Friday, September 14, 2007

Queen 2 to Bloem

September 3 – September 9

The pace is picking up a little in clinic as I get used to the clinic routine. I’m getting accustomed to the electronic medical record, the referral forms, the questions I need to ask, and even picking out some of the Sesotho phrases I hear the patients use like, “why is that white doctor so hairy?” (though still don’t know when the official language lesions are going to start). I’m getting a little more comfortable with managing the 3 year old HIV positive child on active anti-tuberculosis treatment who presents with moderate wasting (acute malnutrition). Just a little more comfortable. Almost every day I see a patient that has a dermatologic finding that could be placed in a dermatology atlas. We actually have this great teledermatology resource. We take a photo, include the patient’s history, send it to a dermatologist/dermatopathologist in Philadelphia with specialty training in tropical medicine who then emails us back her opinion. Very nice. She even accepts biopsies that we DHL to the States. So far I have taken pics of (what I think are): a pyogenic granuloma on a pregnant woman’s cheek; oral hairy leukoplakia of the lateral tongue, widespread flat warts around the face and neck of an adolescent, nail discoloration possibly due to AZT, chronic, widespread molluscum contagiosum, and some sort of benign mucosal hypermelanosis. I’ve also seen what’s most likely inguinal adenopathy from lymphogranuloma venereum, scrofula, a fair amount of herpes and possibly some secondary syphilis and PID.

Queen Elizabeth 2 Hospital
I went to QE2 on Friday and was reminded that I was in Africa. This public hospital truly has a major lack of funding. It makes my “old” community hospital from residency look like the Westin. Plaster was falling off the walls and ceiling, you have to dodge holes in the floor, you try to ignore the occasional many-legged critter on the wall, and LPs are done without iodine, sterile gloves or spinal needles when supplies are out, to name a few of the specifics. The “pediatric ICU” is a small room with one oxygen concentrator (not an oxygen tank, but a machine that can concentrate the room’s oxygen and deliver it up to about 5 L/min) that has 3 to 6 tubes snaking off it in a jumble of tubing in the middle of the floor, each going to a different patient sharing what little oxygen the machine can produce (sometimes you can't even feel the flow of oxygen on your hand; unsure if any reaches the alveoli). There might be a 6 week old sharing a crib with a 4 month old, next to a bed with a 9 year old, all with different ailments, many of which are likely passed fairly freely between them (“here, try my infection; ok, now I’ll try yours”). There is one dedicated pediatrician on the ward (Dr. Phiri, a Malawian woman who has been working there for decades) and about 3 medical officers – people that have graduated from medical school but seem to be stuck, thanks to a lack of funds that would allow them to go out of country to a regular residency, in an odd permanent internship with no lectures, no hope for advancement, and no Thursday group sharing sessions. But damn, can they find a vein. All of their training is on the wards, and they have to start all their IVs, draw all their blood, do the LPs, drop the nasogastric tubes, deliver the specimens, etc. The nurses’ sole responsibility is to give medications (we prescibe Qday dosing whenever possible). There is no phlebotomy, nurses don’t give food (parents feed their kids, but unlike poorer hospitals, they at least don’t have to cook the food as there is a kitchen), people don’t come to pick your patient up and take them to radiology, and there are no Wellness Dogs (though I did find a woman with a monkey in her hair, but that was at a restaurant in South Africa). We see the HIV positive kids that are admitted from our clinic. These are very sick kids, as even the pretty sick kids we try to manage as outpatients since the mortality is so high in the hospital (no attendings or residents in the hospital after hours, and sporadically on weekends). We’ve recently had sort of a neuro service: a 7 month old with severe wasting, dehydration, and likely meningitis with a blown pupil but flat fontanelle, a ~9 month old with possible idiopathic intracranial hypertension (pseudotumor cerebri from…?hypervitaminosis A, iron deficiency anemia, HIV itself?), an adolescent with likely viral encephalitis that growls, kicks, and occasionally goes AWAL, and a toddler with brain lesions of uncertain etiology, subsequent hydrocephalus and Cheyne-Stokes breathing, seizures, and possibly temperature disregulation due to the CNS damage. They are all managed by, that’s right, us. That’s not to say that we manage them exceptionally well; we do what we can. No quick calls to Dr. Warner to manage the case for us, no going down to chat with the neuroradiologist about the differential. Thankfully, the internet really helps, and I’ve written some emails and sent some pictures of CXRs and CTs to friends in the US.

Took a good trip to Bloemfontain, a city of 500,000 in South Africa about 1.5 hrs away from Lesotho. We found hearty food and drink, soft-serve ice cream, and The Simpsons Movie (only 2 bucks!) all at a cheesy waterfront mall. Really made me feel like I was back home. Went for a great run up a big hill near the house. After the chest and jaw pressure subsided I noticed that there was a great, nearly panoramic view of Maseru up at the top. Bright, clear blue skies and 70 degree weather – so this is Africa.

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