Food and Jazz

It was a day to eat! We went to this place called Sanitas for brunch, which does pretty well in providing good American-style brunches. It’s actually a tea garden and horticultural center, where you can buy lots of different plants and gardening supplies. In the winter, Botswana is very dry and brown, so the lushness and greenness of this place is a welcome change, although it probably requires ridiculous amounts of water to keep it that way. At any rate, after eating, it was fun to stroll around and look at all the different things in this large outdoor store. And we also got gelato from their counter, even though we stuffed ourselves during brunch. :)

During the day I tossed a Frisbee around with Amy and Phil. Amy actually was quite good – she said she used to throw a Frisbee in summer camp. It was pretty fun until one of us threw it into the bushes near our apartments. All the bushes have these super sharp thorns, and two of them actually pierced the Frisbee! We used pliers and still couldn’t get them out! Eventually we were able to cut off the ends and file them down so there was no longer any protrusion from the Frisbee, but the little bits of wood were still embedded in the Frisbee. Crazy.

Then for dinner, a few of us went out for Ethiopian food. It was this place located at the Riverwalk mall that Dr. Gluckman recommended to us. They had a buffet which consisted of chicken with egg, beef, lentils, some other vegetable, and of course, plenty of that spongy bread, injera. Unfortunately I wasn’t very impressed – I think I like the Ethiopian food in West Philly better! It wasn’t as spicy as I’m used to it being, and the bread wasn’t sour like it normally is! I think the Ethiopian food in West Philly is actually more authentic, since there are a ton of Ethiopians in that area. I’m willing to bet that the Ethiopian food here has been tamed down a bit for the Motswana.

After dinner, a few of us (Lisa, Amy, Joanne and I) went and joined Kristy, Kiona and Phil at Botswana Craft for a jazz concert. The band playing was called Punah, and I guess they are known to quite a lot of people, but are not really super famous. It was a ton of fun – after a while, we joined in the dancing with the locals who whole-heartedly welcomed us. There was dancing in groups (like in the states), dancing in a circle (I think there were specific steps to this, but we certainly didn’t know them), and dancing in sync with specific movements, like the Macarena (which I could sorta do after watching and miming the other dancers for a while). Most of the dancers ranged from 20-40 years old, with the young men being pretty entertaining to watch. However, there were these two old men (probably in their 60s) dancing and they were hilarious! Their moves were very… original. One of them had very jerky and deliberate movements, like those men in the parks painted in silver who pretend to be statues and move robotically when you put money in their can. Joanne took some video, and I’ve got to get a copy of it. :)

The band Punah was also very good – I definitely enjoyed their music. Kristy bought their new CD and unfortunately it came damaged, but I burned what I could onto my computer. Funnily enough, several days later I was walking through the Main Mall, where there are tons of street vendors out at lunchtime, including ones that cell CDs and DVDs. I heard music being pumped out from one tent, and I said, “that’s Punah!” and the vendor was surprised and said, “Yeah, that’s Punah!” And he asked if I wanted to buy it but I said I already had it. Even though it wasn’t a huge crowd that night at the jazz concert, I guess their music is relatively well-known.

Decompressing

It was a busy day today and we barely had time for lunch because we had 10-11 admissions overnight that were done for us by the MO on call. There were 3 of us working though, so we made it through but were running around all day.

We needed to decompress, so a few of us (Sarah, Amy, Joanne, Jeremy and I) went to the Bull N Bush for dinner, which is a nice chain. It’s a pretty busy bar and club too on Friday nights, but I never went when it was really active. I had a great burger with mushroom sauce here, and we took these funny pictures with a cross-dressing cow statue. In general, I think I’m starting to get tired and worn down a bit – when we got home, Jeremy and I started Skyping each other even though we were in the same room and I thought it was the most hilarious thing ever. And we only had one beer at dinner! :)

When to have children? or When to have fun?

I've had this discussion with a few different friends on separate occasions lately, so it must be on our minds. When is the best time to have children? I don't know if this is right or wrong, but it quickly becomes a question of assuming you want to have children, when do you want to have fun?

A lot of my friends are having children, plan to have children, or may have children in their 30's. Maybe even 40's. I think that's relatively late.... but that means you get to play when you're younger! Sure you can argue that there may be genetic risks the older you get, but let's take that out of the equation by saying you can adopt. And you can do that whenever you want - even when you're 50! The good thing about having fun when you're younger is that you have more energy, and you're usually more accepting and experimental and willing to try new things - these characteristics are perfect for travel and having fun! The problem with having fun when you're younger is that you have no money. And this is supposedly the time when you should be saving for retirement, yada yada yada. Another drawback is that if you have children relatively late, when you retire, you may still have kids in college, or even high school! I don't know about everyone else, but I'd rather have the kids out of the house and out of school by then, or taken care of in some way so that I can travel all over and enjoy retirement. I'll know how much money I have left and how I want to spend it.

Now if you decide to have kids early, you can start saving early for their school, which may not only include college (or post-college stuff), but also include grade school and high school depending on where you live and if the public schools are okay or not. Not to mention day care for the younger kids! And when you retire, they're all taken care of and you can have your fun. And presumably you have plenty of money for that fun. The downside is of course, you don't have as much energy for the fun stuff (i.e. traveling) and because of that, you would probably do different things. Like, I doubt that when I'm 65 I'll go bungee jumping - not impossible, but I probably wouldn't do it.

After thinking through my options, I think I would rather have kids earlier rather than later - it'd be nice to have a lot of energy for the kids too, much less traveling and other fun stuff. But I guess it's too late for me to have kids early in life, so I'll settle for having fun now and having kids later. :)

LuBang! horah video

Well, it took long enough to upload, but here is the ever-anticipated Lubang horah video. I think the highlights are the parents.

West Philly Obama party

I know this is mostly a medical blog, but Tuesday was a pretty great day for many different reasons, one of which was the presidential race. Impromptu street parties broke out in several areas in Philadelphia, one of which was in West Philadelphia - my neighborhood. It was absolutely amazing. Drummers and musicians came out to 47th and Baltimore and started playing for hours and hours. We didn't come across it until 1am, the musicians had already been going for several hours, and apparently it lasted until about 4am! People were chatting and dancing in the street, which was nearly blocked off. When cars or trains did manage to make it through, everyone was hi-fiving passengers and each other. "O-ba-ma" and "Yes we can" and "U-S-A" cheers broke out throughout the night to the drum beats. I saw so many people I know from the community there, and it was a really really great feeling. My cell phone couldn't take any good pictures, but somebody managed to capture it on video:

When things don't go as planned...

Several months ago, I met a patient who had already been in and out of the hospital for months. He already had had many complications and was pretty sick. This guy had bladder cancer and had to have his bladder taken out. His ureters - the tubes that carry urine from your kidneys to your bladder - were instead fused to a part of his colon so that urine was diverted to his colon instead of his bladder. Immediately after the surgery, he had a heart attack, which is not common, but can happen because surgery takes such a big toll on your body, including your heart. He recovered well from this, and went home. Unfortunately, two days later he came back to the emergency room looking incredibly sick. It turns out that his wound had started to come apart, which is a potential complication of any surgery. His ureters were de-attaching from his colon, leaking urine into his abdomen, and he possibly had an infection within his abdomen. They had to open him back up and fix everything. In the end, it was all still leaking, so they had to place stents within his kidneys that led outside his body to drain the urine instead. He was discharged to rehab.

One week later, he was having his stents changed, and he suddenly became very very sick - he had a fever, the chills, and looked really sick. That's when I saw him. He had developed a very serious infection called sepsis where the infection is basically all throughout your blood. His blood pressure started becoming way too low and he had to eventually be transferred to the ICU where they could start him on special medications to keep your blood pressure up and your heart pumping. It turned out he had multiple types of bacteria growing in his urine, as well as fungus growing in his blood! That's pretty rare, but he had many potential sources of infection - not only did he have the normal sources that every else has (lungs that can develop pneumonia, urine that can develop urinary tract infections, and blood that with even just a blood draw can potentially develop bacteremia or sepsis), he had stents in his kidneys as well as an ostomy (his colon came to his skin and his stool came out through a bag) that were at high risk for infection. Moreover, he was a pretty sick guy, and he'd been in the hospital quite a lot over the last few months, so he was immunocompromised and at higher risk for infections, including hospital-acquired infections. Eventually, he was discharged about two weeks later to yet another rehab facility after being treated with multiple antibiotics.

Two weeks later he came back again. Actually, he had two emergency room visits in between as well. This time, he had developed serious bleeding from his gastrointestinal tract, requiring many blood and platelet transfusions. Over the next 6 weeks, he developed sepsis again and multiple infections, and also developed respiratory failure requiring intubation to help him breathe. Although after several weeks we were able to take the tube out and he could breathe on his own, he was still incredibly sick and his prognosis was very very poor. After many discussions and having dealt with this for nearly 6 months, his wife decided to make him DNR. After 6 more weeks in the hospital and the ICU, he eventually died.

I tell this story because sometimes, it can be amazing what a relatively simple procedure can lead to. I would not call a bladder removal a simple procedure, but I'm pretty sure this patient and his wife went into the operation with an optimistic attitude. He had bladder cancer, but it would be removed, and he would have to pee in a bag for the rest of his life. Traumatic, perhaps, but something you could live with. Instead, he had 6 months of increasing medical complications that eventually led to his death. I don't think the doctors did anything wrong at all, or could have done anything differently - sometimes it's just bad luck and unfortunately, patients and their families are often not prepared for things like this.

George Carlin video about swear words

Well, George Carlin died of heart failure today so of course this news is everywhere. I just watched this video for the first time. It's his famous bit about swear words. I'm not going to say much about him because I honestly didn't know him that well or watch him that much, but this is HILARIOUS.

Back to work again....

It was time to go to work again, which was a bummer after such a nice weekend. Plus my team had a ton of patients after last week. Up to 20 patients were on our list, and my team is just Boipelo and I! I believe all the other teams have at least 3 members to do all the work, if not more. And we had to round twice because Dr. Stefanski didn’t know he was still covering for Sara. So Dr. Gluckman sorta rounded with us, then Dr. Stefanski rounded with us again when he got back late morning – we didn’t really finish rounds until 3:30!!! And we had very little time left to do all our work. It was a little frustrating. But Phil helped me out by drawing bloods quite a bit at the end. I guess it was his way of paying back all the help I gave them earlier. Hopefully those will go through and I’ll get results because the computer system for ordering labs was down… I had to manually fill out requisition forms, and those don’t always work. :(

When I got home, I got motivated and made a beef stew with carrots and onions. I didn’t use potatoes because I like to put it over rice. But I usually thicken it with corn starch, which I didn’t have, so I used flour – that worked pretty well, but I got impatient and didn’t put enough flour, so it’s more like really thick soup than stew. But it’s still good. The flavor is great, but some of the meat is pretty tough. But some of it’s soft. So it’s still good. :)

The second day at Tau

We got a wakeup call at 6:30 am today for our second early morning game drive. The first thing we saw were these little vervet monkeys sitting right on our roof! They were pretty cute. During our gram drive, we spent most of the first part of the morning chasing after the mother lion and her 5 cubs, but it was so cold she probably had them hidden away. I was glad I brought all these warm clothes – it was pretty windy and chilly. Some of the other people didn’t realize how cold it was going to be (which I think is a little silly) and didn’t bring much warm stuff.

The first things we saw were more elephants – two more bulls traveling together. Hein also took us on a short walk to see to some elephant bones. This female elephant was one of the lucky ones and actually died of old age. They live about as long as humans do – up to 70 years. Even years after they die, the other elephants will drag their bones around and spread them around. Hein said this was a sign of respect. A few of us took pictures holding Hein’s gun next to the elephant bones – which was a little silly. Being medical people, we also spent some time trying to figure out exactly which bones were which - there were maybe 5 large pieces strewn about. The skull was easily identified of course (it has a huge nasal cavity!), but the rest of the pieces were a little tougher. We thought we identifed the hip bone and maybe a femur, but we were just guessing. Hein thought we were funny. :)

Then Hein took us to a fenced enclosure to see these 3 wild dogs that the park was releasing in a few weeks. They looked like they could be pretty savage animals – I’m glad they were fenced in. There’s already one pack of wild dogs in the reserve, and I think Hein said they were hoping that another pack would form. Hein said that the existing pack once took down a rhino! And they start eating it before it dies, and he said it was pretty brutal – it was several hours before the rhino finally died.

We finally also saw some zebras – there were 3 or 4 of them right next to the trail! They weren’t too scared of us – we stopped right next to them to take pictures and they didn’t run away. Kiona really liked these, and I thought they were cute, but nothing that great. We had a break where we had coffee and tea, and Kiona did some acrobatics. :) And finally, we saw some white rhinos in a pack. They were a little away from the dirt road, so Hein took us off-roading (which he’s not supposed to do) to get a little closer. They were pretty skittish and ran away a little bit when we drove up, but we still got pretty close to them. We saw a few other deer-like things, I think kudu, but they were mostly running away from us and we didn’t get a good look.

When we got back, breakfast ready! It was a huge buffet of eggs, pancakes, bacon and sausages, fruit, cereals, sautéed mushrooms, breads, breakfast pastries, and I’m sure a ton of other things I can’t remember. It was great, especially the sausages. I really can’t say enough good things about the sausages here. It was also somebody’s birthday and towards the end of breakfast, the entire staff came in dancing and singing, bearing a birthday cake! It was a pretty impressive scene and must have lasted close to 20 minutes. One song would end, and they would start another one. It’s amazing how well every single person can sing, and even harmonize.

Then it was time to leave… Goodbye Tau!

It was a super busy weekend already, but it was Steve’s last weekend in Botswana (although he will be coming back in six weeks) so Michael organized a Braai (barbecue) at ICC flats (where we live) and had Steve and Barry over. None of us were hungry, but we had a huge amount of meat again. And Steve made bananas foster, served with ice cream for dessert. He also made a little speech saying how well we were all doing, and how well we had adjusted to everything – I bet he gives a similar speech every time he leaves. :)

It’s actually very nice outdoors – our flats have a large outdoor area, which includes a pool, a large barbecue pit, along with smaller grills, tables and chairs, and shaded wood benches for sunbathers to lie on. It’s also very nicely landscaped, with all sorts of different flowers, plants and trees around. I think it takes quite a bit of water to keep it up, which is a commodity here in Botswana. It actually rained for about 5 minutes! I bet Motswanas were overjoyed for a split second. Apparently last summer they got a ridiculously low amount of rain, something like 3 cm. And they need the rain.

Abusive, Arrogant Doctors

This is an interesting article. It talks about how arrogant and abusive doctors can (not surprisingly) really affect the health care of a patient, not to mention affect the workplace and those around them. I've definitely run into plenty of them myself and experienced it firsthand, not to mention heard of other abuses plenty of times. It's a very unfortunate and inappropriate problem. As the article points out, I think the good thing is that there is awareness of the problem and steps are being taken at every hospital to minimize and eliminate it. Interestingly, many of these doctors happen to be surgeons - go figure.

I just also wanted to mention that I've been on the receiving end of this from not just doctors but also nurses, physicians' assistants, nurse practitioners, you name it. So although I will agree that it's much more prevalent in doctors than other medical staff, it is definitely not phenomena limited to MDs alone.

Valium wonderful Valium, Skype wonderful Skype

This was a frustrating day – I spent 2 hours in the CT room trying to get one of my patients a head CT. He’s confused and agitated, so after trying at first to get him to stay still in the CT, the tech called and said the patient would have to be sedated. So I gave him 10mg of Valium (diazepam) and took him to CT. He fell asleep for about 30 seconds, but woke back up. So 30 minutes later, I gave him another 10mg of Valium. He got more drowsy but was still awake! So finally I gave him his 3^rd ampule of 10mg of Valium, which is the max you can give. He finally fell asleep, but by the time he got his CT pre- and post-contrast, it had been 2 hours. Super frustrating.

Then I got this new admission, even though it wasn’t our day to admit. Dr. Gluckman got this patient from a private doctor who likes to admit only to Penn teams. The patient was a very interesting patient – he had crazy cardiac findings on physical exam, mostly related to aortic insufficiency and right heart failure. But the patient became very focused on this epigastric pain, which I thought he was saying was cardiac at first. But then he said it’s around his stomach, and it only happens when it gets dark and he lays down for a while. So I thought it was reflux, but the patient didn’t think so – I got a nurse to translate and she said it’s traditional medicine for a “traditional” ailment. The way she described it, something (like something he ate) would be trying to eat itself out of him at night, so he had to go to traditional medicine to have it taken care of. He said that when he got this pain, it felt like he was going to die. After another 2 hours, and this is at the end of the day, he finally said that he was willing to try our medicines, and I gave him an antacid, a proton pump inhibitor (omeprazole), and Tylenol. I really really hope that works.

Then I went home with Phil and Lisa after helping them out a bit and we went to Choppies, the local grocery store. Lisa and I cooked pasta and made this yummy cucumber, tomato and mozzarella salad with homemade vinaigrette for us and also for the on call team once they came back (Kiona, Kristy, and Mike). Then I realized that I left my clipboard (which had all my notes and signout and everything on it) in the female ward while I was helping Phil and Lisa out, and I was soooo upset. I was also worried because I wasn’t 100% sure where I had left it. And I tried calling Kiona (and Kristy – they’re sharing a phone) a few times, tried calling Mike, the hospital, the ward… nobody was answering! It was super frustrating. And Phil helped me out by texting too. Finally one of us (not sure who) got through and Kristy called back on Kiona’s phone. I told them my problem and she said they would look. When they finally got back at 11, they had it! And they were very happy to have food. So everything worked out, even though it was a relatively frustrating day.

Oh, another good thing that happened was that I downloaded and installed Skype! I bought some money on it and called Pete… it’s so cheap! It costs like 4 cents per minute to call any phone, and if you call another computer that has Skype, it’s free! So once Pete gets Skype and gets a headset, we’ll be in awesome shape. And it was sooo nice to talk to him for 15 minutes today – we got cut short because his phone ran out of juice. Isn’t that typical?

A traditional Botswana dinner

We were hoping to go to Mokogolodi game park today for a game ride, but it turns out they were all booked. So it was a pretty chill day, which was nice for a change. And to my surprise after the night before, I actually didn’t feel too sick when I woke up. I thought I was going to get a raging cold, with maybe fever and chills, maybe GI symptoms like other people had. But it was mostly a super sore throat with congestion. I stayed in my PJ’s until noon, and then threw a Frisbee around with Lisa and Kristy for about half an hour. Then I took a 2-second dip in the pool at the apartment complex – it was freezing! I guess the nights are still pretty cold here and the pool doesn’t have enough sun or time during the day to gather any warmth. But laying out in the sun felt pretty good. I also managed to set up my blog for the first time, and took a nice nap.

For dinner, we went to the house that Dr. Gluckman and Dr. Nathans are staying at (Malek house) where they cooked us a traditional Botswana dinner. It was soooo good. We had chakalaka, which is actually a vegetable stew dish with all sorts of different Botswana spices. You can buy it in a can, and it's still really really good - you can dress it up some, add some stuff to it, and it can also come with beans added, or other things, and it’s just really good. We also had this thing called sampa, which is a starchy corn dish that you eat with all the flavorful stuff. Also on the menu were beets, salad, veggie skewers and of course, the barbecued meat. The meats here are amazing! I especially like the sausage here, but they also made barbecued chicken wings with a special sauce, and beef skewers. They just have so many different types of meat in Botswana - beef, chicken, fish, ox, goat, livers, and other types that I can't really think of right now, and they cook them all so many different ways! I wish I knew what spices went into these dishes so that I could replicate them when I get back to the states.

So at the dinner, I ate until I was stuffed! Man, I thought I would be eating less here in Botswana, which turned out to be true the first few days, but now I'm eating even more! It's a problem. But not one I'm super upset about. The thing is that lunches here are so cheap and huge and chock full of meat. You can go to the cafeteria and buy this huge lunch for the equivalent of $3 or you can go outside to these ladies with pots of food on tables and buy similar food to what's in the cafeteria for the equivalent of $2. And it's all meat laden (although you can just get vegetarian if you want - and the veggies and salad are amazingly good too), and huge portions. I always eat it all too, it's just soooo good. I usually eat such a huge lunch that I'm not very hungry for dinner, but that's good - I don't need to be eating a big dinner when I have such a large lunch.

Water in Gabs

We went to the yacht club today after work, and enjoyed a gorgeous sunset. I went with Amy, Michael, and Michael's fiancee (whose name escapes me at the moment). It's set over the Gaborone dam, and people can take boats out on the small lake. The yacht club itself is pretty nice - the clientele is almost entirely made up of ex-pats. They serve plenty of alcohol, and some food that they mostly warm in a microwave or grill. Apparently it gets quite crowded on friday and saturday nights usually, but tonight was unusually calm.

This dam provides most of the water for Gaborone and the surrounding area. Right now, the lake is super super low, which you can see by the water line. Last year, Gaborone (and the rest of southern Botswana) experienced a severe drought - they had a ridiculously low amount of rain. I think it was 2.5 cm or something like that for the entire summer. And the couple of years before that was not great either. I think the last time they had great rain was 4-5 years ago. And before that good year, there was a drought for a period of years as well. So it's been relatively dry for southern Botswana for the last decade or so.

As a result, a lot of people have stopped farming and are trying to eke out a living doing other things, usually in urban centers. Cattle look really skinny because there's nothing to eat, and livestock of all sorts are not doing well. It rained for about 5 minutes during our braai last weekend, and everyone was jumping for joy. Rain and water is so important that the word for rain, "pula," is also the word they use for money. That's also what you say when you raise your glass in a toast, like "Cheers!"

Hopefully this year Botswana will get lots of pula!

Night Float

What can I say - I've been on it this month and it sucks. Let me count all the reasons why:

1. You're taking care of 12 interns (plus or minus some medical students) worth of patients at night, which is up to 120 patients. All the little (and big) crap that interns normally get called about during the day gets funneled through to night float. Depending on the intern, sometimes they don't do a very good job of taking care of issues before they leave for the day, so then you have to deal with it at night.

2. You're exhausted. At Pennsylvania Hospital, we work from about 5pm until 7:30am for an average of 3.5 days a week. If you say that's about 15 hours a day, that averages 52 hours a week, which isn't bad, but the timing is horrible. Usually we work 3-4 days in a row. For those days, I usually get home around 8 or 8:30am, shower, maybe get something to eat. I finally get to sleep around 9 or 9:30am, and then get some bad sleep before getting up at 4pm again to go to work - even if I sleep the whole time (usually I waken quite a few times, sometimes for more food), that's barely 7 hours of sleep, and it's never good sleep.

3. You feel very isolated and you never seen anyone. You're completely time-shifted and if you live or have a significant other, you often leave for work before they get home, and you often get home after they've already left for work. So if you work a number days in a row, you might not see them for quite a while. Moreover, you work during the nights half the time, and the other half the time, you're exhausted or recovering from working multiple days in a row, so you never see your friends since they all get together during the evenings. You don't even see your colleagues much - you see most of them for signout when you get there and before you leave. You really only see a couple of people throughout the night, many of whom are also busy. So you spend much of the time alone - it's very isolating.

4. Nighttime is generally a bad time for patients - for whatever reason, if patients start to deteriorate, they often do it at night, so you deal with a lot more critical issues and patients whose hearts may stop beating or who stop breathing. There are many fewer doctors and nurses around at night, so you have less help and have to make many more crucial decisions on your own, which can be daunting at times.

5. The food is horrible. I basically eat cafeteria food around the clock when I'm working, so I usually get cafeteria food only for 3 or 4 days in a row. It's horrible. Although one saving grace is the pancakes on the weekends. Sometimes residents will order out, but unless they take care of it, I often don't have time. Plus that costs a lot of money, so I don't want to do that too often.

One more week to go.

My team at PMH

We were on call tonight and got a lot of patients. We have a new MO – Mpho Mpape. She’s not very good. But she’s pretty good at doing scut. She disappeared for like 3 hours in the middle of the day. But I guess then she stayed late (only until about 5) doing stuff.

There was a little tiff at the end of the night – Boipelo came on for call at 9pm and found a chart on the female side that said the patient was in the ward at 7:30pm and she got all mad because she had not been admitted yet. She got upset at Amy, the resident who was on call on the female side, and also at Shabnam, the Indian MO who is on call until 9pm. But both of them said they had not seen any new admissions! It’s interesting – the MO’s are very strict when it comes to whom new admissions are clocked by and which team new patients are assigned to. It makes sense – they don’t want to do any more work than absolutely necessary. In this case it turns out that Amy had already clocked this new admission but the nurses lost the admission note and so put the file back into the new patient box. So Amy was able to find the lost admission note and put it back in, but people were still aggravated at each other.

In general, I think my team is great, even though it’s the smallest one. We have as much work as every other team, but for some reason we don't get any new students, residents, or interns! At least so far it has been manageable. Boipelo (our MO) has always been there, although she’s taking the next two weeks off for vacation, starting Monday, and is being replaced by Mpape. She’s actually on call tonight. Not all the MO’s are that good, but she’s pretty good, even though she definitely has an attitude and is pretty cynical. She also works pretty hard. The work ethic is pretty interesting around here. Most of the Motswana MO’s and some of the doctors work relatively slowly, compared to the doctors in the U.S. It’s just a different pace – they tend to take 1 hour lunches (at least) and they don’t rush to try to get everything done. If by 4:00 pm there are some things that are left to do, they just leave anyways. They just try to get to the most important stuff early in the day. This I understand, but not necessarily agree with. There is just so much to do that sometimes one person just can’t get to it all. I do get frustrated on occasion, because there doesn’t seem to be a need for 1-2 hour lunches when you can be working on patients!

I think especially on the teams that have Penn people, the MO’s have a lot less work to do because the Penn people are “extra”. And on call nights when Penn people are on call, the MO’s tend to take off early or disappear, because we are also “extra” help on those nights. It can be really frustrating – often, an MO will just disappear for hours at a time because they feel there’s someone else there to do the work! Some of them are really starting to take advantage of us, and the MO’s are starting to fight to be on teams that have Penn people so they don’t have to work so hard. It’s annoying, because although we are there for patient care, Penn people rotate in and out, and we don’t always know the correct way to do something, or what resources are available to us. And more importantly, we can’t speak Setswana, so we need those Motswana doctors and MO’s to help us translate! It’ll be interesting to see how this plays out in the future because I don’t see it getting better unless there’s some kind of intervention.

Each team also has a specialist, who is equivalent to an attending in the states – they make the big decisions and do a lot of teaching. For my team, the specialist keeps on changing. The first two weeks it was Dr. Stefanski, the next two weeks it was Sarah, and now it’s Shanthi. They all do quite a bit of teaching, and are all very good (not all the specialists are good) but I think I liked Sarah the best because she knows how the hospital works and helps us out with the work after rounding. Shanthi will probably be like that too, but she’s relatively new, and is still learning the system.

Below is a picture of my most recent team – it’s Boipelo, Sarah, and I.

Sitting at Tau

This was such an exciting trip! Tau is a lodge in the Madikwe game preserve just across the border in South Africa. It’s basically like a resort – they pamper you, feed you extremely well, and in between meals, they take you on game drives.

We left for Tau at 10:30 am. Steve drove all 10 of us (Barry, Mike, Tara (Mike’s fiancée), Lisa, Kristy, Kiona, Josh, Anne, Betsy and I) there even though he wasn’t staying himself. We all squished into Gill’s (she’s the administrator for this Penn in Botswana program) Land Rover, which fits 10 tightly. It’s not that long of a drive – maybe 30 minutes to the border, then you have to get out, get your passport stamped on the Botswana side, walk/drive to the other side, get your passport stamped on the South Africa side, and the Madikwe game preserve is right there! But we had to drive another 20 minutes or so on dirt roads to get to Tau Lodge.

The pampering started immediately – we got out of the Land Rover and the served us glasses of champagne with juice. They gave us a little tour of the main area – there’s a big building that is located centrally, with 15 huts on either side of it. The capacity of the entire lodge is 60 people (30 huts). Inside the main building there was a large dining area and a large lounge on the first floor, complete with fireplace, gift shop, reception, etc. Upstairs, there is a large bar, with a TV, computer area, pool table, and more tables and couches to sit and chat at. This upstairs area opens up into a large outdoor porch that overlooks this huge watering hole outside of the lodge. This watering hole is amazing – more on that later. Outside, there was another large dining area, which surrounds this huge outdoor fire pit. There’s also a heated pool outside and more areas to sit and drink and hang out.

After this tour and explaining our time table, they took us to our huts, which were super posh. There were two twin beds with mosquito netting (which is just for looks) in a small room, heated blankets, a porch with a personal view of the same watering hole that you can see from the main lodge, a large bathroom with a bathtub, and attached to it, an outdoor shower! I never got to use it – but it seemed really cool. There is a large brick wall that shields you from the outside world, but the top is open to air. It would have been interesting to take a hot shower in relatively cool air. From the porch you got a great view of the watering hole, where animals would just walk up to drink from, and you couldn’t see any other huts or people. You’re protected from the animals by this electric fence that I believe encompasses the entire game preserve – which is huge. But apparently sometimes the animals come right up to the electric fence, which is only a few feet from you!

So that afternoon, after settling in our rooms, we sat around for about an hour first on the porch of the main building and watched the watering hole. It’s amazing how many animals you see just sitting there! It was really nice weather, and these animals just come up to the watering hole. We first saw kudu, which are deer-like animals – they’re probably the most plentiful mammal at this game reserve. We only saw the male, although Steve said that often there’s a female following several yards behind the male. It was amazing, just sitting there on the porch watching the water hole, we also saw hardebeest, a family of wild boars. The boars were pretty skittish and they run funny… their little legs can move them pretty fast, and their heads bob up and down and they keep their tails high as they run. We also saw a sable, which according to Dr. Gluckman, are very rare. They’re amazing animals though – very noble and statuesque. And finally, we saw baboons! I know Pete would say ewwww! There was a huge clan of them, maybe 20 or so. And there was one huge old male baboon that mostly just sat around while the younger ones climbed trees and played around.


There were also tons of birds, which I can’t even name. We saw a Jesus bird, which has a more indigenous name that I can’t remember. It walks on water. There were some big hawks, and white stork-like birds. These little birds, called weaver birds, build these really cool nests in the trees. They build them at the end of thin branches, and they hang there, like a big drop of water. Apparently, the male builds the nest, and if the female doesn’t think it’s up to snuff (probably because it’s not sturdy enough or something), she knocks it down and he has to rebuild it! I find that pretty funny.

Medicare sucks

There are a lot of changes going on in health care. One is that pretty soon in Pennsylvania, it will be mandatory for hospitals to report hospital-related infections. Now, I believe this is a very good step overall. For one, it's important for hospitals to keep track of something like that, and to take steps to lower the numbers. It is probably impossible to completely eliminate it, but it's crucial to reduce it as much as possible. Although hospitals should already be taking measures to do so, I think mandatory reporting will go a long ways toward speeding hospitals along. Secondly, I think it's good that patients will be able to access this information and see the rates of hospital-related infections at different institutions. This may help them make health care decisions, which in turn, will pressure these institutions to lower their rates of hospital-related infections.

However, I also see some potential problems. For one, I have heard that Medicare is going to stop paying for hospital-related complications and infections. Now while I believe that many hospitals will be able to reduce these by quite a lot, hospital-related infections will never be completely eliminated. Let me give an example.

A patient comes in because he had a heart attack. He's on the older side, also has hypertension, and congestive heart failure. The heart attack really does a number on his heart and it starts failing. He can't pump his blood well, fluid builds up in his lungs, he can't breathe, and he gets sent to the ICU and gets intubated - that's getting a tube thrust down your pharynx so that you can breathe with the help of a machine. This is a life-saving intervention. Without it, this patient would have died. However, several days after intubation, the patient develops a rip-roaring pneumonia. He gets treated with antibiotics and gets better. Eventually, the patient's heart gets better, he gets extubated (the breathing machine is removed), has open-heart surgery and lives another happy 20 years.

A relatively high percentage of patients that are intubated develop pneumonia. While this is serious, it can be treated with antibiotics. Medicare is saying that they will not pay for the antibiotics, because this type of pneumonia is a hospital-related infection - even though this infection was the result of a life-saving intervention! This is not the only example of something like this - there are many others.

Who is going to pay for the cost then? The patients? No - they never have enough money. So it will go to the hospitals. They will have to eat the costs and make up for them by billing more for just about everything else. Would it be ethically okay for the hospital and doctors and nurses to say, well, this patient will probably develop pneumonia if we intubate him, and we won't get paid for that, so nevermind. Let's just let him die. Of course that would not be ethically acceptable, and of course that won't happen.

I think it's ridiculous and sustainable for neither the insurance companies nor the hospitals.

Paul Levy, the president and CEO of Beth Israel Hospital in Boston posted about this topic and I think he also brought up some very good issues.

The hospital crowd

So more about the patients and the hospital… Working at the hospital has definitely been an interesting experience! The patients here are so different from the patients in the U.S. There are usually 8-10 patients in a cubicle, with about 5 cubicles in each ward. Often, a small office gets turned into a 6th or 7th cubicle to cram another 5 patients into. Sometimes patients don't even have a bed, they have a mattress on the floor, sometimes in the hallway, if it's too crowded. The ER never closes because the hospital is too full, you just squeeze more patients in. There is absolutely no privacy - you're lucky if you get a curtain to draw around a single patient. You do procedures at their bedside, often with other patients looking on. The picture below is one of the better cubicles (the "high-intensity" cubicle for sick patients - which is right in front of the nurses station should a patient need immediate attention) on a very uncrowded day. There are no patients on the floors and there are a good number of curtains up.

So the patients are crowded together, usually not more than a foot from each other, they have no TV, no books, nothing, and visiting hours are only from 6-7:30am, 1-2pm, and 4-5pm and 6-7:30pm every day. And surprisingly, the hospital and the nurses are very strict about the hours. So right at 1pm, all these friends and family stream in, and right at 2pm, they leave. They're actually sort of necessary because the hospital is so understaffed that often the family helps bathe the patients or feed them if the patients can't feed themselves. The patients come in pretty sick too, because they often don't want to go to the hospital until their symptoms are super bad. Despite all this stuff, the patients rarely, if ever, complain. They just sit there everyday and wait patiently for us to come see them, and to get better. It's such a change from the U.S. patients, who have such a sense of entitlement, and demand every little thing, even things like mashed potatoes for dinner or something.

Patients rarely sue anybody here, and they put up with a lot more crap than do patients in the U.S. I guess that’s necessary because I think mismanagement of a case is pretty common. I think there are a variety of reasons for it – number one being the fact that the hospital is way understaffed. There are not enough doctors, nurses, social workers, physiotherapists, anything you could possibly think of. I also believe (and this is almost definitely egocentric) that the doctors and nurses here are not as well-trained, and so there is some medical mismanagement because of that. The Penn people are very good, but the other doctors sometimes are just here to do their job and make money (not that it’s a huge amount) – they don’t put in the effort to learn, teach, or really help patients get better. I’ve seen so many patients come in with congestive heart failure get put in fluids, or people with focal brain tumors that are obvious on physical exam, get diagnosed with meningitis. It’s a little embarrassing sometimes. Of course, when you get 10 admissions in a night, and are covering 100 other patients, sometimes it’s difficult to do an appropriate workup of a patient. But still, the lack of knowledge can be appalling.

There’s this one M.O. (a doctor who has only finished internship only) the other day who was getting grilled about a patient during intake as she was presenting. The patient had right upper quadrant abdominal pain, and she gave her differential diagnosis as pneumonia. Horrible. When the chief of the hospital asked her what else it could possible be, she could only answer pneumonia… so then he asked her what organs might possibly be in the right upper quadrant. She said spleen. And that’s all she could come with. And this is a doctor! Awful.

The nurses here are also very different. They don't do much here - they don't do IV's, blood draws, put in foley catheters, etc., so you have to do it all yourself. Believe it or not, I actually miss the nurses at HUP. :) I guess some things are still the same – some nurses and good, some are nice, some are moody, some refuse to do anything. There’s a whole variety.

The diseases we see here are different too - we see a ton of HIV and advanced AIDS-related illnesses here: TB (which can be anywhere), cryptococcus (which can be anywhere), PCP pneumonia, different cancers. I'd say about 75% of my patients are HIV positive, which allows a lot of this other stuff (TB, PCP, cancers) to happen. Botswana actually has a free HIV medication program (which is a whole separate topic for a different day) for all of its citizens. Even so, many of the patients refuse to take their medications and instead take traditional medications. They’ve caught patients throwing their medications down the toilet or in the trash before. And sometimes these traditional medications – we have no idea what they are – cause kidney failure or liver failure! I guess that’s the most frustrating thing about these patients, even though they are super nice and appreciative, and their families are by and large amazing in terms of support.

In general, there are so many patients you just can't take care of all of them - some stuff just has to slip through the cracks and you have to let it go. You're already working twice as hard as many of the Botswana doctors and at some point you have to go home, but that means some patient is probably going to die. Luckily I didn't have anyone die on me for my first two weeks, but it's really just luck - almost every team has an average of one patient die every day or two. I will probably have a patient die on me this weekend because there’s less care during the weekend. There’s usually two people covering all 100 patients, and they are really only required to see the sickest ones. It’s also difficult if they admit 10-30 patients over the weekend to see the other sick patients already on the ward – they are just so busy! However, other people just don't take as good care of your patients than you do when you're actually at the hospital. And any signout you give to the covering doctor doesn't usually get done, but it depends a little on who you sign out to and who’s covering the weekend. I guess these things are just things you have to let go because you can’t be at the hospital all the time.

Smallwood

From Smallwood Feb 7, 2009

That was a fun weekend.

Eating in the hospital

There aren't too many options for eating when you're working 10-12 hours a day and rushing around all day. To be honest, especially at the beginning, when I'm carrying a lot of patients, I'm so involved and busy I think my adrenaline is going all day, and I don't have much of an appetite! Even when we're at a meeting and there's food in front of me, sometimes I don't feel like eating. If you know me, you know that's unheard of - first of all, I usually have a huge huge appetite. Secondly, if there's free food, I'm there. But I power through - I make myself eat. :)

Even when there's time, and I'm hungry, one of the problems is that the only option we have is the cafeteria. Sure, you can order in or have something delivered, or take a quick 5-10 minute walk to somewhere to get some food, but all that takes more time and also costs more. The issue really is that it takes more time and that it's difficult to leave. You really have to be in the hospital at all times in case something happens to one of your patients, or to answer pages or put orders into the computer. I guess people can also bring food, but that's rare - you hardly have energy to make dinner for yourself after coming home from a 12-hour shift, much less lunch for the next day. A few people with significant others sometimes can do it. And you can do it sporadically, but it's far from common. So you are really limited to the cafeteria, and sometimes you don't even have time to go the cafeteria!

Even when you're able to make it to the cafeteria, the selections are horrible, limited, and repetitive. And the cafeteria closes down around 7:45pm, so if you are working a late shift, you have to make sure to get in early for dinner. For lunch, we don't have 5-10 minutes to wait for hot entrees to be made often (like cheesesteaks or grilled cheese sandwiches), so we often go for the quick already-prepared foods. Soup is always a good option, and inexpensive, but they go through the same soups every week so those get a little tiring. Sushi is also a good option (although it's not like it's great sushi), but it's expensive. The salad bar is actually pretty good, but it's not cheap and you can't eat salad everyday either. The hot entrees are also not cheap, are often terrible, but are very fast items to get besides soup and sushi. Other fast options include ready-made sandwiches (horrible), burgers, fries and onion rings, chicken wings, mozzarella sticks, and some other fried foods. The options are even more limited for dinner. Because of all these things, doctors usually end up eating horribly if they eat at all. There's a joke that doctor's are the least healthy people in the hospital.

It'll be nice when I can cook more again.