The rest of Africa in one blog entry

So I never had time to blog about the safari Pete and I went on in Botswana (including Victoria Falls) and also my travels in Namibia with Bruce and his friend Mike, but here are some links to pics on kodakgallery.com:

3 albums (Joanne alone, Joanne and Pete on Safari, Namibia with Bruce and Michael)

As expected, it was an amazing experience. Our group consisted of Gunther, this 70ish year old German guy, Linda and Roger, Marcus and Lilian, and our guide Richard. The safari started out with a lot of safari drives in a huge 4x4 truck that held all of us - Richard, who's been doing this for 20+ years and is one of the best, was an amazing driver. Although there was a slight mixup and we were forgotten for the first half of the first day (and we missed Victoria Falls), we eventually caught up with the rest of the group and got taken to this awesome lodge. The next morning we set off! I'm not going to describe it in detail, but it was the same stuff I think everybody does on these safaris... game drives, river cruises, game walks, and mokoro canoe trips (people pole you around on traditional mokoro canoes). Highlights included an awesome game walk by a real San-person, almost getting chased by a huge bull elephant, coming scarily close to a hippo pod in the mokoro canoes, seeing two leopard sisters playing together, all the sunsets over the desert, the Okavango Delta, and everything else. With my brother in Namibia, we had an awesome game dinner, went on the most awesome hike I've ever been on in the Namib-Nauklauf park, climbed up the red sand dunes of Sossusvlei for a sunrise, and quadbiking and sandboarding near Swakopmund in the deserts of Namibia.

Amazing and unforgettable.

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.

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!

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.

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. :)