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

Where you at? (Texan for where are you?)

We’re here in Palm Coast, a resort community about an hour from Jax, just north of Daytona, where we arrived to a sundrenched condo and a placid sea about 50m away. Over the next day through today we have been enjoying Tropical Storm Fay with torrential rain, 50mph winds, and high water. Click here for T.S. Fay track. This being my second tropical storm, the first was Dolly in Texas, I’m starting to get the hang of it. This one was birthed in the Caribbean and has travelled the length of Florida only to stall over top of us. The upside is that we are all here and inside having a hoot, eating, drinking and laughing way too much.
We, being the screwball Pendletons that we are, went into the water this morning and promptly got ourselves maytagged. It was fun but the women-wives-inlaws-outlaws on the beach were a little less than enthusiastic about it. I was the last out and must admit between the incoming tide, shore break, big waves and rip tides life was a touch more immediate.
Since the last post we have enjoyed a bona fide vacation with the offspring and “onspring”. It has been special that we have all been together. Our first grandchild, Judah, keeps us all in stitches and we look forward to more in the next several years. The time has been punctuated by loads of laughter and good natured ribbing. It’s been hilarious to hear from the in-laws about the seldom seen sides of the offspring Pendletons
I’ve gained about 10 lbs. and so what. I remember the last 200fr I did in Houston and probably that will have to do for awhile. We have been given a house to live in Gabs so the transition will be much easier than if we lived in and out of several flats for a month.
For now, Lynne and I will enjoy the company, both human and meteorological, and then head for the next chapter in our lives, as ready as we can be, in three days.

So whats been happenin' the last li'l while?

Been in Texas, takin’ a course, learnin’ to talk Texan.

Lynne and I bade farewell to our beloved Columbia Gorge and drove through central Oregon to Burns, then on back roads (way back!) to Twin Falls, ID then through Utah onto Dillon, CO where we saw my sister Jan and her husband Bob. Then to Denver where we stayed with our daughter Bethany for a couple of days. Then drove down the eastern Colorado border to the Texas panhandle and ultimately to Houston. Most of our travel was on "blue highways" through stressed rural towns many of which had strip malls at the outskirts and a decaying central core.

In Houston Lynne flew to visit family and I began a month long class with Baylor International Pediatric Aids Initiative. They are in several places in Africa, including the same medical campus in Botswana where I'll be based. The class was "Tropical Medicine and HIV, Lite" (my name for it). The information came at this aged learner at a pace that required much studying and time in front of my laptop, and was invaluable.

All the Baylor folks, indeed all the Texans I met, were genuine and welcoming. The medical campus in Houston is the largest in the country comprising innumerable hospitals, schools, and clinics of various specialties, all of which are able to make a financial go of it.

The class attendants were all BIPAI docs save three of us auditors. We were welcomed at any and all activities and received the same material as if we were enrolled. The BIPAU program is extraordinary and the physicians (almost all of them newly minted from residency in Peds) were all very bright.

To clear my head I volunteered with Habitat for Humanity and pounded nails for a couple of Saturdays. There is a measure of extreme satisfaction that is rare in medicine when you show up for work at 7:30am and frame an entire house by quitting time at 12 noon. I would drive home drenched in sweat with a novel sense of fulfillment.

Forrest flew to Houston on the last day of class and we drove together to Jacksonville, FL where he and his family are currently stationed. We stoppped in Mobile and gorged ourselves on barbeque (in the South barbeque is a noun as well as a verb).

Now for an all too brief family reunion at the beach and then on to Botswana on the 24th.

Career in medicine, 2.0

Greetings,

This amounts to my maiden voyage in blogging and as such is probably best viewed as a work in progress at several levels. As I am determined to become a faster and more accurate keyboarder, these postings should improve with time and of course with adventure!

Many of you have heard what follows before. As it puts things into perspective for me, and hopefully you, I'll repeat it so as to give credence to the notion that I'm neither totally off my rocker or suffering from premature dementia.

In the Spring of 2006 I went to South Sudan with Doctors Without Borders, known as "MSF" everywhere else in the universe. I was posted in a heavily stressed part of the African sub-Sahara. During a particularly difficult week when I had lost 9 kids in two days I found myself on the airstrip cussing at God and anyone else who would listen. It was there that I had a life changing moment. I was struck by how little our presence made a true difference. Sure, the people that we treated might have died in our absence but any legacy that we had there would vanish with our departure. MSF was teaching nurses in a formal course setting, and the head nurse of the area was teaching as well. But I, the physician, was sprinting through rounds to prepare for that day's onslaught of new patients and wasn't teaching and thus demonstrating any confidence in the capability of my Sudanese colleagues.

Rounds then went from 2 hours of pressured, superficial evaluating and ordering to all day. The staff, the best of whom had had two years of post secondary education, were highly variable in capability, dedication, and training. As difficult as it was for this white, middle class, male physician to even appear to cede control of "his" patients, the staus quo was of little long term benefit to the Sudanese. On the departure of MSF the mortality rate would rise to baseline, morbidity would rise as the MSF initiated immunization programs would cease. The only true measure of the presence of any western NGO would be the deep water wells in the area courtesy of OXFAM and the agricultural projects being taught by another NGO across the airstrip from MSF's compound.

All the nursing staff was male as women did all the domestic work including the raising of crops, building and maintaining the homes (tukuls), livestock husbandry and the like. Rounds became full of jocular humor, teaching, re-teaching, re-re-teaching, and constant searching for the most appropriate way to inform, cajole, lead, shove....And it worked.

Four months later, as I was preparing to leave, I was informed by MSF that my replacement wasn't coming until two weeks after my departure. Thankfully we had a great expat nurse who could coordinate things but I and MSF were definitely leaving the staff in a bind. On my last day, as the plane was literally circling the strip, I was out at the hospital (a series of three tents located 2.4 km from the living compound and the air strip) and entered the ICU only to find it on its ear. Many of the cots were sideways and there was detritus everywhere. I erupted. Once I took a breath the nurses explained to me how they had admitted two patients with malaria and anemia, had found donors and typed their blood for transfusion (which is where I would have become involved at any time of day or night) and then transfused it. They had also admitted two other kids with pneumonia and started appropriate treatment and compassionately supported a neighborhood child (my dear Nybol) and her family as she died from sepsis. I was stunned and moved beyond anything I had experienced in my career.

On my return to Oregon I decided to look into spending the latter third of my medical career in a developing nation teaching and treating. As I was decompressing and adjusting to medical life at home a letter came in the Spring of 2007 that invited me to consider teaching medicine in Botswana, not exactly a "developing" nation but one on the cusp of entering the first world. The program was sponsored and funded through the University of Pennsylvania, my med school alma mater. As Lynne had made it clear that we weren't going to be separated for six months again and since she hadn't been out of the country (well, Puerto Rico for two weeks) this sounded like a fantastic idea. I visited there in the Fall and was sold. And here we are, on our way.