Botswana 9: Some hospital reflections

Our last day at the hospital was yesterday. It was a wild ride. I will reflect on this experience for weeks, months, and years to come.

There were happy stories, sad stories, horrifying ones, and irritating ones. In a lot of ways, it really was similar to our hospital. The interns were still annoyed by having to write notes. The nurses sprint into action in dramatic fashion when there is a real emergency. People truly want to do good, but sometimes get weighed down and frustrated by systems issues. The medicine in a lot of ways is the same, but the timeline of when things can get done is different. A lot of the available medications are the same, and if they're not, then they're often a related drug-cousin to what I am used to prescribing. The biggest difference was the overwhelming presence of HIV. After a chief complaint (why did you come to the hospital?), the next most important thing to learn about a patient is their HIV status, whether they take their medications, which ones, why if they're not the standard regimen, and what's their CD4/viral load (control of their disease). That completely changes your differential diagnosis. If their immune system is not functioning, you need to think of the infections that are able to take hold in this situation. Every patient here is supposed to have an HIV test active within the last year. If not, we do it upon admission to the hospital. I have seen crazy opportunistic infections that I only learned about in theory in medical school, or maybe once when rotating on the Infectious Disease service: cryptococcal meningitis, TB meningitis, TB adenitis, disseminated MAC, cryptosporidium GI illness, toxoplasmosis in the brain, and pneumocystis pneumonia. I'm used to thinking that these diseases are unlikely, but I learned to put them at the top of my list of likely diagnoses.

Adrienne and I made some friends at the hospital. It took about a week, I think, which is also what made such a difference in having a tough first week and subsequent great weeks after that. We could joke with the nurses, who work in the same space as the doctors, a little desk/alcove on the wards, not separated like we often are at my home hospital. We learned a bit about the lives and aspirations of the medical officers and interns. This past week I was on the Male Medical Ward, and the medical officer there is outstanding, Moshomo. He would love to do a residency in internal medicine in the U.S. to become a specialist. He could definitely do it. He is operating at the level of a hospitalist already. He was so great; we would collaborate on interesting patients, and before leaving yesterday, I signed out all of the patients I was following to him because I trust that he will take care of all loose ends. Being a medical officer in Botswana is tough. You get put in a lottery (sort of like the residency Match, but you don't put in a rank list), and you get assigned a hospital. It could be hundreds of miles away from your family. One of the other medical officers took a vacation; he had not seen his wife or children in 3 months. The interns also have a Match where they do submit a rank list. The girls from University of Botswana medical school told us they ranked highly the programs close to Gabs, but put Princess Marina Hospital low on their list because they had done medical school there and found that the most interesting patients went to the students instead of the interns, so there was less learning and more scut work. They also ranked Maun (city in the north, near the Okavango Delta) low because, as one of them told me, "nobody wants to go to Maun." Some of them hope to go to the U.S. for residency, too, but the expense of taking the boards in the U.S. (USMLE steps) is daunting. Tomer, our boss, tries to help those who are truly motivated.

Adrienne and I also befriended Patricia, the program's research assistant, during our Quality Improvement project weeks, mostly because we worked in her office. Patricia is initially prickly, quiet, and unsmiling. But we wore her down! We sat with her, kept quiet when needed, helped her out when she needed someone with clinical training to decipher a diagnosis in a chart, let her/encouraged her to play music while she worked, and chatted, asking about her life. She's from Maun. During this past week, while Adrienne was on QI, Patricia even told her that she liked us! Then, as Adrienne and I were finishing something up in her office, it was time for Patricia to leave for the day. She announced, "okay, girls, Patricia. Is. Leaving!" with flourish and demanded we give her hugs! ha! It's possible that we are the only residents she has hugged good-bye, hard to say for sure. That was a good personal victory.

We are here as doctors, but our primary task here was to learn and to teach. We certainly learned a lot. At first, I was a bit worried about my ability to teach; I had never seen TB meningitis before! But, we do know very well how to manage patients on the wards, and we have tons to teach about exam skills, history-taking skills, hypertension management, the differential diagnosis for acute kidney injury, loads of stuff. Some of the interns needed more help than others. A couple just needed encouragement and a push to be better still. A few needed a lot of help. One intern we met our first week initially seemed very uninterested in working with us, and even said as much. Our attending had a sit-down with this person, and once this intern realized we were there to help and make him a better doctor, not add to his work-load or boss him around, his attitude completely changed. He asked us our opinion when he was unsure. One day, he asked if he could see me do a neurological exam with a patient, then later told me how impressed he was; he had not truly known how to approach it systematically. He bought us muffins (a lady sells muffins in the hospital, delicious) during busy mornings sometimes. We gave him Adrienne's copy of a Pocket Medicine book and I found some left-over scrubs at our house that he could use. This intern needed some help, and we were more than happy to give it. I pushed him to develop a problem list and come up with differential diagnoses. I made him decide on a plan before telling him my thoughts. I went over blood gas results. It was my usual senior resident role. I saw him improve over the two weeks I worked with him. Yesterday, when we told him good-bye, he very touchingly thanked us for teaching him and said, with tears starting to appear in his eyes, that we were "a blessing." Thinking back to our impression of him the first week, I never would have thought that he would be the intern we helped the most. He made a circling motion with his hands, referring to all of us meeting together, and said, "this is what life is all about." I nearly cried.

Adrienne, Tomer (our mentor), me

Two of our interns, Francis and Chikanda, telling us about intern year in Botswana

Regarding our clinical experiences, some thankfully had happy endings, too. The woman with pneumocystis pneumonia (seen almost exclusively in AIDS patients, horrible pneumonia) who was so sick and on 10 liters of oxygen when I met her day one, walked out of the hospital week 3 and returned wearing a stylish dress and hat combo during week 4 for a check-up. The sister of a man with dementia who had a seizure thanked me very much for my care at the time of his hospital discharge and told me she wanted me to be her doctor, too. There were a lot of sad outcomes. This is a hospital, after all. A man in his 40s with relapsed lymphoma and renal failure died quietly in the night. A young woman who came in with fevers likely had a rare disseminated infection seen in AIDS; we succeeded in transferring her on a Friday to the referral hospital with an attending physician there interested in her case, but she died over the weekend before she could be seen by the specialist.

One of the hardest ones for me to take was a neonatal resuscitation. We are here for an internal medicine rotation, but Adrienne and I are equally trained in pediatrics. One day last week, I called our friend Teju (ob/gyn resident) at the end of the day, telling her we were ready to leave for the day (we drive to/from work with her every day), and she answered saying she was tied up with trying to resuscitate a newborn. I asked whether she could use a couple of pediatricians (myself and Adrienne) to help, and she responded pleadingly for us to come quickly. We ran upstairs, initially had difficulty finding her. I'm used to resuscitations being loud, busy endeavors with too many people eager to help, but not here: 4 people in a dark side room. Adrienne and I rushed in. A medical officer, intern, and two nurses had gathered around a baby on a warmer with a spotlight on. Teju told us briefly that the baby was getting bradycardic during labor, so they tried to rush to deliver, but the baby was limp and pale at the delivery with a faint, slow pulse. We looked upon the scene and tried to quickly process what was going on. The chest compressions were way too slow. After asking twice for them to speed up with limited improvement, I took over and put my hands around the baby's chest. Next, the ventilation. I asked the officer to intubate. Nothing happened. Adrienne tried to trouble-shoot the mask but it was tough to get a good seal with equipment that was different than ours at home. Again, I asked the officer to intubate. And a third time! He attempted, but had a hard time with it (no stylet). I swapped with someone to do compressions and tried to intubate. There were no breath sounds throughout and no pulse whenever we checked. We tried giving adrenaline (epinephrine), no response. It had been going on about 5 minutes before we got there. We tried as hard as we could, but we got nowhere. At about 15 minutes, we called it. There are no functioning ventilators, no cooling, very limited post-arrest care. The baby had died by the time we got there, and our attempts did not bring her back. That was tough, for several reasons. I have done chest compressions on a babies before, but they have all survived. I think all of the pediatric codes I have gone to have had good outcomes. Kids are resilient. It was also tough seeing poor chest compressions, especially because I know one of the recent residents here ran training sessions on neonatal resuscitation. That really made me angry, frankly. I was also pretty annoyed at why I had to ask multiple times for them to attempt intubation, but I think there were a lot of reasons why the medical officer did not do it (lack of confidence with procedure, missing a helpful piece of the kit, seeing futility, possibly not trusting me as a random doctor who came running in). Adrienne, Teju, and I, after leaving the scene, all had a good cry in the stairwell. Tomer, our attending, who was waiting for us to leave for the day, helped us debrief the scene. It was good to get his perspective, as someone who has worked at Scottish for a long time, having seen many failed resuscitations. He focused on the positives, that, aside from the intubation thing, staff was receptive to us and worked together. Sigh. It was a tough ride home. Poor Teju felt even more responsible than us (we really could not have done much of anything), but they do not have much in the way of fetal monitoring here, so her ability to the prevent the situation was limited, also. Sigh. This one will stay with me for a while.

Sunset on our way home after the failed resuscitation

Overall, the time here went by quickly. Around Day 4, I wasn't so sure of how things were going to go, but by Day 6, I was happy in this role, for the most part. As we bid our good-byes yesterday, I felt truly appreciated. The biggest good-bye was from our attending and mentor, Tomer, who, in his hilarious and also meaningful way, told us that we did "stuff" (he didn't say stuff), we did a wonderful job, and he'd be happy to have us back as fellows. Adrienne and I both have our fellowships lined up for next year, but it's always great to be invited back. Plus, he said residents from University of Michigan who have rotated here have always been awesome, and we were right up there. That's great for our residency program. Tomer was a fantastic mentor. He taught me tons about TB/HIV, reminded me of  and re-explained pathophysiology of some common diseases, and showed me ultrasound techniques in doing DVT scans and echocardiograms. We had so much fun learning from him.

Next up, our vacation week! Adrienne and I are very much looking forward to our planned trip to Victoria Falls, Chobe National Park, and the Okavango Delta! More adventures! Plus, we are joined by Brandon (Adrienne's husband and frequent commenter on this blog), Jon (my boyfriend), and Brian (our friend). We are resting and packing up today in preparation for heading out tomorrow!

Botswana 8: Madikwe Safari, Let's Have a Bash At It

SAFARI. SAFARI. SAFARI.

This weekend, Adrienne and I treated ourselves to a weekend (one night) at the Tau Game Lodge at Madikwe Game Reserve in South Africa. It was a once-in-a-lifetime adventure. I loved every aspect of our trip. We hired a local driver, Dimpho (pronounced Dim-po, the "ph" doesn't make an "f" sound), who got us through the South African border smoothly. The border is only about 30 minutes away. Wild. As soon as we got to South Africa, we turned off onto a dirt road and drove another 20 km to the gate of the reserve. We showed our passports again along with lodge confirmation, and drove into the park. On our way to the lodge, we passed elephants and 2 ostriches; we knew we were in for a wild ride. The lodge was incredibly nice. We had a ranger, Stuart, assigned to us for our stay, along with 3 other guests who were working in Gaborone for just a week, one of whom had a sweet camera and promised to send us her pictures. This was a luxury lodge. We lucked out in booking it because they had a huge group renting the place out Friday night, leaving Saturday bookings open, and they have last-minute deals for booking within 14 days of your stay. Sa-weet.

The lodge is situated on a natural waterhole, and within 20 minutes of arriving and watching from an upper deck, we saw zebra, impala, waterbuck (a different type of antelope), a crocodile, and a group of 15 elephants!! I was so happy, I almost cried.

Herd of elephants!!! Adults and youngsters included

We checked into our chalet, an adorable room with a walled-off outdoor shower and a deck looking out onto the waterhole. They fed us delicious lunch, including ice cream dessert. We relaxed by the pool for an hour, and soon enough, it was time for high tea (i.e. gathering up guests) and our first game drive! We left a little before 4:30 p.m. and got home around 7:30 p.m. It was so nice, just Stuart and 5 guests, ourselves included. We all had plenty of space to take pictures. Stuart drove us in a Land Rover with 9 seats hooked up onto the bed and a canopy over the top. There were blankets for when it got cold at night. All of the rangers from the different lodges in the area coordinate when they find something great. Stuart obviously knew what he was looking for right away, but he kept us in suspense of the evening's greatest find. We saw loads of impala, springbok, zebras, warthogs, a few elephants, and a giraffe. He also pointed out smaller animals, including some of his favorite birds and an African wildcat, which he says are fairly tough to spot; he's only seen 10 in his life.

This zebra has a huge gash on his left bum from a lion attack. Also, notice the different colors of stripes! Black and grays. No zebra has the exact same stripes.

Zebras!

Trusty Land Rover

Then, over the radio signals, we were on standby. For what, we were not sure, but he had us wait and chat for a little while until another car came our direction. We took off on an old bush road, approached one other truck departing, and then we saw it: a spotted cat lying in clearing through a bush. It was a cheetah! Two! Stuart told us, "I didn't come all this way to see a cheetah through a bush." Ha! He took his landrover and did a bit of "bundubashing," aka bushwacking, and knocked down a couple small thorny acacia trees with the car, sending leaves spraying all over us. It was worth it: perfect view of two male cheetahs. There are only 5 cheetahs in the whole reserve; they are the highest level of endangered. I never in my wildest dreams thought we'd see wild cheetahs. Stuart then let another truck in, and we went to a clearing and got off for a drinks and snacks while we watched the sun set over the bush. After that, we headed back to the lodge in the dark!

Two male cheetahs, resting up between sprints

In the evening, we all had dinner together, our whole car. Stuart told us answered our questions about about how he got into the business (always loved animals, uncle was a ranger), the training (3-month intensive bush instruction), and his favorite stories. All of this over fabulous dinner. I had antelope! Stuart said it was his favorite, so I trusted him, and it was great. In going to bed, I was so excited about our day and what we might find the next day that it was hard to sleep, ha. Like a little kid before Christmas.

We woke up early the next morning at 5:30. We had tea and muffins at 5:45, then hit the road at 6. Apparently, while we were on our drive with our awesome cheetah sighting, there had been another incredible sight back at the lodge waterhole: two female lions and cubs attacked an impala, killed it, then a male lion came along, took the impala, and headed into the bush with it! So, Stuart was determined the next morning, and we tried tracking the male lion, unsuccessfully.  "Let's have a bash at it, shall we?" Yes, please. We went as far as the back roads in that direction would take us, no luck. So, we headed in another direction. Apparently, later that morning, that male lion we were trying to find headed back to the waterhole for a drink! Ha. Elusive. Instead, we came across another lodge's truck, and the two rangers chatted. They speak in some code about where animals are so that it remains a surprise for the guests as to what animal we find! So much fun. We found... a different male lion! The oldest in the park. There were other trucks when we arrived, but Stuart thought it might get up and walk or call, so we waited, the only truck, and he did just that. After letting us get quite close (!), we tracked him for a while as he moved across the bush before settling in a new spot.

ZOMG Lion!

Mufasa! Beautiful animal

Next, we set off and found rhinos! A mom and a baby, we saw first, then another mother-child pair. There is a huge poaching problem across Southern Africa, Madikwe included, especially when it comes to rhinos. Even with anti-poaching teams, they have lost 10 so far this year. If things keep up at this rate, we may not have any rhinos left in 15-20 years. They are poached for their horns, which are ground up and put into herbal medicines, none of which work, because the horns are just keratin, the same stuff our hair and fingernails are made of. So ridiculous. Stuart said there is debate among the rangers in the reserve as to whether or not to cut off the horns of the rhinos at Madikwe so they won't get poached. The problem is then they couldn't defend themselves against lions, and the males couldn't fight with one another for mates, an important part in establishing their hierarchies. It will be a tough decision.

Mom and baby rhinos

Heyyyyy rhinos!

Our final amazing find was a huge group of elephants around a watering hole. Juvenile males were fighting each other, though not causing any damage. A couple of elephants went for a swim in the water. There was a group of females and babies across the waterhole from us, too. It was amazing. They have such fascinating social interactions. One elephant literally pushed another one into the water, then didn't go in himself! Ha. Another one shook his ears at us. Other than that, they weren't too bothered by us at all. We set up a final tea and snack break a little ways away. One male elephant, a young adult who Stuart described as a teenager, seemed annoyed at our choice of spot. Stuart stood his ground and told him to go away until he settled on grabbing some vegetation then walking along. Haha. We were so ridiculously happy with this drive! What amazing sights!

YOU go in the water! Hurry up!

Ranger Stuart telling the male elephant to move along

With our elephant friend

Adrienne and I are now addicted to safaris. We cannot WAIT for our next safaris in northern Botswana when we are on vacation starting Saturday.

P.S. The end of The Great Banana Caper! (continuation from Botswana 7 post)
While we were at the reserve, our housemate, Teju, was relaxing at home in Gabs this weekend (she went to Madikwe last week with another group). She was working on a presentation at home this morning, and all of a sudden, around noon, she noticed something moving out the corner of her eye: it was a vervet monkey making its way down the stairs! They saw each other, and both got scared! The monkey raced back upstairs and into one of the bedrooms! Teju shut the bedroom door, thinking she had trapped it. Then she panicked again; what do you do with a trapped monkey?? She called the global health fellow who lives a couple townhomes down. He and his wife came over with brooms and a plan; scare the monkey out the front door. But, by the time they checked the room, the monkey was gone! One window was slightly ajar, a window Teju had opened two weeks ago, then shut, but did not 100% completely fasten the window (the latches can be tough). The monkey(s?) had been using its tricky little fingers to open the window and close it behind itself! After the bananas were missing and we suspected monkeys on Friday, I checked every room and every window, and they were all closed! I didn't check every latch, though, and I guess that was my mistake in investigation. Adrienne and I remembered back the past couple weeks and remembered that another bunch of bananas and a loaf of bread that were out on the corner had also gone missing, but it was on days that the housekeeper was here, and we assumed the bananas had gone bad (as they were nearing that point) and the bread had gotten moldy (happened once before), so our housekeeper must have thrown them out. Not so! That stinkin' monkey probably stole that food, too! Honestly, I was happy to have confirmation of our suspicions that a monkey was behind The Great Banana Caper, haha, but I'm also happy that we have our windows properly latched now. No more monkeys in the house!

Botswana 7: The Great Banana Caper

The Number One Ladies' Detective Agency
This incredibly popular book series is set in Botswana, specifically Gaborone and Molepolole! I'm reading the first book in the series while I am here now, and it's been so much fun to recognize important places in the book as places I have now visited, such as Kgale Hill, or Airport Junction Mall. This week we had a couple of mysteries to solve, so we took over for Mma Ramotswe as the ladies of the agency.

The Number One Ladies' Detective Agency had a real humdinger this week! There were actually two cases. In the first, our attending accidentally picked up someone else's phone but couldn't figure out who to give it back to, got impatient when the first person to call it was not helpful in finding the owner's identity, and happily let me take over the mystery. Solved within 10 minutes. The owner called back, and when they finally spoke in English instead of Setswana, I set up a rendez-vous and returned the phone. Boom. Mystery solved.

That brings us to the much greater mystery: The Great Banana Caper. A guest blogger, Adrienne Carey, tells us the tale:
 Jackie and I bought two bunches of bananas on Wednesday night for breakfast for the next week. We have a basket for fruit on the counter and put everything in there. We also bought some "soft citrus" which turns out is related to tangerines but comes from Asia. Anyway, we came home from work yesterday and for some reason, I immediately saw that the bananas were missing. "Hmm, I thought. Did Shumi, the house cleaner, come by today?" I asked Jackie and Teju [our ob/gyn roommate]. No, that wouldn't make any sense. She comes on Tuesdays and Thursdays. Inspecting the area around the basket more closely, the soft citrus was still present but there were two little brown things on the counter. "Is that poop?" Jackie asked. I smelled it. Smelled like poop to me. Hmm. Okay. More details. Looking around more, there was no evidence that anything else was disturbed or moved. I looked in the garbage; bananas nor traces of banana peels were present. Shumi sometimes throws away old food when she comes so maybe she did that? Again, it's not Tuesday or Thursday so why would she come by the house? And if anything, the bananas were green when we bought them so they were no where near being old and needing to be thrown out. That leads us back to the suspicious poop stains on the counter. "Monkeys?" Jackie and I looked at each other. No, there is no way. We hadn't opened any windows in the house except for the window on the second story in the bathroom. And we always lock it. Jackie ran upstairs. Sure enough. Locked. No signs that monkeys came through the window; all the shampoo bottles on the ledge were undisturbed.

Continuing to puzzle over what could have happened to the bananas and also caused the poop stains, monkeys seemed like the most logical choice but also ridiculous because how could they have gotten in? We all decided we should text Janet Gaborone, the impeccable and omnipresent administrative assistant for our program... we sent her a message through What'sApp? as follows..."Hey Janet! We just got home and some our food is missing. All of our bananas are gone. Do you know if Shumi was here today, or were you here today? Nothing else looks messed up and the front door was locked."

Cleaning up the supposed poop stains with "Mr. Muscle" neon pink cleaning spray and some toilet paper, we headed off to dinner at a wonderful Indian restaurant called Chutney and didn't hear back from Janet until we returned from dinner. Janet's reply was waiting when we walked through the door. "Hey just saw your message, i was there but at Connie's house only popped in and collected the envelope didn't even look around..was any window open..there were so many monkeys today by the house." AHA! So monkeys could be an option! But again, how did they get in? I reassured Janet that we were not worried or upset but just puzzled by the lack of our breakfast fruit of choice. Janet replied..."Yeah its weird..thank for understanding though..its kind of a mystery..😳 looks like someone or something was hungry...do have some fun (this weekend)." I then mentioned the streaks of poop on the counter and it sent Janet into a texting frenzy. The emojis were flying. Laughing faces, flames, "hear no evil, see no evil, speak no evil" monkeys, poop swirls. I had set something in motion by mentioning the poop stains and the hilarity ensued. Janet said she was "laughing like an idiot" and that the man sitting next to her on the bus (she is traveling to Francistown to attend a friend's wedding) asked her what was so funny. She told him the story, and he started to laugh. The great banana caper was spreading like wild fire through the Kalahari desert night. The best we could come up with for an explanation was that Janet entered the house, walked in, left the door open for a split second, a monkey ran in behind her (one group of residents left the windows open in the kitchen once and monkeys came in and took EVERYTHING while they were at work), sprinted around the corner and into the kitchen, leapt up onto the counter, set its little poopy bum down on the counter while it grabbed the two bunches of bananas and then bolted for the door before Janet could turn around. Plausible? Possible. We all wish we could be a fly on the wall to actually witness what really happened. We are still waiting for confirmation from Shumi that she just didn't come over and take them. But, secretly, we all hope that it was the monkeys that did it. I mean, how cliche can you get? Monkeys love bananas. 💩🙉🙈🙊💩
--Adrienne

Haha, monkeys stealing bananas, classic case. I also frantically checked all the rooms in the house to make sure a renegade monkey was not hiding out somewhere. Nope, no hiding monkeys. Janet also texted me that she was going to come back and kill the monkeys because they'd never repay us the bananas haha.

What What:
There are some amazing phrases in Setswana and Botswanan English. We have honestly not learned a lot of Setswana because it is very difficult, and we almost never see it in writing, only hear it. We have at least learned the standard greeting, "dumela," which you then follow by Mma (woman) or Rra (man) depending on who you are greeting. People greet us with the phrase "dumela mma" all the time, and they seem to appreciate when we use this greeting, as well. When I was first reading The No. 1 Ladies' Detective Agency and saw the character "Mma Ramotswe" written out, I had thought Mma was maybe a shortening of "mama," or "madame" but now I know it is like both "mrs and miss," and the way you say "mma" includes an exaggerated "mm" sound. Similarly, for Rra, you roll the R, as you do with most R's here. To agree with someone you say either "emma," or "erra," which I delightedly did while ordering pizza over the phone.

There are some other phrases that I truly love. First and foremost, "no matata," meaning "no problem." We use it all the time. Or, as one nurse pointed out our psychotic patient the other day, "matata in the head." I also love the phrase "now now." In Botswana, there does not seem to be a great deal of hurry. Even in the hospital, things just do not move at the speed at which I am used to certainly, but even the speed at which they sometimes truly need to move in an emergency. Hakuna matata. In Botswana, if you truly want something to be done quickly, it is best to emphasize by asking for something not now, but now-now. "Now" seems like it could mean anywhere from within an hour to a day. "Now now" seems to mean within 30 minutes. It seems like they might be missing the phrase "now now now," which might mean "run and do this immediately." Lastly, the final phrase I will share is "what what." These words come at the end of a list and mean, "et cetera." Example used in a sentence: there are so many things we could do this weekend: bike ride, go on safari, take pictures, what what.

The old Scottish missionary church in Molepolole

We got treated to a rainbow on our ride home yesterday. For the most part, it is dry and hot, but we've gotten rain showers about once a week. This was a double rainbow that at one point stretched across the horizon.

Another Week at the Hospital:
We had a pretty good week at the hospital. We know how things work now, for the most part, and we have friends there, especially the medical officers and interns on our ward. This past week, I was assigned my Quality Improvement week, meaning I was given a project to work on instead of directly working on the wards. I worked in the office with the program's research assistant inputting and (my job specifically) correcting/summarizing data about patients' diagnoses on hospital discharge. The research assistant is good at her job, but she has no clinical training, so was unable to draw conclusions about patients' diagnoses. It was sometimes not the most exciting project, but it was pretty interesting to learn a bit about why people get hospitalized here. The biggest reasons, from my non-scientific counting in my head: TB (pneumonia or extra-pulmonary TB, often in the setting of HIV), bacterial pneumonia, gastroenteritis, heart failure, chronic lung disease exacerbation, meningitis. There were more suicide attempts than I would have initially guessed. Adrienne took care of a girl this week who drank paraffin (i.e. kerosene) because she was being abused at home. She is doing fine now, but it's a really sad situation, not sure what social services are like here. There is also a fair amount of stroke, diabetes, and uncontrolled hypertension. Not many heart attacks, which is weird because we do see strokes, but maybe that gets diagnosed as something else, or those patients go to the surgical ward? I'll have to ask about that.

This week I also remained in charge of the TB ward, which is thankfully very quiet. It had a range of 1-2 patients while I was there. Some patients who are diagnosed with TB can be treated as an outpatient if they are not very sick, but others who are sick remain in the ward until their sputum is no longer positive for AFB (test for TB on microscope). There is a robust TB monitoring system for outpatients with direct-observed therapy in patients' communities. It's quite good.

With Sampson! He's our local friend and our cab driver. He doesn't drive us to the hospital and back (the program has a hired driver especially for that task), but he drives us everywhere else if needed. His car could really use "Pimp My Ride," with Xzibit. Too bad they don't film in Botswana!

Adrienne and I are going to get ready for a weekend spent at Madikwe, a nearby game reserve in South Africa! I'm sure I'll have many pictures and stories to post at the end of our stay!

Botswana 6: Hakuna matata

Hakuna matata? "It means no worries!" That is what our cab driver and local friend, Samson, perfectly said when we questioned him as to the meaning of "hakuna matata" in Setswana. Samson usually tells us, about 10 times per 5-minute cab ride, "no matata, no matata, not even one!"

Sunset in Gaborone

No Matata: Work
This past week, work-wise, has been waaaaay better than the previous week. I have a much better sense of what to do and sort of how to get things done, though it is still ridiculous. For some patients, it's very similar to the U.S. For example, on Thursday, the intern and I admitted a woman in her 70s who presented with new-onset hypertension (in hypertensive urgency, BP at clinic was 238/110, whoops) and new-onset diabetes. We talked about anti-hypertensive regimens and tactics in controlling diabetes both acutely and coming up with a chronic management plan. She did well overnight, and we discharged her the next day. Easy-peezy. They largely have the same medications here as in the States, at least for hypertension and diabetes, at least the same classes of medication. It's similar for heart failure, which is also very common, but in much younger patients, generally.

I am becoming increasingly comfortable with treating patients with HIV/AIDS and/or TB (though I am honestly barely competent, certainly no expert). I have seen more patients with these diseases in the past two weeks than I have seen in all of medical school and residency combined. This past week, in addition to working on the female medical ward (Adrienne is on the male medical ward), I have also taken on the task of rounding on the TB ward. The week started with 3 patients, but I discharged one patient on Monday (she was being treated for pulmonary TB, waiting for her sputum to be negative and hence she is less contagious and free to go home), a second patient "absconded" on Tuesday, meaning he left AMA, in other words, he just got up and left. This is not my only patient here to abscond ha. But, he left all of his belongings including a pair of shoes behind so we knew he'd be back. We ended up discharging him, anyway, since he was also better. The third we gave a leave of absence since he was mostly waiting for biopsy results, so he's going home for 5 days. And there we go!

Back on the female medical ward, we were very busy. The ward is set up with 4 "cubicles," meaning open rooms with 6 beds each and a bathroom. One nurse is basically in charge of the cubicle, but there are also a lot of nursing students around who help. There are also isolation rooms. Oddly enough, we had a heart failure patient in an isolation room and a couple likely pulmonary TB patients just out in the open. Great. They keep the windows open to prevent the spread of TB, meaning areas with good air flow instead of stuffy ones are better. Only people who actually test positive for TB go to the TB ward, and patients who also have HIV/AIDS are unlikely to actually test positive, even when they have the disease, because they do not mount as much of an immune response. So, there are multiple patients with TB not in the specific TB ward.

The patients are split between two interns and a medical officer. A M.O. is post-internship, but, like most doctors in Botswana, has not done a residency after intern year. If you do a residency, you are a "specialist," for example in internal medicine or pediatrics. Sub-specialists are virtually non-existent. Our hospital has no cardiologist, oncologist, gasotroenterologist, anything. There apparently is one radiation-oncologist floating around somewhere. Random. For things like a colonoscopy, we have to send a patient to the bigger public hospital in Gaborone, Princess Marina Hospital.

Ridiculous things happen all the time. It's generally not for lack of knowledge, sometimes seems to be due to lack of effort, hard to say, but most often, they are systems problems which no one solves. Until, that is, our attending comes around and cleans up messes left and right. He truly cares and knows how to get things done, but he cannot care for all patients in the whole hospital all the time. Here's an example of a ridiculous thing that happened this week, multiple issues piled up into one. I had a patient come in on Tuesday, a planned admission, easy I thought, to get a bowel prep before a planned colonoscopy on Thursday. I can do this! I've taken care of patients like this in the States! No big deal, hakuna matata! My optimism soon soured. First, I see that her hemoglobin upon arrival is 3.4. 3.4!!! Normal is 12! Her planned colonoscopy is because she has suspected colon cancer or other GI malignancy. She appears tired, but otherwise looks fine with a hemoglobin of 3.4, meaning this has gone on for a long time, and her physiology has learned to adapt to severe anemia. Okay, so the emergency department has already ordered her a couple units of blood (probably needs more than a couple units, but fine, ok start). I ask around, and she has not received them yet, even though she came in overnight. I check our computer system, which we use for labs and blood bank, it says in progress. Well, not really. So I call them up and they say, well, we don't have much blood available in the hospital, but I push back saying she is now tachycardic and hypotensive (true), so they say ok, ok, we'll send her blood this afternoon. Ok, great, I think. The intern and I talk to her a while longer, learning about her history of constipation and melena (not great when you're considering some kind of intestinal cancer). She has been admitted here twice in the past two months with hemoglobins of 3's to 5's, but she got transfusions which at least got it up to 7's and 8's (usually <7 is the threshold at which we give blood). Alright, so she's getting IV fluids, clear liquids to drink, and starting a bowel prep. In the U.S., in the hospital, patients are given a 4-liter jug the day before a colonoscopy and told to drink it prior to midnight, and given more if their stool is not clear. Not so here. I mix the prep myself using a 1-liter water bottle the patient was instructed to bring from home because we cannot provide bottles. She doesn't speak English, but using a nurse as a translator, I give her instructions for the day, and every hour or so, I make her sit up (which is a big deal since she is so tired from being extremely anemic) and drink a cup full of prep. She is so weak she cannot even hold up the 1-liter bottle. Not great. On the morning of her planned colonoscopy, she is shipped to Princess Marina Hospital. That morning, I was curious about whether she had ever actually received her blood. She had not. Argh! How is this possible?? Anywho, I hope that it would be taken care of at the other hospital. It was not. She was shipped back without having received a colonoscopy for 2 reasons: (1) her hemoglobin was too low, and they did not transfuse her there, either, and (2) they said she was receiving iron supplements, which could make her stool darker and affect the colonoscopy, which is baloney. Turns out, multiple problems with our blood bank (that my intern figured out; I was not notified over the phone). They did not have her type of blood, and they ran out of rapid HIV testing kits, so they cannot test the donated blood and therefore it's not safe to transfuse blood at all. ARGH! She was re-scheduled for a time in April. But now what do we do?

Sometimes ridiculous things happen in my hospital at home, too, but not the layering of multiple ridiculous things seen with this example. Or the more frequent ridiculousness, such as medicines or tests not being available. Sometimes, things are intermittently available, but it is so difficult to tell when. It does take a lot of work sometimes, even just giving the ordered antibiotics, because where are they? do we have them? It's hard to see from my perspective, where I am used to having things happen immediately. I get annoyed in the U.S. if there is a delay of an hour for antibiotics, let alone a full day, especially since this can make a definite difference. My attending is able to get things done quickly. When he heard about this situation and the lack of blood available here, he had her immediately transferred to the other hospital's emergency room so that they could start by giving her a transfusion (which was a resolution from hospital higher-ups) but hopefully so that she would also get evaluated again by their internists and surgeons. We shall see. I'm not optimistic any more about this case. The other hospital certainly did not do much for her before except deny her a colonoscopy. She's in a bad state, anyway, an older woman with likely advanced cancer. I think some of the allowance of poor care may be a defense mechanism, stemming from the fatigue of frequent system failure. Matata.

One of the biggest problems is that the financial year in the country (including health department) ends in April. We run out of supplies, and it's just too bad. More will be ordered in April. Note to self, do not get sick in Botswana in March. We have gotten some new supplies, though, so I'm not totally sure that this is an absolute truth.

Sporting my work fanny-pack outside the hospital

The hours are also interesting. The medical officer and interns generally work 7:30 a.m. to 4:30 p.m. with a one-hour lecture from 8 to 9 a.m. and one-hour lunch from 1-2 p.m. Note to self, do not get sick at this time. Every fifth or sixth day, an intern is on call for either the wards or the emergency department, but their call is very different. Their call is overnight, and if they are in the emergency department, they are there, admitting patients. For the wards, I do not totally understand what they do, because the admission notes and orders come from emergency, not the wards. I guess they get called in when a patient is acutely worsening? I'm not sure, I still don't understand. Either way, the place clears out of doctors at 4:30 p.m. It's strange. Note to self, do not get sick at this time, either. They also do not work weekends unless they are on call. No notes are written on patients over the weekend; no one rounds on them. Only the nurses take care of the patients. I told one of my interns that during our internship, we only get 4 days off for a whole month, no guaranteed weekends off, and she did not believe me.

Lunch! Greasy noodles or samp (corn stuff, kinda like hominy), fried chicken or stew chicken, and salad options (beets, butternut squash, cole slaw, or "chakalaka" i.e. spicy cabbage salad). Wash it down with ginger beer or Fanta. Delicious.

Roadside watermelon purchase! Adrienne with Lorato, the residency driver, who takes us from Gaborone to Molepolole and back every day. Also our unofficial Setswana language instructor.

Donkeys in Molepolole

Matata in the Head
So there are happy stories, too! We sent home a couple patients last week who had recovered from pneumonia or heart failure exacerbations, and they were doing great. My intern pretty much saved a young woman's life by diagnosing her with a particular pneumonia seen in HIV/AIDS (PCP) and starting treatment quickly. She's improved dramatically.

There are also ridiculous stories that are just strange. The medical officer cared for a patient who was clearly psychotic, so that was a fun distraction. It is also sad that she has this psychiatric disease, but it certainly kept things interesting. Apparently, over the weekend, she was getting out of bed at night and stealing food from other patients. One of the other patients did NOT appreciate this, and punched her! She would also wander during the work day, one time pestering my intern while she was on the phone until I asked a nurse to please guide her back to bed because my intern was very busy, ha. The nurse motioned towards her and told me, "matata, matata in the head." The last story is a little gross/horrifying, but gosh, you can't make this up. Another time, she was wandering around, reached her hand into the sharps bin (discarded needles and blades), pulled out a needle, and used it as a toothpick! ewwwwww! That was the last straw. She was clearly not safe on the medical ward and was transferred to the psychiatry ward later that day.

After work: No Matata!
I did not know what to expect of Gaborone. When I was in Ghana, I did not have any particular love for the capital, Accra. The author of the Lonely Planet guide I read also was not thrilled about Gabs, but then again, compared to the safari areas in the north, maybe it's not. Still, we have been having a lot of fun! We get back from work fairly late, around 6:30-7 p.m. (with a 9-10 p.m. bedtime). We either cook dinner, or go out to a nearby place. It costs around $6-10 (U.S.). We can walk there when we get home, since it's still light out, then we have our friend, Samson (cab driver) pick us up afterwards when it's dark. He has been the on-call cab guy for this program and for another residency program out of UPenn (they work at Princess Marina Hospital) for years. He lives nearby, so it's a win-win. It's great having someone almost always ready to pick us up (if not, he sends his brother), and he has consistent business. Plus, he is a delight. So, where do we go out to dinner? The News Cafe down the block, attached to a hotel, has salads, burgers, and Mexican food that's pretty good. We went to a Portuguese place last week as a good-bye to one of the residents leaving. Awesome. Most restaurants are at the mall. Adrienne and I excitedly discovered a cheap Thai place. Go figure, but really good.

Last night, Adrienne and I met up with the parents of one of her friends from a previous trip abroad and a few of their friends, who have a beautiful home outside of Mokelodi, the closest game reserve. It was about 30 minutes away, but totally out of town and in the bush. We had a great time at this braai (barbecue in Botswana and South Africa).

Kgale Hill at sunset

We are planning this weekend and next. We're staying in Gaborone this weekend. I have to prepare for a presentation next week for the interns. We're hoping to go to a craft market and maybe another game drive at Mokelodi. Next week, we are trying to plan a trip to Madikwe, a game reserve in northern South Africa, I think 1.5-2 hours away. Just 2 more weeks of work before our vacation up north!

Botswana 5: Losing the Gabs Half-Marathon

So far in my life, I have run 3 half-marathons: Dexter-Ann Arbor my M1 year of med school, Detroit my M2 year of med school, and Ann Arbor in March of my 2nd year of residency. My time was by far my best in the Detroit Half-Marathon, somewhere around an hour and 45 minutes. Never before have I signed up for a race with just 4 days notice.

After going into the Ministry of Health Professions Council in Gaborone on Wednesday, to complete our orientation and our registration as physicians for a temporary Botswana medical license, while driving home, Adrienne and I saw a sign for the Gaborone Half-Marathon. We were a little too far away to see any of the details, so that night, we googled it. Of course. Well, the official website said that there was a race this Sunday (today), but that registration had closed on February 28th. It also said to check their Facebook page, so we went ahead and did that, and lo and behold, they were accepting registrations until the next morning at 8 a.m.! They said to register online. Only problem, there was no link from the website... Hmmm... after a little more digging on the Facebook page, there was a link to register directly from there! So, we went ahead and registered, but could not figure out how to pay. Adrienne emailed the coordinators, who said they would accept payment at the race number pick-up on Saturday. It turns out, people were even registering on the day of, haha, strict deadlines.

Even before racing, Adrienne and I had started running about 3 miles a night whenever we got home earlier, which, last week, corresponded to the two days we did not have to go to Molepolole. I'm not sure how we'll manage to keep up on work days because we get home so close to sunset. To complete our preparation, we went for a nice walk on Saturday morning and ate a lot of pasta, which we washed down with "Energade," a knock-off Gatorade. We went to Airport Junction Mall, about 20 minutes away, to pick up our race packets. This mall was also the start and finish line for the race itself. They also offered a 5K and a 10K, but Adrienne and I decided to go all out.

Early, early this morning, we set off with our trusty cab driver, Samson ("no matata," which means "no problem"), at 4:45 a.m. to make it to the start line for our 5:30 a.m. planned start. Well, we were about the third people to arrive ha. The coordinators were still setting up signs. So, we tightened our shoes, fastened our race numbers and chips, and tried to get warm. When we met, it was about 55 degrees and dark. About 120 people signed up for the half-marathon (21K), my best guess according to race numbers I saw. A lot more for the 5K and 10K, though these races started after ours. At 5:40 a.m., we gathered into the starting pen and took off! There were a fair amount of women running, almost half, and only a few other foreigners. There was a lot of representation from a Gaborone running club called "Striders." At this time, it was still dark, and light was just beginning to shine on the horizon. The sun rose at 6:15 a.m.

At the starting gate, ready to go!

Racers gathering

In looking around at our competition, we could tell that we had absolutely no chance. There were not many truly amateur runners, only a few. There were some who had clearly trained with their running club, then there were some crazy-good runners, which made me wonder if their national team runners participated. We quickly settled toward the back of the pack within the first few kilometers. Every now and then, someone who had arrived late to the race would pass us, including one incredible runner who was kicking his heels and making great time. He was a contender. Adrienne and I, for several kilometers, were in last place! We laughed as we realized we were losing the race.

Sunrise in Gaborone

There was one man with whom we were neck-and-neck for a while. As we passed him one time, he told us that he was an asthmatic who had forgotten his inhaler! A medic was on the way, apparently, but we still did not feel particularly proud of ourselves for passing him. He passed us a bit later and stayed ahead for a while, but we eventually passed him for good around 13 kilometers. I do not think he finished. There was another woman in a bright pink shirt who was occasionally walking (like we were, mostly at the water breaks every 3 kilometers). She was within our line of sight the entire way, keeping us going as we hoped to eventually catch her. That's mostly who we saw for the grand majority of the race! That's it! the rest were far ahead. The people who had signed up to race had been in it to win it! There were not the hoards of amateurs like there are at American races.

The race was mostly flat, except for a couple of "fly-overs" a.k.a. bridges/overpasses. The sun came up in earnest at around 8 km, just over one third of the way there, and it got very hot. We did a pretty good job hydrating and got water at every station, but that sun was beating down and eventually my mouth tasted the dust. The ground here is red clay with a layer of sand/dust over top. For the most part, we were running right on the road, which they had marked with cones, but they had not closed the streets, so in a couple busier areas, we ran instead on the sidewalk so as not to be so close to the cars, especially since the field had thinned out so much. By about 14 km, an ambulance was passing us, stopping, then following us, clearly under instructions to clean up any stragglers. They may have picked up asthma man.

Almost done! 16 km complete!

Finally, there were 5 km to go. My left hamstring was really starting to feel tight, and the sun was beating down. I was about ready to finish. Adrienne does not run as frequently as I do, so she preferred to do more of a walk-run method, but with my hamstring hurting, I just wanted to stay in my stride and finish. I looked ahead to the girl in the pink shirt and told Adrienne I was going to go for it and pass her. Within probably half a kilometer, I first passed a man in a black t-shirt who had fallen behind, but smiled when we exchanged hellos. Finally, going over the last fly-over, I passed the pink shirt, smiled, and said "almost!" which she repeated back to me. As I thought I had reached the turn to the finish, marked by cones and race officials, it turned out, we had to run a bit further and around to get to the finish line! It was tough, but it did give me the opportunity to pass two more people! I would have been more excited, but it was a man with a knee brace and his buddy, ha. Not exactly much to be proud of. As I finally hit the home stretch, I pumped my arms as I crossed the finish line. To my surprise, pink shirt was ahead of me! What! She explained that she could not take the last bit past the expected turn, she just needed to finish. I grabbed some water and watched Adrienne finish! The ambulance and a police man on a motorcycle followed her for the home stretch, hahaha, what an escort!

Adrienne crossing the finish line! Note the ambulance on the right.

We did it!

We celebrated our completion of this task with a big breakfast at one of the restaurants at Airport Junction Mall, which is quite nice. We laughed at how this race felt different from our previous races, but what an experience! We unfortunately did not get race t-shirts, which they did not have this year because, as one of the coordinators said, "our sponsor has disappointed us," but we did get Gabs 1/2 Marathon medals to commemorate the race. Pretty awesome day!

How I felt at the finish

Gabs 1/2 Marathon Finishers

Botswana 4: The Upside Down

Whoa. First week of life in Botswana and first week of work at Scottish Livingstone Hospital in Molepolole, Botswana is complete. It has been somewhat disorienting.

This is not my longest, farthest, or most remote travel experience, but it is my first south of the equator! I remember watching The Simpsons, and Bart's fascination with the water in the toilet flushing in the opposite direction, but the toilets here pretty much flush straight down with no swirling. I'd be lying if I said I wasn't a little disappointed haha. It is, after all, a complete myth based on the actual fact that hurricanes and cyclones swirl in opposite directions. Still, if I think about my placement here on a globe, near the tropic of capricorn (23 degrees south of the equator), and in Michigan (near 45 degrees north of the equator), I can imagine myself standing straight up and standing close to perpendicular from where my friends and family stand in Michigan, plus the difference in longitude. It's dizzying to imagine, sort of like trying to figure out how to be helpful in a foreign hospital with a very different culture, both medical and social, than my own.

Molepolole, or Moleps in the cool local lingo, is a town Northeast of the capital city of Gaborone, where we live. It takes about an hour and 15 minutes to get there due to traffic both in the morning and in the evening when we travel. Gaborone is busy with streets commonly 4-lane boulevards (divided) and frequent traffic lights or roundabouts. We take the A12, a mostly 2-lane highway to Moleps. The drive is quite pretty with farmland on both sides and frequently donkeys, goats, or cows along the sides of the highway. There are faraway hills in the background, but the drive itself is totally flat, just like Gaborone. Molepolole is smaller and less modern than Gabs, but it still has multiple grocery stores, a KFC (which is huge in southern Africa), and both concrete strip malls and tented makeshift stalls. Wikipedia tells me the population of Moleps is about 60,000 people. We have a driver, Lorato, who takes us there and back. She drives the residents (3 of us right now, 2 internal medicine and one ob/gyn), the global health fellow, and our attending. Lorato herself drives the program car in to Moleps, takes a bus back to do other things during the day, takes a bus back, then drives us home! We leave at 6:15 a.m., start work at 7:30, have usually an hour break for lunch from 1-2, finish around 4:30-5, and get home by 6:30. Work hours are less than usual, but it does end up being a long day.

Open land, likely for cattle grazing, on the drive between Gabs and Moleps

Scottish Livingstone Hospital (SLH) is a regional hospital in Molepolole that sends referrals to a hospital in Gaborone, Princess Marina Hospital, if needed. For example, we sent a 20-year-old with severe renal failure (creatinine 21) there on Friday to get dialysis. SLH is a very nice-looking hospital from the outside. It has organized wards. For internal medicine, there is a male medical ward, a female medical ward, and a TB ward for anyone with a confirmed case of TB (sort of loose definition, it seems, because we have people on other wards with very likely TB). The TB ward is smaller with 4 patients currently, and they get a bit less attention. I don't think anyone who is very sick goes to that ward, but I'm still figuring out how things work.

The main entrance of Scottish Livingstone Hospital

The stalls where we buy lunch. We get a starch, meat, and "salad" for $1.50.

My goals for this experience are to learn and hopefully to teach. I'm still trying to best fit into a role on the wards, but it is quite difficult. I am on the Female Medical Ward this past week and next week, and Adrienne is on the Male Medical Ward. There is a Medical Officer, one per ward, who is sort of like a resi-tern. They take patients on their own and are supposed to oversee at least to some degree all of the patients on their ward. Medical Officers have completed medical school and an intern year here. Intern years consist of 3 months each per rotation of internal medicine, pediatrics, ob/gyn, and surgery. We also have 2 interns on each ward. The interns have received variable medical training. In the last ten years, Botswana opened its first medical school at The University of Botswana. The interns I have had from here are excellent. Some interns, however, have to travel as far as China and Russia for medical school. They have to learn the language and culture there in addition to learning medicine, and that is a lot. Medical training here starts right after high school. At University of Botswana, they do 1 year of pre-med studies and 5 years of medical school. So, that's the medical officer and the interns. There is an attending (or global health fellow) on each ward, and then there's us. They frequently but do not always have American residents rotating here, and while there are residencies starting in Botswana, there are no residents yet at SLH. So, we are an extra support person, ideally acting much as we do in the United States. I am accomplishing the learning portion of my goals, but only occasionally adding to the teaching portion. I am hoping that gets better as I learn more about how things work and get more comfortable contributing.

Someone told me that SLH has been referred to as an "empty hospital." The building looks great, but it does not have the equipment one might expect for how it appears. It somewhat feels like that now, especially because we are at the end of the fiscal year for the health ministry, meaning that in April, new supplies are ordered, but for now, we have to make due with what we have. For example, the hospital only has a few, expired 'blue top' blood tubes for labs, which are the coagulation labs, including INR. This is a test we use to monitor patients put on warfarin aka coumadin, a blood thinner frequently used to treat blood clots (DVT, PE). Right now, we cannot put any patients on warfarin because there is no way to monitor its safety. Instead, everyone is put on enoxaparin, which is ok, but it is an injection instead of an oral tablet and more expensive. Aiyiyi. Our ob/gyn colleague also informed us that last week, the hospital ran out of pregnancy tests! I can't imagine. The Upside Down. In terms of studies, our hospital has xrays and ultrasound. One out of the two ultrasonographers can do DVU scans looking for blood clots in the legs. There are no echocardiograms, CT scans, or MRIs. We do bedside echocardiograms with an ultrasound we borrow from the radiology department. For CT or MRI, we have to send patients to the hospital in Gaborone.

The patients we see in the hospital are generally quite sick. Of the general Botswana population, 25% are infected with HIV. There is a robust public health program for monitoring patients and making sure they have access to drugs commonly used to treat HIV, anti-retroviral therapy. Of our hospital population, it seems like about 75% have HIV because many of them are hospitalized for complications from AIDS. On my ward, there are patients with different opportunistic infections related to AIDS, seen when CD4 counts are below 200 or below 50. I have two women with CD4 counts less than 10. There is also a fair amount of congestive heart failure. It is in younger people than we see usually in the U.S., two in their 30s. I have also had patients with acute renal failure related to dehydration plus likely medication side effect, seizure in the setting of prior stroke, and asthma exacerbation. With these patients, I feel that I can be more helpful since their problems are so much more familiar to me. We have about 15 patients on each ward at a time.

Around 4:30, the day tends to wrap up. This is the time the other staff (and most businesses in Botswana) go home. There are nurses who stay overnight, but there is not a night float system like we have in our hospital, and only one intern stays on call for both wards overnight. It's my understanding that they sometimes stay home for call, which seems kind of confusing. I'm still learning more about their training and their responsibilities. Overall, there is much less of a strict watchful eye on patients here. On weekends, too, there is only the one intern on call for both wards. We get our weekends off, but so do the rest of the doctors. An attending, I think, is available over the phone but not always in the hospital? I think? I'm not totally sure. There are still doctors in the Emergency Room, who do most of the work of admitting a patient, including writing their admission orders, but they may not get seen by an internist until Monday if they are admitted Friday night. The medical culture here is a lot to get used to.

Driving home, hills in the background

I will write more tomorrow about what we do when we are not at work or driving to work. Tomorrow, the plan is to run a half-marathon!! Haha, Adrienne and I saw a sign on Wednesday for the Gaborone Half-Marathon, so we googled it, then registered! Today, we picked up our race numbers and paid $20 for our registration, so we're officially in the race haha. I am sure it will be my worst time yet, as I have previously run 3 other half-marathons. It will be an experience, to be sure. The bummer, though, is that they do not have race t-shirts! They were supposed to, but as the woman at registration told us today, "our sponsor has disappointed us." Oh, well. Still, wish me luck! My goal is just to finish, ideally in under 3 hours, haha, not a very lofty goal this time around when 2 of my 3 previous half-marathons were under 2 hours.

Botswana 3: Kgale Hill and Mokolodi

We arrived in Gaborone, Botswana! We were greeted at the airport by the logistical coordinator of the program, Janet. She helped us get settled and checked in. Immediately I was struck by how different things seem here than my last visit to sub-Saharan Africa. I went to Ghana in 2007 where I stayed mostly in a smaller town, but also went through the capital, Accra, for several days. Things in Gaborone seem, in a word, better. The city does not seem as crowded. The streets are cleaner. It does not take far to get out of town and see open fields. There is a large nature reserve just 30 minutes from our house. You can drink the water! I couldn't believe it and had to be told a couple of times that it is okay before I filled up my water bottle from the tap. It seems a little unfair to compare to my experience in Ghana because that was ten years ago, and a lot can change in that time, but overall, Botswana (at least what I have seen thus far in Gabarone) seems to be a richer country with a smaller population localized mostly in the Southeast portion of the country, so more services can be provided per person, at least in this area. I think things will be different when we head out farther or see patients from more rural areas, but, whether based on fair or unfair assumptions, I am surprised by how things are generally very nice. The people are very nice, too, but this was not a surprise.

Speaking of nice, our home is very comfortable. We have a nice, neatly furnished house/condo we share with all visiting residents. It is part of a condo complex of 14 total, and there is a wall and gate separating us from the road outside. Our area of town is called 'the village.' There is also a little pool at the condo complex! The global health fellow and his wife live nearby. In the house, there is a large kitchen that opens into a dining/living space on the first floor. Upstairs, we have 3 bedrooms and 2 bathrooms. Adrienne and I are sharing a bedroom. There are 2 air conditioners, one downstairs and one in our bedroom. Plus, there is wifi. A few weeks ago, they lost power from a big storm, but everything is up and running now. There are 2 other visiting residents, who will be leaving in 1 and 2 weeks. They told us a little bit about what to expect when we start at the hospital, and it is going to be hard work, potentially frustrating and confusing at first.

We arrived on Saturday and spent the day getting acquainted with where we live. We went to the grocery store and loaded up on some essentials. Prices are not that different than in the States, and the store had just about everything an American store would have, though low-fat milk was harder to find (but still available). We met Janet and Lorata, who will drive us to the hospital every day. We also met Adam, the global health fellow who lives a few houses down in the same complex, and his wife, Connie, an occupational therapist trying to volunteer at the hospital but struggling through some of the bureaucracy of getting licensed by the health ministry. That night, Adrienne and I cooked ourselves some curry spiced chicken (there is a fair-sized Indian population in Gaborone), and went to bed, glad to be settled in our home for the month.

We woke up early the next morning to meet Adam and Connie for a hike up Kgale Hill, a public park and the tallest point in Gaborone. Most of Gaborone is totally flat, but there is one big hill at the southern end of town, and a few other hills in the distance. It is about a 15-minute drive from our house. At some times, it is not totally safe to climb the hill as there have been some muggings, mostly of expensive cameras, but on Sunday morning, there were families, athletic-looking hikers, and folks finishing exercise before church. There is one main path that splits into two: a mostly concrete path with a gentle slope and steep path involving scrambling up rocks. We took the steep path up and the gentle slope down.

A view of the hills from a city roundabout

Halfway there! Looking towards nature and nature reserve

Scrambling up rocks to the finish! I think at this point we were "45%" there.

It took us about an hour and a half to reach the top, where there is a sign denoting that we are 11,000 km from Beijing and 10,000 km from Dakar. There were also inspiring signs painted on rocks along the way like "64%" (oddly specific) and "tired." We were greeted with a "you made it" sign at the top. According to Adrienne's fit bit, we climbed 83 flights. According to Wikipedia, it is 4,222 feet in elevation, and in Setswana its name means "the place that dried up." From the view up top, we saw all of Gaborone. We could also see the reservoir behind the Gaborone Dam. Apparently, the reservoir has not been 100% full since 2005 until just recently in the past few weeks. Adam said that when he first arrived in January, it was only 16% full. In fact, that day was declared a national day of thanksgiving to give thanks for the rain. By the way, the currency, the pula, is the Setswana word for rain, so if you get paid, you truly are making it rain. I was also surprised by how much land you could see that was undeveloped. Some of it was nature reserve, but most of it was nothing, just land.

The reservoir! view from the top

At the top of Kgale Hill

After our climb, Adam and Connie took us to one of their favorite restaurants, Sanitas. It is a nursery close to the dam that also has a cafe. The plant life was quite beautiful. I also cannot believe how good the food is compared to my experience in Ghana. I was worried that I would not be eating many vegetables, but with safe water, it is no problem. They also have really good cheese (another thing I craved in Ghana). For example, at this restaurant, where we saw expats and Botswanans alike, I had a scone with cream, lemonade, a side salad, and a sandwich with spinach, mozarella, and red peppers. Unbelievable. Compared to fufu in Ghana, I am not worried at all about eating well and eating healthy foods.

In the afternoon, on the recommendation of Adam and Connie, who we are now calling our camp counselors, Adrienne and I went to a nearby nature reserve, Mokolodi. It is a privately-owned reserve just 30 minutes drive from our house. They have most of the big animals, but our guide, Eddie, made no guarantee that we would see any of them. Fortunately, we did! Adrienne and I went on a game drive with just 3 other guests, including a strange woman from South Africa who kept asking why we could not get out of the jeep to approach the animals. Eddie told her that approaching a giraffe would be a "death sentence," because of their kicking abilities, haha, nice and clear that Eddie. She protested, "I thought they were gentle!" Ohhhh, boy.

Looking for hippos (we didn't see any today)

We first saw a herd of impala followed by a few males in their own group, growing stronger with likely plans to one day take over the breeding herd from the current alpha male. The alpha changes frequently with impalas, as keeping a whole herd of females and youngsters safe is an exhausting job. We saw two other types of antelope, a waterbuck, which has a white circle on its backside, and a kudu, a large antelope (second largest) that can jump up to 3 meters aka about 10 feet! We saw a couple of Lion King characters; warthogs (Pumba) including a baby one and a hornbill (Zazoo)! The hornbill was squawking on a tree as we drove by. Eddie was either uninterested or sped by too quickly to notice. Eddie did find us some zebra hidden amongst some trees. You would think that their stripes would make them easy to spot against a mostly green backdrop, but their stripes make them blend into sticks and tree branches. Finally, our favorite find of the day was seeing giraffes! We saw one male up-close, about 10 feet away at closest, before he walked across the road and hung out eating some leaves in a great position for viewing. He had dark spots, which means he is older than 10 years. Giraffes live to be about 20 years old. We then drove to a look-out spot, and we could see 2 more giraffes! Their white ears were visible over the tree line. They were probably about a quarter-mile away. Overall, a very fun first game drive!

I see you, Zebra!

Seeing a giraffe walk is other-wordly

"Eatin' some leaves with my spongy tongue!" They can eat from thorny trees because the thorns pass through their tongues without causing damage.

In the evening, we hung out with the other residents, who were returning from a weekend safari, ordered a pizza, and got rest for the upcoming week.