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.