My iPhone "Big Five"...with one slight substitution!

I have taken two incredible weekend safari trips.  My first was the Chobe Game Reserve in Botswana (very near to the border of Namibia, Zambia and Zimbabwe).  While there I visited Victoria Falls as well, which I will write about separately.  My hotel near Chobe was overlooking the Zambezi River and Namibia was on the other side. My second weekend safari trip was to Madikwe Game Reserve just across the South African border (about an hour drive from Gaborone).  While in Madikwe, I spent one night at a bush camp (with solar powered lamps and hot water bucket showers) and one night in a fancy hotel where I had a celebrity sighting (Adam Sandler!).  Below are some of my favorite pictures of the "Big 5" that I took on my Iphone5, with one slight substitution...a cheetah instead of a leopard!

"All suffering is not equal" (May 17)

- Quote by Paul Farmer

Tuesday was a good day.  On rounds that morning, I called attention to a patient breathing 40 to 50 times per minute.  My recommendation was to obtain an urgent chest film to rule out a life-threatening pneumothorax (air in the lung that is pressing on the lung tissue and preventing it from expanding) after a procedure had been performed several days before to drain fluid from his lung.  Others on the team felt his symptoms were better explained by a possible infection and were comfortable waiting for the nurse to take the patient to radiology (which in my experience could take days).  This was too long, and I disagreed.  There were many patients on our service who I knew had little hope for recovery, but he was not on this list.  I excused myself from rounds and recruited someone to help me wheel the patient to radiology, shortly after which I was not surprised to learn the patient indeed had a very large hydropneumothorax.  We all agreed he needed a drain placed in his right lung to drain the air and fluid over the next several days, and I performed the procedure myself (my very first chest tube!).  There was an instant rush of air and almost a liter of fluid poured into the drain after the tube was placed.  The patient looked and felt better within minutes, and so did I.  I made a difference today.  I was proud of my education and training, and even prouder I trusted my instinct to save this man's life.

Many of my patients, however, are not this lucky.  This morning, after I had just pronounced the death of one female patient with meningitis, I was saddened to learn another patient of mine with liver cirrhosis had also just died.  Several days ago when he was admitted, I diagnosed with him hepatorenal syndrome and end-stage liver disease from chronic alcohol use and Hepatitis B.  But the hospital had none of the three medications used to treat this syndrome, nor the option for surgical transplantation.   I knew he was going to die, but it did not make his passing any more palatable or just.  I was angry.  All along I knew exactly what needed to be done for him but I was powerless to do any of it.  The satisfaction of my chest tube earlier that week now seemed like a distant memory. I could feel myself pulling away again, and part of me wondered why I even bothered to try for patients like him in a place like this.  Today was a bad day.

The answer to my confusion was in a book I was reading a few hours ago (on my flight to Kasane) by Abraham Verghese, titled "Cutting for Stone."  In it the Matron of the hospital says to one of her benefactors, "We aren't even fighting disease.  It's poverty.  Money for food, medicines…that helps.  When we cannot cure or save a life, our patients can at least feel cared for.  It should be a basic human right."  For the past several weeks I have become increasingly frustrated by the striking (and disturbing) differences in patient care between this hospital and those I am accustomed to practicing in at home.  While these differences are important and should never be overlooked, I can not let my frustration belittle and overshadow my most important responsibility as a physician, a responsibility that has no borders or boundaries or asterisks.  For my remaining time here, I intend to shift the focus of my care from treatment to doctoring.  In the words of Paul Farmer, I am "challenging my belief and desire to always want to think big as a reason for why I am not happy taking care of patients clinically on a small scale."

- Quotes from Paul Farmer in Tracy Kidder's book, "Mountains Beyond Mountains."

An unusually late night out in Gabs (May 8)

Gaborone is a bit of a sleepy town (which according to my bro is true of Philly too).  There are no cabs to hail on the street like would be true of any big American city, only privately arranged taxis and public transport with "combis," mini-bus type vehicles on fixed routes throughout the city that carry 15 people and cost a few pula (less than a dollar).  I was surprised to learn that after 9pm it can also be challenging to find a driver, so I got an early start tonight and headed out to a popular expat hangout, The Yacht Club, to enjoy a glass of wine and watch the sun set on the horizon above the Gaborone Dam on the Notwane River.  In the picture you make out a distant outline of the same double humped Kgale Hill.  After enjoying the sunset, we headed out around 8pm for an unusually late dinner at Chutney, an Indian restaurant and one of our favorites.  The driver afterwards said he was feeling very "sleepy" - not surprising at all!

Kgale Hill (May 5)

The highlight of my weekend in Gaborone (or Gabs) was hiking with Shelton up Kgale Hill for a 360 degree view of the city.  The population is a little over 200,000 and the city is located less than 10km from the border to South Africa.  The hill also overlooks the Gaborone Dam, the primary source of water in Gabs.  We hiked up the rocky face of the hill, called "Rusty's Route," and met a few baboons on the way.  Afterwards, we shuffled back to a local mall for a mango yogurt smoothie before heading home.  The hill was a good workout in the middle of an otherwise relaxing weekend to end my first week in Botswana.  Sadly, however, we bid farewell to both Luke and Sarah as they headed on to greener pastures, Austria and Amsterdam, respectively.  It is possible they may guest blog on Mosimolodi about their adventures during their travels. 

The Wards (May 3)

My first day in the hospital was Thursday.  I walked with Eli and Sarah to 7:30am morning report.  We discussed a patient admitted to the medical wards overnight who had a late presentation of cryptococcal meningitis (an uncommon diagnosis in the US, but not in Botswana which has one of the highest rates of HIV in the world).  The patient received excellent care overnight and received an emergent lumbar puncture to make the diagnosis.  I was impressed.  The morning so far had been almost indistinguishable from my own residency; a sense of relief came over me that perhaps I had misjudged my experience again .  As the case report ended, however, we were informed the hospital had run out of the life-saving and possibly vision-saving medication needed to treat the patient.  My jaw dropped.  Even if medications were in stock, I soon learned they were sometimes not given though ordered, or sometimes incorrectly charted as being given.  Blood vials that had been collected were lost and results routinely took days to come back (or never did).  Patients receiving intravenous medications had no IV in their arms.

The differences in care are striking and somewhat ironic.  In an ICU back home, an extraordinary abundance of resources are directed to prolonging the life of elderly or institutionalized patients in the final few days to weeks of their lives, patients with little to no hope for a meaningful recovery.  Yet here there are countless patients in their 20's and 30's who are dying every day from medically treatable conditions like heart failure, meningitis, HIV/AIDS, or TB, simply because of the lack of resources.  In fact, such deaths seem almost commonplace here.  At the start of ward rounds on my second day, we arrived to find our young postpartum female patient laying in her bed in rigor mortis (a stiffness of the body that occurs well after a patient had already passed), but rounds continued on to the next patient without a faintly palpable interruption.  And the irony is that all Batswana (plural for more than one person here) have something that Americans do not - free and universal education and healthcare. 

By the middle of my second day, I could feel a sense of hopelessness creeping upon me.  I came here to make a difference.  Back home, there were so many people involved in the care of my patients that I often felt disconnected; it was frustrating.  I hoped perhaps here my medical experience would be more valuable.  At the end of my second day in the hospital, Eli (a medical student with me) and I performed a therapeutic lumbar puncture on our patient with meningitis who was not receiving his medication. This procedure was done in an effort to remove fluid from his spinal cord and relieve the pressure that had been building up from his infection and causing him to have severe nausea and headaches.  He instantly felt better and so did I.  While it will take time for me to recognize and make sense of the bigger issues and challenges of healthcare in Botswana, I find satisfaction in knowing I can still make a significant difference here.

The Braai (May 1)

I had no idea what to expect when I arrived at Sir Seretse Khama Airport in Gaborone, the capital and largest city of Botswana. Embarrassingly, it was just a few months prior to my arrival that I was using Google to locate this country on the world map, surprised to discover it was nearly the size of Texas. How did I miss that? Random images were zooming in and out of my thoughts like a projector reel, some borrowed from books or movies or documentaries, still more extrapolated from my conversations with other residents who had ventured here before me.  I prepared myself for the worst, but felt strangely confident that my time in India (Ambala, in particular) had somehow prepared me.  

Much to my surprise, Gaborone seemed cleaner and more organized than I had anticipated.  A driver picked me up and drove me to a gated apartment complex, a short 10 minute walk from the hospital.  I shared a flat with three medicine residents (Sarah, Luke, and Elana) and a dermatology resident (Julia).  Two other flats in Pilani Court had medical students and a psychiatrist working in the area as well.  We had a maid, hot water, wifi internet, couches and a microwave.  The skies were clear and blue, and it was hot enough to wear shorts but not feel too hot with the cool breeze.  The transition seemed almost too easy, and to be perfectly honest, it felt like a vacation.  

And indeed it was a vacation! Although I arrived on a Tuesday and spent most of the afternoon getting official clearance to work in the hospital, Wednesday was a national holiday - Labor Day (or Worker's Day), a commemoration of the labor movement and force.  In support of this event, my new roommates hosted a Braai (Africans for "barbecue"), which is a social custom in South Africa, Botswana and many other African countries.  We did this in the backyard of our shared community. In true customary style, Luke used wood to get his fired started (and maybe some charcoal helped as well).  While we had plenty of meat, we supplanted the traditional corn accompaniment (Pap or Samp) with Shelton's banana bread.  Before we knew it, the sun had set and our sangria was finally finished. We even managed to throw together some smores with strawberry flavored marshmellows.  All in all, it was a great start with some new friends to kick off my arrival to Gabs.

As I drifted off to sleep, again I found my mind racing, not knowing what to expect on my first day in the hospital tomorrow.  Perhaps there I would encounter those harsh realities that I had imagined earlier but had been immune from for the past 36 hours.  I was less sure my preconceptions would be proven wrong this time though.

Takeoff and Landing! (April 29)

Anxiety. Fear. Excitement. Ambivalence. Freedom. Escape.  These words came to mind first after taking off from Philadelphia.  The first few hours of the plane ride were turbulent, swaying left then right, then left again, without interruption.  Like me, the plane seemed to be feeling a bit unsettled at the start.  But the destination for us both had been set - London!  

By the time I arrived the turbulence was long gone and I was feeling different too. Within an hour, I had crossed the UK border and made my way into Zone 1 of the city through the Underground to Piccadilly Circus.  I had no maps with me and no plans in mind.  A part of me wished I had done a little research beforehand to maximize my time there, but a bigger part of me was glad I did not.  The adventure is not knowing what will happen next or what you might find.  Lo and behold, in the first 15 minutes of walking, I already stumbled upon the first boon of my poor planning…M&M World!  Who knew they had enough paraphanalia to fill up five floors? - completely insane.  

For the next several hours I walked along the Thames, ate a Vegetable Tikka Masala Wrap from Pret A Manger (the London equivalent of Cosi) in Trafalgar Square, walked on the not-so-architecturally-impressive London Bridge, met Big Ben, scoffed at the idea of paying 30 pounds for a tour of Westminster Abbey, saw the London Eye and Tower Bridge, and enjoyed an ice cold Kronenbourg at Coach and Horses (quaint local pub near Oxford Circus). All in all a successful impromptu trip.

I left London reinvigorated, ready to explore and have a lot more adventures in Africa.  Not surprisingly, this next flight to Johannesburg was much smoother. Cheers to beginnings - Mosomolodi!