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.
Monday, September 29, 2008
Sunday, September 28, 2008
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.
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.
Sunday, September 21, 2008
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.
"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.
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.
Thursday, September 18, 2008
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.
Tuesday, September 16, 2008
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
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
Saturday, September 13, 2008
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.
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.
Thursday, September 11, 2008
For the medical crowd (all five of you)
Some diagnoses over the last for days: uremic frost (really, not since med school have I seen this), pulmonary tb (PTB) with pleural effusion, septic shock, HIV with a CD-4 count of 2, LOTS of HIV, lots of tb in various manifestations, and much more. Amazing, and a true privilege.
Tuesday, September 9, 2008
For those who are curious, here's a picture of the tat at age two days. I ignore it, but quietly am proud of it. A great icon of Mt Hood and the water from it and that flows by it. Blame Eli for the pink shirt, it seems I don't dress cool enough for eldest son and need a fashion coach. He even showed me how to tuck in the shirt differently "because it is knit". Ignorance was truly bliss.After two days as an attending on the wards I am reassured that this was a great move professionally. The pathology here is thick and deep. It’s fair to say that we are still ironing out the kinks of emigrating as it were but we are well into it and are for the most part truly enjoying it.Yesterday we had a gentleman with HIV (virtually 90% of all the admissions are HIV+) who had severe pneumocystis pneumonia. This bug causes large cysts on the lung about the size of a grape or larger. In the states it’s rare to have this disease anymore as the new anti HIV meds help to prevent it and if one does get it, rarely does it advance to this stage. The cysts are capable of rupturing and causing a collapsed lung (pneumothorax). If the pneumothorax if from a leak in one of the cysts it might cause the collapsed lung to be under pressure (tension pneumothorax) and the chest cavity can become so pressurized that the heart is shoved over into the opposite side along with the wind pipe (trachea). This guy already had a pneumothorax on one side and now had a tension pneumothorax on the other. The lung under pressure was about the size of a lemon! And the cysts were hanging out there in the apex of it, unbelievable! The med resident on the team slipped in a chest tube as slick as you please and our patient started to act like he was enjoying breathing for the first time in a day.Love to all,Papa, Mike
Sunday, September 7, 2008
Can't quite find the synapses
Well to say the least it’s been a week. As a Batswana physician I am required to know and to prove that I know something about HIV. As >80% of the inpatients we see have HIV as a baseline with some other co morbid problem, it of course makes sense. The national health care system here has fashioned a number of what are called “KITSO” courses (Knowledge Innovation and Training Shall Overcome) in various AIDS related disciplines; adult, peds, advanced, and the like. As the country has specific protocols with specific antiretroviral meds (ARVs), and as I’m a nincompoop about this disease having lived quite happily and naively in my professional cocoon as I have for the last 2 decades, the course was invaluable. It was four long days of lecture and group dynamics then a test Friday. Just sharing a large hall with a bunch of bright Batswana was inspiring, if not a touch intimidating. Upon completion of the exam Lynne and I went to the bank to establish some accounts before I could get to the hospital and join my team…..only to find we were admitting on a Friday afternoon and as happens, the Medical Officer (MO) had taken some unannounced personal time.
The teams here for medicine are six, three each for male and female medicine. I have one of the male teams with a crackerjack third year Penn medicine resident, Emily, and an equally eager and hard working third year student, Mike. They (we) admitted a gentleman with a stroke (L hemi-paresis with a P=40, BP=90’s/40’s, long history of HTN and of multiple meds but none had been fully dosed). Emily started on the latest outcomes based data on how best to approach this and I of course find myself standing there with little to offer other than the awe of listening to young bright docs and students go at it for our patient. My natural tendency will be to treat so I need to first learn to stand back and guide. I don’t possess the cognitive brilliance of a newly minted Penn Med IM resident but I’ve made enough mistakes by now that I can offer some wisdom from experience.
We have been helped immeasurable by the generosity of the Jones family here. We are living in the home of Gil’s father, a minister here in country for years, as he visits his family in the UK. This gives us a semi permanent home from which we will move to the condo at the end of the month. It’s nice to have turf that is not shared for a period of time and to be together.
I have lots of catching up to do before my tour of the inpatient side of thing is complete in three months. The pathology is neck deep. Yesterday I saw a gentleman with confluent Kaposi’s Sarcoma of his leg, a 32 y/o man with slight shortness of breath and a complete white out of his left lung from a gigantic pleural effusion and offered some ideas to Mike as he drained 1.5L of fluid before we stopped, a child with retinoblastoma pre enucleation, severe wasting syndrome from HIV everywhere, etc. All in an afternoon!
Urban living is problematic for me. Lots of city noise, effluent, traffic. No clean kills yet as I am becoming use to left sided driving and have been told just once that I was “Number One” with the middle finger of a Beemer driving south Asian. I of course replied in kind, from my generic Toyota Corolla that the Jones tribe has so generously offered for use that, no, it was really he who was number one…..
I LOVE hearing from family and will get back to you as soon as possible. Just know; Eli, Aven, Olivia, Forrest, and Shannon, and Bethany that your letters are sincerely loved and appreciated.
Well off to find a vehicle. Should be some real horse trading, good thing Lynne’s along. She is steel to my straw.
And we found one! If all goes well we will have a 2004 Hyundai Tucson, front wheel drive, in which Lynne feels comfortable so we feel quite fortunate. Buying a used car here is a bit of a flail, not unlike the States with lots of car places lining a district street all or most operated by south Asians from South Africa. We didn’t bargain hard or fast as we need a vehicle ASAP as the Jones been most generous with theirs. Once we live closer in town most of my “commute” will be by bike or foot as we’ll live about 10m from the hospital.
I’ll conclude with some random thoughts:
-This is where I need to be and I am going to be practicing medicine consistent with why I became a physician. It will be FULL of frustrations to be sure, and it is time for me to be more patient, as if I have a real choice.
-I got a tattoo and when I can be on a faster computer and have divined how to do it I’ll put a picture of it up on the site. I did it the Friday before we left Jax. In the process of accomplishing what follows I and my sons went to a local tattoo place. I had an iconic profile of Mt. Hood with a river in the foreground placed forever on the inside of my right upper arm. I’ll post a picture of it later when I have a better connection to the web.
-Lynne had misplaced her rings and they seemed to have evaporated into the ethereal void. I couldn’t let a hot babe like her go to unclaimed as it were so I secretly got her a new wedding band. OK so it wasn’t so secret. ALL the women in my life lead by our daughters in law “suggested” that it would be nice if I got a wedding band before we went to Bots. So Eli, Forrest, and I went to a huge mall (they have those in Florida) got her one and presented it to her at the family dinner we had at a local restaurant, to the tearful approval of the entire XX chromosome contingent.
Monday, September 1, 2008
A little upside down, southern hemisphere style
It’s my intention to be as transparent as possible given the appropriate precautions of writing about medical (mis)adventures here in Bots. Feel free to ask any question that comes to mind and leave your email address. I’ll either answer it in the blog or privately.
Where to begin; how about WE’RE HERE!!! We had a simply delightful time with our family on coastal Florida, punctuated as it was by T.S. Fay. That made three tropical storms I had experienced throughout my stay in TX and the South. It was a mixed blessing as it made for some indoor fun and closer proximity for catching up and laughing. We tearfully said our goodbyes on Sunday morning the 24th and arrived here on Monday night. Currently we’re housed in the home of Rev. Jones, the father of Gill Jones out administrator. He is a Brit that has spent most of his life in sub-Saharan Africa and who has gone to visit family in Britain for a month. So we are blessed to have his house in which we can arrange our lives and begin as expats with a solid home base.
Last week was simply a blur. I sat in on morning report twice and it was better that I remember from the Fall. Lots of good natured ribbing and quality teaching from 0730-0845. Then rounds begin on the wards here at Princess Marina Hospital. Shortly there will be five of us expats that will function as attending, teachers, and outreach docs.
The week has been full of visits to immigration for exemption papers to stay for the duration of my three year (so far) contract, visiting the Ministry of Health to register and therefore be able to practice in Bots, a fair amount of driving to places to shop for ….you name it. We now have rented a town house that is perfectly located near the students, the office, the hospital, and downtown. We move in early October.
It occurs to me that some of you might read “town house” and wonder exactly how hard a gig this is. Botswana is a developing nation, make no mistake. The economic dichotomy here is stark and very real. Yet the country has wealth and is struggling to distribute it. This nation is far away from the resource poor situation that was Darfur and Akuem in Sudan, but is 1 ½ -2 generations removed from true emergence. In the mean time the hospital is thick and teaming with pathology, the internship has just started and the med school will invite its first class next year. I admit to some “survivor guilt” as it is easily the sweetest gig I have done but I’m here to teach and teach in rural areas where things are different than here in the capital. So after one week, we’re here and in fine shape.
One unexpected factor is having Lynne here. This stuff is a little like breathing for me as I have done it many times before; but never in this context, never as a team, as husband and wife. I find myself preoccupied about her well being and adjustment and am teary and tired by day’s end as a result. And, this will come as no surprise, she’s thriving. She has the place wired, has learned Satswana to a fair-the-well and hasn’t met anyone who doesn’t immediately love her.
I have taken the tentative first steps into the land of left sided driving and have been flipped off just once-by a guy in a Benz, in a damn hurry, a situation that would have happened in the States to be sure. Otherwise I’m getting the hang of it although I consistently try to enter the car from the left side, look around to see who may have seen me, and act like I really meant to do that…
Today we went south to Madikwe Game Reserve in northern South Africa. It’s about 45m from here not including the third degree we got at the border. At the reserve we met up with Gill Jones, her husband, Tim, and Steve and Pat Gluckman. They had stayed at the Tau Resort for two night and we went there today for lunch. So we’re sitting on a deck overlooking a river when along comes a herd of elephants to take a long slow drink, followed by springboks, kudus, a fish eagle, and wildebeests. Unbelievable and truly in the wild as they completely ignored us from 75m away! Amazing.
This week I take a class in HIV to qualify for a test such that I can treat HIV patients in this country. Then it’s onto the wards where I’ll lead a team of one attending, one Medical Officer (a doc with a single post grad year of training), and several med students. When I’m not studying as fast as I can I’m simply scared spitless.
Time to go, I’ll update a little more often. We have dial up here so it a little difficult to get everything up and running, but we have it which separates this place form every other place I’ve been. Thanks to all who posted. Best to you all……Mike
Where to begin; how about WE’RE HERE!!! We had a simply delightful time with our family on coastal Florida, punctuated as it was by T.S. Fay. That made three tropical storms I had experienced throughout my stay in TX and the South. It was a mixed blessing as it made for some indoor fun and closer proximity for catching up and laughing. We tearfully said our goodbyes on Sunday morning the 24th and arrived here on Monday night. Currently we’re housed in the home of Rev. Jones, the father of Gill Jones out administrator. He is a Brit that has spent most of his life in sub-Saharan Africa and who has gone to visit family in Britain for a month. So we are blessed to have his house in which we can arrange our lives and begin as expats with a solid home base.
Last week was simply a blur. I sat in on morning report twice and it was better that I remember from the Fall. Lots of good natured ribbing and quality teaching from 0730-0845. Then rounds begin on the wards here at Princess Marina Hospital. Shortly there will be five of us expats that will function as attending, teachers, and outreach docs.
The week has been full of visits to immigration for exemption papers to stay for the duration of my three year (so far) contract, visiting the Ministry of Health to register and therefore be able to practice in Bots, a fair amount of driving to places to shop for ….you name it. We now have rented a town house that is perfectly located near the students, the office, the hospital, and downtown. We move in early October.
It occurs to me that some of you might read “town house” and wonder exactly how hard a gig this is. Botswana is a developing nation, make no mistake. The economic dichotomy here is stark and very real. Yet the country has wealth and is struggling to distribute it. This nation is far away from the resource poor situation that was Darfur and Akuem in Sudan, but is 1 ½ -2 generations removed from true emergence. In the mean time the hospital is thick and teaming with pathology, the internship has just started and the med school will invite its first class next year. I admit to some “survivor guilt” as it is easily the sweetest gig I have done but I’m here to teach and teach in rural areas where things are different than here in the capital. So after one week, we’re here and in fine shape.
One unexpected factor is having Lynne here. This stuff is a little like breathing for me as I have done it many times before; but never in this context, never as a team, as husband and wife. I find myself preoccupied about her well being and adjustment and am teary and tired by day’s end as a result. And, this will come as no surprise, she’s thriving. She has the place wired, has learned Satswana to a fair-the-well and hasn’t met anyone who doesn’t immediately love her.
I have taken the tentative first steps into the land of left sided driving and have been flipped off just once-by a guy in a Benz, in a damn hurry, a situation that would have happened in the States to be sure. Otherwise I’m getting the hang of it although I consistently try to enter the car from the left side, look around to see who may have seen me, and act like I really meant to do that…
Today we went south to Madikwe Game Reserve in northern South Africa. It’s about 45m from here not including the third degree we got at the border. At the reserve we met up with Gill Jones, her husband, Tim, and Steve and Pat Gluckman. They had stayed at the Tau Resort for two night and we went there today for lunch. So we’re sitting on a deck overlooking a river when along comes a herd of elephants to take a long slow drink, followed by springboks, kudus, a fish eagle, and wildebeests. Unbelievable and truly in the wild as they completely ignored us from 75m away! Amazing.
This week I take a class in HIV to qualify for a test such that I can treat HIV patients in this country. Then it’s onto the wards where I’ll lead a team of one attending, one Medical Officer (a doc with a single post grad year of training), and several med students. When I’m not studying as fast as I can I’m simply scared spitless.
Time to go, I’ll update a little more often. We have dial up here so it a little difficult to get everything up and running, but we have it which separates this place form every other place I’ve been. Thanks to all who posted. Best to you all……Mike
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