in order. But while the symptom complex is annoying, it’s largely unchanged from when it began just several weeks after leaving Sudan in '06. In any case, I’m assured by my neurologist (that term again) that whatever it is, it’s treatable.

I’d like to be less annoyed by it all and have truly been moved by the response of my kids and family. Time, I need some time to gain perspective. And I need to get back into the things I was doing and love, teaching medicine in a developing nation.

It has been other-worldly being introduced around Penn as a “faculty member”. While it carries nowhere near the same oomph as a bonafide member of the UPenn faculty, having that moniker associated with my name is kinda cool. I NEVER thought when I left Penn in 1980 I’d be back and working for/with them, both enjoying it and experiencing pride for doing it.

So I wait…... I have appts on Monday and then go from there. For now I have time to do things I’ve missed; get my iPod going, trick out my lap top, and load my PDA. Thanks for all the kind thoughts and support. Some of the thoughts I have in the black recesses of my brain don't warrant all the kindness. And I’ll take it as it makes a huge difference, so thanks, truly I’m blessed and very humbled….

2009-01-25T02:49:00.002+02:00

Thus far, three days on meds and the episodes are now about 25% of the frequency and severity. Amazing, this stuff seems to work! Now, why did it take me 2 yrs to get to this place. Oh well, I'm here now and it seems to be a good thing with no side effects. I also seem to be getting back the edge such that I'm back at 110% from 95%. It feels familiar and I didn't realize how much I missed it.