A new angel

Today was one of those days you just know is out there but dread. I was past due for this....a child died in my care. We, two dermatology residents and I, were in Lobatse today. They had given a great talk about the latest ideas regarding care for a perfectly miserable spectrum of skin diseases characterized by anything from rash to blistered lips to burn-like wounds across the entire surface area of the body. It's called TEN (toxic epidermal necrolysis) for short and is a true bitch.

It is quite prevalent in HIV prone areas because one of the anti-retrovirals used early in the care of HIV is frequently associated with it. It's interesting in that the care for TEN in western countries involves intense intensive care with a mortality rate of 50-70%. I've cared for it in remote Sudan with a perfectly lousy outcome as well. In South Africa they are as diligent but use less invasive techniques and have a rate of generally <10%.

In the middle of the talk a nurse came into the room and asked for Roger, a good friend of mine and excellent doc. We casually finished the discussion and went out to see if the residents could shadow him in the A&E (the emergency area; "Accident and Emergency"). I walked into the room and found him bagging (breathing for) a 3mo old boy.

Apparently the child had gastroenteritis for three days and had visited a "traditional healer" at least once. He was brought by his parents and grandparents who were arguing about whether to let us treat him. By now he was obviously dry and in shock. When the powers that be relented or won, depending on one's point of view, Roger got busy. He had started an IV in the external jugular (the guy can canulate a capillary!) but didn't have normal saline, the mask didn't fit, the 02 wasn't reliable and the tubing the wrong size. In short it was like a lot of pediatric codes in western hospitals that haven't had one in a while.

So I got in the middle of the flail and started to rehydrate, establish and airway, decompress the stomach, and initiate CPR. Now if a three month old's heart stops it has to be from electrolyte abnormality, profound sepsis and shock, or.....well that's about it if it was previously working fine. So we suspected the traditional remedy but who knows. He was terribly ill and appeared to be caught in a power struggle that relented too late. For that matter it could have been a clean kill from traditional medication. We'll never know and that is so damn maddening. Nothing to learn about the cause of death, just an opportunity to review pediatric resuscitation in a secondary hospital. Maybe that can be his legacy. God I feel empty..

The rest of the July story

And what a wedding indeed. It was at the home of Olivia’s sister in east Portland. She, her boyfriend, and anyone walking down the street worked tirelessly to turn the back yard of their home from a patch of blackberries into something out of Sunset Magazine, simply beautiful.

Olivia and Beth exchanged vows in the side yard with Eli officiating. There was enough humor in addition to the vows exchanged to keep it light but very devotional; a truly wonderful and moving memory.

We then moved to the back yard where those in attendance offered blessings on the marriage and laughed, cried, loved. Then the party. We rented an old Masonic Temple in North Portland and had DJ Eli plug his iPhone into a great sound system and danced the floor around. It was wonderful to see family and friends at this celebration.

We flew to Philly where we saw the KA’s and I went to UPenn to have my head examined yet again. I’m still screwed up enough that another med is warranted. I tried to get another MR scan of my gourd but ran head long into the underbelly of US health care. I didn’t need a prior authorization for the MR scan but because Penn had contracted out the process to a third party, that has the huge and necessary data base, I still had to go through them to the tune of waiting “just 24-36h” for an authorization I didn’t need but without the OK from then would be on the hook for paying for an MR scan, HUNGH???!! So needless to say, no MR scan as I had to get to NYC and over the pond.

We had two fantastic farewell dinners with family and then Walt took me to Trenton to board a train to Grand Central in NYC. I arrived there on a Friday afternoon with two large bags and a backpack, navigated my way around and through to the subway and made it out to the hotel at JFK without losing anything other than my mind and dignity. Not sure what I was thinking when this struck me as a good idea and doable. Doable yes, a good idea……

Lynne has stayed in the States to offer much needed and appreciated help with the twin grandbabies in JAX. Forrest and Shannon are doing admirably but like any couple with three kids under two, well, you can fill in the blanks….

And I’m back at it. We are in the middle of Influenza H1N1 here as if things weren’t tough enough already. I was advised that each hospital has been allocated 10 (that’s ten) dosing regimens of the antiviral indicated for this flu. We are in deep yogurt if this truly becomes epidemic here in a country with a HIV prevalence rate of 13-60%, depending on region.

Best to all that we saw in the States, friends and family in Hood River, CGM, CGFM, the BA relatives and friends, and the UPenn crew. Thanks so much.

July!

And here we are in PDX, in the PDT time zone! Lynne has acclimated to the 16hr plane ride from Jo’burg to NYC quicker and better than my slow burn as she is more accomplished at this point. I run out of things to do and my neck starts to bend in new and different ways thanks to being too tall for the seats to sleep comfortably. Hmmm, “sleep comfortably”....on a plane...... in coach; a true oxymoron if there ever was one.

We arrived in New York early in the morning, left our stuff at the hotel and went to Manhattan via the subway to see Central Park. It was amazing; clean, safe, HUGE, friendly. Something, in my ignorance, I didn’t expect. We were caught by a rain storm and delighted in the familiar odor of “east coast wet”. We walked to Times Square where we were overcome with and by the people/tourists and fatigue, ultimately fleeing back to the hotel to sleep then leave for the NW the next morning.

It was delightful to be met at the airport by Aven, TJ, Belle, Bethany, and Olivia. Hugs and greetings of longing all around, a night’s sleep and then, on the 4^th, a trip to Hood River. It’s fair to say that I was floored about how unprepared I was for my reaction as we drove up the Gorge. Call me naïve, but I was overcome with a sense of déjà vu, a sense of “what was I thinking?!!”, as we drove past Multnomah Falls, the Osprey nests, through Cascade Locks and into our old home town of 22 yrs. We parked at my old office and met up with friend after friend as we watched the famous Hood River 4^th of July Parade wherein half of the population is in it as the other half watches. Every kid on roller-skates, every jacked up pickup, every swim club, ball team, politico, and anyone who wanted to advertise their business was in it. We finished the day in our old neighborhood with a classic barbecue; too much of everything including nostalgia, food, and laughter. It was great.

We returned to HR later that week to see old friends and haunts. We spent the evenings at MJ and Michael’s home above Mosier where we had an apartment and could try to catch up to ourselves. They are great friends and fellow swimmers from our previous lives, so generous and kind. Monday we “swam” with the team, ate huge breakfasts, and had a chance to see eagles, The Hook, drink too much good coffee, and read "The Oregonian". I had my eyes and teeth examined and get to return to have a ‘drill and fill” on one of my teeth. It would seem that in addition to having an asymmetric head I also have an asymmetric jaw that causes stress on my teeth. Jeez I just can’t get enough mileage from those guys.

The past weeks have been filled with grandchildren as Forrest and Shannon have adopted twin newborns; Asher and Cora and now have three kids less than 21 months of age. It was a difficult week as they struggled to seek out a space where they could anticipate the additions to their family and care for the mother who was placing them; amazingly moving and courageous on all parties’ parts. Judah is a great brother and is getting that role figured out. Belle is four months, long and tall, and filling out. She loves to seek stimulus and enjoys motion. But to her credit is sleeping well and working on her fourth chin.

Eli and Amber, our son and daughter in law, have arrived. Yesterday we had our first Family Council Meeting. We’ll have more but this one gave us each an opportunity to acknowledge and explore. Forrest and Shannon were present by speaker phone as were the g’kids. Our family is changing and sentiment runs the spectrum but several things remain and persist, our love and devotion to our (nearly) spouses, the extended family Pendleton, and working out how we can be in each other’s lives. Tomorrow we “swim” with the team, have some medical appointments and lunch in HR. Thursday I have another, and last, chance to swim with the team, then a radio show, a real homage to simpler times and a true treat, and finally a noon presentation with the medical staff at my old hospital.

Now on to the wedding!

Its been a a while

Two weeks ago Lynne and I finally took a break and went to an animal reserve south of here, just over the SA border, to a game lodge called Tau ("lion"). It turned out to be one of those all inclusive resorts where you are greeted at the front door and your car is driven away as you settle into a routine of being pampered, not unlike what I imagine a cruise would be, with too much food, drink and the like. We skipped a meal and were called by the desk to check on us! The game drives were amazing with all the usual just not in abundance as the late rains had made it less easy to access the water holes and areas where some of the popular game congregate. It was very relaxing and long overdue.

That Monday I was on the road with two med students, Kandace from UPenn in her fourth year and Kea, a Motswana, schooling in Australia, in her last year. We headed out to Tsabong in the SW of the western frontier to a primary hospital there. I no sooner got out of the car than I assisted the CMO with a C/Section ( a "Cesar" as it is known throughout the area). We discussed the numerous ways to perform this procedure and the benefits of each as we saw them. We then rounded in the small general purpose ward and the next day I taught a class on CHF and HIV. It amazed me that HIV has such a presence even at the "end of the road". All you need is a trucking industry that is "serviced" as it were and spread of STDs is assured.

Tuesday we headed back east then north then west again to Hukuntsi where we met the new CMO, rounded, taught, learned, laughed. We stayed there for two nights, me in a suite with two other guys that enjoyed ladies of the night well into the morning so sleep was with medical aid and ear plugs crammed deep into my EACs. Doubt "protection" was high on the agenda as it was all very alcohol fueled.

Thursday we again headed east, north, then northwest to Ghanzi for five nights. We worked with the local district hospital team on the inpatient services, then in the clinics of Ghanzi with the only MO for the district.

Saturday night we went to a village, D'Kar, about 45km to the east and witnessed a "healing dance" by the San, an ancient ethnicity of the area who use some 20 different clicks in their language. It is impossible to comprehend and I found myself staring into their mouths as they discussed the day, much to their amusement and glee. On the way out we stopped off the road and witnessed what I hadn't seen since Afghanistan, a Milky Way so huge and bright that you could read by it!

There is a school in the same town that houses San kids as they live very remotely. They are a group of people that are very small featured, almost orange in color, broad open faces, always laughing.

I saw the worst case of AIDS I have seen thus far; a 23 yr old woman with wasting, advanced TB, genital condyloma, Kaposi's sarcoma, and a huge fist sized, pendulous, papilloma of the vulva. One of my lasting memories of the hospital will be Kandace and Kea, both of whom thought they might go into a more tertiary specialty, sitting on the floor in peds laughing and giggling with the kids there, then telling me that they just might go into primary care. Nothing like a 9 day adventure into key primary care areas to open one's mind. That and some giggling kids in a peds ward in the middle of nowhere.

Sunday we went to my new favorite town, Charles Hill on the Namibian border, and saw the local and lonely doc there. My lasting memory of the trip will be sitting in the bed of the small pickup truck we were driving, sipping a Coke of all things, taking in the surrounding culture of the town center as Herero women walked around with their characteristic headdress, kids laughed and played, and the rival political parties blared sound trucks at each other across the dusty expanse. Man was that cool or what?

We drove home on Tuesday and spent the rest of the week in the usual outreach routine. Now it appears that the students from Penn might get to spend their time in Mochudi, a huge benefit for them as the experience becomes more truly "global", integrative, and assimilating.

See those of you in the PDT time zone in less than a week!

OK, way, way out there....

This week was amazing:

Monday we began in Moshupa with one of my Stellenbosch mentees, Cathy, a great doc from DRC. There we saw a full slate of illnesses and a pre-septic child or two. We have yet to have any confirmed cases of HINI flu here but we are all confident it is on the continent and headed this way if not here and under-reported already. It will make life very difficult as it overwhelms our health care system. It will make for a tough spring and early summer (read August through November).

Tuesday Cathy and I hit the road to a tiny village outside of Moshupa; about 10km from where she lives called Lotlakane. It rained all night the night before and the road was like grease. On arrival we were surrounded by very familiar sites, sights, smells, spells, and sounds. I discussed this in the entry just previous to this one. It became my new favorite place. I want Cathy’s job.

Wednesday was Mochudi and a rural clinic that has one of my favorite MOs there, a woman about fifty-ish who is very capable. No meds if you don’t need them and you had better have a good reason for not using or “forgetting” why you didn’t use the last ones she gave you. We again saw a wide range of pathology and in general had a great time.

Thursday in Lobatse we saw a wide variety of the sick and those that were just sure they deathly ill with all of five somatic pains and counting if we didn’t act impressed. I have come to recognize a characteristic facial expression on these people (mostly women) that is a dead give away for so called medically unexplained symptoms (now called MUS in the literature instead of somatization or just plain nuts)) from the first breath. We finished the clinic at 1:00pm, got some lunch at the local grocery store, and went back to the hospital to see what trouble we could get into…..quite a bit as it turned out.

There in the A&E was a 9mo old who had been given a “traditional medicine” for vomiting and now was septic, seizing, comatose, “fill-in-the–blank”. The MO was appropriately trying to start an IV in a child with fat hands, no BP and having no luck. I mentioned an intra-osseous line as I have been in his shoes countless times and learned, at the cost of numerous kids’ lives, that one can futz with an IV for an hour or get down to the business of saving her little butt. He didn’t know how so we took her to the peds ward and on the third attempt (it took a minute to have it all come back to me) in it went as sweet as you please and we went about the business of reeling this kid back. Only later did it dawn on me that with the salivation, lacrimation, seizures, coma, and vomiting that we were probably witnessing cholinergic intoxication either from accidental poisoning or the traditional medication. She bounced a little with a fluid challenge and some antibiotics. Hope she makes it; a great teaching case for the students, MOs, staff and an aging family doc.

Friday we were “way out there” as in 100km off the road on a dirt road in the middle of the western Kalahari in my new favorite place. The village is Lolowane. To pronounce it one needs to disarticulate one’s tongue from the back of one’s mouth, allow air to pass around the back it as you try to pronounce the sound of “L”, then immediately roll our tongue to pronounce the “wane”, sounding like “wannae”. I tried to the glee of the people there and their shrill laughter was simply infectious.

There we few enough patients that the students could do the clinic with the supervision of Cathy and I. Each saw a wide array of cases that you see in remote places. We even saw a case of what I last saw in Sudan, Iraq before that, Afghanistan before that, and Turkey before that; Limb Girdle Muscular Dystrophy. This time I think it was complicated and accelerated by HIV but who knows and we'll get some more info with some blood work she gave us in a month. We took pictures all around, laughed likes little kids, and drove back across the Kalahari to Kanye. I’m a touch the worse for wear but man was that a gas. What a great week.

Way out there

Well I’m getting farther off the beaten track these days and it will come as no surprise to those that know me that I’m having the time of my professional life. Yesterday I found myself with one of my mentees, Cathy, in a town very reminiscent of the way Hood River must have been at the turn of the last century; small, familiar, with the onsite health care provider (a male nurse) firmly in charge of who got seen for what and when.

There we were way off the beaten track, in the winter rain, at the medical-cultural-commercial center of a village; its health outpost. The onsite nurse knew everyone and was drawing blood on kids with HIV for CD-4 counts, dispensing meds, chiding patients for not taking their meds properly, flirting with the ladies, and sending us the truly sick that he had triaged. The clinic was very……. what, “guy”. Things were generally neat, but sloppy and might have been underneath stacks of stuff. He knew where everything was just that it might be under something. And he could draw blood out of a mosquito.

We saw all manner of rural HIV and co-morbidities, still saw lots of somatic stuff, and in general had a gas. The school was next to the clinic, across from the rural Botswanan equivalent of a 7- eleven, down the path from the town admin building. We left cold and a little wet as the clinic leaked, but warmed from the adventure and the medicine.

Friday I and Cathy go waaaaay off the road into rural southern Botswana to a remote health outpost. The medicine is as fun and challenging, as are these destinations. This weekend Lynne and I are off to SA to stay at a game reserve and see some larger game (lions, elephants, and the like), then Monday I hit the road for another tour of the western frontier hospitals. Then we head for the US and Oregon. Hard to believe that I’m coming up on a year away from CGFM. I must say I miss the people in my previous life deeply but have no regrets to be doing this at this time in my career. I'm truly fotunate and indeed blessed.

Neat and clean

The Batswana are very fastidious. You never see a dirty car or a piece of litter...they have two people walk the roads wearing bright orange jump suits spearing litter, what there is of it, and in general keep the place quite tidy. They even sweep the dirt free of leaves. 

Now that it is Fall, they are out in force sweeping the area, keeping things in order and orderly. This separates them from the Sudanese where there was so much litter that you soon became quite used to it.  It was surprising to see it in the photos I took.

The women here dress very proper, very British if you will, and will walk for km's in shoes with 4 cm heels along dirt roads, across fields, and the like. 

Every town/village/city has at least one large area that is all dirt and used for football (soccer). There is a local interest in fast pitch softball with teams from all over this area competing on the weekend. All sorts of alcoholic beverages are sold at the games so things can be either animated or quite sedate depending on the average alcohol level of the fans. Beer is sold at all events, even in the local amusement parks.

In have returned to attending at PMH for one day a week under a new paradigm wherein I teach, and write very few notes. This seems to be workable as rounds are better, faster, and more efficient. One of the UPenn students has fashioned a non re-breather O2 delivery mask and it has  made a huge impact on the hypoxia of the PCP pts, taking their o2 saturation from the mid 50's to >95%!  The dysfunction is just the same, especially in contradistinction to the secondary hospitals. 

 The med school has a new founding dean and my role there is still to be defined. In the mean time I love what I get to do each day so I can't go wrong. Fortune has indeed blessed me.

Now that I know my way around this part of the country it is beginning to feel more like "home".  This weekend I meet with my mentees in the FP residency. Next weekend is a getaway with Lynne to Tau, a SA game reserve . Then I hit the road for 10 days to make a circuit to Tsabong, Hukuntsi, and Ghanzi. Find them on the Google maps and you'll get a taste of why this is such a sweet gig. All my best.