Getting things done at PMH

It takes so long to get anything done here at Princess Marina Hospital – and people think HUP is bad sometimes. I’ve been asking for a portable chest x-ray for this guy with a pneumothorax since last weekend, and it still hasn’t been done. I can’t personally wheel him down to x-ray myself because, one, he’s on suction, and two, he’s on oxygen, and although we have one oxygen tank here in the ward, nobody has been able to find the valve that fits it. So I’ve personally gone to the radiology department every day, sometimes twice a day, and begged and pleaded for them to take their one portable x-ray machine down to the male medical wards, and take this guy’s chest x-ray. Half the time, the person who is in charge of portable x-rays isn’t there. Of course, all the people I talk to are radiology technicians, and they could all help me out, but none of them are officially in charge of the portable machine for the day. Then the other half of the time I finally find the person doing portables for the day, and he says, there was no request form (which is a crock – I’ve turned in like 5 request forms, some personally to the technicians), and I turn one in then and there because I’ve anticipated this, and he looks put out, and says, ok ok, I’ll do it this afternoon. I usually say something like, well can we do it now, because this patient is somewhat critical, and I can help you wheel things down and everything. And they always say no, they’ll do it this afternoon. Sigh.

Finally today, we took him off suction, and he was doing ok. He’d been off suction before, but never was stable for long enough for me to wheel him down to x-ray. And I also managed to find the valve for the oxygen tank – it leaks, but at least the patient can get some oxygen. So I pushed him quickly down to x-ray, and we took the film, and hurried and wheeled him back before anything bad happened to him. Thank goodness he didn’t crash or anything. I was patting myself on the back for going to all this effort to get a simple x-ray when I took a look at it. He’s now got bilateral pneumothoraces, and probably has a bronchopulmonary fistula – that’s a direct connection between the inside of your lung, and your chest cavity. Even in the states, that’s very very bad, and many patients don’t do so well. He’s probably not going to survive, which really sucks. I totally thought he was going to pull through.

The supply chain in Botswana

This was a relatively boring day at the hospital since this is our easy week, so maybe now I’ll talk about some another issue at the hospital – the supply chain! This is a favorite topic of Dr. Stefanski's, so we've had quite a few discussions about it.

So here at Princess Marina Hospital, probably the largest public hospital in Botswana, there are often problems with the availability of medicine, or of certain medical instruments, even very common ones. Last week, we ran out of amphotericin, which is a drug we use to treat cryptococcal meningitis - that's an infection in the cerebrospinal fluid that surrounds your brain and spinal cord. It's the type of thing that we diagnose with an LP, which I described in previous posts. Because a lot of people have HIV and AIDS here, a lot more here come down with meningitis than in the states - some of it is due to TB, some bacterial, some bacterial, but more often than not, it's due to cryptococcus. And amphotericin is really the only option they have in Botswana to treat it. Alternatively, you can use a whopping dose of fluconazole, but it doesn't work as well, and we also ran out of that for a few days last weekend. As a result, all these people in the hospital (and in the clinics probably) had no amphotericin, and also no fluconazole - their cryptococcal meningitis went untreated! Now, even if they had come in immediately and started treatment right away, this is an awful disease, and chances are not great that they'll survive. But if treatment is delayed or halted for a couple of days, chances are even worse! Our team didn't have anybody die, but I know other teams that did.

Dr. Stefanski told us this story about how last year, they ran out of the solution needed for peritoneal dialysis, which is a substitute for your kidneys, if your kidneys have failed. Dialysis isn't as common here as in the states, but there are still quite a lot of people on it. And they were out of it for a month! People were basically getting admitted to the hospital to die of kidney failure. Awful.

Apparently, the problem is not lack of money - the ministry of health has plenty of money. It is the largest ministry in Botswana, and controls the largest budget by far. The problem is that somebody or some group, whoever is in charge of ordering medical supplies for the country, did not realize that we were running low on drug X, or medical supply Y, and didn't order it. So the entire country will be out of whatever it is for a month at a time! Supposedly, they've had 3 big consulting companies (probably each making millions of dollars each time) come in and make suggestions as to how to correct the problem, but obviously that hasn't happened. It seems that every time there is a change in who's in charge, they get a new consulting company in (probably they're friend or relative's company) and get new recommendations, which aren't followed. It's such a ridiculous problem, and a very exasperating one that all the doctors complain about. I guess it's another thing to be thankful for in the States.

The patient wards at Princess Marina Hospital

So this might be a good time to talk about the hospital a little bit. I may have mentioned some of this before, but there are several wards at Princess Marina Hospital. Each ward is self-contained in a one-story building. The Penn people work mostly in the male medical ward and the female medical ward. There is also a private ward, an orthopedic ward, an oncology ward, a pediatric ward, an obstetrics ward, and maybe a few others I can’t remember. Baylor also has a huge ostentatious glass-covered air-conditioned two-story building that is for outpatient pediatrics. I say ostentatious because they just sorta came in and built this building on their own – this building uses so many resources when so many of the other wards are super crowded, have no supplies, and have no air conditioning. In fact, as it’s getting hotter hear, it’s getting smellier – I can’t imagine what it’s like in the summer!


Each of the wards are a little different, but I hear the male and female medical wards are the most crowded and the most lacking in common supplies. The private wards are the nicest – patients either get a room to themselves, or they share with only one other patient. The nurses are a lot nicer and more competent on the private ward, and they always have enough supplies and medicine. Of course, patients have to pay 80 pula per night, which is quite a lot for the average Motswana. For example, our maid makes only P600 a month. In contrast, for the general male and female medical wards, patients pay a processing fee of P2 (I think) at the A&E (accidents and emergency – the equivalent of our ER) and if they get admitted, everything is covered by the hospital – that is, if you’re a citizen of Botswana. There are quite a few Zimbabwean citizens here (probably because the situation is not very good in Zimbabwe) and a lot of the prisoners are also Zimbabwean.

The oncology ward is always super crowded, but the specialist there (there’s only one) is really good – his name is Dr. Paleski and he’s Polish or something like that. He’s very political, with a definite liberal bent. He’s famous for asking someone when he first finds that they’re American – so what party are you, or so what do you think of Bush (in his accent)? Even though he’s not connected to the U.S. he hates Bush and republicans, and writes letters to them all the time. It’s pretty hilarious. I think he and Pete would get along pretty well - I bet they visit the same blogs. :) He’s pretty brusque and somewhat brutal too, with everyone, but he’s very good. Like he’ll do a bone marrow biopsy without asking the patient if it’s okay – he just jabs a huge needle in the patients sternum, the patient screams for about 10 seconds, but then he’s done. And he works very hard. He sees all these patients at clinic during the day, as well as the people in his inpatient ward, and does all these consults and biopsies of other patients in other wards as well during the day, and then goes home and looks at slides all night to make diagnoses. I think he’s burning out.

I haven’t been in the pediatrics ward or the obstetrics ward, but I believe they are pretty similar to the public male and female wards, but perhaps less crowded. The pediatrics ward is only for those patients under 14! So on the male and female wards, we still see quite young patients, who in the U.S. would be considered pediatric patients.

It’s funny – the gripes you hear at the hospital here are in some ways very similar to the gripes you hear at American hospitals. We’re constantly wondering why a patient needs to be admitted to the hospital – ideally a patient should only be admitted if they really need critical care in the hospital. If they can be managed as an outpatient, then they should be. We also wonder why some wards transfer patients to us. For example, the orthopedics ward is famous for transferring post-surgical patients to us because they say they don’t know how to manage somebody’s heart condition. Of course, that didn’t stop them from operating on the patient! Likewise, obstetrics transferred a patient to us for us to manage HELLP syndrome, which is an obstetric issue! I hear a lot of the same complaints at the U.S. hospitals, which is sorta funny. :)

There’s a lot more to talk about, but I think I will save a discussion about the patients themselves for a little bit later.

The first day at the Princess Marina Hospital

This was the first day of work! I started my first day on call on the pink male ward (there are female/male pink/green/blue wards). Kiona and Kristy are on blue female. Philip is on pink female, so we are on call the same nights. The good thing about being on call Monday is that the rest of the week is free! However, I only got 4 hours of sleep the night before. So the morning was rough. Every day starts out with intake at 7:30 am, where we go over the previous day’s admissions. Monday intake is super long because it includes all the weekend’s admissions in addition to Friday’s admissions. Then I rounded with Boipelo Lecoge (an MO, or medical officer, which means she’s finished internship at some point and may be working or in transition to residency) and Dr. Stefanski, a specialist (what they call attendings) from Australia. The residents act as specialists here, so Sarah would have been my specialist, but she left yesterday for 2 weeks to go back to the US to take boards. So Dr. Stefanski is covering for her. Mike Chattergoon is also a resident from HUP who is a specialist here, and he is on blue male, so he can be a resource for me when I’m looking for help with procedures or other things.

It wasn’t too crazy of a day, but I ended up admitting 3 patients all by myself – Dr. Lecoge did all the ongoing patient work while I was going to lecture and admitting. She had to go home at 4pm and came back at 9pm because she was on call. Mike left early because he got sick, so I didn’t really have him to help me out either. All the other students are on the female side so I don't really have their support either. Meanwhile this other MO Suna was the covering MO for both the female and male wards and she was awful. She kept disappearing for an hour at a time and she didn’t really want to help me out until Dr. Stefanski made a point to ask her to help me out. All in all it was an okay day. It will definitely take a while for us to adjust to this new hospital and figure out how everything gets done.