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.
Wednesday, December 3, 2008
“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!
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