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.