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.

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.

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. :)

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.

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. :)

ICU incident #2

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

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

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

Walking home

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

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

Yummy Pies!!

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

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

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

Past ICU stories

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

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

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