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.
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.
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!
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!
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