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.

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.

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

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.

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