Inreach

On Monday I saw B.R. she is now 10 months old and weighs 3.7 kg (the weight of a very large newborn and well well below what a 10 month old should weigh). She had disappeared from the clinic for the last 2 months and had run out of her medication for the last 6 weeks (very dangerous when you are dealing with HIV which can easily develop resistance). Her mother only came to clinic after one of the nurses had noted that she hadn't been around in awhile and called the mother begging her to come. She said that she had lost the baby's outpatient records (each patient here is responsible for caring around their medical records in a stack of tattered papers) so she thought she would not be seen.  We assured her that we would always see the baby no matter what. I wanted to admit the baby to the hospital for stabilization of her nutrition status, but her mother was worried about what would happen to the 6 other children at home. See here little children must be accompanied by a caregiver in the hospital. The nurses are not responsible for feeding, changing diapers, etc. I understood her point and given that they baby was not in significant distress (as this has been going on for months) I agreed to extremely close follow-up. I involved the clinic social worker, dietitian and several of the nurses. After 1.5 hours we had a plan and B.R.'s mother was in agreement that she would return to the clinic 2 days later so that we could assess the baby again and review the results of blood we took on Monday.

On Wednesday they did not show up. I had a long discussion with the nurse in charge of the clinic about where to go from here. We agreed that we would go to the patient's house on Thursday and see what the issues were. (At the clinic there is an "inreach" team that goes out to visit the homes of patients with complex social issues). We talked about the possibility of placing the child in foster care, as clearly the mother was having significant issues caring for her, but that is really hard to do in Botswana. The places that take care of neglected and abused children are full and have waiting lists. There is one emergency option that cares for babies for 3 months but it is really a last resort and when the child has a mother the mother must be taken to court and charged before the child is accepted. Admitting the child was another option, but she had been admitted for the same issues in October (though that time she was sicker) and nothing had changed about the home situation so the baby was back where she had started. We called the phone numbers she had given us but they did not work. Luckily we had the address though very confusing because there are no street names in addresses here, just an area of the city, a plot number, and "near the Total gas station," not easy to find.

On Thursday afternoon we rounded up a team. A driver from the clinic who knew the area where the patient lived well, one of the nurses and me. B.R. lives pretty close to the clinic. Once off the tarred road we traveled around several dirt roads looking at the house numbers until we finally found the one we were looking for. You really have to know where you are going as there did not seem to be much of a system to me. Our timing turned out to be excellent as B.R.'s mother was just returning home. I took some very discrete pictures of the neighborhood.

 

 From the front the house did not look too bad. But as we followed B.R.'s mother I realized that she did not live there. Rather behind the house were two other structures running parallel to each other, divided by a small alley. There were several doors and the one she opened revealed a very small room. In the room was a 3/4 size bed, a small bureau, and in the corner was the cooking area. With 4 people in the room it was very crowded. There was one window, no fans, and it was 100 degrees!  B.R. lives there with her mother and sometimes the mother's boyfriend.  Her siblings stay there on occasion as well, but they are often in a village outside the city with their aunt.  B.R. was on the bed with a family friend. She actually looked better than she had on Monday. Her mother showed us all of the medications which looked as though they had been taken. We reviewed how to give the medications and mix the special formula the dietitian had given her. She explained that she had not come to the clinic because she had to see the local social worker to arrange for the food basket (Botswana government's version of food stamps).One of the ARV medications was missing, when I asked her where it was she told me that it was in her landlord's refrigerator because it needed to be cold (seeing as she does not have electricity or running water that would have been impossible in her room).  She told us that her cell phone had fallen in water and no longer worked (that explained why we had been unable to reach her).  We talked for about 20 mins, I examined the baby, and we made a plan to see her in clinic. 

Visiting B.R's house made me begin to realize just how many obstacles she is up against.  I am still not sure if her mother will be able to care for her, but now I have a better understanding of why. I hope that she will make it back to clinic next week and maybe she will even have gained some weight!

Moremi Gorge

Waterfalls in Botswana?  In a country of sandy, dry, flat land the prospect of seeing a waterfall and mountains was very enticing.  I had heard of a place called Moremi Gorge near Palapye, of course it was not on any maps or road signs, so I made a trip to the Botswana Tourisim office in Palapye.  They gave me directions typical of those I have received since arriving in Bostwana: “Go down this highway here (pointing), turn right at the billboard with all the villages on it, drive down that road for awhile past the first sign to Moremi.  Turn right at the brown sign for Moremi village, take that road until it ends at the Kgotla [village civil court] and then someone there will help you.”  Okay seemed easy enough. 

We (Gelane, Dany, and I) set out on a hot Saturday morning (temp according to the car’s outside thermometer was 38C or 100 F at 10:30 am and promised to climb higher.  After a relatively uneventful drive during which we passed very few other cars or people, but many cows and donkeys, we arrived at the village.  There were plenty of houses (mostly traditional huts), many cows, and 2 boys sitting in the shade sharing an MP3 player.  The road we were traveling on ended at a building, which the boys informed us was in fact the kgotla.  But no one was there.  We asked the boys which way to the gorge, but they had no idea and said they did not speak English (though they did know enough English to ask us for money).  So we parked the car and set off to find some people.  After many false starts and many people who did not know what we were talking about, we finally found a man who knew.  He went off to find the manager of the kgotla.  She opened the building had us register, (the last visitors were a week before – no wonder they don’t staff the building 24/7), charged us an entrance fee (30 pula ($4.50) each and 30 pula for the car) and asked if we wanted a guide (another 30 pula).  Given the fact that when she pointed out the “road” to the gorge we questioned what had led her to call the grass with the faintest of tire tracks a road, we thought a guide would be a good idea.  She went off to find one and 15 min later brought back “Charles.”  Charles was a cheery guy with a nice smell of alcohol on his breath and very minimal ability to speak English, but we were not exactly in a position to be picky.  1.5 hours after arriving in the village we were on our way. 

"The road"

Charles pointed us toward the hills and, with me driving my trusty CRV, we set off for adventure.  After about 2 mins. we got to a dry riverbed with a relatively steep hill, I was skeptical but one Charles just kept saying “go” so I went.  The drive was a good test of the car’s four-wheel drive capabilities and it did amazingly well through the sand, rocks, brambles and amongst the cows.  30 min later we reached a point where we could go no further.  Thank god for Charles because there was not a single sign other than one saying “please don’t litter” randomly placed among the trees.  Parking the car among the trees we got out and began to hike, again with no trail or signs we were very lucky to have Charles. 

The landscape was like nothing else I have seen in Botswana.  We were among mountains with lots of lush trees.  We reached the first of the waterfalls without difficulty, though we were dripping with sweat the second we stepped out of the car and wishing that we had brought more than 3 (½ liter) water bottles. 

 “The waterfall” was probably one of the smallest I have seen and yet it was incredible given the landscape in the rest of the country.  A small pool had formed beneath it and throwing cool water on our faces proved to be very refreshing.  We sat happily for a few mins dunking our feet in the water, walking along the edge of the pool, and enjoying the cool breeze.  Then Charles informed us that this was only the first of the waterfalls we could visit.  He began to scale the rock face on one side of the pool and crawl along the edge of the rock. We were very skeptical, there was not much to hold on to and falling meant landing on pointy rocks many feet below but we had come for adventure so we crawled after him.

 Crawling along the cliff was not as bad as we had thought looking up at it and we reached the second waterfall without much problem.  We then climbed higher into the mountains scaling rocks and oftentimes having to swing our legs up one at a time to reach the next level, luckily we are all pretty tall and taller than our 57 yr old guide, so if he could do it….

 The view was amazing some of the prettiest mountains I have ever seen.  I even discovered Botswana’s equivalent to poison ivy.  One tiny brush with the leaves of this plant and you get a burning sensation unlike any I’ve ever experienced.  A min later there is a swelling (as if you have been bitten by a mosquito) with some surrounding redness.  But luckily, unlike poison ivy, the effect only lasts a few hours and there is no subsequent itching.  Of course after I screamed upon touching the plant Charles said “no touch that one.” Oops. 

Don't touch this one...

After the third waterfall we were beyond thirsty and Charles assured us that we could drink from the waterfall (after all it is a spring).  I was very skeptical, but it was nice and cool and the few sips I had did not cause any problems (and after a few days I can say this with confidence ;)  Ironically the only markers we found on the trail were at the top of the mountain – orange arrows pointing one direction or another with no discernable path to follow. 

After the third waterfall the path was completely covered and Charles decided that it was not a good idea to continue.  We were more than satisfied with all we had seen and anything he called dangerous was certainly not worth trying since what we had already done was “Go same” (Setswana for ok) and I thought it was questionable at points.  We made our way down carefully and all reached the car in one piece.  All in all, we had an amazing day and were wonderfully surprised to find such a beautiful oasis in the desert.

Disclosure revisited

This has been a hard week on the wards.  But there have been many rewarding moments as well. 

On Friday, I was able to discharge T.M. from the hospital after his month long stay to treat cryptococcal meningitis!!!!  We bought him a small puzzle and a card that was signed by all the PAC doctors (as we have all taken care of him over the last 3 months since he was diagnosed).  He was very happy to leave and excited (though a bit nervous) to start school on Tuesday. 

On Wednesday, the clinic was packed and the wards were not too busy; so I went over to help out in the clinic for several hours.  One of the patients I saw was an adorable 6 year old boy and we had one of the best clinic visits ever....
I asked him "why do you take your medications" 
"To keep my body STRONG!" 
"Has anyone ever told you about the masole (soldiers)?" 
"No"
"Well then I think Gloria (the nurse) has a good story for you."
"Story, yeah story.  Tell me the story" 
So Gloria tells him the story of the soldiers that are being attacked by the bad guy.  He listens very carefully and answers all the questions right. 
"My soldiers have big muscles" he says, flexing his biceps. 
Then just as we were wrapping up.  He suddenly says "AIDS, Aquired Immunodeficiency Syndrome!"  We were all very surprised, where had he learned that?  I asked him what it meant.  He said "AIDS kills."  We talked about how that is not the case if you take your medications.  And then he broke into song, which I cannot do full justice to in written form, but just picture a six year old singing this to a catchy tune.

"My name Lerato (none of these are his real name, he made them up) I am a solider. AIDS you CANNOT touch me.  I will kill you. (Setswana word that means) "to the ground". 
My name is Thabo, I am a doctor, AIDS you CANNOT hurt me, I will inject you, "to the ground." 
My name is Nametso, I am a lawyer, AIDS you CANNOT kill me, I will rule you "to the ground"

Gloria, the visiting resident, his mother, and I all cheered him on and he marched out of the room singing and flexing his biceps.   Luckily the song was over by the time he reached the line for the pharmacy, where it may have caused a bit of a stir if the other children had begun to ask their mothers what AIDS was.  I guess there are some children who are just ready to be fully disclosed to at an earlier age than we might think they are. 

Since this blog has no pictures; here are some pictures of our adventurous new year's weekend in Rustenberg, South Africa.  We went Zip Lining in the Magaliesberg Mountains.

The longest of the cables, where you could not even see the other end!

 Having fun on the trampoline at the hotel the zip lining was based out of.

I am heading to Serowe for the next two weeks for more outreach and mentoring, so it may be awhile before my next post.  Hope everyone is having a good start to 2010! 

The Wards

Where do I even start?  I guess to warn you that this entry is not for those who are hoping to brighten their day and to apologize for all the medical words (I will try to explain as much as possible)....

See last blog for a partial description of the hospital.  I forgot to mention that it is unbearably hot most days on the wards (of course there is no air conditioning or even fans and it has been around 35-40 Celsius (95-104 F) these days).  As a result, all the windows are open and so there are always tons of flies, it's a losing battle to try to swat at them...) Here are some stories about a few of the patients I've tried to take care of over the last week and 2 days. 

O.N was a 5 yr old diagnosed with osteosarcoma (bone cancer) in July and started on chemotherapy for 2 doses.  Then he never came back for chemo as scheduled.  He finally returned the day after Christmas with a now humongous arm (the cancer is in his left humerus) and respiratory distress.  A chest x-ray showed that his entire left lung was full of fluid, most likely from the cancer spreading.  The only pediatric oncologist in the country is a fellow PAC doctor and he was back in the States for the holidays.  So our team was covering all the oncology patients.  We tried to find a surgeon who would help us to place a chest tube to drain the fluid, but the one pediatric surgeon was not returning our calls and we could not find any other surgeons.  So Gelane and I decided to do a thoracentesis (procedure where you drain fluid from around the lung with a needle).  I did one thoracentesis in medical school, but it has been awhile.  So we read up on the procedure.  Then I acted as anesthesiologist (we actually had ketamine and versed!) and Gelane as surgeon.  We were able to drain a little bit of the fluid, but not enough to provide the symptomatic relief we had hoped.  O.N. tolerated the procedure well, sleeping through the whole thing. He managed to do okay on oxygen for the next 30 hrs until the pediatric oncologist returned.  Upon looking at the chest x-ray (CXR), the oncologist was sure that it was a spread of his malignancy and that the reason we were unable to drain more fluid was because what we were seeing on the CXR was spreading tumor.  After explaining all of this to the family, he worked out a palliative care plan for the patient.  Two days later, just 2 days before the new year, O.N. passed.  

T.M. is a 12 yr old with the greatest smile I have ever seen!  He was diagnosed with HIV 2 months ago when he was first admitted to the hospital for bad headaches and severe malnutrition (he now weighs what an average 8 year old would weigh).  It was discovered that he had crytptococcal meningitis (an AIDS defining illness in that it is pretty much never seen in patients with normal immune function).  At the time he was started on treatment for the meningitis and for HIV, he improved and was sent home on a prolonged treatment course.  He returned in early December and was discovered to still have residual crytptococcus surrounding his brain.  He was begun on an extended course of Amphotericin B (which we are lucky enough to have in Botswana) and after two weeks we did a repeat lumbar puncture.  Seven days later it is still not growing crytptococcus, but is not considered to be truly negative until day 10.  He, his incredibly devoted parents, and I are all keeping our fingers and toes crossed that it will stay negative and we will have finally rid his body of crypto.  He will still need to take medications for cypto for a long time, but at least he will be able to leave the hospital and do what he so desperately wants: to start the new school year on time on January 11!  Every day I give him several stickers and his huge smile in response, despite everything he has been through, makes my day.

My first ever call, before tonight, was on New Year's eve.  I was in the middle of skyping with my family when the pager went off.  When I called back, the voice on the other end said "we need you in the NNU (neonatal unit) there is a baby that won't stop bleeding."  In 10 mins I was at the hospital walking as fast as I could from one end to the other (of course the NNU is on the opposite end from the parking lot and in a country where land was not at a premium, the hospital is flat and the distances far.)  The bleeding had stopped but the baby had lost a lot of blood.  The blood bank was having trouble finding blood that the baby did not react to, but at last they managed.  The medical officer (MO) and I talked about the plan and I was getting ready to go home when the pediatric ward called to say that a child in severe respiratory distress had just been admitted.  Leaving the MO to finish with the baby, I went over to investigate. 

The admission was a 9 mth old baby.  His mother had tested HIV negative during her pregnancy, but had not been tested since until 2 weeks prior when the patient had been admitted for failure to thrive.  On that admission it was noted that the baby who had initially been normal weight for age, was dropping percentiles at each check.  As part of the work up they had retested the mother and found her to be positive.  This meant that the baby was at high risk of being infected with HIV, as the mother had gotten it late in her pregnancy and the baby had not gotten any prophylaxis.  The test for the baby (a PCR) takes 4-6 weeks and was still pending, so we were unsure whether the baby actually had HIV - however given all the signs I am 99% sure he did.  The baby had been discharged and was doing well at home until the 29th when he got a high fever.  The mother brought the baby to the local clinic 4 times in 2 days and each time the baby was sent home with Tylenol and some antibiotics. Finally the mother had enough and brought him to the hospital, but by then it was too late.  When I saw the baby he was working very hard to breathe, had signs of meningitis and was very tired.  We did some blood tests and a lumbar puncture, started antibiotics and oxygen, but it was not enough.  It would have been nice to be able to intubate him, but there is no pediatric ICU here and the adult ICU does not take children very often. The baby died 1 hr before the new year.  I can not even begin to imagine what it must be like for that mother and I have thought about her a lot over the last week.

There are many more patient stories....There is the 3 month old with a heart murmur and beginnings of heart failure who will have to wait at least 2 weeks for an ECHO since the one person who does them is not available until then.  The 6 mth old with focal seizures who cannot get an EEG because the one person who will do them is at the private hospital and the government has not paid him for the patients he has seen for the last year, so he is not seeing any more public patients for the time being. The 2 month old who had not gained weight since birth because there are 11 children at home and no one working, so there is not money to buy food.  The numerous children with measles (a disease I had never seen before coming here) as the country is in the midst of a measles outbreak.  And the list goes on and on.  There are more deaths than I have ever witnessed on a pediatric unit in the States.  And yet many patients do get better.  I am trying my best to channel T.M.'s happiness.  If he can do it, I can too!

Holiday Spirit

A few weeks ago when I was in Mahalapye the chief medical officer told me about a 14 year old girl who had come in with dysfunctional uterine bleeding, (in this case a very prolonged menstrual period causing her extensive blood loss).  Her hemoglobin was 3!  Dangerously low and she need a blood transfusion.  However, there is a nationwide blood shortage and the hospital was out of blood.  He called the two bigger referral hospitals and they said they also were out of blood.  I said "well I can donate blood right now."  In the States I try to donate every 2 months, but I had not donated since I had been here.  It turns out, I even had the same blood type as the patient.  However Mahalapye does not have a blood donation system.  They have no way to collect, test, or separate blood.  The blood donation process can only be done in the two referral hospitals, so that was not an option.  Miraculously, after threatening to refer the patient to the nearest of the two referral hospitals, some blood was found and they were sending it by car which was going to take about 4 hours, but luckily the patient was stable.
So last week when I saw the signs for blood donation at the Princess Marina Hospital in Gaborone, I went to donate.  Of course, I showed up at the end of work (4:30 pm) and they were just packing up.  However they told me I could go to donate the next day at the national blood donation center about 5 mins from the main hospital.  The next day was a slow day on the wards (more about that soon), so I went to donate.  It was basically the same procedure as blood donation in the States, but with less nit picking.  They do have a questionnaire about your habits, through after hearing that I had donated numerous times in the States, my "counselor" marked "no" for all the questions. They check your hemoglobin and your weight, and then voila they are sticking a 16 gauge needle in your arm while you hold the blood bag in your lap.

A similar sticker sheet full of millions of bar codes gets put on your bag.  At the end they take two test tubes of blood, as they do screen the blood for all the things we test blood for in the States.  Then you get the choice of fanta, coke, or sprite and you proceed to the couch where you find....

An entire package of biscuits and the largest Sprite I have ever seen.  I thought the touch of the sliver platter was quite funny.  Here women can only donate every four months (as opposed to men who can donate every 2 months, in the states everyone is eligible every 2 months).  The difference is that they are worried that women will be more prone to anemia because of menstruation; more of a worry here given the poor diet of many people here.  

Last week also marked my first week as attending on the inpatient wards.  I have been consulting at various local hospitals when I was based in Serowe, but now that I am spending more time in Gaborone I also will be spending some time in Princess Marina Hospital (PMH).  PMH is one of two referral hospitals in the country, and one of the few places where pediatricians staff the inpatient unit.  However, we do not have many pediatric sub-specialists, so us general pediatricians end up managing a lot of things specialists would manage in the States.  In addition to lack of specialists, we also don't have many of the things one would find in a children's hospital in the States.  We don't have child life specialists (people who help children deal with their feelings about illness and fears about procedures), there are no private rooms (the patients are in beds lining either side of several 3 sided rooms), there is no place for parents to sleep (and yet almost every single patient has a parent with them 24/7; they sleep in chairs or on the floor next to the child, or in bed with the smaller children.)  Parents provide a lot of the care in the hospital from feeding and cleaning their children, to reminding the nurse when the child's IV fluids have run out, to acting as monitors when the child is really in distress.  It can be a really dismal place.  But last week I noticed that someone had gotten the children to make wishes for the holiday.  

This Christmas tree was up on the wards with each little ornament reflecting the wish of one child.  Some were pretty unique..... 

Sorry for the poor quality photo, but it says "I wish my brothers liked (or he/she may have meant tickled since the first letter looks like a t) me every second"

 

While others seemed liked things kids in the States would write.  "I want to be a pop star," " I want an X Box 360," or the one above "I wish I had a TV in my room."  Unfortunately I don't think that Santa brought these children exactly what they wished for, but at least a local radio station did visit the hospital with some gifts around Christmas.

More stories about the wards in upcoming blogs, but I wanted to share one final photo. 

 He is one of the children I met in Serowe.  He did not want to be put down so he sat on my lap as I wrote notes and finally fell asleep in my arms as I read through one of the other patient's charts.  He was so excited to see his picture on the camera, that he could not wait for the photo to actually be taken!

Happy 2010 everyone!  I hope this year brings some health, happiness, hope, peace, equality, and the ability to experience small joys through the eyes of a child to all corners of the world!