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.
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.
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.
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.
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.
I love these updates. Will you have a chance to visit the hospital in Gaborone that you are sending some of your patients to? Also - interesting to hear how supplies and medicine is rationed.
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