The Elusive Black Rhino

Last weekend we decided to go to the Khama Rhino Sanctuary for the weekend.  I have been there many times since it is in Serowe (where I used to live), but I had never spent the night.  A group of 12 went up and we stayed at the wonderful chalets that they have.  There was also a great tree for tree climbing (as you can see above ;)

A really pretty ?grasshopper and a Daddy ostrich with babies

We went on a game drive on Saturday afternoon and saw plenty of wildlife.  We told our guide that we really wanted to see a black rhino since none of us had ever seen one.  In the sanctuary there are 35 white rhinos and only 3 black ones.  The black rhinos are also harder to spot as they eat from bushes so stay in the dense parts of the park while the white rhinos are grazers eating grasses in the more open areas.  He was on the look-out and managed to find many other things, but no black rhinos.

A lilac breasted roller in flight.
They have the colors of the Botswana flag under their wings, something I never noticed before

We even saw one of the oldest rhinos in the park.  Apparently, you can tell by the length and the straightness of their horns - the longer and straighter the horn the older the rhino. Above is a mama and her baby.  After 2 hours we returned to our chalets and began to prepare for the brai (South African way of saying barbecue).  I wanted to make roasted potatoes, but realized we had forgotten to bring oil.  So I headed to the restaurant (a few hundred meters from our chalets) to see if we could borrow some.  They were nice enough to let me have a small cup of oil and I started to head back to the brai.  As I stepped out of the restaurant I saw a black rhino staring at me!  I shouted to the others to bring the cameras and watched as the rhino tapped on the edge of the pool which was covered.  He was rescued as a baby, so is more used to humans than the other rhinos in the park and has grown accustomed to drinking from the pool outside the restaurant.   One of the park staff members came to remove a section of the pool covering for him and we watched as he stuck his head in the pool and drank.

I offered him some oil as well, but he was not interested ;)  After he finished drinking he began to walk towards us so we scattered.

We followed behind him for a bit and at one point he turned around looked at us and then sprayed the area around him to mark his territory.  It was quite entertaining.

We returned to our brai and had a great feast which included a nice fire on which to roast s'mores!

Long Time

Celebrating my birthday with karaoke night and great friends 

Has it really been more than 2 months since I have written a blog post?  Wow time is flying!  At the end of November I went back to the States since my mother was having her foot reconstructed (after 6 weeks on crutches she is now happy to have one foot free of bunions and neuromas), celebrate my birthday, and Thanksgiving.  It was great to see family and friends and stock up on some of my favorite supplies (M+Ms, esp the mint ones, peppermint patties and black beans ;)

In Khami Ruins, near Bulawayo, Zimbabwe. 

One of the few remaining walls at Khami Ruins.  The royal family apparently lived on elevated rock walls on top of the hill (anything they could do to make themselves appear better than the common folk....)

The month of December flew by with a trip to Bulawayo, Zimbabwe over Christmas to see a beautiful national park, rock paintings, and ruins of an ancient civilization (Khami Ruins).  I celebrated New Year's Eve weekend in Cape Town which was a lot of fun as it is one of the most beautiful cities ever!

New Year's Eve in Cape Town! (thanks to Alexis for picking out the perfect shirt ;)

I feel like I wrote about these trips since all the pictures are on facebook, but I guess I never did.
I still cannot believe that January is over, it feels like the new year started yesterday.
I have also been doing some work ;)  I am still learning a lot from my patients.  Here are a few interesting stories.
B.C. is a 17 yr old who is doing really well on his HIV medications.  He always has good adherence, his virus is suppressed and he was a seemingly uncomplicated patient.  When I saw him at the end of December he said he had no issues, his physical exam was normal and his blood work looked good.  We talked about school (he is in Form 5, which is the last year here) and he said it was going okay, but that he wasn't doing as well as he wanted to be doing. He has been getting Bs (which is considered excellent here, esp at our clinic where most patients are getting Ds or Cs).  I told him about the tutoring program which we recently started to help kids with their school work since many of them are doing poorly and spend a lot of time at the clinic waiting for the doctors, medications, etc. He was excited and we agreed that he would meet the volunteers coordinating the program that day.  As I was printing out his note he said "you know I actually have been feeling kind of empty recently."  I turned around.  "What has been going on?" It then came out that he has been feeling depressed, has tried to commit suicide (he tried to drown himself in the bath tub) and is having a terrible relationship with his older brother who is his primary caregiver.  After several hours of discussion, involving our clinic psychologist, calling his aunt who came in (when I called her at work she dropped everything and came right away - she had sensed something was different, but did not know what to do and he had not told her anything), we worked out a safety plan.  He said he was feeling a bit better having told people and both he and his aunt felt that he could be safe at home.  He came back the following week and was feeling better having spent the Christmas holidays with his family in the north of Botswana.  He is now coming several times a week for tutoring, has brightened-up considerably, and has really formed bonds with the volunteer tutors.

I also got some sad news.  B.R. the very sick 10 month old whose house I went to back in Jan (see "Inreach" Jan 29) and who a few months later went missing has died.  We tried our best to track down the family last year, getting the local social worker and even the police involved, but we were unsuccessful.  This week our in-reach team was finally successful in contacting the mother's boyfriend who told them that the child had died.  We do not know what happened and still have not been able to contact the mother (according to her old boyfriend she does not have a cell phone) and get her care.  It is incredibly sad to know that B.R. most likely would have been fine had she been able to get her medications.  But unfortunately medications only work if you take them and sometimes there is no way to get that to happen.

Other times we are more successful.  P.S. is a 6 yr old who was admitted to the wards in January with severe pneumonia and Tuberculosis.  At an outside hospital they asked the family for permission to test for HIV and the parents declined.  However, since it was medically necessary to know, the hospital sent the test anyway and it came back positive.  The child was very sick so she was transferred to Gaborone.  When she arrived the team disclosed the positive diagnosis to the parents (it had not been disclosed at the outside hospital) and the parents were quite upset with the fact that the child had been tested despite their objections.  The reasoning was explained to them, but they refused to believe the diagnosis and refused to have her retested.  The ward team spent a lot of time with the family and the child recovered from her acute illness but they were still unable to convince them of the HIV positive status and need for treatment.  So they sent the family to our clinic for further counseling.
The nurse manager and I spent 2 hours trying to explain things to the parents, get them to consent to re-testing (so they could believe the diagnosis) and get them to test themselves.  The father (and culturally he spoke for the mother who refused to make any decisions without him) was adamant that no tests be done and wanted to have the opportunity to take the child to a church in South Africa to pray for her.  He is a primary school teacher and did have a basic understanding of HIV and said that he did not believe that praying could cure HIV, but he wanted the opportunity to pray for his sick child.  After much discussion and talking with the wards team it was agreed that the family would take the child to South Africa for the weekend and then return to the wards to have further discussion.  When the family did not return to the clinic as expected the following Monday we called the father who said he was still not ready to have the child tested.  However, he eventually did bring the child back to the wards that night.  Further discussion reveled that he thought that I (and the rest of the doctors) were on a mission to prove that his child was positive for research purposes (though we had never mentioned research of any kind).  So our social worker (whom he had not met and did not associate with the clinic) spent 5 hours with the family trying to come up with a solution.  At that time we had gotten the child's CD4 count back and it was 20 (showing that she was incredibly immune suppressed and needed to start treatment ASAP).  As this issue was quite urgent, they told the father that they might have to involve the police and what little child protective services there are here if he did not agree that the child needed treatment.  At that point the father took the child and the mother and stormed out of the hospital.  We were all worried that we had lost them and were planning to contact the police to try to find them.  However 24 hours later, the family returned.  The father had taken them all to a local testing center and they had all been tested and came back positive.  He brought the results to the hospital ward and apologized to the ward team for not believing them.  The next day we started the child on medications and the parents will go to have their CD4 count check to see if they need to start as well.  It has only been a week, but so far it seems that the family is giving the medications well and we remain hopefully that things will continue to go well.

So things are not always what they seem.  Sometimes the "stable" patients are actually the ones who need the most help and the ones who you think will never see the light eventually come around.  Of course, there are also the times, as in the case of B.R., when despite all of our best efforts we cannot reach an acceptable arrangement.  And I have also re-learned that sometimes patients just need time to come around and feel in control of the situation.  And of course gained even more appreciation for the importance of a team approach.