Chinese food!

I’ve been dying for Chinese food! So finally tonight, I forced everyone to come with me for Chinese food at J Ma Oriental at the Riverwalk Mall! They all ordered very American dishes (like beef with broccoli, chicken stir fried with vegetables, etc.) and I guess we were planning to eat everything individually. But they came out with all the dishes so irregularly that it became family style. I ordered eggplant and minced pork, which was by far the best dish, and everyone ate mine! But that’s okay – we all ate until we were ridiculously full. We also had these good dumplings in soup, that came with this straw fungus/mushroom thing (which my mom puts in Chinese jai) in the soup.

Prisoners as Patients

We were on call today and miraculously got no patients!!!! It’s the first time ever! I was pretty excited. :)

I’d like to mention a special subset of patients we have at Princess Marina – the prisoners. There is a prison near Gabs (which we actually saw on the way to the Kalahari) that often sends prisoners to us for medical treatment. There is a small clinic within the prison but I think they can only treat patients to a very limited degree – so for very sick prisoners, they send them to PMH, shackled at the ankles, along with at least one prison guard.

You never really find out what these prisoners were jailed for. Boipelo and Maggie (another MO) told us that it’s mostly small things, like theft, but occasionally there are murders (usually crimes of passion, or as they say, “passion killings”) and rapes. Sometimes if a prisoner comes with two prison guards, I think that they must have committed some more offensive crime. But we treat them all the same. They stay shackled with these old-fashioned metal chain shackles, and anywhere they go, a prison guard goes with them. Some of them are relatively healthy and walk around everywhere, while others are incredibly sick and stay in bed all the time – it’s interesting because they stay shackled no matter what, even if they’re too sick to move!

Most of the prisoners are pretty sick by the time by the time they come to PMH. I think the prison clinic does everything it can to help them and then sends them to the hospital only when absolutely necessary. There probably is a huge incentive to fake illness – PMH is like a vacation for these guys. They get mattresses, decent food, and they can even have visitors at PMH!

A high percentage of the prisoners are foreigners, especially Zimbabwean. It’s actually a big problem because foreigners don’t get the same medical treatment that Motswana prisoners do. Because they aren’t citizens, they can’t get CTs without paying (and it’s expensive!), and they can’t get free HIV or TB medications. One patient I had was diagnosed with HIV in prison a few months ago, and is starting to get these complications from AIDS. These are mostly due to opportunistic infections, like Cryptococcus, or TB, and if you get them, it’s a sign that your CD4 count is pretty low and you need to start HIV medications as soon as possible. If this patient could just start taking HIV medications, then it would be ok, his immune system would recover enough for him to fight off the infections on his own. But since he’s a foreigner, he can’t get the free medications from Botswana, and obviously he’s in jail, so he can’t make any money to pay for them. If he was out of jail, he might be able to make enough money, either here or in Zimbabwe, to pay for medications, but here he’s just out of luck. It’s a horrible situation – I don’t know how much jail time he has left to serve, but he might die in there just because he can’t get the HIV medications.

The San-people resettlement villages

On the way back from the CKGR (Central Kalahari Game Reserve), Jo took us to see a resettlement village of the San-people. The San-people were removed from the Kalahari Desert years ago – maybe not physically, but many of them were told to move and intimated out of the Kalahari and relocated to these settlements where the government provides them with free water and maize, education, roads, and a variety of other free services. So now, the San-people live on 3 main settlements in Botswana, but they really have nothing to do! The government tried to teach them to farm, but historically they are a nomadic group, and there wasn’t much motivation for them to learn farming or keep up with it once the government left. There are no jobs for them, but even if there were jobs, popular opinion is that they probably wouldn’t be interested in taking them. The government provides everything for them – food, water, shelter, so there’s not really a reason for them to work or go to school.

There even seems to be a degree of resentment among the other Motswana – they say that the government gives everything free to them, and if they want to go to college, they’ll pay for them and everything, but they don’t even take advantage of these things! Instead, they sit around all day, and they make this drink called Chibuku. The San-people get free water, sorghum and maize, so they use some of it to make this very strong alcoholic drink. They mix it together, dump in some termite mound for yeast (the more termite mound, the stronger the drink!) and it only takes a day or two to brew. They’re often drunk by noon or 1pm because they just sit around and drink all day and hang out. We visited one of these Chibuku establishments (a bar) and actually got a carton. It’s not bad – a little sour and mealy, but it’s ok. It was definitely very strong. Jo said that after you drink two cartons, you’re drunk. It was only about 11 am and many of them were well on their way to being drunk. It was a little sad.

So how did all this happen? The government made up some excuse about the roads not being good enough in the desert, so the San-people had to move (not that the San-people used roads anyways, or not that the government couldn’t have build the same roads that they built for the San-people’s resettlement out in the Kalahari). The rumor is that the real reason the government relocated the San-people is diamonds, which were discovered in the Kalahari. Some of the San-people have won the rights to move back to the Kalahari, but now the government is saying only those 200 or so whose names were on the legal suit are allowed to move back. So they had to sue again, saying (rightfully so) that they represented all of the San-people. They eventually won, but by that time, the government had been providing so much free stuff now to them that only the older people want to move back. The young ones just want to stay on the resettlement grounds and stay drunk. It’s a very sad story.

Camping in the Kalahari!

We went camping in the Kalahari this weekend! Joanne, Amy, Jeremy and I went with Johannes (Jo), a guide that works with Tim. It took us 3-4 hours to get there, we had lunch at the campsite, and set up our lion-proof tents. We were staying in Khutse game reserve, which is connected, or adjacent to, the huge Central Kalahari Game Reserve (CKGR) – the largest game reserve in Africa.

We had a huge lunch – quiche, salad, other things – and then went on our first game drive. We saw a few funny things, but no huge game. We did see this huge flock of vultures near the air strip – very impressive. Of course, we saw many springbok and steembok, some oryx gazelle, these cute ground squirrels that ran fast everywhere and use their tail to shade themselves. And we saw a ton of birds – the lilac-crested roller, hornbills, some weavers, and the kgori (or kori) bustard (which we were saying bastard the entire time) – apparently it’s largest flying bird in the world. We also collected some firewood and saw a beautiful sunset! Here are just a few pictures of the things we saw:

Vultures

Ground squirrel

hornbill

kgori bustard










After we got back, Jo made dinner. It’s funny – there were 3 Jo’s on this trip so it was very confusing when Jeremy or Amy tried to talk to one of us. They would say Jo, and three heads would turn. Dinner was delicious – we had steak, garlic bread, and green beans with pap. And we also had chocolate cake for dessert. We sat around the campfire for a while, and eventually crawled into our tents. I slept with Amy, Jeremy slept alone, and Jo(anne) slept with Jo(hannes). J We were a little afraid of lions – they often go right into the campsite at night although they stay away from humans for the most part. So I didn’t make it out to the drop toilets all night because I was so worried! I think that was a good decision because apparently campsite 5, which was right next to us, had a lion visit them!

We went on another relatively uneventful game drive the next morning after breakfast, and Jo took us to a relocated village of the San-people (they’re also called bushmen, which is derogative, or Basarwa, also derogative since it literally translates to “stick-people”). I thought it was the most interesting part of the trip, but it’s a pretty sad story. I’ll talk more about it in the next blog entry. After visiting the San-village, we stopped at the Khutse Lodge, which is right on the border of the Khutse Game Reserve, for a light lunch of sandwiches and salad. We were there for a couple of hourse, so we went swimming in their pool to cool off, and then drove home. Even though we didn’t see any big game, it was still a great experience, and I’m totally glad I went. It was so quiet and beautiful out there. I think it was a good preview of what our safari will be like…

My team at PMH

We were on call tonight and got a lot of patients. We have a new MO – Mpho Mpape. She’s not very good. But she’s pretty good at doing scut. She disappeared for like 3 hours in the middle of the day. But I guess then she stayed late (only until about 5) doing stuff.

There was a little tiff at the end of the night – Boipelo came on for call at 9pm and found a chart on the female side that said the patient was in the ward at 7:30pm and she got all mad because she had not been admitted yet. She got upset at Amy, the resident who was on call on the female side, and also at Shabnam, the Indian MO who is on call until 9pm. But both of them said they had not seen any new admissions! It’s interesting – the MO’s are very strict when it comes to whom new admissions are clocked by and which team new patients are assigned to. It makes sense – they don’t want to do any more work than absolutely necessary. In this case it turns out that Amy had already clocked this new admission but the nurses lost the admission note and so put the file back into the new patient box. So Amy was able to find the lost admission note and put it back in, but people were still aggravated at each other.

In general, I think my team is great, even though it’s the smallest one. We have as much work as every other team, but for some reason we don't get any new students, residents, or interns! At least so far it has been manageable. Boipelo (our MO) has always been there, although she’s taking the next two weeks off for vacation, starting Monday, and is being replaced by Mpape. She’s actually on call tonight. Not all the MO’s are that good, but she’s pretty good, even though she definitely has an attitude and is pretty cynical. She also works pretty hard. The work ethic is pretty interesting around here. Most of the Motswana MO’s and some of the doctors work relatively slowly, compared to the doctors in the U.S. It’s just a different pace – they tend to take 1 hour lunches (at least) and they don’t rush to try to get everything done. If by 4:00 pm there are some things that are left to do, they just leave anyways. They just try to get to the most important stuff early in the day. This I understand, but not necessarily agree with. There is just so much to do that sometimes one person just can’t get to it all. I do get frustrated on occasion, because there doesn’t seem to be a need for 1-2 hour lunches when you can be working on patients!

I think especially on the teams that have Penn people, the MO’s have a lot less work to do because the Penn people are “extra”. And on call nights when Penn people are on call, the MO’s tend to take off early or disappear, because we are also “extra” help on those nights. It can be really frustrating – often, an MO will just disappear for hours at a time because they feel there’s someone else there to do the work! Some of them are really starting to take advantage of us, and the MO’s are starting to fight to be on teams that have Penn people so they don’t have to work so hard. It’s annoying, because although we are there for patient care, Penn people rotate in and out, and we don’t always know the correct way to do something, or what resources are available to us. And more importantly, we can’t speak Setswana, so we need those Motswana doctors and MO’s to help us translate! It’ll be interesting to see how this plays out in the future because I don’t see it getting better unless there’s some kind of intervention.

Each team also has a specialist, who is equivalent to an attending in the states – they make the big decisions and do a lot of teaching. For my team, the specialist keeps on changing. The first two weeks it was Dr. Stefanski, the next two weeks it was Sarah, and now it’s Shanthi. They all do quite a bit of teaching, and are all very good (not all the specialists are good) but I think I liked Sarah the best because she knows how the hospital works and helps us out with the work after rounding. Shanthi will probably be like that too, but she’s relatively new, and is still learning the system.

Below is a picture of my most recent team – it’s Boipelo, Sarah, and I.

Decompressing

It was a busy day today and we barely had time for lunch because we had 10-11 admissions overnight that were done for us by the MO on call. There were 3 of us working though, so we made it through but were running around all day.

We needed to decompress, so a few of us (Sarah, Amy, Joanne, Jeremy and I) went to the Bull N Bush for dinner, which is a nice chain. It’s a pretty busy bar and club too on Friday nights, but I never went when it was really active. I had a great burger with mushroom sauce here, and we took these funny pictures with a cross-dressing cow statue. In general, I think I’m starting to get tired and worn down a bit – when we got home, Jeremy and I started Skyping each other even though we were in the same room and I thought it was the most hilarious thing ever. And we only had one beer at dinner! :)

Food at Princess Marina Hospital

My team was on call tonight and it was relatively busy – we got 4 patients, but all of them were handled well. There were some interesting cases, but instead of talking about medical stuff I think I’ll talk about food at the hospital a little bit.

The cafeteria is run by the restaurant Moghul, which is right down the street from our flats. The restaurant serves decent Indian food (so I’m told) but the cafeteria makes very affordable and excellent local (Botswana) food. It’s just one counter long, so there’s not much selection, but it’s always very good, and a full meal is about P14, which is only a little more than $2!

At the cafeteria, you choose from a selection of starches, such as rice, pap (maize meal), sometimes samp, sometimes dumplings (which I think are just these huge balls of steamed or boiled bread), and a one other thing I’m not familiar with – and they cover this with a little bit of sauce. Then you can either get chicken or red meat, and you get a hot vegetable. A common red meat dish is seschwa, which is sort of like pulled pork, but with beef and without the sauce. It looks pretty nondescript and boring, but it’s really really good. The often also have beef stew or oxtail stew. Being a red meat fan, I rarely get the chicken, but it’s often stewed, grilled or fried chicken with sauce. The hot vegetable can be cabbage, spinach (which is not exactly like our spinach), creamed spinach, carrots, and a few other possibilities, depending on the day. But there is just one vegetable made per day.

Further on down the counter, you then get 2 or sometimes 3 different salads – they make regular lettuce salad, sometimes there’s a potato salad, sometimes bean salad (which is basically cold baked beans), and sometimes there’s carrot or beet salad. All in all, it’s a huge amount of food, and I usually eat it all! As a result, my lunches have become the main meal of the day, and sometimes I barely eat any dinner at all because I’m so stuffed from lunch. The only thing is, you have to make sure you get there before 1:30 because the cafeteria starts to run out of food.

More recently, I’ve been going outside of the hospital to eat lunch. Right outside the hospital entrance there are many options for food. Some people have small tables set up where they have food in several pots and the food is very similar to what’s in the cafeteria, but cheaper and with much less selection. For example, for P10 you can get pap, seschwa, and spinach, but those are your only choices, and you get a little less food than you would at the cafeteria (which I actually welcome). There are also people in small huts selling food – there they have some pots too, and you can get a small little bowl of food (like chicken or beef stew or something) for like P4. They also have this pita-like thick bread called papata for P1 which is great to eat with the stew. Some of the huts also sell fresh-fried chips! They are so good. They come fresh out of the deep fryer into your little blue plastic bag, which you then take to the table to sprinkle on salt, vinegar, and hot pepper. It’s soooo good and it’s only P4! Lastly, my favorite is the sausage guy. He grills huge homemade sausages right there outside the hospital, puts them in a bun, and adds whatever toppings you want (mustard and tomato sauce – what they call ketchup here). It’s the most amazing sausage ever, and only for P6.

Another alternative is to walk the 10 minutes to the Main Mall, which is an outdoor mall. There are two pie places there (that sell meat and vegetarian pies) that are pretty good, a bunch of fast food, and again people selling food on the street. There are several sausage guys here, and they have small tables with women selling food in pots as well as grilling up big pieces of steak. They also have a few large groups of people who have set up long rows of tables with food in pots – the equivalent of the pot ladies, but super-supersized. They have even more choices than the cafeteria, and it’s only P12! And you can stuff as much as you can into your takeaway container – I’ve seen people pile it on incredibly high, with 3 or 4 different meats and tons of veggies. Also a 5 minute walk away is the museum - which serves similar food to the cafeteria at basically the same price, but there is a nice environment to eat it in. You eat at outdoor round tables, shaded by these grass roofs, and we often have our bi-weekly feedback sessions there.

Ironically, today, I was actually a little tired of stuffing myself every day and actually brought lunch – a salami and cheese sandwich. I think I just felt like eating something American for once, but it all worked out because when I got home, Lisa had made lasagna (sort of) and salad. So I ate a big dinner. :)

Children of Men

Tonight Amy and I watched the movie Children of Men, an excellent movie. It’s a British film, set in the future, where for unknown reasons, people have become sterile, and no more babies are being born. The last person was born 20-something years ago, he’s basically a celebrity because of that, and the movie starts out with him dying. The whole world has become chaotic, with London being the last refuge of order, so all these people are trying to illegally sneak in. The main plot involves this woman who is surprisingly 8 or 9 months pregnant, and they are trying to smuggle her into London. The human race is facing its own extinction and she may be their last hope for survival since nobody else can produce babies. It’s an interesting concept, and I think they filmed the movie in a very interesting way.

Arranging travel plans at Game City

I had been stressing about how I was going to get from Gaborone to Livingstone to meet Pete, then from Maun back to Livingstone after our safari, then from Livingstone to Windhoek to meet Bruce, and then from Windhoek back to Gabs. I decided that I could take this overnight bus from Gabs to Livingstone, and Pete and I could either rent a car or take public transportation for getting from Maun to Livingstone. Both trips seemed pretty secure, and I had reliable sources tell me that they were possible.

However, taking public transportation from Livingstone to Windhoek, and then from Windhoek to Gaborone was not only unpredictable and uncertain, but it would also take a ridiculous amount of time! Between the two trips, I think I would have been en route for a total of 45 hours! And there was the possibility of missing transfers (I think the Livingstone to Windhoek trip alone would have required something like 5 or 6 transfers to different combis and buses), or there not being buses at all, leaving me stuck in some pretty small towns. So I bit the bullet and bought a $1000 plane ticket taking me from Livingstone to Windhoek and then eventually from Windhoek back to Gabs. Both flights go through Jo’burg since it’s a South African Airlines flight. It’s super expensive, but I think if I was traveling for 45 hours later, I would be cursing myself for not buying the ticket. So this afternoon we finished way early and I went to Game City (another American-style mall) to the SAA office and got my plane ticket. I’m so relieved!

Game City is pretty interesting – it’s the only completely indoor mall in Gabs, and it’s very westernized. There are tons of clothing stores, a movie theater, some restaurants and a food court, and other little shops selling random things. After school, teenagers were everywhere, dressed as nice as possible. J I had lunch at the Mug N Bean (a big yummy chicken burger with avocado, cheese, etc) and wandered around a bit.

Food and Jazz

It was a day to eat! We went to this place called Sanitas for brunch, which does pretty well in providing good American-style brunches. It’s actually a tea garden and horticultural center, where you can buy lots of different plants and gardening supplies. In the winter, Botswana is very dry and brown, so the lushness and greenness of this place is a welcome change, although it probably requires ridiculous amounts of water to keep it that way. At any rate, after eating, it was fun to stroll around and look at all the different things in this large outdoor store. And we also got gelato from their counter, even though we stuffed ourselves during brunch. :)

During the day I tossed a Frisbee around with Amy and Phil. Amy actually was quite good – she said she used to throw a Frisbee in summer camp. It was pretty fun until one of us threw it into the bushes near our apartments. All the bushes have these super sharp thorns, and two of them actually pierced the Frisbee! We used pliers and still couldn’t get them out! Eventually we were able to cut off the ends and file them down so there was no longer any protrusion from the Frisbee, but the little bits of wood were still embedded in the Frisbee. Crazy.

Then for dinner, a few of us went out for Ethiopian food. It was this place located at the Riverwalk mall that Dr. Gluckman recommended to us. They had a buffet which consisted of chicken with egg, beef, lentils, some other vegetable, and of course, plenty of that spongy bread, injera. Unfortunately I wasn’t very impressed – I think I like the Ethiopian food in West Philly better! It wasn’t as spicy as I’m used to it being, and the bread wasn’t sour like it normally is! I think the Ethiopian food in West Philly is actually more authentic, since there are a ton of Ethiopians in that area. I’m willing to bet that the Ethiopian food here has been tamed down a bit for the Motswana.

After dinner, a few of us (Lisa, Amy, Joanne and I) went and joined Kristy, Kiona and Phil at Botswana Craft for a jazz concert. The band playing was called Punah, and I guess they are known to quite a lot of people, but are not really super famous. It was a ton of fun – after a while, we joined in the dancing with the locals who whole-heartedly welcomed us. There was dancing in groups (like in the states), dancing in a circle (I think there were specific steps to this, but we certainly didn’t know them), and dancing in sync with specific movements, like the Macarena (which I could sorta do after watching and miming the other dancers for a while). Most of the dancers ranged from 20-40 years old, with the young men being pretty entertaining to watch. However, there were these two old men (probably in their 60s) dancing and they were hilarious! Their moves were very… original. One of them had very jerky and deliberate movements, like those men in the parks painted in silver who pretend to be statues and move robotically when you put money in their can. Joanne took some video, and I’ve got to get a copy of it. :)

The band Punah was also very good – I definitely enjoyed their music. Kristy bought their new CD and unfortunately it came damaged, but I burned what I could onto my computer. Funnily enough, several days later I was walking through the Main Mall, where there are tons of street vendors out at lunchtime, including ones that cell CDs and DVDs. I heard music being pumped out from one tent, and I said, “that’s Punah!” and the vendor was surprised and said, “Yeah, that’s Punah!” And he asked if I wanted to buy it but I said I already had it. Even though it wasn’t a huge crowd that night at the jazz concert, I guess their music is relatively well-known.

Water in Gabs

We went to the yacht club today after work, and enjoyed a gorgeous sunset. I went with Amy, Michael, and Michael's fiancee (whose name escapes me at the moment). It's set over the Gaborone dam, and people can take boats out on the small lake. The yacht club itself is pretty nice - the clientele is almost entirely made up of ex-pats. They serve plenty of alcohol, and some food that they mostly warm in a microwave or grill. Apparently it gets quite crowded on friday and saturday nights usually, but tonight was unusually calm.

This dam provides most of the water for Gaborone and the surrounding area. Right now, the lake is super super low, which you can see by the water line. Last year, Gaborone (and the rest of southern Botswana) experienced a severe drought - they had a ridiculously low amount of rain. I think it was 2.5 cm or something like that for the entire summer. And the couple of years before that was not great either. I think the last time they had great rain was 4-5 years ago. And before that good year, there was a drought for a period of years as well. So it's been relatively dry for southern Botswana for the last decade or so.

As a result, a lot of people have stopped farming and are trying to eke out a living doing other things, usually in urban centers. Cattle look really skinny because there's nothing to eat, and livestock of all sorts are not doing well. It rained for about 5 minutes during our braai last weekend, and everyone was jumping for joy. Rain and water is so important that the word for rain, "pula," is also the word they use for money. That's also what you say when you raise your glass in a toast, like "Cheers!"

Hopefully this year Botswana will get lots of pula!

The supply chain in Botswana

This was a relatively boring day at the hospital since this is our easy week, so maybe now I’ll talk about some another issue at the hospital – the supply chain! This is a favorite topic of Dr. Stefanski's, so we've had quite a few discussions about it.

So here at Princess Marina Hospital, probably the largest public hospital in Botswana, there are often problems with the availability of medicine, or of certain medical instruments, even very common ones. Last week, we ran out of amphotericin, which is a drug we use to treat cryptococcal meningitis - that's an infection in the cerebrospinal fluid that surrounds your brain and spinal cord. It's the type of thing that we diagnose with an LP, which I described in previous posts. Because a lot of people have HIV and AIDS here, a lot more here come down with meningitis than in the states - some of it is due to TB, some bacterial, some bacterial, but more often than not, it's due to cryptococcus. And amphotericin is really the only option they have in Botswana to treat it. Alternatively, you can use a whopping dose of fluconazole, but it doesn't work as well, and we also ran out of that for a few days last weekend. As a result, all these people in the hospital (and in the clinics probably) had no amphotericin, and also no fluconazole - their cryptococcal meningitis went untreated! Now, even if they had come in immediately and started treatment right away, this is an awful disease, and chances are not great that they'll survive. But if treatment is delayed or halted for a couple of days, chances are even worse! Our team didn't have anybody die, but I know other teams that did.

Dr. Stefanski told us this story about how last year, they ran out of the solution needed for peritoneal dialysis, which is a substitute for your kidneys, if your kidneys have failed. Dialysis isn't as common here as in the states, but there are still quite a lot of people on it. And they were out of it for a month! People were basically getting admitted to the hospital to die of kidney failure. Awful.

Apparently, the problem is not lack of money - the ministry of health has plenty of money. It is the largest ministry in Botswana, and controls the largest budget by far. The problem is that somebody or some group, whoever is in charge of ordering medical supplies for the country, did not realize that we were running low on drug X, or medical supply Y, and didn't order it. So the entire country will be out of whatever it is for a month at a time! Supposedly, they've had 3 big consulting companies (probably each making millions of dollars each time) come in and make suggestions as to how to correct the problem, but obviously that hasn't happened. It seems that every time there is a change in who's in charge, they get a new consulting company in (probably they're friend or relative's company) and get new recommendations, which aren't followed. It's such a ridiculous problem, and a very exasperating one that all the doctors complain about. I guess it's another thing to be thankful for in the States.

Tele-dermatology at PMH!

This was the first day for a new dermatology resident – Jeremy. He’s from Stanford, and is going to work with a derm attending from HUP (Carrie), who is supposed to arrive over the weekend. It’s pretty interesting – they are actually going to set up a tele-derm system. She did her training at Baylor, and so has already set up a few other African hospitals that have Baylor pediatrics up with this tele-derm system. Basically, you take pictures, email them and a clinical history to a pediatrician in the states (usually her) and after a few days, you get a probable diagnosis. I’m sure some of you are wondering why dermatology is at all needed in Africa… There’s actually quite a few dermatology cases related to the diseases you see here, like HIV, TB, Cryptococcus, all sorts of parasites, etc. Often a patient hasn’t been diagnosed with something yet, but the dermatology (along with a biopsy of a dermatological lesion) can provide the diagnosis less invasively than a biopsy somewhere else. So hopefully this will work out. Other than this tele-derm system, Carrie is hoping to be here about 6-8 weeks a year, and trying to get a senior dermatology resident out at Princess Marina 6 months out of the year.

Nothing else really happened today – got off work at around 5:30 and went to Riverwalk with Amy, one of the new Penn residents that arrived last weekend. The other one is named Joanne (Mazzarelli). We bought Amy a phone, and went to Pick N Pay where we spent P510!!! But we were cooking dinner for everyone that night, including the on call people. I directed everyone – I was the head chef. :) We made enchiladas, which were ok – I don’t have quite the right ingredients here. But I think everyone was satisfied. I made both chicken and eggplant enchiladas because we have so many vegetarians here.

The Patient from Zim

I was on call again this week and my team admitted 7 patients. It wasn’t too bad because it was dispersed throughout the day. Except this morning during rounds we mixed up two of the patients and we wrote a note after having examined the wrong patient. But actually, they had similar presentations, and a similar clinical picture and everything still applied, so it was okay. I felt really embarrassed because they were my patients, but I wasn’t that familiar with them since I hadn’t been around the week before when they were admitted. I felt a little better after we saw another team rounding, and they were talking to a patient and wrote a note on him, and then later, we found out that it was our patient they were talking to! So they did the same thing! It was pretty funny. :)

The most incredulous thing that happened today concerned a patient who I admitted last week. He spoke English very well, and was very nice, and it turned out, very religious. HIV tests are the norm here, and although we’re supposed to (I think) ask for consent, almost every patient, if we don’t know their HIV status, gets tested whether they want to or not. I actually went to the trouble of asking this patient, and he refused! Boipelo wanted to go ahead and test him anyways, especially since it had already been sent from the A&E without his knowledge. But anyways, the patient refused, so I had to call the lab and track down the blood and cancel the order. I tried for a long time to talk him into it, telling how important it was, and how it would help us diagnose and treat him. He said he wanted to get tested, but that he was very religious (praise the lord and all that) and wanted to get tested together with his wife. He promised that as soon as he was out of the hospital, they would go together to get tested. I actually sorta believed him, he seemed so credible.

This patient had come in with several months of weight loss, night sweats, productive cough, and progressive shortness of breath. He was a very fit guy – said he worked out for 2 hours every day – but obviously became short of breath even when walking. On his chest xray, he had a classic round “water-bottle” heart suggestive of a pericardial effusion (that’s fluid around your heart), which was confirmed by echo – that’s basically an ultrasound of the heart. It was only a moderate effusion though and wasn’t squeezing his heart significantly, and was probably too small to be drained, so we left it along. The upshot of this whole picture is that this patient very likely has TB, and although it’s not definite, if he has TB, he likely has HIV. We found a big lymph node in his neck which I biopsied, and stained for AFB, and it was swimming in it. He eventually consented for an HIV test, and we started treating him for TB over the weekend.

Anyways, to get to the interesting part of the story, when we saw the patient this morning, he was visibly upset, and had bruises all over his body, and had several teeth knocked out!!! We pieced the story together from several different sources. Apparently after we all left on Friday night, the patient started praying very loudly and disturbing other patients. He’s also Zimbabwean (there are a lot of Zim immigrants everywhere right now, but that’s a different discussion), although he has a Motswana (a person from Botswana) wife, and I guess started praying in a manner that let people know he was foreign. As the story goes, he was confused and acting strangely and wouldn’t be quiet, and he got up, and touched a prison guard on the shoulder, or perhaps slapped his shoulder or his face – it depends who you talk to. A single nurse claims to have seen the slap, the patient says he touched the guard on the shoulder, and the guard of course claims to have been hit. There were four guards camped out there in the male medical ward at the time – watching over 2 or 3 of the prisoners we had as patients. They had nothing to do with my patient, but after my patient touched/hit one of them, they ganged up on him, dragged him into the procedure room and held him down and beat him up!!! Absolutely awful!!! Even if he did hit a guard he was reportedly “confused” and should only have been restrained at the most. It was ridiculous what happened. Unfortunately, I think a lot of this happened because he was a foreigner.

The patient’s wife was incredibly upset, and rightly so. She took the matter to the police, and there’s going to be an investigation, supposedly. Although since the matter concerns prison guards, nobody believes that anything is going to happen. Boipelo had to fill out paperwork and give a statement about what might have happened, and the superintendent of the hospital had to get involved! It was pretty crazy. The poor patient – he had to go to the dental clinic the next day to get his teeth pulled.

And about a week later, a story appeared on the front page of one of Botwana’s papers – I have it at home, called “The View.” It had a head shot of my patient with his missing teeth and a somewhat exaggerated story about what happened to him at the hospital! Crazy. I’ll upload the article when I get home, but it’s pretty ridiculous.

Mokolodi Game Reserve

Today we went to Mokolodi game reserve, which is just 20-30 minutes away, still really a part of Gaborone. It’s not nearly as wild as Tau, but it was still pretty fun. It’s probably about 1.5 times the size of center city in Philadelphia, and it’s a little more zoo-like than Tau. The animals are still wild, but they are tamer, and there aren’t as many predators. They don’t have any lions, and they only have 4 elephants. On our game drive, we of course saw tons of game, but our guide was not nearly as good as Hein from a week ago. She tended to blaze past the animals and recite memorized bits of trivia about the animals. I didn’t get the sense that she knew a whole lot about the animals other then the stuff the game reserve probably gave them to memorize. Nevertheless, it was pretty cool.

We saw tons of kudu and other deer-like animals, likely springbok and steembok. We also saw this baby rhino with its mother, which I took a million pictures of. I think Aaron and Jacob (Pete’s nephews) will love this picture – I can’t wait to email it to them! We also came upon this giraffe just by the side of the trail munching on a tree. This was very cool, since I’d never seen a giraffe so up close before. We also got to see their 4 elephants – they had one male and 3 females. The male one was definitely bigger than the rest, but was chained, and they had a staff of about 3 people watching over the elephants, I guess to make sure everything stayed okay as people came by in the safari vehicles to gawk at them. It was a little sad, actually. Although it was super impressive – they came within an arms reach away, and they (rather angrily, I thought) started ripping to shreds this massive tree right next to us. They were reaching above our heads to the branches and pulling them down! It was amazing! And we got close-up views of their tusks and their mouths, and just how strong their tusks and legs can be. Pretty scary, actually.

Finally, one of the highlights of the trip was that I got to pet a cheetah! There were two male cheetahs that were in this large fenced enclosure. Apparently their mother died when they were very young, and the only way they were able to survive was being bottle fed by humans. So they got used to humans at a young age – although they’re still somewhat wild. So now, they feed them every day at 2pm, and around 3 or 4pm, they’ll bring a small group of tourists in to their fenced enclosure to pet them! I wasn’t going to do it at first. It was an extra P100 to pet the cheetah, and I was just going to watch other people do it. But in the end I figured, eh, it’s an extra $16 and I don’t want to walk away from this regretting not going to pet the cheetah, even if it is super touristy. :) However, I think Phil put it in a pretty funny way: “why would I pay an extra $16 to go get my hand bitten off?” I thought that was hilarious, but maybe you had to be there.

So it wasn’t quite as I expected. For some reason I had in my head the idea that we would be petting the cheetah through a fence, or that there would be a trainer there holding them or calming them or something while we petted the cheetah. Not so. Our guide unlocked a gate to let us into the first fenced enclosure (sort of like a foyer), and then unlocked another gate to let us into the second fenced enclosure, which was large, and was where the cheetahs were. The cheetahs were prowling around, and eventually lay down in the shade of some bush. We went over to them, and the guide said to go up one by one, and avoid petting the paws and the tail. She went up first and petted the cheetah, and then we all did it. One cheetah was feeling feisty I guess and didn’t want to be petted, so we petted the other one.

There were these two Indian guys on our safari who I swear deserved to be eaten. They were so intent on taking pictures and everything that they seemed to forget that this was a CHEETAH. They were kinda like that the entire trip – almost jumping out of the jeep to take pictures, and being totally touristy. I mean, I know I’m also a tourist, but they were a little obnoxious. Anyways, during the cheetah petting, we were mostly petting one cheetah because the other one was a little grumpy. The two Indian guys kept on almost stepping on that cheetah’s tail because they were too busy taking pictures of them petting the other one. And the one that we were petting, they petted it too hard or something, because it took a swipe at one of the Indian guys. I’m sure it was just a little annoyed and doing the equivalent of batting a fly away (if he had really wanted to hurt the guy or attack him, I’m sure the cheetah would have), but the Indian guy didn’t seem to realize it! He dodged backwards, but then went back for more petting! Then the cheetah reared its head, and looked at the guy, who finally seemed to get the picture.

Anyways, it was a fun trip overall. We hung out in the Mokolodi restaurant for a while afterwards, drinking some beer. It’s supposed to be one of the best, or maybe the best, restaurant in Gabs. I think they changed chefs recently though, so I’m not sure how it’s supposed to be now. I know that some of the Caucasian doctors go there for special dinners. They also apparently have more exotic things on the menu, such as kudu, and their steaks are supposed to be amazing. I wanted to eat there for dinner, but I think some of the other people either didn’t want to eat out or wanted to go home. It’s expensive by Gabs standards, but definitely not by American standards – it’s probably about P80-120 for an entrée (which is about $15-$20), and drinks are relatively inexpensive. But that’s okay. I’ll try kudu eventually.

Speaking of kudu, while we were sitting out there on the restaurant terrace, they had set out some grass for animals to come and eat, and we saw a few warthogs and a lot of kudu. This family of kudu seemed to come up – one male and several females. Then we saw another male kudu a hundred feet behind, who seemed a little hesistant to come forward, probably because of the first male already there feeding. Eventually he came up, and we thought they were going to fight! They lowered their heads and met horns softly several times, but didn’t end up fighting or anything. I think it was a way of greeting each other or making sure everything is okay. It was pretty impressive and I got a few good shots of them greeting each other with their horns.

The hospital crowd

So more about the patients and the hospital… Working at the hospital has definitely been an interesting experience! The patients here are so different from the patients in the U.S. There are usually 8-10 patients in a cubicle, with about 5 cubicles in each ward. Often, a small office gets turned into a 6th or 7th cubicle to cram another 5 patients into. Sometimes patients don't even have a bed, they have a mattress on the floor, sometimes in the hallway, if it's too crowded. The ER never closes because the hospital is too full, you just squeeze more patients in. There is absolutely no privacy - you're lucky if you get a curtain to draw around a single patient. You do procedures at their bedside, often with other patients looking on. The picture below is one of the better cubicles (the "high-intensity" cubicle for sick patients - which is right in front of the nurses station should a patient need immediate attention) on a very uncrowded day. There are no patients on the floors and there are a good number of curtains up.

So the patients are crowded together, usually not more than a foot from each other, they have no TV, no books, nothing, and visiting hours are only from 6-7:30am, 1-2pm, and 4-5pm and 6-7:30pm every day. And surprisingly, the hospital and the nurses are very strict about the hours. So right at 1pm, all these friends and family stream in, and right at 2pm, they leave. They're actually sort of necessary because the hospital is so understaffed that often the family helps bathe the patients or feed them if the patients can't feed themselves. The patients come in pretty sick too, because they often don't want to go to the hospital until their symptoms are super bad. Despite all this stuff, the patients rarely, if ever, complain. They just sit there everyday and wait patiently for us to come see them, and to get better. It's such a change from the U.S. patients, who have such a sense of entitlement, and demand every little thing, even things like mashed potatoes for dinner or something.

Patients rarely sue anybody here, and they put up with a lot more crap than do patients in the U.S. I guess that’s necessary because I think mismanagement of a case is pretty common. I think there are a variety of reasons for it – number one being the fact that the hospital is way understaffed. There are not enough doctors, nurses, social workers, physiotherapists, anything you could possibly think of. I also believe (and this is almost definitely egocentric) that the doctors and nurses here are not as well-trained, and so there is some medical mismanagement because of that. The Penn people are very good, but the other doctors sometimes are just here to do their job and make money (not that it’s a huge amount) – they don’t put in the effort to learn, teach, or really help patients get better. I’ve seen so many patients come in with congestive heart failure get put in fluids, or people with focal brain tumors that are obvious on physical exam, get diagnosed with meningitis. It’s a little embarrassing sometimes. Of course, when you get 10 admissions in a night, and are covering 100 other patients, sometimes it’s difficult to do an appropriate workup of a patient. But still, the lack of knowledge can be appalling.

There’s this one M.O. (a doctor who has only finished internship only) the other day who was getting grilled about a patient during intake as she was presenting. The patient had right upper quadrant abdominal pain, and she gave her differential diagnosis as pneumonia. Horrible. When the chief of the hospital asked her what else it could possible be, she could only answer pneumonia… so then he asked her what organs might possibly be in the right upper quadrant. She said spleen. And that’s all she could come with. And this is a doctor! Awful.

The nurses here are also very different. They don't do much here - they don't do IV's, blood draws, put in foley catheters, etc., so you have to do it all yourself. Believe it or not, I actually miss the nurses at HUP. :) I guess some things are still the same – some nurses and good, some are nice, some are moody, some refuse to do anything. There’s a whole variety.

The diseases we see here are different too - we see a ton of HIV and advanced AIDS-related illnesses here: TB (which can be anywhere), cryptococcus (which can be anywhere), PCP pneumonia, different cancers. I'd say about 75% of my patients are HIV positive, which allows a lot of this other stuff (TB, PCP, cancers) to happen. Botswana actually has a free HIV medication program (which is a whole separate topic for a different day) for all of its citizens. Even so, many of the patients refuse to take their medications and instead take traditional medications. They’ve caught patients throwing their medications down the toilet or in the trash before. And sometimes these traditional medications – we have no idea what they are – cause kidney failure or liver failure! I guess that’s the most frustrating thing about these patients, even though they are super nice and appreciative, and their families are by and large amazing in terms of support.

In general, there are so many patients you just can't take care of all of them - some stuff just has to slip through the cracks and you have to let it go. You're already working twice as hard as many of the Botswana doctors and at some point you have to go home, but that means some patient is probably going to die. Luckily I didn't have anyone die on me for my first two weeks, but it's really just luck - almost every team has an average of one patient die every day or two. I will probably have a patient die on me this weekend because there’s less care during the weekend. There’s usually two people covering all 100 patients, and they are really only required to see the sickest ones. It’s also difficult if they admit 10-30 patients over the weekend to see the other sick patients already on the ward – they are just so busy! However, other people just don't take as good care of your patients than you do when you're actually at the hospital. And any signout you give to the covering doctor doesn't usually get done, but it depends a little on who you sign out to and who’s covering the weekend. I guess these things are just things you have to let go because you can’t be at the hospital all the time.