Well I kissed my sweetie goodbye today, leaked a little as I walked out to the parking lot at the airport and began a two month period of bachelorhood. Did I mention I miss her? I’ll be fine but did I mention how much I miss her? Sure things will be different, not worse, just different but did I forget to say how much I love this woman and miss her. She’s off to visit her sister and walk on the beach sorting out their relationship and other pressing issues.

Then it’s off to VA then FLA to visit sons and some truly extraordinary daughters in law. I truly have been blessed with the presence of some extraordinary women in my life, including my daughter in law to be. Finally she will arrive sometime near (we hope) the delivery of our second grandchild, first granddaughter and first child to TJ and Aven. Yes Aven is the one who’s pregnant but they both have symptoms and both deserve lots of love and support. The fam was out there this past weekend to “shower” the expectant Middlesworths with stuff. They hung out and laughed the weekend away, which at a most basic level validates my/our parenting as it is truly delightful that they enjoy each other’s company.

Today was one of sadness and reflection for me as I don’t enjoy being separated for great periods of time even if there is adventure involved, contrary to popular myth. I worked a local clinic and saw more of the same. It is the MOs that I enjoy as I seem to have something to offer on each case. I gave a talk this afternoon on hypertension; how it’s not a number were treating but a patient associated with the number, maximizing one med before adding another, when to switch, which to use based on race and ethnicity, and who not to treat. It was a hoot, very stimulating conversation, and I hope worthwhile.

Tomorrow it’s off to Cape Town for a class from Stellenbosch University from SA on decentralized post graduate training of family docs. The paradigm they use is to place a resident in a small community where the need is great then teach over the web. This way the resident has a local mentor who also benefits, bonds with the community, and generally stays there after residency is completed.

Jeez I miss her.

Then the third week in March I take to the road for a trial run out into the wilds of Western Bots to visit some remote hospitals and clinics so I can assess need and desire for assistance. That should be a true adventure. Love to hear from anyone out there,

 

Mike  

This has been the week to confirm in my mind why we are here. Wednesday thru Friday I had a chance to teach in clinics that were way off the grid. Wednesday I arrived in a clinic associated with Mochudi district, north of here. The clinic is on the SA border and way off the beaten track.

As in many places in this part of the world, women here are worked to the bone, especially in rural areas. As a result one of the few ways they can take a break is if they are “sick”. So they come to the clinic and are in exaggerated extremis with hand to forehead fainting, general body failure and “altered state of consciousness”. The nurse or physician (if indeed he is there that day) will receive the woman and designate a family member to be her advocate as she rests. She gets an IV as that is what is used to treat this. When you think about it, it makes sense in that she is “forced” to rest for about 3-4 hours as the iv goes in, “recovers’, and goes home to her multiroled and exhausting life.

So as we entered the clinic two nurse practitioners were in the middle of treating a couple of women in this modality. We were invited to evaluate them mostly as a courtesy to us in recognition of our station. The problem was that both were septic. Sick to be sure but getting as IV wasn’t about to address the problem. So this was a great opportunity to reinforce the clinical skills the nurses were demonstrating and at the same time discuss what represents infectious disease in an HIV/Tb infected woman who appears ill, why to take vital signs more frequently and when to transfer. Interestingly each of these clinics has an ambulance on standby for that very reason. We are a touch dollar (Pula) foolish over here: huge new hospitals in many districts that are empty when what we need are more providers and decentralized imaging/lab. Oops, sorry, rant over…So off they went on a 60km odyssey to DRM Hospital in Mochudi, hope they made it.

Yesterday I was at the central clinic in Kanye where there wasn’t a doc as he was “at a conference” so a nurse practitioner and I saw about 50 pts with lots of teaching opportunities involved.

The weather is like late August/ early September back in the Pacific NW, hot and dry. All the grass is seeding out so allergies are at a max and many people come in plugged to the gills. For some reason the grass along the roads is whipped down with a curved machete like tool. It keeps people employed but is unbelievably difficult work. All the vehicles are covered with a fine layer of pollen.

Speaking of which; there are no junkers here, no shanty towns, no homes with cars on blocks in the yard, litter in the street. It is a very fastidious society that is predominantly middle-working class, educated (at government expense), and one used to a tradition of due process. They/we have the usual weird circumstances inherent in an emerging nation with deep pockets (see above and previous rants).

So why am I here and not trying to “make a difference” in, say, Appalachia, the depressed Mid-West, inner city Gulf coast? Well, I only have so much time left in my career and with 1.8 million people here in a country the size of Texas I can find the handle and begin to manipulate health care here as this nation gets its first med school, FM residency, and residencies in peds and medicine. And I am a citizen of the world.

 

 

Today was one of those days that confirmed for me why I/we came here. Outreach can be a bit of a crap shoot in that I never know what will be out there and if there is anything I know well enough about which to teach. Not unlike an average day in the clinic back in Hood River in that each day was a new one and represented a challenge in and of itself. That is what makes family medicine so fascinating to me.

 Today I visited outlying clinics and outposts in the Kanye district that is SW of here. I introduced myself and then was promptly enveloped in the patient sitting in front of the health care provider and actually had something to offer all of them at each clinic. I saw acute on chronic pediatric malnutrition for the first time and was able to invent a way to save the child an IV and a referral. The nurse provider and I had a great conversation about how to detect dehydration in a child who already has a quasi-positive tent sign from lack of calories, let alone fluids. I demonstrated how weights were essential in the evaluation of a child especially one on whom you have previous measurements; all this in the middle of nowhere. It was all very reminiscent of, dare I say it, “MSF”. The TFC kids taught this old family doc so much and some of it actually stuck, imagine. And now that I’m on anti-seizure meds things are recallable so much more efficiently, as much as I hate to acknowledge it.

 I came home through Molepolole, a town the size of The Dalles, with three times the population and a spanking new hospital. The building is so very out of place with corridors that are 200m long, empty wards, no specialists (at least a radiologist would be nice), and now CT scanner. We’re learning slowly here and in the process make many of the same mistakes well endowed developing nations make; equating physical plant with quality care.

 The drive was amazing; the African sky extending on forever with clouds and sun, brisk wind and green everywhere. We are at the equivalent of late August with the nights getting longer and days brighter and shorter. Fall, like back in OR, is more of an acknowledgement than a date.

Lynne leaves in 10 days for a tour of the kids and then the advent of our second grandchild. That would be Aven and TJ’s first, a much anticipated daughter.

 While she’s gone I intend to hit the road and visit some very remote clinics that will take a couple of weeks to really see and evaluate. Should be a hoot. 

Back at it

We’re home and in one piece. I dove back into my work here and find myself seriously jet- lagged at this writing: I’m grouchy (to our kids: NO EYE ROLLING) and when I get a chance to nap I awaken from what feels like an unconscious state.

I find myself day dreaming on the road about how weird and other worldly the last month has been. A delightful trip to the Cape of Good Hope area followed by an out of body experience wherein I became a patient, was with the ones we love, was fairly sure I had a brain tumor (a low grade glioma to be specific), then reassured that my brain was not tumorous, just asymmetric and in a weird shaped vessel (my skull). Oooohkaay, how the hell do I put all THAT in perspective? How does a guy who has pursued health his whole life, not unlike a lot of my generation, process this bleep? Just God’s way of introducing some humility in my life I suppose, and never a bad thing as painful and annoying as it might be.

So thanks to all of you for being there for me/us. Interaction at that level, at any level, doesn’t come easy to me, just ask my sibs. Never the less I am at once humbled and blessed, and grateful.

I continue to be amazed that I have anything to offer the medical officers at the neighboring hospitals here. They are just like the FP’s familiar to me who see a patient in the out- patient setting, admit them to the hospital, treat them, discharge them, and see them in follow-up. Today I saw a woman with HIV, on HAART (highly active anti-retroviral therapy) with a month long history of fever on at least five different antibiotics and still febrile. What did I suggest they do? Well, harkening back to my training a million years ago, I said lets stop all meds and see what develops!

The nurses who always accompany me and the doc on rounds immediately chimed in that that was abandoning the patient, a 30+ year old woman with a family to care for. We had an animated conversation during which I invoked all the ID docs I know/knew and assured them that they would agree with me (I deeply hoped) and since we had a good idea of what DOESN’T work, let’s start from the beginning. The harried MO, a guy becoming a close friend, was post call and NOT the least bit interested in another lengthy workup. I demonstrated how it took less than 5 minutes to reinvestigate, via history and physical, what to test and treat, and how, and with what. He was grateful, the patient was grateful, the nurses were convinced, now if the patient’s immune system would just cooperate and improve.…

The drive out and back to these areas continues to amaze; troops of baboons and monkeys, wild jackasses (I know, I know me included), goats, and cattle. Everything is green now and the temp is now humane. I feel like we are where we’re supposed to be for the foreseeable future. We are expats successfully living in Botswana! A new med school, a new family medicine residency, and I get to go way off the beaten track top some remote clinics to teach. All in all, seizure disorder aside, I’m a lucky dude.

 

 

 

Life's little curve ball....is hit outta the park!

Just got off the phone with "my neuro-oncologist" (that term again) who reviewed the data with all her colleagues and the consensus is this: I have an asymmetric brain with a particular septum structure that is missing, a mid brain structure that is larger on one side than the other (hence the concern about a tumor), NO hole as the area referred to was from a slight asymmetry in the "cut" of the previous MR scan, but so significant change from the MR scan of last Spring. 

Bottom line: no evident tumor.

So WHEW! Bullet dodged and I'm back in the saddle with a malformed brain but one that most likely DOES NOT have a tumor and apparently doesn't have a hole! The congenital abnormalities can last a lifetime without causing symptoms or can manifest as seizures. So here I is and I haven't had a seizure for the last 5 days.

Now it's back to Bots to continue the exciting work begun there with a new perspective on things.

The last week has been a growing, painful, disorienting, and yet worthwhile experience to say the least. I just hope I prove worthy of the lessons contained therein.

Thanks for all the support.

Mike

Life's little curve ball

So there I was minding my own business after having appointments with specialists in infectious disease and neurology Monday of last week, lots of lab drawn, an EEG and MR scan on Wednesday of this week and then “the phone call” came on Thursday. My neurologist (weird how that sounds to me) had seen the new MR scan, comparing it with the old one, and found a “new finding” this time in the L temporal lobe. Those that follow this remember that I have a “hole in my head”, actually an area of unexplained encephalomalacia about 3mm wide in my R temporal lobe. That finding is unchanged and stable, whatever the hell that means. No new holes this time around but there is “a subtle area of inflammation on the cortical surface of the L temporal lobe", the significance of which is cause a fare amount of debate in several departments at Penn.

The end result of all this is that I/we were asked to delay our return to Bots for another week to sort this out with a PET scan and an evaluation by a neuro-oncologist. The differential is tumor vs. infection vs. who-the-hell-knows.  All are treatable and the anti-seizure meds are really making a noticeable difference. Both of those evals are on Monday of next week, then who knows…

This feels a little like what I often referred to with my patients as “specialist hell”. The risk of visiting a high powered place like Penn is that, while I have received nothing but very kind and solicitous care, I may get tested to a fare-thee-well only to find out what it ain’t or, worse, “could be” without any definitive sense of what this is or where it's headed. While I’m prepared for that I honestly never thought I’d find myself in this fix. I know, who does, right?

So I’m amused that I seem to be experiencing the classic and well defined grief reaction: denial, anger, bargaining, depression, and acceptance. And I’m slamming around between poles of these stages with a rapidity that is as annoying as it is fatiguing. The truth is that these episodes had been a relatively minor but persistent pain in the ass and had reached a place in my life where some answers were in order. But while the symptom complex is annoying, it’s largely unchanged from when it began just several weeks after leaving Sudan in '06. In any case, I’m assured by my neurologist (that term again) that whatever it is, it’s treatable.

I’d like to be less annoyed by it all and have truly been moved by the response of my kids and family. Time, I need some time to gain perspective. And I need to get back into the things I was doing and love, teaching medicine in a developing nation.

It has been other-worldly being introduced around Penn as a “faculty member”.  While it carries nowhere near the same oomph as a bonafide member of the UPenn faculty, having that moniker associated with my name is kinda cool. I NEVER thought when I left Penn in 1980 I’d be back and working for/with them, both enjoying it and experiencing pride for doing it.

So I wait…... I have appts on Monday and then go from there. For now I have time to do things I’ve missed; get my iPod going, trick out my lap top, and load my PDA. Thanks for all the kind thoughts and support. Some of the thoughts I have in the black recesses of my brain don't warrant all the kindness. And I’ll take it as it makes a huge difference, so thanks, truly I’m blessed and very humbled….

 

 

Thus far, three days on meds and the episodes are now about 25% of the frequency and severity. Amazing, this stuff seems to work! Now, why did it take me 2 yrs to get to this place. Oh well, I'm here now and it seems to be a good thing with no side effects. I also seem to be getting back the edge such that I'm back at 110% from 95%. It feels familiar and I didn't realize how much I missed it.