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.
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