Somethimes you eat the bear...

Sometimes the bear eats you....chews you up into little bite size pieces, sucks the marrow out of your bones, and spits out,...well, you get point. This was one of those weeks where I truly wondered whether I was making a difference that was worth more than a bucket of warm spit. Was I truly "capacity building" or just thinking so.

I began the usual road trips to the usual district hospitals and basically heard the same song and dance at each one. Now Matt and I have emphasized the early diagnosis and emergency treatment of sepsis at least twice a month. It is rampant here what with a huge HIV prevalence and other impediments to care. Given the nature of some hospitals here one is at more risk in one than out. So Wednesday we heard about a man admitted with an unrecordable temperature (that means under 35.5C), an unrecordable blood pressure, and pulse of >110. I exchanged a look with Matt, one of "are you effing kidding me??!!" After everything we have tried to emphasize about this disease?! And here we are listening to the vital signs of a patient circling the drain, from three hours ago?! I have made some sweet saves from this disease, mostly in kids. Adults are easier. And no one got up and went to this guy's aid. It was cold outside about -5C, the rooms are unheated and after the ABC's come warmth! There is no way this guy could have warmed himself up with a blanket.

I went off to round in peds as I thought I'd just go ballistic if I went to the ward of this guy. Matt went and started the requisite lines and meds on this guy He even sent me an SMS to let me know he was on it. Regrettably is was probably too late. That steam from peds? Me.

Then yesterday I heard the same song and dance at another district hospital and found the same mess, except I had the privilege of watching him take his last breath. We had a nurse come into the docs room asking for help with an emergency in the OPD. No one moved, including me as I wanted to see if ANYONE was interested in the entreaty of this triage nurse. Nope. And this happens everywhere; the US, some of the-off-the-grid places I've been, everywhere. So I stepped outside and went down to the OPD. I had given a presentation on status

epilepticus (seizures that don't stop) that morning, just 20m prior, and low and behold the guy there was in status! A great teaching case but for the fact that there weren't any other docs there.

The nurses had done a fantastic job with this guy, had assessed that he was in status, and had given him first line therapy. They even had performed a rectal and found a worm which in essence made the diagnosis . I congratulated them and they sighed that they could really use a cup of hot tea. I told them I had some hot coffee (can't have caffeine dysregulation doncha know) and they drank it with relish.

Then today another place another patient with the same HIV and same unnecessary sepsis. She, a beautiful 16y/o with HIV, will die. That coupled with a Monday wherein I was a small part of one of the worst medical experiences I have had (I simply won't/can't bear to get into it) and a Tuesday that was equally awful, and the bear had me good. Hope the bastard enjoyed every bite. Maybe he'll get septic, wouldn't that be justice.

" Mike, do you believe in God?"

Again first things first. I had a gas in Atlanta. Swam lousy but really loved seeing my swimming friends and community. And getting away from medicine is always healthy in a weird sort of way.

There are some certifiably FAST master swimmers out there. The so called fast suits are tight girdles from which oozes well marbled flesh causing, as Bill so aptly puts it, wives to laugh themselves silly and children to run into the night. And they really don't make a difference. I, again, got vertical in the 100fly, a big no-no, and was headed to the light. My teammates were all lined up to cheer/groan as I dropped my by now leadened legs and couldn't get my arms, or for that matter brain, to cooperate.

Bill, MJ and I finished up the experience with a great carnivorous meal at "Fat Matt's" rib place. Picture a shoe box shaped building you can smell before you can see. You get in line and order, and enjoy some live blues from one end of the place. You see two guys enter the back door each with 12 loaves of Wonder Bread; truly authentic. Bill and MJ ordered big meals o' meat and I ordered my favorite, a pork sandwich. It tasted fantastic and I was having a great time, until my manhood was questioned, again, by my "friends" and for that matter the staff. It seems I only ordered a "small" sandwich. The woman behind the counter shot me a "you'll be back honey" look. And I was. Conversation stopped as I dove into some amazing ribs. That and beer. Did I mention the beer? So much better than here, and there you have it.

Seeing Eli, Amber, Aven , Beth, and Belle was fantastic as well. Watching Belle, 15 mos (I think and hope), entertain herself with a basin of water and have Uncle Eli encourage her to "wash your bachachas" was hilarious. Beats any digital toy out there.

Then the long flight home and to SOS that week. I sometimes walk out onto the dirt field to see the starry ski and did so this night as I was hitting the jet lag wall. Out there I met Thabong, a 13yr old guy with whom we have taken a mutual shine. He was staring into the night and came over to me. I could see this might be an interesting time as he truly had a look about him that I hadn't seen.

With inquisitive and.......what, a very disarming facial expression, he asked 'Mike, do you believe in God" I did the shake and bake as I didn't want to answer before we fleshed out where this came from. He attends a private evangelical school on a very generous scholarship, one for gifted kids. So I put it back to him. "Do you?"

"I don't know." "Why?" "I can't see him." A perfect place for a thirteen year old wrestling with the angst of youth to be in my opinion. "Do you need to SEE him?", say I. And on went the conversation. He wanting proof. So I stepped behind him on this absolutely beautiful night and said, "Do you see me?" "No." "Then how do you know I'm here?" "Do you feel me close to you?" I said as I was stepping away from his turned back. "Yes." "Even now?" "Well I think so." "So you know I'm here but can't see me..." He laughed and said to the effect that he knew where this was going. And we became silent, in the cold night air, he enjoying the company of an old man. And the old man enjoying and marveling at the emergence of a young one.

Living Color

Yesterday I was at a district hospital attending morning report. The report included a child who was abandoned on the side of the road and was admitted pending placement. The child, a boy, was thought to be of Zimbabwean decent as "he is very dark". He was placed in peds to the consternation of the ward nurses there as they were worried that he might catch one of the ever present bugs looming in any ward.

I mentioned that these kids are often abandoned because the mother is overwhelmed, but also because the child might have some condition that confers high needs on him/her. So indeed we should do a careful exam to find any evidence of a congenital disease.

As we were rounding there, we went into a remote office where there was a child in a bassinet, in the corner. As I approached her I stepped over a mattress in the floor underneath the bassinet that had, I thought, a pile of blankets on it for the child above. I was getting ready to move the mattress aside with my foot, as it was clearly in the way. You can tell where this is going...The blankets moved and gave a little baby noise and I realized that this was the second child brought in last night! As always the tension was defused with laughter that a peds doc like me was going to "kick" the other child and "what, what, what".

So I put both kids in the bassinet head to toe, lying in opposite directions. The kids were children of color to be sure, African in conformation, and very different in pigmentation. One was the color of a double shot of espresso and the other a vente latte with lots of milk (or is it skinny?).

A nurse in the room remarked that these kids represented "black and white television" and then corrected himself and stated that they really were in "living color"! The laughter went on and on.

I needed that.

Kernicterus and opisthotonus (#2)

Was in a district hospital today and rounded in the peds ward. Now, as a doc, there exists a side of me that has a "life list" of pathology as it were. I see people with diagnoses that would rarely be seen in the US and "collect" them on my list. I know, sick and wrong. But there you have it, all in the name of transparency. So today we were in peds and the pathology was waist deep.

There were two kids with malnutrition and other co-existing diseases. Often they have been admitted many times with the same co-morbid diagnoses and nobody asks why. I may have mentioned that the kids here are compared to growth curves that are weight and height for age, not weight for length. So they can be happily tracking along at a low percentile, not raising suspicions and still be quite malnourished by w/l measurements. We saw both of the major kinds of malnutrition and had a long discussion about what the nutritional requirements are in theses variants of disease and why they are somewhat altogether different, not unlike diabetes type 1 and 2. Both are wasting illnesses with different manifestations and nutritional therapies.

Then we saw a child with a constellation of symptoms that medical types in the States spend a lot of time worrying about but rarely if ever see. This child was admitted with "pneumonia", an all too common diagnosis, one I/we frequently "undiagnose". In the process of discussing the situation, the mother volunteered that she had taken the child to an ophthalmologist for an eye exam and had been told the eyes "were just OK". As we looked at the child I noticed some slow grimacing and posturing called choreo-athetoid movements. His eyes were averse to upward gaze to the extent that he looked so far downward his pupils were buried in the lower lids. And his mother reported that it seemed as though he couldn't hear. She then volunteered that he was admitted with a post birth bilirubin that was 36 times normal. He had all the cardinal signs of kernicterus. This is also a true bastard; his fate is sealed. In the States there is a lot of preoccupation about this very rare ( in the Western World) complication of bilirubin metabolism. But this is the first case I have seen.

Then it was opithotonus, again. A child that was in the ward a week ago with this was now on ATT but was still in great pain and distress. I asked to take a picture as this was on the list but I now have seen enough that the novelty has worn off.

Then a young boy with monstrous neck nodes that, I think, were misdiagnosed as extra pulmonary Tb. We wanted to take him to the OR ("theatre") but the anesthetist was resistant. There was a bit of gesticulating and animated conversation following and she called PMH (now called the "Hospital of Death" in the local media, well deserved in my opinion) and they accepted the child in transfer to undergo anesthesia by an anesthesiologist. The nodes should explode and reduce in size significantly. I'll really be surprised of this is Tb.

More for the list.

Ntlantle and a caboose

For some reason we seem to see a fair number of malnourished kids from this village. The discerning reader will recall that this was the place where I and a nurse resuscitated a child with sepsis. He and his grandfather showed up on the doorstep of the outpost there with initially, no one but moi to get started. And it went (well) from there.

This morning I was again in Lobatse and was asked to do business rounds wherein one rounds on those that need it only as Thursday is a day for the staff to pursue other areas of medicine. The staff there has been reduced to four from ten earlier in the year so they are beat and desperate. I saw a bunch of difficult cases in the male and female wards, maternity, and Tb. We saw a critically ill woman with cryptococcal meningitis (a real bastard when your immunity is wracked by HIV) who was not responding to therapy. When it has been longer than two weeks and the patient is getting worse one needs to think about Tb meningitis. So we started her on ATT and moved on. In the States she would have had a zillion tests and, cynically, the end result would have been the same.

In the process of rounding on her there were about 10 nurses and students watching me (old white dude that I am) and I thought I'd engage them in a conversation about withdrawing care. Well didn't THAT just put a nickel in their collective slots. Away we went; murder, euthanasia, cruelty, and even felony. It is unlawful to withdraw care here, I knew that, but wanted to discuss not adding any additional care. A big time clash of cultures. Most would "do anything" until the patient is "late", satswana for death. It was a great 30min.

Then on to peds. There is a little newborn boy there who was no sooner born then his mother "absconded", leaving the child at the hospital. Every time I'm there I play with him and he, just like Empho, is thriving thanks to the excellence of the nurses. They call him my "son" and are always asking why I don't adopt him. I confess that Lynne would in a blink, not a good idea at our age but never the less a temptation. And it is not only unfair to the child but as I understand it, against the law for a non-Batswana to adopt in this country. And it should be.

While there I was asked to see a 4mo old girl who was from Ntlantle. Her mother was dutifully with her at crib-side. One look and I knew that whatever the admitting diagnosis was, this child was severely malnourished.

It is very important to take an accurate history about food security with each mother or parent equivalent (often the grandmother) of a malnourished child. This child was the caboose in a family of five kids. It is always the caboose that is the most vulnerable in a family with an insecure source of food. After starting our inquiry the mother responded that she ate three times a day and cited what food she ate and when. She described what her kids ate and that they all ate a meal at school. Time for the true art of medicine.

I gently inquired if there were times when she didn't eat because of food shortage. Yes for two days at a time. You could begin to read her body language; despair for herself and her beloved children, fear that her child would be taken from her, and all these conflicting emotions in the context of her own huge protein calorie malnutrition. Makes me tear up just writing this. As she turned away and started to cry, we ever so gently continued. Her mother lived with the family and it was she who got a monthly pension, the only income the family had. The food gaps were two weeks long and she simply felt horrible about it. The nurses took a weight for height (a true coup as this has been a subject of conversation for months) and we found that she was 70% of normal weight for her length, severe malnutrition. More to the point; acute on severe malnutrition.

Now the only way to get to a child, loved and cherished by the mother, is indeed through the mother. We explained to her that she was a good mother, if not overwhelmed, and that her custody wasn't at risk. To which she burst into tears. Man I was shook and still am. A great moment to remind me why I do this. We will feed the mother along with the child and will make sure that food is more available in a better balance. In Sudan the mothers were as beat as the kids so we always fed them up as well and gave them a months supply of food on discharge.

On the way home I was able to reflect on the moment. I am a point of care doc, perhaps not a programmatic one, as intimate care of people is what I enjoy most. The stories, the excitement, the rewards, the victories, the fall flat on your face losses. Gotta get back into MSF again. When?

I "might" have been chased by a hippo

But more on that later...

First things first. Forrest and Shannon left last Tuesday and it seems so long ago. As with Eli and Amber, I found myself asking "did that really happen?" They came on a Sunday and Monday was a rest day. These guys have been sleep deprived for, oh, the last two years. And if anyone needs sleep it's those two. So Lynne's instructions were something to effect of "listen you early riser, if you wake them up as you slam around out there...." She didn't finish her warning and didn't need to. I got it loud and clear. At first they were up around the time I was (0530) due to jet lag, then they progressed to sleeping the clock around.

On Tuesday we went back to Chobe and "had" to duplicate the trip we had with E&A. The weather was rough the week before as it is Fall here. We had the first crystal clear days in weeks for our visit. Picture a gorgeous October day in Hood River, you get the point. We had a game drive in the morning where we were effectively skunked. F&S were good guests and said that it didn't matter. It did to me.

That afternoon we saw a mother hippo and her adolescent calf in the creek that runs through the hotel area. She would snort and sink, snort and roar, and sink. Her calf was hidden in the bushes near her but was almost invisible. We then went on the most amazing river cruise. As before we all hopped in a boat with dozens of others from around the world (is there a LL Bean in every country?) and went up the river to see the sights and any animals that were on shore. It had been hot but now the sun was setting and it was turning cool. We saw many crocks on the shore cooling off, a gillion hippos and too many to count elephants. Cape buffalo, impala, kudo, gemsbok, baboon, more elephants, and more hippo, fish eagles, beautiful birds. The sun set and it was just magic.

That night I was able to resist the dreaded buffet monster. Tempting to be sure but with just two weeks 'til nats I just couldn't become well marbled again. We went for a short walk to view and photo some extraordinary spiders and see some stars. As we were on our way I noticed a group of twelve or so people off in the distance, all of them excited and pointing. Well I just had to see what all the commotion was all about so I sauntered over to see for myself. Off in the distance was a grazing hippo, on the lawn, probably the mother we had seen earlier.

As I'm sure most of you know, hippos are a cranky and contrary lot. They are responsible for more animal attacks than any other in this part of the world. And some idiot was taking flash photographs...begging to be skewered. So of course the hippo snorted add made a mock charge. Now these guys can go from 0-60km/hr in a blink. We all backed up and I found myself next to the same idiot who again took some flash pics. Real dumb. And I found myself standing beside him, also reeaal dumb. Still I thought all I have to do is keep the flasher between me and the hippo and I'm safe. Darwinian selection at work doncha know.

Well this time the hippo was appropriately upset and charged again, but we couldn't tell if it was a mock charge or the real deal. I thought it was probably of the mock variety so I was a touch slow on the uptake. When she didn't stop, and was about 10m from us, I took off up between some buildings with idiot close on my heals. The space between hotel buildings was a tight fit and wouldn't admit a hippo, or so I hoped. I ran out of my sandals and might have sprained my ankle. My first thought? Not "that was close", it wasn't. Not "that was so cool", it was! It was "this is really going to eff up my nats!"

Forrest came to my "rescue" and was amused until we got back to our respective wives tapping their feet, arms crossed, glaring. Then he was on their side! Safe to say there weren't any couches in the rooms or I would have had to cram myself onto one for the night. The alpha female was upset.

Next it was off to Victoria Falls. As it had been raining for the previous week, and the river was way up we had a difficult time seeing all of the falls for the spray. But could we ever feel them. Not unlike the feeling you get when a crack of lightning is followed by thunder that seems a touch too close. What power and sound. We of course got soaking wet and then mutually (OK, Forrest and I did) decided to cross the "Amber Line" at one of the lookouts. But just by a meter, I swear Amber.

We went home to have the most rain and cold in a given week that Bots has had in quite some time. THAT really messed with my training. On went the farmer john and out went the sea anchor. I was reminded of the t-shirt at masters meets that says "I'm old, but I'm slow". I also like the one, "The older I get the faster I was". True that. My pace was more appropriately timed by a calender. I had to add at least 10s per hundred to even stay within a set.

This week has been great medically. I was in a primary hospital and was rounding on a woman who was having seizures that we not well controlled by medication. Interestingly she was fine after the seizure which is a touch unusual when they are major motor type; no loss of consciousness, no post seizure disorientation or lethargy. In the process of examining her I noticed her face was without expression and she had some cog wheeling rigidity. We got her to stand an she had a wide based, tremulous gait; Parkinsons disease. That explained her "seizures" and her level of consciousness after.

Every once in a while I can overcome my lamictal brain and make a clean diagnosis. And she had been in the hospital for two weeks! The third doctor to round on a patient is always the smartest as s/he knows what the diagnosis, or treatment, ain't or ain't working. This time I got to be the third.

A better week

I visited Kanye today and saw the little guy with ANUG, who was looking much better! His cheek had gone down and while his mouth was still a fetid hole he is indeed better, but a long way from "good". No x-rays had yet been taken so I encouraged that idea and we'll see.

There has been an outbreak of Rift Valley Fever in all of the countries with which we have a border, not us. Which makes me wonder if we aren't looking hard enough or if the disease just isn't recognized here yet. It is one of the hemorrhagic fevers but is typically transmitted via handling of infected beef. It isn't Ebola or Marburg thankfully, but gives one pause to consider the situation over in this part of the world. Typically it behaves itself and looks like the flu. On rare occasion the disease can become quite virulent nasty and difficult. Rare meaning <1%.

The week has been full and rewarding. We had a chance to teach 4 students at Kanye (KSADH), two from Loma Linda in CA and two from Zambia. There were some unexpected cases of malnutrition that we discovered by actually looking for it. It made for some interesting conversation as I have been harping on this for quite some time to wit: if we don't ask the question we won't detect it early enough to interrupt it.

And Sunday Forrest and Shannon arrive! Should be a great week next. We are all due for one. Now if I can just stay away from the dreaded "BUFFET BEAST" and peck away at something only a bird would eat I can stay in training form. Like THAT'S gonna happen. Here's to you in gluttony.