Madikwe and My Final Day on the Wards

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.

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...