1-2 Dec 2008:
Monday brought another day at Greys Hospital with Dr Gounder, the former Edendale registrar turned private doc who attends at Greys a couple days a week. We saw another pacemaker insertion in the morning… but this one was more complicated, as first he entered an artery instead of a vein, and then later the patient had sustained ventricular tachycardia (a bad heart rhythm) upon pacer insertion. He stayed stable and talking to us throughout, but it probably lasted for 5-10 minutes before it stopped. Suboptimal. Since this case took longer than normal, we were left with less time for morning rounds, which meant they were less interactive and less didactic, which was also suboptimal. Alas.
That evening Rachel and I again fulfilled our obligation as part of the Zulu meal plan to cook, and we chose to do a Mexican night. I made veggie quesadillas (mushroom, tomato, avocado, cheese, and kidney beans since they have neither black nor pinto beans here), and Rachel made tacos. They had never tasted anything like it, and they liked it. Their reaction to the crispy taco shells was “this tastes like Doritos” – they assured us this was a compliment. We taught them gin rummy as an alternative to Go Fish, but this was complicated by the fact that the deck is missing a king, a queen, and a two (easier to work around in Go Fish). I spent a fair bit of time that night preparing my talk on the HIV transmission paper before turning in.
Tuesday we went on another Red Cross trip (driving instead of flying again), this time to Christ the King Hospital in Ixopo. I enjoyed exploring the region featured in Cry the Beloved Country; it was indeed an area of beautiful green valleys and rolling hills. Fortunately the hospital was not as bible-thumping as its name might have suggested. We again started the day with the third iteration of our sepsis talk, and we probably got the most engagement on the subject that we have had on these trips. It evolved into a discussion of how to manage medical illness in resource-limited settings where blood products, monitoring, and opportunity to mechanically ventilate are scarce. We then saw a lot of patients on the male and female wards; the two medical officers had very different presentation styles, and I was again struck by how much the manner in which a patient is presented affects the ease of providing input for a consultant. Lessons there beyond medicine, I’m sure. We were again able to provide input on many of the patients. One had been admitted overnight and was septic; the medical officer put our talk into action right away, which was good to see.
Another interesting and sad case was a woman who had been brought in having collapsed a week earlier. She had since been functionally quadriplegic and was being treated as a stroke patient. We examined her thoroughly and found her able to open her eyes to voice, cough, and track sounds with her eyes, but she seemed unable to make any other movements with her limbs. Reflexes were normal throughout. I asked how they felt a stroke might explain these symptoms, and they weren’t sure. Our best guess is that she had “locked-in” syndrome, an unusual and devastating type of stroke of the basilar artery that feeds the brainstem, leading to loss of cortical control of the body. Patients in this state can open their eyes and perceive the world around them (as she seemed to be able to do) but not move at all. This is the type of stroke described in “The Diving Bell and the Butterfly”, a book (and recent movie) by a French magazine editor who actually suffered this type of stroke. He “wrote” the book thanks to a speech therapist who heroically devised a way for the patient to communicate using a card with letters and a series of blinks. She would scan her finger over the card and when she came to the letter he wanted to write next, he would blink his assent. Thus, letter by letter (!), he wrote the 100-page book that was published within a few days of his death. In any case, this was our best shot at explaining her symptomatology, and we quickly arranged for transfer to a hospital with Neurology and an MRI and CT scanner for diagnostic purposes. Sadly, after a week of symptoms, if we are correct, nothing can be done to reverse the damage.
After seeing the inpatients, we wandered over to the outpatient department to see a select set of patients who had been referred to the attending clinic due to difficult management issues. Again, I found it more uplifting to see ambulatory patients who were overall quite well. We saw patients with cardiac issues or difficult TB management that were beyond the training of the NPs or residents who normally see them. After this, we had a quick meal and headed back to PMB.
On the way, it began to rain, and as we descended into a valley approaching PMB, I saw a bolt of lightning strike a hillside in the middle of a bunch of homes in PMB, followed closely by thunder. When we got home, the lightning and thunder were becoming more frequent and closer together, and the thunder built in intensity. Around 5 pm, as I walked past the doorway, I saw a flash touch just outside the door, heard a staticky sizzle, and immediately afterwards heard the loudest thunder I’ve ever heard. The lights immediately went out in the house. Two minutes later, it happened again – the flash, the simultaneous sizzle, and the immediate roaring thunder. We had been hit by lightning not once, but twice! Doesn’t that define an unlikely event? Upon inspection, it seemed to have hit the electrified fence that surrounds the house. Turns out the power went out because the surge tripped a circuit breaker; once I flipped this back on, the lights (as well as the internet’s warm glowing warming glow) returned. But the motorized gate to our house no longer worked, and a look at the wiring showed some black, charred connections. Unbelievable!
Thursday, December 4, 2008
Wednesday, December 3, 2008
Must be the clouds in my eyes
30 Nov 2008:
With some sadness, I climbed in the Land Rover instead of aboard a mountain bike and headed up Sani Pass. Our companions were a mother and daughter from Jo’burg, a pair of post-college kids from Belgium, and our driver, Busani. Making me even sadder, the weather was gorgeous on the way up. The road itself was very bumpy, rocky, and unrelentingly ascending. All told, it is about 20 km from Underberg, with an elevation gain of about 1600 meters (5000 feet). The longest uphill I’ve done in a day was climbing Mt Tam with my crazy German roommate several years back (20 miles each way and a fairly steep climb of 4000 ft at the end), but those were in bygone days when I was well conditioned. I’m sure I would have struggled with this one, and not just with the grade but also with the technical parts of quite a rocky climb. And the descent would have been sheer pain on the forearms and hands. But man, would it have been fun.
Anyway, we got gorgeous views along the way up the bumpy ride. Near the top, we produced our passports and headed into another country! Lesotho was beautiful in a mountainous sort of way. We first visited a village and were invited into a hut with a family (all pre-arranged with the tour group). Five very cute children ages 1 to maybe 10 watched us from the doorway as we paraded in to a circular mud and brick hut (bricks fashioned from cow dung) with no windows. We learned that the lack of windows was due to the extreme cold in the winter (20 below or more); they also had their only door facing away from the prevailing winds for the same reason. They had central heating as well, after a fashion: a fire pit in the middle of the floor with an array of larger stones arranged around it (buried under the earthen floor) to retain the heat of the fire. They would put out the fire at night when the door was to be closed, and these stones would remain warm and heat the house for the rest of the night. When they could open the door again for light and ventilation in the morning, they would restart the fire and begin re-warming the stones. They also cook in the fire pit, and our hostess offered us delicious bread made from the grains that constituted the majority of their nutrition. It was hot out of the fire pit and absolutely spectactular. The hut was maybe 15 feet in diameter, maybe less. It had a small bed at one end but most of the family slept on sheepskins on the floor. One side of it had a small bench that was a built-in part of the wall; we sat on this. The one-year old girl waddled up to me and hugged my leg right after I sat down, just before her mother whisked her up in her arms. After we heard about the lifestyle of a typical Basotho family (the name of the people in Lesotho), and learned a few phrases in Sisotho, we made a donation and I bought some crafts that the mother had made.
We then looked around the village a bit (briefly; it was very small) and our driver pointed out a nearby empty square building that was soon to be a school and clinic for the village. Apparently this and several other clinics like it had been donated to Lesotho villages by none other than Sir Elton John! No details were available on this unexpected benefactor. Busani also told us about some other Basotho customs, including that most boys headed up to the mountains by the age of 10 to herd sheep for the village; they would typically return to society at around 20, at which point they would be circumcised and be known as men. They decorated their walking sticks to commemorate this transformation; one can identify each Basotho man by his personalized stick.
After seeing the village, we went back to the top of Sani Pass to eat lunch at a pub (slogan: “The Highest Pub in Africa”) that adjoined the Sani Top Chalet (slogan: “Lesotho is not for wusses”. Seriously, that’s on their brochures, word for word. It’s part of a longer treatise about how this is more a lodge than a hotel, and things like “heat” and “running water” don’t always work). I ate well, tried Masuti (the only mass-produced Lesotho beer), and then left to find a dense fog had rolled in over the pass that obscured vision beyond 20 feet. At this point, I must confess, I was pretty happy not to be on a bike with that technical rocky descent ahead of me (though it would have been possible).
The part of Lesotho I got a brief glimpse of was much poorer than most of South Africa that I have seen. The land was barren except for sparse grass, barely enough for the sheep to gnaw on; for this reason the herds must constantly be on the move (shepherded by the 10+ year olds, mostly). The village was beyond simple, and they had to traipse kilometers to gather water or grain. There was one supply store owned by the rich guy in town; he stocks up in Underberg and sells to the Basotho people as they are able to afford goods. He is apparently doing well enough to have sent his children to Europe for schooling. Otherwise, though, boys do not get education beyond age 10 (shepherding age), while girls and young boys must travel great distances to school. Apparently 2 million people live there; this was hard to fathom given the small corner of it that I saw, as the country is quite small and what I saw was very sparsely populated and indeed did not seem capable of sustaining dense population. Perhaps things are different in and around Maseru, the capital on the northwestern end of the country.
We headed down in the mist uneventfully and headed on our way (but not before Busani gave us “certificates of adventure” for sitting on our ass all day). Back home, in Northdale, we had dinner with Sne (the 11 year old daughter of someone from the office) and she led us in a rousing game of Go Fish. She also told me my pronunciation of her full name was improving, but still not quite right.
p.s. another song reference in the title; maybe this one’s easier…
With some sadness, I climbed in the Land Rover instead of aboard a mountain bike and headed up Sani Pass. Our companions were a mother and daughter from Jo’burg, a pair of post-college kids from Belgium, and our driver, Busani. Making me even sadder, the weather was gorgeous on the way up. The road itself was very bumpy, rocky, and unrelentingly ascending. All told, it is about 20 km from Underberg, with an elevation gain of about 1600 meters (5000 feet). The longest uphill I’ve done in a day was climbing Mt Tam with my crazy German roommate several years back (20 miles each way and a fairly steep climb of 4000 ft at the end), but those were in bygone days when I was well conditioned. I’m sure I would have struggled with this one, and not just with the grade but also with the technical parts of quite a rocky climb. And the descent would have been sheer pain on the forearms and hands. But man, would it have been fun.
Anyway, we got gorgeous views along the way up the bumpy ride. Near the top, we produced our passports and headed into another country! Lesotho was beautiful in a mountainous sort of way. We first visited a village and were invited into a hut with a family (all pre-arranged with the tour group). Five very cute children ages 1 to maybe 10 watched us from the doorway as we paraded in to a circular mud and brick hut (bricks fashioned from cow dung) with no windows. We learned that the lack of windows was due to the extreme cold in the winter (20 below or more); they also had their only door facing away from the prevailing winds for the same reason. They had central heating as well, after a fashion: a fire pit in the middle of the floor with an array of larger stones arranged around it (buried under the earthen floor) to retain the heat of the fire. They would put out the fire at night when the door was to be closed, and these stones would remain warm and heat the house for the rest of the night. When they could open the door again for light and ventilation in the morning, they would restart the fire and begin re-warming the stones. They also cook in the fire pit, and our hostess offered us delicious bread made from the grains that constituted the majority of their nutrition. It was hot out of the fire pit and absolutely spectactular. The hut was maybe 15 feet in diameter, maybe less. It had a small bed at one end but most of the family slept on sheepskins on the floor. One side of it had a small bench that was a built-in part of the wall; we sat on this. The one-year old girl waddled up to me and hugged my leg right after I sat down, just before her mother whisked her up in her arms. After we heard about the lifestyle of a typical Basotho family (the name of the people in Lesotho), and learned a few phrases in Sisotho, we made a donation and I bought some crafts that the mother had made.
We then looked around the village a bit (briefly; it was very small) and our driver pointed out a nearby empty square building that was soon to be a school and clinic for the village. Apparently this and several other clinics like it had been donated to Lesotho villages by none other than Sir Elton John! No details were available on this unexpected benefactor. Busani also told us about some other Basotho customs, including that most boys headed up to the mountains by the age of 10 to herd sheep for the village; they would typically return to society at around 20, at which point they would be circumcised and be known as men. They decorated their walking sticks to commemorate this transformation; one can identify each Basotho man by his personalized stick.
After seeing the village, we went back to the top of Sani Pass to eat lunch at a pub (slogan: “The Highest Pub in Africa”) that adjoined the Sani Top Chalet (slogan: “Lesotho is not for wusses”. Seriously, that’s on their brochures, word for word. It’s part of a longer treatise about how this is more a lodge than a hotel, and things like “heat” and “running water” don’t always work). I ate well, tried Masuti (the only mass-produced Lesotho beer), and then left to find a dense fog had rolled in over the pass that obscured vision beyond 20 feet. At this point, I must confess, I was pretty happy not to be on a bike with that technical rocky descent ahead of me (though it would have been possible).
The part of Lesotho I got a brief glimpse of was much poorer than most of South Africa that I have seen. The land was barren except for sparse grass, barely enough for the sheep to gnaw on; for this reason the herds must constantly be on the move (shepherded by the 10+ year olds, mostly). The village was beyond simple, and they had to traipse kilometers to gather water or grain. There was one supply store owned by the rich guy in town; he stocks up in Underberg and sells to the Basotho people as they are able to afford goods. He is apparently doing well enough to have sent his children to Europe for schooling. Otherwise, though, boys do not get education beyond age 10 (shepherding age), while girls and young boys must travel great distances to school. Apparently 2 million people live there; this was hard to fathom given the small corner of it that I saw, as the country is quite small and what I saw was very sparsely populated and indeed did not seem capable of sustaining dense population. Perhaps things are different in and around Maseru, the capital on the northwestern end of the country.
We headed down in the mist uneventfully and headed on our way (but not before Busani gave us “certificates of adventure” for sitting on our ass all day). Back home, in Northdale, we had dinner with Sne (the 11 year old daughter of someone from the office) and she led us in a rousing game of Go Fish. She also told me my pronunciation of her full name was improving, but still not quite right.
p.s. another song reference in the title; maybe this one’s easier…
Shades of Dragon Lake
29 Nov 2008:
This weekend’s plans were the most nebulous by far. Saturday we drove to Underberg in the southern Drakensbergs, South Africa’s gateway to eastern Lesotho. I had been tempted by Anne Griffin’s stories of biking up Sani Pass into Lesotho – sounded just up my alley, except (a) I’m in pretty bad shape at this point, and (b) I tend to be too conservative to ride trail on my own (even in the US). After long consideration and a check of the weather forecast (scattered showers with lightning – not a small deal above the tree line when riding a metal object), and with some consideration to the incivility of ditching my traveling companion, I wimped out. Instead, we booked a ride up the pass in a Land Rover for the next day, the more traditional way to get into Lesotho.
After making these reservations, we headed to nearby Cobham nature reserve for a simple hike. The trail map was the first I’ve encountered here that cost money, and also by far the worst one I’ve seen. There was no map at all, and only a very crude description of what one could see on certain trails that neglected to mention the starting points for most of them. Shortly after we set out on an unmarked trail that looked pleasant, it started to rain lightly, then briefly heavier. After maybe 45 minutes it stopped, but we were both pretty wet by this point. Anyway, we kept at it, and I’m glad we did. The hike was a gently sloping stroll on mostly imaginary trails through broad grasslands, the sort of trail that was suggested only by a slight thinning in the thigh-high grass when the wind blew a certain way and would be all but impossible to find once it was lost. This worked, though, because the landscape was so open that we could see for miles in any direction, so even if we went off trail, it would have been easy enough to find our way back. After a little while, the grass became a bit lower, the trail easier to follow. All in all, it reminded me of one of my favorite places growing up, Dragon Lake forest preserve in little ol’ Naperville IL. Except there were mountains, which is nice! It was a pleasant hike, all told. At one point, we saw the back of what looked like a wild dog or perhaps a jackal (or, worst case, a hyena?) running away over a slope maybe a hundred yards off.
This weekend’s plans were the most nebulous by far. Saturday we drove to Underberg in the southern Drakensbergs, South Africa’s gateway to eastern Lesotho. I had been tempted by Anne Griffin’s stories of biking up Sani Pass into Lesotho – sounded just up my alley, except (a) I’m in pretty bad shape at this point, and (b) I tend to be too conservative to ride trail on my own (even in the US). After long consideration and a check of the weather forecast (scattered showers with lightning – not a small deal above the tree line when riding a metal object), and with some consideration to the incivility of ditching my traveling companion, I wimped out. Instead, we booked a ride up the pass in a Land Rover for the next day, the more traditional way to get into Lesotho.
After making these reservations, we headed to nearby Cobham nature reserve for a simple hike. The trail map was the first I’ve encountered here that cost money, and also by far the worst one I’ve seen. There was no map at all, and only a very crude description of what one could see on certain trails that neglected to mention the starting points for most of them. Shortly after we set out on an unmarked trail that looked pleasant, it started to rain lightly, then briefly heavier. After maybe 45 minutes it stopped, but we were both pretty wet by this point. Anyway, we kept at it, and I’m glad we did. The hike was a gently sloping stroll on mostly imaginary trails through broad grasslands, the sort of trail that was suggested only by a slight thinning in the thigh-high grass when the wind blew a certain way and would be all but impossible to find once it was lost. This worked, though, because the landscape was so open that we could see for miles in any direction, so even if we went off trail, it would have been easy enough to find our way back. After a little while, the grass became a bit lower, the trail easier to follow. All in all, it reminded me of one of my favorite places growing up, Dragon Lake forest preserve in little ol’ Naperville IL. Except there were mountains, which is nice! It was a pleasant hike, all told. At one point, we saw the back of what looked like a wild dog or perhaps a jackal (or, worst case, a hyena?) running away over a slope maybe a hundred yards off.
“You have a tree?”
26-28 Nov 2008:
And now for a quick summary of the rest of the week. Wednesday we started the day at Greys Hospital to attend the weekly grand rounds, a seminar for the registrars (residents) and more senior faculty. Two thirty-minute presentations, neither particularly inspiring. I joined rounds at Edendale upon my return and found that we have a new registrar on the male ward, Dr Madlala. She was kind enough to engage me in discussion about all of the patients she saw, which is still the way I feel I am able to make the most contribution to care (it is still somewhat bewildering to navigate the systems issues here in order to get things done; the interns are much better at this than I am). Dr Thambela came by for attending rounds after that to round out the morning.
In the afternoon, Rachel and I led a teaching session for the interns. We weren’t sure what sort of turnout to expect, but it was very well attended, in part because of the promise of teaching (a rarity for them) but undoubtedly in part due to the pizza provided. Rachel led off with a presentation on aortic dissection and I followed with a workshop on reading EKGs, which they apparently never get trained to do. They were very engaged (including the registrars and even some attendings, who also had seemed to have little in the way of a formal approach to EKGs) and asked if we could do this sort of thing again. We agreed to lead another teaching session next week.
Thursday (Thanksgiving! I almost forgot) was a normal day at the hospital for me. Rachel went on another community service trip with Dr Caldwell, and I went to Edendale. Saw some interesting cases with the new registrar, and a new medical student who just arrived from Jo’burg joined us as well. We saw a textbook case of miliary TB (a particularly widespread lung infection more common in immunocompromised patients), and an elderly patient with innumerable lung abscesses, likely a complication of prior TB infection. We put both on TB treatment and the latter on antibiotics as well, but the elderly man has a terrible prognosis, unfortunately.
In the evening, Rachel, Gugu, myself, and more of the iTEACH crowd gathered at the home of Krista Dong, the ID doctor who leads the iTEACH program, for Thanksgiving dinner. Sadly (as a person indifferent to turkey), it was traditional turkey, stuffing, gravy, and such. One of the iTEACH crowd brought her daughters, one of whom is an engaging 11 year old named Snenhlanhla (Zulu for “I have luck”). Try as I might to say her full name (which she abbreviates Sne for Americans), the best I could do with those consecutive lispy sounds was “Snehlahla” (like Hluhluwe, the game reserve we went to). I said this and she gave me a sideways look and asked incredulously, “Mm-hmm, you have a tree?” (the direct translation of what I pronounced).
Friday Rachel and I drove with Dr Caldwell out to Emmaus hospital in the foothills of the central Drakensbergs for another outreach trip. Again, it was a success; the housestaff were more or less engaged in the morning seminar (Rachel and I reprised our sepsis talk), and during rounds, one of the medical officers told us about the many patients they had questions on. As before on these trips, we puzzled through the cases with them and offered our best advice on how to proceed with diagnosis and treatment. As before, some of our suggestions included hospital transfer for such things as CT scans or specialist evaluation or treatment.
I also found a paper in the Lancet (e-publication) on mathematical modeling of comprehensive efforts in identifying and treating of ALL HIV positive patients in the world. The authors claim that with a massive up-front investment, this strategy would be able to effectively eliminate the HIV epidemic within 20 years and would be cost-saving by 2050. Color me skeptical, but I will present this paper as my exit talk next Friday.
And now for a quick summary of the rest of the week. Wednesday we started the day at Greys Hospital to attend the weekly grand rounds, a seminar for the registrars (residents) and more senior faculty. Two thirty-minute presentations, neither particularly inspiring. I joined rounds at Edendale upon my return and found that we have a new registrar on the male ward, Dr Madlala. She was kind enough to engage me in discussion about all of the patients she saw, which is still the way I feel I am able to make the most contribution to care (it is still somewhat bewildering to navigate the systems issues here in order to get things done; the interns are much better at this than I am). Dr Thambela came by for attending rounds after that to round out the morning.
In the afternoon, Rachel and I led a teaching session for the interns. We weren’t sure what sort of turnout to expect, but it was very well attended, in part because of the promise of teaching (a rarity for them) but undoubtedly in part due to the pizza provided. Rachel led off with a presentation on aortic dissection and I followed with a workshop on reading EKGs, which they apparently never get trained to do. They were very engaged (including the registrars and even some attendings, who also had seemed to have little in the way of a formal approach to EKGs) and asked if we could do this sort of thing again. We agreed to lead another teaching session next week.
Thursday (Thanksgiving! I almost forgot) was a normal day at the hospital for me. Rachel went on another community service trip with Dr Caldwell, and I went to Edendale. Saw some interesting cases with the new registrar, and a new medical student who just arrived from Jo’burg joined us as well. We saw a textbook case of miliary TB (a particularly widespread lung infection more common in immunocompromised patients), and an elderly patient with innumerable lung abscesses, likely a complication of prior TB infection. We put both on TB treatment and the latter on antibiotics as well, but the elderly man has a terrible prognosis, unfortunately.
In the evening, Rachel, Gugu, myself, and more of the iTEACH crowd gathered at the home of Krista Dong, the ID doctor who leads the iTEACH program, for Thanksgiving dinner. Sadly (as a person indifferent to turkey), it was traditional turkey, stuffing, gravy, and such. One of the iTEACH crowd brought her daughters, one of whom is an engaging 11 year old named Snenhlanhla (Zulu for “I have luck”). Try as I might to say her full name (which she abbreviates Sne for Americans), the best I could do with those consecutive lispy sounds was “Snehlahla” (like Hluhluwe, the game reserve we went to). I said this and she gave me a sideways look and asked incredulously, “Mm-hmm, you have a tree?” (the direct translation of what I pronounced).
Friday Rachel and I drove with Dr Caldwell out to Emmaus hospital in the foothills of the central Drakensbergs for another outreach trip. Again, it was a success; the housestaff were more or less engaged in the morning seminar (Rachel and I reprised our sepsis talk), and during rounds, one of the medical officers told us about the many patients they had questions on. As before on these trips, we puzzled through the cases with them and offered our best advice on how to proceed with diagnosis and treatment. As before, some of our suggestions included hospital transfer for such things as CT scans or specialist evaluation or treatment.
I also found a paper in the Lancet (e-publication) on mathematical modeling of comprehensive efforts in identifying and treating of ALL HIV positive patients in the world. The authors claim that with a massive up-front investment, this strategy would be able to effectively eliminate the HIV epidemic within 20 years and would be cost-saving by 2050. Color me skeptical, but I will present this paper as my exit talk next Friday.
Thursday, November 27, 2008
Catch-22
25 Nov 2008:
Today, like last Tuesday, we headed for the airport to join Dr Caldwell on a Red Cross flight as part of a community outreach effort to help provide health care to more rural areas of KZN (KwaZulu-Natal, the province that Edendale is in). While the skies were again overcast, the clouds were higher this time and the rain less, so we were able to get off the ground, unlike last week.
The trip (to a small town hospital in Dundee, northern KZN) was memorable. We (Dr Caldwell, Rachel, I, and a general internist from UC-Davis doing a sabbatical at a TB hospital near Durban) accompanied one of the two medicine residents at this underserved hospital on his rounds through two different wards for which he was responsible (probably a total of 50 patients). From what I gathered, it was at least the only time that week that he would see an attending-level MD for advice, and possibly the only time in a month. He presented what he knew of each patient, we put together what we could from the chart, and we made what recommendations we could, anything from tweaking medications to suggesting more diagnostic tests to recommending transfer to Grey’s or another similar “step-up” hospital.
At every point, our input (very much including that of Rachel and myself) was valued, and it really felt like we were making a contribution to the care of the patients there (a feeling I have only occasionally have gotten at Edendale, for various reasons). We started on the women’s ward, which was teeming with sick patients. The first one we saw was 30 yo, HIV positive, with an enormous mass in her left hip that, on X-ray, had eroded nearly all of that side of her pelvis and caused tremendous pain. Apparently she had had this mass for a year, went to a hospital in Jo’burg 6 months ago for a biopsy, but never followed up as instructed in clinic; several days ago, the pain became unbearable so she came in to the clinic. The list of possibilities here is quite short (summarized by Dr Isaacs, the UC-Davis doc: “1. Primary bone cancer, 2. Primary bone cancer, 3. Primary bone cancer"). We added TB to the list, just to hold out some hope of recovery, but TB doesn’t usually do this to bone; her left hemi-pelvis was entirely absent. We advised that as usual in these cases, “tissue is the issue”, so the resident planned to arrange for a surgical biopsy and transfer to Gray’s for whatever orthopedic stabilization of the joint might be possible for palliation. He was also going to try to track down the results of last year’s biopsy, but nobody was too optimistic that we would find anything. We saw a handful more patients on the women’s side, all of the ones he was having difficulty with, then saw a few more on the men's ward. For each one, we had some type of intervention to suggest, most of which I am hopeful will actually be of benefit.
The workup at a hospital like this proceeds at a VERY different pace than I am used to in the US. Especially in these rural settings, lab tests take days to come back, imaging studies (except for plain films) take a week to arrange, any more specialized studies (biopsy, MRI, even many consults) require a hospital transfer. In the meantime, all that is left in the absence of diagnostic certainty is to treat empirically for many possibilities. What this does to drug resistance among local microbes is concerning, though in truth, we in the US see many more problems with multiply-drug resistant bacteria (though obviously TB is a different animal here…). Also, with fewer interventions available, the number of things one does for a patient are fairly limited, so it seems that really, we scratch our heads and check HIV status, start empiric TB treatment and antibiotics, occasionally antiepileptics or antifungals, decide between fluids and diuretics (though a disconcerting number of times people here are on both), and wait for things to evolve. Not always, but often. One of my favorite quotes about medicine is from Voltaire; to paraphrase: the job of a doctor is to entertain the patient while time cures his illness. Here, the docs have less tricks with which to entertain, but the patients are certainly used to waiting longer without active entertainment. And I would amend the quote to say “while the disease runs its course”, because certainly time does not cure all the things seen here.
Another issue that arose here that I somehow hadn’t focused on before was the Catch-22 that arises when a patient is uncommunicative due to altered mental status from a sequela of HIV/AIDS. By South African law, a patient may not be started on anti-retrovirals without completing counseling and a course on how to reliably take their medications. This is a public health measure to reduce the chances of sporadic medication adherence leading to viral resistance to the affordable medications. It seems to be quite effective; it is pretty amazing to me that the entire nation seems to treat HIV with only three first-line regimens (Ia, Ib, and II, each of which is a three-drug combo of fairly common agents). We encountered a huge downside of this policy, though: a young patient with advanced AIDS who had not been started on ARVs before for whatever reason, who was now too confused to participate in counseling and classes. By law, we were not able to start her on ARVs (even in the hospital) because of her clouded mental status. But without these medications, she will never regain mental status (whereas with them she might have some, admittedly perhaps slim, chance). Difficult trade-off; I’m glad I’m not the one making decisions like that.
This hospital had many more female than male patients. Probably because Edendale always runs at capacity on both sides, I have not noticed this trend there. In thinking about why, I asked about the HIV prevalence among men and women in South Africa; sure enough, infection rates are much higher among women. I suspect (though I can’t recall statistics on this) that the US has the reverse rates. The ratio in South Africa makes good biological sense in a culture where heterosexual transmission is the norm; females are statistically much more likely to be infected during heterosexual intercourse than are males. Still, I find this difference between the US and Africa interesting: why is it more established in heterosexual populations in Africa than in the US? Conversely, why does the US see more homosexual and IVDU related infections? Or am I mistaken in my assumptions; is my perception simply a result of stereotypes in the US that have broken down or never existed in Africa in the face of the overwhelming, undeniable disease burden?
When all the problem patients were seen, we gathered with the local housestaff for lunch and an impromptu teaching session led by me on sepsis management. It was loosely based on a talk I'm preparing for the end of my Edendale stay, but I wasn't forewarned, so it wasn't all that organized. Luckily, I'm a ham when I need to be (the ludicrous length of this blog is proof enough), and the residents got engaged, and Dr Caldwell and Rachel pitched in, and it was very well received and, I'd like to think, helpful for them. After this, we looked at a peripheral blood smear from one of the patients we had seen earlier (no blasts!) and headed back to the airport to wait for the plane. Turned out the weather in Pietermaritzburg was "on the deck" (read: bad), so we had to divert to Durban and get a ride back to PMB; the evening ended later than we're used to here (back home by 9 pm, again through the nightly rain and mist).
On the plus side, I got a good chance to read a book I picked up here, one I've read long ago: Cry, the Beloved Country by Alan Paton. It is beautifully written; I remembered this in abstract but had forgotten all of the particulars of both the writing style and the story (which is good when one is rereading a book!). Like when I read "Dharma Bums" on a solo backpacking trip in the California Sierras, it has been particularly moving to read it so close to the place where it is set (I drove past a road to Ixopo today, as well as on Alan Paton boulevard - Paton was born in PMB). The writing style is in parts simplistic and in parts beautiful; it reminds me of "The Old Man and the Sea" in some ways. As I have learned a handful of phrases in Zulu, I am able to appreciate the dialogue between the Zulu characters (written in English, but with Zulu turns of phrase) more... much like, I think, Hemingway used direct translations of Spanish phrases into English. Anyway, I finished more than half of it today and can't wait to finish the rest. Can't recommend it enough to anyone who hasn't come across it.
Today, like last Tuesday, we headed for the airport to join Dr Caldwell on a Red Cross flight as part of a community outreach effort to help provide health care to more rural areas of KZN (KwaZulu-Natal, the province that Edendale is in). While the skies were again overcast, the clouds were higher this time and the rain less, so we were able to get off the ground, unlike last week.
The trip (to a small town hospital in Dundee, northern KZN) was memorable. We (Dr Caldwell, Rachel, I, and a general internist from UC-Davis doing a sabbatical at a TB hospital near Durban) accompanied one of the two medicine residents at this underserved hospital on his rounds through two different wards for which he was responsible (probably a total of 50 patients). From what I gathered, it was at least the only time that week that he would see an attending-level MD for advice, and possibly the only time in a month. He presented what he knew of each patient, we put together what we could from the chart, and we made what recommendations we could, anything from tweaking medications to suggesting more diagnostic tests to recommending transfer to Grey’s or another similar “step-up” hospital.
At every point, our input (very much including that of Rachel and myself) was valued, and it really felt like we were making a contribution to the care of the patients there (a feeling I have only occasionally have gotten at Edendale, for various reasons). We started on the women’s ward, which was teeming with sick patients. The first one we saw was 30 yo, HIV positive, with an enormous mass in her left hip that, on X-ray, had eroded nearly all of that side of her pelvis and caused tremendous pain. Apparently she had had this mass for a year, went to a hospital in Jo’burg 6 months ago for a biopsy, but never followed up as instructed in clinic; several days ago, the pain became unbearable so she came in to the clinic. The list of possibilities here is quite short (summarized by Dr Isaacs, the UC-Davis doc: “1. Primary bone cancer, 2. Primary bone cancer, 3. Primary bone cancer"). We added TB to the list, just to hold out some hope of recovery, but TB doesn’t usually do this to bone; her left hemi-pelvis was entirely absent. We advised that as usual in these cases, “tissue is the issue”, so the resident planned to arrange for a surgical biopsy and transfer to Gray’s for whatever orthopedic stabilization of the joint might be possible for palliation. He was also going to try to track down the results of last year’s biopsy, but nobody was too optimistic that we would find anything. We saw a handful more patients on the women’s side, all of the ones he was having difficulty with, then saw a few more on the men's ward. For each one, we had some type of intervention to suggest, most of which I am hopeful will actually be of benefit.
The workup at a hospital like this proceeds at a VERY different pace than I am used to in the US. Especially in these rural settings, lab tests take days to come back, imaging studies (except for plain films) take a week to arrange, any more specialized studies (biopsy, MRI, even many consults) require a hospital transfer. In the meantime, all that is left in the absence of diagnostic certainty is to treat empirically for many possibilities. What this does to drug resistance among local microbes is concerning, though in truth, we in the US see many more problems with multiply-drug resistant bacteria (though obviously TB is a different animal here…). Also, with fewer interventions available, the number of things one does for a patient are fairly limited, so it seems that really, we scratch our heads and check HIV status, start empiric TB treatment and antibiotics, occasionally antiepileptics or antifungals, decide between fluids and diuretics (though a disconcerting number of times people here are on both), and wait for things to evolve. Not always, but often. One of my favorite quotes about medicine is from Voltaire; to paraphrase: the job of a doctor is to entertain the patient while time cures his illness. Here, the docs have less tricks with which to entertain, but the patients are certainly used to waiting longer without active entertainment. And I would amend the quote to say “while the disease runs its course”, because certainly time does not cure all the things seen here.
Another issue that arose here that I somehow hadn’t focused on before was the Catch-22 that arises when a patient is uncommunicative due to altered mental status from a sequela of HIV/AIDS. By South African law, a patient may not be started on anti-retrovirals without completing counseling and a course on how to reliably take their medications. This is a public health measure to reduce the chances of sporadic medication adherence leading to viral resistance to the affordable medications. It seems to be quite effective; it is pretty amazing to me that the entire nation seems to treat HIV with only three first-line regimens (Ia, Ib, and II, each of which is a three-drug combo of fairly common agents). We encountered a huge downside of this policy, though: a young patient with advanced AIDS who had not been started on ARVs before for whatever reason, who was now too confused to participate in counseling and classes. By law, we were not able to start her on ARVs (even in the hospital) because of her clouded mental status. But without these medications, she will never regain mental status (whereas with them she might have some, admittedly perhaps slim, chance). Difficult trade-off; I’m glad I’m not the one making decisions like that.
This hospital had many more female than male patients. Probably because Edendale always runs at capacity on both sides, I have not noticed this trend there. In thinking about why, I asked about the HIV prevalence among men and women in South Africa; sure enough, infection rates are much higher among women. I suspect (though I can’t recall statistics on this) that the US has the reverse rates. The ratio in South Africa makes good biological sense in a culture where heterosexual transmission is the norm; females are statistically much more likely to be infected during heterosexual intercourse than are males. Still, I find this difference between the US and Africa interesting: why is it more established in heterosexual populations in Africa than in the US? Conversely, why does the US see more homosexual and IVDU related infections? Or am I mistaken in my assumptions; is my perception simply a result of stereotypes in the US that have broken down or never existed in Africa in the face of the overwhelming, undeniable disease burden?
When all the problem patients were seen, we gathered with the local housestaff for lunch and an impromptu teaching session led by me on sepsis management. It was loosely based on a talk I'm preparing for the end of my Edendale stay, but I wasn't forewarned, so it wasn't all that organized. Luckily, I'm a ham when I need to be (the ludicrous length of this blog is proof enough), and the residents got engaged, and Dr Caldwell and Rachel pitched in, and it was very well received and, I'd like to think, helpful for them. After this, we looked at a peripheral blood smear from one of the patients we had seen earlier (no blasts!) and headed back to the airport to wait for the plane. Turned out the weather in Pietermaritzburg was "on the deck" (read: bad), so we had to divert to Durban and get a ride back to PMB; the evening ended later than we're used to here (back home by 9 pm, again through the nightly rain and mist).
On the plus side, I got a good chance to read a book I picked up here, one I've read long ago: Cry, the Beloved Country by Alan Paton. It is beautifully written; I remembered this in abstract but had forgotten all of the particulars of both the writing style and the story (which is good when one is rereading a book!). Like when I read "Dharma Bums" on a solo backpacking trip in the California Sierras, it has been particularly moving to read it so close to the place where it is set (I drove past a road to Ixopo today, as well as on Alan Paton boulevard - Paton was born in PMB). The writing style is in parts simplistic and in parts beautiful; it reminds me of "The Old Man and the Sea" in some ways. As I have learned a handful of phrases in Zulu, I am able to appreciate the dialogue between the Zulu characters (written in English, but with Zulu turns of phrase) more... much like, I think, Hemingway used direct translations of Spanish phrases into English. Anyway, I finished more than half of it today and can't wait to finish the rest. Can't recommend it enough to anyone who hasn't come across it.
How the other half dies
24 Nov 2008:
First, a challenge: can anyone name the group and/or song that inspired this blog entry’s title? No googling! (Hint below) Post it if you know it!
This morning we went to a crosstown hospital called Grey’s. This is the mysterious hospital to which all of our patients who have needed CTs for the past few weeks have been ferreted. We went in search of a consultant (aka attending) who used to work at Edendale and was a popular teacher for MGH residents, Dr Devan Gounder. He has since moved on to private practice but still attends at Grey’s (a government hospital and formerly the “white” hospital during apartheid, just as Edendale was the “black” hospital) two mornings a week.
Dr Gounder is a surprisingly young man of Indian descent, born and raised in South Africa and never having left the Continent in his life. He was indeed an engaging teacher who led “pimp” style rounding – putting us and the South African interns and residents on the spot as we went from patient to patient, quizzing us about physical findings, lab values, diagnoses, or whatever was on his mind. It was fun, actually: the sort of thing you hear about a lot on Scrubs but doesn’t happen all that much, at least in my experience. And he did a good job mixing in questions that we (the US kids) knew and the locals didn’t, and vice versa, so that each group of residents had a chance to teach the other.
Grey’s and Edendale were like chalk and cheese. The place just “felt” like a western hospital. It had a working CT scanner (heck, maybe more than one!), an MRI, a cardiac cath lab, a cardiac ICU, and more fundamentally, the basic organization/infrastructure/resources required for reasonable patient care (all features that Edendale lacks). Now that it is no longer exclusively for whites, Grey’s population is predominantly black as well, reflecting the local population. But unlike Edendale, it is not a primary hospital; patients can only be admitted by referral/transfer from another hospital. I guess that’s a way to ensure that only the sickest get this level of care (though they have to be stable enough to survive the journey to Grey’s; in truth, Edendale's patients seemed sicker on the whole than the ward patients at Grey's). From what I hear, the next level of referral hospital up, Albert Luthuli hospital in Durban (a big city an hour east of here) has facilities that even puts MGH to shame, so South African government hospitals really seem to run the gamut. All told, fun as pimp rounds were, and though we did see some interesting “TIA” type cases, for the most part, this was not what I came to South Africa to see. We were invited to stay and watch some cardiac catheterizations later in the day, but we’ve both seen those before, and of the many differences between medicine in the US and in South Africa, I’m willing to bet that coronary anatomy is not one of them; we chose not to stay.
It was interesting, if somewhat depressing, to hear Dr Gounder’s take on why he moved to private practice. He is in all respects a very competent doctor who takes responsibility for all patients in his care. He left as soon as his debt to the government was paid, though, because his salary is 20 times higher in private practice. Literally. Twenty times. By comparison, that’s the difference between the poverty line and a radiologist’s (somewhat egregious) salary in the US. He had a young child, sounds like it wasn’t a hard decision for him. (Also, my 30 second take was that he wasn’t quite cut out for Edendale, evidenced by his statement that what he missed about working there was the fascinating pathology… one needs either an overriding commitment to service or, perhaps, an inability to function in a competent hospital system, to endure working at Edendale, and he had neither. But I have little to base this take on.)
That night, Rachel and I fulfilled our obligation as part of the “Zulu meal plan” (normally our host cooks for us most nights) and prepared a small feast for Gugu and ourselves. I made my specialty (or, as they say around here, “speciality”), green eggs and ham. It was a hit. (A complete aside, spurred by “speciality”… I didn’t realize they spelled that the way they pronounce it; ditto for “aluminium”. Other random favorite things about the accents of white South Africans: they say “fifty” like “fufty”, or maybe “foofty”; also, instead of “also”, they say “AS well”, with strong emphasis on the “as”. OK, I’m done for now.)
(Hint on the group/song that inspired the title: think 1980s. And no, everyone, it’s not Bob Dylan.)
First, a challenge: can anyone name the group and/or song that inspired this blog entry’s title? No googling! (Hint below) Post it if you know it!
This morning we went to a crosstown hospital called Grey’s. This is the mysterious hospital to which all of our patients who have needed CTs for the past few weeks have been ferreted. We went in search of a consultant (aka attending) who used to work at Edendale and was a popular teacher for MGH residents, Dr Devan Gounder. He has since moved on to private practice but still attends at Grey’s (a government hospital and formerly the “white” hospital during apartheid, just as Edendale was the “black” hospital) two mornings a week.
Dr Gounder is a surprisingly young man of Indian descent, born and raised in South Africa and never having left the Continent in his life. He was indeed an engaging teacher who led “pimp” style rounding – putting us and the South African interns and residents on the spot as we went from patient to patient, quizzing us about physical findings, lab values, diagnoses, or whatever was on his mind. It was fun, actually: the sort of thing you hear about a lot on Scrubs but doesn’t happen all that much, at least in my experience. And he did a good job mixing in questions that we (the US kids) knew and the locals didn’t, and vice versa, so that each group of residents had a chance to teach the other.
Grey’s and Edendale were like chalk and cheese. The place just “felt” like a western hospital. It had a working CT scanner (heck, maybe more than one!), an MRI, a cardiac cath lab, a cardiac ICU, and more fundamentally, the basic organization/infrastructure/resources required for reasonable patient care (all features that Edendale lacks). Now that it is no longer exclusively for whites, Grey’s population is predominantly black as well, reflecting the local population. But unlike Edendale, it is not a primary hospital; patients can only be admitted by referral/transfer from another hospital. I guess that’s a way to ensure that only the sickest get this level of care (though they have to be stable enough to survive the journey to Grey’s; in truth, Edendale's patients seemed sicker on the whole than the ward patients at Grey's). From what I hear, the next level of referral hospital up, Albert Luthuli hospital in Durban (a big city an hour east of here) has facilities that even puts MGH to shame, so South African government hospitals really seem to run the gamut. All told, fun as pimp rounds were, and though we did see some interesting “TIA” type cases, for the most part, this was not what I came to South Africa to see. We were invited to stay and watch some cardiac catheterizations later in the day, but we’ve both seen those before, and of the many differences between medicine in the US and in South Africa, I’m willing to bet that coronary anatomy is not one of them; we chose not to stay.
It was interesting, if somewhat depressing, to hear Dr Gounder’s take on why he moved to private practice. He is in all respects a very competent doctor who takes responsibility for all patients in his care. He left as soon as his debt to the government was paid, though, because his salary is 20 times higher in private practice. Literally. Twenty times. By comparison, that’s the difference between the poverty line and a radiologist’s (somewhat egregious) salary in the US. He had a young child, sounds like it wasn’t a hard decision for him. (Also, my 30 second take was that he wasn’t quite cut out for Edendale, evidenced by his statement that what he missed about working there was the fascinating pathology… one needs either an overriding commitment to service or, perhaps, an inability to function in a competent hospital system, to endure working at Edendale, and he had neither. But I have little to base this take on.)
That night, Rachel and I fulfilled our obligation as part of the “Zulu meal plan” (normally our host cooks for us most nights) and prepared a small feast for Gugu and ourselves. I made my specialty (or, as they say around here, “speciality”), green eggs and ham. It was a hit. (A complete aside, spurred by “speciality”… I didn’t realize they spelled that the way they pronounce it; ditto for “aluminium”. Other random favorite things about the accents of white South Africans: they say “fifty” like “fufty”, or maybe “foofty”; also, instead of “also”, they say “AS well”, with strong emphasis on the “as”. OK, I’m done for now.)
(Hint on the group/song that inspired the title: think 1980s. And no, everyone, it’s not Bob Dylan.)
Wednesday, November 26, 2008
Game day
23 Nov 2008:
After a cold 45 minute ride in a tarp-topped, open-sided, high-backed old SUV at the crack of dawn, we arrived in Hluhluwe-Umfolozi Game Reserve around 6 am excited to see some wildlife! (Note: Hluhluwe is pronounced roughly like “Shlu-shlu-way”, but the “sh” sounds are made with a kind of lisp from the sides of your mouth; it’s a Zulu “hl” thing.) Our guide was a friendly white South African who had (as he often reminded us) spent a great deal of time in the Bush. He spoke reasonably good Zulu and Xhosa (both are local languages with clicks) in addition to Afrikaans and excellent English. He had worked as a ranger in this game reserve for 10 years before transitioning to leading tours; he was either very knowledgeable about the park, it’s history, and it’s flora and fauna (including animal behaviors), or he was a remarkably skilled and lucky BS artist. And his audience was only three on this day: Rachel, myself, and a slightly odd Swedish woman who was also staying at our B&B. The tour vehicle sat 9, so we felt lucky to have a semi-private tour.
Shortly after arriving in the park, before even passing the entrance, we saw a family of vervet monkeys just beginning to greet the day. Some of the young ones were playing, trying to push each other off the low branches of the fig tree they had slept in. That was just a prelude to a fantastically successful day of wildlife viewing; we got very lucky. About 45 minutes in, we saw four of the “big 5” all within 500 meters of each other (lion, rhino, elephant, and buffalo; missing only leopard). The lions we never saw up close; we saw a pride of 9 sleeping on a hillside across a valley perhaps 300 meters off, and later we saw one of the females crossing a river from a couple hundred meters away. Everything else, though, we got up-close-and-personal views of (occasionally too close for comfort!).
Some of the highlights included seeing seven species all converging at the same watering hole: 5 giraffe (one of whom took a drink, a delicate proposition that makes them quite vulnerable), two white rhinos, impala, zebras, warthogs, wildebeest, and one large elephant that flared its ears in challenge and started lumbering towards our open-topped and open-sided vehicle. (This was one of the too-close-for-comfort moments.) He got within 15 feet or so before veering off to the left. Our car was off to keep things quiet, so we would have had a very hard time making our exit had we needed to; the old machine never started on the first try, plus we would have had to reverse up a hill on a dirt road, not ideal conditions for a getaway from a creature that can hit 40 kph! Our guide decided that turning the engine on would startle it, so instead he just held his ground and told us all to be “deathly still”. Fortunately, it all worked out! After he ventured off a bit, he proceeded to scoop up muddy water with his trunk and spray himself all over to cool off (the elephant, not our guide). We also saw a male rhino about 10 feet away off to the side of the road, with a female and child close behind. We tracked them to a watering hole and watched them drink and play in the mud a bit.
After a whole day of this, I felt like I had gotten reasonably good at spotting animals, certainly better than when I arrived in the morning. But we had nothing on our guide, who was truly impressive at spotting things while driving. All told, we had seen so many impala and zebra that we were bored of them by mid-morning; we also saw waterbuck, warthog, white and black rhino, lion, wildebeest, elephant, giraffe, vervet monkey, baboon, buffalo, a large and colorful assortment of birds, and too many dung beetles to count. Our guide also, upon hearing that we were doctors, found a bunch of medicinal plants to show us, which was kinda cool.
Our Swedish companion was, as I said, a bit of an odd duck. Her job was quite interesting; a PhD in social science, she was in South Africa researching the extent to which black natives have been empowered to financially recover after the end of apartheid. But she kept extolling Sweden’s endless virtues in complete non sequiturs. We talked about homelessness, and she’d bust out with “Sweden is very accepting of homosexuals, that’s why nobody there has AIDS.”
During a late lunch back at the entrance to the game reserve, a warthog came traipsing up into the parking lot and came within just a few feet of us and a few other people who were nearby. (This is, in my very limited exposure, quite unusual, as all the other warthogs I have seen here have been very skittish.) A couple of Euro guys who had been busy mugging for pictures by pretending to "wear" antelope horns that were on display decided it would be great fun to get a super-close-up of the warthog. So they got up within 5 feet of the thing, laughing and snapping pix. The hog was pretty obviously getting pissed off, and it started to charge them twice. They laughed and took a couple steps back, then got right back to taking pictures. It was remarkably stupid; warthogs have lower teeth sharp enough to flay your legs open. Anyway, it all ended OK (unless, like part of me, you were actually rooting for the warthog...).
After the day had ended (we got in nearly 10 hours of game viewing!), we (I) drove back home, 3.5 hours which (as has become the custom) culminated in evening rains and mist. But I’m getting more used to that, and to the lack of lights on the roads, and it wasn’t too painful. I even had enough energy left to “watch” the Bears (via intermittent internet updates) again, with better results this time – an easy 27-3 win over a truly awful football team (apologies to any Rams fans that might be lurking… not for calling the Rams “awful” but for what you’ve had to put up with this year….).
After a cold 45 minute ride in a tarp-topped, open-sided, high-backed old SUV at the crack of dawn, we arrived in Hluhluwe-Umfolozi Game Reserve around 6 am excited to see some wildlife! (Note: Hluhluwe is pronounced roughly like “Shlu-shlu-way”, but the “sh” sounds are made with a kind of lisp from the sides of your mouth; it’s a Zulu “hl” thing.) Our guide was a friendly white South African who had (as he often reminded us) spent a great deal of time in the Bush. He spoke reasonably good Zulu and Xhosa (both are local languages with clicks) in addition to Afrikaans and excellent English. He had worked as a ranger in this game reserve for 10 years before transitioning to leading tours; he was either very knowledgeable about the park, it’s history, and it’s flora and fauna (including animal behaviors), or he was a remarkably skilled and lucky BS artist. And his audience was only three on this day: Rachel, myself, and a slightly odd Swedish woman who was also staying at our B&B. The tour vehicle sat 9, so we felt lucky to have a semi-private tour.
Shortly after arriving in the park, before even passing the entrance, we saw a family of vervet monkeys just beginning to greet the day. Some of the young ones were playing, trying to push each other off the low branches of the fig tree they had slept in. That was just a prelude to a fantastically successful day of wildlife viewing; we got very lucky. About 45 minutes in, we saw four of the “big 5” all within 500 meters of each other (lion, rhino, elephant, and buffalo; missing only leopard). The lions we never saw up close; we saw a pride of 9 sleeping on a hillside across a valley perhaps 300 meters off, and later we saw one of the females crossing a river from a couple hundred meters away. Everything else, though, we got up-close-and-personal views of (occasionally too close for comfort!).
Some of the highlights included seeing seven species all converging at the same watering hole: 5 giraffe (one of whom took a drink, a delicate proposition that makes them quite vulnerable), two white rhinos, impala, zebras, warthogs, wildebeest, and one large elephant that flared its ears in challenge and started lumbering towards our open-topped and open-sided vehicle. (This was one of the too-close-for-comfort moments.) He got within 15 feet or so before veering off to the left. Our car was off to keep things quiet, so we would have had a very hard time making our exit had we needed to; the old machine never started on the first try, plus we would have had to reverse up a hill on a dirt road, not ideal conditions for a getaway from a creature that can hit 40 kph! Our guide decided that turning the engine on would startle it, so instead he just held his ground and told us all to be “deathly still”. Fortunately, it all worked out! After he ventured off a bit, he proceeded to scoop up muddy water with his trunk and spray himself all over to cool off (the elephant, not our guide). We also saw a male rhino about 10 feet away off to the side of the road, with a female and child close behind. We tracked them to a watering hole and watched them drink and play in the mud a bit.
After a whole day of this, I felt like I had gotten reasonably good at spotting animals, certainly better than when I arrived in the morning. But we had nothing on our guide, who was truly impressive at spotting things while driving. All told, we had seen so many impala and zebra that we were bored of them by mid-morning; we also saw waterbuck, warthog, white and black rhino, lion, wildebeest, elephant, giraffe, vervet monkey, baboon, buffalo, a large and colorful assortment of birds, and too many dung beetles to count. Our guide also, upon hearing that we were doctors, found a bunch of medicinal plants to show us, which was kinda cool.
Our Swedish companion was, as I said, a bit of an odd duck. Her job was quite interesting; a PhD in social science, she was in South Africa researching the extent to which black natives have been empowered to financially recover after the end of apartheid. But she kept extolling Sweden’s endless virtues in complete non sequiturs. We talked about homelessness, and she’d bust out with “Sweden is very accepting of homosexuals, that’s why nobody there has AIDS.”
During a late lunch back at the entrance to the game reserve, a warthog came traipsing up into the parking lot and came within just a few feet of us and a few other people who were nearby. (This is, in my very limited exposure, quite unusual, as all the other warthogs I have seen here have been very skittish.) A couple of Euro guys who had been busy mugging for pictures by pretending to "wear" antelope horns that were on display decided it would be great fun to get a super-close-up of the warthog. So they got up within 5 feet of the thing, laughing and snapping pix. The hog was pretty obviously getting pissed off, and it started to charge them twice. They laughed and took a couple steps back, then got right back to taking pictures. It was remarkably stupid; warthogs have lower teeth sharp enough to flay your legs open. Anyway, it all ended OK (unless, like part of me, you were actually rooting for the warthog...).
After the day had ended (we got in nearly 10 hours of game viewing!), we (I) drove back home, 3.5 hours which (as has become the custom) culminated in evening rains and mist. But I’m getting more used to that, and to the lack of lights on the roads, and it wasn’t too painful. I even had enough energy left to “watch” the Bears (via intermittent internet updates) again, with better results this time – an easy 27-3 win over a truly awful football team (apologies to any Rams fans that might be lurking… not for calling the Rams “awful” but for what you’ve had to put up with this year….).
Hippos in the pool
22 Nov 2008:
Saturday morning we woke up, not especially early, and headed out for the 3-4 hour drive to St Lucia, a coastal game reserve in northeastern KwaZulu Natal. As this is the part of the state that is said to be malarial, we had started taking our atovaquone-proguanil prophylaxis this past week. We had nothing on the docket until 4pm when we were going to go on a hippo and croc-spotting cruise on the St Lucia estuary. We stopped at a lovely beach with crashing surf and a strong riptide; we only waded and still felt the pull, and nobody at the beach was brave enough to swim. Everyone (else), however, did seem to be brave enough to wear a Speedo (young and old, men and women).
We then headed to Afrikhaya, a pleasant B&B run by a friendly Dutch couple; they showed us to our room and told us about the town of St Lucia. (Summary: very small.) We ate a meal at a place called “St Pizza”; despite the name, I had a calamari steak that was tasty but buttery. After that, we strolled along the main drag (all of 500 meters), browsed at some sidewalk vendors, and headed on to the boat.
The boat ride was as promised – a handful of crocs and many, many hippos, as well as some birds. The hippos were definitely the highlight. If manatees are sea cows, these suckers are definitely river cows. But dangerous river cows (“never get between a hippo and the water”, I’ve said probably 10 times this trip… hippos kill more humans than any other mammal besides humans). We saw a few young hippos playing “whose mouth is bigger”, and pushing themselves up out of the water to try to reach some tree branches, which was fun to see.
All in all, a good show. After the ride, we cased the town for all of the four minutes it may have taken to see the entire place, then stopped off near a restaurant that had a viewing area where hippos supposedly come out of the river at sunset. However, we were beaten to this viewing deck by four screaming children, one of whom was whacking a stick on a railing. On a related note, no hippos chose this particular spot to come out of the river (huh…), so instead, we drove on a circumferential road around the town that is rumored to have wildlife. We saw some kudu, which are big grey antelopes (larger than horses) with spiraling horns, and called it an early night; our game drive the next day was to leave at 5 am! Our B&B was nice, but it could have used a door to the bathroom and either an opacified door to the shower or a shower curtain… Shame! (as they say here).
Saturday morning we woke up, not especially early, and headed out for the 3-4 hour drive to St Lucia, a coastal game reserve in northeastern KwaZulu Natal. As this is the part of the state that is said to be malarial, we had started taking our atovaquone-proguanil prophylaxis this past week. We had nothing on the docket until 4pm when we were going to go on a hippo and croc-spotting cruise on the St Lucia estuary. We stopped at a lovely beach with crashing surf and a strong riptide; we only waded and still felt the pull, and nobody at the beach was brave enough to swim. Everyone (else), however, did seem to be brave enough to wear a Speedo (young and old, men and women).
We then headed to Afrikhaya, a pleasant B&B run by a friendly Dutch couple; they showed us to our room and told us about the town of St Lucia. (Summary: very small.) We ate a meal at a place called “St Pizza”; despite the name, I had a calamari steak that was tasty but buttery. After that, we strolled along the main drag (all of 500 meters), browsed at some sidewalk vendors, and headed on to the boat.
The boat ride was as promised – a handful of crocs and many, many hippos, as well as some birds. The hippos were definitely the highlight. If manatees are sea cows, these suckers are definitely river cows. But dangerous river cows (“never get between a hippo and the water”, I’ve said probably 10 times this trip… hippos kill more humans than any other mammal besides humans). We saw a few young hippos playing “whose mouth is bigger”, and pushing themselves up out of the water to try to reach some tree branches, which was fun to see.
All in all, a good show. After the ride, we cased the town for all of the four minutes it may have taken to see the entire place, then stopped off near a restaurant that had a viewing area where hippos supposedly come out of the river at sunset. However, we were beaten to this viewing deck by four screaming children, one of whom was whacking a stick on a railing. On a related note, no hippos chose this particular spot to come out of the river (huh…), so instead, we drove on a circumferential road around the town that is rumored to have wildlife. We saw some kudu, which are big grey antelopes (larger than horses) with spiraling horns, and called it an early night; our game drive the next day was to leave at 5 am! Our B&B was nice, but it could have used a door to the bathroom and either an opacified door to the shower or a shower curtain… Shame! (as they say here).
False localization
20-21 Nov 2008:
Sorry for the delay between posts. I’ll catch up, sometimes briefly, sometimes in detail. For now, I’ll briefly summarize the rest of the week on the wards. Briefly, because nothing too dramatic happened. People are still sick, and the hospital is still under-resourced. I spent both mornings rounding on patients on the male ward; I have cherry-picked a few of the interesting ones to help out with (accumulated because they were the only patients for whom I could persuade the interns to seek my help). I saw these patients, left notes, and spoke with the interns about what we thought were the important next steps in their care. Friday we had attending rounds on the male side, which is always helpful.
For the medical aficionados (and with apologies to the rest of you; keep reading only if you’re bored or interested), an update on the patient with the neurological findings from a week ago. Yes, a week ago, and still no head CT. To refresh your memory, he was the young (20 yo) man who had previously been diagnosed with TB meningitis who came in with three months of headache and one month of lethargy; he was unable to look leftwards with his left eye, which had made me think of a problem on the left side of the brainstem, but also had weakness in his left arm, which actually localizes to a completely different part of the brain (the right cerebral cortex, or conceivably a very particular lesion in the left medulla, but in neither case would these two neurological deficits localize to the same place). This is disconcerting to neurologists, because it is much easier to explain one problem in the brain than multiple (especially in a 20 yo man). If a patient has end-stage AIDS, or metastatic cancer, you can sometimes stop expecting parsimony like this, but as I mentioned before (I think), this patient was HIV negative.
This was beyond my current powers of neurological reasoning, and since the only recommendation of the local Neuro consultants (who only come by once a week anyway) was: “pending brain CT” (thanks, folks…), I solicited help from across the Atlantic – Michael Wilson to the rescue! This overseas Neuro consult ended up being prescient; he suggested that the left eye problem might be due to false localization; that particular cranial nerve is very long and therefore most susceptible to elevated pressure in the brain. So he thought it might be possible that the primary problem was in the right cerebral cortex, explaining the left arm weakness, and that the left eye problem was due to swelling in the brain from this lesion. Would be a way to tie all the patient’s symptoms together into one lesion. The day I got Michael’s email, the patient developed the same problem in his right eye (inability to look laterally), which essentially clinched Michael’s hypothesis: it is much more likely that both of these cranial nerve lesions were due to brain swelling than that the patient had developed yet a third separate lesion.
Sure enough, when we (finally) got the CT Thursday afternoon, the patient had a large (3-4 cm) mass in his right cerebral cortex causing the right side of his brain to push over into the left side. I still don’t know what was causing it, and the way medical records are here, I will never know. But we sent him off to the Neurosurgeons to biopsy the lesion and decompress his brain, and perhaps to try to surgically remove or debulk it depending on what it is. This, of course, required hospital transfer; no such thing can happen at our hospital. I am certain that we saved his life in the short term with the corticosteroids we gave him (strong anti-inflammatory medicines that would have decreased the swelling in his brain), but I’m sure his prognosis is not good. Best case is probably that this is all from tuberculosis, which is probably the most likely thing in this region and in a patient of his age. Still, even that would have very high predicted mortality given the size and location of the mass, in addition to which his symptoms had gotten worse on a month of TB treatment.
Anyway, that’s the only thing I recall worth writing about from the end of last week. The rest of the patients I saw were fairly stable; the gentleman with the congestive heart failure and high blood pressure improved quite a bit once we got his BP under control (a triumph!) and the rest of my patients have actually hung in there. For the weekend, Rachel and I are planning to go to a local game reserve for some animal-spotting!
Sorry for the delay between posts. I’ll catch up, sometimes briefly, sometimes in detail. For now, I’ll briefly summarize the rest of the week on the wards. Briefly, because nothing too dramatic happened. People are still sick, and the hospital is still under-resourced. I spent both mornings rounding on patients on the male ward; I have cherry-picked a few of the interesting ones to help out with (accumulated because they were the only patients for whom I could persuade the interns to seek my help). I saw these patients, left notes, and spoke with the interns about what we thought were the important next steps in their care. Friday we had attending rounds on the male side, which is always helpful.
For the medical aficionados (and with apologies to the rest of you; keep reading only if you’re bored or interested), an update on the patient with the neurological findings from a week ago. Yes, a week ago, and still no head CT. To refresh your memory, he was the young (20 yo) man who had previously been diagnosed with TB meningitis who came in with three months of headache and one month of lethargy; he was unable to look leftwards with his left eye, which had made me think of a problem on the left side of the brainstem, but also had weakness in his left arm, which actually localizes to a completely different part of the brain (the right cerebral cortex, or conceivably a very particular lesion in the left medulla, but in neither case would these two neurological deficits localize to the same place). This is disconcerting to neurologists, because it is much easier to explain one problem in the brain than multiple (especially in a 20 yo man). If a patient has end-stage AIDS, or metastatic cancer, you can sometimes stop expecting parsimony like this, but as I mentioned before (I think), this patient was HIV negative.
This was beyond my current powers of neurological reasoning, and since the only recommendation of the local Neuro consultants (who only come by once a week anyway) was: “pending brain CT” (thanks, folks…), I solicited help from across the Atlantic – Michael Wilson to the rescue! This overseas Neuro consult ended up being prescient; he suggested that the left eye problem might be due to false localization; that particular cranial nerve is very long and therefore most susceptible to elevated pressure in the brain. So he thought it might be possible that the primary problem was in the right cerebral cortex, explaining the left arm weakness, and that the left eye problem was due to swelling in the brain from this lesion. Would be a way to tie all the patient’s symptoms together into one lesion. The day I got Michael’s email, the patient developed the same problem in his right eye (inability to look laterally), which essentially clinched Michael’s hypothesis: it is much more likely that both of these cranial nerve lesions were due to brain swelling than that the patient had developed yet a third separate lesion.
Sure enough, when we (finally) got the CT Thursday afternoon, the patient had a large (3-4 cm) mass in his right cerebral cortex causing the right side of his brain to push over into the left side. I still don’t know what was causing it, and the way medical records are here, I will never know. But we sent him off to the Neurosurgeons to biopsy the lesion and decompress his brain, and perhaps to try to surgically remove or debulk it depending on what it is. This, of course, required hospital transfer; no such thing can happen at our hospital. I am certain that we saved his life in the short term with the corticosteroids we gave him (strong anti-inflammatory medicines that would have decreased the swelling in his brain), but I’m sure his prognosis is not good. Best case is probably that this is all from tuberculosis, which is probably the most likely thing in this region and in a patient of his age. Still, even that would have very high predicted mortality given the size and location of the mass, in addition to which his symptoms had gotten worse on a month of TB treatment.
Anyway, that’s the only thing I recall worth writing about from the end of last week. The rest of the patients I saw were fairly stable; the gentleman with the congestive heart failure and high blood pressure improved quite a bit once we got his BP under control (a triumph!) and the rest of my patients have actually hung in there. For the weekend, Rachel and I are planning to go to a local game reserve for some animal-spotting!
Wednesday, November 19, 2008
A day of blitzing and football (but not at the same time)
19 Nov 2008:
I left this morning expecting another day on the wards, but when we arrived, we were told of a once-a-year opportunity to join in a TB Blitz! The Blitz is a community outreach project where the iTEACH (integration of TB in Education And Care for HIV/AIDS… cumbersome, I know) program of which I am a part and several other local anti-TB campaigns (as opposed to the many pro-TB campaigns) join together to spread the good word about TB. It was very interesting, actually. Nine of us from the iTEACH office started out by getting lost on the way to a small field in a township where this event was to be held. We waited for a bit while the other teams assembled, and then we headed out door to door just talking to people about their living conditions, asking if anyone was coughing, and handing out literature on TB in English and Zulu. (Apparently literacy rates are such that usually at least one person per household can read; these brochures were written at a fairly high level, eg at least middle school English.)
The door-to-door experience was an interesting one… the township was composed of mostly small brick or corrugated aluminum one-room houses. However, I was quite surprised that the insides of some of them were quite well-maintained; one even had a television that the kids were watching! I only saw a handful of homes, some of which were single-mother and others of which were two-parent (half-and-half of the small subset I saw). We didn’t find any suspicious TB cases or other health problems to refer, but we did engage people in a discussion about HIV and TB at each home. Several of the parents had already been tested for HIV (most often as part of prenatal testing). We also helped fill out a bizarre, poorly organized demographic survey that the organizing group had given us; I have no idea what the point of this was given the limited scope of our canvassing efforts. All in all, this was no well-oiled machine, but it did give me the closest contact I have yet had with a township.
After the door-to-door, we returned to the field, where a large open-air tent and stage had been set up for a good old-fashioned health fair. People descended from the townships to get their glucose, BPs, heights, and weights checked (I didn’t see a BP lower than 156/80) and to learn more about TB. Off to the side stood smaller, enclosed tents where patients could go for a “VCT” (voluntary counseling and testing, which is what they call an HIV test). Patients enter, meet with a counselor and a technician, take the fingerstick blood test, and learn their results within minutes! The test is very sensitive but not terribly specific, so if the result is negative, there is no follow-up, but any positive screening test is followed up with confirmatory testing. There was a steady line outside these tents all day, sometimes as long as 40-50 people. I asked one of the other volunteers what fraction of the tests he expected to be positive; in keeping with the prevalence rate in the area, he expected that about 40% would be. I suspect it may be a bit lower, since the incidence of newly positive results must be lower than that, but still, it was powerful to think how many people would be learning that they were HIV positive today, some likely already with AIDS, while the rest of us enjoyed the festivities.
And there were festivities. A group of youngish DJs played a hip-hop song called “TB Free” (this was the name of the organizing group) with mostly Zulu lyrics but occasional English phrases about taking your medication and getting tested and “you can be better”. They brought children (who had been let out of a nearby school for the occasion) on stage and had them take turns trying to fire up the crowd by saying “TB it is curable”, then they had a dance competition. Then a public health worker and a social worker addressed the crowd for a while, followed by skits about the symptoms of TB and the importance of finishing treatment. Most of the proceedings were in Zulu, so I only followed what I was told by my iTEACH colleagues. The ceremony dragged on (given that I couldn’t understand a word of it), but otherwise it was an interesting day. The event was very well attended (I guess I have no frame of reference), with several hundred people assembled.
We got back to Edendale Hospital in the afternoon and I worked on a presentation for the interns for next week. I decided to prepare a session on EKGs they might commonly see. It can take up to a full day for labs to come back, and while EKGs can be logistically difficult to obtain, at least the results are immediately available, so one could argue that it is even more important here than in the states to be able to interpret them in the absence of other data and recognize ischemia, electrolyte abnormalities, pericardial effusions, etc. Of course, one could take this argument one step farther and say that since there is not much to be done about any such abnormalities, what’s the point… but that’s not entirely true; heart attacks can be treated with thrombolytics, hyperkalemia is seldom treated (I’ve seen Ks of 6.9 a full day after they are drawn that are just noted in passing) but certainly could be if there were EKG changes, and pericardial effusions are nearly always TB here and could be treated as well.
In the evening, I went out with some of the iTEACH crowd to a bar in PMB to watch South Africa play Cameroon in the finals of the Nelson Mandela Cup, a pan-African soccer tourney. South Africa were the underdogs, but they played well and jumped out to an early 2-0 lead on a couple of exciting plays before giving up two goals on set plays to concede a tie game heading into halftime. The second half was tense, but with about 10 minutes remaining in regulation, South Africa put one off a rebound on a frantic play to take the lead! They got a penalty kick several minutes later and the game looked over, but the forward who had scored the first to goals hit the post, so they had to sweat out another 8 minutes of Cameroon chances before pulling off the upset win. The players were ecstatic, my co-workers were ecstatic, the Cameroon coach was all pissed off about some sort of administrative snafu getting into South Africa and refused to answer questions about the game, it was fun.
Before the game, Mandela gave a taped address to the crowd that was broadcast on TV. The entire crowd in the stadium and at the bar came to a complete hush; nobody spoke, nobody moved, the waitresses stopped serving, and everybody just listened. He wasn’t even saying anything too dramatic, just about how the game benefits his Children’s Foundation, and good luck to both sides, and whatnot. The power of this man to draw the attention of the people of South Africa, even today, is amazing.
I left this morning expecting another day on the wards, but when we arrived, we were told of a once-a-year opportunity to join in a TB Blitz! The Blitz is a community outreach project where the iTEACH (integration of TB in Education And Care for HIV/AIDS… cumbersome, I know) program of which I am a part and several other local anti-TB campaigns (as opposed to the many pro-TB campaigns) join together to spread the good word about TB. It was very interesting, actually. Nine of us from the iTEACH office started out by getting lost on the way to a small field in a township where this event was to be held. We waited for a bit while the other teams assembled, and then we headed out door to door just talking to people about their living conditions, asking if anyone was coughing, and handing out literature on TB in English and Zulu. (Apparently literacy rates are such that usually at least one person per household can read; these brochures were written at a fairly high level, eg at least middle school English.)
The door-to-door experience was an interesting one… the township was composed of mostly small brick or corrugated aluminum one-room houses. However, I was quite surprised that the insides of some of them were quite well-maintained; one even had a television that the kids were watching! I only saw a handful of homes, some of which were single-mother and others of which were two-parent (half-and-half of the small subset I saw). We didn’t find any suspicious TB cases or other health problems to refer, but we did engage people in a discussion about HIV and TB at each home. Several of the parents had already been tested for HIV (most often as part of prenatal testing). We also helped fill out a bizarre, poorly organized demographic survey that the organizing group had given us; I have no idea what the point of this was given the limited scope of our canvassing efforts. All in all, this was no well-oiled machine, but it did give me the closest contact I have yet had with a township.
After the door-to-door, we returned to the field, where a large open-air tent and stage had been set up for a good old-fashioned health fair. People descended from the townships to get their glucose, BPs, heights, and weights checked (I didn’t see a BP lower than 156/80) and to learn more about TB. Off to the side stood smaller, enclosed tents where patients could go for a “VCT” (voluntary counseling and testing, which is what they call an HIV test). Patients enter, meet with a counselor and a technician, take the fingerstick blood test, and learn their results within minutes! The test is very sensitive but not terribly specific, so if the result is negative, there is no follow-up, but any positive screening test is followed up with confirmatory testing. There was a steady line outside these tents all day, sometimes as long as 40-50 people. I asked one of the other volunteers what fraction of the tests he expected to be positive; in keeping with the prevalence rate in the area, he expected that about 40% would be. I suspect it may be a bit lower, since the incidence of newly positive results must be lower than that, but still, it was powerful to think how many people would be learning that they were HIV positive today, some likely already with AIDS, while the rest of us enjoyed the festivities.
And there were festivities. A group of youngish DJs played a hip-hop song called “TB Free” (this was the name of the organizing group) with mostly Zulu lyrics but occasional English phrases about taking your medication and getting tested and “you can be better”. They brought children (who had been let out of a nearby school for the occasion) on stage and had them take turns trying to fire up the crowd by saying “TB it is curable”, then they had a dance competition. Then a public health worker and a social worker addressed the crowd for a while, followed by skits about the symptoms of TB and the importance of finishing treatment. Most of the proceedings were in Zulu, so I only followed what I was told by my iTEACH colleagues. The ceremony dragged on (given that I couldn’t understand a word of it), but otherwise it was an interesting day. The event was very well attended (I guess I have no frame of reference), with several hundred people assembled.
We got back to Edendale Hospital in the afternoon and I worked on a presentation for the interns for next week. I decided to prepare a session on EKGs they might commonly see. It can take up to a full day for labs to come back, and while EKGs can be logistically difficult to obtain, at least the results are immediately available, so one could argue that it is even more important here than in the states to be able to interpret them in the absence of other data and recognize ischemia, electrolyte abnormalities, pericardial effusions, etc. Of course, one could take this argument one step farther and say that since there is not much to be done about any such abnormalities, what’s the point… but that’s not entirely true; heart attacks can be treated with thrombolytics, hyperkalemia is seldom treated (I’ve seen Ks of 6.9 a full day after they are drawn that are just noted in passing) but certainly could be if there were EKG changes, and pericardial effusions are nearly always TB here and could be treated as well.
In the evening, I went out with some of the iTEACH crowd to a bar in PMB to watch South Africa play Cameroon in the finals of the Nelson Mandela Cup, a pan-African soccer tourney. South Africa were the underdogs, but they played well and jumped out to an early 2-0 lead on a couple of exciting plays before giving up two goals on set plays to concede a tie game heading into halftime. The second half was tense, but with about 10 minutes remaining in regulation, South Africa put one off a rebound on a frantic play to take the lead! They got a penalty kick several minutes later and the game looked over, but the forward who had scored the first to goals hit the post, so they had to sweat out another 8 minutes of Cameroon chances before pulling off the upset win. The players were ecstatic, my co-workers were ecstatic, the Cameroon coach was all pissed off about some sort of administrative snafu getting into South Africa and refused to answer questions about the game, it was fun.
Before the game, Mandela gave a taped address to the crowd that was broadcast on TV. The entire crowd in the stadium and at the bar came to a complete hush; nobody spoke, nobody moved, the waitresses stopped serving, and everybody just listened. He wasn’t even saying anything too dramatic, just about how the game benefits his Children’s Foundation, and good luck to both sides, and whatnot. The power of this man to draw the attention of the people of South Africa, even today, is amazing.
Tuesday, November 18, 2008
Ngiyapila (I am well)
Yet another note: on pictures, sadly internet access here does not easily (or cheaply) support the uploading of pix, so I am forced to give you a boring text-only blog. Pix aplenty once I return, I promise. I’m already over 200 for the trip!
OK, here are three more days worth of blog. Hope you enjoy.
16 Nov 2008: Are you ready for some football?
In the morning, Rachel and I headed north to Howick, a quick 20-minute drive from Pietermaritzburg, to see a supposedly popular waterfall and then tour a small-time game park. My expectations were pretty low, as I hadn’t heard of either of them before and they were only mentioned in passing in the guidebooks we had. But, they were close by, so we went. The town of Howick itself was pretty bland, a well-to-do suburb with malls and souvenir shops stretched out lazily along some rolling hills. On the way into town, we crossed a bridge over a lazily flowing stream maybe 50 feet across, and I didn’t have high hopes for the falls.
When we got there, though, I was taken by surprise. Somehow, this lazy stream turned into a fairly impressive waterfall, cascading easily several hundred feet down a sheer face into a valley below, beyond which it turned lazy once more. We hiked down an easy path to the valley floor for a closer look at the falls before moving on.
From there, we went to Umgeni Valley Nature Reserve, where we hoped to see giraffes, zebras, antelope, and more. As we pulled in to the guesthouse, we immediately saw some zebras strolling around the grounds. We drove back through the reserve across some tough, windy, narrow, bumpy dirt roads (luckily we only encountered two cars, and they were good enough to do the off-roading that my Yaris probably couldn’t so we could pass) to get to a trailhead that would take us through the part of the reserve frequented by the animals. At first, the trail descended steeply from a ridgeline into a river valley; the forest was alive with birdsong and other noises, but we saw no land animals until we got down to the valley. We came to a clearing and saw so many impala and zebra we got bored of them, plus a blesbok (nice-looking creature, larger than an impala, dark brown with a striking white nose), and several larger gray hoofed beasts I have yet to identify. Also, at one point a warthog surprised us (and itself) by sidling out of the woods across the trail just in front of us; it scurried off at an impressive pace for such a stout creature with stubby legs. But alas, though we were told they might be down in the valley, and though we looked hard for them, we never saw giraffe. We managed to lose the faint trail at one point, but we had more than enough landmarks to re-encounter it even using the rough map we had. We ran into a friendly couple (one of whom I believe was a doctor) who joined us for the climb back up out of the valley, and we went on our way.
After getting back home, I had a nice skype-chat with JJ, then tuned in to “watch” the Bears game online. (I had dreams of finding a sports bar in PMB that would show American football, but I think this is not in the cards: PMB closes early on Sundays, nobody likes American football here, and also our neighborhood is not conducive to staying out late, as we are kept in by a freaking electrified fence which dissuades me from wandering out alone after dark.) Alas, in a game with big implications for the division race, they got absolutely crushed by the Pack. Worse, I was playing a college buddy from Milwaukee that week in fantasy football, and he kept a running commentary going on how badly his favorite team was dominating mine. After a resounding 37-3 defeat for my favorite team, I went dejectedly to sleep.
17 Nov 2008: Clinic and culture
Monday morning, back to work. Rachel’s first day at Edendale, and my return after a weekend. I was happy and only a little surprised to see that all the patients I wrote about on Friday in this blog were still alive, and did not seem to be much the worse for wear. Maybe seeing a doctor isn’t as important as we doctors like to think…
Anyway, I spent part of the morning seeing something I had never seen before at Edendale: attending rounds! (For the non-med types, this is where the supervising doctor, which Americans call attendings and South Africans call consultants or specialists, sees patients with some or all of the housestaff; in US teaching hospitals, this happens every day.) I went to the women’s ward to join a particularly good attending on rounds named Dr Caldwell. He normally leads “outreach trips” where he serves as a consultant/specialist at more rural sites (Edendale, though under-resourced, is not really rural, as it is nestled in the middle of several poor townships), but once or twice a week he attends on one of the Edendale wards. This was actually quite a joy to see, as many (though not nearly all) of the patients were seen and their plans of care discussed, if only for the single most pressing issue. Putting this plan into action, of course, was still a challenge, as the CT scanner had not yet been fixed as hoped. Fortunately, though, the cross-town hospital had agreed to let our patients be transported over for a scan, then sent back with the results. We had to arrange for transport, and it was only available for cases their radiologists deemed urgent, but still, it was better than nothing.
Sadly, though these rounds were the closest approximation to what I was used to thinking of as medicine, I had to step out partway through in order to fulfill a request I had made to help out in the outpatient antiretroviral (ARV) clinic for HIV patients. Even more sadly, the clinic attending I had spoken with previously, a pleasant and thoughtful doctor I got along with well, was tied up with administrative matters, so he turfed me to a colleague whom I had not met. While I was sad to miss out on educational time on the wards, I found the clinic to be quite a refreshing change of pace. Patients came in, most with quite low CD4 counts and high HIV titers (ie, AIDS), since that is required to be eligible to start ARVs under government regulations, but as this was the outpatient setting, many of them looked quite well, with at most some thrush (a yeast infection of the oral cavity) to show for their immunodeficient state.
The doctor I was paired with was friendly and young, perhaps my age, and had trained in the Congo before fleeing that nation as so many of his colleagues did to get away from the violence. Perhaps it was just as well that I worked with him, as the other attending I thought I would be working is a native Zulu speaker, as were most of the patients, so I would have either been totally lost or slowing everyone down. This doctor did not speak Zulu, so we got by in English (only once needing a translator), which made my job easier. I played the med student role, just watching, for the first several patients before starting to lead the questioning. We blitzed through the patients, seeing as many as 6 or 7 an hour with maybe 10 seconds’ break in between. After I saw my first patient (having watched the first few), he asked how busy our hospitals were. Misunderstanding, I told him about our typical inpatient load. He gently said, no, he meant how many patients did we see in a typical clinic day? I got the hint, and I sped up after that as best I could.
The best part of my clinic experience was seeing healthy patients, and more than that, patients who were on the road to even better health. Though their education was poor compared to most of the patients we see in the US, the patients who came to clinic were nearly all committed to taking their ARVs. Of course, they are a carefully selected group: most were flagged during a recent hospital admission or as a result of an outpatient HIV test (random, or during pregnancy, or all too often because a child got sick with AIDS, leading the parents to get tested). Once flagged, a patient must express interest in treatment, commit to coming to clinic monthly to pick up their medication refills, identify a “treatment buddy”, and, importantly, they must attend an instructional counseling session on taking ARVs. This session goes over in great detail the different regimens they can choose from (one standard regimen, with modifications in case of a desire to become pregnant, or drug intolerance, or resistant virus, etc). Because of this counseling, patients came to this clinic, even those who had yet to start treatment, able to rattle off the names of drugs, when to take them, and what the expected side effects were! It was truly impressive to see their level of commitment to the process. Again, this was clearly a selected group, but still represented quite a different experience than I had previously enjoyed.
After clinic, I grabbed lunch (“country pie”: nondescript but decent, kinda like shepherd’s pie) and headed with Rachel for a cultural tour arranged by the iTEACH program. Two iTEACH employees, Thulani and Vusi, both from Zulu townships (one right near Edendale, the other closer to Durban), told us about the history of South Africa starting with the arrival of the Dutch and British in the 17th century and leading all the way up through apartheid to the present day. Much of this story was told from the roof of Edendale hospital, from which we could see many of the rolling hills on which some of the relevant action took place. We then drove around the community and saw important historical sites, touring the Imbali township where Thulani grew up, highlighted by a trip to a hall in his old high school (a technical school that had not had electricity for most of the year) where Nelson Mandela had given his last public address before his arrest that led to his imprisonment. It is now being converted into a memorial; public funds are being promised to upgrade it from a stripped-down classroom to a tourist-friendly memorial, while the adjacent high school will lose an 80-seat assembly hall and remain without power. We also visited a memorial erected to commemorate victims of violence between the African National Congress (the main political party in South Africa, of which Mandela was a leader) and a rival local party; one of these victims was Thulani’s brother.
All in all, a more rewarding day than my previous; though I am still not sure I’m contributing much to patient care, I certainly am gaining perspective on health care delivery in underserved areas. After this moving afternoon, I again came home tired, had dinner, and slept. Tomorrow I have plans to join Dr Caldwell (the attending from this morning) on a Red Cross flight out to one of the rural clinics! Should be exciting.
18 Nov 2008: Condition grounded
Drove in to Oribi Airport in PMB through a light drizzle and heavy clouds, hoping the Red Cross plane could take us (Dr Caldwell, Dr Dlawati – the friendly attending whom I missed working with yesterday in clinic, two Columbia residents also working at Edendale, and a visiting physician from UC Davis who has been working at a TB hospital near Durban, and I) to a rural hospital for an “outreach visit”. Unfortunately, after sitting for a few hours and chatting with Dr Dlawati about a couple of the patients we had seen together in the ED the prior Friday, the pilot and Red Cross coordinator came by and told us that we would be grounded due to the weather.
I swung back to Edendale by 10 am and checked in on the male ward to see how the team was doing. The registrar (resident equivalent) for that ward grabbed me immediately and asked for my opinion on a patient. I was actually quite surprised by this, since she seems very confident and I felt that I had done nothing to distinguish myself as someone worthy of asking for advice from. Still, I went with her to hear about and examine one of her patients. He was a 54 yo man with years of uncontrolled hypertension and diabetes that had caused blindness, nerve damage, kidney failure, and now heart failure. In addition, he had high blood pressure in his lungs; the combination of these things was making his breathing very labored. They had tried to treat his heart failure, but his kidney failure was making this difficult. She asked if I had any ideas on how to proceed. I examined the chart, which is in horrible disarray. Though a sign “monitor input and output strictly” was posted by his bed (this sort of bookkeeping is critical in managing heart failure patients), it had not been recorded even once during his 2-week hospitalization. It was likewise impossible to tell what medication changes had been made when, and he only had labs every few days to document his poorly functioning kidneys. I agreed that it was a difficult management situation and the patient’s prognosis was very poor; my best suggestion was to try to control his blood pressure (still 170/110) to take some of the strain off his heart.
Soon after this, I was again surprised by the appearance of an attending; again, this was one of the docs I have identified as a good one, Dr Thembela. He speaks Zulu, so he can actually take a history, which it turns out is a pretty helpful thing. And even better, he saw every patient in the ward today with the housestaff, a real treat. The CHF patient I had seen with the registrar was one of the sickest ones on the ward, so he spent more time on this one. When he had heard the story, he asked me what I would do next. I suggested some medications we could use for better blood pressure control; he agreed with the idea and seemed to warm to me after that. He encouraged all the housestaff to speak their minds on every patient and to defend their reasoning; I personally love this style of rounding and tend not to be shy about thinking out loud. Even though I know it will be hard to enact the plans we come up with, it felt good yesterday and today to at least be talking about them as a team and making rational decisions (at least sometimes; an odd patient here or there was still getting both IV fluids and diuretics to remove fluids despite my gentle heckling).
Unfortunately, the gentleman I described at length from last Friday with the cranial nerve palsy and the maybe TB meningitis still has not had his CT; he was to be sent to the crosstown hospital for one, but they were so deluged with urgent CT scans from our hospital that they were refusing them again. At least it's nearly Wednesday, so he will get a Neurology consult at long last tomorrow!
Attending rounds lasted past noon; the afternoon was quiet, and Rachel and I headed home a bit early because the internet was down again in the office so we had a hard time preparing some of the teaching materials we are hoping to share with the interns after Doug Wilson (the medicine director at Edendale) returns from MGH, where he is visiting. Unfortunately, his stand-ins seem to view teaching from MGH residents as presumptuous (which perhaps it is in some ways) and a total waste of time (which I’d like to think it is not), so we haven’t pushed to do it yet. Soon, though, I hope!
OK, here are three more days worth of blog. Hope you enjoy.
16 Nov 2008: Are you ready for some football?
In the morning, Rachel and I headed north to Howick, a quick 20-minute drive from Pietermaritzburg, to see a supposedly popular waterfall and then tour a small-time game park. My expectations were pretty low, as I hadn’t heard of either of them before and they were only mentioned in passing in the guidebooks we had. But, they were close by, so we went. The town of Howick itself was pretty bland, a well-to-do suburb with malls and souvenir shops stretched out lazily along some rolling hills. On the way into town, we crossed a bridge over a lazily flowing stream maybe 50 feet across, and I didn’t have high hopes for the falls.
When we got there, though, I was taken by surprise. Somehow, this lazy stream turned into a fairly impressive waterfall, cascading easily several hundred feet down a sheer face into a valley below, beyond which it turned lazy once more. We hiked down an easy path to the valley floor for a closer look at the falls before moving on.
From there, we went to Umgeni Valley Nature Reserve, where we hoped to see giraffes, zebras, antelope, and more. As we pulled in to the guesthouse, we immediately saw some zebras strolling around the grounds. We drove back through the reserve across some tough, windy, narrow, bumpy dirt roads (luckily we only encountered two cars, and they were good enough to do the off-roading that my Yaris probably couldn’t so we could pass) to get to a trailhead that would take us through the part of the reserve frequented by the animals. At first, the trail descended steeply from a ridgeline into a river valley; the forest was alive with birdsong and other noises, but we saw no land animals until we got down to the valley. We came to a clearing and saw so many impala and zebra we got bored of them, plus a blesbok (nice-looking creature, larger than an impala, dark brown with a striking white nose), and several larger gray hoofed beasts I have yet to identify. Also, at one point a warthog surprised us (and itself) by sidling out of the woods across the trail just in front of us; it scurried off at an impressive pace for such a stout creature with stubby legs. But alas, though we were told they might be down in the valley, and though we looked hard for them, we never saw giraffe. We managed to lose the faint trail at one point, but we had more than enough landmarks to re-encounter it even using the rough map we had. We ran into a friendly couple (one of whom I believe was a doctor) who joined us for the climb back up out of the valley, and we went on our way.
After getting back home, I had a nice skype-chat with JJ, then tuned in to “watch” the Bears game online. (I had dreams of finding a sports bar in PMB that would show American football, but I think this is not in the cards: PMB closes early on Sundays, nobody likes American football here, and also our neighborhood is not conducive to staying out late, as we are kept in by a freaking electrified fence which dissuades me from wandering out alone after dark.) Alas, in a game with big implications for the division race, they got absolutely crushed by the Pack. Worse, I was playing a college buddy from Milwaukee that week in fantasy football, and he kept a running commentary going on how badly his favorite team was dominating mine. After a resounding 37-3 defeat for my favorite team, I went dejectedly to sleep.
17 Nov 2008: Clinic and culture
Monday morning, back to work. Rachel’s first day at Edendale, and my return after a weekend. I was happy and only a little surprised to see that all the patients I wrote about on Friday in this blog were still alive, and did not seem to be much the worse for wear. Maybe seeing a doctor isn’t as important as we doctors like to think…
Anyway, I spent part of the morning seeing something I had never seen before at Edendale: attending rounds! (For the non-med types, this is where the supervising doctor, which Americans call attendings and South Africans call consultants or specialists, sees patients with some or all of the housestaff; in US teaching hospitals, this happens every day.) I went to the women’s ward to join a particularly good attending on rounds named Dr Caldwell. He normally leads “outreach trips” where he serves as a consultant/specialist at more rural sites (Edendale, though under-resourced, is not really rural, as it is nestled in the middle of several poor townships), but once or twice a week he attends on one of the Edendale wards. This was actually quite a joy to see, as many (though not nearly all) of the patients were seen and their plans of care discussed, if only for the single most pressing issue. Putting this plan into action, of course, was still a challenge, as the CT scanner had not yet been fixed as hoped. Fortunately, though, the cross-town hospital had agreed to let our patients be transported over for a scan, then sent back with the results. We had to arrange for transport, and it was only available for cases their radiologists deemed urgent, but still, it was better than nothing.
Sadly, though these rounds were the closest approximation to what I was used to thinking of as medicine, I had to step out partway through in order to fulfill a request I had made to help out in the outpatient antiretroviral (ARV) clinic for HIV patients. Even more sadly, the clinic attending I had spoken with previously, a pleasant and thoughtful doctor I got along with well, was tied up with administrative matters, so he turfed me to a colleague whom I had not met. While I was sad to miss out on educational time on the wards, I found the clinic to be quite a refreshing change of pace. Patients came in, most with quite low CD4 counts and high HIV titers (ie, AIDS), since that is required to be eligible to start ARVs under government regulations, but as this was the outpatient setting, many of them looked quite well, with at most some thrush (a yeast infection of the oral cavity) to show for their immunodeficient state.
The doctor I was paired with was friendly and young, perhaps my age, and had trained in the Congo before fleeing that nation as so many of his colleagues did to get away from the violence. Perhaps it was just as well that I worked with him, as the other attending I thought I would be working is a native Zulu speaker, as were most of the patients, so I would have either been totally lost or slowing everyone down. This doctor did not speak Zulu, so we got by in English (only once needing a translator), which made my job easier. I played the med student role, just watching, for the first several patients before starting to lead the questioning. We blitzed through the patients, seeing as many as 6 or 7 an hour with maybe 10 seconds’ break in between. After I saw my first patient (having watched the first few), he asked how busy our hospitals were. Misunderstanding, I told him about our typical inpatient load. He gently said, no, he meant how many patients did we see in a typical clinic day? I got the hint, and I sped up after that as best I could.
The best part of my clinic experience was seeing healthy patients, and more than that, patients who were on the road to even better health. Though their education was poor compared to most of the patients we see in the US, the patients who came to clinic were nearly all committed to taking their ARVs. Of course, they are a carefully selected group: most were flagged during a recent hospital admission or as a result of an outpatient HIV test (random, or during pregnancy, or all too often because a child got sick with AIDS, leading the parents to get tested). Once flagged, a patient must express interest in treatment, commit to coming to clinic monthly to pick up their medication refills, identify a “treatment buddy”, and, importantly, they must attend an instructional counseling session on taking ARVs. This session goes over in great detail the different regimens they can choose from (one standard regimen, with modifications in case of a desire to become pregnant, or drug intolerance, or resistant virus, etc). Because of this counseling, patients came to this clinic, even those who had yet to start treatment, able to rattle off the names of drugs, when to take them, and what the expected side effects were! It was truly impressive to see their level of commitment to the process. Again, this was clearly a selected group, but still represented quite a different experience than I had previously enjoyed.
After clinic, I grabbed lunch (“country pie”: nondescript but decent, kinda like shepherd’s pie) and headed with Rachel for a cultural tour arranged by the iTEACH program. Two iTEACH employees, Thulani and Vusi, both from Zulu townships (one right near Edendale, the other closer to Durban), told us about the history of South Africa starting with the arrival of the Dutch and British in the 17th century and leading all the way up through apartheid to the present day. Much of this story was told from the roof of Edendale hospital, from which we could see many of the rolling hills on which some of the relevant action took place. We then drove around the community and saw important historical sites, touring the Imbali township where Thulani grew up, highlighted by a trip to a hall in his old high school (a technical school that had not had electricity for most of the year) where Nelson Mandela had given his last public address before his arrest that led to his imprisonment. It is now being converted into a memorial; public funds are being promised to upgrade it from a stripped-down classroom to a tourist-friendly memorial, while the adjacent high school will lose an 80-seat assembly hall and remain without power. We also visited a memorial erected to commemorate victims of violence between the African National Congress (the main political party in South Africa, of which Mandela was a leader) and a rival local party; one of these victims was Thulani’s brother.
All in all, a more rewarding day than my previous; though I am still not sure I’m contributing much to patient care, I certainly am gaining perspective on health care delivery in underserved areas. After this moving afternoon, I again came home tired, had dinner, and slept. Tomorrow I have plans to join Dr Caldwell (the attending from this morning) on a Red Cross flight out to one of the rural clinics! Should be exciting.
18 Nov 2008: Condition grounded
Drove in to Oribi Airport in PMB through a light drizzle and heavy clouds, hoping the Red Cross plane could take us (Dr Caldwell, Dr Dlawati – the friendly attending whom I missed working with yesterday in clinic, two Columbia residents also working at Edendale, and a visiting physician from UC Davis who has been working at a TB hospital near Durban, and I) to a rural hospital for an “outreach visit”. Unfortunately, after sitting for a few hours and chatting with Dr Dlawati about a couple of the patients we had seen together in the ED the prior Friday, the pilot and Red Cross coordinator came by and told us that we would be grounded due to the weather.
I swung back to Edendale by 10 am and checked in on the male ward to see how the team was doing. The registrar (resident equivalent) for that ward grabbed me immediately and asked for my opinion on a patient. I was actually quite surprised by this, since she seems very confident and I felt that I had done nothing to distinguish myself as someone worthy of asking for advice from. Still, I went with her to hear about and examine one of her patients. He was a 54 yo man with years of uncontrolled hypertension and diabetes that had caused blindness, nerve damage, kidney failure, and now heart failure. In addition, he had high blood pressure in his lungs; the combination of these things was making his breathing very labored. They had tried to treat his heart failure, but his kidney failure was making this difficult. She asked if I had any ideas on how to proceed. I examined the chart, which is in horrible disarray. Though a sign “monitor input and output strictly” was posted by his bed (this sort of bookkeeping is critical in managing heart failure patients), it had not been recorded even once during his 2-week hospitalization. It was likewise impossible to tell what medication changes had been made when, and he only had labs every few days to document his poorly functioning kidneys. I agreed that it was a difficult management situation and the patient’s prognosis was very poor; my best suggestion was to try to control his blood pressure (still 170/110) to take some of the strain off his heart.
Soon after this, I was again surprised by the appearance of an attending; again, this was one of the docs I have identified as a good one, Dr Thembela. He speaks Zulu, so he can actually take a history, which it turns out is a pretty helpful thing. And even better, he saw every patient in the ward today with the housestaff, a real treat. The CHF patient I had seen with the registrar was one of the sickest ones on the ward, so he spent more time on this one. When he had heard the story, he asked me what I would do next. I suggested some medications we could use for better blood pressure control; he agreed with the idea and seemed to warm to me after that. He encouraged all the housestaff to speak their minds on every patient and to defend their reasoning; I personally love this style of rounding and tend not to be shy about thinking out loud. Even though I know it will be hard to enact the plans we come up with, it felt good yesterday and today to at least be talking about them as a team and making rational decisions (at least sometimes; an odd patient here or there was still getting both IV fluids and diuretics to remove fluids despite my gentle heckling).
Unfortunately, the gentleman I described at length from last Friday with the cranial nerve palsy and the maybe TB meningitis still has not had his CT; he was to be sent to the crosstown hospital for one, but they were so deluged with urgent CT scans from our hospital that they were refusing them again. At least it's nearly Wednesday, so he will get a Neurology consult at long last tomorrow!
Attending rounds lasted past noon; the afternoon was quiet, and Rachel and I headed home a bit early because the internet was down again in the office so we had a hard time preparing some of the teaching materials we are hoping to share with the interns after Doug Wilson (the medicine director at Edendale) returns from MGH, where he is visiting. Unfortunately, his stand-ins seem to view teaching from MGH residents as presumptuous (which perhaps it is in some ways) and a total waste of time (which I’d like to think it is not), so we haven’t pushed to do it yet. Soon, though, I hope!
Sunday, November 16, 2008
Love the Drakes
15 Nov 2008: Love the Drakes
Headed up to the Drakensburg mountain range Saturday with the other MGH resident, Rachel Grisham, who got in last night. We drove out to Royal Natal park in the northern region of the mountain range and set out for a 20 km round trip hike towards the Amphitheater, a spectacular arc of 3000m peaks rising nearly vertically up out of the valley, just begging for big-wall adventure. Instead, we strolled (though Rachel called my early pace a “jog”, so I slowed up) across a gorge headed for Tugela Falls, a popular trail. We started late enough in the day, though, that we didn’t see too many people most of the way, just a handful of groups coming back and one group whom we passed on the way out.
Around the 9 km mark (by my estimation), we were making excellent time and I was wondering why people said it should take 3 hours each way (it had been maybe 2). Then things got interesting. It started with a simple class 2 scramble down a small slope to lead to a stream crossing via rock-hopping (or fording, as Rachel opted for). And from then on, it didn’t let up, as the trail stayed class 2 and we crossed the river 3 more times (again, me hopping rocks, Rachel fording). Going was slow, as they said on the Oregon Trail. Eventually we got to a place where a rickety ladder of wood rails connected by chain link about as thick as barbed-wire led up maybe 35 feet to a ridge on a cliff. There was no vista to be gained by this climb, so we passed, though other groups shinnied up, only to come back down. Instead, we headed off to the left, across the river once more, where the trail continued to switch back up a hillside to give us our best view of Tugela Falls (which was still from quite a ways across the valley). We could have pressed on, but my read was that we wouldn’t get a better view than we had, and I think it was the right time for us to head back. So we grabbed lunch beneath a little rock outcropping (me: Snickers) and headed back the way we came. Though the falls were a bit of a disappointment, the stream crossings added some fun, and the valley we walked through as well as the mountains all around were spectacular. The weather was glorious too, perhaps a bit too hot and sunny to be perfect hiking weather, but a genuinely pleasant day.
On the way up, just before the start of the numerous river crossings, we had seen a couple of monkeys up on a ledge high above the trail. They seemed to be pacing the ledge and eyeballing us hikers. Later on as we returned, we heard yelling that sounded like monkeys, and looking back in the direction of the ruckus, sure enough, we saw one of them again on a ledge above the trail, and he descended the ledge to swing into the forest we were hiking through. Rachel got a bit worried, so she set the pace the rest of the way out and tried to hightail it as best she could! Speaking of simians, we had an amusing incident on the way in, as perched less than 20 feet from a sign reading “do not feed the baboons”, a baboon ate calmly by the side of the road. He did not seem bothered when I backed the car up to take pictures. Clearly, not everyone has been obeying this particular sign.
After the hike, we went to the “Tower of Pizza”, a pleasant local joint that was actually mentioned in Lonely Planet. It was tasty enough, and I enjoyed their homemade ginger beer and sampled the last of the three South African beer labels, verifying indeed that they all taste the same, while Rachel had a famous Savanna cider. We were debating whether or not to stay the night; I wanted to check out some of the San rock art, but I got vetoed (“isn’t it just graffiti?”). This sharing a car thing is trickier than I anticipated! Anyway, it was early enough that we headed back to Northdale and planned to do some local stuff Sunday.
Headed up to the Drakensburg mountain range Saturday with the other MGH resident, Rachel Grisham, who got in last night. We drove out to Royal Natal park in the northern region of the mountain range and set out for a 20 km round trip hike towards the Amphitheater, a spectacular arc of 3000m peaks rising nearly vertically up out of the valley, just begging for big-wall adventure. Instead, we strolled (though Rachel called my early pace a “jog”, so I slowed up) across a gorge headed for Tugela Falls, a popular trail. We started late enough in the day, though, that we didn’t see too many people most of the way, just a handful of groups coming back and one group whom we passed on the way out.
Around the 9 km mark (by my estimation), we were making excellent time and I was wondering why people said it should take 3 hours each way (it had been maybe 2). Then things got interesting. It started with a simple class 2 scramble down a small slope to lead to a stream crossing via rock-hopping (or fording, as Rachel opted for). And from then on, it didn’t let up, as the trail stayed class 2 and we crossed the river 3 more times (again, me hopping rocks, Rachel fording). Going was slow, as they said on the Oregon Trail. Eventually we got to a place where a rickety ladder of wood rails connected by chain link about as thick as barbed-wire led up maybe 35 feet to a ridge on a cliff. There was no vista to be gained by this climb, so we passed, though other groups shinnied up, only to come back down. Instead, we headed off to the left, across the river once more, where the trail continued to switch back up a hillside to give us our best view of Tugela Falls (which was still from quite a ways across the valley). We could have pressed on, but my read was that we wouldn’t get a better view than we had, and I think it was the right time for us to head back. So we grabbed lunch beneath a little rock outcropping (me: Snickers) and headed back the way we came. Though the falls were a bit of a disappointment, the stream crossings added some fun, and the valley we walked through as well as the mountains all around were spectacular. The weather was glorious too, perhaps a bit too hot and sunny to be perfect hiking weather, but a genuinely pleasant day.
On the way up, just before the start of the numerous river crossings, we had seen a couple of monkeys up on a ledge high above the trail. They seemed to be pacing the ledge and eyeballing us hikers. Later on as we returned, we heard yelling that sounded like monkeys, and looking back in the direction of the ruckus, sure enough, we saw one of them again on a ledge above the trail, and he descended the ledge to swing into the forest we were hiking through. Rachel got a bit worried, so she set the pace the rest of the way out and tried to hightail it as best she could! Speaking of simians, we had an amusing incident on the way in, as perched less than 20 feet from a sign reading “do not feed the baboons”, a baboon ate calmly by the side of the road. He did not seem bothered when I backed the car up to take pictures. Clearly, not everyone has been obeying this particular sign.
After the hike, we went to the “Tower of Pizza”, a pleasant local joint that was actually mentioned in Lonely Planet. It was tasty enough, and I enjoyed their homemade ginger beer and sampled the last of the three South African beer labels, verifying indeed that they all taste the same, while Rachel had a famous Savanna cider. We were debating whether or not to stay the night; I wanted to check out some of the San rock art, but I got vetoed (“isn’t it just graffiti?”). This sharing a car thing is trickier than I anticipated! Anyway, it was early enough that we headed back to Northdale and planned to do some local stuff Sunday.
TIA
14 Nov 2008: TIA
First of all, thanks to everyone who’s commented and encouraged me to keep writing; I still feel like I write too much but I’m glad to hear that people are enjoying it. That makes me more likely to keep doing it. I have a lot of medical stories from Friday in the hospital that I feel like sharing, mostly because they are unusual compared to what we see in the states. But I am aware that one of the less charming traits of a med student and/or physician is to overuse medical stories, so here’s what I’ve decided: I’ll start today’s entry with my general reactions to the day in the hospital, and then I’ll indulge myself in some of the medical stories. For the non-medical types who are following, forgive me. I will try to explain as much as I can, but feel free to not read that part.
I learned a saying during my travels from the good folks at Buccaneer’s Backpackers in Cintsa: “TIA”, which stands for “This is Africa”. They use it often and in many circumstances; one example is when a guest might ask about a certain amenity that is not available, or if there is an extended power outage… TIA. I must say, it is a phrase that has never been far from my mind since I first set foot in Edendale Hospital; at no time am I able to forget it. It can be a reaction to nearly every situation I have encountered. In fact, I think it can even become a crutch that could prevent one from trying to act, though the benefit is that it helps one to retain one’s sanity in some ways when reacting to conditions that are sometimes hard to fathom.
One interesting theme that came up during discussions today was how disparate the conditions are at different hospitals in the same country. The public-private divide is tremendous, as I discussed yesterday (“chalk and cheese”, remember? Janina set me straight; I had reversed the order). But even within publically financed hospitals, there are considerable differences from what I hear. Edendale is one of the most resource-poor of the hospitals in South Africa, I gather. Before I leave I plan to visit a couple of others and will have more basis to evaluate this claim.
Even more, it is amazing how resources are distributed not just within the health care system but within the nation. South Africa is hosting the World Cup in 2010, and massive financial and manpower resources are being sunk into stadia to host these games: in Durban, in Cape Town, in Port Elizabeth, and in other cities as well, huge fields are being built to host the world’s favorite sport. They hope to recoup some of their investment in tourism dollars, but in the meantime, hospitals like Edendale feel the crunch. Edendale has been told that they are “over budget” as a hospital, so many supplies are limited and will not be refilled. Even the equipment for basic procedures such as lumbar punctures (aka “spinal taps”… by the way, done an estimated 10 times per night by the two admitting interns, with over 50% positive) is often lacking. Many people here feel that the real reason the hospitals are being told they are running over budget is that money is being diverted to finance the World Cup stadia (which are also 2-fold over budget, to the point that the local papers are calling FIFA “bullies”). It is probably not a stretch to say that people are dying every day because of this distribution of resources. And nobody will use these stadia once they are complete… Not to mention that even if some of the cost is recouped from tourism, I doubt too much of it will be funneled back into health care in settings like Edendale.
At this morning’s intake meeting, one of the hospital administrators attended as a guest. He requested a few minutes at the end of the meeting to give a pep talk to the housestaff. He basically said that he recognized that times were tough, worse than at this time last year. To paraphrase, he said, “Trust me, things were much worse 20 years ago, so knuckle down and do the best you can with the system and resources you have in front of you. Just think of the patients, and do your best for them, and don’t worry about what you can’t control.” The whole thing came off from my perspective as much more depressing than rousing or motivating. I was reminded of Animal Farm: he wanted everyone to be Boxer (“I will work harder”), and he spurred everyone on by reminding them how much worse things used to be in the bad old days. TIA.
Warning: now for the medical part (with translations into plain English as best as I am able)…
I spent the morning tagging along with one of the interns, reading charts as she checked in on the patients, and discussing the management plan with her after I got to know a bit about the patient. The first interesting case we saw together was a young gentleman in his 20s who came in with 3 months of headache followed by one month of lethargy. He had reportedly been diagnosed with tuberculous meningitis (TB infection of the sac that holds the brain and spinal cord) several weeks earlier at another hospital, but we had no records of how this diagnosis was made. All we knew was per the family, he had been told to take TB medicines, which he had reportedly been doing for about 3 weeks. When I met him, he was looking better, apparently (i.e., not as lethargic). He spoke a little English and was clearly interactive, though not exactly sharp; this apparently was a big improvement from the day before when he was admitted, at which point he was barely responsive. An LP (aka spinal tap) done on admission, though, was completely normal (no white blood cells, normal levels of glucose and protein), so the TB team didn’t think it was likely to be tuberculous meningitis after all, since they didn’t think the spinal tap would become normal that quickly after starting treatment. His gaze looked disconjugate to me, and I suggested that we take him through as much of a formal neurological exam as we could (we got a Zulu-speaking nurse to help us). It was immediately obvious that he was unable to look to the left with his left eye, indicating a problem with his 6th cranial nerve on the left side. This cranial nerve courses through the brainstem, suggesting that he had a lesion there (a somewhat alarming place to have one, since critical things happen in the brainstem). He may have also had a slight facial droop and slight deviation of his tongue when it protruded. He also clearly had left arm weakness, both proximally and distally. It was impossible to tell how long he had these symptoms; he could not tell us and an exam from admission the day before did not include a clear neurological exam. The best clue we had is that he did not report dizziness or double vision despite his disconjugate gaze; this suggests that the process is not acute (though it could also mean he was too confused to report such a symptom, or that something was lost in translation). I asked the intern why she thought he had improved from one day to the next; she wasn’t sure. We looked back at what they had treated him with: only the TB meds (which he had been on for 3 weeks already with progression of his lethargy during that time; this didn’t seem likely), steroids that had been started on admission, and ceftriaxone, an antibiotic in case of bacterial meningitis. Given the lack of fever and (especially) the normal spinal tap, bacterial meningitis was vanishingly unlikely. So the only treatment to which we could ascribe his change in course was the steroids. The intern was happy to see him better; I was concerned, though, since steroids decrease swelling (probably explaining his improvement) but do not actually treat essentially anything that could be causing his symptoms. In fact, if it is an infection causing these symptoms (as is most likely), then in the long run the steroids will make it harder for his body to fight the infection. He needed them, I suspect, since his lethargy was probably caused by brainstem swelling that was affecting his level of consciousness, but at best this is a temporary stop-gap for a problem that needs definitive treatment. The things I can think of to explain his symptoms are TB meningitis (treatable, but he’s been on the right treatment and worsening), and three things that presuppose that he has HIV (we can’t test because he hasn’t been able to consent; even in Africa, though impressively not in California, HIV tests require patient consent): PML (progressive multifocal leukoencephalopathy, a brain disease caused by a virus known as JC virus that attacks severely immunocompromised people; would be treatable with HIV therapy), cerebral toxoplasmosis (treatable with antibiotics), or brain lymphoma (much more common in HIV; treatment would be very difficult, particularly in Africa). I’m sure there are other possibilities I’m missing. What he needs is an MRI to help with diagnosis, but hey, TIA. The nearest MRI is in another town, and the hospital that has it is not accepting transfers this week because of a bed shortage caused by construction in their cardiac and neurology intensive care units (which means, by the way, that anyone in this region that has a heart attack or stroke requiring ICU level care basically dies while the construction is happening; this is the only cardiac ICU anywhere nearby). He could have gotten a head CT, which is poor for showing the brainstem but might be able to locate and help identify a clear brainstem lesion, but again, TIA. Edendale Hospital’s only CT scanner has been broken since yesterday, and might be fixed by Monday at the soonest. He cannot be transferred because he does not qualify as an “urgent” CT, essentially because he is now too awake. So instead, his only diagnostic test is my imperfect neurological exam and partial knowledge of neuroanatomy and likely distributions of the various possible diagnoses that I can think of. Since Neuro consultants only visit this hospital on Wednesdays, I called an overseas consult by emailing Michael Wilson about the case. Left to my own devices, I still favor TB. We may never know; for all I know he might be dead before Monday when I return. TIA.
The broken CT scanner actually had quite an effect on patient care. One gentleman in his 50s who came in with abdominal pain, found to have a belly riddled with TB but also incidentally found to have a renal mass that did not look like TB on ultrasound, was discharged home on TB treatment and told to come back in two weeks for a CT to characterize his renal mass; hopefully by then the scanner would be working again. Other patients who were relatively well but awaiting a scan were similarly sent home. Those who were not well enough to be discharged but needed scans were just sitting around waiting. “Urgent” scans could be obtained by hospital transfer, but again, to qualify for an urgent scan, you had to be kinda, but not totally, comatose: too awake and you weren’t urgent (no matter what the clinical situation), but too comatose and you were too unlikely to recover no matter what the scan showed. This rule even affects scans within the hospital when the scanner is working; a man with new onset blindness earlier this week was put in a queue rather than getting a same-day scan because he was too lucid; when he became comatose the following day, he was scanned and cerebral toxoplasmosis was finally diagnosed with a 3 cm mass in the occipital lobe, the part of the brain that controls vision, that was causing swelling that had ultimately caused his depressed level of consciousness. He was treated and improved, thankfully; he can now see again.
Later in the day, I went down to the ED (“Resusc”) and saw a woman who came in with several months of worsening headache and focal seizures. She had seen a doctor in clinic about the headache a while ago, and he had recommended a painkiller. Shortly after this, she began having seizures at home, but she did not seek medical attention again for several weeks until her family insisted. I saw her have three seizures in about 30 minutes; each time we gave a medicine (diazepam, or Valium) to help stop them. This knocked her out for a while, but when she awoke again, she would begin to seize again (rhythmic left-sided facial twitching and deviation of the head to the left). The most common cause of new-onset focal seizures in this part of the world is cerebral toxoplasmosis caused by HIV. She had no known diagnosis of HIV, but she is probably about to get one. Incidentally, she is also diabetic (recently diagnosed) and had a sky-high glucose and ketones in her urine, indicating that her diabetes was raging dangerously out of control as well, possibly because of this infection. Yet again, she very much needed a head CT to help with diagnosis. I discussed the patient with one of the good attendings I’ve encountered, and he was going to call over to the neighboring hospital and argue as best he could to get her transferred for the CT. If that didn’t work, we would just start treatment for cerebral toxo, test for HIV, and hope we were right. We also gave her insulin and fluids to help treat her diabetes, and started her on a longer-acting medicine for seizures. I left for the weekend before this case was completely sorted out; I had to go pick up the other resident at the airport. It was not without a hefty dose of guilt that I stepped out of the hospital, to return on Monday. The patients will see no doctors over the weekend. TIA. Some people refer to the weekend as a “stress test” for the patients; if they survive, you know they weren’t all that sick…
I will spare you some of the other cases I saw, but suffice it to say that nearly every one was managed differently in fairly major ways than I am used to. But still, it is fun to engage people in discussions about the patients, because (a) I think it is a valuable part of patient care that does not always happen, certainly not every day with every patient, and (b) it reminds me that at some level, medicine is still medicine; the diagnostic thought process is similar even if the steps you are able to take are different.
First of all, thanks to everyone who’s commented and encouraged me to keep writing; I still feel like I write too much but I’m glad to hear that people are enjoying it. That makes me more likely to keep doing it. I have a lot of medical stories from Friday in the hospital that I feel like sharing, mostly because they are unusual compared to what we see in the states. But I am aware that one of the less charming traits of a med student and/or physician is to overuse medical stories, so here’s what I’ve decided: I’ll start today’s entry with my general reactions to the day in the hospital, and then I’ll indulge myself in some of the medical stories. For the non-medical types who are following, forgive me. I will try to explain as much as I can, but feel free to not read that part.
I learned a saying during my travels from the good folks at Buccaneer’s Backpackers in Cintsa: “TIA”, which stands for “This is Africa”. They use it often and in many circumstances; one example is when a guest might ask about a certain amenity that is not available, or if there is an extended power outage… TIA. I must say, it is a phrase that has never been far from my mind since I first set foot in Edendale Hospital; at no time am I able to forget it. It can be a reaction to nearly every situation I have encountered. In fact, I think it can even become a crutch that could prevent one from trying to act, though the benefit is that it helps one to retain one’s sanity in some ways when reacting to conditions that are sometimes hard to fathom.
One interesting theme that came up during discussions today was how disparate the conditions are at different hospitals in the same country. The public-private divide is tremendous, as I discussed yesterday (“chalk and cheese”, remember? Janina set me straight; I had reversed the order). But even within publically financed hospitals, there are considerable differences from what I hear. Edendale is one of the most resource-poor of the hospitals in South Africa, I gather. Before I leave I plan to visit a couple of others and will have more basis to evaluate this claim.
Even more, it is amazing how resources are distributed not just within the health care system but within the nation. South Africa is hosting the World Cup in 2010, and massive financial and manpower resources are being sunk into stadia to host these games: in Durban, in Cape Town, in Port Elizabeth, and in other cities as well, huge fields are being built to host the world’s favorite sport. They hope to recoup some of their investment in tourism dollars, but in the meantime, hospitals like Edendale feel the crunch. Edendale has been told that they are “over budget” as a hospital, so many supplies are limited and will not be refilled. Even the equipment for basic procedures such as lumbar punctures (aka “spinal taps”… by the way, done an estimated 10 times per night by the two admitting interns, with over 50% positive) is often lacking. Many people here feel that the real reason the hospitals are being told they are running over budget is that money is being diverted to finance the World Cup stadia (which are also 2-fold over budget, to the point that the local papers are calling FIFA “bullies”). It is probably not a stretch to say that people are dying every day because of this distribution of resources. And nobody will use these stadia once they are complete… Not to mention that even if some of the cost is recouped from tourism, I doubt too much of it will be funneled back into health care in settings like Edendale.
At this morning’s intake meeting, one of the hospital administrators attended as a guest. He requested a few minutes at the end of the meeting to give a pep talk to the housestaff. He basically said that he recognized that times were tough, worse than at this time last year. To paraphrase, he said, “Trust me, things were much worse 20 years ago, so knuckle down and do the best you can with the system and resources you have in front of you. Just think of the patients, and do your best for them, and don’t worry about what you can’t control.” The whole thing came off from my perspective as much more depressing than rousing or motivating. I was reminded of Animal Farm: he wanted everyone to be Boxer (“I will work harder”), and he spurred everyone on by reminding them how much worse things used to be in the bad old days. TIA.
Warning: now for the medical part (with translations into plain English as best as I am able)…
I spent the morning tagging along with one of the interns, reading charts as she checked in on the patients, and discussing the management plan with her after I got to know a bit about the patient. The first interesting case we saw together was a young gentleman in his 20s who came in with 3 months of headache followed by one month of lethargy. He had reportedly been diagnosed with tuberculous meningitis (TB infection of the sac that holds the brain and spinal cord) several weeks earlier at another hospital, but we had no records of how this diagnosis was made. All we knew was per the family, he had been told to take TB medicines, which he had reportedly been doing for about 3 weeks. When I met him, he was looking better, apparently (i.e., not as lethargic). He spoke a little English and was clearly interactive, though not exactly sharp; this apparently was a big improvement from the day before when he was admitted, at which point he was barely responsive. An LP (aka spinal tap) done on admission, though, was completely normal (no white blood cells, normal levels of glucose and protein), so the TB team didn’t think it was likely to be tuberculous meningitis after all, since they didn’t think the spinal tap would become normal that quickly after starting treatment. His gaze looked disconjugate to me, and I suggested that we take him through as much of a formal neurological exam as we could (we got a Zulu-speaking nurse to help us). It was immediately obvious that he was unable to look to the left with his left eye, indicating a problem with his 6th cranial nerve on the left side. This cranial nerve courses through the brainstem, suggesting that he had a lesion there (a somewhat alarming place to have one, since critical things happen in the brainstem). He may have also had a slight facial droop and slight deviation of his tongue when it protruded. He also clearly had left arm weakness, both proximally and distally. It was impossible to tell how long he had these symptoms; he could not tell us and an exam from admission the day before did not include a clear neurological exam. The best clue we had is that he did not report dizziness or double vision despite his disconjugate gaze; this suggests that the process is not acute (though it could also mean he was too confused to report such a symptom, or that something was lost in translation). I asked the intern why she thought he had improved from one day to the next; she wasn’t sure. We looked back at what they had treated him with: only the TB meds (which he had been on for 3 weeks already with progression of his lethargy during that time; this didn’t seem likely), steroids that had been started on admission, and ceftriaxone, an antibiotic in case of bacterial meningitis. Given the lack of fever and (especially) the normal spinal tap, bacterial meningitis was vanishingly unlikely. So the only treatment to which we could ascribe his change in course was the steroids. The intern was happy to see him better; I was concerned, though, since steroids decrease swelling (probably explaining his improvement) but do not actually treat essentially anything that could be causing his symptoms. In fact, if it is an infection causing these symptoms (as is most likely), then in the long run the steroids will make it harder for his body to fight the infection. He needed them, I suspect, since his lethargy was probably caused by brainstem swelling that was affecting his level of consciousness, but at best this is a temporary stop-gap for a problem that needs definitive treatment. The things I can think of to explain his symptoms are TB meningitis (treatable, but he’s been on the right treatment and worsening), and three things that presuppose that he has HIV (we can’t test because he hasn’t been able to consent; even in Africa, though impressively not in California, HIV tests require patient consent): PML (progressive multifocal leukoencephalopathy, a brain disease caused by a virus known as JC virus that attacks severely immunocompromised people; would be treatable with HIV therapy), cerebral toxoplasmosis (treatable with antibiotics), or brain lymphoma (much more common in HIV; treatment would be very difficult, particularly in Africa). I’m sure there are other possibilities I’m missing. What he needs is an MRI to help with diagnosis, but hey, TIA. The nearest MRI is in another town, and the hospital that has it is not accepting transfers this week because of a bed shortage caused by construction in their cardiac and neurology intensive care units (which means, by the way, that anyone in this region that has a heart attack or stroke requiring ICU level care basically dies while the construction is happening; this is the only cardiac ICU anywhere nearby). He could have gotten a head CT, which is poor for showing the brainstem but might be able to locate and help identify a clear brainstem lesion, but again, TIA. Edendale Hospital’s only CT scanner has been broken since yesterday, and might be fixed by Monday at the soonest. He cannot be transferred because he does not qualify as an “urgent” CT, essentially because he is now too awake. So instead, his only diagnostic test is my imperfect neurological exam and partial knowledge of neuroanatomy and likely distributions of the various possible diagnoses that I can think of. Since Neuro consultants only visit this hospital on Wednesdays, I called an overseas consult by emailing Michael Wilson about the case. Left to my own devices, I still favor TB. We may never know; for all I know he might be dead before Monday when I return. TIA.
The broken CT scanner actually had quite an effect on patient care. One gentleman in his 50s who came in with abdominal pain, found to have a belly riddled with TB but also incidentally found to have a renal mass that did not look like TB on ultrasound, was discharged home on TB treatment and told to come back in two weeks for a CT to characterize his renal mass; hopefully by then the scanner would be working again. Other patients who were relatively well but awaiting a scan were similarly sent home. Those who were not well enough to be discharged but needed scans were just sitting around waiting. “Urgent” scans could be obtained by hospital transfer, but again, to qualify for an urgent scan, you had to be kinda, but not totally, comatose: too awake and you weren’t urgent (no matter what the clinical situation), but too comatose and you were too unlikely to recover no matter what the scan showed. This rule even affects scans within the hospital when the scanner is working; a man with new onset blindness earlier this week was put in a queue rather than getting a same-day scan because he was too lucid; when he became comatose the following day, he was scanned and cerebral toxoplasmosis was finally diagnosed with a 3 cm mass in the occipital lobe, the part of the brain that controls vision, that was causing swelling that had ultimately caused his depressed level of consciousness. He was treated and improved, thankfully; he can now see again.
Later in the day, I went down to the ED (“Resusc”) and saw a woman who came in with several months of worsening headache and focal seizures. She had seen a doctor in clinic about the headache a while ago, and he had recommended a painkiller. Shortly after this, she began having seizures at home, but she did not seek medical attention again for several weeks until her family insisted. I saw her have three seizures in about 30 minutes; each time we gave a medicine (diazepam, or Valium) to help stop them. This knocked her out for a while, but when she awoke again, she would begin to seize again (rhythmic left-sided facial twitching and deviation of the head to the left). The most common cause of new-onset focal seizures in this part of the world is cerebral toxoplasmosis caused by HIV. She had no known diagnosis of HIV, but she is probably about to get one. Incidentally, she is also diabetic (recently diagnosed) and had a sky-high glucose and ketones in her urine, indicating that her diabetes was raging dangerously out of control as well, possibly because of this infection. Yet again, she very much needed a head CT to help with diagnosis. I discussed the patient with one of the good attendings I’ve encountered, and he was going to call over to the neighboring hospital and argue as best he could to get her transferred for the CT. If that didn’t work, we would just start treatment for cerebral toxo, test for HIV, and hope we were right. We also gave her insulin and fluids to help treat her diabetes, and started her on a longer-acting medicine for seizures. I left for the weekend before this case was completely sorted out; I had to go pick up the other resident at the airport. It was not without a hefty dose of guilt that I stepped out of the hospital, to return on Monday. The patients will see no doctors over the weekend. TIA. Some people refer to the weekend as a “stress test” for the patients; if they survive, you know they weren’t all that sick…
I will spare you some of the other cases I saw, but suffice it to say that nearly every one was managed differently in fairly major ways than I am used to. But still, it is fun to engage people in discussions about the patients, because (a) I think it is a valuable part of patient care that does not always happen, certainly not every day with every patient, and (b) it reminds me that at some level, medicine is still medicine; the diagnostic thought process is similar even if the steps you are able to take are different.
Thursday, November 13, 2008
Like cheese and chalk
13 Nov 2008: Like cheese and chalk
My first full day in the hospital was certainly interesting. Mornings start off with intake rounds, in which the overnight interns read off the census from the night to the remaining housestaff and attendings. Today’s was a singularly terrible meeting. It turns out that the chief of medicine, Doug Wilson, who is reportedly an excellent teacher, just left the country for the US and won’t be back until December; if we overlap, it will only be by one day. Since he normally steers these meetings, it felt quite rudderless. Indeed, we spent the whole time discussing logistics of who would cover what floor, and the attendings got angry about how many people were still awaiting admission because the wards were all full. This lasted one hour. No medicine was discussed.
The housestaff (interns and “registers”, which are like our residents) went off to do their work, accompanied briefly by the few attendings who were present today; the attendings (“consultants”) all had obligations at other hospitals or in clinic so they did not spend much time on the wards. I spent much of the rest of the morning getting oriented, which involved a tour of the wards, clinics, ED equivalent (MOPD and Resusc), getting my TB mask fitted, and getting a brief talk on the culture of the hospital and the goals of the “iTEACH” program of which I am a part.
The demographics of the hospital are staggering. The hospital is the only truly public facility available for a cachement area of over 1 million people, referred in by 23 clinics. (Contrast this to Boston, with half a million people and probably 50 hospitals.) People come from a great distance, and in part because it is such an intrusion in their lives to come at all, they tend only to come at very advanced stages of disease. Despite this, the hospital is busy enough that it is difficult for them to get beds, like today, when 20 people requiring admission were sitting down in the admission area, often lying on benches in the waiting room. (Some of these people waiting have freaking bacterial meningitis! In the US, they’d be in respiratory isolation; here, they lie on a public bench and occasionally get ceftriaxone, when people remember to think of it – standing orders tend not to be written until patients are admitted.) And the patients are young; many are admitted with end-stage AIDS (often previously undiagnosed) or TB in their 20s and 30s. Probably younger too, but I don’t see the peds patients.
Ethnically, too, the situation is interesting. The housestaff (this month, at least) are nearly all white or Indian, only one black who was there today. The attendings are also more white than black, while the patient population from what I’ve seen is literally 100 percent black, and 90% Zulu speaking. Zulu has many different clicking sounds that people not raised in the language have great difficulty intoning; as a result, most of the housestaff can only barely communicate with most of the patients. Interpreters are available, but as you can imagine at a place with resources this limited, they are not plentiful.
The difference in resources between providers and patients could not be more stark as well. The housestaff deal with it as best they can; they all find it very frustrating to work in a setting with such scant resources (they also rotate through two other hospitals with more resources and find Edendale the most challenging). One I was talking to for a while today commented on how frustrated she was by this point (near the end of a two-year transitional internship); it made her almost stop caring – she couldn’t talk to her patients, they mostly ended up dying, and she didn’t even always have the resources to keep them comfortable while they died. She also reflected on how many of the patients were her age: “Imagine if that were my life?” Later, the same intern was talking at length with other housestaff about what dress to wear to the upcoming formal, and how her gold jewelry didn’t really go with her tan dress, and how it was really hard to match that dress but she liked it…. The dichotomy was striking. I suppose it’s healthy to continue to live your life within your own means, and it would be maddening to constantly focus on the limited resources of others in assessing your own status.
I also learned a new idiomatic phrase, one of my favorite parts of meeting people from other cultures. One of the interns commented on how government hospitals (like Edendale) and private hospitals in South Africa were “like cheese and chalk”. When I looked quizzical, she clarified, “You know, completely different.” After explaining the American version of the related idiom, I was forced to admit that, yes, in fact apples and oranges are not that different, certainly not compared with cheese and chalk. (My all-time favorite foreign idiom is the Greek equivalent of “the pot calling the kettle black”, which is “the donkey calling the rooster big-head”.)
I came home exhausted, ate a Zulu meal prepared by my host Gugu, and am ready to turn in at the crotchety hour of 9 pm. (I do have to wake up around 5:30 am to beat traffic, so it’s not all bad). I also tried to make plans for a place to stay this weekend in the Drakensberg mountains, which should be fun. Tomorrow evening the other MGH resident arrives, so the house should perk up a bit and I’ll have someone to share thoughts with; perhaps then my blog will get less cumbersome. Thanks for reading so far.
My first full day in the hospital was certainly interesting. Mornings start off with intake rounds, in which the overnight interns read off the census from the night to the remaining housestaff and attendings. Today’s was a singularly terrible meeting. It turns out that the chief of medicine, Doug Wilson, who is reportedly an excellent teacher, just left the country for the US and won’t be back until December; if we overlap, it will only be by one day. Since he normally steers these meetings, it felt quite rudderless. Indeed, we spent the whole time discussing logistics of who would cover what floor, and the attendings got angry about how many people were still awaiting admission because the wards were all full. This lasted one hour. No medicine was discussed.
The housestaff (interns and “registers”, which are like our residents) went off to do their work, accompanied briefly by the few attendings who were present today; the attendings (“consultants”) all had obligations at other hospitals or in clinic so they did not spend much time on the wards. I spent much of the rest of the morning getting oriented, which involved a tour of the wards, clinics, ED equivalent (MOPD and Resusc), getting my TB mask fitted, and getting a brief talk on the culture of the hospital and the goals of the “iTEACH” program of which I am a part.
The demographics of the hospital are staggering. The hospital is the only truly public facility available for a cachement area of over 1 million people, referred in by 23 clinics. (Contrast this to Boston, with half a million people and probably 50 hospitals.) People come from a great distance, and in part because it is such an intrusion in their lives to come at all, they tend only to come at very advanced stages of disease. Despite this, the hospital is busy enough that it is difficult for them to get beds, like today, when 20 people requiring admission were sitting down in the admission area, often lying on benches in the waiting room. (Some of these people waiting have freaking bacterial meningitis! In the US, they’d be in respiratory isolation; here, they lie on a public bench and occasionally get ceftriaxone, when people remember to think of it – standing orders tend not to be written until patients are admitted.) And the patients are young; many are admitted with end-stage AIDS (often previously undiagnosed) or TB in their 20s and 30s. Probably younger too, but I don’t see the peds patients.
Ethnically, too, the situation is interesting. The housestaff (this month, at least) are nearly all white or Indian, only one black who was there today. The attendings are also more white than black, while the patient population from what I’ve seen is literally 100 percent black, and 90% Zulu speaking. Zulu has many different clicking sounds that people not raised in the language have great difficulty intoning; as a result, most of the housestaff can only barely communicate with most of the patients. Interpreters are available, but as you can imagine at a place with resources this limited, they are not plentiful.
The difference in resources between providers and patients could not be more stark as well. The housestaff deal with it as best they can; they all find it very frustrating to work in a setting with such scant resources (they also rotate through two other hospitals with more resources and find Edendale the most challenging). One I was talking to for a while today commented on how frustrated she was by this point (near the end of a two-year transitional internship); it made her almost stop caring – she couldn’t talk to her patients, they mostly ended up dying, and she didn’t even always have the resources to keep them comfortable while they died. She also reflected on how many of the patients were her age: “Imagine if that were my life?” Later, the same intern was talking at length with other housestaff about what dress to wear to the upcoming formal, and how her gold jewelry didn’t really go with her tan dress, and how it was really hard to match that dress but she liked it…. The dichotomy was striking. I suppose it’s healthy to continue to live your life within your own means, and it would be maddening to constantly focus on the limited resources of others in assessing your own status.
I also learned a new idiomatic phrase, one of my favorite parts of meeting people from other cultures. One of the interns commented on how government hospitals (like Edendale) and private hospitals in South Africa were “like cheese and chalk”. When I looked quizzical, she clarified, “You know, completely different.” After explaining the American version of the related idiom, I was forced to admit that, yes, in fact apples and oranges are not that different, certainly not compared with cheese and chalk. (My all-time favorite foreign idiom is the Greek equivalent of “the pot calling the kettle black”, which is “the donkey calling the rooster big-head”.)
I came home exhausted, ate a Zulu meal prepared by my host Gugu, and am ready to turn in at the crotchety hour of 9 pm. (I do have to wake up around 5:30 am to beat traffic, so it’s not all bad). I also tried to make plans for a place to stay this weekend in the Drakensberg mountains, which should be fun. Tomorrow evening the other MGH resident arrives, so the house should perk up a bit and I’ll have someone to share thoughts with; perhaps then my blog will get less cumbersome. Thanks for reading so far.
Wednesday, November 12, 2008
The rest of the vacation
Another disclaimer: I just arrived in PMB today (12 Nov), and I should now be able to upload some pix and such. I'll try to do that in the days to come; at this point I'm just settling in. Here is what I've written (again offline) over the past few days during the rest of my vacation time:
11/8: Weekend at the Cape: neither the southernmost, nor the westernmost, but debatably the most southwesternest point of Africa
Another full day; I just rolled in to my rondavel in Wilderness Nat’l Park at around 8:30pm, which seems to be a late arrival for them (gate was closed when I got there). I had beautiful weather for my trip to the Cape (not that Cape, Bostonians) – windy (as always) but perfectly clear. The cape itself was gorgeous, and it’s somehow neat to think that this is where the Atlantic and Indian Oceans meet. (I had missed out on Ushuaiya when we went to Argentina.) From what I hear, it is a powerful place to be when there are storms; today the water was relatively calm. This stretch of park has some beautiful hiking, and I was only able to do a little bit (from Cape Point across to Cape of Good Hope and back) before hitting the road for my first long driving day. I did see a turtle and some big game (more unspecified boks, these ones male – with antlers – and enormous, bigger than horses) quite close-up during the Cape of Good Hope hike. The turtle was on the trail, and the closest of the hooved beasts was probably 50 feet away without any barriers between us. Luckily, he seemed less interested in me than I was in him.
On the way out, I stopped in Kalk Bay, a small, scenic, and pleasant bump in the road that seems mainly to serve tourists. At Janina’s suggestion, I had lunch at Olympia Café, which was as good as she described. It was cool to think that someone I know had eaten there several years ago, so far from home! There was a paper sitting around, and I couldn’t help reading more about Obama, along with a few choice cracks about Palin (a “seal-clubbing fundamentalist with no spark of intellect behind her designer specs” and a “libidinous choice of running mate” that is contextualized when one considers McCain’s “scary Barbie” wife). Also on the way out, I stopped off very briefly at a penguin colony (honestly, if the other name for African penguins wasn’t “jackass penguins”, I might have skipped this, as it was getting late). They were short and furry and cute, and I moved on.
An unexpected view on the way out of the Cape Town peninsula left me with my most powerful memory of the trip so far. While driving on R310 east along the coast, I saw Cape Flats for the first time; they stretch at one point (the Khayeltisha “neighborhood”) right up to the road. This is the part of Cape Town where the blacks who were evicted from District 6 (see my 11/6 entry) and other neighborhoods were deposited, and it is a slum in every imaginable sense. Living quarters (“houses” is a gross overstatement) comprising corrugated aluminum siding pasted just a few feet from each other stretched for as far as the eye could see. I had read that the majority of blacks in Cape Town lived in Cape Flats, but tourists are strongly discouraged from visiting because of the absolutely atrocious crime rates. I am very glad I saw them; that said, I did not feel comfortable even stopping at the side of the road for a picture; I have only the indelible image left in my mind. Unequal distribution of wealth is often cited as a problem in the US; the rich-poor gap is of an unimaginable magnitude here.
The drive itself was very uneventful. I have gotten more used to the whole left-sided gear shift and even can size up my car a bit better. Good thing I don’t have a car back in the states, because my instincts are changing. And now I sit in a charming little circular hut in a place that feels quite a bit like a national park facility in the US. I’m not used to not camping in places like this, but I had too much crap with me and decided not to bring a tent. Alas. The stars are gorgeous on this clear night; it’s a shame I don’t have the first clue what any of them are. What is the brightest star in the southern sky? Anyone?
11/9: Woody Guthrie would have been disappointed
I had planned a leisurely morning hike through Wilderness National Park, but the one I had planned to do was closed, according to a sign blocking the way. After briefly considering Woody Guthrie’s opinion on such things (“on the back side, the sign don’t say nothin’”), I decided that as a solo traveler on a foreign continent, I should obey, so I left earlier than planned. As today was my shortest driving day anyway, this left me with a bit of time to kill. I went back to the town of Wilderness (a few km from the national park) and got more cash and found a hallowed beverage that my dad and I remember fondly from travels during my childhood: Schweppes Bitter Lemon (now called Dry Lemon). Maybe quinine-containing drinks caught on in malarial areas back when it might have helped…. Just as tasty as I remembered. I also stopped briefly in Knysna, an affluent outpost whose downtown seemed to comprise several malls stuck together. I got gas and a few odds and ends here, including blank CDs – I didn’t realize my car would have a CD player, and now I can burn some music to drown out the sound of my singing (which is all I’ve had to keep me entertained so far).
Not long thereafter, I arrived at Storm’s River Mouth, another national park outpost and the centerpiece of my trip up the coast. It reminds me a lot of the Steep Ravine cabins in the SF bay area, for those who remember… Cabins nestled on a rocky coast overlooking a rough sea, the sound of waves crashing all night; all that’s missing is the great company and the guitar! (And I do miss both….) I went on a delightful class-3 scramble for about 3 km up the beach to a gorgeous waterfall emptying into the ocean, along the way passing countless excellent bouldering and climbing options that rival the Egg but remain untapped as far as I can tell. The hike was rated as difficult and was fun without being dangerous as long as one paid attention; another (ageist) way to describe its degree of difficulty is: I saw a few people over 60, but they all looked nervous… (sorry, Mom and Dad!). One can swim near the waterfall, and the water wasn’t too cold, but it looked pretty disgusting actually, so I didn’t jump in; nobody else did while I was there either. I ate a bit of a snack and enjoyed the waterfall and the waves, eyeballed the class 4 climb that could have taken one about 3/4 of the way up to the top of the 100-plus-foot waterfall, and quickly decided not to be stupid, then headed back. Unfortunately, I took a bit of an unintended detour on the way back and took the long way home (route-finding was an issue; the trail was a rumor most of the way), so I couldn’t do the second hike I had in mind for the day (another Woody Guthrie moment as I faced a locked gate noting a trail that had been closed for the evening; again, I obeyed). Instead, I hung around for an hour to watch a spectacular sunset over the Indian Ocean, then got dinner at the restaurant in the park (a delicious prawn curry). When I had reserved my table for dinner earlier in the day, I was the only one who said I wanted to sit outside. They made fun of me for this; apparently that option was only for daytime meals. Heck, it was like 60F out; I dressed warm and was ready to sit out on the deck and listen to the ocean! I think they thought I was nuts, and they made me eat indoors. Alas… Back in my cabin, I burned some CDs for the road and typed this blog entry off-line before turning in. I’ll do that second hike here at Storm’s River Mouth before heading out for a longer drive up to the Wild Coast.
10 Nov: Yarr, a fun night at Buccaneer’s on the Wild Coast
Woke up in Storm’s River Mouth to the beautiful view out my forest hut window. I tried the hike that was closed the night before; it is supposed to go out across a suspension bridge that crosses the mouth of the river as it empties into the Indian Ocean. However, I was once again thwarted, this time by risk of rockfall; they closed the trail about 500 meters short of the bridge. Instead, I scrambled out onto some rocks that jutted out into the ocean so I could get a view of the bridge and at least part of the river mouth. (I’m sure this was more risky than the rockfall that made them close the trail to begin with, but really, what choice did I have?)
I ate a quick breakfast of fruit and PBJ, then headed out to start the long drive to Cinsta (500 km to cover both today and tomorrow). The CDs helped to pass the time on the drive, and it seemed to fly by. I arrived at the famous Buccaneer’s Backpacker Lodge (reportedly the best hostel in South Africa) around 4pm. The last 3 km to the hostel was unpaved and very rocky, and after I arrived, I realized that somewhere along the way I had gotten a flat. Luckily, I had a spare in the car; in South Africa, they don’t have the US-type solid rubber spares, but instead they just have a fifth tire in the trunk, just like the other four. This would have been good (no need to drive around with a small tire), except that the reason for non-inflatable spares is that since they are seldom used, inflatable spares leak over time, and sure enough, my spare was pretty flat too. Luckily a guy named Pete at Buccaneer’s had an air compressor, and he offered to let me use it in the morning. Several people offered to help when they saw me changing the tire; I didn’t need it, but the sentiment was appreciated – the place had a friendly vibe.
After changing the tire, I had time to go down to the beach and run/play in the ocean a bit. I turned around to see a truly spectacular sunset over a freshwater lagoon just next to the sea; the sky turned from normal to fiery red in a matter of two minutes. I sprinted over to get my camera and captured the show for the next 10-15 minutes. On my way back I ran into a couple from Australia who had been watching the sunset too (curiously, we were the only people out on the beach at sunset despite a very full hostel a 5 minute walk away). They were a fun couple, about my age; he is Irish but lives near Sydney (Bondi Beach), she is of Indian ethnicity (family from Tamil Nadu) but was born in Singapore and raised in Brunei, then relocated to Australia. I don’t believe I had ever met anyone who had lived in Brunei before. I ended up having dinner with them at the lodge as well, and we (along with a few Euros) played pool and drank and talked until 3 am! Good people.
The hostel was fantastically fun, just as advertised. The staff were very energetic, warm, and friendly, and although I couldn’t partake since I was there so briefly, they arrange for many cultural and/or athletic activities from the lodge. Many of the staff were Xhosa (the first sound is a “click”, not an x- or z-sound as you might expect by looking), the local tribe along the Wild Coast, and it was fun to hear them click when they talked! Dinner is a communal event every night and blends seamlessly into a night of talking, dancing, pool, drinking, and listening to music if one so chooses. Easily the most social of the places I stayed in, with a crowd that ran from early 20s to mid-60s (including two fun recently retired Swedish couples who talked a lot, especially one guy who kept saying “I can’t speak good English” but must have talked more than anybody else there!).
11 Nov: Flat tire saga
Today was a boring, tough day of driving. I awoke to rain and a spare tire that was quite a bit more flat than when I went to bed… not confidence-inspiring. Did someone else get a flat and just put the flat tire in the trunk in place of the spare, so that I had replaced a flat with a flat? I called Dollar and they assured me all spares are checked; still, I was a bit nervous as I am quite reliant on that car and will be miles away from anywhere for most of my journey! Car trouble was the one thing I was worried about as I planned this trip, and now here it was (albeit minor). The rain didn’t help lift my spirits, either; it was alternating between a drizzle and a downpour.
I found Pete the resident handyman, and he helped me fill up the spare; it certainly seemed to take air without trouble and without an evident leak. Still, I asked directions to the nearest filling station and planned to get a new tire. Unfortunately, the directions they gave me to the closest filling station would have taken me several km down another unpaved, rocky road; I decided to head back out to the highway instead (since the tire was still holding up at this point) and take my chances with the next filling station. By the time I got to one, I had been driving for a good 20 minutes and the spare tire looked perfect. Luckily, the gas station I happened upon also had a mechanic next door; they didn’t sell tires but they were able to plug the leak in the flat tire, so at least I had a functioning backup in case I got another flat (or the new spare failed to hold air). This made me feel a lot better about the rest of the journey, but it did set me back a good two hours. I enjoyed seeing the service station; they kinda stared at me a bit and we had a bit of trouble communicating (I gather they don’t get too many white folks through there), and I realized when I gave them my tire I didn’t have a good idea of how long it would take them to fix it; I wasn’t able to get that message across. But, just when I was getting anxious, they wheeled the tire back out to me, all fixed and inflated. All for 8 bucks (US). Not bad. It’s easy to be a generous tipper, too, with a 9:1 exchange rate!
So on I went. The drive was not much farther than yesterday, but much more painful. I had less sleep (though for good reason; last night was fun), and a much later start on the day; after the tire saga, it was 12:30 pm before I really got going. I still had 550 km to cover, which could take under 5 hours under good conditions, but conditions were far from good. It rained steadily, and worse, a thick mist descended just as I entered KwaZulu-Natal that limited visibility to maybe 50 feet for a good stretch of the drive in two different places, so I had to drive much slower than I anticipated. Also, the N2 (highway) here was two-lane, undivided, windy, and up-and-down for most of the way today, leaving us at the mercy of trucks, since it was completely impossible to pass in the mist. So I spent a good chunk of the drive stuck behind an 18-wheeler chugging its way up a winding incline at 40 kph instead of the normal 120 kph. All that said, I ended up getting in to my hostel around 8:30 pm instead of a hoped-for 5ish, exhausted and hungry.
An observation on South African drivers: they use their hazard lights differently than we do in the US. Rather than denoting engine trouble for a car on the side of the road or some such, they appear to use them to say “I’m about to create a hazard by doing something stupid and reckless that will endanger my life and yours”. When attempting a risky pass into the oncoming lane, or when they cut you off or tailgate and want you to drive off into the shoulder so they can get by, they’ll turn on the hazard lights. I heard yesterday that South Africa has the highest rate of traffic fatalities of any country in the world, and after today, I see why. Some people are freaking psychos behind the wheel, and there are many delusional truckers who think they’re driving Porsches.
Anyway, it’s good to have most of my driving behind me, and it’s even better to be able to sleep tonight! Found a nice clean backpacker’s hostel in Umtentweni, just north of Port Shepstone and maybe 100 km south of Durban. That just leaves a short hop up the coast to Durban, then west to Edendale to get a peek at the hospital, then on to my new home for the next month!
11/8: Weekend at the Cape: neither the southernmost, nor the westernmost, but debatably the most southwesternest point of Africa
Another full day; I just rolled in to my rondavel in Wilderness Nat’l Park at around 8:30pm, which seems to be a late arrival for them (gate was closed when I got there). I had beautiful weather for my trip to the Cape (not that Cape, Bostonians) – windy (as always) but perfectly clear. The cape itself was gorgeous, and it’s somehow neat to think that this is where the Atlantic and Indian Oceans meet. (I had missed out on Ushuaiya when we went to Argentina.) From what I hear, it is a powerful place to be when there are storms; today the water was relatively calm. This stretch of park has some beautiful hiking, and I was only able to do a little bit (from Cape Point across to Cape of Good Hope and back) before hitting the road for my first long driving day. I did see a turtle and some big game (more unspecified boks, these ones male – with antlers – and enormous, bigger than horses) quite close-up during the Cape of Good Hope hike. The turtle was on the trail, and the closest of the hooved beasts was probably 50 feet away without any barriers between us. Luckily, he seemed less interested in me than I was in him.
On the way out, I stopped in Kalk Bay, a small, scenic, and pleasant bump in the road that seems mainly to serve tourists. At Janina’s suggestion, I had lunch at Olympia Café, which was as good as she described. It was cool to think that someone I know had eaten there several years ago, so far from home! There was a paper sitting around, and I couldn’t help reading more about Obama, along with a few choice cracks about Palin (a “seal-clubbing fundamentalist with no spark of intellect behind her designer specs” and a “libidinous choice of running mate” that is contextualized when one considers McCain’s “scary Barbie” wife). Also on the way out, I stopped off very briefly at a penguin colony (honestly, if the other name for African penguins wasn’t “jackass penguins”, I might have skipped this, as it was getting late). They were short and furry and cute, and I moved on.
An unexpected view on the way out of the Cape Town peninsula left me with my most powerful memory of the trip so far. While driving on R310 east along the coast, I saw Cape Flats for the first time; they stretch at one point (the Khayeltisha “neighborhood”) right up to the road. This is the part of Cape Town where the blacks who were evicted from District 6 (see my 11/6 entry) and other neighborhoods were deposited, and it is a slum in every imaginable sense. Living quarters (“houses” is a gross overstatement) comprising corrugated aluminum siding pasted just a few feet from each other stretched for as far as the eye could see. I had read that the majority of blacks in Cape Town lived in Cape Flats, but tourists are strongly discouraged from visiting because of the absolutely atrocious crime rates. I am very glad I saw them; that said, I did not feel comfortable even stopping at the side of the road for a picture; I have only the indelible image left in my mind. Unequal distribution of wealth is often cited as a problem in the US; the rich-poor gap is of an unimaginable magnitude here.
The drive itself was very uneventful. I have gotten more used to the whole left-sided gear shift and even can size up my car a bit better. Good thing I don’t have a car back in the states, because my instincts are changing. And now I sit in a charming little circular hut in a place that feels quite a bit like a national park facility in the US. I’m not used to not camping in places like this, but I had too much crap with me and decided not to bring a tent. Alas. The stars are gorgeous on this clear night; it’s a shame I don’t have the first clue what any of them are. What is the brightest star in the southern sky? Anyone?
11/9: Woody Guthrie would have been disappointed
I had planned a leisurely morning hike through Wilderness National Park, but the one I had planned to do was closed, according to a sign blocking the way. After briefly considering Woody Guthrie’s opinion on such things (“on the back side, the sign don’t say nothin’”), I decided that as a solo traveler on a foreign continent, I should obey, so I left earlier than planned. As today was my shortest driving day anyway, this left me with a bit of time to kill. I went back to the town of Wilderness (a few km from the national park) and got more cash and found a hallowed beverage that my dad and I remember fondly from travels during my childhood: Schweppes Bitter Lemon (now called Dry Lemon). Maybe quinine-containing drinks caught on in malarial areas back when it might have helped…. Just as tasty as I remembered. I also stopped briefly in Knysna, an affluent outpost whose downtown seemed to comprise several malls stuck together. I got gas and a few odds and ends here, including blank CDs – I didn’t realize my car would have a CD player, and now I can burn some music to drown out the sound of my singing (which is all I’ve had to keep me entertained so far).
Not long thereafter, I arrived at Storm’s River Mouth, another national park outpost and the centerpiece of my trip up the coast. It reminds me a lot of the Steep Ravine cabins in the SF bay area, for those who remember… Cabins nestled on a rocky coast overlooking a rough sea, the sound of waves crashing all night; all that’s missing is the great company and the guitar! (And I do miss both….) I went on a delightful class-3 scramble for about 3 km up the beach to a gorgeous waterfall emptying into the ocean, along the way passing countless excellent bouldering and climbing options that rival the Egg but remain untapped as far as I can tell. The hike was rated as difficult and was fun without being dangerous as long as one paid attention; another (ageist) way to describe its degree of difficulty is: I saw a few people over 60, but they all looked nervous… (sorry, Mom and Dad!). One can swim near the waterfall, and the water wasn’t too cold, but it looked pretty disgusting actually, so I didn’t jump in; nobody else did while I was there either. I ate a bit of a snack and enjoyed the waterfall and the waves, eyeballed the class 4 climb that could have taken one about 3/4 of the way up to the top of the 100-plus-foot waterfall, and quickly decided not to be stupid, then headed back. Unfortunately, I took a bit of an unintended detour on the way back and took the long way home (route-finding was an issue; the trail was a rumor most of the way), so I couldn’t do the second hike I had in mind for the day (another Woody Guthrie moment as I faced a locked gate noting a trail that had been closed for the evening; again, I obeyed). Instead, I hung around for an hour to watch a spectacular sunset over the Indian Ocean, then got dinner at the restaurant in the park (a delicious prawn curry). When I had reserved my table for dinner earlier in the day, I was the only one who said I wanted to sit outside. They made fun of me for this; apparently that option was only for daytime meals. Heck, it was like 60F out; I dressed warm and was ready to sit out on the deck and listen to the ocean! I think they thought I was nuts, and they made me eat indoors. Alas… Back in my cabin, I burned some CDs for the road and typed this blog entry off-line before turning in. I’ll do that second hike here at Storm’s River Mouth before heading out for a longer drive up to the Wild Coast.
10 Nov: Yarr, a fun night at Buccaneer’s on the Wild Coast
Woke up in Storm’s River Mouth to the beautiful view out my forest hut window. I tried the hike that was closed the night before; it is supposed to go out across a suspension bridge that crosses the mouth of the river as it empties into the Indian Ocean. However, I was once again thwarted, this time by risk of rockfall; they closed the trail about 500 meters short of the bridge. Instead, I scrambled out onto some rocks that jutted out into the ocean so I could get a view of the bridge and at least part of the river mouth. (I’m sure this was more risky than the rockfall that made them close the trail to begin with, but really, what choice did I have?)
I ate a quick breakfast of fruit and PBJ, then headed out to start the long drive to Cinsta (500 km to cover both today and tomorrow). The CDs helped to pass the time on the drive, and it seemed to fly by. I arrived at the famous Buccaneer’s Backpacker Lodge (reportedly the best hostel in South Africa) around 4pm. The last 3 km to the hostel was unpaved and very rocky, and after I arrived, I realized that somewhere along the way I had gotten a flat. Luckily, I had a spare in the car; in South Africa, they don’t have the US-type solid rubber spares, but instead they just have a fifth tire in the trunk, just like the other four. This would have been good (no need to drive around with a small tire), except that the reason for non-inflatable spares is that since they are seldom used, inflatable spares leak over time, and sure enough, my spare was pretty flat too. Luckily a guy named Pete at Buccaneer’s had an air compressor, and he offered to let me use it in the morning. Several people offered to help when they saw me changing the tire; I didn’t need it, but the sentiment was appreciated – the place had a friendly vibe.
After changing the tire, I had time to go down to the beach and run/play in the ocean a bit. I turned around to see a truly spectacular sunset over a freshwater lagoon just next to the sea; the sky turned from normal to fiery red in a matter of two minutes. I sprinted over to get my camera and captured the show for the next 10-15 minutes. On my way back I ran into a couple from Australia who had been watching the sunset too (curiously, we were the only people out on the beach at sunset despite a very full hostel a 5 minute walk away). They were a fun couple, about my age; he is Irish but lives near Sydney (Bondi Beach), she is of Indian ethnicity (family from Tamil Nadu) but was born in Singapore and raised in Brunei, then relocated to Australia. I don’t believe I had ever met anyone who had lived in Brunei before. I ended up having dinner with them at the lodge as well, and we (along with a few Euros) played pool and drank and talked until 3 am! Good people.
The hostel was fantastically fun, just as advertised. The staff were very energetic, warm, and friendly, and although I couldn’t partake since I was there so briefly, they arrange for many cultural and/or athletic activities from the lodge. Many of the staff were Xhosa (the first sound is a “click”, not an x- or z-sound as you might expect by looking), the local tribe along the Wild Coast, and it was fun to hear them click when they talked! Dinner is a communal event every night and blends seamlessly into a night of talking, dancing, pool, drinking, and listening to music if one so chooses. Easily the most social of the places I stayed in, with a crowd that ran from early 20s to mid-60s (including two fun recently retired Swedish couples who talked a lot, especially one guy who kept saying “I can’t speak good English” but must have talked more than anybody else there!).
11 Nov: Flat tire saga
Today was a boring, tough day of driving. I awoke to rain and a spare tire that was quite a bit more flat than when I went to bed… not confidence-inspiring. Did someone else get a flat and just put the flat tire in the trunk in place of the spare, so that I had replaced a flat with a flat? I called Dollar and they assured me all spares are checked; still, I was a bit nervous as I am quite reliant on that car and will be miles away from anywhere for most of my journey! Car trouble was the one thing I was worried about as I planned this trip, and now here it was (albeit minor). The rain didn’t help lift my spirits, either; it was alternating between a drizzle and a downpour.
I found Pete the resident handyman, and he helped me fill up the spare; it certainly seemed to take air without trouble and without an evident leak. Still, I asked directions to the nearest filling station and planned to get a new tire. Unfortunately, the directions they gave me to the closest filling station would have taken me several km down another unpaved, rocky road; I decided to head back out to the highway instead (since the tire was still holding up at this point) and take my chances with the next filling station. By the time I got to one, I had been driving for a good 20 minutes and the spare tire looked perfect. Luckily, the gas station I happened upon also had a mechanic next door; they didn’t sell tires but they were able to plug the leak in the flat tire, so at least I had a functioning backup in case I got another flat (or the new spare failed to hold air). This made me feel a lot better about the rest of the journey, but it did set me back a good two hours. I enjoyed seeing the service station; they kinda stared at me a bit and we had a bit of trouble communicating (I gather they don’t get too many white folks through there), and I realized when I gave them my tire I didn’t have a good idea of how long it would take them to fix it; I wasn’t able to get that message across. But, just when I was getting anxious, they wheeled the tire back out to me, all fixed and inflated. All for 8 bucks (US). Not bad. It’s easy to be a generous tipper, too, with a 9:1 exchange rate!
So on I went. The drive was not much farther than yesterday, but much more painful. I had less sleep (though for good reason; last night was fun), and a much later start on the day; after the tire saga, it was 12:30 pm before I really got going. I still had 550 km to cover, which could take under 5 hours under good conditions, but conditions were far from good. It rained steadily, and worse, a thick mist descended just as I entered KwaZulu-Natal that limited visibility to maybe 50 feet for a good stretch of the drive in two different places, so I had to drive much slower than I anticipated. Also, the N2 (highway) here was two-lane, undivided, windy, and up-and-down for most of the way today, leaving us at the mercy of trucks, since it was completely impossible to pass in the mist. So I spent a good chunk of the drive stuck behind an 18-wheeler chugging its way up a winding incline at 40 kph instead of the normal 120 kph. All that said, I ended up getting in to my hostel around 8:30 pm instead of a hoped-for 5ish, exhausted and hungry.
An observation on South African drivers: they use their hazard lights differently than we do in the US. Rather than denoting engine trouble for a car on the side of the road or some such, they appear to use them to say “I’m about to create a hazard by doing something stupid and reckless that will endanger my life and yours”. When attempting a risky pass into the oncoming lane, or when they cut you off or tailgate and want you to drive off into the shoulder so they can get by, they’ll turn on the hazard lights. I heard yesterday that South Africa has the highest rate of traffic fatalities of any country in the world, and after today, I see why. Some people are freaking psychos behind the wheel, and there are many delusional truckers who think they’re driving Porsches.
Anyway, it’s good to have most of my driving behind me, and it’s even better to be able to sleep tonight! Found a nice clean backpacker’s hostel in Umtentweni, just north of Port Shepstone and maybe 100 km south of Durban. That just leaves a short hop up the coast to Durban, then west to Edendale to get a peek at the hospital, then on to my new home for the next month!
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