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!