I'm sitting at Sanitas, a quaint and pretty garden in Gabarone where we just finished a tasty brunch. We're all enjoying the free hour of internet. And while I digest I'm enjoying my last full day in Botswana. I realized with the shaky internet situation I wasn't able to write about our trip to Madikwe...
Last weekend a group of us took a luxurious trip to Tau Lodge in Madikwe. It's a South African game reserve just across the border from Botswana, only about 40 minutes from where we stay in Gabarone. We arrived to glasses of fresh lemonade and a very nice staff. The lodge was extremely well-decorated with trendy modern art and pictures of game. We almost felt guilty for being there (seeing as the majority of us were still in med school and had not seen a paycheck in many years) - they had a fully stocked bar, a pool, multiple places to eat where they had buffet style meals, a spa, and incredible bed rooms with outdoor showers and balconies up against a watering hole where we saw zebra, wildebeast, elephants, impala and other animals playing by and drinking from the water.
We had two game drives - after arriving Saturday afternoon and early Sunday morning, where we saw amazing exotic birds, including the lilacbreasted roller, the national birds that boasts brilliant bright colors. We also saw a pride of lions - my personal favorite - and watched three sisters and two brothers napping with the mother bathing herself not too far away. They are such powerful creatures. We also saw a herd of ~ 100 buffalo, families of elephants with some sleeping and some snapping trees, rhino, giraffe, kudu, steenbok, the list goes on. I love game drives, there's so much time to just sit and think, covered in fluffy blankets and warmed by tea and coffee and wine, while taking in the nature all around. We also had a solid group. Anant and I shared a room which was actually slightly bigger than the others. The beds were pre-warmed to ensure comfort, and I actually had to turn the heat down a bit. I had a neck and back massage for amazing value. And we ate like kings and queens. The buffet lunch and dinner on Saturday, and breakfast on Sunday can only be described as criminal in terms of the amount of food I ate. And it was all tasty and delicious and quite healthy. Our final lunch was ostrich carpaccio and impala steak - pretty good actually. In the evening, we all hung out, played a game of pool while drinking Pinotage, sat by the fire and played two truths and a lie. The stars were incredible overhead. It was one of those trips that reminds you how lucky you are to be alive.
Fast forward to my last day at BLH this past Friday...it was actually tough to say good bye to the medical officer staff at the hospital. They are wonderful people and they were such a pleasure to get to know. I made some carrot cake for them on the last day which they really enjoyed. And then we said our goodbyes before rounds. The patients on the male medical ward have actually been fascinating this past week, many I will leave unresolved for the next medical student, but I felt good about us moving towards a diagnosis. One patient in particular that I've been thinking about all weekend - he's not a local Batswana so he's paying for each day that he's in the hospital. He has impressive swelling on one side of his body, lymphadenopathy, unexplained kidney failure, as well as a DVT. He also has other lab abnormalities. And none of this fit into an easy diagnosis. We're treating him empirically for some things, and I'm just hoping it's not a malignancy. He asked me if I could fly back soon to finish treating him. I certainly wish I could.
All in all, it's certainly been a challenge thinking about the meaning of giving good care in a place like Botswana. The range of patients I have seen has been extremely varied, and the ability to get imaging or send off certain tests seemingly depends on the day, but one constant thing that remained was the rapport one could build with the patients, as well as their endless gratitude. There's such an emphasis on doing the best you can with what you have, which I think really challenged me to rely less on the fancy tests and more on my confidence in my own training and collaboration with the families and other doctors to bring about good outcomes for the patients. I can easily see myself returning one day - it was an easy place to be despite how difficult it was to see patients suffer and the many frustrations of the system. And that's saying a lot in favor of the spirit of the amazing people who I met.
Sunday, August 11, 2013
Thursday, August 8, 2013
One More Day
My time in Botswana is slowly coming to an end. It's my last day on
the wards tomorrow and I'm already feeling nostalgic. As I spoke with a
patient's brother on the phone today, and he explained to me how much
his brother meant to him and wanted my opinion on his future management,
I realized how much I have loved the ability to meet patients and their
families during my time here, and the fascinating medicine that I have
been privy to.
BLH has definitely been a rollercoaster. Two weeks ago, I arrived to the wards to the screams of a young 13 year old girl, blind for the majority of her life, seemingly hysterical from some recent trauma. The BLH physicians came by to help us put our heads together to figure out what could be the cause of her cries. I watched as her arms flailed about. She kicked indiscriminately into the air, at one point flinging herself out of bed. I carried her back on to the bed as she fought to be free of my arms. She apparently had been that way from the previous evening. Her eyes were yellowed, her liver slightly enlarged. Her course was complicated, as she went from hysteria to somnolence. She passed away shortthereafter. And she's been on my mind ever since...
As I've continued to be intimately involved in patient care at BLH, so many patient encounters involve the question of how far we push to save someone. Thinking about someone who is end-stage AIDS for example, how many resources do we spend on one person, especially in a resource-poor setting? What are the ethics to our approach? And then there are the cases where people pass away before a lab result comes back or before a lumbar puncture can be done. It seems that no guiding principles exist, only one's personal conviction and value system when it comes to life and death and the role of medicine in mediating between the two, if that is indeed possible.
I'm convinced that Botswana is filled with possibility. I'm told the lab techs are seeing less HIV positive results, that people living with HIV are stable on ARVs, that more and more children are being born free of HIV to HIV+ mothers. I'm told the government is intent on ridding the country of tuberculosis. The indicators point to continued to improvement, but it's difficult to reconcile this with my daily experiences on the wards, seeing people gasping for their last breaths, others so wasted they don't have the energy to hold up their own body weight. Then there are those patients who are stable clinically, but clearly have some underlying process going on that will eventually unmask itself. One of my patients has rather diffuse lymphadenopathy, pleural effusions, anasarca (diffuse swelling) on one side, renal failure, anemia, etc. etc. The list of problems goes on, and every day he tells me, "I don't know what is going on, or why this is happening to me."
Tomorrow will be a good day to reflect and to consider all I've seen over 4 weeks at BLH. I'm eager to search for some conclusions to share...
BLH has definitely been a rollercoaster. Two weeks ago, I arrived to the wards to the screams of a young 13 year old girl, blind for the majority of her life, seemingly hysterical from some recent trauma. The BLH physicians came by to help us put our heads together to figure out what could be the cause of her cries. I watched as her arms flailed about. She kicked indiscriminately into the air, at one point flinging herself out of bed. I carried her back on to the bed as she fought to be free of my arms. She apparently had been that way from the previous evening. Her eyes were yellowed, her liver slightly enlarged. Her course was complicated, as she went from hysteria to somnolence. She passed away shortthereafter. And she's been on my mind ever since...
As I've continued to be intimately involved in patient care at BLH, so many patient encounters involve the question of how far we push to save someone. Thinking about someone who is end-stage AIDS for example, how many resources do we spend on one person, especially in a resource-poor setting? What are the ethics to our approach? And then there are the cases where people pass away before a lab result comes back or before a lumbar puncture can be done. It seems that no guiding principles exist, only one's personal conviction and value system when it comes to life and death and the role of medicine in mediating between the two, if that is indeed possible.
I'm convinced that Botswana is filled with possibility. I'm told the lab techs are seeing less HIV positive results, that people living with HIV are stable on ARVs, that more and more children are being born free of HIV to HIV+ mothers. I'm told the government is intent on ridding the country of tuberculosis. The indicators point to continued to improvement, but it's difficult to reconcile this with my daily experiences on the wards, seeing people gasping for their last breaths, others so wasted they don't have the energy to hold up their own body weight. Then there are those patients who are stable clinically, but clearly have some underlying process going on that will eventually unmask itself. One of my patients has rather diffuse lymphadenopathy, pleural effusions, anasarca (diffuse swelling) on one side, renal failure, anemia, etc. etc. The list of problems goes on, and every day he tells me, "I don't know what is going on, or why this is happening to me."
Tomorrow will be a good day to reflect and to consider all I've seen over 4 weeks at BLH. I'm eager to search for some conclusions to share...
Monday, July 22, 2013
A New Beginning at BLH
Last Wednesday I started a new rotation at Bamelete Lutheran Hospital (BLH) in Ramotswa, a town about 45 minutes outside of Gabarone. It is different from Princess Marina in countless ways. First, there aren't nearly as many doctors. There are three surgeons (one an Ob/Gyn specialist) and five or so generalists who take round in the female and male medical wards, the pediatric ward, the TB ward, the maternity ward and the outpatient clinics. It's pretty impressive how such a small group can really cover so many patients. But it makes sense understanding the shortage of physicians in the country. In one of our journal clubs we had an interesting discussion about "brain drain" and the loss of qualified health professionals due to immigration in sub-Saharan Africa and other low-middle income countries facing health crises. I would say BLH is a good example of this phenomenon. Not only are there a small number of doctors, each physician is from a different country. There are two German doctors, two Indian doctors, a Chinese doctor, Congolese, Zimbabwean and Nigerian. Morning report is colored by the many different accents, and certainly many different approaches to medicine. Yet it's interesting how medicine is a universal language in itself at the same time, allowing people to communicate pretty fluently about patient care issues.
My first day I rounded in the TB ward, which was fascinating. Botswana has made a commitment of ridding the country of TB by 2016, a goal some here find laughable, but certainly it's important to strive for lofty goals in this fight. The patients ranged from end-stage patients to those making a full recovery, almost all with the same symptoms of fever, night sweats, cough and weight loss. One healthy looking gentleman explained to me through the nurse translating that TB almost took his life, "I was dead" he told me. He was safely on treatment and excited about what lay ahead for him after discharge.
There seems to be a pretty rigorous system in place when new TB cases come in. Case workers go to patient's homes and exposed, at-risk individuals are started on TB prophylaxis treatment. And if patients deny or refuse treatment, they can be sent to a location where they must remain until they finish their regimen. The physician I worked with called it "TB prison" - an interesting concept.
We then went to the outpatient clinic called the IDCC where we saw patients who are currently on HAART for HIV. What I found fascinating about this experience was that it showed how HAART is really amazing and life-saving treatment. People came in being managed for other medical issues such as hypertension and erectile dysfunction, and many wanted to discuss family planning type issues. HIV was just part of their lives, but did not define them. It's a testament to how far a place like Botswana has come, when people who are HIV infected can worry about and focus on other life problems and live long enough to encounter other chronic diseases. The physician I was working with told me "this is how we know it's working, and it makes me happy to see it."
My next three weeks will be interesting because there are no longer teams at BLH, just a physician and myself. Should make for some good learning experiences.
My first day I rounded in the TB ward, which was fascinating. Botswana has made a commitment of ridding the country of TB by 2016, a goal some here find laughable, but certainly it's important to strive for lofty goals in this fight. The patients ranged from end-stage patients to those making a full recovery, almost all with the same symptoms of fever, night sweats, cough and weight loss. One healthy looking gentleman explained to me through the nurse translating that TB almost took his life, "I was dead" he told me. He was safely on treatment and excited about what lay ahead for him after discharge.
There seems to be a pretty rigorous system in place when new TB cases come in. Case workers go to patient's homes and exposed, at-risk individuals are started on TB prophylaxis treatment. And if patients deny or refuse treatment, they can be sent to a location where they must remain until they finish their regimen. The physician I worked with called it "TB prison" - an interesting concept.
We then went to the outpatient clinic called the IDCC where we saw patients who are currently on HAART for HIV. What I found fascinating about this experience was that it showed how HAART is really amazing and life-saving treatment. People came in being managed for other medical issues such as hypertension and erectile dysfunction, and many wanted to discuss family planning type issues. HIV was just part of their lives, but did not define them. It's a testament to how far a place like Botswana has come, when people who are HIV infected can worry about and focus on other life problems and live long enough to encounter other chronic diseases. The physician I was working with told me "this is how we know it's working, and it makes me happy to see it."
My next three weeks will be interesting because there are no longer teams at BLH, just a physician and myself. Should make for some good learning experiences.
Tuesday, July 16, 2013
Victoria Falls, Kasane and Chobe National Park
I just returned from a brilliant holiday weekend with Ali and Julie in the north of Botswana and Zimbabwe. We had the luck of two national holidays on both of Monday and Tuesday of this week, so we could plan to enjoy the weekend pretty liberally.
We left Friday evening on an overnight bus to Kasane from Gabarone, about a 12 hour trip which seemed to be on a straight-long highway with no street lights. I'm always a bit hesitant about long bus trips, not only because of the space issue with fitting in those small seats (I can't imagine how people taller than me survive!), but also because craziness seems to follow me on bus trips. This time was no different. We left at around 7pm and our bus was pulled over by the police about 45 minutes into the trip. Without explanation, we were all shuttled off the bus and stood around as policemen and women sifted through people's bags. Soon a tense conversation ensued between a police officer and one woman about something in her bag. People whispered that she may have had a firearm in her bag. After about 10 minutes we got back on the bus, and people said she was arrested. Ten more minutes later she entered the bus, with a small smirk on her face. I'm still unsure what happened there.
Anyway, we kept going on the bus, and there were about four people standing the entire bus ride. Unfortunately, one man decided to use my seat as an arm rest. So for the next couple of hours as I fell in and out of sleep, I would nudge his arm away with my bald head. He would move it and then when I fell asleep, sneak his arm back on my chair. As I engaged in a silent battle with this man for my chair, a creepy noise came from the radio, which I imagine could only be played to torture soldiers in war. It was literally like someone scratching a chalkboard with long fingernails. When that inappropriately long "song" ended, the people around us were talking incredibly loudly. I looked up and it was about 3am when the talking reached a ridiculous crescendo. There was a man and a woman between Julie and I talking in the aisle. The lady was continually bending over looking out the window for her stop, so when I would open my eyes her ear would literally be two inches from my face (presumably her butt was in Julie's face). This same woman leaned so heavily on Julie's shoulder that she was pretty much on the seat. Poor Julie and I tried to sleep through it, but eventually we had to say something - I don't think she understood anything I said, so I laughed a bit to myself and attempted to go back to sleep (lucky Ali slept through this entire ordeal). This whole time the man sitting to my left invaded my personal space over and over again, at one point literally nestling in my armpit. I was so overwhelmed by all this violation of personal space, there was nothing to do but laugh...
We arrived in Kasane and crossed the border to Victoria Falls, Zimbabwe, a sleepy yet quite touristy town with fancy hotels and hostels on every corner, all leading to the magnificent falls. Vic Falls is the largest waterfall in the world, a World Heritage Site, and when we got there we could see why. Rainbows seemed to be all around us as the mist from the falls moved in different directions. There was the constant low rumble of water hitting the rocks below, the chirp of exotic birds landing on trees. It was truly amazing. After that we had a great meal with local food at a restaurant named Mama Africa and returned to our hostel to find music blaring and people everywhere. We apparently stayed at a party hostel, and I'm so glad we did. This group from South Africa led by Jeremy Loops gave a small concert which was awesome - he played guitar, harmonica, and beat-boxed, backed up by a rapper and a saxophone player, building compelling rhythms for the audience.
Julie and I woke up early in the morning to go to an elephant park and ride elephants! It was breathtaking. We rode the matron of the group, an elephant named Coco who they said was a lesbian because she had no children and wouldn't let any male elephants mate with her. She was quite sassy, and even stopped for awhile to fart, despite her trainer's calls to move. It was fascinating though, the trainer had worked with her for over 16 years since she was young. When we got back from our walk, we got to feed the elephants, and I watched the three year old elephant cling to her mother as we fed them. I'm really obsessed with elephants now.
The three of us then went back to Kasane and stayed at a beautiful place in town. We took a wonderful boat cruise, where we saw elephants, hippos, crocodiles, baboons, impalas. It was just the three of us, with the awesome guide who was so knowledgeable. And then we all watched the sunset in awe, as the sky was a fiery red and the sun looked as if it was falling into the water. It was one of those moments where you realize only some divine power could create something so beautiful.
We landed back in Gabarone feeling grateful for seeing and experiencing so much in one weekend. I've now been to South Africa, Namibia, Botswana and Zimbabwe. Southern Africa is gorgeous - hopefully one day I'll get to Mozambique...
We left Friday evening on an overnight bus to Kasane from Gabarone, about a 12 hour trip which seemed to be on a straight-long highway with no street lights. I'm always a bit hesitant about long bus trips, not only because of the space issue with fitting in those small seats (I can't imagine how people taller than me survive!), but also because craziness seems to follow me on bus trips. This time was no different. We left at around 7pm and our bus was pulled over by the police about 45 minutes into the trip. Without explanation, we were all shuttled off the bus and stood around as policemen and women sifted through people's bags. Soon a tense conversation ensued between a police officer and one woman about something in her bag. People whispered that she may have had a firearm in her bag. After about 10 minutes we got back on the bus, and people said she was arrested. Ten more minutes later she entered the bus, with a small smirk on her face. I'm still unsure what happened there.
Anyway, we kept going on the bus, and there were about four people standing the entire bus ride. Unfortunately, one man decided to use my seat as an arm rest. So for the next couple of hours as I fell in and out of sleep, I would nudge his arm away with my bald head. He would move it and then when I fell asleep, sneak his arm back on my chair. As I engaged in a silent battle with this man for my chair, a creepy noise came from the radio, which I imagine could only be played to torture soldiers in war. It was literally like someone scratching a chalkboard with long fingernails. When that inappropriately long "song" ended, the people around us were talking incredibly loudly. I looked up and it was about 3am when the talking reached a ridiculous crescendo. There was a man and a woman between Julie and I talking in the aisle. The lady was continually bending over looking out the window for her stop, so when I would open my eyes her ear would literally be two inches from my face (presumably her butt was in Julie's face). This same woman leaned so heavily on Julie's shoulder that she was pretty much on the seat. Poor Julie and I tried to sleep through it, but eventually we had to say something - I don't think she understood anything I said, so I laughed a bit to myself and attempted to go back to sleep (lucky Ali slept through this entire ordeal). This whole time the man sitting to my left invaded my personal space over and over again, at one point literally nestling in my armpit. I was so overwhelmed by all this violation of personal space, there was nothing to do but laugh...
We arrived in Kasane and crossed the border to Victoria Falls, Zimbabwe, a sleepy yet quite touristy town with fancy hotels and hostels on every corner, all leading to the magnificent falls. Vic Falls is the largest waterfall in the world, a World Heritage Site, and when we got there we could see why. Rainbows seemed to be all around us as the mist from the falls moved in different directions. There was the constant low rumble of water hitting the rocks below, the chirp of exotic birds landing on trees. It was truly amazing. After that we had a great meal with local food at a restaurant named Mama Africa and returned to our hostel to find music blaring and people everywhere. We apparently stayed at a party hostel, and I'm so glad we did. This group from South Africa led by Jeremy Loops gave a small concert which was awesome - he played guitar, harmonica, and beat-boxed, backed up by a rapper and a saxophone player, building compelling rhythms for the audience.
Julie and I woke up early in the morning to go to an elephant park and ride elephants! It was breathtaking. We rode the matron of the group, an elephant named Coco who they said was a lesbian because she had no children and wouldn't let any male elephants mate with her. She was quite sassy, and even stopped for awhile to fart, despite her trainer's calls to move. It was fascinating though, the trainer had worked with her for over 16 years since she was young. When we got back from our walk, we got to feed the elephants, and I watched the three year old elephant cling to her mother as we fed them. I'm really obsessed with elephants now.
The three of us then went back to Kasane and stayed at a beautiful place in town. We took a wonderful boat cruise, where we saw elephants, hippos, crocodiles, baboons, impalas. It was just the three of us, with the awesome guide who was so knowledgeable. And then we all watched the sunset in awe, as the sky was a fiery red and the sun looked as if it was falling into the water. It was one of those moments where you realize only some divine power could create something so beautiful.
We landed back in Gabarone feeling grateful for seeing and experiencing so much in one weekend. I've now been to South Africa, Namibia, Botswana and Zimbabwe. Southern Africa is gorgeous - hopefully one day I'll get to Mozambique...
Thursday, July 11, 2013
The Human Side of Illness
As I go into my last day at Princess Marina Hospital tomorrow, scenes of patients suffering left and right stick out in my mind. I don't think I've been around so much suffering in one place before. And I've already felt my reaction to it change in the eight days I've worked here. Rounding in the male and female medical ward, there are multiple delirious and cachectic patients, gripped by the throes of illness after presumably years of not taking care of themselves. Pessimism floats in the air - how can any of these folks be saved? For example one of my patients admitted today came in with a week of confusion, after having weight loss, cough and night sweats for weeks. He's in his mid-20s and HIV+ and his brother described how he became non-responsive in the last few days. His chest x-ray came back a few hours later, and both lung fields were marked with what looked like small millet seeds, a cardinal sign of miliary, or disseminated tuberculosis infection. I watched as he writhed in bed, both arms strapped down to keep him from pulling out the IV lines he needed for his medication, his eyes floating around the room to nothing in particular, groaning and speaking insensible words. THe mortality rate of his infection is extremely high. Unfortunately his sight is a typical one.
Yet another one of my patients today actually reminded me why it doesn't have to be about hopelessness in these situations. He is also in his mid-20s, newly diagnosed with HIV. When he arrived on the ward earlier this week, his oxygen saturation was very low and whenever he took off his mask which gave him supplemental oxygen, he began to hyperventilate. He looked incredibly scared, surrounded by a team of concerned doctors, laying next to beds of patients much older and much sicker than him. He likely had PCP (pneumocystis pneumonia), an opportunistic infection often seen with a low CD4 count in HIV. I was scared for him. We started treating him unsure about what course he would take. The ICU is very small and rejected him when we requested he be transferred. And in a chaotic place like PMH, the nursing care leaves much to be desired, so someone like him with a lot of needs really needed a good response to his meds in order to do well.
Each day this week, he would call me over as I passed his bed in the hall. We talked about his work as a waiter, how he missed school, how much he loved his family. He felt like a little brother. And I told him he'd be okay, even though ultimately I wasn't sure what would happen. Luckily today he flashed a smile when we got to him on rounds. His oxygen sat stabilized, and he had minimal shortness of breath. He looked more energetic, more hopeful. He was also excited to introduce me to his mother when she arrived at his bedside. His cell phone would always ring in the morning while I was drawing blood on him, and the name "Mom" would flash on the screen. He explained to her that I was the guy poking him with needles every day.
I was encouraged by the fact that even at Princess Marina, where there are so many patients and so many health professionals, and the medical teams are big and the patients are very sick, one can still make a human connection. One can still give a patient fearing for his or her life some companionship, some understanding. I'm humbled by the difference one can make here. Everyday at 1pm families flood the wards for visiting hours. Watching them pray to God for mercy, and watching some of them weep at the bedside, you remember that this isn't just another number, but a father or a mother, a brother or a sister, a lover or a friend.
Despite how much illness resides here, the generosity and spirit of the medical officers and interns make the hospital run. But I know just how much the forces are stacked against them. In my short span working at this hospital, I have seen and learned so much about how important it is to not give up on patients, and to humanize them despite the dire picture they present. This is an incredible challenge in a resource poor setting, where there's only so much one do, and only so many tests one can order. I applaud the folks in the trenches every day; it is a pleasure to work with them.
Yet another one of my patients today actually reminded me why it doesn't have to be about hopelessness in these situations. He is also in his mid-20s, newly diagnosed with HIV. When he arrived on the ward earlier this week, his oxygen saturation was very low and whenever he took off his mask which gave him supplemental oxygen, he began to hyperventilate. He looked incredibly scared, surrounded by a team of concerned doctors, laying next to beds of patients much older and much sicker than him. He likely had PCP (pneumocystis pneumonia), an opportunistic infection often seen with a low CD4 count in HIV. I was scared for him. We started treating him unsure about what course he would take. The ICU is very small and rejected him when we requested he be transferred. And in a chaotic place like PMH, the nursing care leaves much to be desired, so someone like him with a lot of needs really needed a good response to his meds in order to do well.
Each day this week, he would call me over as I passed his bed in the hall. We talked about his work as a waiter, how he missed school, how much he loved his family. He felt like a little brother. And I told him he'd be okay, even though ultimately I wasn't sure what would happen. Luckily today he flashed a smile when we got to him on rounds. His oxygen sat stabilized, and he had minimal shortness of breath. He looked more energetic, more hopeful. He was also excited to introduce me to his mother when she arrived at his bedside. His cell phone would always ring in the morning while I was drawing blood on him, and the name "Mom" would flash on the screen. He explained to her that I was the guy poking him with needles every day.
I was encouraged by the fact that even at Princess Marina, where there are so many patients and so many health professionals, and the medical teams are big and the patients are very sick, one can still make a human connection. One can still give a patient fearing for his or her life some companionship, some understanding. I'm humbled by the difference one can make here. Everyday at 1pm families flood the wards for visiting hours. Watching them pray to God for mercy, and watching some of them weep at the bedside, you remember that this isn't just another number, but a father or a mother, a brother or a sister, a lover or a friend.
Despite how much illness resides here, the generosity and spirit of the medical officers and interns make the hospital run. But I know just how much the forces are stacked against them. In my short span working at this hospital, I have seen and learned so much about how important it is to not give up on patients, and to humanize them despite the dire picture they present. This is an incredible challenge in a resource poor setting, where there's only so much one do, and only so many tests one can order. I applaud the folks in the trenches every day; it is a pleasure to work with them.
Friday, July 5, 2013
The Normalcy of Dying
You wonder what the effect of watching loved ones die one after another could be. You think of the psychological trauma caused by a country losing so many of its young men and women. You consider the effects on morale when hopelessness seems to reign for so many years. When the president in Botswana in 2001 gave an impassioned speech at the UN (https://www.un.org/ga/aids/statements/docs/botswanaE.html), telling the world his people were threatened with the extinction from HIV/AIDS, the world responded. It really was a beautiful call for revolution, for re-thinking the notion that we should accept people dying in such impressive numbers. Investments from PEPFAR to Bill and Melinda Gates to multiple universities (like Penn) and NGOs followed, and in many ways it was inspirational that the world resolved not to let things continue as is. Twelve years later, after many successes and indeed some failures, it's interesting to see the effects of the epidemic on the ground as a medical student.
I just finished my first week at Princess Marina Hospital, and to say the least, it has been a rollercoaster of emotions. The hospital is a fascinating place. Each morning starts with morning report, where cases from night before are presented and administrative issues are discussed. Medical students line the back row, attendings sit toward the front - from diverse places like Italy and China and Cuba - and house staff fill the rest of the room. After report, young medical officers, interns and residents fly through the halls with their masks on as patients wait to be rounded on, some in fear, some grasping for air, some casually texting on their cell phones. One thing the patients have in common is that they are very ill, many on the precipice of life and death, coming in with serious opportunistic infections. As a medical student I am learning so much everyday - I'm doing procedures (did my first lumbar puncture!!) and I am engrossed in our discussions of topics like HIV and TB co-infection or cryptococcal meningitis. I love the process of thinking about the diagnosis and the challenge of management decisions in the context of a resource poor setting. For example, one of our HIV+ patients has profound anemia and thrombocytopenia, however they had no family member to donate blood for days and there was no blood available. There was also only one unit of platelets. As the patient continued to have epistaxis, the hem-onc team was hesitant to do a bone marrow biopsy. So we thought hard about how to proceed with such limited options, we thought critically about which labs we needed to send off and which procedures would be helpful - in the US, we'd send a full battery of tests without even a thought to the cost, and of course blood would be available. I'm hoping it will make me a better doctor one day gaining this perspective...
While the medicine part is great, the more personal side has been frustrating and maddening at times. The week started with the death of the Stevens Johnson patient from last week. I couldn't stop thinking about him, how much he likely suffered before he died. How is this fair or just? And how often must this have happened that some of the staff in the hospital were not moved emotionally by the possibility of losing him? Do we become numbed to such suffering? In my mind, I figured that in one week I've seen multiple end-stage AIDS patients, in terrible condition, wasting away from malnutrition. Many are not far from death. Theoretically, if I continued to see this for years into the future, what would it do to my sensibilities? How would it affect my thoughts on death? Would I even think twice about this boy?
I'm sure all healthcare providers feel helpless at many points in their career. There's only so much that can be done, and in many cases should be done to try to save someone's life. But when it's these 20 or 30 something year old people losing their lives instead of the 80 something year old, multiple co-morbidities type of patient, it boggles my mind. And from my experience as an American medical student, there's nothing normal about it. From the Botswana perspective though, this has become a new normal. And I'm not sure what can be done to reverse it...
However, what makes me hopeful is the diligence and kindness of the University of Botswana medical students I have worked with and the residents who work so hard everyday. It is because of them hope is not lost in this situation, and I think they will be the key to addressing this new normal that has arrived in the wake of HIV/AIDS. This country has come a long way from that speech in 2001, and we'll see what direction these young leaders will take. I'm excited to be a participant and a witness to this process.
I just finished my first week at Princess Marina Hospital, and to say the least, it has been a rollercoaster of emotions. The hospital is a fascinating place. Each morning starts with morning report, where cases from night before are presented and administrative issues are discussed. Medical students line the back row, attendings sit toward the front - from diverse places like Italy and China and Cuba - and house staff fill the rest of the room. After report, young medical officers, interns and residents fly through the halls with their masks on as patients wait to be rounded on, some in fear, some grasping for air, some casually texting on their cell phones. One thing the patients have in common is that they are very ill, many on the precipice of life and death, coming in with serious opportunistic infections. As a medical student I am learning so much everyday - I'm doing procedures (did my first lumbar puncture!!) and I am engrossed in our discussions of topics like HIV and TB co-infection or cryptococcal meningitis. I love the process of thinking about the diagnosis and the challenge of management decisions in the context of a resource poor setting. For example, one of our HIV+ patients has profound anemia and thrombocytopenia, however they had no family member to donate blood for days and there was no blood available. There was also only one unit of platelets. As the patient continued to have epistaxis, the hem-onc team was hesitant to do a bone marrow biopsy. So we thought hard about how to proceed with such limited options, we thought critically about which labs we needed to send off and which procedures would be helpful - in the US, we'd send a full battery of tests without even a thought to the cost, and of course blood would be available. I'm hoping it will make me a better doctor one day gaining this perspective...
While the medicine part is great, the more personal side has been frustrating and maddening at times. The week started with the death of the Stevens Johnson patient from last week. I couldn't stop thinking about him, how much he likely suffered before he died. How is this fair or just? And how often must this have happened that some of the staff in the hospital were not moved emotionally by the possibility of losing him? Do we become numbed to such suffering? In my mind, I figured that in one week I've seen multiple end-stage AIDS patients, in terrible condition, wasting away from malnutrition. Many are not far from death. Theoretically, if I continued to see this for years into the future, what would it do to my sensibilities? How would it affect my thoughts on death? Would I even think twice about this boy?
I'm sure all healthcare providers feel helpless at many points in their career. There's only so much that can be done, and in many cases should be done to try to save someone's life. But when it's these 20 or 30 something year old people losing their lives instead of the 80 something year old, multiple co-morbidities type of patient, it boggles my mind. And from my experience as an American medical student, there's nothing normal about it. From the Botswana perspective though, this has become a new normal. And I'm not sure what can be done to reverse it...
However, what makes me hopeful is the diligence and kindness of the University of Botswana medical students I have worked with and the residents who work so hard everyday. It is because of them hope is not lost in this situation, and I think they will be the key to addressing this new normal that has arrived in the wake of HIV/AIDS. This country has come a long way from that speech in 2001, and we'll see what direction these young leaders will take. I'm excited to be a participant and a witness to this process.
Saturday, June 29, 2013
Oh hey Gabarone! Dumela my people!
"You were right Daddy, Africa IS beautiful!!" said an adorable little boy to his father as our 20 hour journey from JFK, with a quick layover in Johannesburg, came to an end. As the plane descended on the yellow fields and pale green trees of Gabarone, I felt lucky to have made it this far on my medical school journey. I remember my excitement during the med school application process when I heard about the 4th year rotation in Botswana. I chose Penn, in part, because of this opportunity. And after a challenging three years, to put it mildly, my time in Botswana finally arrived.
From the airport, we rode on the flat highway toward the hills in the distance. The weather was crisp, with the sun providing warmth and the air dry. There was a calm to the city, reminiscent of my trip to Windhoek but with a little more hustle and bustle. Exhausted from the long journey, we arrived at the flats of the Botswana-UPenn Partnership to the smiles of the housekeepers. The grounds are impressive, complete with a barbecue and pool area, and three units with fully stocked kitchens and comfortable common areas. I wasn't expecting to be living such a posh lifestyle over here, but I won't complain, especially since I've had my fair share of rough living. I still shudder when I think about my first trip to Ghana, when my host family had no idea I was coming (a true testament to their quality of character to let me stay anyway) and I was sleeping in a room on the bare floor with the ceiling fan swinging precariously overhead.
Anyway, we settled in to our new digs pretty quickly. For the next few days I was treated to a wonderful hotel stay by my sister. We planned so that we would overlap during her time here in Botswana working on a sex workers' rights project, so I dashed off to her hotel in the evenings to take advantage of the hotel gym and breakfast buffet (so much delicious food and coffee in the mornings). Being a younger sib has so so many perks! One day when I finally see a paycheck, I will have to start repaying these debts.
This past week was our orientation week, so we were placed at a different site each day to get a sense of how the health system here operates. Monday we met with Nikki Jones, Dr. Reid and the BUP staff to get an overview of our assignments while we're here, and had a fun intro Setswana session. Tuesday I went to a hospital in Mochudi, Wednesday was the private hospital where I'll spend 4 weeks in Ramotswa, Thursday was Princess Marina Hospital in Gabarone where I'll spend my first two weeks and yesterday, Friday, was Dermatology clinic at Princess Marina. I'll give some highlights from each of the days, but I must say I am confident that this will be an invigorating, challenging, heartbreaking, transformative experience just from a few days on the wards...
Mochudi - It was a very cold morning when we arrived in Mochudi at the local hospital for morning report. We walked through the entrance to what felt like a small gated community, the different wards each separate small buildings with their own entrances. We found the meeting room for morning report where the doctors filed in, quiet and solemn, all incredibly nice and welcoming to Ali and I. The on-call doctor was responsible for the whole hospital for admissions, looking exhausted as he told us of the 14 year old boy who was shot in the leg, the 4 year old with pneumonia, an elderly HIV+ woman just started on HAART, a young lady denying a D&C after a spontaneous abortion.
We then joined a young Congolese doctor named Mindana for the morning in the female medical ward. Ali and I were surprised but delighted at how much he engaged us. He basically allowed us to see the patients, do an exam, write the note and come up with our own assessment and plan. We also joined him in the outpatient clinic in the afternoon which was equally interesting. The women on the wards were all lovely. The medical issues ranged from a patient with a schizophrenic break to one recovering from Stevens Johnson syndrome. I particularly will remember a 95 year old woman who came in after likely suffering from a stroke that morning. She was no longer able to verbalize, pain marking her facial expression, her pulse barely palpable, her latest blood pressure quite low. At Penn, she would be in the ICU with all-hands on deck, everything moving toward prolonging and saving her life. But in this setting the nurse was simply attempting to place a second IV and the main part of Mindana's plan was to speak with her family. The inevitability of her passing drove the actions of the staff, and as we moved on from her bed, I felt myself wanting to do more, asking questions and probing further about what we could do for her. Interestingly, in this cultural context, with the low level of resources, our plan had to involve whether her situation warranted an all hands on deck approach. Her situation is still on my mind...
BLH (Ramotswa) - I followed Scott for the day as he worked with another Congolese physician who I'll be working with in a few weeks when I rotate through there. We arrived to the male medical ward and immediately encountered a recently admitted 16 year old kid in septic shock. His eyes were glazed over as we struggled to find IV access for him. He had presented with vomiting and diffuse abdominal pain, and the admitting doctor was concerned about a bowel obstruction. After we placed an NG tube, a copious amount of fluid drained into the bag. It was very likely that he would need surgery and luckily the only surgeon in the hospital had been able to see him. He stabilized somewhat with fluids, but looked incredibly scared and confused. There were no monitors for vitals, the X-ray machine was broken. Labs take a day or two to come back. As we rounded on the other patients, who had a variety of medical problems, some fascinating presentations of HIV complications I had never seen before, we continually returned to the young boy's room as he became increasingly agitated, pulling out his Foley catheter and attempting to pull out his IVs. I told him he would be okay, that he needed to remain calm. I felt such unease around the care of this young man without the continuous vitals and labs and imaging at my fingertips. It was clear that one's physical exam skills were the most important thing in this context. Just halfway through my orientation week it was clear that the prospect of death was everywhere in the hospital setting, since often times people only come to or are admitted to the hospital when they are quite ill.
Princess Marina/Derm clinic - The last two days of the week I was at Princess Marina, the major public hospital in Gabarone, and where I will start on Tuesday. PM is definitely a chaotic place, nurses, medical students, interns and residents zipping by in different directions, everyone wearing masks to stop the spread of TB. Here it is possible to get a further work-up of patients done, but the resources are certainly still very limited. It was another incredibly stimulating couple of days - with some of the bread and butter medicine patients from heart failure to anemia to stroke. But the HIV patients presented such a diagnostic dilemma (HIV prevalence is above 20% in this region of Botswana). One woman lay in bed after a week of odd behavior and being unresponsive, with an MRI concerning for HSV encephalitis and an LP positive for cryptococcus. After days on acyclovir and amphotericin, treatment for both herpes and crypto, she was responding to Meghana and I in English. But her mental status was still altered. She developed pressure sores all over her legs from laying in the same position for days and days. The cause of her clinical picture was still unclear, but she was improving. Unfortunately, she looked in terrible shape and needed more frequent and attentive nursing care. It took some direct and passionate appeals on the part of our team to impress upon the nursing staff that our patient would need more care. With so many people in bad shape, patient advocacy becomes so important.
Derm clinic was equally interesting. I worked with Dr. Roth from Penn for the day in the outpatient clinic. At one point I had to ask myself, "do I want to do Derm?" We saw some rare autoimmune skin diseases like pemphigus folliaceous and some complications of HIV and HAART therapy like terrible photosensitivity dermatitis. The most poignant moment of the day and the week though came with our one consult for the day on the male medical ward - a 13 year old HIV positive boy who had developed toxic epidermal necrolysis (TEN), the worst variant of Stevens Johnson syndrome, after being switched to nevirapine therapy. It is an unfortunate and devastating side effect of the medication. He laid there with the skin on his face and neck sloughing off, large hemorrhaging blisters all over his body, drool pouring from his mouth, his eyes completely red. I've never felt so emotionally touched by a patient's visual condition before. The mortality of this condition is extremely high. I left him thinking of the broader questions - why does a young boy like this have to deal with the significant emotional, physical and psychological turmoil of HIV infection? Why wasn't he given a fair shot at a healthy life? Why must he lay in so much pain and stare death right in the face at this point? If I have the opportunity to make an impact on patients in this kind of situation, I know I have an intense experience ahead of me.
It was all in all a great week. I had the opportunity to see and hang with my sis, Meghana and Luke, and get more acquainted with all the other students at the BUP flats. I have a feeling this will be a really special summer.
From the airport, we rode on the flat highway toward the hills in the distance. The weather was crisp, with the sun providing warmth and the air dry. There was a calm to the city, reminiscent of my trip to Windhoek but with a little more hustle and bustle. Exhausted from the long journey, we arrived at the flats of the Botswana-UPenn Partnership to the smiles of the housekeepers. The grounds are impressive, complete with a barbecue and pool area, and three units with fully stocked kitchens and comfortable common areas. I wasn't expecting to be living such a posh lifestyle over here, but I won't complain, especially since I've had my fair share of rough living. I still shudder when I think about my first trip to Ghana, when my host family had no idea I was coming (a true testament to their quality of character to let me stay anyway) and I was sleeping in a room on the bare floor with the ceiling fan swinging precariously overhead.
Anyway, we settled in to our new digs pretty quickly. For the next few days I was treated to a wonderful hotel stay by my sister. We planned so that we would overlap during her time here in Botswana working on a sex workers' rights project, so I dashed off to her hotel in the evenings to take advantage of the hotel gym and breakfast buffet (so much delicious food and coffee in the mornings). Being a younger sib has so so many perks! One day when I finally see a paycheck, I will have to start repaying these debts.
This past week was our orientation week, so we were placed at a different site each day to get a sense of how the health system here operates. Monday we met with Nikki Jones, Dr. Reid and the BUP staff to get an overview of our assignments while we're here, and had a fun intro Setswana session. Tuesday I went to a hospital in Mochudi, Wednesday was the private hospital where I'll spend 4 weeks in Ramotswa, Thursday was Princess Marina Hospital in Gabarone where I'll spend my first two weeks and yesterday, Friday, was Dermatology clinic at Princess Marina. I'll give some highlights from each of the days, but I must say I am confident that this will be an invigorating, challenging, heartbreaking, transformative experience just from a few days on the wards...
Mochudi - It was a very cold morning when we arrived in Mochudi at the local hospital for morning report. We walked through the entrance to what felt like a small gated community, the different wards each separate small buildings with their own entrances. We found the meeting room for morning report where the doctors filed in, quiet and solemn, all incredibly nice and welcoming to Ali and I. The on-call doctor was responsible for the whole hospital for admissions, looking exhausted as he told us of the 14 year old boy who was shot in the leg, the 4 year old with pneumonia, an elderly HIV+ woman just started on HAART, a young lady denying a D&C after a spontaneous abortion.
We then joined a young Congolese doctor named Mindana for the morning in the female medical ward. Ali and I were surprised but delighted at how much he engaged us. He basically allowed us to see the patients, do an exam, write the note and come up with our own assessment and plan. We also joined him in the outpatient clinic in the afternoon which was equally interesting. The women on the wards were all lovely. The medical issues ranged from a patient with a schizophrenic break to one recovering from Stevens Johnson syndrome. I particularly will remember a 95 year old woman who came in after likely suffering from a stroke that morning. She was no longer able to verbalize, pain marking her facial expression, her pulse barely palpable, her latest blood pressure quite low. At Penn, she would be in the ICU with all-hands on deck, everything moving toward prolonging and saving her life. But in this setting the nurse was simply attempting to place a second IV and the main part of Mindana's plan was to speak with her family. The inevitability of her passing drove the actions of the staff, and as we moved on from her bed, I felt myself wanting to do more, asking questions and probing further about what we could do for her. Interestingly, in this cultural context, with the low level of resources, our plan had to involve whether her situation warranted an all hands on deck approach. Her situation is still on my mind...
BLH (Ramotswa) - I followed Scott for the day as he worked with another Congolese physician who I'll be working with in a few weeks when I rotate through there. We arrived to the male medical ward and immediately encountered a recently admitted 16 year old kid in septic shock. His eyes were glazed over as we struggled to find IV access for him. He had presented with vomiting and diffuse abdominal pain, and the admitting doctor was concerned about a bowel obstruction. After we placed an NG tube, a copious amount of fluid drained into the bag. It was very likely that he would need surgery and luckily the only surgeon in the hospital had been able to see him. He stabilized somewhat with fluids, but looked incredibly scared and confused. There were no monitors for vitals, the X-ray machine was broken. Labs take a day or two to come back. As we rounded on the other patients, who had a variety of medical problems, some fascinating presentations of HIV complications I had never seen before, we continually returned to the young boy's room as he became increasingly agitated, pulling out his Foley catheter and attempting to pull out his IVs. I told him he would be okay, that he needed to remain calm. I felt such unease around the care of this young man without the continuous vitals and labs and imaging at my fingertips. It was clear that one's physical exam skills were the most important thing in this context. Just halfway through my orientation week it was clear that the prospect of death was everywhere in the hospital setting, since often times people only come to or are admitted to the hospital when they are quite ill.
Princess Marina/Derm clinic - The last two days of the week I was at Princess Marina, the major public hospital in Gabarone, and where I will start on Tuesday. PM is definitely a chaotic place, nurses, medical students, interns and residents zipping by in different directions, everyone wearing masks to stop the spread of TB. Here it is possible to get a further work-up of patients done, but the resources are certainly still very limited. It was another incredibly stimulating couple of days - with some of the bread and butter medicine patients from heart failure to anemia to stroke. But the HIV patients presented such a diagnostic dilemma (HIV prevalence is above 20% in this region of Botswana). One woman lay in bed after a week of odd behavior and being unresponsive, with an MRI concerning for HSV encephalitis and an LP positive for cryptococcus. After days on acyclovir and amphotericin, treatment for both herpes and crypto, she was responding to Meghana and I in English. But her mental status was still altered. She developed pressure sores all over her legs from laying in the same position for days and days. The cause of her clinical picture was still unclear, but she was improving. Unfortunately, she looked in terrible shape and needed more frequent and attentive nursing care. It took some direct and passionate appeals on the part of our team to impress upon the nursing staff that our patient would need more care. With so many people in bad shape, patient advocacy becomes so important.
Derm clinic was equally interesting. I worked with Dr. Roth from Penn for the day in the outpatient clinic. At one point I had to ask myself, "do I want to do Derm?" We saw some rare autoimmune skin diseases like pemphigus folliaceous and some complications of HIV and HAART therapy like terrible photosensitivity dermatitis. The most poignant moment of the day and the week though came with our one consult for the day on the male medical ward - a 13 year old HIV positive boy who had developed toxic epidermal necrolysis (TEN), the worst variant of Stevens Johnson syndrome, after being switched to nevirapine therapy. It is an unfortunate and devastating side effect of the medication. He laid there with the skin on his face and neck sloughing off, large hemorrhaging blisters all over his body, drool pouring from his mouth, his eyes completely red. I've never felt so emotionally touched by a patient's visual condition before. The mortality of this condition is extremely high. I left him thinking of the broader questions - why does a young boy like this have to deal with the significant emotional, physical and psychological turmoil of HIV infection? Why wasn't he given a fair shot at a healthy life? Why must he lay in so much pain and stare death right in the face at this point? If I have the opportunity to make an impact on patients in this kind of situation, I know I have an intense experience ahead of me.
It was all in all a great week. I had the opportunity to see and hang with my sis, Meghana and Luke, and get more acquainted with all the other students at the BUP flats. I have a feeling this will be a really special summer.
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