Hail yes!

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

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

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

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

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

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

More randomness

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

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

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

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

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

Monday

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

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

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

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

Down time

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

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

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

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

Today in Ghanzi

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

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

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

Historic

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

Outreaching

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

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

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

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

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