Merry Christmas

Hello all,

Many thanks for all of your support, kind thoughts, love, and assistance. We are off on holiday for a while and will look forward to staying in touch via email. The blog will take a break 'til next year.  

Today I was solicited, a little, by some LDS missionaries; two black South Africans and one white Utahan, all women. It struck me how I have been fortunate to see many people in many places worship their deity. And how convinced I have become through reading and contemplation that in the end there must more than one way to enter the afterlife given our immense diversity. I have no idea if my way of worship is the "one true way" and in the end it matters little. That we seek to be guided by a deity, live lives of love and charity, love and be loved; that is the true gift of this season to me. I hope I can perpetuate it. 

I have been blessed with the love of my God, an extraordinary woman, children, friends. I am indeed a wealthy man. All the best to you,

Mike 

First field trip

It’s been a full week. As we try to decide what course we want to take as an organization here, it looks like we have a bit more autonomy from Philly. Our boss was able to hear our concerns and the student rotation will change to accommodate the present situation here on the ground. Interestingly I’m not sure what the program I do (outreach) will morph into/look like as I bring a different skill set to the table. 

Whereas Daniel is a highly skilled internist with certification in Infectious Disease and is now back in Australia pursuing and ID fellowship, I’m a primary care doc. He rounded with the medical staff at local and distant secondary hospitals and saw challenging adult medical cases. I can round in any ward, on any age, and see consults a little faster than he as that is what I did for my career to date. I am not as comprehensive as my predecessor but am a touch more broad in scope. As such I now meet with the local district primary care docs each Monday and Tuesday in their clinic settings and teach there. Then give a talk on Tuesday afternoon that is interactive and hopefully as amusing as it is informative. The rest of the week is a little less defined and therefore anxiety provoking.

As the subject was seizures this last Tuesday, I related the episode early in my career in Hood River where I invented “Seize-ON” and “Seize -OFF”, based on a lecture I had heard in Portland, to “provoke” seizures in a very skilled charlatan. The details are sworn to secrecy but the end result was hilarious and instructive.

On Thursday and Friday I was in Bobonong, a community that is in the NE of the country and about 400km from here. It has some of the worst statistics regarding HIV, TB and combinations thereof. I went there with a section of our program that is very well organized and had a chance to see what should be involved in initiating a new program in a new site. We first met with the local chief’s council, the Kgotla. This is where all the village politics and traditional politicking are carried out. Here in Gabs it is of less importance but in villages throughout Botswana it is the first place to stop and the true portal of entry into assessing the health care system. Then we met with the District Health Team, analogous to our own County Health Department, to inform and gain approval, and then with the hospital. All this was done with an eye to the politics of the situation and with a sensitivity that I need to acquire if I intend to be of any effect in small community primary health care settings.

On the way over and back we passed camps of tents that were made of bent sticks covered with sheets of carpet, plastic, what have you. The people were collecting caterpillars off a specific tree, the mapahne tree, hence the name mapahne worms, which are flash boiled and dried. Then they are sold as a delicacy along the roadside by people holding up cups full of them, for about P5.00/cup, weirdly reminiscent of salmon season or morel season. I have had them in a tomato-based stew and they are a little like tofu in that they adopt the taste of whatever they are mixed with. Alone they are a touch tough and tasteless.

All for now, best to you for the season!

Thursday in Mochudi

Have a few moments before we meet as a group to try and decide our future course, here in Gabs and Greater Bots.

Yesterday I was in Mochudi where the morning got off to a fast start when an ambulance pulled up and out from it were poured 7 victims of a roll over out on the main highway that runs N-S. The public transportation sector is predominantly “combis”, Toyota vans with four bench seats that have a capacity of about 18, no seat belts are driven all over by guys with Pula signs in front of them. One can go anywhere locally for P3.00, about $0.50. One vehicle rolled, ejected three passengers, killing one, and injuring all the rest. By the time all was stable (used loosely here) we were way behind the rounding and outpatient visits. Patients cue up at 0700 to be seen here and are at the mercy of what little system we have on any given day. If they leave for a meal, they lose their place in the line so more often than not a day at the doctor’s office is 12-14h and without food.

In my clinic I saw a man who was 105, looked 65, and was a true delight.

On the way home I stopped in a rural clinic off a dirt road in Morwa. It is one of many that feed into Mochudi. I think that I’ll be visiting all the remote clinics in this catchment area as a model for outreach for the rest of the country.

Last night female medical had a clean kill. A woman was admitted from A&E with “DKA”. Except that while she was diabetic and did have ketones in her urine, she wasn’t acidotic and oh-by –the-way had crushing substernal chest pain and was in shock. She died this morning of her MI, blood sugar be damned. It is interesting how the emergency docs here latch on to lab abnormalities in the middle of a chaotic shift to admit the patient, absent a cogent history. And this in no way separates them from their counterparts throughout the planet.

Hope all have a good weekend,

Mike

Wednesday in Lobatse

Went to Lobatse today and spent a little time in the town proper during a lunch break. It reminded me of so many towns (villages if you will) in the hills of Appalachia. The building locations are dictated by the hills surrounding them and the creek bottoms below. Now that it is the Christmas season there are vendors along the streets and sidewalks aplenty. Yes, I said sidewalks. The goods being hawked are genuine imitation African schlock. The real stuff is out there just harder to find. Given that the population of westerners is relatively light most of the stuff is bought by nationals, I guess.

Again the solid merchant class is South Asian; Indian, Pakistani, Bangladeshi, and the like. These guys are real hard core and are able to scratch a living out of Lobatse but at the cost of being real bottom line minders (read jerks).Yet, they provide a good or service and in turn employment, job security, a peek at free enterprise.

As a family doc I can round and offer insight into patients on any ward so we’re still trying to figure out how to integrate me into the fabric of the hospital. My predecessor is an internist so he just saw adults. I enjoy the fact that all the MOs take patients to the OR for C/sections, lumps and bumps, and the like. Today we saw a woman at 35 wks gestation, first baby, with a “contracted pelvis” that “needed a Caesar”. We examined her and she wasn’t in labor, hadn’t had a trial of labor, and was having somatic pain. Discussion ensued but not a C/S, so a good thing all around. Because there is room, patients are often kept for longer than we would think is necessary in the western world, that plus the fact that this is a litigious society (believe it or not) means that we err on the side of too long a hospitalization, at government expense.

Today we saw a young boy with hemophilia who had a sister with a respiratory tract infection and fever. Both were admitted although neither would have been in a developed nation. We saw a schizophrenic man near the end of his natural life who was sent over by the national mental health institution so he would be a statistic at the medical, not mental, facility. We saw a man with crypto meningitis with a new dx of HIV and CD-4 count that had to be in negative numbers. One of our patients was a newborn girl with a slightly redundant labia minora that had the staff worried. A quick snip and that “problem” was solved.

The maternity ward is run by a midwife who is simply extraordinary. She knows all the patients and is delivering children of patients she has delivered in the past. All premies are fed from a cup as there aren’t any disposable “teats” and no one can clean them fast enough. So these premies york down a two ounce feeding in record time and get belly pain, all for want of a bottle. Breast feeding is discouraged in HIV + mothers who are at about 45% in the 20-45yr old population.

The drive continues to amaze. I drive by an area that is famous for a buzzard rookery, with guano on the cliffs and huge, broad winged birds enjoying the air currents. That plus the occasional baboon and life is good. All my best…..

Pardon my roooop

Yesterday Lynne, I, and two Penn friends decided to climb Kagale Hill. I think I may have mentioned this location in past entries. It’s the tallest hill in Gabs and gives a great view of the whole of the region. It is mentioned by the US embassy as a place that is off limits to US citizens because of its reputation as a place of muggings and the like. When I think of a mugging I associate it with guns and weapons. Most of the muggers act tough and that seems to be enough.

I awoke yesterday a little under the weather but thought little of it. Unfortunately about half way up the hill I lost my breakfast and most of the previous days meals as well. We made it to the top, saw the sights, and went down a different easier way as Lynne and our friends were a touch tired and I was more than a touch nauseated. The route ended in a working quarry where we were able to catch a ride back to the car, another 2km. By the time I got home I was quite ill. Over the rest of the day I became quite dehydrated with orthostasis so bad that I really wasn’t trustworthy on my feet. Nicola finally came over in the afternoon and two liters of RL later I felt like I might just survive.

Today I’m fine if not a touch queasy. It was indeed a wise and wizened old man who looked back at me from a bed after I had just pumped him full of fluids for the same problem as mine who said," Ya know doc, ain't nothin' as over-rated as sex or as under-rated as a good bowel movement!" Add to that "farting safely". Nothing like being sick to appreciate health. Thanks for being out there, I truly enjoy and anticipate the feedback.

Ah, Friday

It’s been a week indeed. The bad news: the service admitted 15 patients last night and now stands at 42! The good news is that I’m no longer on it (but in some strange way miss the chaos). The current Penn resident is simply fantastic, as are the Penn student and Batswana intern. Christine the MO has slid into an ill-defined funk wherein she will leave, state she’ll soon return and not be seen until the next day. Try as I might to help I get nowhere.

This week I visited Kanye and Mochudi.

Both are on Google Maps: (http/maps.google.com/maps) and are even better if viewed as the satellite image. Kanye was fun as we rounded in the peds ward again, then in the male and female wards. They really are a touch unsure about me as I am the first one with expertise in all ages and both genders to show up and offer help/instruction/guidance. Then I saw some patients in consultation with a great nurse who is herself disabled (some neuro-muscular degenerative disorder) but has a personality that fills the entire place. The cases were generally easy and addressed the fears of the M.O.s that this might be something more pathologic.
They are gifted clinicians and delightful individuals. Yet I undiagnosed CREST syndrome, undiagnosed pericardial effusion/pericarditis, and so on. I am amazed as I normally wouldn’t have thought of the diagnosises on my own. That this happens in this country is magnificent.

The part about this that is a little like having to bake a cake and then eat it is the drive. It will come as no surprise to those that know me that I love it. I of course find the most obscure way out to these sites so I get to see some amazing bird and mammal life. I see kites, osprey, herons, weaver birds, hornbills, egrets, and more I can’t even identify. I rounded a corner to find a troop of 50+ baboons galloping across the road. The females vaulted a 2m fence with one hand, using the other to hold a baby! Goats and cattle are everywhere, donkeys and horses as well. The terrain is green, flat, interrupted by table top hills and rocky bluffs, and would remind one of sage country in the West. The flora and fauna is quite distinct however and that’s what makes it more fun!

I get lunch at the local grocery stores and get stares as I am the only non-African there, let alone in the town.

Mochudi was a hoot as morning report is run by a gentleman of my era, from Uganda, who graduated med school in the same year as I did. He is undoubtedly 5+yrs younger than I am and is very paternal as he sits at the head of a 7m table lined by the docs (a few) and nurses (a lot) and holds forth. I love his style as he in very inclusive of all disciplines there. I gave my first talks at these places, discussing the emergency treatment of seizures and was impressed with the depth of ability (but lack of resources) in the resultant conversations.

Next week I try to establish outreach in Gabs (I know, weird that we have leap-frogged over it) and try to solidify a schedule. Tomorrow Lynne and I climb the same local hill I discussed in the last entry. Tonight we say good-bye and God-speed to Daniel and his family as they prepare to leave to Australia and the next chapter in his training.

That’s probably enough for now, take care.

Saturday pm

Last night was the final night of call for me for the next 9 mos. Silly me, I mistakenly thought the Great Call God in the Sky would take pity on me and make it a routine (read QUIET) night, nope. I was awakened at 2400 by a call from the A&E doc stating that they had a patient known to our service with a blocked PD catheter. Peritoneal dialysis, as opposed to hemodialysis that is used in developed nations, is the preferred (read only) mode of therapy for renal failure here. A catheter (tube) is inserted into the abdominal cavity and fluid is infused that acts to exchange toxins across the membrane lining the cavity. It prolongs life but is VERY preoccupying and difficult, and life becomes all about PD in that has to happen 5x/day, each taking about 2 hrs.

Traditionally a blocked PD catheter is admitted to the medical ward whereupon we try, usually in vain, to contact urology to come and unplug it. This of course is nuts as we have nothing to offer the patient and because the passive aggression of the urology service is legion; they never answer their pages on the first page, preferring to use the common and hackneyed excuse that they are in the theatre (read OR) which of course is patent BS.

So I was called by a particularly sympathetic A&E doc last night asking if I would admit this guy, I declined and said it was a urologic problem and they should clean up after themselves. He agreed (!!!). I should not have been so naïve, silly me. I got a call about one hour later from the urologist on call that actually came in (!) and saw the patient and wanted me to admit him until he got around to fixing the catheter. That would have been mid next week. I stated so and then went to the hospital where the fight began. We had a rather animated conversation during which I pointed out the logic of admitting a guy to medicine that needed a new surgical appliance. Ultimately this guy admitted our patient to undergo placement of a new peritoneal dialysis tube for renal failure. If for some reason this doesn’t work he will need hemodialysis and this will be his death knell.

The urologist was so frustrated with my reluctance to admit him to an irrelevant service (medicine) and my insistence that he be cared for on the urology service, with our consultative input as needed, that he threatened to return to China (!?). Oh really and when might that be? Ooooohkaay, but don’t blame me.

Later this morning (about 0400) my MO got a call from the head admin guy for the hospital demanding he admit the above patient, as the urologist thought that he could make an end run around me. The MO was in on the situation and refused. This morning our patient was waiting for the urologist to act like one and take him to the OR to install another permanent catheter or concede that he can't tolerate another PD catheter (this might actually be the case) and we'll move from there.

This morning I climbed the tallest hill above Gabs and looked out over the city for about half an hour before I followed a secondary school class down the hill another way to a local mall where I met up with Lynne and then went to lunch. The vistas were breath taking and at the same time familiar…odd. Best to all, Mike.

The day after Thanksgiving

It’s been a week of outreach and fun. It will come as no surprise to my family and those that know me when I say I finally felt like I was in my element. I had the pleasure of sharing three sites with Daniel this week as he is signing off and moving back to Oz where he is to do some locums in N. Queensland and at some point begin a fellowship in Infectious Disease. His input and hand holding have proved invaluable.

On Tuesday we were in Kanye, a town of about 50,000 NW of here by about 100km. The hospital sits on a bluff overlooking the town. The staff there is well trained and dedicated and eager to have discussions about alternative ideas for care of their inpatients. Like many places at the district level and below, they over treat and do so out of fear of missing something. It is always a pleasure to reassure them that they are treating the patient appropriately and that what I have to offer is simply one more right way to care for their patient. Generally they are relieved to hear that they can use fewer meds and have as good a therapeutic effect.

Wednesday we were in Lobatse, about 100km WSW of here and had a large outpatient clinic waiting for us. The frustration is that the medical staff, while quite strong, view me not as a teacher but as another provider so they can go about their hurried and harried professional lives without my teaching component, which after all is the purpose for outreach. I’ll need to slowly work on them. I spent a fair amount of time undiagnosing and withdrawing meds from patients, spending LOTS of time reassuring them that their doctor is quite intelligent and that mine is simply another idea based on more experience/mistakes, that’s all.

Yesterday we were in Mochudi, about 60km NE of hear where I finally, after three months, had a chance to round on some (lots of) sick kids. I of course loved it and discovered I was actually able to teach more about this aspect of care than adult medicine. We were again able to reassure the care providers and basically clear off the service for the weekend. There were toddlers everywhere with scalding burns, febrile seizures, asthma/bronchiolitis, marasmus (malnutrition; really took me back to South Sudan), cellulitis, pneumonia, and the like. We saw some clinic patients in the afternoon that were very reminiscent of the US. One was a man, with his wife of 35 years, who was becoming progressively demented. Her care for him and the discomfort that each had for the current status quo was exquisitely touching.

Then is was home for a traditional Thanksgiving dinner at Mallach House with all the Penn folks and students/housestaff. It was a hoot. And I ate like one would back in the US, waaaaay too much, delightful.

Tomorrow I’ll climb a local hill early in the morning before the bad guys who rob and harass you are up. It should provide some beautiful vistas. Then Lynne and I will drive some of the back roads around here out into the desert and enjoy the green wide open spaces, and rest for the coming week. It’s my intention to get farther out into the sticks and visit the primary hospitals as well as the nurse run clinics and get a sense of how things are done here. I only hope I have something to offer in return for the privilege of doing so.

Sunday on call

I’ve been on call today and have had the usual frustrations marked by some truly remarkable stuff. The ICU is a bastion of, what, a system that is such that one can’t admit there without the expressed permission of one of the anesthetists who are conveniently “preoccupied” such that they are impossible to contact or otherwise choose not to return their page. Thus one talks with nurses of various cultures and ethnicities all of whom are intimidated by these bastards and do as they say. I got a call today to start somebody on anti-HIV meds (HAART) as he was on it on the outside, had it at his bedside and needed a medical consultant to write the orders, unbelievable. When I informed the nurse that it a) could be started tomorrow, b) was best done through the clinic that is set up to do so (the infectious disease care clinic here at the hospital), and c) could be done by anyone there- I was rudely admonished to come in and hung up upon. OK, those that know me can fill in the blanks from here. Suffice it to say that he’s on HAART and the head dude and I are going to have a conversation about this tripe tomorrow.

We admitted a woman who is truly the face of HIV in Botswana. She has had HIV for an undetermined period of time, is wasted, has TB and goodness knows what else. She came in because of intractable vomiting and abdominal pain and was found to have decreased breath sounds on the left. A chest X-ray showed the most beat up (L) hemi-thorax I have seen. She had a tension pneumothorax with numerous huge fist sized cavities from TB and lung that was tightly collapsed in very bizarre areas. She was not in respiratory distress so we chose to go slowly with this and will CT the chest to best decide how to decompress this. The chest findings on CXR here are unbelievable. Easily 80% of the exams are grossly abnormal with findings that are present because of prolonged processes that precede admission, something I simply never saw in the States.

Steve Gluckman, my colleague and friend from Penn, and I climbed a hill that overlooks Gabs today. The similarities to Eastern Oregon were striking and beautiful as green is now the dominant color here.

Outreach for good this week, wow. How lucky can a guy like me get?

Musings for a Saturday morning

It‘s been a week! Outreach this week was to Mahalapye, at about half the distance to Francistown (200km) from here. The hospital is new, as in opened in the last year and rather out of place. It is beautiful with huge atria, tall ceilings, very wide corridors and large wards. It is a district level hospital that is staffed by M.O.s of various capability and motivation, not unlike any hospital in similar circumstanced in the US. It is this hospital that is slated to become the home of a family medicine residency in the next two years or so. The chair of the department is a Scot but isn’t in the country as yet. The first class of students at the med school has been accepted as of August ’09; lots to do between then and now.

Things are GREEN. In just a three week period things have greened up amazingly. Where everything was brown, or a shade of it, now is brilliant green and oh so refreshing. The travelling to outreach sites will be interesting in and of itself but with the green vistas it should be breath taking.

Our weavers are nesting and we are expecting in the next month!

As expats in the capital city it is easy to shop, eat, socialize with our like and more difficult than I anticipated to become true friends with nationals. Some of the barriers include ethnicity (read color) where assumptions are made in both directions, class where the national people that are sitting in the same eating establishment are of an income bracket that is elevated but still associate with similarly cultured friends as they are served by members of a similar ethnicity, and the like. Virtually all kids here are educated through secondary school (high school) and many attend college. I hope I can find us in an environment where this intercourse is easier or am I being too naïve?

The wards are full of challenging cases that have been handled with extraordinary skill by our current team: a national (actually Tanzanian)MO, Christine, national intern, Maposa, Penn student, Kate, and Penn residident, Keith. We had a gentleman that we thought had LP negative cryptococcal meningitis and wasn’t rallying after about 10 days so Keith looks at him and decides this just might be Listeria, starts him on appropriate medication and now our patient is laughing with us. A great save.

Another was a woman who had heard some bad news and began to have bonafide heart failure. Turns out the really IS a diagnosis of ‘broken heart syndrome” of which I was completely unaware (add it to a huge and lengthening list) where in the adrenaline (catecholamine) surge in the blood from stress causes the heart to “fail” and pump inefficiently, as the muscle is stunned but not damaged. Whodathought? We have a young guy on the service that has was started on TB meds two months ago and presented with a probable hypersensitivity reaction to INH with a significant rash, mental status changes, liver injury, renal failure and the like. We started him on steroids (dexamethasone in high doses) to combat the inflammatory component only to find out that he didn’t get any for 36 hours as we were “out” (read the ward was out but no one had gone to central supply to get more). The fact was dutifully recorded but no one outside of the nurse who did so was notified and the patient quietly slipped deeper into his symptomatology.
I found my response to this interesting in that I didn’t light up as much as was simply resigned to the status quo; making a mental note to, what…., talk with , who…., about how to fix, what…..Sometimes the energy is there but zeal is required. Frustrating to be sure, but the next patient awaits.

Day to day

Well for starters the refrigerator is smaller, more narrow than in the US and powered by 220v. Milk is expensive, better preserved and in boxes of 1L. So we pay P11-16.00 for a liter or about $1.60-$2.30/liter or roughly twice that for a half gallon. We have fruit that is grown in this hemisphere, typically in S.A., grapes, apples, pears, guava, kiwi, papaya (called papa here), small but delicious pineapples, and the like. We of course pay a large sum so I eat less fruit but hey, here I am in Bots having fruit on some morning oats.

The oats are from SA as well, as are many cereal products. The favorite grain here is sorghum (mealie meal), samp (coarse ground white corn), pap (finely ground sorghum, I think) are all served at meals here. One eats with ones hands in the home. It’s only us expats from the west that use utensils. Although the hands thing sounds inviting.

One can have any variety of manufactured drinks here. The soft drink area is reminiscent of Menifee County, occupying a huge area in the grocery store with pastel colors of drinks that are sure to dye ones insides. Coke is huge here, not Pepsi. One can get Tab as Bots apparently is less worried than the US about phenylalanine. Fanta is generic for any non-Coke, non-Sprite drink in a can again in a variety of technicolor displays.

Beer is local, meaning both Bots and SA, and light lager in variety. All the liquor stores have the same varieties like in Pennsylvania. The only non local brand that I have found thus far is Black Label, from Philly(!), source of a great hangover after first semester finals in med school, courtesy of Mad Dog John Mallili.

Meat (beef) is a source of national pride and is raised rurally in numbers that far exceed the 1.6 million human population. It is uniformly good and I enjoy it about once a month in some form or fashion as we try to remain vegetarian.

This afternoon we went to Mokolodi, a local game reserve, travelling throughout the park, seeing the usual assortment of bush wildlife. Interesting that I have become so casual about the fact that we can see these animals so readily. The trip also included an opportunity for the Penn folks to pet a domesticated cheetah, accompanied by pictures and poses; odd and a little over the top for my tastes.
Then tonight a brai (barbecue) to celebrate the tenure of one of the best and most regular neurology residents I have met. Good food, lots of it and now home to bed. Not a bad weekend, indeed.

Hail yes!

I went on outreach to Mochudi yesterday, a town the size of The Dalles in area but with probably 1.5x the population, that has a hospital and a well established medical community. It's only about 45 km from here to the north. They have a nursing school where the female students wear hats and dresses while the male students wear white coats. All are beautiful and eager to learn. We held bedside rounds on numerous patients on the wards that were a true delight. Many nurses, students and staff along with the M.O.s who were caring for the patients were there and entered into the discussion.

For the medically inclined, we saw another case of Progressive Multifocal Leukoencephalopathy (referred to as PML mercifully) a rare neuro-degenerative disorder that is much more prevalent in HIV+ individuals. The prognosis is horrible but the dignity with which the patients here endure is moving to the core. I also "undiagnosed" a series of worrisome problems that, as is sometimes the case with the MOs, are generally over worked up. In medicine the danger in trolling through the lab is that an abnormality even if trivial will lead away from the proper diagnosis. The MOs, afraid of missing a diagnosis, do what we all so often do, compensate for their insecurity about the disease process they are witnessing by generating lots of data and trying lots of remedies. I find I spend a lot of time teaching about “other right ways” of reaching a diagnosis and treating illness.

We had lunch in a chicken place in the downtown area that was interrupted by a HUGE hail storm, stones the size of 3cm. It tore apart the roof of the lunch place and water cascaded in all directions. In all we must have had 5cm of ice and rain in 20min.

The quiet dignity of our patients and attendant families continues to impress me. We are caring for a 16 yr old boy with AIDS from birth (mother had it) who has cryptococcal meningitis. If you make it to your teens with HIV here you are usually cared for by relatives as your father may be dead or never was in the picture, your mother is dead and you are bounced from pillar to post by generally well meaning relatives. By now in your life you look different; quite small for your age, are thin and chronically ill, have a different circle of friends and experiences (the staff at Baylor, other HIV kids, the hospital staff that is indifferent on a good day) and need to take meds daily. And even if you do everything right you still get sick, REALLY sick, with increasing regularity. This boy wears a plastic bracelet with the national football team logo, the Zebras, on it. I wrote a note to the team, conveniently based here in Gabs, to see if one of them could visit with a jersey for our young fan.

My current team has a third year medicine resident, a fourth year student headed into Peds, an outstanding Batswana intern, another outstanding MO, and me. The team is bigger than I’ve experienced and makes for some lively discussions. We (actually they as I was away yesterday) got slammed with 12 admissions over night and to their credit they did fantastic. The Penn people were the only ones there as our intern had a death in the family and was on the road home, our MO is on a two week leave, and I was in Mochudi. So here’s to Keith and Kate, great work by two excellent examples of bright dedicated physicians in training.

And here’s to you all for your support. The comments, letters, chat, Skype are most welcomed and help us more than you can know. We blessed to have you in our lives. Thanks…..

More randomness

The weather has been truly Northwestern; heavy low overcast with rain, only warmer/hotter in between. We’re taking Setswana classes at UB and it is interesting to be on campus. It is full of the same spectrum of students found on any campus; jocks, chatty groups of coeds, metro-sexuals, rural based kids that dress as such, openly effeminate men dressed in makeup and pressed denim, and Jane and Joe Average. The professors are busy teaching evening classes and the corridors (all outside) are buzzing.

Setswana class is tough but if a Batswana can learn to speak English the least we can do is learn the national language here. On the wards is a perfect place to practice and it adds humor to the day for many of the patients.

I’m still impressed with the number of Batswana that ask me on a daily basis about the election result and my opinion of it. Uniformly and without exception they are excited about the new administration. They see Obama less as a black man that I suspect the average American does (after all in the US you are white or you’re not, even if a parent was white). To them he is an inspiration but as a person of color, in this case mixed race, he lends validity to the US in areas of the world like this.

Things are greening up at an accelerated pace, three weeks from now it will be so different. The weaver birds are all bedded down in their nests so there is much less courting than a week ago. Next up, baby weavers!

The staff people at the hospital get a huge kick out of the fact that I ride a single speed bike to work. The good news about that is that virtually everyone knows it’s mine. Security in familiarity doncha know. Time to sign out, thanks so much for your comments and letters, I sure enjoy them.

Monday

I can't remember, and am too busy to review, all the previous posts and whether I related in this space about a guy who has been on the service since 4 July. He was a disagreeable type before he was admitted as he was a prideful alcoholic, HIV+ and just generally a parasite to those around him. I had tried to discharge him before only to have him bounce back because even though we would afford a cab ride for him he never could quite remember where he lived.

He embodies that blurry, poorly demarcated region between passive aggression-alcoholic dementia-personality disorder and the like. All who cared for him thought he was alone in the world as he was from Zimbabwe and was never visited. Well don't ya know today he was visited by five of the nicest women on the face of the planet. No they absolutely would NOT take him into their home, he was and is a jerk. But the were genuinely concerned for his welfare and wondered if they could pay for his mounting hospital bill, P10,000 and counting, and afford his ARVs. Since he is from Zim he will be billed, as if that will do any good, but to the credit of the hospital they haven't tossed him out on his ear.

After a long conversation at which time they were informed that he was deteriorating and that the most compassionate thing to do for him was to simply make him pain free and withdraw him from all meds aimed at Tb, AIDS, co-morbidities and the like, they concurred and we'll see how this goes.

It was admittedly refreshing to be able to do this, realizing the gravity with which we collectively made the decision, without the attendant fear of suit, legal reprisal, need for 2nd-3rd-4th opinion and so on. He will be free, and so will we; a break even day if there ever was one.

Down time

We finally got the heck out of Dodge this weekend, our first sojourn into travelling as it were. We headed south to the northwestern area of South Africa to Groot Marico a small town very reminiscent of Mosier, or Boulder Creek 20y ago, or Hood River 30y ago; small and very quaint with several art studios, a restaurant that is open on the weekends only and such. We spent the night at a “guest house” (read B%B) of which there are numerous about the area. It was all of 200km from home and was a delightful time away. We had a room away from the main home, spent time communing on a beautiful river, and started today with a great breakfast.

We had heard about the source of the river being a huge spring about 30km from where we were so this mornig took off on back roads (unpaved) through some terrain very much like the high desert from Prineville east. There were farms, ranches and lots of stratigraphy much like KY. The source of the Marico River, it turns out, is on a farm at the top of a ridge and is a huge, deep spring about 30m across and about 40-60m deep (http://www.dive4life.co.za/marico-oog). Then out to the west to return to Gabs via Lobatse so Lynne could see one of the sites I visit. And now home to some down time before we start the week again. Loved it!

The ward has been quiet and the cases are rather routine, not to say they aren’t challenging, I seem to have hit cruising altitude and have a better handle on the pathology.

It was fun to hit the road as a couple and explore. Lynne was fantastic, course I knew she would be, and that made the adventure even more of one. I chatted with some of my CGFM buddies and caught up on the stuff. I honestly miss the personalities, Hood River, the efficiencies of the US, just not the medicine. I/we are where we’re supposed to be for the time being and that makes us truly fortunate.

Today in Ghanzi

This morning I flew to Ghanzi. along the Western frontier of the country where we taught and rounded with the M.O.'s there. The level of enthusiasm was eager and earnest and the level of medicine was of the standard one might expect in a rural hospital. The building was new and very spread out, a lot like a new elementary school in some sunny clime in the States. The nurses are enthusiastic which separates them from the staff at Marina. The patients represented a spectrum of rural problems: an elderly woman with a hemoglobin of 1(!!, normal is 13-15) who probably was losing blood slowly over time so she could actually stand upright, a child with probable slipped capital femoral epiphysis (a problem with the thigh bone), a woman with dysfunctional uterine bleeding, and the like. Truly bread and butter family medicine.

And one of the most amazing things about this place (800km from Gabs) is that the staff was just giddy about the Obama victory! It really is infectious and kept things light and fun. He'll need time to be sure but to have that level of enthusiasm at that place at this moment is time is incredible.

Thanks for the comments and letters, they make my day.

Historic

On my way into the hospital this morning, riding my bike, I was hailed twice by national Batswana:
"Are you American?"
"Yes."
"Congratulations!!!"
Truly historic for the US and the rest of the world.
All the hospital staff were already up to speed about the results and were talking about it incessantly.
Amazing.

Outreaching

I went on my first outreach yesterday to a community WSW of here about 75km. Lobotse is one of the older settlements of Botswana. The hospital is old, built in the 1920’s with walls that are half a meter thick so the inside temp can be 10-15 degrees C cooler than the outside. The drive is very reminiscent of eastern Oregon and the high desert around Jordan Valley. The flora and fauna are strikingly different (beginning with troops of monkeys and baboons!) but the geology and relatively dry climate are very familiar.

Once there, my partner, Daniel, gave a great and quick talk on the treatment of epilepsy and we adjourned to the wards to consult on inpatients. The pace there is refreshing, a more deliberate rhythm. We saw a deeply comatose man who had not received treatment or substantial workup since his admission two days previously in anticipation of our consultation. As diplomatically as possible I offered that this was guy on whom one could damn the workup and start treating for Tb, to encephalitis, to jock itch without our input and offered up some contact information so they could consult me over the phone. The workup and treatment were initiated but too late and he died that afternoon. We then saw a woman who was discharged from Princess Marina Hospital and was promptly driven home to Lobatse where she was admitted again with what amounts to significant psychosomesis (she’s nuts, but isn't malingering). She was in bed and the closer I got the longer her stare grew. She looked as though she had suffered a significant psychological insult and most probably had. I was able to walk the staff through some tricks to determine this and expand their comfort zone about how to best care for her.

We saw some outpatient consultations that were just bread and butter family medicine, and I of course was in my element. Then lunch at a local hotel with a fairly famous buffet and back to the IDCC (euphemism for HIV clinic) for some more consults. I loved every minute of it; the interaction with the MO’s, staff, patients, the rural nature of the experience and the drive, all great.

Today I’m on call for the hospital and as such get to round without all the attendant teaching. It is faster and much more efficient, just not anywhere near as fun. We currently have a 15y/o boy with HIV in end stage who doesn’t take his meds, making him no different than any other 15y/o with a chronic disease. Unfortunately this has lead him to have MDR Tb and end stage HIV, an incredible story of bravery and just plain guts. May I and the ones I love never have to show half that much courage in the face of such daunting odds. Many of these kids are orphaned on top of that so reliable adult input is at a premium and often is provided by the staff of the hospital, Baylor, or us.

As most of you know our home has been stood on its ear with tile floors being replaced. The process has left the place a dust heap. Lynne felt uncomfortable leaving the place while they were here so she was trapped as it were for four days and now is cleaning up with my help when I’m not at the hospital today. As she so aptly points out, “this too shall pass”. True, a home on its ear is no big deal in the context of why we're here. Still we're both running a little too close to empty (at least I am) and this "one more thing" is an unwelcome challenge. I think of Lynne and am struck by her courage and grace, and am eager to see how this chapter of her life unfolds. I’m a lucky guy to be sure.

Speaks for itself

Percentage of women who seek prenatal care, and are tested, with HIV in Botswana:

Age-----------------------2003------------------------ 2005
15-19---------------------22.8--------------------------17.8
20-24---------------------38.6------------------------- 30.6
25-28---------------------49.7 ------------------------- 44.5
30-34---------------------45.9--------------------------45.2
35-39---------------------41.5--------------------------40.2
40-49---------------------34.4--------------------------30.4

Tuesday 28 October 2008

Today was almost one of those “take the patient to the ICU and damn the consequences” type days except the patient died before I had a chance to get a good head of steam worked up. Now that I have been here for some time it’s interesting to me how different the various wards are. Since I take call (“second call”) about seven times a month I consult during the day one surgical patients with fevers and the like and then help the M.O.’s at night with difficult cases. Lately I’ve been able to visit Ob-Gyn, Surgery, and Ortho for simple stuff and have been impressed how the nurses gather around me and listen intently as I explain the pathophysiology of whatever and the best approach to it. They greet me as I come onto the ward and always are very professional.

The nurses of the male and female medical wards would have a difficult time being any more ambivalent. Today we had a woman crashing on the female side and getting a nurse to a) show interest and b) move was horrific. The passive aggression of the wards is deafening. And I think we share the fault to some extent. The HUP (read Penn) mentality can really come on strong and is somewhat off putting, even to an Oregon family doc like me. Apparently when this all began six (?) years ago there was a service of HUP only providers and as can be imagined the culture clash was significant.

This isn’t to say that this hasn’t been addressed and to some extent remedied by us but it is a long way from even and easy. And the patients suffer. We had two clean kills in four days where the nursing service admitted an unstable patient and dutifully noted that he was so, didn’t notify anyone and the patient quietly and inappropriately died.

So there’s one of the challenges. The nursing service isn’t used to questioning the wisdom of the admission and doesn’t see its role as doing anything other than carrying out the orders of the doctor. Hence; no orders-no therapy. Many has been the time we are blithely rounding only to find a patient admitted from last night that is unstable with nursing notes confirming that. On any other unit the nurses would be acting in the advocacy of the patient and would be notifying the world. Why not the medical wards?

The biking is great and my back is sore from the weird confirmation of the thing. Never the less I’m a happy guy. The flat is torn up at the moment as many tiles were loose and are being replaced, a good if very dusty thing. I’m hoping to get a peds gig in mid December to mid January as things slow down in outreach.

Best to you all. I Love hearing from anyone via the blog or e-mail. It makes my day.

Better, bordering on great..

Sunday afternoon, 26 October 2008

I got a bike! And not just any bike, a Supa Hamba, a Chinese knock off, made in India, that is almost exactly like the one I rode in Sudan. It’s “all steel” which makes it heavy and indestructible. It has fat tires, and a coaster brake (here it differs from the one in Sudan in that I can stop this one). I bought it for under $100.00 as the exchange rate is P8.00 to the greenback, up (actually down as iy were) from P6.00/$1.00 on our arrival. I’m now about a 2min ride from the hospital, faster than by car as I can ride it on a dirt strip that cuts through the neighborhood straight to the hospital gounds.

Where we had a legitimate couple of saves! We had a guy with sepsis and a systolic pressure of 30mmHg for who knows how long before we got to him. He was comatose, wasn’t making much of a fuss and besides seemed comfortable so the cubicle nurse just dutifully recorded his pressure as “unrecordable” and moved on. We got to him on routine rounds and began vigorous resuscitation with gobs of fluids and what has become the antibiotic cocktail of choice here; cefotaxime, metronidazole, and vancomycin. Today, Sunday, he is alive, awake, and wondering what the big deal is. Another came in with sepsis and a CD4 count in negative numbers and is slowly doing better. The energy expended on simple vigilance here is staggering and takes its toll by weeks end.

On Friday we reviewed the death of a 22y/o woman who died with and from an acute abdomen. The old saw about how one should never let the abdominal wall stand between you and a diagnosis doesn’t play well with the surgery folks here, or at least some of them. We have an old ex-Soviet surgeon who is fantastic. Unfortunately for the patient he was off call. She came in with classic signs of infectious cholecystitis (a serious infection of the gall bladder). Before she would be accepted for “theater” she needed a chest X-ray, something that takes two days on average. Interesting that virtually everyone is admitted through A&E with a CXR that is many times of little use. So the surgeons have deniability built into their refusal to manage an acutely ill patient for whom surgery is clearly indicated , even without a blasted chest X-ray, and radiology continues to stumble along in all its passive-aggressive glory. Nicola and I have vowed that this is the last time this happens on our service and that the theater might just be the next site of a harried attending wheeling a sick patient across its threshold for definitive care, a la the ICU and me about three weeks ago.

We are moved in and things are definitely better. Today I worked on my bike, did some yard work, went shopping for tools, drank some coffee at a local shop and watched the amazing array of peoples that populate this capital pass by. Many had kids with whom I’d play around and it was a hoot.

It’s the beginning of a new week that promises to bring change and challenge as I start outreach on Friday part time. It should be interesting. Thanks for joining this stream of consciousness.

My service as of tonight, and more...

For the more medically inclined a run down of the service, all are male:

-35y/o with HIV on HAART for two weeks with crypto meningitis and a CD4 of <50
-81y/o with a ® parietal tuberculoma of the brain, seizures, inability to communicate or locomote for 1 wk.
-54y/o with inability to swallow for 1 wk, and as it turns out a host of other neurological deficits that span the upper and lower motor neuron spectrum with reflexes preserved making this a process that could really have only one diagnosis; ALS. Why is it that the really nice guys get this?
-36y/o with 3rd admission in one month for focal seizures and malcompliance with anti seizure meds.
-51y/o with HIV, low CD4 and ® sided weakness and chronic diarrhea.
-35y/o with HIV and alcohol withdrawal, panic disorder, and a CD4 in negative numbers.
-30y/o with crypto meningitis on day 10/14 of amphotericin.
-37y/o with HIV and now on HARRT with end stage pneumocystis of the lungs and chronic bronco-pleural fistulae necessitating bilateral now unilateral chest tube(s).
-36y/o with bilateral lower extremity paresis c/w with a Guillian-Barre like syndrome but he has had it long enough that is should be resolving to some extent by now. He has bloody emesis and was transfused three units, now more stable but with significantly depressed mental status.
-42y/o with HIV and recurrent TB.
-52y/o with numerous tumors of the lung and presumed mets to the brain.
-49y/o with HIV, DM II, and encephalitis that has improved and will go home soon.
-38y/o with XDRTB (extremely drug resistant TB) who is housed in an isolation ward such that it appears that he is imprisoned.

As I review this list I again marvel at the depth and breadth of pathology; ALS and XDRTB on the same service? I am definitely in the right place at the right time in my career. I miss CGFM to be sure yet this is so stimulating and fascinating, so immediate, requiring a creative approach to everything that I feel truly fortunate.

And as of tonight we have moved! Not lock, stock, and barrel but tonight is the first night in our own digs. The house here is wonderful and the Jones have been amazing hosts, and the bedroom will always be an icon for violation unfortunately. We simply need to have it behind us. I am surprised how insecure I feel at night. I have been in loads of worse places but never have had this happen to me/us and it will be nice to take a step forward. We have high speed internet wireless and will soon have DSL. Life has been good and this is a blessing indeed.

At the end of next week I start outreach and begin it full time in December. Wow, I am indeed blessed. Blessed to have the friends we have thus far with the Jones family at the top pf that list and many people from Gabs, Penn, Baylor, and elsewhere with whom to become better acquainted.

Musings

It occurs to me that I’ve used this space too frequently of late as an avenue for venting and the occasional rant. Those of you kind enough to respond have been very supportive and that has been most welcomed. The last week has been a little tough as sleeping is frequently interrupted after the break-in to our bedroom. From the shadow of the guy and the size of the shoes he left by the window he was small, probably just a kid but the sense of violation of security is quite real and a pain to process through.
We are prevailing however. Lynne is incredible in that I never expected to see her grow so much and so fast. She is at ease with most anyone here, and is well known in many circles. Me, I’m just the guy that commutes to the hospital every day. Although I will state categorically that this has been most invigorating. I truly have no regrets. I think it will take about 6 mos before the pratfalls, pitfalls, and stupid foreigner stuff eases back. I feel myself changing ever so slowly; thinning out, looking for the teachable moment on the wards, becoming more comfortable with the breadth and depth of disease, more pragmatic about death.
Certainly death is frequent here, often referred to as being “late”. It is a privilege to witness it first hand and know the dignity that accompanies it. An added bonus is to vicariously experience it through my students who often are seeing it for the first time.
Nicola and I get together every Wednesday evening to talk shop and drink some beer and whiskey. It’s fascinating how we come from such different backgrounds, different eras in medicine (he is two years older than our eldest) and share similar values, ideas regarding teaching and treatment, and the like. Lynne is a great host in that she quietly rolls her eyes as we giggle like little boys caught with our hands in the cookie jar, but we get a lot done on these evenings. I get to osmoze some infectious disease info and he gets to unwind and just be himself for an evening.
We are in spring now with temps routinely in the high 30’s (remember 36C is roughly 99F) and the climate is at its driest time of the year. Because of the break in we sleep with all windows closed and a fan on in our room so it’s hot, not as hot as Sudan, but hot enough to be bothered by it. In any case is makes for a challenging night’s sleep, and a nap each day.
I’m slowly getting a hand on the pathology of male patients with HIV and look forward to travelling to outlying hospitals and with Lynne around the country. That will come in time. The rhythm is slower here, refreshing at some level once one gets used to it, costly if you are on our ward for the weekend and get sick as you might not come to the attention of the medical staff unless a capable nurse speaks up. We simply are understaffed on weekends and can’t round on everyone.
It is derisively referred to as “Botswana time” by expats. I actually like the pace, the down side being that there is potential medical cost to pace that is more measured. Finding middle ground will come in time.

Yes, one for the team!

Things have slowed down a little and have allowed me to be a touch more reflective from a more experienced point of view.

Virtually all our patients on the male side are HIV+ with some co morbid problem; TB, pneumonia, wasting, hepatitis, pancreatitis, fever of unknown origin, meningitis or some combination thereof. All are younger than 40 and all are at various stages of use of Highly Active Antiretroviral Therapy (HAART). The meds are administered by the local clinics and are so tightly controlled for compliance that even if I order them here on the ward, they won’t be administered unless initiated by the Infectious Disease Control Clinic (IDCC). So today I walked over five charts of our patients that needed to start or restart HARRT. It’s important to emphasize that the majority of hospitalizations are avoidable if compliance of the patients was better. Even at that, the evidence is that compliance here in sub Saharan Africa is around 95% vs. 55-60% in Europe and the US. On rare occasion we will have a patient with routine hypertensive emergency with a diastolic pressure of >140 and headache or status asthmaticus, or the “feel bads” and are dropped off at the A&E by the family who is going for a vacation. This might be one of the larger down sides of medicine available to all in this country, we will have a service that is best described as more nursing home than acute hospital.

There is a lot of drinking here. My past ventures have been to either remote places or Muslim populations or both so the alcohol use was lighter. Here it is heavy and frequent on the weekend. And I find myself looking forward to some hooch in the evening. We have lousy beer and garden variety whiskey but it still does the job. Coming from a long line of drunks as I do, I find myself treading uncomfortably close to the ragged edge, and know it. The last time I was this close was in KY when I had just started practice. I need to exercise and will start as soon as the month is out and we are moved into our own digs, and I feel more comfortable on the wards, all are within about two weeks time. I’ll be OK, no need to worry, but can really see how my dad looked forward to it at the end of the day. He used to say in reply to me when I would raise the issue, not to worry as it helped him relax. I now get the seduction.

As it turns out the neighborhood in which we live that has enjoyed some measure of ambivalence on the part of the robbing establishment. No longer, each morning there is new discussion about who was hit. Suffice it to say we weren’t the only

--------------------------3hr later------------------------

I was interrupted by a stat page to the ICU by our M.O., Christine. One of our patients was dribbling off the court and she needed a hand. I zoomed over to the hospital from here (the UPENN office where I have internet connection) and she wasn’t there. OhhhKaaay, back to the male medical ward to find her with our patient, a 59 y/o male, intubated and being bagged but with a blood pressure after a mg each of atropine and epinephrine (called adrenaline). It was obvious that we needed to transfer him to the ICU so I called them to ask if this was OK. Nope, gotta call the anesthetist and get his approval. Approval??!!, he’s intubated and needs a damn respirator!! Sorry…..

Bleep! So I paged the bleeping anesthetist, and his bleeping partner, a bleeping THREE TIMES! Even called him at home, no luck, and now it's 30m later. Bleep it, we’re going to the unit anyway. So off we went with Christine learning how to manage the head and airway and me pushing. The nurses of the male medical ward largely came along as they perceived the confrontation that was in the offing.

We entered the ward and were met with dead silent looks of disbelief. I found myself asking for meds and then looking at each of the eight nurses and pointedly asking each one if they were going to call the anesthetist as I was a touch busy running a CODE. After some more stunned silence I shoved aside a gurney at a bed station and moved our guy up there. He was being well ventilated and had a palpable pulse, for about the next minute. Then crash, no pulse and once the staff realized we had a CODE on our hands they all pitched in and after another mg of atropine and a total of 3mg of epi; pulse and BP(!!!!) It gave me the opportunity to congratulate all of them and joke that the patient would name his next grandchild after them. Along came the anesthetist who placed a central line and put him on the ventilator and on dopamine to support his BP. The prognosis is perfectly awful, but better than dead for now….And I left in the good graces of the anesthetist, like could give a bleep.

Then off to the mobile phone place as mine had broken and needed to be replaced. I met Lynne there who is better from a stomach bug and showed up with all the necessary paper work,..except that box that it came in. See they need the box to do….. what, hell I don’t know and I don’t have the bleeping box. So after a few exchanges and me invoking the fact that I was a doc at Marina and needed to be back (truth, but still very unlike me to play that card) they acquiesced and gave me a replacement. So now I have a new phone. They have no replacements for Lynne’s one that was stolen and little idea when they might come in.

To my credit I have been fairly patient, for me. Our kids are laughing out loud at this but, TO MY CREDIT (I certainly could use some) I’ve been fairly well behaved.

Dammit...

Sat AM,
11 October

It’s been a week (I think I keep saying that). Things had smoothed out on the ward as the nurses gave me wide berth and were quite attentive to the needs of the patients of our team and the male medical ward in general. Everyone said I should bring chocolates. Nope, not to reinforce what had happened and make nice, that has been tried and since the ambivalence about the episode was deafening, better to keep ‘em guessing for a while. The head nurse won’t meet my eyes but is very attentive to our patients. It’s not something about which I’m proud and it won’t happen again, soon. Hopefully my frustration meter never gets past yellow and I can handle it better. Hopefully accountability and initiative will creep into the culture of the ward. Hopefully.

I had the privilege of hearing about a death witnessed for the first time by my student. We had a young man who had multi-system failure from the usual suspects and died as she was preparing to do a procedure. She counselled the family and proceeded from there without any input from me and with great skill and compassion. Many of us have this happen in training, indeed if we are fortunate, and I had not anticipated how much a privilege it would be to see it through some one else’s eyes for the first time.

Then early this morning…..
We had heard some rumors about break-ins in the neighbourhood here. This is supposedly a secure development as it is an enclosed neighbourhood with just one entrance guarded by a watch man. Bottom line is that at 0330 Lynne awoke to a man at her side of the bed in the process of stealing her laptop and phone. He had to have known where to look as it was quite a distance from where he entered the house and without that info would never have risked entering our room. The school marm in Lynne came out in force as she yelled at him to get out and chased him down the hall with me trying to get passed her to kill the guy. He ran back down the hall and dove back through the window and vaulted the wall. I went to the entrance of the neighbourhood and awoke the guard (not a good thing) and reported it to him and called the cops who took a report.

All the homes here are walled in. The walls have either razor wire on top or spikes or broken glass or any combination of the above and most place have obnoxious dogs. We have none of the above. Having said that, the home has been secure since it has been occupied by the Rev. Jones. That or there really is honor among thieves.

Other than feeling hugely violated we’re safe and Lynne is processing this as best as can be expected. She’s scarred, scared, pissed, righteously indignant (our lives were on that laptop), and fearful all at once. And she is amazingly brave and courageous. Not sure how this will develop. She may want to head back across the pond and return when we are moved into our new, and more secure, digs at the end of this month. For right now, just too much stuff flying around to be able to easily sort it out.

It's all small stuff except when it ain't

Right now my frustration meter is pegged in the red zone. The morning began with a conference with some docs from the ministry of health, a matron (head nurse) from another hospital, and the sister of one of our patients on the private service. Like a lot of places with medicine that is accessible to all, at government cost, the line can be be shorter if you pay as you go. This patient was a transfer from an outside private hospital because they had run out of ideas and he had had a fever for a month. His sister was politically well connected.

We have him on broad spectrum coverage and, of course, did the one remaining test yet to be performed at the outside hospital, an HIV. Which was positive. See you can be getting top of the line antibiotics, but nothing will happen in the absence of an intact immune system. They seemed to understand but that will be an officious 90mins I'll never get back....Why weren't we doing more blood work; because the bleeping lab looses the blood or the ordering system has changed back to the computer system so anything ordered for the last two days manually is ignored. Why don't we get a CT scan; because it won't change the management and takes a week for OB to dethrone and condescend to allowing and reading it. What about outside lab; not needed as the HIV is the most revealing test and no other tests are necessary, other then time.

Then back to the ward where we had a somatisising guy in his mid 30's who allegedly had hip pain, or was it leg pain, or was it buttock pain. So I stood him up to the deeply inhaled chagrin of the team and low and behold, A MIRACLE, he can stand....Anti-inflammatories and get this guy off my service.

We have a high needs cubicle of eight or more beds and one of the guys in there is HIV+ (OK they all are) with a big peri-rectal abscess. During rounds I checked on the site that had been drained by the surgeon only to find that it was awash in stool. Deep breath....clean the stool, retract the packing to show no stool and re apply the nappie (adult diaper), all of this as three nurses stood around watching this. As I asked for an item, it took multiple requests to get their attention. I lit up (our kids are rolling their eyes as they read this) and said how this wasn't cooperation or help and was beneath all of us that a nimrod like me was doing all of this solo. And of course that got me nowhere, and with a headache and worsening reflux to boot. I know, there is a lesson in there for me. To my credit, meager though it may be, this was the first time I blew it.

On to the next patient on whom we got a chest X-ray yesterday only to find that ALL the films were under penetrated that were taken yesterday and are of no value, we of course were kept quietly out of that loop. Arrrrgghhh!!!! So home he went without a CXR that would document that we had done a bloody thing for him.

I've been here long enough to appreciate the difficulties of practicing here, not how to creatively solve the hindrances to good care. It will come.....

The ward on a Tuesday

The service has expanded to about 24; 4 with meningitis of various varieties, one with TB meningitis and hydrocephalus (pressure on the brain), some with the “feel-bads” that are refractory to any attempt at intervention until today when we one dressed and ready to go (something about a woman), many with somatic complaints that resolve before we can effectively start treatment, and most with HIV and co-morbidities. We did three LP’s today (make that Kathleen did them) and all were successful. One of our patients started to decompensate at about 1500 and was showing signs of elevated pressure on the brain by his posturing; arms extending with wrists flexed and comatose.

To get a CT scan on an emergent basis one must get on bent knee and address the chair of the radiology department:
“Good afternoon Dr._____, how is your beautiful family”
“What do you want?”
“We really need an emergent CT scan of our patient who has decompensated in just the last half hour.”
“Can’t it wait until tomorrow?” (it was about 1515h).
“Uh, no because you see it is and emergency at this is happening rapidly and indicates worsening clinical status.”
“Can’t it wait until tomorrow?”
(“No you officious and power hungry b-----h, it’s an EMERGENCY!!, but maybe you haven’t heard of that as all you do is read films and do crosswords all day!!!”) “It really can’t as we would like to know if there is an intracranial process and affect treatment as soon as possible.”
Gesturing, “OK, sigh, bring him here as soon as possible and it better be quick.”
(“Thanks you OB”) “Thank you, I’m sure the family is grateful, as are we.”

The CT was revealing for communicating hydrocephalus secondary to presumed TB meningitis. Unfortunately the treatment will be too little too late.

We are getting a little bogged down and need to thin the service before the weekend. On occasion we try to discharge only to be met with resistance on the part of the family as they are either scarred or simply want their family member to stay longer to give them a break, something that happens a fair amount around the Christmas holidays and is perhaps the underbelly of the “socialized” system here.

In any case I came home with a monstrous head ache, am now recovered, and ready to try again in the morning. We continue to get closer to moving in. The place has been cleaned but not painted and it is more difficult to know who is responsible for what. We leapt at this in the first week of our stay here and it may not be the best option for us for several reasons. Still we look forward to our own turf if only so we can move in and put away the suit cases.

We have been blessed indeed with the home in which we live. Still, it’s time….

Sunday reflections

We both hit a bit of an emotional wall today. Lynne has been unbelievably patient with the banking dilemma in which we find ourselves and innumerable other little aggravations. The short version is that we had a sum wired to here the first week of our sojourn. It made it here in two days (average) but because the bank didn’t recognize the number and because it was $30.00 less than what was wired it sat there in ambivalent never land for 17days. With the aid of some very indulging and diligent staff we (Lynne) was able to get this squared away and the bank will add interest and restore the original amount.

We of course are used to online banking and our bank here “offers” it but the short of this is that the traditional method of deposit/withdrawal in person is still such an institution that our online balance isn’t ever current so we have only a rough idea of our worth. If one is an “I dotter” and “T crosser” not unlike the woman to whom I am married this is uncomfortable at least and fraudulent at worst. We joke about “Botswana time” and the truth is that with gentle but firm persistence Lynne is slowly becoming a customer advocate in that the bank is eager to learn what her expectations are. And it takes a toll. So today there were tears from both of us as we had little to do for the morning other than dwell on the annoyances of the aggregate.

It’s easy to feel homesick for the efficiency and the familiar. We realize it for what it is, small stuff, but that doesn’t make it any easier to shake. Thankfully we have the Jones tribe just down the street that have opened their home and, perhaps even more important, their wireless connection so we can stay in touch. We thoroughly enjoy the company and hope we can at least pay it forward to the next soul(s) that moves here and longs for the familiar on occasion.

This evening we had an early dinner with the Jones and went to the local game reserve where they have incorporated the local sewage treatment ponds into the park and they were full of birds of all kinds; lots of new additions to my list. The ibis were incredible and everywhere. On the way in we saw zebra (with a new foal), wart hogs of all ages, impala, kudu, mongoose, monkeys of all sizes and mischief, and others I’ve forgotten. The termite mounds are huge and everywhere.

This week we’ll try to swim at UB and Lynne will volunteer at a local AIDS orphanage that should help get us out from behind our eyeballs. The week will be busy and will end with me on call on Saturday. And it’s OK as it still is what I/we want to be doing at the time of life we want to do it in. It’s rare a guy like me who can say that and see the love of his life move forward in so many new and different ways. We are blessed indeed…

Saturday stuff

Today I went to PMH to round and see what it was like on a Saturday in anticipation of being on call next weekend. Nicola is on call today and showed me how what seems to work on the male and female side of the medicine wards. The computer system “is up” but that unfortunately doesn’t mean that the desired info has been
a) registered on the system,
b) generated by the lab or x-ray,
c) placed back on the system,
d) under the right name and accessible.

I find that I have been here just long enough to experience the frustrations of the immense lack of efficiencies but not long enough to have creative ways of working around/through them. This morning was delightful as there were few people on the wards and the nurses were very collaborative and could more easily approach me. The happy median is out there, I know it, just can’t quite find it yet.

North Side School, a private school where many expats enrol their kids is having a school fair to raise money. The mix of ethnicities is amazing; orthodox Hindis with top knots, orthodox Moslem, shorts wearing westerners, some Batswana. Interestingly there were many over weight kids that you simply don’t see on the play ground of a national school.

It looks like I’ll start part time outreach in another month and then assume it fulltime in January. After six weeks I continue to marvel at the luck, pluck, and challenges we (mostly Lynne as this is ALL new to her) have and are faced with. At some very real level we ARE truly fortunate to be this age and stage and facing this life, together.

I had to come to this area to see...

What follows is probably of more interest to the medical types in and out of the fam:

Today we were looking at a CT of the brain with a radiology resident from Penn. He is GREAT in that he is used to being prompt, accurate and communicating findings to us in person, a welcome change from what can appear as passive aggression on the part of the department. True I should and am getting used to the SOP here but to have some one like him is huge. Today we were looking the CT from a guy with HIV and a CD-4 count in negative numbers. There were many white matter lesions all over the place and the radiology resident was a little hesitant to give a definitive call. Up pipes Kathleen (a fourth year student), "Looks like PML!"

That's Progressive Mulitfocal Leukoencephalopathy, a rare disease process of the brain white matter, somewhat like multiple sclerosis, seen more commonly in HIV. But very rare. After I picked my jaw off the floor and all of us exchanged looks of "well I'll be" we agreed that she was probably right on the money. An unfortunate diagnosis for the patient to be sure but, wow, made by a med student.

The uncommon is so frequent here. Today I saw a classic case of milary tb on CXR. They see this so often that it wasn't any big thing, except to me. And this afternoon witnessed an echocardiogram on a 30y/o with HIV cardiomyopathy and an EF=40%. This damn disease can kill you in so many ways.

I continue to be blown out of the water by the pathology. I'm a better diagnostician, but I hope I never lose the "wow gee-whizz" side of things here.

Randomness rules

Some (more)random thoughts:

A wind blew through last night and with it the first hint of rain. It left us with a humidity that we haven't had since arrival. At this elevation (900meters) and with a desert environment things are at their driest. Everything is shades of brown or dark brown-green. The humidity makes for an interesting time on the wards especially when doing procedures.

We had three LP's today and I was in a flop sweat by the end. Two of them were diagnostic so they needed the proper tubes to be sent for analysis. The third was for reducing ICP (intra-cranial pressure) secondary to cryptococcal meningitis. I still find myself in too big a hurry to treat/perform procedures vs teaching. The excitement of intervening is too seductive and I need to back off already. Generally I do this well as I teach but today for some reason I was too aggressive.

We, Christine (the M.O.) and I, have a new student from Penn, Kathleen Tran. She is every bit as bright as the rest and a Rhodes Scholar to boot. She has fit right in and is making great contributions in the discussion of differentials, etc., where I simply look dumb and try not to drool on myself. I'm slowly getting there, but jeez its slow.

Today, Thursday, is the second workday of the week as Tuesday and Wednesday were national holidays celebrating Independence from Britain. I'm on second call today and will be six times this month including two weekends which are rather a mess. I thought I had finessed that back in HR, but alas, the call gods have followed me here.

Lynne continues to be a champ. She has run head first into the sense of propriety around here as she has negotiated her way through bank accounts, checking, debit cards, electricity hookups, water, and Internet wireless. It hasn't been easy but she has kept her sense of humor and pace about it. She continues to amaze...

All for now, more later. Thanks for your posts of support, they really mean the world.

Mike

Rhythm and pace

A little about the rhythm of my day…

I awake to my watch alarm at 0600 and get up quickly as Lynne enjoys this time of day with her eyes closed. I have breakfast which generally consists of cold oat flakes with fruit, yogurt, and milk. The milk has a shelf life of months here and is sold in a small carton with an airtight mechanism. The fruit is all from South Africa and is papaya, strawberry, apple, banana, or the like. I usually will watch CNN or BBC to catch up and am looking forward to enjoying OPB on the web as soon as we move. After about 30min of this I generally check email, get ready for work in clothes that are the same ones as at CGFM and drive an old but trusty Toyota Corolla about 8km to Princess Marina Hospital. The commute is complicated by countless “kombis”, Toyota vans that are licensed to carry 11 passengers plus driver to various places in the area. One can ride for P3.00 or about $0.50. The drivers are aggressive, but the flow, once one “gets it”, is generally forward. It is much different than a quick bike or scooter ride down May Street however, and I’m sure that I don’t enjoy it. This will change when we move and are a quick walk (bike ride) from the hospital.

On arrival there I park and walk to the Male Medical Ward where I am the attending for the Pink Firm (team). We usually have 10-20 patients with a wide variety of disease processes that are typically associated with HIV/Tb. As an example we have a guy with esophogeal pathology for whom we have attempted to get a barium study for the last 1 ½ wks. Today I finally went to the radiology area and inquired why it was taking so long only to discover that they don’t do them anymore as the fluoroscope died. Nice of them to let us know. Also we have been waiting the same time for a lateral of the T-spine on a man with paralysis of the legs and cryptococcal meningitis only to hear today that the X-ray machine can’t generate enough kV to penetrate the body on the guy. Moral; walk all requests to radiology and become a thorn in the side of the tech so we’ll know right away.

Where was I, oh yeah. The morning begins at 0730 with morning report, a quick summary of the patients admitted by the medical officers during the afternoon and night. The patients are admitted by MO’s (medical officers with a single year of training post med school) but cared for by the men’s and women’s admitting firm for that day. So today we got a 15y/o with HIV/AIDS since birth (so called vertical transmission) who has MOTT (Mycobacterium Other Than Tb), read MAC, a 32 y/o man with a sudden change in mental status and some variety of intracranial process awaiting a CT of the brain so we can do an LP, A patient, HIV+ and wants it kept confidential from the family, who had gastroenteritis, and the like. We will often have a quick talk about the work up of something like anemia that Nicola can give off the top of that genius brain of his then it’s to the ward at 0900.

We round and write notes on all of our patients with a coffee/tea break at 1100 to bring the attending’s caffeine level up to therapeutic. These are fun as we get to know each other and discuss cases we have or have seen. During rounds we make a list of scut (read procedures, iv’s, lab, consultations, etc.) that is needed and begin that after break. This ends promptly at 1300 as visiting hours begin. This is one of the more moving times of the day as extended family will arrive to bathe, dress, feed, and otherwise care for the patient(s). We eat lunch around this time. The cafeteria lunch is more Sunday dinner style, based on a LARGE helping of rice, maze meal, or mashed potatoes drenched in soup-gravy, covered by an equally large helping of meat with a side of vegetables and beets (currently). This costs P14 or about $2.35. I usually go home for lunch.

The afternoon is occupied by helping and teaching the student or M.O. I don’t have the brilliance of a Nicola but have done a lot of procedures and can teach how not to screw up. I try to find just the right length of rope to give the team. It gets longer by the week.

Records are hand written with orders put on the front and iv rates in the progress notes or on a computer system that has been broken for the entire time I have been on the wards. Nursing runs the spectrum from outstanding to passive aggressive. Chocolate helps.

Then home by about 1700 unless I’m on call in which case I may get consulted on into the evening.

And I’m loving it, realize I’m fortunate to be living the dream, and look forward to more with the love of my life at my side.

Finding pace

Sunday am, 28 Sept. 2008

It has been a week of achievements and an attendant sense of accomplishment; and, the realization that even with a lot of help from our circle of support, frustrations are inevitable and take an emotional toll that is both difficult to characterize and more significant than anticipated. And, it’s all small stuff in the scheme of things.

After looking more closely at a sum of money wired to our Botswana bank (Stanbic)
-two days after requested from the US,
-the sum of which wasn’t the same but close,
-the number for which wasn’t the same but was close,
-and after tracing it twice,
Stanbic decided that this really was ours 17days after reception, and after two more long days of negotiations by Lynne restored it to the original amount and agreed to pay lost interest. In the process we met some genuinely nice people and they now are on the cookie list. With a rapidly emerging middle class in Botswana services are more eager to attract business so that look of ambivalence that one sometimes gets in a developing nation is very rare here.

Oh, since we now have a bank account with some money in it we were able to get our car. A small high clearance, front wheel drive SUV’ish vehicle called a Hyundai Tucson. Mind you when it was picked up it had different tires than when we test drove it, oh well. Next week we should be able to move into our flat so things are moving apace to get settled and begin to nest a bit.

Yesterday Lynne and I took our house keeper, actually Rev. Jones’ housekeeper to her home as we had hosted a small dinner gathering on Friday and she wanted to stay and help. She lives in Mochudi, a large town about 45min to the NE from here. This was the first time we had a chance to experience semi-rural life in Bots. Picture Forest Grove or The Dalles and you get the idea. Most of the roads there are dirt and she and her grand-daughter Tsi-tsi live in a four room cinder block home with a metal roof and outdoor plumbing. Cooking is on a two burner gas camp stove or more often outside over an open fire with a three legged pot. The pace is “rural Kentucky”; things happen with lots of attendant visiting, sharing of stories, and laughter. It was our first more than superficial exposure to the non-Gabs Batswana in their home environment and was most enjoyable.

The terrain is very familiar here, think eastern Oregon with high desert and buttes. The flora and fauna are vastly different and refreshingly so. It is early spring and very dry. Despite that all the tress are in bloom with the bougainvillea in stunning display everywhere. We walk by plumeria, flowering acacia, trees and shrubs that I can’t identify and the fragrance is wonderful. Unfortunately trash burning in Gabs is a way of life so on calm days that can be the dominant odor.

Work on the wards has slowly found a pace where I can actually offer something of value. My side-kick over here, Nicola, leads his rounds with a measure of teaching and competence that is incredible. He finds and hands out papers to his team, including nurses and then has them comment on them the next day. Me, I just round and try to keep up with the brilliance around me. I find I offer logistic notions from the experience of many mistakes over my career. We will discuss pathophysiology of cases but never with the comprehensive approach that is Penn or Hopkins. With time will come balance, I hope. And if not, it’s still on me to find it. I am definitely living in the present, so each day gone seems like a year ago. I’ll be on the wards through December and then will start outreach. It will be interesting to see how/who I am by then.

A interesting encounter

Yesterday we were shopping for furniture. I entered a shop and was met by a young man, Richard, who asked if he could help. I explained that I had moved here, was just looking and would be buying some furniture in the next couple of months. He pegged me for an American and said,
"You mean at election time in your country?"
"Uh, yes"
"Tell me, do you think Obama can win? Because I would love to visit your country but only if Obama wins."

The discussion went from there to McCain and Palin, Botswana, why I would leave the US, what did I think of Bush, and more. Unbelievable.

Reflections...

It certainly has been a fast month (alright 28 days). Some reflections if you please:

It has been an interesting and welcomed transition from “living in the future” while in Hood River for the last six months of our stay there, to “living in the past” as we left our beloved Columbia River Gorge, the Cascades, Oregon, the west, and our family to “living in the present” as we adjust to living here. The days on the wards scream by as I try to stay at least one step ahead of the diseases here and attempt to teach at the same time. My team is responsible for all the weekend admissions so, while we don’t have to actually admit the patients, the medical officers do that and do it extremely well, our service will be huge on Monday and the attendant frustrations will multiply.

This will be the first week without the on site leadership of Steve Gluckman, the clinical director of the UB/Penn partnership. So we are down to two Penn attendings, me and Nicola Zetola, with four others who are on the staff here. Together we lead the six medical services called “firms”, three male and three female. We are from all across the map; US, Cuba, India, Pakistan, Peru, other sub-Saharan African nations and of course Botswana.

Nicola is simply amazing. A guy one year older than our eldest, he grew up in Peru, entered medical school there at age 16 (it is an 8 yr program beginning at the undergrad level) where as a seventh year intern and an eighth year extern they ran the hospital, was the ONLY foreign applicant accepted to Johns Hopkins for residency (medicine) where he of course excelled, and completed an Infectious Disease Fellowship at UCSF where he published no less that 25 papers and got a MPH in at Berkeley in just one year. And is here now, a newly minted ID specialist/generalist with extraordinary clinical skills. We have become fast friends and rely on each other heavily; me on him for his clinical knowledge and skills in an inpatient environment and he on me for pace and experience from the opposite end of a medical career. He was looking pretty rough on Friday as he had been on call and had slept little in the previous 72h. So we kidnapped him at 6pm, took him to our place where he and I participated in the time honoured tradition in medicine of hepatic stress testing, smoked pipes, passed out in bed thereby properly incurring the clucking of the women staying here (yes Lynne included) and awoke new men, if not a touch the worse for wear.

I find I have moved into a more spiritual side of myself. I pray more, reflect more, fear and ask for guidance more. Lynne and I have moved away from the traditional Lord’s Prayer and are extemporaneous in our reflections and prayer, something we both find liberating, more immediate and enjoyable. I pray for the ability to demonstrate and live the love I feel from the Lord to the people here. The Batswana have been uniformly friendly (except perhaps when they are driving) and welcoming. When we tell anyone that we have moved here we are met with a smile and gleeful handshake.

About Gaborone, it is an emerging city in an emerging nation. Much of it would remind one of, say, Austin, TX, a college town and capital of about the same size. Eugene is another appropriate comparison. Botswana is blessed with abundant wealth and a large and expanding, educated, middle class. It finds itself on that ill-defined threshold between the security of the past and the blessings of a brighter, yet to be defined, future. It isn’t resource poor in the traditional sense although there are days when we have no linen, no suction, little true cooperation from other services, and no IV kits on the wards. The challenge is not only how to acquire the needed goods and services for this nation but how to distribute them equitably. Picture perhaps the Industrial Revolution in our country.

The seduction of this place at this time is that I can truly make a difference that is lasting, by simply teaching. That of course is also the challenge. It would be nice, although thoroughly boring, if life came in well outlined and clearly defined packages. I am slowly finding my feet. Writing this down helps, Lynne helps immeasurably, praying and reflecting has become a much larger and welcomed part of my life, and the challenge proceeds. I am blessed to be here with all the attendant anxiety and self accountability. I am out of my comfort zone, challenged to be in the lives of my patients and colleagues in training. For now I wouldn’t have it any other way.

An idea of the pathology

It's my intention to be a little less medical than in the past. It's just that attending at PMH is still in the wow-geewhiz phase. The following is my service as of today:

• Chronic gastroenteritis with a HUGE affective overlay
• Type II diabetes with multiple episodes of "hypoglycemia". HIV+, not on Highly Active Antiretroviral Therapy (HAART) with signs of cryptococcal meningitis
• Pneumonia in a 94 y/o
• Pneumonia in a 64 y/o with a history of treated pulmonary TB (PTB) on anti TB therapy (ATT)
• Bilateral tension pneumothorax in an HIV+, HAART- man being treated for pneumocystis pneumonia
• Cryptoccocal meningitis
• Large hemo-pneumo thorax (both blood and air in the chest cavity causing the lung to collapse
• Multiple lobe pneumonia, HIV/HAART+ with possible IRIS (Immune Reconstitution Inflammatory Syndrome)
• Cryptococcal mengitis
• HIV+ with pneumonia
• Multiple drug resistant TB
• 14y/o girl with cyanotic heart disease and pre-ecclampsia post delivery

We admit this weekend and the service with triple in size. The process is tiring but fulfilling and fascinating.

We are settling in and making it. More later.

I'm here for the next three months so might as well get used to it...

I’m S-L-O-W-L-Y getting the hospital figured out and am a long way off. We do good medicine to be sure, and it could be so much better but for (fill in the blank). Today our team “admitted” to the ICU a transfer from the local private hospital that had bleeding on the brain and blood that won’t coagulate because of an attempted suicide with rat poison. As I’m in way over my head with this I asked my colleague if he wouldn’t mind helping. In the spirit of the place he volunteered to assume care of the intubated/ventilated patient as I look over his shoulder and catch up on treatment options.

Another consult was for a 14y/o girl who had an undetected pregnancy, on top of cyanotic heart disease, delivered at term, at home, yesterday and came in with renal failure and a pressure of 110 diastolic.

The ICU, much like many of the other specialty areas is a little fiefdom, run by an anaesthesiologist who insists on having the medicine team round but not comment on the very reason the patient is there; the need for support of respirations and circulation. Ohhhhkaay, so we sort of stand around and try to divine what we are supposed to do and not piss this guy off as he has the ability to make our lives complicated and knows it.

Some departments are also the quintessence of political gamesmanship. I’m sure the Divine is testing me in that I truly need more patience for my patients. One department head is the Queen of Passive Aggression. In point of fact, any resource that is in high demand and has limited capacity usually has as its head a political animal, with the exception of Hematology where a delightful German doc simply says to send the patient down whereupon he will see them immediately! So we routinely weigh the need for lab, x-ray, etc. and find ourselves either doing without or playing “the game”. I of course am happy to do this and very understanding (my kids are seizing with laughter at this point).

So I’m in the hospital for the next three months, sure that I’m in the right place, doing the right thing. Would love to hear from some of you. How is CGFM? How’s the new hospital coming? How is fall? Here of course it is the threshold of summer.
Best to you all…
Mike

It's been a week!

Well it’s been a week of attending on the wards and-so far-no clean kills. I’ve had a great team; Mike, a 3rd year Penn med student, Emily, a third year Penn med resident, and Christine, a Medical Officer who is in her fourth post graduate year having had a rotating internship here at “Marina” (as Princess Marina Hospital is called). Each is wicked smart, able to evolve a differential diagnosis way faster and much more completely than me, and has a delightful manner and sense of humor. Having spent the last 25 yrs as a rural family doc my approach has been one of selecting what the pathology is vs. what it might also be. Now that I’m back in an academic environment this will be one of my bigger challenges; outlining and guiding a student/house officer through a comprehensive differential diagnosis.

Christine is simply extraordinary. She is Batswana, living with her parents and family here in Gabs. She went to med school in Russia (!) and learned the language as she attending school!!! She is a fantastic healer and has that ability to walk onto the ward and have a quick and comprehensive sense of not only the patients’ status but the staff as well. They and we love her. She is a huge asset to this nation.

Death here is a lot like Sudan, with a measure if dignity and resignation that I find hugely refreshing. We can quickly run out the string on the options we have for our patients here as they come in with devastating neurologic, cardiologic, respiratory, and infectious injuries. We do what we can, and do it very well, but death here is not as much of a defeat as it is a part of life. Trite I know, but also liberating; almost as if I can breathe again.

We had a great episode yesterday. We were rounding on the ward where we try to begin with the most ill finishing with the most stable. The ward is so chaotic with nurses who seem ambivalent on occasion that it makes for many distractions when I’m trying to “lead, follow, or get out of the way” of my team. As we were just about finished (isn’t this when these stories always happen?) we encountered a newly admitted young man, HIV+, with a level of consciousness that was all over the scale. Mike joked that his Glasgow Coma Scale was 4-12 (on a scale of 4-15), meaning from operating on the lowest parts of the brain to like me on a good day. We exchanged that knowing look and muttered,”crypto”, as we set about to do an LP. Even I after just five days on the ward I was up to speed with the team on this one. Crypto is medspeak for cryptococcal meningitis, an infection of the brain and central nervous system that raises the pressure around the brain and causes a picture of inebriation-somnolence-ambivalence.

He was moved to the procedure area and Emily did his LP as I gave her the only tips I can, which have more to do with the logistics of performing procedures i.e. never with a full bladder or an empty stomach, always be comfortable as you might be here a while, talk to not down to your patient (something she would never do), etc. We use a hollow tube (a monometer) to measure the pressure of the CSF. The fluid was under so much pressure that it went out the top of the tube like a fountain! After the LP where we took off about 40cc of spinal fluid I excused myself to go across the corridor to the woman’s side for a quick conversation, only to find Mike rushing over saying “You gotta see this guy!” Thinking the worst I raced over only to find that with the decrease in fluid and consequent decrease in pressure he was awake, lucent, and wondering what the big deal was. Oh, and why did his back hurt! A great career making experience for the team. I had seen this in Sudan several times and had forgotten just how dramatic it can be. The treatment is medication and therapeutic taps as needed until the pressure is reduced reliably.

We continue to count our blessings as we stay in this house. We’re (OK I am) old and grumpy enough that having one domicile to return to at night is wonderful as opposed to moving from one flat to another. We are developing friends, I seem to be navigating this left hand driving thing better and better, and am enjoying my colleagues very much. This weekend is for nesting and reading. I/we need it and are relaxing into the Africa that is called Botswana.