Hospital Woes

So, I know this is supposed to be an elective rotation for us (and a CALL-FREE rotation, despite Jyoti's mandatory 5 call nights this month) -- but it's probably bad news when you're the hardest worker on your team. My team is probably the best medicine team to be on (MO who really knows his stuff, tries to get patients out quickly and safely, and has a great attitude; intern who [sometimes] tries hard and is generally willing to stay late [it helps that her husband is in Australia]). But the pace of life here is so slow, and it spills onto the wards as well. That means that something that should take 1 hour ends up being stretched into 2 or 3 hours, and this compounds the time spent in the hospital (unnecessarily). For example, AM report finished a bit late, so rounds started late. But the MO was post-call, so he went off to eat breakfast before rounds, and asked the intern, me, and the med student to start rounding on the old patients. So we three gathered at the Male Medical Ward to start rounds. But then the intern said she lost her N-95 mask and went to go find a new one. So the med student and I rounded on three patients (almost 30 minutes) before the intern came back with a mask. I'm not sure if it really does take that much time to find a mask (and it very well could take that long; finding a pair of gloves on Monday took about that much time), but I'm betting that some of that time was spent catching up with other interns, musing about the weather, etc. There's just no sense of urgency. We couldn't communicate effectively with one patient, so the intern had to go back and redo what we had just done...so inefficient! And the real trouble is that little things like that add up throughout the day, and before you know it 5 0'clock rolls around and there are still things left to do. They either just don't happen, or get pushed to the next day, which extends length of stay unnecessarily! And when I try to be more efficient and do things myself, the intern complains that she's not getting enough autonomy. I've decided that I'll just try to help out where I can, but ultimately I am not here to change the pace of anything.

But Jyoti's team is even more exasperating (notice my use of that word twice in the last two blogs; it's a good one). Her team consists of herself; an absentee attending (old prof who makes split second decisions based on vast years of clinical judgement); a hard working intern; a med student from Jamaica who's treating this month as a half day only rotation; and an MO who makes unnecessary statements like "I don't like Americans" on rounds. Today was a call day for her team. After Jyoti gave a fantastic presentation on fetal cardiac development for morning report, the team lounged around until rounds, from 9-10. Then her med student left for the day. Her intern had to go home to let the cable guy in. And her MO promptly exclaimed that she was tired and went to take a nap. Which lasted well into the afternoon, as we didn't see her again the rest of the day (keep in mind the MO was on call today!). This left Jyoti to essentially do all the work for her team the entire day. When she asked the MO to do some things before the nap, the MO replied "nothing is really that urgent." I can only image what would happen at HUP or at CHOP if anyone acted like that!

It's amusing in retrospect (really? the cable guy?) but I'm not sure how medical care can be changed to fix these issues. Maybe they're not really issues at all, since Batswana people tend to accept the care as given? Still can't help thinking there's got to be a better way to deliver medical care...

But, to end on a lighter note -- we thought this was hilarious. My theory is that it's where kids go to give a sample to test for TB. Which is odd, since kids supposedly lack the diaphragmatic fortitude to be able to cough up TB. Jyoti has a better idea -- if you happen to be passing by the IDCC building, and you begin to have a coughing spasm, this little shack is where you go to remove yourself from others' company. It's the polite thing to do, of course. Any other ideas?

Khama Rhino Sanctuary

We just got back from the National Khama Rhino Sanctuary. Apparently all the rhinos were dying in Botswana (mainly poachers) so Khama, the first president of the country, decided to set aside land and create a true Rhino Sancutuary. Some rich guy was persuaded by the Botswana Government to donate his land near Serowe, and they brought over 33 white rhinos and 3 black rhinos from across the country to habit the area. It's about a 16 square mile area that has 3 prominent watering holes, all naturally formed (but sometimes abetted by pump water when the land is particularly dry). It was cool to hear the Batswana tour guide talk about her country, the history of the sanctuary, and the rhinos; there was more than a trace of pride in it. A little different experience than the luxury of Madikwe.

We took a bus from Gabs to Serowe (4 hour ride, relatively pleasant once we got going on the A1 main highway). We wandered through the main mall at Serowe once we alighted, and ran into a nice indian aunti who pointed us toward the Tshwaragano Hotel, which is built into the hill that houses His Excellency Sir Seretse Khama's grave. It does provide a nice view of the whole town ("the biggest village in Botswana" we were told). It was a cute bed&breakfast that served us chips and beans&toast, along with milk, juice, tea, and fruit. They were quite baffled when we said "no eggs or meat" but managed to get the breakfast right in the end. :)

Getting to the right place was no problem, but once we got there we were sort of stared at blankly. It's something that I've noticed a lot about Batswana, something that Mosepele warned me about before we left -- I called it "underhandedness." The lady at the front desk basically said nothing and waited for us to explain why we were there. We tried to ask about any game drives departing soon, and she continued to stare at us blankly, then in an exasperated soliloquy to no one in particular, said "some people are just very difficult to understand." It would have been much more pleasant for her to directly ask me what I said, or to repeat something; but in Botswana people tend to wait for you to figure out that they're confused and want something more from you. It's as if we're supposed to take very subtle cues from the head movement, or body position, or respiratory rate, or something else that I must be missing...!

In any case, we ended up having 3 hours to kill before the next game drive. It rained on and off for those few hours while we chillaxed at the Sanctuary, but when it came time for our game drive the weather cooperated very nicely. Jyoti took this artistic picture of a tweetie bird's nest (apparently they're called "yellow weavers").

There was also this blue-monarch looking butterfly interspersing with some angry looking hornets around the swimming pool. Yes, we could probably use a lesson in entymology (it's blue, and has eyes like a monarch butterfly...).

A lot of the animals we had seen already (Kuru, Impala, ostrich, spring bok, etc.) so although we continued to take lots of pictures (what do you do with a 4 GB disk drive anyway?), I will only post some interesting pics. This one is a bird looking into the distance, enjoying the shade of a brightly lit cloud.

Here's Jyoti with a background of zebra. We learned that Botswana Zebra have not just black and white, but brown as well, whereas South African Zebra have just black and white.

And of course, what would a Rhino Sanctuary be without rhinos? We did see a few white rhinos, but no black rhinos. I like the bird just chilling at the feet of the baby rhino (2 yr old; after 1 more year with her mom she'll go off on her own!).

We also encountered a cool new species of gazelle called "Oryx." I love the black stripes. Probably the coolest animal I saw at the sanctuary.

And here's the sun setting on us as we leave the Sanctuary...

Life at Princess Marina Hospital

Though the blog is appropriately titled Travel Notes, I do occasionally go to work while I'm here in Gaborone/Botswana (though don't tell Customs this; officially I'm here for "7 weeks of holiday"). We had a crazy busy call night on Wednesday, and so Thursday/Friday was spent getting to know the 16 new patients (we were entering call with 14) and trying to get through all 30 patients on rounds. It turns out our attending (Specialist Dr Ditlotlo) has clinic on Tuesday and Wednesday, so she only rounds with us 3 days a week (except for when she has random meetings on a Thursday...). The Medical Officer (Moolooki Mathake) and I run rounds and essentially make all major decisions (which happen very slowly here...the decision to get a CT scan may take 2-3 days of hemming and hawing and discussion before it gets ordered, and then another 2-3 days to actually get the scan, since our machine is currently broken and we ship patients to a private facility to get the scans...). We do have a great intern (Celia Odometse) who is very motivated, stays late, and in general is on top of things.

Meredith Edwards is a UPenn student who was on our team until today, when she started another rotation in a community hospital. It was a big loss not having her around, since she was so competent and got lots of things done on rounds. But we did get an infusion of Australian medical students to Princess Marina Hospital, and joining our team today was Nadia, a 4th year (out of 5) medical student. I showed her the basics of the hospital and was able to get in some good teaching, reviewing several chest xrays and procedures (blood draws, cannula insertion, paracentesis). She's a good student and I think she'll be able to help out the team since we're so busy.

PMH is overflowing, as usual, and we went into the weekend with 30 patients. We came in this morning to find 27 patients on our census; since there are rarely weekend discharges, I knew this was bad news. 3 patients had died, all with meningitis. Two were RVD (retroviral disease; or HIV) positive patients with presumed cryptococcal meningitis. When Meredith and I did the spinal tap on one of them on Friday, we actually could not measure an opening pressure because the spinal fluid kept rising in the barometer and then eventually overflowed to an undetectably high level. The last guy was a young suddenly ill 35 year old, RVD negative, who had a horrible bacterial meningitis; he died roughly 48 hours after admission to the hospital. We're still waiting on the gram stain/culture from the spinal fluid, but my bet is strep pneumo meningitis because it's actually really common here...we had him on all the right medicines, but I just don't know if we could have saved him.

Hopefully the next few days brings some better news; we did send home a few people today, including one woman who had been in the hospital since September 28th! We're on call again tomorrow, so I think we'll be okay as long as Moolooki doesn't admit another 16 patients...

On a more cheerful note, I walked by the Peds wards looking for Jyo today, and found her hard at work doing a paracentesis and two very difficult cannulations. Her team was post-call, so she held down the fort very nicely. Strong work Jyo!

Madikwe - Tau Lodge

Jyoti and I spent a fabulous weekend at the stunning Tau Lodge at the Madikwe Game Reserve in South Africa. We got T-Man (Luis' Botswanan counterpart, for those Guatemalans who may be perusing this blog) to drive us there and back, with minimal hindrance from Customs (except on the way back...need to remember out address is 154 Pilane Road, not Pilane Court, because apparently that matters...).

We got there early (as recommended) and we had some extra time to hang out and chill at the Lodge before the game drive that evening. We lounged in the sun, and dipped in the pool, but were then driven away from our swimming hole by this creature. Yes, it is bright blue.

I was quickly rinsing off after swimming, when Jyo called me to the window -- about 50 feet away across the pond a thirsty rhino came to bathe in the mud!

We ate lunch (the chef "threw together" a delicious lactovegeterian meal for us after patiently going through all our dietary discretions).

Then we went on the game drive -- huge toyota landcruiser 4x4 that was pretty gnarly. We saw lots of impala, kuru, zebras, red hartbeest, and springbok before we came across this -- a lion having just finished off the last of a zebra. It smelled awful! Apparently he had been eating the zebra meat for 3 days...

Not far from there we were stopped in our tracks by a wildebeast infiltrating a pack of zebras. Apparently if a wildebeast gets left on his own he'll pretend to be a different herd animal to try and stay safe from predators. This close up of a zebra came out well.

And finally, no big game drive would be complete without elephants! We saw a group of 4 elephants, all females of different ages, and 1 male lagging behind (he had been cast out on his own, but still had some separation anxiety...). The matriarch of this group was 35 years old and was leading her group to safety, but not before stopping to sniff the landrover :).

The sunrise and sunset were beautiful, and I'll leave you with one of each. Enjoy!

Mokolodi

After a grueling 2 days of work (surprisingly, work was actually grueling), we decided to join Paul (Brown Med R3 here in similar capacity) for his first (and only) sightseeing in Africa -- theMokolodi Game drive. It's only 15 km away, but it's an expansive (2x5km) game reserve that has protected areas for all its animals. And did we see animals?! Here are some pictures:

Big ol' rhino. Mom is 15 years old, and daughter was born on the reservation, is 5 years old (but ready to have kids of her own...)

Real live wild male giraffe. Nothing like Bo, the uni-gonadal inhabitant of the Franklin Park Zoo in Boston (another story for another day, another time...). But still pretty cool. And really really tall...

Wild Kuru stopping traffic by leaping 6 meters into the air in front of our truck. I got off this picture just in the nick of time. The beast is bigger than a moose! And much faster.

A crazy-eyed spotted hyena trying to figure out a way to eat Jyoti as she takes this picture. Don't worry, I was right behind her in case anything happened... :)

LAST BUT NOT LEAST -- yes, we did. We did pet the cheetah. It purred. That was frickin' awesome.

Diary Entry: 13 Nov 2010

...at the Okavango River Lodge...I've been able to comingle and cavort with all sorts of people. ... I will talk about 4 of them. (1) Barman at ORL - Leo. 23 yo guy who is surprisingly well traveled for a Botswanan (he admits his countrymen don't get out much). He's completed high school, but doesn't know what he wants to do with his life, and lived at his sister's house for a while not doing anything. Then a friend invited his dad to Mauritius to work there, and he volunteered to take his dad's place, so he could get out of Bots...the family friends were sure enough surprised when he arrived instead of his dad! (apparently the letter describing the substitution was still in the mail...) He spent 1.5 years there working as a barman, then returned to Bots, moved to his mother's homtown (Maun) and began working here. He's studing for the driver's license exam because he wants to be a mobile safari driver next. I was impressed by his (relative) wanderlust, and dedication to career advancement -- which I actually haven't seen much of here. (2) Marlene, from Ohio -- a ~71 yo white woman, originally from the Deep South, who has spent her life traveling. All 48 contiguous states by 40 yo, then all of them again with her 2 cats and mobile home over 12 years before deciding to take the show abroad. She's retired (I never got her former profession) and has blocked off 5 months for "Southern Africa." She has no real itinerary, and backpacks everywhere, staying in youth (!) hostels. It's quite impressive but I do have to say she was one of the more annoying Americans I met -- extremely cheap, always complaining how expensive everything is, trying to haggle everything and get things for free while not spending much, and basically expecting everyone to drop what they're doing for her. Which they do, by the way...she told me a story of how she was taking a bus into Mozambique, refused to pay the visa fee, hitchhiked to a gas station at the border, where she met a nice local friendly woman who took her home, fed her, and arranged for a backdoor visa traveling through a neighboring African country -- all for free. Which is great/cool/impressive (especially for a 71 yo!) but she was more expectant than appreciative of this type of service... (3) EmDee, my tour guide on the 2 d/overnight mokoro/camping trip. He's 28, but had been in a mokoro since age 8, and has 2 families -- wife and 2 kids in a far away village in the Central Kalahari, and girlfriend+kid here in Maun. He just built a house here inthe Delta -- mud + sticks, with empty beer/cola cans to mimic bricks. I felt bad for him because he had a cold ("flu" he called it) but took us on the tour anyway -- I guess he couldn't really afford to take a "sick day" :(. He never finished school, and learned English purely through tourists, but he actually paid someone to teach him to read/write Setswanan, whichi I found extremely impressive. He also had a good heart -- shared his food with others, always tried to see if he could help with anything. He had really ratty hiking boots, and even rattier socks, which were more hole and sock! I gave him my socks as a present, but in retrospect wished I gave him a larger tip :( (4) Brendan -- a 70ish ultraconservative British aviator who was a Yankophile but had a lot to talk about re: USA (specialty = ~1830-1882). He told me about flying bush planes (and the undiscovered benefits of owning a Cessna); flying helicopters in LA (and celebrity sex scandals that occurred *in* his choppers); a detailed description of the play-by-play events at the gunfight at the OK Corral; and expositions on "Why Africa [as a continent] will fail." Did I mention he's conservative (though married to a very nice GP, Claire, who may not share *all* his views)? He believes "AIDS" is more "environmental" than a real biologic disease. He has a whole theory backed by "three well done Canadian studies" about needing "lifestyle," "constitutional," and "exposure" -- all 3 mind you, not just 1 or 2 -- in order to get HIV or develop AIDS. I had to politely change the discourse ASAP! He was rather witty, very well read, and very entertaining to listen to though some things made me cringe...

What am I doing here?

Oops, forgot to include my mission statement in the introductory post.

Given that I haven't actually started working yet, I'm not exactly sure what I'll be doing for the next 4 weeks (other than certainly traveling a lot over the weekends!). There is a partnership between the University of Pennsylvania and the University of Botswana (BUP) that facilitates exchange of ideas, resources, and training manpower. Because the University of Botswana medical school and training program are relatively young, Penn has been providing faculty guidance and advice for development. As part of this, one Penn resident (in past years more) rounds with one inpatient medicine team daily for a month. That will be me starting tomorrow! I'll be working with one attending, one "Medical Officer" (trained at the level of an intern, but in actuality may have had many years of medical practice since then), and one medical student. I'll be responsible for some teaching (morning report, resident report, journal club, etc.) but in the beginning I'm sure *I* will be the one learning -- how the hospital system works, HIV basics, etc.

I do this for the 4 weeks, 7.30a - 5.00p daily, with no overnight call, and no weekend responsibilities. Hence the wide travel plans...

Jyoti comes today; I'm excited to go pick her up from the airport. Maybe I'll have a swim in the pool this morning as a bit of a workout (we're spoiled here, aren't we?). :)

The Okavango Delta

Hi everyone! I'm typing from a cute internet cafe ("Internet Cafe," across from the Engen gas station in central Maun) after a leisurely breakfast of muesli and yogurt at the Okavango River Lodge, where I've been the last three nights. I will later transcribe some of my diary that I wrote over the past few days, but in the mean time -- pictures are worth thousands of blabberings from me, so I will get right to it -- my trip to the Delta!

I got here on a random Wednesday morning with not much planned (which I realized is a big mistake...too many things to do, easy to get distracted and do nothing...). I met up with Michael, a UPenn medical anthropology grad student, and we hit up the crocodile farm. This is Okie, the oldest known crocodile at a whopping 87 years old. He's the one with the open mouth. It's pretty darn amazing how well adapted crocodiles are to their environment -- apparently no big mutations/genetic changes since the time of the dinosaurs!

I stayed at the Okavango River Lodge, where I met a barman named Leo (of whom, more later). I stayed in a chalet, which is essentially a thatched-straw roofed hut, open to the environment (but with a screen wire meant to keep out the pests). I had my first experience with a mosquito net...hopefully I put it on correctly. I'm not really sure if I was supposed to tuck in the net *into* the bedding, but I figured better safe than sorry!

I had a fabulous veggie burger with "chips" and a salad for dinner (chips = fries, apparently the ORL is run by a hybrid Canadian/British couple). I met interesting person #2 (Marlene...see diary entry) over dinner, but she was making her own food, and she "detested" the smell of the citronella lanturn, so she left after ordering a glass of ice. That was fine by me, as I thoroughly enjoyed the relaxed atmosphere, the great '70s - '80s tunes (when was the last time you heard "Hungry like the wolf"?), and the beautiful view of the Delta. I played around the the few setting I have on my point-and-shoot, but these pix were nice:

Leo convinced me that an overnight camping trip in the Delta was the only way I would *truly* experience the Eastern Delta, so I signed up for a

2 d mokoro (canoe) trip with an overnight stay on one of the islands. Given the 40 deg (C) weather, I would soon realize that even a few kilometers of walking on flat land was utterly exhausting...we did 6 km the first day (saw 4 elephants, 2 of whom I spotted for the group; and 1 antelope, and 3 wild hogs [apparently the Setswana word for which is "poombah"!]. however, my dinky zoom is so bad that it's not even worth posting pictures yet...let me work on photoshopping it first). We did 12 km the next day! But we also saw zebras cavorting with wild buffalo and a whole lot more elephants. In fact, we stumbled upon 2 grazing elephants quite by accident, and were (un)fortunately only about 20 yards away from them! This is apparently really close, too close if the elephants decide to attack, and I was quickly shooed away by the tour guide -- but I did manage to shoot this picture. :)

Our hike ended with a quick stop at a real live Baobab Tree (of de Saint-Exupery fame). It was the most glorious shade I have ever had...even with long sleeves and a recently purchased safari hat, the sun was brutal. Baobab was our friend, but we were soon off to return to camp before the *real* heat came out at noon, when the sun is the highest. I had stupidly forgotten my water at ORL, but was able to make do with boiled river water (which tasted faintly of dirt...clay?). The only problem is...boiled water never really cools when it's 40 deg outside! But I did have a nice dinner of Upma, which itself had about 750 ml of water in it, so I think I stayed relatively hydrated. :) Also, my fellow campers were kind enough to share their water with me when the going got tough (they had brought over 10 L for just the two of them...).

Upma cooking on the fire:

Finally, despite all the trials/tribulations of African Bush Camping (who knows how many critters I slept with in my tent that night...) I would say the views of the river at sunset made the entire trip worth it. I was camping with 2 German engineers, one of whose father was a professional photographer, who had serious digital SLRs...they've promised to email me the pictures when they get back to Germany, but here's the view from my camera. Enjoy!

Southern Africa

Welcome! It's been a while since I've written (last post on "Pdogg's Pages" was 4/22/08, a beautiful memory of Oasis Chiyu in Central Guatemala!). I seem to only find time to write when I'm traveling, so I've named the new Blog appropriately.

I am now in Southern Africa (Botswana x5 weeks; South Africa x2 weeks). It's my first time south of the equator, and I am eager to test the Coriolis Effect.

After a grueling 28 hour journey I finally arrived in Gaborone, the capitol city of Botswana, a full 25 minutes early. This meant that my driver (commissioned from the Botswana-UPenn Partnership, or BUP) was not there, and I had some time to kill. A large, loud, fun-loving Gujarati family was on the plane (one dadima, two uncles, two auntis, and two kids) from Joburg to Gaborone, and there was much rejoicing when another family (one uncle, one aunti, and four kids) came to pick them up at the airport. I didn't want to feel left out, and I was new and alone in this large (hah) city, so I went up to the uncle (Harshad Uncle) and introduced myself. He let me borrow his cellphone and I called the driver, who confirmed he was almost there, and got myself (and Jyoti) and invitation to their house for dal-baath whenever we wanted. His son goes to college at UChicago, and I promised to email him when I got back.

This story may seem bizarre, but as I've traveled all over the world, I have to agree with my dad when he says that Indians can be among the friendliest group of people -- certainly true for other Indians, but really towards anyone. I'm looking forward to seeing the Indian influence and culture here in Africa. I do get to spend 3 days by myself in Durban at the tail end of the trip (27% Indian!).

Re: travel plans within Botswana, I think Luke has convinced me that the Okavango Delta is a region that cannot be missed; and given how far away it is (taxi=>plane=>taxi=>plane=>canoe) Jyoti and I figured it won't be possible to do in just a weekend trip when she gets here. So I decided to fly out to Maun tomorrow, and spend a few days exploring the flora/fauna of the Delta. I'm very excited, and should be able to take a bunch of pictures to share soon.

Speaking of pictures, here is the first installment.

My humble abode, Pilane Court in Botswana.

The computer lounge whence I am typing.

Our gated community.

More pics to follow...