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!"
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.
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.
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).
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!
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!
Great stories - and to think it's only a sampling of the things you're seeing there. I had to take a moment after reading about the patient that picked her teeth with something out of the sharps bin. I mean Adrienne sometimes picks her teeth with a steak knife and that gives me the willies.
ReplyDeleteKeep us updated on the absconded patient - will he ever come back?
Excited to hear more about your time at the hospital and your upcoming presentation. Thanks for sharing!