March Madness

A Few Interesting Points From The CIA World Fact Book

https://www.cia.gov/library/publications/the-world-factbook/geos/lt.html

Average life expectancy at birth
US: 78 years
Lesotho: 39.9 years

Lifetime risk of maternal death
Sierra Leone: 1/6
NW Europe: 1/30,000

Countries with the highest HIV prevalence (% of the population living with HIV)
Swaziland 38.8% (1st)
Botswana 37.3% (2nd)
Lesotho 29.8% (3rd)
USA 0.6% (71st)

Equatorial Guinea
Only African country with Spanish as one of its official languages
12th highest GDP per capita in the world (Luxemburg is 1st, US is 9th)
But most of the people live on less than a dollar a day, since all of the money (oil) is in the hands of the politicians

A Hard Week At The Baylor Center of Excellence (COE)

The COE is getting busy. We are seeing over a hundred patients every day, with several newly diagnosed kids and adults per day. The new kids are always our sickest ones, as I’ve mentioned in prior blog entries. Several of them have been losing weight, and suffering from fevers, cough, diarrhea and malnutrition for months before they are brought in – frequently by their grandmothers, as the mother has recently passed away. They often come in with skin stretched on bone, with so little muscle and fat. They are basically on Death’s door. We work hard, giving them strong antibiotics and oral rehydration solutions specially formulated for severely malnourished children. We battle over starting and restarting IVs for the administration of the medicines and for emergency fluid replacement when they go into shock. Anu admitted 4 of these very sick children on Monday, and I admitted 3 children on Tuesday, most of which sadly have passed away. Later in the week a woman came in and spontaneously went into labor in the blood drawing room, delivering a stillborn fetus that had probably stopped living a week before. The next day I found myself on a panel that is in charge of writing Lesotho’s national prevention of mother to child transmission of HIV guidelines. It is an unfair world where a recent residency graduate plays a big part in making these kinds of decisions for an entire country. During the week we saw some kids that were incompletely or inappropriately managed at outside hospitals dumped off at our clinic, hoping for better care and more resources. I saw my first case of ophthalmia neonatorum, an experience I won’t forget. Seema was seeing this newborn in the exam room next to mine. The child was born at home and started having eye discharge during the first week of life. After about a week of eye goop, the mother finally brings the baby to our clinic. She has a rag that she’s been using about once a minute to wipe pus off of the closed eyes. I went to better examine the eyes, and while trying to open the lids a thimble full of pus came out from under the lids. The lids were so swollen I couldn’t open them. I was amazed, others were shocked, the mom wasn’t impressed. No one fainted. Those of us that see kids in the office have met a hundred new moms who come saying that their baby has “eye discharge”. The med student or resident in training needs to know how to differentiate harmless eye discharge from true ophthalmia neonatorum. There is no confusing what I saw that day for harmless eye discharge. If all of the new moms of the world could see what I saw, none of them would ask if the scant eye boogers that they have to wipe off in the morning once in awhile were dangerous eye discharge. Seema treated the child with ceftriaxone and erythromycin, treated the Mom, and asked for the dad to come in. That’s because the pus coming out of the baby’s eyes was likely caused by infection from gonorrhea (and probably also chlamydia) – transmitted to the child while traveling down the birth canal. Yes. Gonorrhea of the eyes. I’ve never seen this in the States, due mostly to the fact that most newborns get preventative eye medicine at birth (and partly due to a lower rate of gonorrhea in the US). While reading up on eye medicine for the newborn, I found a study in Kenya showing that iodine eye drops not only are cheaper than the meds we use in most of the world, they worked better and were less irritating. This study was done 13 years ago! My best guess why we haven’t changed to iodine drops is that Big Pharma (the pharmaceutical industry) can’t market cheap iodine and prefers us to use their expensive meds. Gotta love Big Pharma.

A Louse In The House?

Kara (fellow PAC doc and one of my two roommates) found a very small bug on her back when she was changing her shirt. She squashed it, and realized that it was full of her blood. We all took a close look, and voted that she most likely had body lice picked up from a patient at clinic. We also by a non-unanimous decision voted her off the island. I kept the squashed bug in a piece of clear tape and looked at it under the microscope at work the next day. Upon closer look under the scope, we saw a creature of uncertain identity but one that did not resemble a body (or other) louse. That night I woke up because I felt something crawling on my foot. I’m a vegetarian and don’t like to kill things, but I occasionally make exceptions for evil creatures I find in my bed. I caught the thing and squashed it. In the morning I opened UpToDate (a medical resource on the computer) and on a hunch opened the article on bed bugs. Yep. I was right. The thing I found crawling on my foot was a dead ringer for the bed bug featured in the article. What in the world? I’m not a particularly dirty guy. The sheets get washed, I bathe fairly frequently, I don’t wear clothes I find in alleys. We have a really clean, modern house. There are no thatched roofs or mud floors here. Going into crime scene investigator mode, I found another 2 that night, losing one on the floor in the living room (much to my roommates’ dismay). I quickly learned a lot about bed bugs. Bed bugs are a little gross. They suck your blood. They can live for a year. They are found in dirty homes but also well-kept abodes. They have a sweetish smell when squashed (like a South Texas stink bug). They come out of cracks and crevices at night, attracted by your body heat and carbon dioxide, and they feed on you while you sleep. They are associated with areas where birds and bats roost, and they can live for a loooong time without a blood meal. I bombed my room with FumaTab, something I bought at the store that has more health warnings on the label than a nuclear bomb and behaves like a ninja smoke bomb when lit. I quarantined myself to the couch (again to Anu’s and Kara’s dismay). I slept there for 7 days as the smell of the Fumatab’s carcinogens slowly cleared. One day I came back from a run, and Anu said to me, quite seriously, “You’re going to have to stop sleeping on the couch. Because Kara is going to start sleeping on the couch”. She showed me her bed, which was totally infested. Of course that meant that it wasn’t a louse on her the week before - it was a baby bed bug, a nymph, if you will. So now, about 3 FumaTabs and a can of Doom insect spray later, we seem to be bed bug free. We’re both back in our own beds, and Anu’s room, somehow, still seems to be bed bug naive. Apparently they prefer Mexican food and California cuisine to Indian food. Hopefully they aren’t in our couch. Hopefully they aren’t looking over my shoulder while I write this about them. They might get upset. Unfortunately, the chance is moderately high that they’ll surface again. Then we’ll call the exterminator. If that doesn’t work, we’ll get new beds. If that doesn’t work, I might come back to the US. Or better yet, Antarctica. They don’t do particularly well on icebergs. See attached NYT article.

http://www.nytimes.com/2006/10/15/realestate/15cov.html?pagewanted=1&_r=2

8th Trip to Mokhotlong

It was good trip. I came in on Sunday night, having made the beautiful 4 hour drive without incident and arrived at the Touching Tiny Lives orphanage in Mokhotlong proper where I’ve been staying. This has been a cool place to stay. I get to hang out with Dan and Mo, two North Americans who have been working here for several months. They are fun to hang out with, and coincidentally happen to be good cooks. The orphanage is well funded from the US, so they have hot running water, electricity and dial-up internet.

I spent the week in the typical fashion: rounding with the local docs on some of the inpatients, driving to rural health clinics in the mountains, mentoring nurses on the care of HIV positive and negative patients. The weather has been great; it’s starting to rain less but isn’t terribly cold at night. It’ll start snowing here in May or June.

I saw a variety of patients during the week: HIV positive adults with lung cavitations caused by tuberculosis, sick and healthy HIV positive kids and pregnant women, a term pregnant woman with 5 days of a big swollen tender leg, likely caused by a blood clot that could break off and float to her lungs - possibly killing her (there’s no access to PTT monitoring at that hospital, and at times nowhere in the country. We started her on subcutaneous unfractionated heparin and flew her to the capital). There was a young boy with a Colles’ fracture, an impressive case of pruritc papular eruption, a 12 fingered baby, severe nipple eczema, hydranencephaly with hydrocephalus, and a 2nd case of ophthalmia neonatorum. This one had been “treated” by a nurse assistant a few days earlier with chloramphenicol eye drops and trimethoprim/sulfamethoxazole. We started the right drugs and think the baby will be fine (the infection, when left untreated, can cause blindness).


Back At The COE

Work in Africa has brought a mixture of strong emotions. You’ll find a family slowly wasting away due to lack of money, education, and power. The man of the house just won’t let them test for HIV until it’s too late. Then you’ll see a new mom who did everything right from the beginning – like the woman who I met in the first trimester when I had just arrived in Lesotho – and the newborn baby’s test shows that he is HIV free. Both instances affect your soul.


Lesotho’s First 80s Party of 2008

So the 80s was an interesting time. I was reminded of this decade of my life as I found myself “pegging” (aka, “tight rolling”) my jeans, putting on clothes that didn’t match, and creating my mohawk for the 80’s party on Saturday night. A


mid the sounds of Toto, Bon Jovi and Journey, we enjoyed a bit of caipirinhas, drinking games, and dancing. There isn’t much more I can say about the party. Is there really much more to say about 80s parties? Let the pictures do the talking.

News From The Farm

By brother David and his wife Jessica just celebrated their 6th anniversary together. Dave, I owe you a twenty. Just kidding. I’m very excited to think about spending some time together with you guys when I get back home, and maybe we’ll even get a chance to meet up off the continent before then. I love you.

I’m excited to say that my mom is enjoying her first weeks of retirement. She put in a ton of years at Del Mar College in Corpus Christi, Texas, and they are missing her already. I can’t remember life before coming to see Mom at the office, hearing her laughter from down the hall, and selling Christmas wrapping paper and chocolates to the nice ladies and gents in the office. I want to send a big hello to all at the Registrar’s Office that read the blog – your support has kept mom sane (relatively) and helps me all the way out here as well. Thank you.

Happy Moshoeshoe’s Day,









Jeff

Tanzania and the Seventh Trip to Mokhotlong

Anu and I headed out early on Friday morning to start our 2 weeks of vacation (the PAC treats us well, we get 22 days of vacation per year). After a rough start (one of our tires has a slow leak and was almost flat in the morning; oh, and the car wouldn’t start), we made the 3.5 hr drive to Joberg pretty uneventfully. Our friends recommended this great economy airport parking for a whopping $1.25 US per day. We had our tall Castel Lager on tap at our favorite airport restaurant (it was after noon somewhere in the world) and caught our flight from Joberg to Arusha via Dar Es Salaam and Zanzibar, where we stayed at the Outpost Lodge under torn mosquito netting (malaria prophylaxis: I was on doxy, Anu was on prayers).

Saturday morning, after a brief breakfast sprinkled with E. coli (as Anu would find out later), we met our driver and cook, Marco and Abdullah, and headed off on safari. We spent the next few days seeing tons of animals in famed sites such as Lake Manyara, Ngorongoro Crater, and the Serengeti. Yes, The Serengeti. I had to repeat that to myself several times during the trip. This huge area of plains, acacia trees, and heards of thousands of grazers was something just seen on the Discovery Channel and not something that I'd ever go to. Of the three sites, Ngorongoro was perhaps the most beautiful. As we descended in our 4x4 early Sunday morning, Anu and I felt like we were driving through the Garden of Eden. Vibrantly garbed Maasai herders were the only humans moving through this huge area inhabited by thousands of animals. The animal density here was amazing. Every where you looked, animals grazed, ran, and rested, giving little care to the various Land Rovers that crawled over the landscape. Over the four days of safari through Lake Manyara, Ngorongoro and the Serengeti, we saw herds of zebra and wildebeest, over 30 lions, water buffalo, hippos, leopards, cheetah, flamingos, cranes, hyena, you name it (well, no rhino, but we had seen some great ones back at Kruger Park). One early morning in the Serengeti we awoke to find a pack of elephants walking through our campsite. We were very glad that they were in a good mood.

Though the camp food was impressive (items of note: vegetarian quiche and creme brulee), we were glad to get back to civilization where we were able to eat an amazing dinner at Onsea House. We met gourmet Flemmish chef, Axel, who prepared one of the two best meals I’ve had in

Africa (the second one was also made by him, one week later) – a 5 course meal of vegetarian fair paired perfectly with choice African wine. We joined Heather Crouse, pediatric ER fellow and friend who came in from Houston a few days before we got back from safari.

Mt. Kilimanjaro

We needed that great meal, as the next morning we started our trek to Mt. Kilimanjaro, the highest mountain in all of Africa. We were greeted at our hotel in the morning by our team – enough guides, assistant guides, porters and cooks to make a few soccer teams (19 in all). Climbing the mountain was an interesting, if not fun, experience. The hiking wasn’t impossible, but it was no cake walk. The scenery was not beautiful, but definitely exotic – more like a science fiction writer’s depiction of a planet in another solar system. The camp food was getting a bit repetitive by now, and sleeping in a small tent with Anu after not bathing for several days was getting a little difficult (I have no idea how he smelled, I couldn’t make it past my own foulness). The outhouses were pit latrines where you basically tried to do your business through a hole cut in the floor without getting anything on your feet. Somehow I managed to not use a single squat toilet in all of southern India but was forced to learn here, where my quads were often shaking from the strain of the day’s hike. I could go on and on about the woes of eliminating on Mt. Kili, but I’ll spare you the details. Flora was scarce, and Fauna more so – mostly four-striped mice that tried to get into your tent and ubergrande crows that would probably go for your eyes if you didn’t make it successfully to your campsite in time. We discovered first hand that in addition to worrying about mountain illnesses such as AMS (acute mountain sickness), HAPE (high altitude pulmonary edema) and HACE (high altitude cerebral edema), perhaps the most troublesome if not most dangerous form of these diseases was HAFE (high altitude flatulent explosions). I had heard of this entity but felt that it was most likely a myth made up by mountaineers to keep weaker people off their mountains. Let me tell you. It is a reality.
We began our trek to the summit a little before midnight. It was cold, real cold. The headlamps accented the glittering ice on our tents as we began our ascent. Aside from the temperature, we were blessed with great weather. The wind was low and the rains from the day before had stopped. We were greated by heavenly stars, an orange moonrise and the glittering lights of Moshi city so far down that you felt like you were in a plane. The climb took us from around 4,600 meters at campsite to the peak at around 5,800 meters. During the hike, climbers experienced symptoms from mild headaches and nausea all the way to vomiting, confusion, and loss of balance. I was pretty lucky. The last couple hundred meters were pretty tough. As I wondering if any of my toes would be frostbit and was nauseated and really tired, I had this great image of all of my family and friends watching me as I was climbing. Anu says it was due to hypoxia, but I had a huge endorphin rush from imagining all my family and good friends from Texas and Santa Rosa right there with me, cheering me on, giving me the support I needed to get to the top. So, to all my family and friends out there, thank you. I don’t know if I could have done it without you.

We made it to the summit right before sunrise. Our guides gave us chocolate bars and sang local songs that sounded like prayers of thanks to the mountain gods. The top is all snow and glacier, beautiful, breath taking, and very cold. You certainly don’t feel like you are in equatorial Africa. I took some good pictures with Heather’s fancy camera, and some OK ones with my own basic digital cam (those included here). What a feeling of accomplishment. What a feeling of, thank God I never have to do that or anything like it again.
The descent was long and hard on the knees, but it was great to sleep at a better altitude. The shower back at our hotel was wonderful; I probably lost a kilo of dirt. We had our second great dinner and then flew off early the next morning to Zanzibar, an island off the coast of Tanzania. We stayed at Fumba Lodge, a picturesque beach resort where I read The Time Traveler’s Wife, ate great food, and watched the ancient Moorish dhows sail by. Beach time with nothing on the agenda was exactly what I needed after the mountain. I'll add some photos later; my camera was out of batteries by this time. I’m thankful for Heather for doing so much of the ground work for this trip. She was a good traveling partner and put up with my complaining and eccentricities. I’m also thankful for Anu, who I’ve traveled with to more countries than any other person (10), and who continues to still be a comrade even after all of that.

Mokhotlong (Seventh Trip)

After a whopping 2.5 hours of sleep the night we returned from Tanzania, I woke up early and headed off to Mokhotlong for outreach work. As usual, it was, as my friend put it, a mixture of successes and frustrations. The health providers are getting more comfortable with the management of children with HIV, antiretrovirals are being distributed more widely, and more people are testing so they know their HIV status. Frustrations included seeing advanced disease that should have been treated months or years ago (a child with a case of Potts disease – TB of the spine that causes disfiguration and sometimes paralysis, seen in a 6 year old orphan), continued stigma (an entire family present in clinic, both parents looking thin, an adolescent child with signs of HIV infection – diffuse lymphadenopathy and bilateral parotid enlargement, and their brand new baby; no matter what we said about the benefits of testing and treatment, the father was deathly afraid of knowing his status and wouldn’t let us test him or any of his family members), and poor access to care (a first time mother presenting at the end of clinic with her one month old baby that had a blueberry muffin type rash for a week and was in status epilepticus; we were at a rural health clinic in the mountains, the anti-seizure medication was expired by 8 months, and there was no oxygen or breathing mask available; we made the drive back to the hospital in record time, started emergency measures and the child made it through the night, though his prognosis is grim). I’m back in Maseru now, and I’ve spent the weekend being a veg around the house, catching up on some much needed bumming around.

Hope you are all doing well,

Jeff

Finishing at QE2 and The 6th Trip to Mokhotlong

QE2 Winds Down

The last 5 days at the Queen Elizabeth 2 (QE2) Children’s Medical Ward (CMW) were, unsurprisingly, not easy. My patient load was certainly manageable. Unfortunately, this was due to both discharged patients (yay!) and children that had died. Looking back, I certainly worked harder during most of residency rotations. The reason that I was so burned out after only 2 weeks of QE2 (which doesn’t even involve being on-call) was due mostly to a combination of preventable deaths, lack of supplies and an apathetic staff. I passed off the baton to Anu, my roommate who helped me during my rotation at QE2 both by giving advice on how to manage the patients and offering moral support. I felt bad passing the work to him, as he had already, in a way, gone through the rotation with me. It was interesting to see him react similarly to me as his time at QE2 progressed. The frustration settles in, you begin to question your skills as a doctor, and you start to feel like Death himself, roaming the ward in a black cloak holding his scythe.

Whew. That was a bit dark. Glad that’s over. I’ll probably do one more rotation on the CMW closer to August.

Mokhotlong

After a great weekend of sleeping in (and not having to go in to QE2), I drove out to Mokhotlong, along with Ntate Thuso, a local counselor, seen in the pic (I'm on the right). Though the work in outreach is always exhausting, I felt great to get out into the countryside and travel among the sheep under the open sky. The routine was the same: mentor docs and nurses both in the hospital and the more rural health centers, distribute medications, and see a few patients on my own. Probably my favorite encounter of the trip was diagnosing a woman as pregnant, about half a year after her tubal ligation surgery. I was able to show the local physician how to do an early pregnancy ultrasound (thanks to many days in OB intake and on therapeutic abortion rotations) and prove that it wasn’t an ectopic pregnancy. Overall, I felt that things in Mokhotlong were slowly moving in the right direction. The health centers seem to be on the verge of getting their own supply of meds, the nurses are getting more adept at seeing HIV positive patients, and Riders for Health (http://www.riders.org/) are supplying some motorcycles to be used by the health system, to name a few advancements.

Maseru

Back at home base, we celebrated by watching the entire Lord Of The Rings trilogy over Friday, Saturday, and Sunday. Anu gets the prize for Most Dedicated Hobbit by lasting the entire extended version of the Two Towers (until 3:45AM) and then going in the next morning to QE2 to round on the entire ward. Work this week at the clinic has been steady and routine. I’m seeing a mixture of healthy HIV positive pregnant women, children on long term anti HIV therapy, newly diagnosed HIV positive adults, and some really, really sick kids (most of which were recently diagnosed with HIV). Most of these sick kids we try not to admit, since the conditions at QE2 are so atrocious and what can be done for the patients therapeutically is so limited. Today I admitted another child to QE2 with vomiting, diarrhea, malnutrition, and possible sepsis. Yesterday the child looked relatively healthy, with what I though was just going to be a case of viral gastroenteritis. Some of these kids can get sick so quickly. I don’t think the child will survive. Today, I’m kicking myself for not admitting the child yesterday. You just never know. In similar fashion, I’m managing a severely malnourished child with possible meningitis as an outpatient! This would never happen in the States. Medicine is very different here.

Kilimanjaro

Friday Anu and I’ll be flying out to Tanzania for two weeks of glorious vacation. The plan is to go on safari in the Serengeti, see famed Ngorongoro crater, climb Mt. Kilimanjaro, then relax on the beaches of Zanzibar. And while it might seem to my friends (Dolan, et al) that I’m not actually working but only vacationing in Africa, I must remind them that I blog mostly about my vacations while sparing you most of the details of the day to day work life here, therefore causing the aforementioned confusion.

Your's truly,

Wolverine

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

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,