Random randomness

Some random thoughts and observations:

-Having Matt here is GREAT. He is a natural teacher and mentor, and a great partner with whom to discuss medicine and life.

-I went out to Kanye to teach my Family Medicine residents from Stellenbosch (did I mention I PASSED the boards?). They are all bright and gifted docs. Three are national Botswana, two are from DRC and one from Uganda. I spent the next day with one of them where she was working in what is known as the IDCC (Infectious Disease Care Clinic). The euphemism breaks down in that everyone who is there is aware that they are in the queue because they have HIV and are getting their monthly clinic appt. We saw a 50'ish woman with a year long history of post menopausal bleeding, and she was a classic "last patient of the day" story. She was bleeding enough that she was concerned and mentioned that she had to wear a pad. My MO was close to blowing all this off as she needed the time to study and for other things. I recalled to her that a wiser attending than me had once said that I should never miss the opportunity to place my finger in a bleeding orifice. So after an appropriate eye roll she went to the clinic next door and found a speculum, brought it back and inserted it. She is really good but I I had to get a touch testy saying that this is what I, as her mentor, expected from her.

We couldn't visualize the cervix easily for all the blood. So recalling that adage from an attending smarter than I, we did a manual exam; the first in a year as this was always temporized by other MOs in the out-patient settings. She had had an ultrasound of her pelvis and a PAP smear but no true exam. The PAPs are done under dim light often without a manual exam and then they become important only because we finally did one and found a fungating squamous cell carcinoma involving the cervix and vaginal side wall.

Blast and damn, this should have been picked up months ago and wasn't. It occurs much more frequently in HIV and should have been expected.

-These talks we give are all patient based and have apparently become quite popular. There was discussion about substituting another speaker for us on a Wednesday in Mochudi and the hue and cry was flatteringly great enough that they scheduled around us, WOW!

-We flew! Yeah, out to Tsabong where I felt so at home it was a touch spooky. It is a town in the far west of the country that takes 6-7hrs to drive to or 56min to fly. We took off with me in the right seat (thanks for the suggestion For') and had a gas out there. Very reminiscent of Hood River and the old Hood River Memorial Hospital; small number of beds, small staff, everyone knows everyone, and great comprehensive general care.

We spent a fair amount of time dissuading them from transferring patients to Gabs as the care here offers little more than what they get there except some more comprehensive testing. Specialist consultation can be obtained over the phone and is often sketchy depending on the motivation of the specialist. I swear some of these guys (all expats from various backgrounds, training, and medical cultures) look for reasons NOT to intervene when it stares them right in the face. They embody an arrogance and indifference that is the ugly side of medicine. The only indication for transfer to the ICU here is imminent death (i.e. an 02 sat of less than 60!), and one has to get on bent knee to plead with an anesthetist(!) for transfer. We tend not to look for quality as much as to fill the specialist slot with a widget. As long as the slot is filled....

Hope all are well. Now that the boards are over I can try to learn Setswana. Ke a leboga! (Thank you)

Lynne's Home, and I Passed!

Lynne’s here and life is good, or did I mention that? She was happily up to her neck in twins and now is home, soon to be up to her neck at SOS. She got home on Monday and is slowly recovering from jet lag. The fare has definitely picked up and I have filled out. Last night we had roasted vegetables; delicious. Apparently I had forgotten about that whole category of the food pyramid.

P=MD(BC). Make that Pass=MD(Board Certified). And I’m old enough, yep I’m 57, that I think this is the last time I have to/get to/have the privilege of sitting in front of a computer screen for the better part of a day, sweating. The medicine here is so very different. I have definitely lost the edge to practice in the US and the style of family medicine that I left there. And I’m old, or did I mention that?

Yesterday we were in Kanye where I had Matt, the newly minted and gifted Internal Medicine outreach dude, and married to Premal (see below), Jessie; a third time visitor and this time as a Infectious Disease Fellow, Premal; a newly minted IM doc working for Baylor and married to Matt, and me, an aging and aged family medicine doc with a seizure disorder (that, by-the-way, is under better control with a new med). Matt drove and led the discussion on TB, that I had led at other venues, to try on his chops and did fantastic. We then rounded on a patient with Multiple Drug Resistant TB (MDR-TB) who was being managed admirably by the docs at Kanye SDAH. ID is not my strong point, and TB is the weakest link in that chain thus far. Actually based on my score on the board exam it would seem I no longer have a strong point (P=MD(BC), I just gotta keep saying that to myself). The Kanye docs were doing great.

We then went to a local clinic where we saw some amazing infectious disease. This is not even close to the stuff I saw in South Sudan but we shouldn’t be seeing that in this nation, as often or severe. What we see here is HIV/TB co-infection and it complications with a little medication side effect (mostly hepatitis) thrown in. The disease spectrum here is more narrow but deeper. And for a mono-neuronal family doc it is a touch easier to get a purchase on so as to move the patient towards health.

We of course had to weed out the truly sick from the “wanna-be-sick-so-as-to-get-sick-leave-on- a-Friday” folks. I came across a way to cynical to these guys I fear but I wanted to demonstrate the MOs that you need to dissuade patients with multiple somatic pains and an agenda from taking up your time so you can attend to the truly sick and needy. The sick leave situation here is a great exercise in abdication of employer responsibility. All the waiting rooms from the smallest outpost to the downtown clinics are crammed with anyone from the truly sick to the majority “wanna be’s” all wanting medically sanctioned time off on a Monday or Friday, absurd and a total waste of time. Yet we give them meds, sometimes five of them (acetaminophen, and four types of vitamins and a mineral or two) so they truly think they are sick and show their friends on the way out how they were treated so well that they got all these meds. We have created this monster and only we can fix it.

Did I mention Lynne is home? Wahoo!!!!

Restoration of the soul...

Something about a couple of kids on your lap after their dinner, snuggled in tight, as you read to them that fills and repairs the spirit.

I went to SOS last night and it began with the marimba band practice, still fantastic. They are amazing, have innate rhythm, and play faster than my tired eyes could follow. We were oriented by the head the orphanage, Bikia, a man in his thirties. There are 24 “homes” staffed by “aunties” and housing 8-12 kids. The adolescents live autonomously within a budget and learn to purchase food and necessities, cook, and clean their home. Their home is a happy mess but they are well fed and fantastically well socialized. Other younger kids live two or more to a room and are cared for by the auntie. The campus is home to kids who are orphaned from HIV, destitution, or abandonment. Once there, they are rarely adopted out and frankly that’s a good thing. The extended “family” they have and the life skills they are taught are extraordinary.

So I was sitting down with a child on each side and one on my lap reading nursery rhymes, something we rarely read to our own kids as they are dated and not a little racist and sexist. The kids lapped it up. I have cut my hair very short so the boy on my lap sucked his thumb and wuzzed my hair because he liked the texture. It was a dead heat as to who would fall asleep first. The other boys felt the hair on my arms as I have become rather hairy now that I’m not in the pool.

We read then wrestled then read some more. Then time to go home with hugs all around and “when are you coming back?” Each week for sure. This is where the Penn students should spend more time. I was introduced to there by Caitlin, a student headed for family medicine and I think they’d all love it. I know the kids would.

As sweet a save as you'll find....

And not by me. By our eldest son, Eli, and a rural Charlottesville family!

So there he was, minding his own business, while on an organized run outside Charlottesville, VA. He is training for a marathon and a group of runners of like mind (there really is "a group" that want to do this?) were running through the rural farmland when he came upon a runner who was walking with an odd posture. She had her arms away from her side, stuck out at a 45 degree angle and, well, looked curious. So he stopped and asked if she was OK.

He recognized her from his work at UVA where he is a family doc. Seems she'd been stung behind her ear by a wasp and was a little rattled for the experience. That and she had urticaria (hives) from head to toe(!), hence the posture.

"Gee, you OK?"

"I think so, I'll just walk a bit and see how things go", she says.

"Breathing OK?"

"I'm a little wheezy....." Wrong answer.

Thinking fast he decides to stop a home up ahead and see if, perhaps, they might just have some Benadryl, an antihistamine. They knock, he identifies himself as a doc with a concern about this runner and do they by any chance have some Benadryl? Why yes, in fact they do. So down goes 50mg. But by know she is really wheezing and getting a touch light headed. Bleep.

So he calls 911, then asks, knowing its against all odds, "You don't by any chance have an "Epi-pen" do you?" As a matter of fact they do!!!! He administers the epinephrine injection.

A few minutes later the rural first resp0nders show. They take her blood pressure and its below 80mmHg systolic; full on anaphylaxis. By now she is a little the worse for wear but hanging in there and all are thanking their lucky stars. An ambulance shows up. They take her pressure again as they load her for the ride to the UVA emergency department, and it's unchanged. She goes on O2, and is taken to the ED.

As clean a save as you'll ever find thanks to a runner-physician who had his antennae out and a welcoming home that, unbelievably, had the appropriate meds. Incredible.

This week has been a little bit of a watershed for me and the program.

Tuesday- It began in a local clinic where I was to mentor an MO there but beat him to the office. I was in the exam room, door closed, to await the MO when a nurse stuck her head in and said she needed me next door.

“Ohhhhkay, why?”

“A little girl is in status”

“Uh, status what?” Hoping she meant asthmaticus.

“Epilepticus, she’s fitting Naka!”

“Bleep!”

So in I walk only to be handed a premeasured syringe with diazepam for rectal administration! She is a chubby three year old with epilepsy since birth secondary to birth injury fitting away for the last hour with no IV sites. In went the diazepam and in five minutes off went the seizures. We piled her into a car and off she went to PMH. The nurse was exceptional and acted like having things THIS much under control was no big deal. Would love to clone her!

Wednesday-I have been giving talks at Deborah Retief Memorial Hospital in Mochudi to the entire staff (about 30 professional from across the spectrum) and have made an annoying arss of myself trying to get the outpatient docs to join. Yesterday 6 showed up and stayed for an hour as we discussed innumerable issues that were shared and at times contentious. A great episode in medical staff intercourse and huge for quality of patient care. A true first.

Today-For the last several months I have struggled with the outpatient medical staff in Lobatse. They and I worked to come to some agreement about how best to participate with them. One of them lined up a bunch of patients about whom he had questions and away we went. Then I gave the same talk in the afternoon to them and it was received well. I, again, gave them my info and encouraged them to call anytime, and was before I had left town.

Its freaking cold here, just like you might expect from a high desert in the early spring. But the wards aren't heated so all the kids in peds are under 50 blankets and are just bumps on the bed. We have a diabetic in DKA here at Athlone Hospital in Lobatse. I swear that adolescents are the same the world over. He is sweet, too sweet literally, but is experimenting with controlling his own life, disease, meds, and, like all of us, his first foray into this arena was a little rough. We discussed how to treat this without lab back up, just with a glucometer and urine dipsticks. It was all very reminiscent of Frenchburg in the winter when I would treat two brothers with DKA, at the clinic as outpatients, as their mother was afraid of travel in the snow and ice.

Last night I did some more volunteering at the SOS village,

http://archive.soschildrensvillages.org.uk/sponsor-child/botswana_select_a_village.html

a large and well established "orphanage" here in the area, one of dozens. It sits on a campus the size of a small secondary school with houses numbering in the teens and kids numbering in the hundreds. Each house has a resident "auntie"/mother and a relatively static group of kids of similar age and development. No outside adoption is allowed as it is too stressful on the kids and siblings are housed together.

All the kids are incredibly well socialized as they have literally hundreds of brother, sisters, adult mentors and care providers. It is located in an area of greater Gabs where all the people are national Batswana, no expats.

I usually stop at the teenage girls area first and help with homework. Last night is was quadratic equations, a real blast out of the past. Then it's over to the home of younger kids where there are is a toddler who can't get enough lap time, and brothers who love to read and be read to. In particular they love to sit close and gets hugs, have their heads rubbed, wrestle and giggle. I usually read from their favorite book of old fairy tales and have them read with me. It's amazingly racist and they couldn't care less, it's the story they love even if I try to modify it to be a touch less British Empire-like.

As we about to leave we were asked if we would like to hear some marimbas. Uh...sure. We walked out to the back only to see a room full of marimbas and kids of every size and flavor playing their hearts out, and GOOD. They are invited all over the place. The shortest kid plays the largest bass, the most outgoing plays tenor as fast as I've seen it. Incredible. A great time.

These things tend to occur in threes...

Shit….it does happen in medicine, and in "threes" if I’m not mistaken. Yesterday morning I was solo, something that is rare these days but welcomed on occasion. I made the drive to Kanye and was just sitting down to morning report by the staff at the hospital when a call came in from OB for newborn resuscitation. A child has been born over a prolapsed cord and wasn’t breathing.

These situations are true buggers in any country. The child (read brain) has been deprived of blood (read oxygen) due to compression of the cord between the side wall of the pelvis and the infant's body. Any attempt at resuscitation is mis-named. Instead of cardio-pulmonary resuscitation it should be called brain resuscitation.

In newborns the cardio-pulmonary tree is so pristine it usually “starts” without a lot of carrying on. It’s the brain….that jello-like mass of goo that needs the 02 more than the other organs. It can shut down so completely such that blood doesn’t even make it past the neck. Now if you’re a dumb family doc like me with a moth eaten brain in the first place, maybe no big deal. In a child it isn’t compatible with life.

So the flail was on. It was truly other-worldly in that it was conducted in room where there were no less than six deliveries on two beds by three midwives. While we proceeded people casually were moved about accompanied by all the sounds of women in labor, and cleaning ladies mopping floors in between deliveries. Like other hospitals, they had a warmer but no one knew how to use it. They did have neonatal intubation ability and my colleague did admirably in establishing an airway. We had 02, and an ambu-bag, now full of meconium, that I washed out and then used to provide ventilation.

So; “Airway”-got that covered, “Breathing”-yup breathing OK, “Cardiac”-seems to be perfusing well, below the head at least, “Drugs” need bicarb and D-10 or at least D-“something”. As I asked for bicarb I was informed that we were “out of stock”. “Of @#$%#ing bicarb?!” I lit up like a damn cruise liner at night. My colleague shrugged. I fumed and called the pharmacist to the room asking how in the name of all that makes sense we could be out of bicarb, ...today, ...now,... here?!? She shrugged. I asked that she check everywhere as I felt this child’s brain leak through my hands. She left.

We attempted au umbilical line but to no avail as the iv cannulas were too stiff and the feeding tubes too big, so my colleague got a line in the foot; in the foot of a clamped down, meconium stained, non-perfusing deeply pigmented neonate! These guys are amazing. We found some D-50, diluted it up and gave it, some very old bicarb appeared from surgery where it had been used many times from the same bag (no clue about how that made sense), and tried to figure out the difference between milligrams, milli-equivalents, and millimoles as all three were cited on the bag, and we had no idea if it had any bicarb in it in the first place.

By now every baby doc's fear was being realized; we were saving the heart and lungs but the brain was dying or dead. We gave some of the supposed "bicarb", she started to breathe on her own, … and then the seizures started. Well shit again.

We called PMH and were told that since she didn’t need ventilation she didn’t need transfer. We all exchanged looks, calculated doses and rates and put her next to her mother. We couldn’t get her warm so adhering to the adage that “you aren’t dead ‘til your warm and dead and sweet and dead” we heated two liter bags of iv solution, placed them along side of her and gave more D-10 (or D-something).

Blessedly she quietly died last night at 1830.