Saturday, December 29, 2007





Queen Elizabeth 2 Government Hospital

Wednesday, December 19, 2007

Today was my first day as pediatric AIDS corps (PAC) doc assigned to the Children’s Medical Ward (CMW) at QE2. I can already tell that these are likely to be two of my most trying and memorable weeks during my assignment in Lesotho (though I think I get to do this again in 2008). This morning I met with Dr. Guada Richter, PAC pediatrician who was finishing her two weeks on the CMW. We rounded on the current list of patients that the Baylor docs are in charge of. Malnutrition, tuberculous meningitis, bacterial pneumonia, pleural effusion with shifted mediastinum, bacterial meningitis, impressive hepatomegaly, and gastrointestinal bleeding were some of the “run of the mill” diagnoses. Queen2 is rich in contrasts. It affords a wonderful teaching opportunity. The variety of diseases seen, the autonomy it provides (think of the opposite of inpatient peds at Sutter – when it used to have inpatient peds), the procedures – all bring amazing learning opportunities. I started my first scalp vein IV catheter on a baby that had poor peripheral venous access. I have no attending. More unbelievably, I’m the “private” referral doctor in charge of patients on the CMW of the national referral hospital. Yes, it’s ridiculous. I’m way out of my league.

I was rounding in the nursery, a small oven of a room with babies stacked in neat little rows lining the room – tiny premature babies, babies with communicable infections, all lined up next to each other in their cribs. It really catches your attention the first time you see a roach scurrying up the wall next to a row of cribs. I asked why my 20 day old baby with suspected meningitis hadn’t had his temperature recorded (this is normally done only once a day in the nursery at QE2).
“The thermometer (mercury) is broken”.
“OK, could you borrow one from the busy maternity unit next door (I’m sure it has hundreds of deliveries per month)”
“No, they don’t have one either”.
What? Wow. It turns out they can only get one from the pharmacy on Fridays and Mondays. Oh. I see.
Back at the CMW, I was starting an IV on a child on one of the two exam tables in the treatment room and looked over at a small, still form. A 4 month old child was covered with a sheet, left alone on the exam table. My first thought, Why is there a dead child on the procedure room exam table? Where is the mother? Why are the same tables that are used for lumbar punctures and initiating IVs also used for holding the deceased children? Why do children die on the ward almost daily? The child had been seen in the Casualty Department, our version of an emergency room and admitted to the CMW. While the child was waiting in his mother’s arms on the bench to see the admitting medical officer, the child died. No Code Blue called, no rush of doctors and nurses to bring the child back from the clutches of Death. Just a child that presented too late to the doctor due to a hundred reasons. I quickly (and coldly?) thought to myself, move on, keep working on your list of patients to save the ones that you still can.

Day 2

Really the morning of day 3 before work; I was too tired and depressed to write last night. Yesterday was a tough day. Rounding on patients throughout the day, catching up on things that needed to be done to the patients I was getting to know, admitting new patients, doing procedures. Blood that needed to be hung over night and wasn’t, meds that should have been given but weren’t. Kids in respiratory distress with only a weak hint of oxygen piping through tubing from an oxygen concentrator split between 3 kids. No ventilator for kids in respiratory failure. Bad attitude from nurses (How much can I blame them? They have too many patients, they see death all the time, and they get paid $8,000 a year). Still no thermometer in the NICU. A patient trying to kill a roach on the wall with her shoe. I expect at least a few kids to be dead this morning. Most of the deaths would be preventable in the States. Man, I’m already getting depressed.

The Weekend

Weekend rounding went more smoothly. I was able to see the patients and get out into the fresh air by midday. Going for runs, reading a book, trying to learn the guitar – all keep the sanity in my life during this tough rotation.

Holiday

Christmas Eve at the CMW was tough. Patients are often kept two to three in a single bed due to overcrowding. I was rounding on one of my patients (a child that had seized for an hour at home because the mother didn't have money for a taxi ride to the hospital - the fair was 50 cents) when the mother of the child sharing the bed started wailing. The translator told me she was crying because her child just died. What? I called for the other doctor, and we brought the child into the procedure room and started resuscitation. The attempt was futile. The heart had already stopped. There was no support staff. The was little equipment. The child had gastroenteritis and likely bacterial sepsis and died from cardiopulmonary arrest, due possibly to aspiration or electrolyte imbalance. There was nothing we could do.
Coming home that afternoon, I decided to go with my friends to the Drakensburg mountains for Christmas. This expansive mountain range runs through Lesotho and South Africa (SA), and we visited a resort in the central Draks located east of Lesotho in SA. We camped on Christmas Eve in a light, mesmerizing drizzle that soothed my hospital pains, and I stayed in a swank room the following night. Christmas dinner was OK, but it sure didn’t compare to the feasts at the Pierce house in Corpus. I thankfully was able to talk to the family as they opened presents and sipped on their morning coffee. Wednesday I was off from work for Boxing Day, a holiday that reportedly has nothing to do with fighting or underpants (though there is Dad in his undershirt; caught with my webcam!). We had a leisurely drive back to Maseru, stopping once again in Clarens for a little microbrewery reward, in celebration of Boxing Day, of course.

Back For More

Back from the beautiful Drakensburg mountains, I awoke Thursday morning with the intent of a run. The days can be long at QE2, so I like the idea of running before work. Unfortunately, the bed gravitational pull (BGP) was again too strong (perhaps the 3rd failed attempt so far while on the QE2 rotation). On the way to work, I was expecting the worst. I felt pretty sure that there would be at least a few of my patients that had passed away over the holiday. Believe it or not, all of the patients that I was in charge of were alive. In fact, most of them were getting better without me. It made me wonder if I should try coming to work every 3rd day more often. I was able to move all of the “sick” patients out of the acute room and into rooms where the more stable patients stay. I also discharged a number home. I am amazed how the reaction to the news of leaving the hospital is universal: giddiness, smiling, even occasionally dancing. I guess most people aren’t happy in the hospital. I suppose that includes me as well.

Note: Roach count today - 2 in the nursery, only 1 on the children’s ward.

While I was seeing my patients another child with advanced diarrhea died. Eerily similar to Christmas Eve, I was rounding on my patients when a mother started wailing. Resuscitation attempts were again futile. This time I realized that we do have some suction available. It is a plastic looking contraption that you have to pump with your foot to create a weak suction. This “code blue” and aftermath were so starkly different from similar events in the US. A nurse would briefly come in the room and then leave. It’s as if they have no training in resuscitation, almost as if they are afraid to be involved. The medical officers found the medications, and drew them up in syringes; there was no one from lab (“stat labs” mean within the same day), no one from x-ray (no portable x-ray device that I’ve seen), no intensive care expert from the ICU to lend a hand (no Jim Gude or Ken Lamb; no Bombers). Just fumbling with worn down equipment, expiring medications, and apathetic staff. The environment in the acute room where the child had been staying was also sad and intriguing. The mother was not taken from the acute room after the death (though I offered; there is no “quiet room” for families of the deceased); instead she stayed there, crying while the other mothers fed their babies, changed their diapers, and joked about various things. Though childhood death is so common here, there seemed to be no camaraderie among the mothers (I expect this had something to do with her being new to the ward). The doc who had seen the baby in the morning didn’t stop rounding on her other patients, so I did what I could to help console the mother.

For a further look at QE2 in the news:

CNN online special that mentions Queen Elizabeth 2 hospital (check out: http://edition.cnn.com/video/#/video/international/2007/12/05/inside.africa.hope.for.aids.orphans.cnn?iref=videosearch)
You can also see the recent (though fairly inaccurate) LA Chronicle article on Queen 2 and Bill Gates funding (see: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2007/12/16/MNJFTVFK3.DTL).

Friday and Saturday

I’ve been getting more into the swing of things. There have been several days without an admission, there have been fewer IVs to struggle with (I’ve become best friends with IM ceftriaxone), and I’ve had a chance to discharge some patients. Discharge basically comes down to: the patient no longer needs IV meds or oxygen? Ok, pa' la casa - they’ll probably do better at home. I’m sending patients home in worse condition than I would in the States, but with the lack of quality nursing care (there are medication errors every day) and infection control (I’m almost the only staff person that washes his hands) I feel the hospital is a danger zone, a ticking time bomb. We’re working with the medical officers and the nurses, giving suggestions and the occasional lecture, but we’re not in the position to make major changes. I wish we were. Take, for example, the 12 year old girl that has been walking around the entire CMW. She plays with the other children, jokes around with the nurse and the patients’ parents, goes up to the medication cart and receives her meds along with the other patients. She wears a surgical mask. Why, you might ask? She is being treated for pulmonary tuberculosis for the third time and still has TB in her sputum. She most likely has multidrug resistant TB (MDRTB), a form of TB that is very difficult and very expense to cure, even in the US. Her mother doesn’t visit often, so she gets lonely in her “isolation room” with is about the size of a closet – similar to what I imagine solitary confinement cells are like in prisons. The docs and nurses have all tried to keep her in her room but sympathize with her loneliness; she therefore has been allowed to pretty much do as she pleases. I called a meeting of the staff and talked with the child. We made a compromise where she is allowed to be outside in the little playground when she isn’t in her isolation room (TB is very hard to catch when you are in the open air). Also, I bribed her with a cookie. We’ll see how long the deal lasts.

I’ve got 5 more days to go on this rotation. I’ll let you know how it goes.

A story about the Mission Aviation Fellowship that flies docs around in Lesotho just came out in the Houston Chronicle. Our work in Mokhotlong is mentioned in the article; make sure to also click on the audio slideshow. Smiley Pool (photographer and longtime comrade to the PAC and BIPAI) did an awesome job.

http://www.chron.com/disp/story.mpl/life/religion/5408265.html

Take care,

Jeff

Thursday, December 13, 2007

Wow, finally!



Finally, A New Blog Entry!

It’s hard to believe it’s been months since I’ve updated the blog. I’m not sure why it’s taken so long. The work here in Lesotho has become a little more involving, and in addition we seem to be traveling every weekend. I’m not complaining. It keeps us out of trouble, I’m sure. The good news is that we now have high speed internet at the house, so I should get a little better at keeping you informed (I know you’ve been on the edge of your seats). Included in this blog entry are more details and pictures from the outreach work in Mokhotlong, an HIV testing event, weekend trips to South Africa, and my vacation to India.

Second Trip To Mokhotlong
October 21 – October 26

This time the scenic trip up into the Maloti mountains was undertaken by a group of four: Paola Peacock-Villada (Clinton Foundation), Tony Garcia-Prats and Heather Draper (Baylor), and myself. The Clinton Foundation works internationally to obtain more affordable prices for HIV meds and testing supplies. Some of Paola’s work has included increasing testing of HIV positive children under 18 months with the DNA PCR method, improving access to care, insuring good follow up after diagnosis is made, and helping to streamline the labs across the country so that crucial lab monitoring is available. The PAC doctor’s work would be impossible without the hard work put in by the Clinton Foundation.

Again as we headed up the mountains we were greeted by heavy clouds, though this time they only released a light drizzle instead of hail. Though later we rounded a bend and were awed by an expanse of freshly fallen snow! Snow in Africa as spring turns into summer. Amazing.

At the end of that first Monday, I felt like I was already getting more done than my first time in Mokhotlong. I spent more time working with the nurses of the maternal child health clinic and the maternity (labor and delivery) ward. Regardless of overtime or effort, nurses at this hospital earn next to nothing (yes, even Sutter Santa Rosa pays more). There are 5 maternity nurses, one on overnight at a time, pulling 12 hour shifts. There are over 100 deliveries a month, and the nurses, who are all trained as midwives, do just about all of the vaginal deliveries. For the most part during the night shift, the physician on call is just called to perform cesarean sections [and they aren’t even obstetricians…shocking! (said with sarcasm)]. The physicians still write the orders (like inducing with 50 mcg of misoprostol; they only have the 200 mcg tablets so they can only break them down to quarters; though it’s better now…most of their inductions were failing possibly due to expired Cytotec), perform the ultrasounds (I was teaching them how to do 3rd trimester biometrics – measuring various fetal parts to help determine how far along the pregnancy is; thank you Tom Neal), and of course perform operations like tubal ligations, etc. I have heard conflicting information about pregnancy terminations. A doctor in Maseru told me it is a legal procedure, and she does them at her private clinic for roughly $200 dollars (remember that the average income is less than 2 dollars a day here). One of the Zimbabwean docs working in Mokhotlong says he was told that it was illegal (women have been brought to the clinic by police after having an abortion), and it seems no one in this expansive district performs them. Some women go across the border to South Africa to obtain the procedure. I haven’t seen any septic abortions come through the maternity ward, but with access as limited as it is, I won’t be surprised when I do.

One morning I walked onto an interesting scene. I found a lone nurse in the delivery room scrambling to get oxygen and suction started for the struggling baby she just delivered. I took over the resuscitation, while the same nurse returned to the new mom who was lying naked on a rubber sheet that covered a foam “mattress”. Not changing gloves, she took out the needle and thread and started repairing a 2nd degree laceration. She was a little flustered when, wide-eyed and open-mouthed, I asked her if they always did the repairs without local anesthetic. She shuffled around the room looking for lidocaine, found it, then went back to the repair (same gloves on) without using it. Wow, that patient was sooo stoic; she just made faces and a few quiet grunts. Amazing. I didn’t like it; but amazing none the less. Following the repair, the patient put on her dress, picked up the baby, and walked out of the delivery room and over to the communal post partum room. I’m not sure, but I don’t think she had a birth plan.

Soccer with the princes

The PAC docs and the clinic staff helped test and screen kids at an awesome HIV testing event/soccer tournament in Mohale’s Hoek, Lesotho, organized by our friends David, Pete, and Paola. Prince Harry of England and Prince Seeiso of Lesotho, whose charity organization Sentebale (meaning “Forget-Me-Not”) was involved, popped by in their helicopter to watch HIV education and testing practices. See attached pic of the prince with Baylor docs Kathy Ferrer and Edith Mohapi, as well as Paola and Pete. Check out the Sentebale website for more info: http://www.sentebale.org/home/index.html


Arrival of the visiting scholars

I was very happy to see my old UT Pan Am alum and friend Yvette Almendarez and her pediatric colleague Ashley Cox arrive safely in Lesotho. They are both Baylor Med School grads and are in their final year of pediatric residency at Texas Children’s Hospital in Houston. They came to learn a little more about pediatric HIV, help us in the clinic, and see the sights of southern Africa. Mostly they just called John to fix their plumbing and fight off squirrels in the attic at 3 in the morning. But that’s too long of a story for now. We took another day trip to Clarens, the quaint town in South Africa that has good cheese and beer on tap. Sounds strange to travel to another country for cheese and beer, huh? Well, not if you know me. This picture is us in our car on top of a moving tow truck. Read on for more details. Yvette and Ashley are back in Houston now. Thanks for coming guys and good luck; we miss you.

3rd trip to Mokhotlong

Following an interim “routine” week seeing patients in Maseru, I made the trip out to the mountains again, for the first time going it alone. It was slightly romantic, being the lone doc in his 4x4, slowing winding his way up the mountain roads between remote villages, greeting sheep herders and dodging sheep dung. This picture was taken on the way back from Linakaneng. The animal is an nku (sheep; maker of sheep dung). Along with the African docs assigned to Mokhotlong city, I saw children in the children’s medical ward (CMW), adult inpatients, and patients at the dedicated Lerato (meaning “love” in Sesotho) HIV clinic. This is the clinic that is a smidge bigger than a closet, but with fewer resources. I drove out to the rural health centers of Libibing, Linakaneng, Malefiloane and Mapholaneng. The roads are unpaved and super rocky, but wind through gorgeous terrain – one of the best commutes in the world. There is always plenty of variety in the conditions the people have to face (usually more advanced in their course and always with fewer resources available to diagnose and treat them). To name a few, I saw 2 likely new cases of lupus, gestational hypertension, a kid with total body swelling due either to malnutrition or kidney disease, active tuberculosis (so common that it’s routine), and conditions associated with the weakened immune system caused by HIV infection. Every day is different, offering the chance to work in the hospital and outpatient setting, do home visits, deliver lectures, mentor nurses and docs, and perform tough blood draws (including external jugular and femoral vein blood draws on infants).

Reunion in Joberg

Thanks to the planning and hard work of Seema, the medicine/pediatric PAC physician – gourmet chef – vacation planner extraordinaire working with us in Maseru, several of the PAC docs from around southern Africa got together to enjoy museums, food, caipirinhas, dancing, and the occasional irritant gas bomb (random). As Yvette and Ashley will attest (they will, just ask them), the trip from Maseru to Joberg was a bit hectic. While driving the car on the highway Anu realized that the clutch pedal stopped working, and he could no longer change gears. While theoretically we could have completed the remaining 3 hours to Joberg in 5th gear, it was his better judgment that had him pull off to the side of the road. Thanks to our South African car insurance, we were quickly towed to a “24 hour station” manned by some of the toughest looking men (and women) of the Free State (the name of the South African state in which we were stranded). I wish I had a picture, but the leader, a huge Afrikaans guy, had the most impressive mullet I’ve seen in Africa. They were great, and actually worked on the car for about an hour on a Friday at 8pm, eventually replacing a broken seal and getting us on the road (for an amazing $70 US) in time to meet the rest of the group for dinner in the Melville district of Joberg. The picture is not actually of the garage crew but two sexy hunk Botswanan PAC docs - Jonathan Bernheimer and Paul Mullen.


Two weeks in India

I had the pleasure of joining Anu and his parents on a whirlwind trip of southern India. Anu and I flew via Emirates Airlines, leaving on a red-eye from Joberg to Dubai, the capital of the United Arab Emirates (I actually remember learning about that country in Mrs. Putman’s 6th grade Social Studies class) and on to Mumbai (which is not, strangely, the sister city of Dubai, but did used to be called Bombay) on the west coast of India. Anu’s family was truly wonderful, treating me like part of the family from my first moments in the country. This was my first trip to India, and was it ever much anticipated. Since going to med school, where 80% of my friends were 2nd generation Indian-Americans (not to be confused with American Indians, Native Americans…or Pakistanis), I have been in love with what I have learned of the culture. The colorful and flowing saris, the permeating presence of Hinduism, Christianity and Islam, the music, and the food (ahhh, the food) were richer than I had anticipated. I was impressed with how much more crowded it is compared to Africa, especially Lesotho (I imagine much of Nigeria might be more similar to India in this respect). There is little possibility to get away from honking horns, city lights, and jostling crowds – even in the relatively less populated south where we were traveling. Anu’s parents, originally from India and currently living in Midland, TX, set a busy but enjoyable pace. We took several night trains, and I experienced first hand the difficulty of voiding on a bumping Indian train. I also saw more rats (Anu insisted they were just mice) among the tracks one night than I might have seen in all my life. Just imagine that scene from “Indian Jones And The Last Crusade”, then imagine world peace. Well, why not, you were already imagining, weren’t you? We traveled through 6 states: Maharashtra, Goa, Karnataka, Kerala, Tamil Nadu and Andhra Pradesh, went to a family wedding at the Tirupati temple (so much gold and sooo crowded), hung out at a hill station in Coonoor, and motored and slept on a house boat in Kochi. By far the most amazing experiences were the meals. I had so much masala dosa,
idli, vada, chapatti, sweet lassi...and thank goodness, never got sick...as far as I know. Well, I guess maybe a course of mebendazole before things “mature” might be a safe strategy.





Dubai




On the way back we spent a day and night in Dubai. Besides a few sneaky merchants and a sketch hotel, it was a great experience. I loved: the savory hummus, extra helpings of falafel, a coast with a warm breeze reminiscent of Corpus, hanging and speaking Spanish with a Colombian back packer, eating Dunkin Donuts, seeing a Hardees, and gazing at a beautifully lit mosque at night.








Back To Africa
Since coming back from vacation things have been moving fast. I’ve been back to Mokhotlong (check out the pics of A Tale of Two Cellulitis Cases: two women in red dresses in two different cities presenting within a week of each other with right hand cellulitis; the child in the picture has typical lesions of scabies), where I continue the tradition of transporting more people with active pulmonary TB in the back of the Land Cruiser. I stayed at the Louis Gregory Center this time - a farm in a gorgeous valley (pic of the house included). I’ve been traveling on the weekends, and the clinic schedule during the week in Maseru is getting busier (we saw about 155 patients today in clinic). I’m hoping things will slow down a bit during Christmas. I’m having a little difficulty feeling the holiday spirit during the summer in a country that doesn’t really deck the halls. I’ve certainly felt more homesick around the holidays, as Thanksgiving and Christmas are celebrated in full regalia by the Pierce clan. Similar to last year, where during residency I had the good luck of being on inpatient medicine call (albeit with some awesome fellow residents) for Christmas Eve and New Year’s Eve, I’ll be the PAC doc assigned to the Children’s Medical Ward at Queen Elizabeth 2 (QE2) hospital. While being around kiddos during the holidays is usually a welcome opportunity, unfortunately it seems half or more of the kids we admit to QE2 die during hospitalization. Infant and child death is so common here. This specific contrast between here and the States will always simply blow me away. The death toll certainly wears on you, whether you’re a visitor or a local (a South African nurse’s child told her, “you don’t smile any more”). But every day that we see a baby or her mom die of malnutrition or TB, we see a hundred more that are healthy, running around, gaining weight, and smiling thanks to the medicines and the people that we work with. I am so grateful to have this opportunity and continue to realize that I get more out of it than I contribute.

Miss you all very much,