Not Much To Say

I'm finding myself having a little bit of "blog block" over the past few days. I think the problem is that there is not exactly an overabundance of excitement in my life right now. I'm hanging out in the Presby CCU, which is a "q3" rotation (meaning that I'm on-call, sleeping overnight in the hospital every 3rd night), and have been unable to take advantage of the recent surge in nice weather we've recently encountered. Eat, sleep, work. In my free time I am either actively working on or actively procrastinating (usually in the form of comic books) the Grand Rounds medical conference I need to prepare for April 18th.

Oh yeah, I did get a haircut a few days back. I've been on the "2 haircuts a year" plan all through residency and now all I have to do is hold out until June 21st and I will have successfully pulled it off.

Final Four

UCLA, LSU, Florida, George Mason University....

I can't recall a more bizarre Final Four in my lifetime. I wonder if anybody in any office pool anywhere had picked these four teams to make it all the way...I seriously doubt it though. I didn't have a chance to fill out my own brackets this year on account of being in Africa, but I helped Claire fill out 3 submissions for her own lab March Madness pool. I picked a grand total of ZERO of the Final Four teams in all three chances...

Because it's been kind of a slow Sunday call day in the CCU, I've managed to catch the end of both games today. Florida looks good, and they've got a Frenchman (Joachim Noah, son of famous French tennis player Yannick Noah) to boot. They're my pick to win it all. Though it would be cool to see George Mason be the lowest-seeded team ever to win the NCAA Championship.

African Wildlife

Here are some of my better pictures of the African wildlife I saw on my trip...

Giraffe Convention in the Kalahari.

A cheetah roaming the plains...

A veritable buttload of impala...

Hungry, hungry hippos!

Elephant crossing

More monkey business (or: more fun than a barrell full of baboons)

CCU Blues

Thursday night. On-call in CCU. Only my 2nd night on-call since coming back from my African journey (which was supposed to refresh and invigorate me) and already I feel like I'm dragging a little.

It's been a rough call so far. A Bangladeshi guy who had been seemingly safely moved from the Unit to the floor started having hypotension and new ST-elevations at about 6PM--he was emergently cathed and comes out with a balloon pump. Can't be good. Another woman was transferred from an outside hospital having had floundered there since mid-December...and it seems a safe bet that she won't be going anywhere anytime soon. Now a fellow resident is calling me about a patient of theirs who needs an emergency transfer to the Unit for cardiogenic shock, a Swan-Ganz catheter, and what night wouldn't be complete without a 2nd balloon pump to manage?

Wish I had more interesting things to report, but sadly I do not. Saturday is a day off so they can only hurt me so much tonight...

Tragic Loss to Penn Program in Botswana

Sadly, I returned home from call yesterday to hear some horrible news regarding one of the physicians with whom I had worked in Botswana.

Unfortunately, there's no easy way to say it, so I'll just come straight to the point. Dr. Richard Root, pictured on the right with his wife Rita, was attacked and killed by a crocodile while taking a river cruise in Botswana this past Sunday. Some details of the incident can be found in this news article.

I wish it were some kind of joke. Crocodiles are not generally considered a big danger--in fact, when we went rafting on the Zambezi we saw several, and on a few occasions we were thrown from the raft into the water and transiently separated from the raft. We were in fact told by our guides that nobody had ever been attacked by a croc in all their experience rafting, so don't worry about it.

I had visited the exact same place as the Roots in the region known as Tuli Block approximately 3 weeks ago, a sobering realization. He was my roommate at the Penn flats and my attending physician on the Male Medical Ward for about 2 weeks. He had intended to stay and teach in Botswana for the next 2 months in an effort to help improve their health care system. This is truly a tragic loss for the Penn Program in Botswana as well as the general field of medicine.

Reverse Culture-Shock

Since I was just rudely awakened by the CCU charge nurse that we have a patient with an ST-elevation myocardial infarction (translation: bad heart attack) being flown in from South Jersey at 4:30 in the friggin' am, I thought since I'm up, why not throw in a blog entry?

I guess I shouldn't be surprised at the degree of reverse culture-shock I am experiencing as a result of going straight from a public hospital in Botswana, Africa to the Presbyterian Medical Center CCU. For starters, there's the 73-year-old male patient with a history of heart disease bad enough that he's already had a triple bypass surgery, bad emphysema due to smoking so much so that he has a chronic tracheostomy (a hole going into his trachea which allows him to be attached to a ventilator easily since he often can't breathe on his own), diabetes, hypertension, severe peripheral vascular disease with stents already having been placed throughout his body, and heart failure. Why is he admitted? He's admitted for an ICD evaluation. An ICD is an intracardic defibrillator--a device which is implanted in the heart and when it detects a potentially fatal arrhythmia delivers a brief shock intended to flip the heart back into a normal rhythm. So an ICD in this gentleman will basically prevent him from having any chance of passing slowly and peacefully into the night.

No who am I to say that he shouldn't get one? Maybe he wants to fight the good fight up until the end, and if the technology exists and he's willing to take advantage of it--let's go for it. It is, however, hard to justify from the perspective of limited health care resources. ICD's cost good money, and spending it on a 73-year old guy with multiple horrendous medical problems and a limited quality of life (he currently lives at a ventilator facility--basically, a nursing home which knows how to take care of patients with tracheostomies who may periodically need to be hooked up to a ventilator) are probably not the best bang for your buck.

Anyways, it turns out that he may not even get the ICD...we need to do a bunch of tests first and then decide. But this dude would have run out of options about 20 years ago had he been living in Botswana...

Honey, I'm home!

I'm back!

After one of the more grueling traveling experiences I've had thus far (our flight left Cape Town at about 1:40 pm Friday and we didn't get to Philadelphia until 31 hours later) I've made it back to home soil!

Mostly I'm just happy to see my wife after all these weeks. That and they managed to rapidly track down my luggage in a timely fashion, as my big camping backpack stuffed full of African goodies was temporarily lost. It was delivered to my apartment yesterday evening.

What do I have to look forward to now? Well, on Monday I have the joy and honor of being ON CALL in the Presbyterian CCU (Cardiac Intensive Care Unit), where I shall be for the next month. It's going to be quite a bit of culture shock, as my overall strategy for managing heart attacks in Botswana (give 'em an aspirin, check an EKG in the morning when the machine is working, and hope for the best) is generally not going to fly in the Presby CCU.

Oh yeah, and I also have to file my taxes, apply for a French work visa for next year, pay the bills, plan out my Grand Rounds for next month, and catch up on a host of other crapola that builds up after having visited "The Dark Continent" for 6 weeks...

Oh and here's a grauitous shot of a lion chowing down on an impala carcass to whet your appetites for my African pics, which I intend to post in the weeks to come...

Homecoming

Well, it's my last day in Africa! I've been here for about six weeks now, and I can honestly say that I still have that little voice in my head saying, "Holy shit! I'm in Africa!"

This is a beautiful continent with a lot going for it. Nice people, a ton of natural resources, stunning landscape, a rich history. There are understandably a lot of problems here--we drove past miles and miles of shanty towns made up of discarded aluminum siding on the outskirts of Cape Town, a grim reminder of the vast inequality of South African society--plus there is the HIV/AIDS epidemic which I realized in all its shocking magnitude while working in Gabs. But at least in the places that I've traveled thus far, it's clear that they are on the right track. The end of apartheid. The Botswana government providing free HIV medications for all of its citizens that need it. Improving race relations. I'm going to follow with much greater interest now the progress of southern Africa because of this trip.

Yesterday's activities: rented a bicycle and drove all around the city. Checked out the "District Six" Museum, an homage to a once-vibrant neighborhood comprised by the African and coloured populations of Cape Town which was razed to the ground during the ugliness of the apartheid era. They're in the process of giving this land back to its previous owners, and they've set up a nice little museum to commemorate the families and businesses that had lived there. Also spent some time in the "Bo-Kaap" (the old Muslim area of the city) and ate some tasty roast chicken in a public park. I also foolishly set about biking up a mountain as a "short cut" back to the hotel from which my quadriceps are still burning...

Today was a lot more relaxed...we drove our Volkswagon Chico out to Wine Country and spent the day meandering through the beautiful mountains and vineyards that comprised the area just east of Cape Town. As the sole driver of manual transmission vehicles, I was unfortunately the designated driver for the day...but I am bringing home some excellent South African vintages that I picked up along the way.

I'll be back in the good ol' U.S. of A. on Saturday afternoon. Hope to see all of you soon!!!

South African News

Here are the South African headlines since I've been here:

1) The Jacob Zuma rape trial. Seems to be a repeat of the Clarence Thomas/Anita Hill trial, with a very prominent public official in a sensationalist spotlight. That public official is Jacob Zuma, the Deputy President of South Africa, who has long been thought of as the likely successor to current President Thabo Mbecki, who had succeeded none other than Nelson Mandela. Zuma's accuser is apparently a long-time family friend who thought of Zuma as her "uncle" who claims she was awoken from her sleep and raped while sleeping at his house. Zuma initially denied the claims of having sex with her outright but later changed to state that the sex was consensual. The defense council has also made a big issue out of the accuser's past, as she has apparently accused others of rape three other times without a lot of evidence. As in most public rape cases I've seen in the 'States, it's very difficult to tell who is telling the truth.

2) An epic cricket match in which South Africa defeated Australia by a narrow margin which the South African newspapers have proclaimed "The Greatest Cricket Game Ever." I actually watched the end of this game on our hotel T.V. a few days back and had no idea what the hell was going on other than the fans and announcers were going absolutely nuts.

3) A new 2000-rand (the equivalent of about $400 U.S.) fine being levied against people caught throwing their stumpies out the window. What are stumpies you ask? CIGARETTE BUTTS! There is a growing concern about causing forest fires in the bush, which has been unusually dry due to a mild drought in this part of South Africa. My Dad, whose major pet peeve is people who unabashedly throw their cigarette butts out the window in America, would be proud of such a policy, and I can't say that I disagree.

Today's a "free day"--nothing planned! I think I may try and arrange a tour to Robben Island, or perhaps just rent a bike and explore the city.

Don't Feed the Baboons

This was the central message of the numerous signs at the Cape of Good Hope, the southwesternmost point on the African continent (it is a widely-held misconception that the Cape of Good Hope is the southern tip of Africa and divides the Atlantic & Indian Oceans...this honor in fact goes to Cape Agulhas, a little bit down the coast from the more famous Cape of Good Hope, which was named by Bartolomeu Dias in 1488). Oh, and we didn't see any baboons today.

It's been a glorious two days in Cape Town, and we've fortunately taken advantage of it. Monday was spent scampering up Table Mountain (actually, the word "trudging" or perhaps even "limping" would seem more appropriate...it's not easy), which provides spectacular views of the entire Cape Town area as well as sore, achy calves the following day after taking the hike up (you can choose to take a cable car, but where's the fun in that?)

Today (Tuesday) was spent driving down the Cape Coast towards the Cape of Good Hope, where we took in some more ridiculously beautiful scenery, swam in the ocean, and frolicked with the numerous penguins in nearby Simon's Town. We just returned from a very filling Thai dinner close to our hotel, and thought I'd pop by "Technically Correct", my Internet Cafe of choice, to update my blog before turning in for the evening...

Welcome to Cape Town

My tour of duty at Princess Marina Hospital has sadly come to an end. My last day was Friday, which I largely spent taking photos of my favorite nurses & patients and just barely sneaking in one last LP (my streak of consecutively successful LP's is definitely in the double digit area...in general, they are much easier on cachectic, HIV-infected Africans than they are on obese, diabetic Americans).

Now it's on to the VACATION portion of the trip! On Saturday, Jon, Kara, and myself boarded a plane to Jo'Burg, and then to Cape Town, where we will spend our final week on the Dark Continent. Jon's wife Sonal (an Anesthesiology resident at Temple) met up with us there so it's the four of us sharing a hotel and rental car together.

What a breath-taking city! Our hotel is about a block away from the Cape coast, and in prime viewing distance of Lion's Head, part of the ridge of mountains which forms a backdrop against the city. Today was spent gorging ourselves silly at the all-you-can-eat breakfast buffet our hotel features, followed by hiking around Kirstenbosch Botanical Gardens. The Gardens are on the eastern face of Table Mountain, which we intend to hike up a little bit later on in the week as it was a bit cloudy today. Apparently the viewing conditions can change dramatically upon the weather; it is not uncommon for a sheet of clouds to completely cover the top of Table Mountain, the so-called "tablecloth".

And to top it all off...a fast & cheap Internet connection at a nearby Internet Cafe which allows me to finally post some photos up! Admire me in all my facial hair glory! (Don't worry, Claire...I intend to shave it off shortly after arriving back in the 'States ;)

Last Day

It's my final day at Princess Marina Hospital!

The Male Medical Ward service has dwindled to a shockingly manageable 10 patients. With my fellow resident Helen and our new medical student Lori having learned the ropes with relative ease, I feel like I'm leaving things in overall good shape. Also, one of my cryptococcal meningitis boys--the first patient I ever admitted on my own here at PMH--is going home on Monday; I just had a long family meeting with them and his departure gives me a good sense of closure for the month.

I think I'll spend the rest of the day taking photos of the nurses & medical ward, maybe do a little shopping, and also have my LAST DAY OF PIES at the Main Mall. I'm just keeping my fingers crossed that they have my favorite, the ostrich pie, when I show up today.

I bought a sweet Botswana Zebras soccer jersey yesteray...

Men are from Mars, etc. etc.

It's interesting to see the natural ebb & flow of admissions here at Princess Marina Hospital. For instance, the Male Medical Ward (where I am) when I started was getting hit hard--lots of admissions, even on days when we weren't on call somehow, thanks to the highly confusing schedule here. Now it's the Female Medical Ward which is getting killed--they have probably about 3 times as many patients as the Male side. However, due to cultural differences, it's probably about the same amount of total work: I've found that in general here, men wait until they are pretty damn sick before they'll come into the hospital--which often means that because their HIV has gone unchecked for many years, they'll likely have some big-ass pleural effusion which needs to be tapped. The Male side has had fewer patients overall, but lots more procedures--which in general I like, so I"m glad I ended up on the Male side.

Another common admission on the female side is the "parasuicide". They use this term here to refer to anything ranging from a half-hearted suicidal gesture all the way to a frank suicide attempt. It always happens afte r a "misunderstanding" between the patient (who is nearly always a young female, it seems to me) and their boyfriend/husband/mother. Fortunately, most of the time it's not successful--they'll take something completely benign like trying to O.D. on their HIV meds (which won't really do much except perhaps reduce your viral load) or 5 tablets of ibuprofen or something like that. However we have seen a few more serious ones like paracetamol (their equivalent of Tylenol--which can definitely cause fulminant liver failure that can be lethal), insecticide (the only male suicide attempt I saw was with insecticide--and it was sadly successful even after a brief bout in the ICU here), and something called "Jeye's fluid", some type of cleaning fluid that for whatever reason seems to be the beverage of choice for Motswana looking to off themselves quickly.

It's getting hot in here

It's getting hot n' humid again. After the initial few weeks during which there was plenty of rain to cool things down, the past few days have been pretty sweltering. I've managed to keep up with a reasonable jogging schedule--I have my route where I run from our flat toward the soccer stadium, which is near the University of Botswana--then head to the back of the stadium where I'm able to check out the action at the cricket fields and then finally to "the bush", a series of meandering paths that I discovered for the first time yesterday. The highlight of each run is at the very end, when I come back to the flat and hop into the pool for a quick cool-down swim!

Only a few more days in Gabs today. We're going for Indian food tonight (for some reason lots of good Indian resaturants in Gaborone) and then tomorrow a farewell bry in honor of all the residents who will be leaving shortly, myself included.

LP Machine

I'm telling you, my team is a well-oiled L.P. Machine these days. Another day, two more L.P.'s. (again, for those non-medical types out there who may be perusing this blog...L.P. = lumbar puncture = spinal tap). I was trying to calculate how many L.P.'s I've either performed myself or supervised since being here and I would estimate that it's almost certainly over twenty. There are some senior residents back in Philly in my own residency program who have not yet been "signed off" on L.P.'s (which requires only 5).

One of the cool things about the Penn Program in Botswana is that it's always in flux...there is a revolving door of students, residents, and attendings which is constantly changing. As such, our Male Medical Ward-Pink Firm has undergone quite a transformation. It now consists of myself and Helen (who fortunately does not have a scaphoid bone fracture, as we had initially suspected, after our Zambezi rafting trip) as the residents, Rebecca & Laurie as the medical students, and Rose Kim (a recent graduate of Penn's Infectious Diseases fellowship) as the attending. It's been smooth sailing as of late.

One of our crypto meningitis boys is going home today! Once looking like he was at death's door, he's walking around with this big grin on his face all day long. Always nice to have a true "save" on the team after our share of lost causes. Also our Zambian patient with the cryptococcal meningitis--his mother managed to scrape together enough money to pay for his 2 weeks of iv amphotericin, so we're back in business.

In other news, my facial hair has grown to impressive lengths over the past several weeks.

Reading List

On call again today (my last one!) So far we've only had three cases: (1) a man who took an enema as part of a "spiritual cleansing" at his church a few days ago and continues to have nausea, vomiting, and diarrhea--which you might think is just related to the enema, but turns out he is also jaundiced (skin turns yellow...often tough tell in black people but you can usually tell based on a yellowish color in their eyes or beneath the tongue), (2) an HIV-positive guy with confusion who we just LP'ed, and (3) a dude with a past history of a subarachnoid hemorrhage (a type of brain bleed) who presents with headache and vomiting which is very concerning for another SAH. Unfortunately he has ABSCONDED...the all-too-commonly used word here for patients who have flown the coop without our permission or knowledge.

Having a markedly improved work schedule compared to at home (on days that I'm not on call I usually get home at about 4-5pm, with no other responsibilities once I get there), I've had the opportunity to do much more pleasure reading than I normally get to do! Here's the list so far:

#1: Wicked--funny novel describing the life of the Wicked Witch of the West (of Wizard of Oz fame). It makes her into a very sympathetic character and describes the course of events which turns her into the evil witch we all know from the movie. Very amusing.

#2: Love Me, by Garrison Keillor--made me feel not too far away from my Minnesota home by reading, even half-way across the world...

#3: Know it All, by A.J. Jacobs--non-fiction book about a guy who decides he's going to read the entire Encyclopedia Brittanica. Each chapter is a different letter--for example, "A", "B", etc--during which the author describes interesting factoids or lessons he's learned in that particular volume which can applied to his everyday life. A little bit of a slog to get through it but a great idea.

#4: Poisonwood Bible, by Barbara Kingsolver--started slow but now I'm really into it. It's the story of a missionary family with 4 young girls who travel to the heart of the Congo, in a disastrous attempt to convert an entire village to Christianity.

The Mighty Zambezi

Dr. Livingstone, I presume?

Just got back from a phenomenal weekend at Chobe Game Preserve & Victoria Falls. I've come into the hospital on this lazy (and all-too-beautiful-for-being-indoors) Sunday in order to use the computer facilities, which are quite difficult to get to in our present living arrangement.

Several of us (myself, Jon, Kara, Helen, George, Nabila as well as newly-arrived Head of the Penn Infectious Diseases Department Harvey Friedman and his son Steven) left work early on Friday and boarded a plane which took us from Gabs to Kasane, in the northern part of the country. One of our travel agent connections had secured for us a rather luxorious room at the Chobe Marina Lodge...on the banks of the Chobe River, fairly close to the Game Preserve of the same name. The weather was remarkably nice and made for a wonderful game outing, this time in a boat (similar to a pontoon boat) rather than a Land Rover. I read where there are 45,000 elephants in Chobe alone, and they did not disappoint! We saw probably about 25 elephants all told; several of them in a large female breeding herd. The highlight was watching one large male elephant cross the river just in front of our boat...he was really quite close! The rest of the drive featured several hippos, crocs, baboons, kudu, impala, eagles, and other birds. Very, very cool...

The next day we split up into two different groups: the adventuresome, and the not-so-adventuresome. I cast my lot with the adventuresome group, which had opted to begin the day by whitewater rafting the mighty Zambezi River. Ordinarily you can start just below Victoria Falls...however, because of all the rain we've had recently, it would apparently be far too dangerous to attempt the upper rapids, and we started much lower down. Mostly Class 4 and a few Class 5 rapids I am told. Just thrilling! We didn't flip the boat but several people tumbled out...towards the end I was feeling a little jealous that I hadn't yet been thrown out so I went into the drink semi-purposely during one of the Class 4 rapids towards the end...

After the rafting, we went to visit Victoria Falls, which were absolutely spectacular, throwing up mist so violently that at times when the wind blew it over towards us on the walking path that it was not unlike being pelted by a heavy rain. Raincoats were a prerequisite. I am told that when my friend went to visit during the dry season several months ago, there was no water coming down from the Falls whatsoever. Now they are literally several miles long of gigantic, raging waterfalls...

I should mention that although our lodge was in Botswana, we had to cross the border to Zimbabwe to get to Vic Falls (the falls form the border between Zim and Zambia). We ended our day at a crafts market in Zimbabwe, which was interesting and provided insight into the horrendous economic conditions in this country. They have nice stuff there--lots of wooden carvings, beautiful masks, etc, some of which is of very high quality. The vendors are incredibly aggressive to make a sale--probably moreso than anywhere else I've visited so far--and it is clear that they are willing to give away almost anything in exchange for non-Zimbabwean dollars. It's crazy--some of my friends were buying these beautiful wooden bowls for the equivalent of $5 to $10. They'll even ask to buy your clothes--I saw one person trade in a pair of water-logged running shoes in exchange for a nice mask, and another person even bartered a pair of socks! I had mixed feelings about the whole ordeal and ended up buying only a few animal carvings and a necklace for about $20 U.S. The funny (and perhaps also sad) thing is, is that both sides walk away from the encounter thinking they got the better end of the bargain...

Tomorrow begins my last day of service at Princess Marina Hospital! I'll actually be on-call Monday but the rest of the week not, which should hopefully allow me to have a relatively relaxing week...

Bry Time

Over the past two nights we've had two fantasic "brys"--a Motswana barbecue. The first was following Tuesday's call just at our flats (cooked up by Dr. Root & his wife Rita) and the second was last night at a Motswana residents' house. Absolutely delicious.

On call again today. It's been a wee bit frustrating over the past few days just because the novelty of doing iv's on my own, wheeling patients down to X-Ray, and performing all my own EKGs is starting to wear off. Also, since my superstar medical students Prateeti & Sophia are finishing up their tours of duty, it will be up to myself and fellow resident Helen to perfom all the mindless scut. I swear, if somebody told me that I had to repeat internship again...I think I'd have to find another profession...