The two steps back part...

Admission

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

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

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

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

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

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

Random randomness II

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

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

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

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

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

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

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

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

3 grand!

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

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

Made it to 2800m!

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

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

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

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

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

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

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

Cheers

Scratching that creative itch..

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

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

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

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

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

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

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

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

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

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

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

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