Been a while

Oh wait I tried that excuse already...

I got into a bit of deep yogurt from the story, name identification, and pics I posted of "that little child in a peds unit with Marasmus" Seems that people sue for that here and that puckers some of the admin folks. Never mind that:

a) her mother died from HIV or abandoned her,

b) so did her father,

c) her brother allegedly has been seen on the streets begging,

d) she now lives in the middle of nowhere and the pics were to celebrate the fact that nurses here are amazing and that she is alive today because of them.

And of course I hear all of this second hand which is typical in our organization if not the culture at large. Nothing about how the blog praises this amazing country, just how I may have screwed up, again. OK vent over.

I have been in the pool a lot lately and have decided to represent Oregon Masters at the national meet in Atlanta. There I said it. In point of fact the pool is less a pond now that we are on the same page about chlorine. So I have run out of excuses other than I have no training partner....I know stop the whining. MJ and Bill have been great motivators and hilarious at the same time; sending me workouts with tongue in cheek commentary. I need to do more fly and IMs. I think I'll enter the 1650 and 400IM as that is where I stand to score the most points for OR. Which is another way of saying that few people in my age group are as dumb and stupid as to enter both. I did a 1650 on Friday and actually did legal turns with a pull out on every turn, all 65 of 'em. Sometimes I do more than a 1650 as I get lost somewhere around the 900 and do an extra 100 just be on the safe side. Ain't hypoxia great?

Last week I went to a remote outpost with one of my Family Medicine mentees only to find that there was no nurse for translation. So we re-traiged and discovered that most of the patients were there for the usual, "altered comfort state" and were after the African equivalent of Tylenol. They all went to the back of the queue and were furious! We triaged to the front any kid with a fever, any HIV+ patient with a fever or change in status quo, and the like. A woman who worked there was kind enough to translate.

In the first three patients we saw a young boy with peri-orbital cellulitis, an infection that can be devastating as the blood from the orbits drains through the brain and the bone there is very thin making meningitis a real threat. Then we saw a 1wk old with pneumonia, then a family with neurofibromatosis. The mother was intact but her kids were either cognitively injured of psychiatrically so. One was in status epilepticus (constant seizure), one with schizophrenia, and one who would go up to anyone and start up a conversation (something that even in this country is considered inappropriate). All had the tell tale fibromas of the face and body. These are small mole-like protrusions from the skin and they cover the body. This is of course bad enough except they can grow as tumors in the central nervous system. It is a genetic disorder that carries a risk of 50% transmission with each pregnancy and unfortunately they all lost the toss.

Never the less, a great teaching moment to reinforce getting control of ones queue. And some great teaching surrounding these disease entities.

Eli and Amber are two weeks away and we can't wait. We'll greet them, let them settle in, and then head to the north to see some amazing vistas and animals in a huge panorama. Lately the birds have been migrating and we are seeing some interesting flights of long legged cranes and others; hornbills, eagles, kites, ducks and geese.

I have been asked to present an interpretation of the effect of HIV on rural Botswana. Somewhere I got a reputation for this and will be giving it to the HIV folks at UB and anyone else that might to wander in. I'll review the history of HIV here than narrow it down to the rural impact. The real story is how HIV is affecting those that live with it and their care givers in rural Bots. These people must travel many km for care, have less reliable access to it, meds, and food. They, and their urban compatriots, are the true heroes in this saga.

Enough already. Will try to keep more up to date. Cheers!

Been a while

First things first: Empho is thriving. Her "grandmother" is faithfully bringing her in for weekly weights. She is walking better and has truly transitioned into a head strong 2 year old; way cool. All the "nurse mothers" are so matter of fact about how they brought her back from the brink it amazes me, they are truly extraordinary.

Christmas Day found me in Mochudi where I mentored on the wards and then the OPD. The doc on call was very strong and the queue was out the door and down the street. I'm not sure why it was like that but maybe people thought that it would be a good day to get some attention. Once again the OPD was crowded with somatization, malingering, and the like. The bona fide pathology is usually quite thick and this day was no different with fractures, death and dying, and the like. One that sticks out is a woman who was "hit by a car" and was apparently brought in the night before wailing. The original doc the night before sent her to PMH for x-rays as she was protesting so much. She was seen by the OPD doc down there, had films that we negative and sent home. On the way she again stopped by our hospital demanding admission as she "couldn't walk". Well let's see....Can you lift your legs? Yep, flex your ankles? Yep. Any bruises? Nope. OK let's see if you can stand. And let the wailing begin. The short of the next 20 minutes was that she could in fact walk but was so deep in conversion disorder that she flopped on the floor kicking around and yelling that "you want me to die", a common declaration.

I took a break and gave myself a treat by investigating a clinic in an area north of there named Oliphants Drift. It is next to the RSA border and quite remote. I saw the clinic and the nurse that staffed it and it reminded me of how remote villages still get care that many nationalities would love to have.

Then the next day off to the States. I made to DC without a hitch was reunited with Lynne in the departure area to the tune of lots of mutual tears. Her beloved sister Terry had finally made the transition and we were/are still in bereavement. Then we had the classic situation where we boarded the plane for JAX were on the flight line only to find that the flaps didn't work, returned to the gate, and waited only to find out that the flight was cancelled. Several hours in line later we were given accommodations at a local hotel, and quite a hotel it was. Full of upper middle class people, an outdoor mall in the back street with an ice rink, and every national brand establishment (save Walmart) in the 4 block area. Every little yuppie named child was there, skating and having a great time as a parent would call out to them. Well and good, but I was reaching toxicity. So naturally I ducked into a Starbucks much to Lynne's amusement and while the coffee was welcomed and good, the toxicity went into the red zone. Not sure what I was expecting.....Called Eli and we laughed at how much of a third world hick I have become.

Next off to Jacksonville to see Forrest, Shannon, Judah, and the twins! And then we were joined by Eli and Amber! It was great. Now, I am blessed with strong willed kids who have in turn married women of equally strong will. The topic of the time was why I had "checked out" and what the hell was I going to do after my contract was completed, assuming Penn keeps me that long. Again the short of it is I GOT IT. Have no idea where the future will take us yet but the options including staying are being heavily considered. Anyone know of a town that has four seasons, is near an ocean, with an NPR radio station, great remote roads for cycling and motorcycling? Oh and has an opportunity to doctor with an under served population that would be happy for me to boogie off about every 12-18 mos to the wilds of some truly under resourced place for three to six months?

We went to Portland where we saw OUR twins and their spice. Oh and I best include yet another grand child (4 for those that are counting) where we engaged in the life of too much; food, sleep, treats, and the like. I had a chance to swim with my old masters teams in Portland and Hood River. My old lane mates put me to shame.....I saw my close friend and former partner for a cup of joe and then sank myself into my favorite breakfast at Egg Harbor. I really miss Hood River, much more than I anticipated; friends, masters swimming, the Columbia, having my choice of two national forests to see, cycle and hike. Jeez did I do the right thing?

Now it's back to what floats my medical boat and yet with a more concerted glance over my shoulder. I love the people of this great country and continue to make friends in the national population. I enjoy and hold dear our ex-pat friends to be sure but I want to miss the national Batswana. I'll be truly fortunate if I can achieve that.

3-2-1 Discharge!

I was out in Lobatse today and discharged Empho. But before that I gave her some Crayon-like markers with which she colored the accompanying paper, then the floor of the ward, then ate one. Surprised....me? It was hilarious and we were all holding ourselves with laughter. Here come blue poops!

The ward was a touch crowded with kids who have measles, chicken pox, and dehydrating gastroenteritis. As she has free reign of the place, she frequently crawls into the rooms to see what is happening and in the process is exposed. An infectious swamp to be sure. So....for the sake of preventing a nosocomial infection, out she went. It was far from clean and neat as she is to be cared for by the "grandmother of her uncle". Since she will live near a rather remote clinic we indoctrinated the nurse there about how often she should be weighed and seen for follow up. I don't think this will be entirely satisfactory as rumor has it that her brother, 7 y/o, was seen on the street begging for food the other day. So the head matron has her radar on and will yank Empho at the first sign that her grandmother can't keep up with a now willful 2 year old. Who can???

Then it just might be SOS for her and her brother. Who knows. I would have preferred to send her there as she meets two of three criteria for admission; abandonment and abuse. It's unknown if her mother is alive or had HIV. Empho does not. Anyway, ain't my country and this is way above my pay grade. Hope things work out.

Was at SOS the other night and an adolescent girl walked up to me and asked "what is your name?" I replied "Mike" and she immediately scoffed. "You need a proper Satswana name". "OK how about silly goose". She glared. "Well, how about water?". Glared again; you know that thirteen year old girl, eye rolling, "I can't believe this white guy from America is such a doofus" look? "How about earth?" say I. Finger to chin she ponders and then says, "We will call you Empho!" I stifled a rather knowing grin and accepted her moniker. She then used it enough that it became rather un-unique and hilarious at the same time. Adolescents are the same everywhere...... "boundaries, what are boundaries?!

Still can't get used to 40 degree heat here at Christmas time. And yet it's rather festive to be sure. When on the road by myself I usually contemplate what I'll miss about Botswana if and when we leave here. Without a doubt it will the kind and gentle people, the smiles, the laughter, the genuine lightness of heart. There is definitely a widening economic dualism that is expanding with a burgeoning middle class, more concerned with the usual stuff (career, family, cars) than that of their countrymen. I swear I have not seen so many 'Benzes, 'Beemers, Audis, and Range Rovers as here. It makes for rare episodes of envy and self righteousness but the smiles seem to ameliorate it.

I had to be the primary physician the other day in a town that is famous for abusing the doc there. On any given morning about a fifth of the population is queued up and expect "treatment" or sick leave. As I had worked with a strong willed Motswana doc earlier that week who announces each morning that she will be the one that decides about meds and leave and that she rarely gives either, I thought I'd give it a shot. I stood beside a scared nurse who announced that there would be no leave given out that day and that meds would be given only if needed, and that didn't include your desire to have them. The hue and cry was deafening. And after that about half of the assembled crowd stomped off! The day was full of difficult cases that truly needed a doc and not more of the usual somatization and malingering. I don't get that about this culture but again; above my pay grade.

The topography here would remind anyone of the arid west or high Midwest. The flora and fauna are different to be sure. The birds are fantastic. Monkeys, baboons, warthogs, and the ever present cattle-donkeys-goats, can be seen on a trip from Gabs to an outlying area. So on these trips I get to get behind my eyeballs and realize that I have a loving wife of 35 years, a great and grown family that pays it forward, and a great job in an amazing part of the world. I am indeed blessed. Best wishes for Christmas, and Peace.

Who'd a thunk it...

This has been a week to be sure. It began with the usual in the clinics here in Gabs where I do some mentoring and teaching. I had an opportunity to work alongside a great Ethiopian doc who is one of my favorites; inquisitive, sensitive, compassionate. As things wind down toward Christmas, (I must have been the last one to find out that it is now called the "festive season"), indeed this is a predominantly Christian area intermixed with North African Muslims and Indian Hindi, the docs thin out and we are generally under staffed. Even the streets have about half as many cars. Next week and the week after they will become deserted.

I was informed that I can be, or am, too "paternalistic" and that that puts distance between me and some of the MO's in training and some of the BUP docs. It is difficult to know where the line is. I think this dates back to a Monday morning report where we had had 9 deaths over the weekend with 17 admissions. Many of the deaths were reported off handedly and were certified when the patient was "cold and stiff". I looked around and was disappointed that this wasn't bothering anyone or that they weren't speaking up about it. I pointedly raised the notion that this can never be OK. Some of the patients would have died anyway to be sure, but they deserved a physician at the bedside and some could have been saved had they had a doc earlier on in the process. And that the leadership in this had to come from "us" (I was sure to use this term) as it would not come from the nursing service.

But first we had to care. After I finished this rant there was silence. And then the finger pointing began. It was the nurses, the docs, etc. The nurses are used to not having their pages answered so don't call, and the docs claim they are busy in the A and E so they can't respond or that they aren't paged in the first place; a monstrous and emblematic mess. In any case as this came across from a guy my age and since it was pointed it was apparently interpreted as paternalistic. Hell yes I was angry and dumbfounded. Why wasn't anyone else? So deniability is automatically built in if it comes from a "paternalistic old, angry man". I'm still not sure what that means except that I am old enough to be the uncle or father of all the trainees and younger MO's in the health care system, or at PMH, or at BUP for that matter. And dysfunction continues to reign supreme. There are providers and colleagues that are gifted and highly capable to be sure, yet I have found the delivery systems to be increasingly burdensome.

I fear we aren't building capacity (read rehabilitating) here as much as participating in a westernized agenda of rescuing. At this point I have a better idea of what doesn't work that what does. Building relationships is difficult to quantify and yet that is what I do most of time. Never the less in a grant based program it is important to quantify what it is we do. I haven't found the appropriate way to do this and it becomes frustrating to slowly realize that this might not be what I originally signed on for. I have no problem with those that do enjoy this and have a passion for it; it just isn't this aged doc's idea of practice.

And moving back to the States isn't as easy as it might seem. I love and miss my family to be sure. And I love clinical medicine, especially the creative, working without a net part. Things in the US were dysfunctional enough that I felt suffocated. And the pathology often bypasses me or the etiology is based in overindulgence (witness metabolic syndrome). Add that to entitlement and things rapidly stopped being fun and engaging. Here and other places I at least get to do the following:

I was at a district hospital this week and heard about an 18m/o that came in very dehydrated and probably septic. The resuscitation was great; fluids and meds by IO, somehow including D50W in small boluses. I was asked to review the patient and did so. All the MO's dropped by peds and remarked how much better he looked. I thought great until I noticed that he was still breathing rapidly and deeply. By now he should have been back to base line respirations with a pulse that was normal for age. I started to connect the dots in this aged, Lamictal affected brain of mine and asked for a finger stick blood sugar. It came back at 5x normal.

Ohhhhkay now we have a better idea of the what and why. Let's get a quick UA as we can't get a bicarb level, let alone an ABG. The UA indicated a pH of 5 (acidotic) and ketones were 1+ with glucose of 3+; a slam dunk; DKA. So I shipped him to PMH as they have pediatricians and better lab support. Nowhere in the US world of primary care would I have that chance to diagnose DKA with a minimal amount of, or no, lab support. We could have treated it but I had to leave that afternoon and I/we would have needed to check on him q30m. It was a great teaching opportunity, and exactly how can that be quantified? Or, perhaps more to the point, where in the US could I duplicate that?

Time here is flying by as I get to live in the present. I am working with some truly brilliant and gifted docs, for many of whom this represents their first career move or they are in the first 5-10 yrs of their career. I'm not and this is becoming a bit of an issue I fear. Time to wait and see I guess.

Best to all for a festive season!

GREEN

Everything is green! We have had some sustained rains and some hard hail, the size of marbles that dimple a car roof or hood. As a result things are green, damp, and humid. What once was brown is green and all Botswana is glad for it.

One of the interesting things about this place is that it in some way is held hostage to its own lack of food production. Some say that 80% of the food stuffs here are imported. Much of the cereal processing occurs here, much of it in Gabs, but most of the grains are grown elsewhere. The farms that I can see from the air are all subsistence type. We can sustain our own eggs and beef, a LOT of goats, but no significant and sustainable fruits and vegetables. Currently it is kale and cabbage season so much is bought from road side stands (called tuck shops) or harvested at various prisons where it is grown to keep the prisoners occupied.

Yesterday I was rounding on the peds ward at Lobatse (Athlone Hospital), one of my favorite. Recall that this was the place where we had a septic man on the ward and it was met with a touch too much ambivalence to suit me. I had just given a presentation on it and I thought we had this diagnosis well worked out. So onto peds I go to spell the CMO who is up to his "waist" in alligators. First thing I see is an infant with sunken eyes and panting, admitted two and a half days ago with gastroenteritis. She was in deep yogurt to be sure.

We weighed her only to find that she had lost weight since her routine weight 2 wks ago. Starting to sound familiar? She had a temp of 39C, a pulse of >140, and R's of 40. Dehydrated to be sure but truly this was sepsis. She was being hydrated with half strength solution, not the right stuff, and not doing well. I switched out the IV to saline and promptly discovered that her IV site was toast. I tell you I cannot devine how the staff can start IV's on these hypotensive, chubby, African kids. They have the touch and I don't that's for sure. So the nurses brought everything needed for another "cannula" and gave me that "you don't think I'M going to start it do you"? I proceeded to turn this little girl into a pin cushion, finally getting one in her foot.

By now you know the rest of the story; in goes 20ml/kg in a bolus than a flow rate to account for her at least 10% dehydration and baseline fluid needs, and a quick change in antibiotics to get after the things that cause sepsis in kids under 1 y/o. She did her part and promptly fell fast asleep and awoke cooing and hungry. Was a great teaching case in that it so very important to track a daily weight and take accurate intake and output. Oh and diagnose sepsis early and come after it with fluids. A sweet save none the less.

The little girl with marasmus-kwashiorkor is thriving. She is stimulated no end at the nursing station. She is 2 and learning to walk for the first time; and having hissy fits when she doesn't get her way. All of this is to the delight and squeals of laughter from all the adults. She no longer has the "1000m stare" and is engaging with everyone. I held her and she promptly inspected my goatee and arm hair, again to the delight of amusement of the nurses. She might wind up at SOS which is cool in and of itself. Her name by the way is Npo, "gift". Truly.

Rumor has it that she'll be around at Christmas. I probably'll go up there and play with her, show her how to use, hopefully not eat, crayons and generally carry on. Then it'll be over to Mochudi to work in the OPD with the MO on call as the pathology there is always thick and fascinating. And then the next day, I to head to the US!

The two steps back part...

Admission

There is a little girl that has been on the Athlone (Lobatse) peds ward for a month with both kwashiorkor (protein calorie malnutrition) and marasmus (all calorie malnutrition). These kids are a nursing challenge but as each is a mother or a sister they have done a magnificent job. She has done wonderfully and the nurses are teaching her to walk in a walker, eat, and coo. Her hair is coming in black underneath white now which is why the nurses shaved her head! She is a hoot and has recovered nicely. And can really chow down. And I finally learned how to upload pics so here she is.....

Today was Lobatse day, a day where we usually begin with morning report. As I was reading our handout trying to ready myself for the presentation to the medical staff I heard out of the corner of my ear that there was an HIV+ man who had been admitted for suspected pulmonary Tb. This morning he was reported by the nurse with the softest, rather ambivalent of voices to have "no measurable temperature and no measurable blood pressure." Yet he had respirations of 20, and then went on to the next case...

This got me to look up and inquire again about the guy as I couldn't believe my ears. She reviewed the patient and I unfortunately lit up. Uh, sports fans whatever he was admitted for is mute, HE'S SEPTIC. They acknowledged that, well, that could be why he was hypotensive and hypothermic..and presented the next patient. I blew a gasket as I had just presented sepsis as a topic for discussion within the month. "He could be dead by now". No movement to the door. "Why isn't some one going to check on him right now?" Again shuffling but no movement to the door. I guess this is the "one step forward...two steps back" part.

I picked up my stuff and headed for the door. By now I had raised enough of a point that another MO came with me. We first checked the VS again and they were worse. Then started two iv's and poured in 4L of saline from which he began to recover and had a measurable blood pressure. I spoke to the Matron (nurse in charge) who expressed frustration that the docs often don't come so the nurses don't call...and hence the nurses are less likely to do so. We'll just add it to the list.

I "MacGyvered" a tool this week to pull a faux pearl from the nose of a two year old. Well what else do you do with one of those things if you're two and wonder what happens when? Normally the child is sent to the ED to be consulted by ENT and then with a lot of fanfare the foreign body is removed. Well why go the fetid hole that is PMH, although the ED is good, when one can remove it here? Out comes the Gerber Tool and a paper clip. In a minute we had a curette and in less than that out came the pearl, sweet.

The rhythm of the place is becoming familiar. Many Batswana speak at the same time and loudly. If the cadence is from LOUD to soft with a descending tone it is generally an important point. If the last word is higher pitched than the one before it, than the speaker is serious. Better than "upspeak", if you ask me? Enough, got to roast some veggies for a dinner tonight. Happy Thanksgiving!

Random randomness II

Mondays can be rather long (a schlep as Matt would call it) but they finish at SOS; a good thing. Last Monday I brought two hula-hoops, two jump ropes, a soccer ball, a whiffle ball and bat, and assorted other out door things for the kids to play with before it got too dark. They'll play way after dark but we try to have some simmer down time before they head to bed.

On occasion I'll wander to the side of the playing field (read large dirt football field) and enjoy the sight of the kids playing and laughing. Everyone here laughs even if it is a difficult situation. The usual response is not to get exercised about it but to laugh. As I was enjoying the sunset and the moon rise two kids came over to me, each about 8-10y/o sat down with me and proceeded to "inspect" me. I have taken to shaving my hair, what there is of it, very short and they love to run their fingers through it and feel the texture of short European hair. 'Course they won't hear me complain as it feels wonderful and truly is a "bucket filler". Then they examine my arms and runs their hands up and down them to feel all the arm hair, something that most Motswana don't have. THAT feels fantastic. Then lift my shirt to look at my graying chest hair all with the most innocent of intentions.

I banged up my leg (getting out of the pool-pond no less) and have a bit of an abscess that I finally treated with antibiotics after draining it three times. Man that hurts but it's easier than finding a doc that can do it for me and maybe just a touch cleaner. Anyway after draining it I rap it in a tight bandage to avoid accumulation of goo and hope the goo won't return. As I had the bandage on they were interested in what was under it.

Well, OK, so I took it off and showed them. They were genuinely saddened that their friend had this and expressed that I "should see a doctor". I told them I was one but that wasn't satisfactory and they told me again. Something tells me that they had somehow been in communication with my family!

I was out of the pool for a week and resumed yesterday. I am definitely a nicer guy if I swim. There is talk about using drivers and state vehicles to deliver us to our sites. This will really cramp my style so I have been more that a little hyped up lately, I feel like a I'm a touch "toxic" and in need of a break. I'll wait until 26 Dec for that. Maybe drive some back roads to out of the way places 'til then.

Things have changed here in the office, generally for the better. We have a huge staff, many of whom are Motswana. We now have a large document that outlines the conditions of employment. It's seems interesting that we spend so much time protecting the entity that is BUP when I'd much rather spend that time protecting and treating their countrymen.

The currency of visits to the doctor is still pain and the currency of treatment is still acetaminophen. People will complain of six kinds of pain to get 7 paracetamol (Tylenol to the US). I gave a talk on malingering, somatization, and conversion disorder and it was well received so maybe we'll start to call it what it is, not the symptom.

That's enough for now, best to all who read this and celebrate Thanksgiving. And to those that don't!