Getting things done at PMH

It takes so long to get anything done here at Princess Marina Hospital – and people think HUP is bad sometimes. I’ve been asking for a portable chest x-ray for this guy with a pneumothorax since last weekend, and it still hasn’t been done. I can’t personally wheel him down to x-ray myself because, one, he’s on suction, and two, he’s on oxygen, and although we have one oxygen tank here in the ward, nobody has been able to find the valve that fits it. So I’ve personally gone to the radiology department every day, sometimes twice a day, and begged and pleaded for them to take their one portable x-ray machine down to the male medical wards, and take this guy’s chest x-ray. Half the time, the person who is in charge of portable x-rays isn’t there. Of course, all the people I talk to are radiology technicians, and they could all help me out, but none of them are officially in charge of the portable machine for the day. Then the other half of the time I finally find the person doing portables for the day, and he says, there was no request form (which is a crock – I’ve turned in like 5 request forms, some personally to the technicians), and I turn one in then and there because I’ve anticipated this, and he looks put out, and says, ok ok, I’ll do it this afternoon. I usually say something like, well can we do it now, because this patient is somewhat critical, and I can help you wheel things down and everything. And they always say no, they’ll do it this afternoon. Sigh.

Finally today, we took him off suction, and he was doing ok. He’d been off suction before, but never was stable for long enough for me to wheel him down to x-ray. And I also managed to find the valve for the oxygen tank – it leaks, but at least the patient can get some oxygen. So I pushed him quickly down to x-ray, and we took the film, and hurried and wheeled him back before anything bad happened to him. Thank goodness he didn’t crash or anything. I was patting myself on the back for going to all this effort to get a simple x-ray when I took a look at it. He’s now got bilateral pneumothoraces, and probably has a bronchopulmonary fistula – that’s a direct connection between the inside of your lung, and your chest cavity. Even in the states, that’s very very bad, and many patients don’t do so well. He’s probably not going to survive, which really sucks. I totally thought he was going to pull through.

The patient wards at Princess Marina Hospital

So this might be a good time to talk about the hospital a little bit. I may have mentioned some of this before, but there are several wards at Princess Marina Hospital. Each ward is self-contained in a one-story building. The Penn people work mostly in the male medical ward and the female medical ward. There is also a private ward, an orthopedic ward, an oncology ward, a pediatric ward, an obstetrics ward, and maybe a few others I can’t remember. Baylor also has a huge ostentatious glass-covered air-conditioned two-story building that is for outpatient pediatrics. I say ostentatious because they just sorta came in and built this building on their own – this building uses so many resources when so many of the other wards are super crowded, have no supplies, and have no air conditioning. In fact, as it’s getting hotter hear, it’s getting smellier – I can’t imagine what it’s like in the summer!


Each of the wards are a little different, but I hear the male and female medical wards are the most crowded and the most lacking in common supplies. The private wards are the nicest – patients either get a room to themselves, or they share with only one other patient. The nurses are a lot nicer and more competent on the private ward, and they always have enough supplies and medicine. Of course, patients have to pay 80 pula per night, which is quite a lot for the average Motswana. For example, our maid makes only P600 a month. In contrast, for the general male and female medical wards, patients pay a processing fee of P2 (I think) at the A&E (accidents and emergency – the equivalent of our ER) and if they get admitted, everything is covered by the hospital – that is, if you’re a citizen of Botswana. There are quite a few Zimbabwean citizens here (probably because the situation is not very good in Zimbabwe) and a lot of the prisoners are also Zimbabwean.

The oncology ward is always super crowded, but the specialist there (there’s only one) is really good – his name is Dr. Paleski and he’s Polish or something like that. He’s very political, with a definite liberal bent. He’s famous for asking someone when he first finds that they’re American – so what party are you, or so what do you think of Bush (in his accent)? Even though he’s not connected to the U.S. he hates Bush and republicans, and writes letters to them all the time. It’s pretty hilarious. I think he and Pete would get along pretty well - I bet they visit the same blogs. :) He’s pretty brusque and somewhat brutal too, with everyone, but he’s very good. Like he’ll do a bone marrow biopsy without asking the patient if it’s okay – he just jabs a huge needle in the patients sternum, the patient screams for about 10 seconds, but then he’s done. And he works very hard. He sees all these patients at clinic during the day, as well as the people in his inpatient ward, and does all these consults and biopsies of other patients in other wards as well during the day, and then goes home and looks at slides all night to make diagnoses. I think he’s burning out.

I haven’t been in the pediatrics ward or the obstetrics ward, but I believe they are pretty similar to the public male and female wards, but perhaps less crowded. The pediatrics ward is only for those patients under 14! So on the male and female wards, we still see quite young patients, who in the U.S. would be considered pediatric patients.

It’s funny – the gripes you hear at the hospital here are in some ways very similar to the gripes you hear at American hospitals. We’re constantly wondering why a patient needs to be admitted to the hospital – ideally a patient should only be admitted if they really need critical care in the hospital. If they can be managed as an outpatient, then they should be. We also wonder why some wards transfer patients to us. For example, the orthopedics ward is famous for transferring post-surgical patients to us because they say they don’t know how to manage somebody’s heart condition. Of course, that didn’t stop them from operating on the patient! Likewise, obstetrics transferred a patient to us for us to manage HELLP syndrome, which is an obstetric issue! I hear a lot of the same complaints at the U.S. hospitals, which is sorta funny. :)

There’s a lot more to talk about, but I think I will save a discussion about the patients themselves for a little bit later.

Dialysis

This was a pretty busy day at the hospital, probably because we admitted a lot of patients yesterday. I had a lot of LP’s to do today. One surprising thing involved this one young patient – 30ish male, who was pretty sick and we didn’t know why. He was confused, and as a side issue, his family mentioned that he hadn’t peed in like a week! So we measured his creatinine and he had like a creatinine of 18. Meaning he had renal failure, and it probably was a chronic problem that acutely got worse. To make a long story short, we did a few tests (you can’t get a kidney biopsy here) and eventually came to the conclusion that he had end stage kidney disease. And this is something else that is vastly different from the united states. At home, you get free dialysis for life. Here, there is only peritoneal dialysis (through your abdominal cavity), and many of the patients, if they’re on it for more than a couple of weeks, eventually get infections and die. So dialysis here is really for people with acute kidney failure who just need support for a week or two, and will probably recover. This guy’s kidneys were shot (probably due to HIV), and he would never recover. So again, we were just waiting for him to die.

It’s weird with some of these young guys – in the states we would be doing everything possible to try and save them. Sometimes I think that’s bad though. We push the limits of life so much at home, and often it just leads to more suffering for the patient and their family. It’s not a pretty site. And often they still die anyways. We counseled the family and he died two days later.

We also went to Chutney for dinner – it’s this really good Indian restaurant in Gaborone. Interestingly, there is a pretty large community of Indians here. Not so many Chinese. But anyways, we’d all had a tough day/week so far, so we were all glad to go out to dinner. Kristy and I decided to drink a bunch of beers. :) It actually took quite a while for the food to get to us, so we had maybe 3 beers before the food got to us, and we were pretty tipsy. It was pretty fun. :)

TB patients

I was on call tonight and I admitted 4 patients, which is a lot for me. There wasn’t anybody to really help me either… on the pink female side, they have 3 team members all working on the same number of patients. However, it seems like the female side gets many more admissions than the male side. I have a theory about that. I don’t think it’s that different than in the states. Women tend to come in for the health problems and for health maintenance more often, and sooner, than men do. So there are more women admissions. Our lists of patients on the male side also seem to be a lot smaller than on the female side. I think that’s also related to the men not coming in soon enough. So many times we get a male patient that comes in comatose, or barely breathing, and it’s really too late to do anything for them here. So more men die than women, and less men come in the hospital in general, keeping our lists smaller.

It’s pretty sad – the other day, we had a man come in because he was barely conscious, and really struggling to breath. For those of you know what I’m talking about, he was already having Cheyne-Stokes respirations and barely responded to sternal rub. He had this huge mass in his neck that we FNA’d (fine-needle aspirated – it’s a way of taking a biopsy) and stained it to look for AFB (acid-fast bacilli – the sign of TB). And it was swimming in TB. We made a token effort of putting him on anti-TB medications, and giving him oxygen, but really we were just waiting for him to die. It wasn’t worth sending him to the ICU because in this resource-limited setting, only people who have a pretty good chance of making it through an ICU stay go to the ICU. And he was definitely not one of them. Not to mention the fact (as you’ve seen in previous posts) that the ICU doctor is horrible and has no idea what he’s doing, so most patients, even though with relatively good prognoses, rarely make it out of there alive. Anyways, he lasted until 11:30pm that night. And this is a disease that is easily treatable. If only he had come in a week or two earlier. It’s awful.

Tonight I also admitted an XDR TB patient! So a patient first diagnosed with TB is put on first-line anti-TB treatment (ATT). They have to go to the clinic every single day to get their medications, as part of the DOT (directly-observed therapy) program for TB treatment. This program was started because patients weren’t taking their medications, and they weren’t getting better, but more importantly, their bad drug adherence was resulting in the emergence of resistant strains of TB! And we just had a lecture about this – because there’s no money in developing TB drugs, and it’s really a third-world problem, the last effective TB drug was developed in 1960 (or something like that)! So we only have a limited set of drugs to work with. Anyways, so I had a patient who was diagnosed with TB in 2005, was on 6 months of treatment, and then relapsed and was diagnosed with TB again a month later. He probably had multiple-drug resistant (MDR) TB. So in 2006 he was placed on second line treatment for 6 month, got better, and then after another month, relapsed again! They finally cultured his sputum (which is tough to do here), and it turns out he’s resistant to 4 of the 5 commonly-used TB drugs (XDR TB). So now he’s on all these weird medications, many of which aren’t indicated for TB, but probably have some effect. There’s really no other choice for this guy.

However, the problem isn’t that we can’t treat this patient, the problem is that he’s in the hospital! In the states, there are all these negative-pressure isolation rooms that you can put patients in. Here, there is no such thing. There is an isolation room that you put all the MDR patients in, but sometimes patients who aren’t even proven MDR go into the room. And our XDR patient went in there too – meaning he’s probably going to give all the other patients XDR TB. Plus the room is not negative-pressure. We just open all the windows to improve ventilation, and try to keep the patients in the sun for the UV exposure (which actually helps to kill TB). We wear these N95 masks that are supposed to protect us to some extent from TB, but it’s not 100%. If you’re lucky, you can sometimes get your MDR or XDR TB patient put into a private room in the private ward (no such thing in the public wards – there are 10-12 people per large room, or cubicle). But those rooms are still not negative-pressure. I’m not too worried because I’m only working here for 6 weeks, but apparently of the students who have stayed for a year or more, 3 of them (I don’t know out of how many) have converted their PPD – meaning they have TB in their system, although it might not be active. Scary.

Back to work again....

It was time to go to work again, which was a bummer after such a nice weekend. Plus my team had a ton of patients after last week. Up to 20 patients were on our list, and my team is just Boipelo and I! I believe all the other teams have at least 3 members to do all the work, if not more. And we had to round twice because Dr. Stefanski didn’t know he was still covering for Sara. So Dr. Gluckman sorta rounded with us, then Dr. Stefanski rounded with us again when he got back late morning – we didn’t really finish rounds until 3:30!!! And we had very little time left to do all our work. It was a little frustrating. But Phil helped me out by drawing bloods quite a bit at the end. I guess it was his way of paying back all the help I gave them earlier. Hopefully those will go through and I’ll get results because the computer system for ordering labs was down… I had to manually fill out requisition forms, and those don’t always work. :(

When I got home, I got motivated and made a beef stew with carrots and onions. I didn’t use potatoes because I like to put it over rice. But I usually thicken it with corn starch, which I didn’t have, so I used flour – that worked pretty well, but I got impatient and didn’t put enough flour, so it’s more like really thick soup than stew. But it’s still good. The flavor is great, but some of the meat is pretty tough. But some of it’s soft. So it’s still good. :)

The second day at Tau

We got a wakeup call at 6:30 am today for our second early morning game drive. The first thing we saw were these little vervet monkeys sitting right on our roof! They were pretty cute. During our gram drive, we spent most of the first part of the morning chasing after the mother lion and her 5 cubs, but it was so cold she probably had them hidden away. I was glad I brought all these warm clothes – it was pretty windy and chilly. Some of the other people didn’t realize how cold it was going to be (which I think is a little silly) and didn’t bring much warm stuff.

The first things we saw were more elephants – two more bulls traveling together. Hein also took us on a short walk to see to some elephant bones. This female elephant was one of the lucky ones and actually died of old age. They live about as long as humans do – up to 70 years. Even years after they die, the other elephants will drag their bones around and spread them around. Hein said this was a sign of respect. A few of us took pictures holding Hein’s gun next to the elephant bones – which was a little silly. Being medical people, we also spent some time trying to figure out exactly which bones were which - there were maybe 5 large pieces strewn about. The skull was easily identified of course (it has a huge nasal cavity!), but the rest of the pieces were a little tougher. We thought we identifed the hip bone and maybe a femur, but we were just guessing. Hein thought we were funny. :)

Then Hein took us to a fenced enclosure to see these 3 wild dogs that the park was releasing in a few weeks. They looked like they could be pretty savage animals – I’m glad they were fenced in. There’s already one pack of wild dogs in the reserve, and I think Hein said they were hoping that another pack would form. Hein said that the existing pack once took down a rhino! And they start eating it before it dies, and he said it was pretty brutal – it was several hours before the rhino finally died.

We finally also saw some zebras – there were 3 or 4 of them right next to the trail! They weren’t too scared of us – we stopped right next to them to take pictures and they didn’t run away. Kiona really liked these, and I thought they were cute, but nothing that great. We had a break where we had coffee and tea, and Kiona did some acrobatics. :) And finally, we saw some white rhinos in a pack. They were a little away from the dirt road, so Hein took us off-roading (which he’s not supposed to do) to get a little closer. They were pretty skittish and ran away a little bit when we drove up, but we still got pretty close to them. We saw a few other deer-like things, I think kudu, but they were mostly running away from us and we didn’t get a good look.

When we got back, breakfast ready! It was a huge buffet of eggs, pancakes, bacon and sausages, fruit, cereals, sautéed mushrooms, breads, breakfast pastries, and I’m sure a ton of other things I can’t remember. It was great, especially the sausages. I really can’t say enough good things about the sausages here. It was also somebody’s birthday and towards the end of breakfast, the entire staff came in dancing and singing, bearing a birthday cake! It was a pretty impressive scene and must have lasted close to 20 minutes. One song would end, and they would start another one. It’s amazing how well every single person can sing, and even harmonize.

Then it was time to leave… Goodbye Tau!

It was a super busy weekend already, but it was Steve’s last weekend in Botswana (although he will be coming back in six weeks) so Michael organized a Braai (barbecue) at ICC flats (where we live) and had Steve and Barry over. None of us were hungry, but we had a huge amount of meat again. And Steve made bananas foster, served with ice cream for dessert. He also made a little speech saying how well we were all doing, and how well we had adjusted to everything – I bet he gives a similar speech every time he leaves. :)

It’s actually very nice outdoors – our flats have a large outdoor area, which includes a pool, a large barbecue pit, along with smaller grills, tables and chairs, and shaded wood benches for sunbathers to lie on. It’s also very nicely landscaped, with all sorts of different flowers, plants and trees around. I think it takes quite a bit of water to keep it up, which is a commodity here in Botswana. It actually rained for about 5 minutes! I bet Motswanas were overjoyed for a split second. Apparently last summer they got a ridiculously low amount of rain, something like 3 cm. And they need the rain.

My first game drive!

We had lunch around 1pm, which was one course – we got to choose between steak with peas and mashed potatoes or calamari salad. They both sounded good, but of course I got the steak. It was sooo delicious! It was incredibly tender and had great flavor, and the sauce that it came with was good too. The salad also looked very good, and people said the vinaigrette dressing was great. Steve stayed for lunch before he left, so with such a big group, we didn’t finish until about 2:45 pm. And they told us that we were going to meet for high tea at 3:30 before setting off on our first game drive at 4pm! So we were going to have half an hour before we were supposed to eat and drink again! But not to worry – it was just tea and these super buttery small cookies/biscuits. I tried only one, but they were so good I grabbed another for the road as we set off for our first game drive.

We all piled into this huge 4WD car/truck that seated 11 people, including the driver. So it was perfect for our group since we had 10! This car was super heavy duty, and it was really good we had it, because some of the dirt roads were pretty uneven, and we did a little off-roading as well. The way the game preserve works is that there are probably about 10 different lodges that have access to the preserve. And there are more traveled dirt paths that are pretty even and stamped out, and there are more private dirt paths that are often pretty small and uneven. The driver/guide, whose name was Hein (he was a pretty cute Afrikaan guy), told us that during the wet season, even these heavy duty trucks get stuck in the muddy ruts sometimes. And these trucks can go off-roading as well, although the drivers have to be careful of course, because there are all sorts of incredibly thorny shrubs and trees in the way, not to mention the uneven terrain.

So the game drive started out with a bang – the first animals we saw were two lions who were brothers. Lions sleep 20 – 24 hours a day, so we didn’t see them active or anything, but just lying curled up against each other on the ground. We got really close, and our guide told us that of course, the lions know we’re there – they have super keen senses – but don’t perceive us as a threat. They were breathing really fast, so Hein told us that they probably recently had a meal – they eat until they’re bursting, but they only eat once every 3 days or so. They eat so much that they don’t have room for their lungs to expand so they have to breathe really fast. It’s so funny! Sounds like me when I eat too much. :) Apparently close by, other trucks saw a mother and 5 lion cubs, but we didn’t get to see them. Hein told us that 3 of those cubs were hers, and 2 were her sister’s. Her sister died, leaving 3 cubs. One of them died, and just when the other 2 were about to starve to death, they were found and sort of adopted by their aunt. Kind of a cute story. We tried to find them again the next morning, but it was sort of cold and windy, so she was probably hiding them away in some shelter.

The next things we saw were two bull elephants. All the female elephants stay in a pack, but once male elephants reach about 13 years old, they get kicked out. So they often stay solo or keep company in small bull packs of 2 or 3 animals. They can get pretty aggressive though and charge at the truck, like they charge at each other. One of the bull elephants started getting a little aggressive, and our guide backed the truck up a little bit, which the elephant took as a sign of us backing down, and stopped being aggressive. I was a little worried, because those elephants can go pretty fast – Hein said up to 30-35 km per hour. But he didn’t charge us, so it was okay. We also saw them using their trunks to drink water and eat – they were pretty impressive. That snout has a lot of flexibility and strength!

Then I saw far off in the distance two giraffes! Everyone congratulated me on spotting them. :) We couldn’t get any closer, but my camera was able to get some questionable pictures of them. If you look closely, you can just see their shadowy outline. Apparently giraffes have the same number of vertebrae in their neck as humans do – 7 cervical vertebrae. Their vertebrae are just huge! They also have this sensor in the back of their head that monitors their blood pressure. Normally, like when they’re eating, they have to maintain a very high blood pressure so that enough blood gets to their head. Because their heads are so high, if they lower their head to drink from water, the blood pressure could shoot up as the blood flows downward, and they could pass out! What this sensor does is monitor when the giraffe lowers its head, and decreases the blood pressure while the head is lowered. This makes me wonder if there are mutant giraffes out there with malfunctioning sensors, who are passing out every time they try to drink some water. That’s probably selected against in evolution. :)

Then we saw some white rhinos. There are two types of rhinos – white and black, although I was told that because of political correctness they have renamed them to something like wide-snout and horned-snout. I’m sure I’m not getting those correctly. Compared to black rhinos, that usually eat from trees and keep their heads up (and have the correct type of snout/mouth to eat from trees), white rhinos tend to keep their nose to ground because they eat grass, and also have wider snouts, ideal for eating off the ground. They also are supposed to have different horn patterns, which I know nothing about. Black rhinos are supposed to be more skittish too – we certainly didn’t see any during our safari.

By this time, it was getting pretty dark and we saw a beautiful sunset. Hein stopped the truck and we all got out and took more pictures - we all climbed on top of the truck canvas too and took a good look around. It was pretty cool. He set up drinks and snacks, and I had some biltong – that’s beef jerky – and it was amazing!! They told me you can’t take it back with you to the states due to regulations, but it’s the best beef jerky I’ve ever had. We drove around for about an hour more after this, with Hein shining this huge penetrating light around to search for animals, but we didn’t see too much more.

We did see some really cool insects. There are these huge termite mounds everywhere, and at some point, Hein stopped and showed us these huge African ants. These ants go en masse to a huge termite mound, kill all the termites, and bring them back to their ant mound for the rest of the colony. We saw a huge line of incredibly large ants (and they can sting!), each carrying a dead white termite on their back, going back to their hive. It was somewhat scary.

We also saw a dead rhino skin. It apparently died about 6 months ago, and was immediately eaten up, leaving only the skin. It looked like leather, and Hein said around their neck, the skin can get up to 3 inches thick – pretty tough for animals to eat or chew through.


We got back around 8pm, and I finally could pee. :) Then we had a few minutes to freshen up, and then basically went straight to dinner, which was delicious! The appetizer I chose was smoked salmon on top of a potato cake on top of smoked kudu, on top of another potato cake. And there was this good sauce spread all around it. The entrée I chose was roast duck, which also had this really good tangy sauce all around it. And for desert I got a cheese plate with 4 or 5 different cheeses, some jam and some honey. Yum!!!! I left feeling very full and satisfied.

After dinner, we went upstairs, and some of us checked email, some of us just hung out, and some of us played pool. Only Kristy, Hein and I kept drinking, and I eventually played pool with them. My partner, the bartender, had to leave to settle up, but I beat them even though I was down by 3 balls! There was definitely some big-time flirting going on between Kristy and Hein, so eventually I left them alone and went to bed. Everyone else had already gone. Apparently that night, he took her on another midnight game drive! But he had to leave his gun because he was a little drunk – but I guess not too drunk to drive the 4x4 truck. :)

Sitting at Tau

This was such an exciting trip! Tau is a lodge in the Madikwe game preserve just across the border in South Africa. It’s basically like a resort – they pamper you, feed you extremely well, and in between meals, they take you on game drives.

We left for Tau at 10:30 am. Steve drove all 10 of us (Barry, Mike, Tara (Mike’s fiancée), Lisa, Kristy, Kiona, Josh, Anne, Betsy and I) there even though he wasn’t staying himself. We all squished into Gill’s (she’s the administrator for this Penn in Botswana program) Land Rover, which fits 10 tightly. It’s not that long of a drive – maybe 30 minutes to the border, then you have to get out, get your passport stamped on the Botswana side, walk/drive to the other side, get your passport stamped on the South Africa side, and the Madikwe game preserve is right there! But we had to drive another 20 minutes or so on dirt roads to get to Tau Lodge.

The pampering started immediately – we got out of the Land Rover and the served us glasses of champagne with juice. They gave us a little tour of the main area – there’s a big building that is located centrally, with 15 huts on either side of it. The capacity of the entire lodge is 60 people (30 huts). Inside the main building there was a large dining area and a large lounge on the first floor, complete with fireplace, gift shop, reception, etc. Upstairs, there is a large bar, with a TV, computer area, pool table, and more tables and couches to sit and chat at. This upstairs area opens up into a large outdoor porch that overlooks this huge watering hole outside of the lodge. This watering hole is amazing – more on that later. Outside, there was another large dining area, which surrounds this huge outdoor fire pit. There’s also a heated pool outside and more areas to sit and drink and hang out.

After this tour and explaining our time table, they took us to our huts, which were super posh. There were two twin beds with mosquito netting (which is just for looks) in a small room, heated blankets, a porch with a personal view of the same watering hole that you can see from the main lodge, a large bathroom with a bathtub, and attached to it, an outdoor shower! I never got to use it – but it seemed really cool. There is a large brick wall that shields you from the outside world, but the top is open to air. It would have been interesting to take a hot shower in relatively cool air. From the porch you got a great view of the watering hole, where animals would just walk up to drink from, and you couldn’t see any other huts or people. You’re protected from the animals by this electric fence that I believe encompasses the entire game preserve – which is huge. But apparently sometimes the animals come right up to the electric fence, which is only a few feet from you!

So that afternoon, after settling in our rooms, we sat around for about an hour first on the porch of the main building and watched the watering hole. It’s amazing how many animals you see just sitting there! It was really nice weather, and these animals just come up to the watering hole. We first saw kudu, which are deer-like animals – they’re probably the most plentiful mammal at this game reserve. We only saw the male, although Steve said that often there’s a female following several yards behind the male. It was amazing, just sitting there on the porch watching the water hole, we also saw hardebeest, a family of wild boars. The boars were pretty skittish and they run funny… their little legs can move them pretty fast, and their heads bob up and down and they keep their tails high as they run. We also saw a sable, which according to Dr. Gluckman, are very rare. They’re amazing animals though – very noble and statuesque. And finally, we saw baboons! I know Pete would say ewwww! There was a huge clan of them, maybe 20 or so. And there was one huge old male baboon that mostly just sat around while the younger ones climbed trees and played around.


There were also tons of birds, which I can’t even name. We saw a Jesus bird, which has a more indigenous name that I can’t remember. It walks on water. There were some big hawks, and white stork-like birds. These little birds, called weaver birds, build these really cool nests in the trees. They build them at the end of thin branches, and they hang there, like a big drop of water. Apparently, the male builds the nest, and if the female doesn’t think it’s up to snuff (probably because it’s not sturdy enough or something), she knocks it down and he has to rebuild it! I find that pretty funny.

ICU incident #2

I had another run-in with the ICU doctor today. My team went to the ICU to see our patient with PCP pneumonia and the pneumothorax. He had ended up getting a chest tube that night I had the first confrontation with the ICU doctor. We were in there seeing the patient when the ICU doctor came in. He asked me what I thought was wrong with our patient – I said the oxygen saturation was 86% (for normal people the oxygen saturation in the blood should be 100%), which is super super low, and pretty worrisome. He asked if that was okay, I said I didn’t think so, that I would prefer that it be above 90%. He asked if I knew why the patient had such a low sat, and I said because for some reason, he was unhooked from the ventilator. He said I was wrong, and in this case it was okay for the saturation to be this low. Then he asked Boipelo the same questions, and she answered the same way, and he just turns to both of us and says, you are both wrong and YOU KNOW WHY! And he stalks out of the room. We were like, okayyyyy. And we look at Dr. Stefanski, and asked him if he knew why, and he says no. That ICU doctor is such an idiot. So we write our note, and then we leave the room and run into the ICU doctor again, and Dr. Stefanski says to him “so I think you were trying to make a really good teaching point back there – could you tell us what the reason was?” And I pipe up and ask if it was because the patient looked clinically well despite having a very low oxygen saturation, and he just interrupts me and says “YOU INSULT ME LITTLE GIRL” and he stalks into his office. I was absolutely dumbfounded, as was the rest of my team! Boipelo starts laughing and Dr. Stefanski just says don’t worry about it. What an ass.

I was on call today too. It was finally pretty busy – I admitted 3 patients, and there were two more to admit when I left. That’s when Boipelo came back (she leaves from 4-9pm, but has to stay overnight) and she saw the two patients sitting there. I felt pretty bad, but I was pretty busy with other admissions and also from getting calls about random patients needing IV’s or falling out of bed, or getting nose bleeds. Things like that. She kinda gave me a hard time about leaving her all that work, but I think she was joking. Plus when we take call, we’re sort of “extra” help anyways – if we weren’t there they’d have to take all the patients themselves, so I don’t feel too bad. I had to get home, I was so tired, and I was still sick and coughing up a lung.

When we got home, it was really nice though – Kristy and Kiona had made dinner for us! They made us eggplant parmigiana and salad! They complained that it tasted like barbecue sauce, because the pasta sauce here is different from in the states, but I still really liked it. I had two servings! I was pretty excited, because the next day, we were going to go to Tau!

Walking home

Nothing much happened again today. I had very few patients – I think our list is down to 8 people! So I finished all my work by 11am, and went to Main Mall again with Betsy for about an hour and a half. We stopped at the Spar (a grocery store) for some household items, and I came back and helped Phil and Lisa out a bit but still got home pretty early. I was willing to stay later and help them some more, but they pretty much insisted that I go home. I have to say, it was a little disconcerting walking home alone, even though it was still light out. We use these back paths to get to the hospital because it’s closer and faster than walking along the main roads, and unless it’s morning “rush hour” or evening “rush hour” it’s pretty deserted even during the daytime. And people have definitely gotten mugged before, even when it’s light out. It's funny - I end up saying hi to everyone, as a sort of prophylaxis. And others do it too! I guess we figure that if we seem nice to someone, they won't mug us. And it's not like it's strange - it's actually very common for complete strangers to say "Hello, ma'am/sir" passing each other on the street. So it was a little weird, but nothing happened.

I got home and finished my personal statement. Woo hoo. I sent it to Pete to have a look at it. But I’ve seriously got to get working on the rest of my applications for residency!

Yummy Pies!!

Nothing much else happened today – I was on call, but there weren’t that manyt admissions. I was actually a little bored. I had to stay until 9pm, and I only admitted 2 new patients. And I missed Quizzo with everyone else (except Lisa and Phil, who were also on call) at the Bull & Bush. I actually did try to make it, because we got out right at 9pm, and Quizzo didn’t end until about 10pm. The night transport people at the hospital (which we use when it’s too dark to walk home) actually said that they would drive me there. But then we got on the road, and apparently a big football (soccer) game between Botswana and some other country – which is a big deal – had just ended and there was a ton of traffic! The driver was no longer willing to take me to the Bull & Bush, but even if he had been willing, it probably would have taken him half an hour to get me there, and then I would only have stayed for half an hour. So it wasn’t really worth it. We’ll make it to the Bull & Bush eventually – it’s a big place for ex-pats and foreigners to hang out.

I did go to have lunch at the main mall with a bunch of people. We all went to Pie City, which sells all these different handheld pot pies. I had a chicken peri peri pie. Peri peri is their version of a hot sauce, and the pie was pretty spicy! But it was really good, and it’s pretty inexpensive – the pie, plus a drink ran less than P10. I will definitely be coming back for more pies. Although I may try the competing pie place next time – it’s called Pie Time. I think that’s sorta funny.

It was also pretty cool because I talked with Betsy a lot today – she’s getting an anthropology PhD from University of Chicago. I believe she’s on a Fulbright scholarship, and knows Setswana relatively well. So I had her teach me a bunch of stuff. We also had some good discussion about the health system in Botswana, and the different organizations, both international and home governmental, that provide health care, medications, and supplies. If I have time, I’ll definitely write more about it later, because it’s pretty interesting.

Past ICU stories

Today was just an okay day – the whole ICU thing sorta blew over, so it was alright. Dr. Stefanski basically said that no female student should ever go into the ICU alone, and he, Boipelo and I all went in to the ICU as a group to see our patient today. And the doctor was very civil. They both told me all these stories about this ICU doctor. Boipelo told me that when she was an intern, she had a patient in the ICU, and this doctor said “go away, and never talk to me again! I don’t talk to interns.” And that’s just crazy! Often an intern is the only person taking care of the patient!

Dr. Stefanski also told us a story about how he had this critical asthma patient that he transferred to the ICU. The ICU doctor refused to use epinephrine on this asthma patient, who was breathing like 50 breaths per minute and really struggling. And for those of you non-medical people, epinephrine can be a huge life-saver for asthmatics – it can open up your airways until the attack has died down a little bit, otherwise patients can literally suffocate to death. Anyways, the ICU doctor refused to use it because he said it was never done, and there was no proven benefit. So Dr. Stefanski got two big legitimate papers that described in large multicenter randomized studies that epinephrine was of benefit for severe asthma attacks, and he gave them to the ICU doctor. The ICU doctor just threw them away. Apparently, the patient kept going in her awful suffocating state for about 3 or 4 days, and then the ICU doctor finally said, okay, she’s not getting better, maybe we should try the epinephrine. And the day they finally tried it, it was basically too late – the woman was so tired from breathing so hard for so long that her body just gave out and she died. I would say that this ICU doctor was personally responsible for this woman’s death, which was very preventable.

Oh, and in case anybody cares, his name is Mkubwa. So if you ever bump into a Dr. Mkubwa that runs an ICU in Gaborone, Botswana, I hope it’s not as a patient.

STUPID ICU DOCTOR

I was the only one on my team that showed up today – the MO Boipelo was sick, and Dr. Stefanski is not at Princess Marina Hospital (PMH) on Tuesdays, plus he’s been sick himself. So I had a few problems today. The morning was great! I got all my work done, and it generally went smoothly as I rounded by myself, but I definitely hit a few snags this afternoon.

The main person that ruined my day was this stupid ICU doctor. The first thing he did was yell at me in the morning, as I was standing there doing nothing but writing my note in the chart for my one ICU patient. He was yelling at me about all the other ward doctors not coming everyday to round on their patients in the ICU. And went off on a tangent about how the ward doctors d/c (stop) medications inappropriately once their patients get to the ICU. He must have ranted for about 10 minutes and all I could say was that, well, I’m rounding on my patient in the ICU and this the reason we d/c’d the tuberculosis medications. So he was like, ok that’s reasonable, and said he didn’t mean to rant directly at me. But he did.

So my patient in the ICU was supposed to get a CXR (chest x-ray) two days ago when he was transferred, and they dropped the ball and never got one, so I asked for one this morning. Then this afternoon, I looked at it, and I was a little panicked because he had a collapsed lung and a left pneumothorax! That’s air in the thoracic cavity, and can be really really bad if it starts compressing other structures, like the heart. So I run all the way back to the wards to ask an attending about the CXR to make sure I wasn’t totally interpreting it wrong, and she said I was right, and that I should call a surgeon immediately to put in a chest tube and decompress the air in the thoracic cavity. So I did. The surgeon said he’d see the patient in the ICU, and I went there right away. He got there at the same time I did, and the ICU doctor saw us right away, and came in storming. “WHO CALLED SURGERY?” And that started another rant. I told him the patient had a pneumothorax and he said there was no way. I said I was pretty sure, as both Dr. Gluckman and another attending had seen it. He still didn’t believe me and made me show him the x-ray, and then he got really mad. I think showing him wrong set him off – he started accusing me of trying to tell him how to do his job, and doing things the wrong way (apparently I’m supposed to tell him about the problem, and then he would call surgery). He must have yelled for about 10 minutes and went off on me with things like “WHY did you not call me first?”, “YOU AMERICAN DOCTORS THINK YOU CAN WALK IN HERE AND DO WHATEVER YOU WANT?”, “YOU’RE TRYING TO TELL ME I DON’T GET THINGS DONE RIGHT??” and “YOU DON’T THINK I’M CAPABLE?” I couldn’t get a word in edgewise, and finally I said I’m leaving, and he said FINE GO I DON’T NEED YOUR HELP HERE GO! I was super upset and, actually, pretty angry. I didn’t realize that I had to tell him first – I thought that since we rounded on the patient, and he wanted us to round on the patient, that we were calling the shots. But apparently he just wants us to round on them and not do anything. Absolutely ridiculous. And he definitely could have told me that I did things wrong in a better way than yelling at me for 10 minutes. Plus, he’s a moron – he didn’t diagnose that pneumothorax and I think he was pissed that I did.

So after I calmed down a bit, I called Dr. Gluckman and told him there might be a problem with the ICU doctor. He told me three main things. One, that I probably should have told the ICU doctor first because they are super super territorial. Apparently about two years ago there was a huge fight between the residents and the ICU doctors because the residents were changing the vent settings because they didn’t think the ICU doctors were setting them correctly. And the ICU doctors resented it. I understand their feelings though – I would probably resent it too if a bunch of foreign doctors came in and started trying to tell me what to do. Still, I think this is a stupid system – what’s the point of us rounding on them if we can’t do any management? If we transfer them to the ICU, the ICU doctors should just take over their care. The second main thing Dr. Gluckman told me was related to this – that in general, the ICU doctors resent all foreigners and automatically are biased against them. So it’s difficult for us to get anything done with them. And finally, he told me that they have a problem with women. So being a foreign woman, he probably didn’t like that fact that I pointed out that he didn’t see the pneumothorax on the CXR, even if it wasn’t my intention to highlight his stupidity. And actually, Dr. Gluckman said that he wrote a note (which I didn’t see) saying that if the pneumothorax was stable, we could probably wait until tomorrow to call surgery.

Anyways, at the end of the conversation, Dr. Gluckman said that if I was brave enough to go get the ICU doctor’s number, he was willing to talk to the guy. I told him who it was, and he was a little surprised – he said that he and the guy were sorta buddies! I was a little surprised too. I wonder if I mispronounced the name, or if Dr. Gluckman was thinking of a different guy. So I went back after calming down a bit, and talked to the guy. I apologized for any misunderstanding there might have been, and said that my intentions were not to imply that they were doing a bad job, but to help the patient. He was actually quite civil, but still quite condescending. I know now I should have gone to him first, but it sort of galled me to have to apologize to the guy when he couldn’t even diagnose the problem. And then he had the nerve to say that he did call the surgeon, but he didn’t think it was a pneumothorax!! He was going to let the surgeon make the decision about what to do, but he thought it was a mucous plug! I highly doubt it, and I argued for a brief second, but then I said, well, why don’t you just talk to Dr. Gluckman about it and asked for his contact number. He sorta was like, OH, Gluckman is your attending? And I said yes, because he basically was today, and has been helping me out for the last few days since nobody else on my team has been around. When I talked to Gluckman a few minutes later, he was like there’s no way that is a mucous plug. It doesn’t look like it on the CXR, and plus, this guy has PCP pneumonia, and getting a pneumothorax is actually pretty common in patients with PCP pneumonia.

That wasn’t it – after I finished with that ordeal, I had to come back and the relatives of this comatose guy were all there asking about him. So we had a family meeting (which I was hoping Dr. Stefanski or at least Boipelo would be around for) and I told them the prognosis really was not good. I told them they could meet again with Dr. Stefanski the next day, but I think I conveyed everything pretty well. But it was pretty tough too.

So that was the day… I was pretty drained at the end, and I went home at about 5pm. I felt guilty about that too – I normally stay and help Phil and Lisa out until we can all go home together, but I was drained. I didn’t tell them the story, but I think they understood.

Dinner with the big wigs

So intake this morning was a little surprising – my team had 3 patients die over the weekend – one 77 year-old with metastatic adenocarcinoma, which wasn’t too surprising. But the other two were young, 30 and 42, with mental status changes, that I thought were going to live! It was a little difficult to take – I was not expecting it, and I had poured so much work into them to try and make them better. Some of these patients you know are going to die, so it’s not worth 3 hours of your time to try and diagnose or treat them. But these two I thought were going to make it. I guess that’s the way it is here… Nothing much happened today though. I thought we might pick up a huge number of patients since Boipelo was on call Saturday, but we only picked up 3 or 4.

Tonight we went out for dinner again, this time at Tendani’s house – she used to be an MO, and was leaps and bounds better than the other MO’s, so got recruited to run IDCC, which is the Infection Disease Clinic at Princess Marina Hospital – it mostly takes care of patients with HIV and AIDS. However, she is rarely ever there anymore as she now is very involved in PEPFAR (the U.S. President’s Emergency Plan for AIDS Relief). Her dad is the Minister of Finance in Botswana, arguably the 3^rd most important person in Botswana, so she comes from what seems like a line of administrators. Interestingly, her husband is an artist, and seemed to be a very cool guy – although I didn’t really get to talk to him.

There were some very interesting people at the dinner. The entire Penn team had been invited, and she had invited a lot of PEPFAR people as well. I had very interesting conversations with a few different people – one was the son of a prior president and he told us a lot of stuff about Botswana politics. I met a few PEPFAR people too, and they explained to me what PEPFAR does – it helps set up HIV/AIDS clinics in small towns in Botswana so that eventually, hopefully all citizens will be able to receive treatment. HIV is such a huge problem here – I would say that 75% of my patients come in knowing they are HIV positive. And who knows how many of the other 25% are HIV positive. We offer the testing to everyone, but not everybody wants it. Boipelo says it’s because most of them are in denial or are afraid, but they have really good accessible treatment now, so it’s starting to become a little more openly talked about.

A traditional Botswana dinner

We were hoping to go to Mokogolodi game park today for a game ride, but it turns out they were all booked. So it was a pretty chill day, which was nice for a change. And to my surprise after the night before, I actually didn’t feel too sick when I woke up. I thought I was going to get a raging cold, with maybe fever and chills, maybe GI symptoms like other people had. But it was mostly a super sore throat with congestion. I stayed in my PJ’s until noon, and then threw a Frisbee around with Lisa and Kristy for about half an hour. Then I took a 2-second dip in the pool at the apartment complex – it was freezing! I guess the nights are still pretty cold here and the pool doesn’t have enough sun or time during the day to gather any warmth. But laying out in the sun felt pretty good. I also managed to set up my blog for the first time, and took a nice nap.

For dinner, we went to the house that Dr. Gluckman and Dr. Nathans are staying at (Malek house) where they cooked us a traditional Botswana dinner. It was soooo good. We had chakalaka, which is actually a vegetable stew dish with all sorts of different Botswana spices. You can buy it in a can, and it's still really really good - you can dress it up some, add some stuff to it, and it can also come with beans added, or other things, and it’s just really good. We also had this thing called sampa, which is a starchy corn dish that you eat with all the flavorful stuff. Also on the menu were beets, salad, veggie skewers and of course, the barbecued meat. The meats here are amazing! I especially like the sausage here, but they also made barbecued chicken wings with a special sauce, and beef skewers. They just have so many different types of meat in Botswana - beef, chicken, fish, ox, goat, livers, and other types that I can't really think of right now, and they cook them all so many different ways! I wish I knew what spices went into these dishes so that I could replicate them when I get back to the states.

So at the dinner, I ate until I was stuffed! Man, I thought I would be eating less here in Botswana, which turned out to be true the first few days, but now I'm eating even more! It's a problem. But not one I'm super upset about. The thing is that lunches here are so cheap and huge and chock full of meat. You can go to the cafeteria and buy this huge lunch for the equivalent of $3 or you can go outside to these ladies with pots of food on tables and buy similar food to what's in the cafeteria for the equivalent of $2. And it's all meat laden (although you can just get vegetarian if you want - and the veggies and salad are amazingly good too), and huge portions. I always eat it all too, it's just soooo good. I usually eat such a huge lunch that I'm not very hungry for dinner, but that's good - I don't need to be eating a big dinner when I have such a large lunch.

Botswana vs. Tanzania rugby match

When we got back, we were super tired. But we didn’t really have time to rest – we went almost immediately with the rest of the group to a rugby game! I’d never been to a rugby game before, and it was pretty big. It was Botswana vs. Tanzania, and they were playing in one of the two grass stadiums in Botswana (both are in Gaborone). Botswana trounced Tanzania – it was so much fun! They played some awesome music and the crowd was great. There were these teenage girls sitting a few rows in back of us that were so funny… they kept doing these great cheers and were so into the game! It was hard to not get involved, and I was totally rooting for Botswana. When they played the techno-ish music, all of us were dancing in the stands with the crowd. I definitely missed Pete during some of the dancing. They kept on playing this really really good song called “Stand up.” Apparently, it’s by Right Said Fred! Who even knew he was still around? I need to download it. And it’s funny – in the states, the bar closes before the stadium closes, I guess so people don’t drive home drunk. Here, the bar stays open way after the game ends. Most people aren’t driving anyways, I guess, but the definitely make more money that way.

It was cool seeing a rugby game and learning about it too. There are these funny things called scrums… where the two teams basically have a shoving match against each other as a team. It’s sort of like a jump ball in basketball. Whoever gets to the ball in the middle first throws it to someone on their team on the outside. And the scoring is a little tricky, but it’s basically like football in that you have to run it into an endzone. The only passing that is allowed is lateral or behind you, otherwise it’s an off sides call. And when you run into the endzone, it doesn’t count as a score until you touch the ball to the ground. And where you touch the ball to the ground is the point at which you line up at to kick the extra point, so many players try to get to the middle as much as they can before touching the ground. I’m sure I’m butchering the rules, but it was pretty fun to learn.

We also met quite a few people there – they seem to enjoy meeting foreigners, and I think some of them don’t know quite what to make of me, a Chinese woman. Two guys we met were Tanzania fans, and they were so funny. Every time Botswana scored, they ordered another beer, and were like, maybe this will make it better. And after the next score, nope not any better! They're the two guys in striped shirts in the picture. It turned out that one of the guys owns Primi’s (the place we went to dinner two nights ago). Their names were Ronald and something I couldn’t quite make out – it sounded like Adam. They invited us out for drinks at Primi’s, so a few of us went there for dinner after the rugby game. Even Steve Gluckman and Barry Nathans went! It was a ton of fun, and they ordered us so many different shots, especially me at first. But I was getting sick and by the end, I had stopped drinking and was ready to go. It was nice to meet some other people though… they invited us out for other things later, like fishing or going out to other clubs! I don’t think we’ll keep in touch with them that much, but it’s nice to know we have other options. Here are a few more pictures of us and the people we met:

Ronald took this nice picture of Kiona, Kristy and I.

This is Kiona, Thabo, Josh and Lisa.

From top left: Dr. Steve Gluckman (who started the whole Penn in Botswana program), Dr. Barry Nathans (pediatrician), Kristy (med student), Kiona (med student), Lisa (resident), Mike (resident), and Josh (recent Penn grad)