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.

STUPID ICU DOCTOR

I was the only one on my team that showed up today – the MO Boipelo was sick, and Dr. Stefanski is not at Princess Marina Hospital (PMH) on Tuesdays, plus he’s been sick himself. So I had a few problems today. The morning was great! I got all my work done, and it generally went smoothly as I rounded by myself, but I definitely hit a few snags this afternoon.

The main person that ruined my day was this stupid ICU doctor. The first thing he did was yell at me in the morning, as I was standing there doing nothing but writing my note in the chart for my one ICU patient. He was yelling at me about all the other ward doctors not coming everyday to round on their patients in the ICU. And went off on a tangent about how the ward doctors d/c (stop) medications inappropriately once their patients get to the ICU. He must have ranted for about 10 minutes and all I could say was that, well, I’m rounding on my patient in the ICU and this the reason we d/c’d the tuberculosis medications. So he was like, ok that’s reasonable, and said he didn’t mean to rant directly at me. But he did.

So my patient in the ICU was supposed to get a CXR (chest x-ray) two days ago when he was transferred, and they dropped the ball and never got one, so I asked for one this morning. Then this afternoon, I looked at it, and I was a little panicked because he had a collapsed lung and a left pneumothorax! That’s air in the thoracic cavity, and can be really really bad if it starts compressing other structures, like the heart. So I run all the way back to the wards to ask an attending about the CXR to make sure I wasn’t totally interpreting it wrong, and she said I was right, and that I should call a surgeon immediately to put in a chest tube and decompress the air in the thoracic cavity. So I did. The surgeon said he’d see the patient in the ICU, and I went there right away. He got there at the same time I did, and the ICU doctor saw us right away, and came in storming. “WHO CALLED SURGERY?” And that started another rant. I told him the patient had a pneumothorax and he said there was no way. I said I was pretty sure, as both Dr. Gluckman and another attending had seen it. He still didn’t believe me and made me show him the x-ray, and then he got really mad. I think showing him wrong set him off – he started accusing me of trying to tell him how to do his job, and doing things the wrong way (apparently I’m supposed to tell him about the problem, and then he would call surgery). He must have yelled for about 10 minutes and went off on me with things like “WHY did you not call me first?”, “YOU AMERICAN DOCTORS THINK YOU CAN WALK IN HERE AND DO WHATEVER YOU WANT?”, “YOU’RE TRYING TO TELL ME I DON’T GET THINGS DONE RIGHT??” and “YOU DON’T THINK I’M CAPABLE?” I couldn’t get a word in edgewise, and finally I said I’m leaving, and he said FINE GO I DON’T NEED YOUR HELP HERE GO! I was super upset and, actually, pretty angry. I didn’t realize that I had to tell him first – I thought that since we rounded on the patient, and he wanted us to round on the patient, that we were calling the shots. But apparently he just wants us to round on them and not do anything. Absolutely ridiculous. And he definitely could have told me that I did things wrong in a better way than yelling at me for 10 minutes. Plus, he’s a moron – he didn’t diagnose that pneumothorax and I think he was pissed that I did.

So after I calmed down a bit, I called Dr. Gluckman and told him there might be a problem with the ICU doctor. He told me three main things. One, that I probably should have told the ICU doctor first because they are super super territorial. Apparently about two years ago there was a huge fight between the residents and the ICU doctors because the residents were changing the vent settings because they didn’t think the ICU doctors were setting them correctly. And the ICU doctors resented it. I understand their feelings though – I would probably resent it too if a bunch of foreign doctors came in and started trying to tell me what to do. Still, I think this is a stupid system – what’s the point of us rounding on them if we can’t do any management? If we transfer them to the ICU, the ICU doctors should just take over their care. The second main thing Dr. Gluckman told me was related to this – that in general, the ICU doctors resent all foreigners and automatically are biased against them. So it’s difficult for us to get anything done with them. And finally, he told me that they have a problem with women. So being a foreign woman, he probably didn’t like that fact that I pointed out that he didn’t see the pneumothorax on the CXR, even if it wasn’t my intention to highlight his stupidity. And actually, Dr. Gluckman said that he wrote a note (which I didn’t see) saying that if the pneumothorax was stable, we could probably wait until tomorrow to call surgery.

Anyways, at the end of the conversation, Dr. Gluckman said that if I was brave enough to go get the ICU doctor’s number, he was willing to talk to the guy. I told him who it was, and he was a little surprised – he said that he and the guy were sorta buddies! I was a little surprised too. I wonder if I mispronounced the name, or if Dr. Gluckman was thinking of a different guy. So I went back after calming down a bit, and talked to the guy. I apologized for any misunderstanding there might have been, and said that my intentions were not to imply that they were doing a bad job, but to help the patient. He was actually quite civil, but still quite condescending. I know now I should have gone to him first, but it sort of galled me to have to apologize to the guy when he couldn’t even diagnose the problem. And then he had the nerve to say that he did call the surgeon, but he didn’t think it was a pneumothorax!! He was going to let the surgeon make the decision about what to do, but he thought it was a mucous plug! I highly doubt it, and I argued for a brief second, but then I said, well, why don’t you just talk to Dr. Gluckman about it and asked for his contact number. He sorta was like, OH, Gluckman is your attending? And I said yes, because he basically was today, and has been helping me out for the last few days since nobody else on my team has been around. When I talked to Gluckman a few minutes later, he was like there’s no way that is a mucous plug. It doesn’t look like it on the CXR, and plus, this guy has PCP pneumonia, and getting a pneumothorax is actually pretty common in patients with PCP pneumonia.

That wasn’t it – after I finished with that ordeal, I had to come back and the relatives of this comatose guy were all there asking about him. So we had a family meeting (which I was hoping Dr. Stefanski or at least Boipelo would be around for) and I told them the prognosis really was not good. I told them they could meet again with Dr. Stefanski the next day, but I think I conveyed everything pretty well. But it was pretty tough too.

So that was the day… I was pretty drained at the end, and I went home at about 5pm. I felt guilty about that too – I normally stay and help Phil and Lisa out until we can all go home together, but I was drained. I didn’t tell them the story, but I think they understood.

ICU incident #2

I had another run-in with the ICU doctor today. My team went to the ICU to see our patient with PCP pneumonia and the pneumothorax. He had ended up getting a chest tube that night I had the first confrontation with the ICU doctor. We were in there seeing the patient when the ICU doctor came in. He asked me what I thought was wrong with our patient – I said the oxygen saturation was 86% (for normal people the oxygen saturation in the blood should be 100%), which is super super low, and pretty worrisome. He asked if that was okay, I said I didn’t think so, that I would prefer that it be above 90%. He asked if I knew why the patient had such a low sat, and I said because for some reason, he was unhooked from the ventilator. He said I was wrong, and in this case it was okay for the saturation to be this low. Then he asked Boipelo the same questions, and she answered the same way, and he just turns to both of us and says, you are both wrong and YOU KNOW WHY! And he stalks out of the room. We were like, okayyyyy. And we look at Dr. Stefanski, and asked him if he knew why, and he says no. That ICU doctor is such an idiot. So we write our note, and then we leave the room and run into the ICU doctor again, and Dr. Stefanski says to him “so I think you were trying to make a really good teaching point back there – could you tell us what the reason was?” And I pipe up and ask if it was because the patient looked clinically well despite having a very low oxygen saturation, and he just interrupts me and says “YOU INSULT ME LITTLE GIRL” and he stalks into his office. I was absolutely dumbfounded, as was the rest of my team! Boipelo starts laughing and Dr. Stefanski just says don’t worry about it. What an ass.

I was on call today too. It was finally pretty busy – I admitted 3 patients, and there were two more to admit when I left. That’s when Boipelo came back (she leaves from 4-9pm, but has to stay overnight) and she saw the two patients sitting there. I felt pretty bad, but I was pretty busy with other admissions and also from getting calls about random patients needing IV’s or falling out of bed, or getting nose bleeds. Things like that. She kinda gave me a hard time about leaving her all that work, but I think she was joking. Plus when we take call, we’re sort of “extra” help anyways – if we weren’t there they’d have to take all the patients themselves, so I don’t feel too bad. I had to get home, I was so tired, and I was still sick and coughing up a lung.

When we got home, it was really nice though – Kristy and Kiona had made dinner for us! They made us eggplant parmigiana and salad! They complained that it tasted like barbecue sauce, because the pasta sauce here is different from in the states, but I still really liked it. I had two servings! I was pretty excited, because the next day, we were going to go to Tau!

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.

Mira Loma High School and the Science Bowl

I just have to post something unrelated. I went to Mira Loma High School, and (shockingly) I was pretty nerdy - I competed in all the science and math competitions, including Mathletes, Science Olympiad, Science Bowl, etc. There were a few others that I can't remember off the top of my head right now, but our crowning achievement was winning third place in the National Science Bowl competition under our chemistry teacher, Mr. Torgeson, wayyyy back in 1994. This won us a week-long all-expenses-paid trip to Hawaii. Needless to say, for a bunch of high school students, we were ecstatic!

Well, it seems we've been outdone, as this year's team took first place, getting them a trip to Australia! See the link below for the article in the Sacramento Bee:

http://sacbee.com/topstories/story/1833334.html

Congrats!! I'm glad to see the legacy continuing.

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