HIV in south africa

a paradigm which has shifted my clinical reasoning and permeated all of my hospital experiences here: HIV/AIDS. last week, the results from a survey of the human sciences research council (HSRC)'s "national HIV prevalence, incidence and behaviour study" were released -- and were all over the headlines and radio here in south africa. this survey had last been done in 2008, and the current results were incredibly striking. i'll get to the details in a minute. first, a little history.

in my first post, i referenced the lancet's series on health in south africa. the third article in this series explores the epidemics of HIV and TB in the country: "in 2007, south africa, with 0.7% of the world's population, had 17% of the global burden of HIV infection." when i talk about rounds at edendale and suggest most patients have HIV, i'm not exaggerating. particularly in kwazulu-natal province, the prevalence is astronomically high, and this has had major, major implications in all aspects of healthcare (including the previously discussed concomitant TB co-epidemic). the province of kwazulu-natal has been disproportionately affected which undoubtedly has much to do with the large population of black Africans here living in poverty, an unfortunate, ongoing after-effect of the apartheid government.

how did this happen? the early history of HIV in this country is not dissimilar from the US: although the early epidemic was focused in groups of men who have sex with men, IV drug users, and those requiring blood transfusions, in the late 1980s and early 1990s, there was an exponential increase by heterosexual transmission. in south africa, from 1990 to 1994 alone, the prevalence in pregnant women went from 0.8% to 7.6% -- which further climbed to 20.5% in 2000, 24.8% in 2001, and 30.2% in 2005. unfortunately, under the apartheid government (finally dissolved in 1994), HIV was stigmatized and labelled a "black disease." both the lack of education and the "migrant worker" lifestyle of much of the poorer black African population was implicated in the rapid spread (multiple partnerships). little was done by the south african government to control the epidemic during this time; their response has been described as being "marked by denial, lack of political will, and poor implementation of polices and programmes." it wasn't until 2003 that the government began to provide antiretroviral therapy in the public health sector. despite this, by 2006, mortality from HIV exceeded the incidence -- and south african life expectancy had decreased by almost 20 years.  

despite all of this, efforts are underway in an attempt to make a dent in this epidemic. huge scale-ups in condom distribution and education, HIV testing and counseling, and education about and adherence to treatment have been prioritized. standardized regimens have been created and are available almost everywhere patients are seen. today i had the pleasure of spending time in the "communicable diseases center" or HIV clinic (the name remains from a time when the disease was much more stigmatized), where there were two doctors available to see the 128 patients scheduled for routine visits to have their ARVs refilled.

these boxes with free packets of condoms can be found as frequently as purell dispensers at US hospitals.

clinics and hospitals (including edendale) are sites where people can get tested.

the standardized ARV regimens available for free through the government.

so, back to the survey. one of the biggest headlines: prevalence in the overall population of south africa had climbed from 10.6% in 2008 to 12.2% in 2012. young black African women accounted for the highest burden of disease (in ages 30-34, 36% are infected) followed closely by their male counterparts (in ages 35-39, 28.8% are infected). you guys, this is essentially 1 in 3 people. the survey also turned up that self-reported condom use had significantly decreased since the prior survey in 2008 -- in fact, more than half of all respondents reported never having used a condom. again, the burden was found to be highest in kwazulu-natal province. despite all this discouragement, the increased prevalence of disease in the population was felt to be in part due to new infections, but also secondary to the scale-up of the ARV programs allowing for more people to live longer with the infection. the report cited that access to ARVs has actually doubled since 2008.

so what does this all mean? in short, south africa is drowning in HIV. it's no secret that years of apartheid, denialism, and lack of government initiative for controlling the spread has left the country and its most vulnerable population miserably behind in this battle. programs are now in place to better educate and treat those infected, however these are still far from adequate.

despite all i've said, i've had the pleasure of meeting and working alongside dozens of highly-motivated, compassionate health-care workers at edendale who focus on chipping away at the epidemic by taking care of one patient at a time. in HIV clinic today, i met two dedicated doctors and a handful of their nursing counterparts who work tirelessly not only to prescribe medications, but also to provide ongoing education. theoretically, we all expect this, however watching it play out in practice, especially against such a formidable epidemic, is absolutely inspiring. what an eye-opening, challenging, valuable experience this has been.

until next time,
sharon

references:
Salim S Abdool Karim, Gavin J Churchyard, Quarraisha Abdool Karim, Stephen D Lawn. (2009) Health in South Africa 3: HIV infection and tuberculosis in South Africa: an urgent need to escalate the public health response. Lancet; 374: 921–33.

Shisana, O, Rehle, T, Simbayi LC, Zuma, K, Jooste, S, Zungu N, Labadarios, D, Onoya, D et al. (2014) South African National HIV Prevalence, Incidence and Behaviour Survey, 2012. Cape Town, HSRC Press.

on safari

believe it or not, things have gotten busy around here, and i apologize for the lack of the (over-ambitious) daily postings. my initial goal had been 2-3 times/week, so i'll settle for that. expect a little more about the hospital and HIV in south africa this week! 

this past weekend, marybeth and i had planned our most-anticipated trip: SAFARI! we opted to stay in st. lucia at a bed & breakfast recommended by several who have come from our group this year. st. lucia is situated just next to a large estuary and is over-run by hippos, crocodiles, and thousands of birds. it's also conveniently located about an hour from one of the biggest game reserves in kwazulu-natal: hluhluwe-imofolozi. 

orientation: our farthest trip from p-burg, almost to swaziland.

our safari started on saturday morning at 5AM! hardly a price to pay for what came next. our guide, simphiwe, picked us up at our hotel in st. lucia and we rode in the back of the open-air safari vehicle (basically a pick-up truck fitted with a platform/benches in the back) to the park. we arrived just as the sun was rising!

simphiwe, our guide, briefing us: "no hands outside the vehicle when carnivores are spotted!"

the safari itself is a pretty easy concept: sit, ride, and find wildlife! simphiwe had some additional tactics to aid in the finding part -- an extensive knowledge of animal tracks and droppings (the latter not pictured for obvious reasons, although less gross than i originally thought given most of the stuff we were tracking this way eats primarily grass).

fresh hyena tracks

we had a great day! the cooler temperatures of coming autumn, overcast skies, and relatively few people out meant that the animals were roaming around everywhere. going on safari feels initially a little bit like going to the zoo... but then you realize that everything is living in its natural habitat, able to avoid or interact with you at will, and not guaranteed to be seen. but how much more joyful than a zoo for these exact reasons!

rhino crossing!

herds on herds on herds of impala!

obviously we expected to see elephants, rhinos, giraffes, zebras... but we also saw lots of beautiful birds, antelope, and monkeys. the hilariously entertaining baboons were truly a highlight, as were the trees full of adorable vervet monkeys.

baboon road block. we seem to always encounter them crossing the road!

the vervet monkeys kept a close eye on us from the trees.

although we were really hoping to see a lion, we didn't. our guide reminded us they sleep during the day and often aren't seen. despite this, it was a huge highlight getting to see a beautiful adult male cheetah! it was almost by accident we found him; he was sitting quietly, scanning the savannah for lunch. simphiwe turned off the engine, and we all sat quietly admiring him. we realized quite quickly that he wasn't just scanning the savannah, but had actually spotted a group of impala, zebra, and wildebeest grazing a little ways off. we were then lucky enough to witness something i've only ever seen on wildlife programs: the cheetah carefully stalked, then chased his chosen prey! we weren't able to see the final outcome as they disappeared over a hill, but it was all so exciting.

such a beautiful, graceful creature.

luckily, i brought an african mammals guide along with me and was able to identify a number of animals -- although i didn't need the guide for our next friend. these guys are much bigger in person than i realized. and knowing they're unrestrained and you're only a few meters away in an open vehicle adds to the excitement. we saw a total of four different elephants throughout the day, and all were adult males hanging out alone. 

hanging out on his own, snacking on the trees

all-in-all, i somehow managed to take close to 300 (THREE HUNDRED!) pictures throughout the day. i'll never forget the warmth of the early autumn sun rising over the savannah, the brilliant and iridescent colors of birds and spiders, the sound of breezes rustling through the tall grasses... and the sight of so many majestic creatures in their natural (protected) habitat. suffice it to say, if you ever find yourself in south africa, i would highly recommend you carve out a day to spend on safari. i'm already trying to figure out how i can save up the money and time to bring my husband back with me someday in the (near!) future.

even the view without animals is, in my estimation, perfect

more from the hospital this week!
until then,
sharon

outreach visit to dundee

on the very first day at edendale, one of the consultants insisted that going on an outreach trip was a must. in fact, he made some calls that day to see if he could get a spot on the plane for the following day! although unsuccessful for that trip (the plane only has six passenger seats), i was lucky enough to be able to go this past tuesday to dundee. totally worth it! 

orientation: dundee is north of pietermartizburg, still in KZN province

so on tuesday my day started out early, just like going to edendale, waking up before sunrise. tiptoeing around in the dark with the just-prior-to-sunrise light streaming into the windows of our cottage... and then, as if in an instant, the rising sun creeps through the windows and bathes everything with golden light, reminding you it's the day and you must get on with things!

marybeth dropped me off at the airport where i waited in the arrivals area. the plane, a pilatus aircraft used by the south african red cross, cannot be missed. it's bright red, with a cheery propeller at the front, and streaks across the blue sky and green fields in no subtle fashion. when it arrived, i was ushered through a security point and then directly onto the tarmac. i'd never been on a helicopter or other small aircraft and found the whole thing a bit intimidating for the first time. i climbed the four steps into it and sat in one of the six seats in the cabin. i was promptly handed paperwork to fill out detailing my name, position, contact information... and next of kin. breathing deeply in attempts to loosen the gigantic knot that had formed in my stomach, i snapped my seat belt into place and re-focused my attention on enjoying the fleeting moment in my air travel career in which i would have both an aisle AND window seat at the same time.

the plane!

inside the plane, view forward standing next to my seat

the flight was surprisingly smooth. it was sort of fun having the cockpit open to the rest of the craft, listening to the pilots go through their routine of turning things on and off. we were instantly in the clouds... and climbed no higher. i'm not sure the altitude or speed at which we were flying, however i'm sure some sort of physics problem might be able to solve this if i were so inclined as we arrived at our destination, dundee, within 40 minutes. 

the view out my window: flying over the tugela river

as we approached dundee, it became abundantly clear that an airport did not exist here. no matter! one of the many benefits to taking such a small, nimble aircraft is that it routinely lands in fields. the pilots brought the plane in for landing, and then quickly took it back up again. we all looked at each other nervously. the pilots banked, made a loop, and came down in another spot landing the plane safely in the field. one of the pilots turned around, grinning: "sorry about that -- we didn't want to take out the the horses!"

popping out of the plane, a bright yellow kwa-zulu natal department of health vehicle appeared out of thin air. we were beckoned into it. it was at this point that i met dr. caldwell, a seasoned medicine consultant from edendale, with whom i'd be spending the day in his medical specialty (yes, specialty!) clinic at dundee hospital. 

entering dundee hospital.

dundee is a provincial hospital, and as i came to understand, only has "general" doctors. they provide first-line care to the patients in this part of the province, however if something becomes medically more than routine, they refer the patients to dr. caldwell's medicine specialty clinic which he holds on the first tuesday of each month. (in fact, dr. caldwell goes every tuesday and thursday on these outreach trips, holding eight separate medicine specialty clinics at eight provincial hospitals each month.) the clinics work on 'referrals' and thus every patient seen has a letter describing the nature of the problem, basic labs, XR, ECG, or whatever else is relevant. these letters are of varying help; one such letter stated: "dear doctor, please evaluate this patient. the trouble is most certainly with the heart." (and the referrer was right: the patient was a 14yo with syncope, palpitations, and the most impressive visible thrill and massively palpable impulse i've ever seen -- really almost no need for a stethoscope at all.) dr. caldwell would carefully re-hash salient points of the history, examine the patients, and help arrange either follow-up with himself at the next month's clinic or with specialists at a tertiary care hospital in pietermaritzburg (cardiology, pulmonology, etc). the patients were not dissimilar from those at edendale; the burden of TB and HIV/AIDS was overwhelming. even so, he saw patients with other medical conditions like pulmonary fibrosis, dilated cardiomyopathy, peripheral neuropathy, and heart block.

the clinic lasted for the morning and early afternoon, after which time the staff had prepared a light lunch and tea for us. it was charming, really, to be in such a simple hospital where dr. caldwell was clearly so well looked-after.

we met the pilots back at the field mid-afternoon and made our way back to pietermaritzburg. less smooth, however, as we were working against the weather on the way back: a sudden late-summer afternoon storm had rolled in. flying through the clouds, we witnessed a terrifically frightening lightning show off to our west and the fascinating view of rain showers from the side of the cloud. much to the improvement of our collective blood pressures, we arrived safely (on a paved landing strip!) at pietermaritzburg airport just before the heavens opened.

heading back to p-burg, xrays in tow.

the view on the way back: rain showers in the (not so far) distance

what an experience! obviously, the excitement of the flight itself is still at the forefront of my memory. beyond that, though, the trip was really illuminating. it's quite a position for dr. caldwell; he is able to primarily diagnose many conditions and help coordinate care for these individuals, many of whom would otherwise go undiagnosed and/or treated. not only that, but he is also able to have ongoing therapeutic relationships with patients he cares for through the recurring monthly clinics -- the continuity being something so many of us in internal medicine value greatly about our career choice. it was a pleasure being witness to this unique program and involved in small ways.

cheers!
until next time,
sharon

2nd weekend: relaxing on the coast

first of all, if you read nothing else in this post: the eastern coast of south africa is an underrated, perfect vacation spot and you should all go there. probably tomorrow. 

this week's trip: orientation

after only a short drive of 1.5-2 hours, MB and i arrived friday afternoon to the bewilderingly lovely colonial masterpiece that is fairmont's zimbali lodge.

drive up to the reception

our room overlooked the vast coastal forest which blankets the land down to the indian ocean. the ecosystem here was quite different from the savannah/bush where we're staying at the lodge. we were instantly warned about the vervet monkeys who lived on the property: much smaller and gentler than their baboon cousins, however wickedly smart and able to get into the rooms (for snacks!) if you left the balcony door unlocked. i saw one briefly and mistook it for a cat; probably for the best or i might have attempted to play with it!

view from the balcony of our room

the property was quite vast and different buildings were somewhat isolated from each other requiring golf-cart drives between them; our driver the first night described the previous night's drive when he was stopped short secondary to a large python (of which he could see neither the head nor the tail as both were in the woods) completely stretched across the road. in case this wasn't enough, there was a full page in the welcome book in the hotel room dedicated to "what to do if you get a snake bite" which humorously began with "please phone the reception" followed by "remain as calm as possible." spoiler: we didn't see any snakes! 

what we did see: beautiful, beautiful things! we spent most of the weekend napping at the pool, reading, admiring wildlife, and even dipping our feet in the indian ocean. as many of you reading this in NY can attest to, the pool and/or beach and a temperature allowing for entering said bodies of water without developing frostbite is a sight for sore eyes this winter. all hail the southern hemisphere! genius! 

the site of most of this weekend's action

even in the peacefulness of it all, i felt like i learned a lot about this part of south africa and its wildlife. i'm a bit of an amateur photographer (all credit to my husband, Henry, who i miss dearly back in NY), and what you'll find that follows are my attempts at documenting some of the beautiful parts of nature we experienced this weekend. cheers, you guys! here's to another great week at edendale... and more adventures along the way!

until next time,

sharon

one of the many, many lizards we met. 

macro shot: beetle, ants, blooming flower. 

another macro shot: spiny caterpillar

the indian ocean: no swimming! (see: strong tide and sharks)

sea dune greenery

one more macro: seaweed washed up on the coarse sand.

the universality of sea and sand. can't beat it.

allocation of resources & teaching

it's been a few days' hiatus from the blog, however i assure you much has transpired despite the availability of the world wide web! for ease of reading (and writing), i'll tell you about a few days at a time here and in my next post.

last thursday was our first taste of rain and cool weather. this made navigating the outdoor wards a bit tricker, although a whole lot less sweaty for all parties involved. (hooray!) prior to catching up with the registrars for rounds, we accompanied dr. draper to the radiology department to make a case for a patient having a CT chest. 

visiting the radiology department

it was a pretty straight-forward request, really. 60-something year-old gentleman, long-term smoker, recurrent right-sided pleural effusion requiring chest tube drainage with suspicious-looking CXR. six weeks prior, when a CT chest had been requested, radiology had denied the request stating that because cytology had been sent from the pleural fluid sample, the results would need to come back prior to obtaining the CT chest. [at edendale, if you want an imaging study, you must fill out a "request form" for the radiologist and plead your case. the radiologist has the final say in who gets imaged. tests are not guaranteed to be done.] after six long weeks, the cytology came back: negative. nobody really believed it; certainly his story, imaging, and clinical signs were still quite suspicious. cytology is notoriously low yield anyways, and it was a head-scratching decision to have waited for its results until the CT was obtained. 

armed with this information, we followed dr. draper into the head of radiology's office. he pleaded his case on behalf of the patient. "his diagnosis has already been delayed six weeks," draper reasoned. the radiologist faltered: "can't you send off some kind of tumor markers or something?" the discussion continued; after almost begging hand-and-knee, the radiologist relented and gave the patient a CT chest spot THREE weeks in the future.
although we occasionally have our issues getting imaging done at columbia, this was certainly shocking. a timely article in the health section of this week's mail & guardian (south african newspaper) addresses the frustration of regular south africans who need outpatient imaging tests, and unless they have oodles of cash lying around, have to wait two months to obtain them (and still pay a fee!). i'm still learning about the south african healthcare system, but it seems to be similar to many others throughout the world where there's a huge chasm between public and private; those that don't and do have money.

the interminable wait for imaging

afterwards, we headed out to the con wards (outdoor wards i previously described) for rounds.

the walkway to the outdoor wards

i've really enjoyed rounding with dr. draper. he has a strong clinical sense and excellent bedside manner; he looks at patients as a whole and then focuses on specific points of their care to teach the team. interacting with the staff throughout the open wards, you get a sense that he holds respect from them as well. he speaks a bit of zulu and is religious about organizing the paper charts (carries a small stapler and portable hole-punch with him!). he is an excellent role model for the registrars here and undoubtedly has a strong impact on the tone of care on the wards.

a medical ward: windows open, breezes crossing through, nurses hard at work

the variety of diagnoses i'm exposed to on a daily basis is staggering. i find myself often asking, with eyes wide, "does that present that way? how often do you see that? wow, i had no idea..." i feel very lucky to have this opportunity; even if i never see these diseases or presentations going forward in my career in the US, the experience of growing my clinical experience and ability to think "outside-the-box" of typical cases is invaluable.

 oxygen at a patient's bedside. open wards don't lend well themselves to wall oxygen points.

an aside: for those asking about whether or not marybeth's black cloud stowed away on the plane to africa... i think she might have left it at milstein. (can anyone confirm or deny?) i can proudly say that we haven't had any patient care disasters occur that are exceedingly different from the usual here. so... WHATEVER YOU ARE PRAYING, KEEP PRAYING. :)

====

after the rain and cool temperatures of thursday, we woke up to absolutely gorgeous skies on our drive to work friday morning. although i am not a morning person (not even a little bit), it's been a lovely experience driving to work at sunrise. on the left side of the road. with cows and pedestrians and things. but seriously!

clouds, mountains, and cars coming up at you on the wrong side!

on friday, we had prepared teaching for the department's current hoard of clinical medical students! our topic was ECG reading, one specifically requested by the group. MB had rustled up an old powerpoint, and we put some cases together to make things more applicable to the patient population. after morning report (which on this particular day was a very positively-toned M&M conference), we swiped a projector, computer, and screen. MB manned the powerpoint, and i took the whiteboard to jot salient points as we went along. our conclusions? medical students everywhere are the same: totally smart, hilarious, and easily overwhelmed. (plus, who doesn't love the shouts of 'atrial fibrillation!' and 'V TACH!' in a south african accent?) we resolved to meet again next friday for CXR reading.

after teaching, we gathered with the residents for what they call "tea", but was really indian-themed catered lunch in the morning report room (dominican friday, columbia?). this was one of the best opportunities we've had so far to just kick back and chat with the registrars and interns about life in general. we chatted about the differences in our medical education systems, then transitioned to where we should go on safari. and oh, that roti. mmmmm.

roti friday!

we had a low-key afternoon of helping out with technological things (helping to set up video-conferencing... not sure how we got picked for this task, but it worked out on the end!) before we packed ourselves into our little left-sided toyota corolla and headed for the dolphin coast. could really get used to this mini-vacation-every-weekend-thing.

until next time,
sharon

day 7: adventures in N95-mask wearing

after a fairly uneventful (but eye-opening) first day and an (unfortunately) eventful second day, marybeth and i entered edendale on wednesday without a sense of expectation apart from our eagerness to continue to learn and experience new things! today proved to have a theme which will likely permeate through most of our days here: tuberculosis.

what do you know about TB? at columbia, many of us have seen at least a handful of cases of TB in our immigrant population. did you know that according to both CDC and WHO, TB is one of the world's deadliest diseases? they estimate up to 1/3 of the world's population is infected; that last year alone, ~9 million people became infected and 1.3 million died (www.cdc.gov). the most recent US data: 9,945 cases in 2012 (3.2 cases per 100,000 people); over half of these cases (63%) were in foreign-born people living in the US. in south africa, 1% of the entire population contracted tuberculosis in 2009: 139,468 (949 cases per 100,000 people). additionally, there is >70% co-infection rates with both HIV/TB (HIV being a topic for another day; >30% of south africa's population is infected with HIV, the highest rate on the entire continent). in south africa, specifically kwa-zulu natal province (where we are located), multi-drug resistance (MDR) and extensively drug resistant (XDR) TB have emerged and are huge problems; this has much to do with late detection and incomplete treatments. (www.un.org/milleniumgoals/aids.shtml).

it is within this population that we work each day; although stuffy & claustrophobia-inducing, we don our N95 respirators religiously in the hope that we won't inhale too many tuberculosis bacilli to become infected ourselves. today's morning report case was a fairly common case: a young gentleman with weight loss, cough, and upper lobe findings on his CXR for whom the overnight medicine registrar could have diagnosed tuberculosis in her sleep (and might have!). the reason it was presented at morning report was not to highlight a rare diagnosis (as we do at columbia), but to solidify for interns and registrars the management of sensitive, MDR, and XDR disease. i was absolutely fascinated; for me, this was not solidification of knowledge, but a whole new realm to explore. (i'm sure the budding ID specialist in me helped with the fascination part; some of you might be nodding off now...)

morning report today: pretty routine (for edendale) case of pulmonary TB. if you look closely at the board, the discussion surrounds MDR and XDR TB -- what they are and their risk factors.

as if to highlight the above discussion, we spent the day with several registrars in the triage area of what is usually the medical outpatient department (MOPD) which was closed from the day prior's sewage leak. we encountered at least 5-10 patients with either confirmed or suspected TB. one gentleman seemed to highlight the above discussion too well: a strikingly cachectic zulu-speaking man in his 70s, perched on a wheelchair, a simple face mask placed haphazardly over his face whilst he coughed heartily around it without regard to his neighbors. on review of his chart, he had been diagnosed the prior year, prescribed therapy, and promptly stopped taking it for unclear reasons. he presented to the clinic on this particular day for what he described in as many words as blood-streaked sputum. did he now have MDR TB? maybe (although we joked he may not have even taken enough of the therapy initially to induce this). how many people might he have infected over the past year coughing, coughing, coughing not on therapy? likely many. the registrars admitted him to reinitiate therapy, and we all kept our N95 respirators snug on our faces for the next few minutes... uneasily taking them off sometime later knowing that TB particles can remain in the air up to 6-8h after they're coughed there. 

posters all over the clinical areas act as reminders of the MDR drug regimen adopted in south africa.

although pulmonary TB is a commonplace diagnosis here, extrapulmonary TB is equally as common with varying sites of infection, especially given the high prevalence of co-infection with HIV. already, i've encountered patients with miliary TB, massive pleural effusions requiring chest tube drainage, scrofula (tuberculous cervical lymphadenitis), several cases of TB meningitis, and a fontal lobe tuberculoma. another clinic patient this morning was evaluated for gastrointestinal TB; i'd expect more pott disease (spinal), however the lack of availability of imaging likely limits this diagnosis and it may be more prevalent than can be identified.

looking forward to learning more about tuberculosis this month -- and the multi-faceted approaches to start controlling the epidemic. here's hoping my N95 stays snugly on my face and my fascination doesn't lead to seroconversion!

until next time,
sharon

day 6: settling in & a few hiccups

thought you all might enjoy a quick exterior tour of new workplace: 

driving in to the hospital. most signs are in both english and zulu.

just after coming through the front gates: new building being constructed (new ED, outpatient clinic)

driving around the back of campus for parking: great view of the main building.

another view of the main building. the trailer in the foreground is the iteach office which is home base for us.

our second day (tuesday) at edendale started in a very familiar way: 8am morning report! led by the post-call registrar (resident) or intern, the flow is fairly similar to any other morning report you might find yourself in: a case presentation followed by discussion. at edendale, the post-call intern or registrar typically presents an interesting case they admitted overnight. it's not typical to have any "admission labs" back at that point, and no imaging would have been available apart from radiograph films which could be viewed on the light box. the focus is primarily on the presentation, physical exam, and differential diagnosis; the discussion typically focuses on the management of the ultimate diagnosis.

morning report room. note the light box for xrays on the front table. no computers here!

at the end of morning report, an actual morning report (fancy that!) is given to the teams coming on to intake (call): number of patients waiting in the ED for beds, to be admitted, and any exciting overnight events. on this particular morning, the night resident also interjected that part of first floor of the hospital was completely uninhabitable secondary to sewage pipes having burst in the hospital overnight. (suffice it to say, we weren't the slightest bit disappointed to wear our masks today!) this rendered a large part of the ED, the waiting area, and a room where already admitted patients waited for beds (columbia people: think 'launchpad' patients all put in the same room!) completely unsafe for people. additionally, the operating rooms had to be closed. the medical outpatient area (MOPD), which had actually been without lighting for unclear reasons the prior day (clinics were being held in semi-darkness with flashlights!) would also have to be closed. so much for business as usual to get oriented to.

the ED: i had snapped this picutre the day prior to all the excitement.

as a result, the consultants (attendings) and medicine teams sprung into action and all descended on the inhabitable parts of the ED and waiting area. it was amazing to watch the surgeons, ER docs, and nurses all pitch in to help find places for patients to wait to be evaluated -- and to watch all the medicine teams work tirelessly to help triage patients as quickly as possible to ensure expeditious care for the sick. ward rounds had to wait. although it was far from a "normal" day at edendale, i quickly got a sense of the spirit of the place and the admirable efforts of the teams.

this appeared in the doctor's room sometime in early afternoon. (MOPD = outpatient clinic area)

getting better acquainted with members of the team and nursing staff has helped flesh out edendale hospital's motto: silwanezifo, silwanobubha, sinikaithemba (zulu for 'fighting disease, fighting poverty, giving hope'). it is a place of tremendous hope in a country struggling not only with the devastating disease burdens of HIV and tuberculosis, but the after-effects of years of apartheid -- a place where passionate, deeply-caring white doctors work alongside their zulu brothers and sisters, striving to mend broken relationships, all aiming for a common goal of bettering their community and ultimately their country. i consider it a tremendous privilege to be witness to this, even in small ways available to me... even on days the hospital is covered in sewage. :)

until next time,
sharon

day 5: welcome to edendale!

yesterday was our long-awaited first day at edendale hospital. 

waking up quite early, we left for the hospital before the clearing of the daily heavy mist-like fog which blankets the hilltop on which our lodge is situated. visibility was low, but surprise! in the short distance from our lodge to the front gate of the reserve, the thick, curled horns of african buffalo popped into view from the mist. they quickly scattered. our eyes now keen for animal-spotting in the mist, we identified several small monkeys in the nearby trees. i'm sure at some point this stuff gets old for south africans, but for us -- a constant thrill!

we arrived at the sprawling hospital complex shortly after 7am. lost immediately, we eventually made our way to the iteach office. we were greeted warmly and led to the main hospital building by sipho (who had met us at the airport) where we climbed the five flights of stairs up to the medicine department on the fifth floor (avoiding the elevators secondary to increased risk of tuberculosis transmission, although we had our masks on at this point. columbia colleagues -- our explanation of the 168th street 'tuberculator' rendered a hearty chuckle from sipho!) 

after spending a few minutes in morning report, we met dr. wilson, the soft-spoken & incredibly gentle head of the medicine department. he gave us a brief introduction to the hospital, followed by a quick tour of the hospital. he showed us the labs, several wards, and eventually landed in the ED. we saw and examined the patient who had been presented at morning report -- at that point the differential was a viral hemorrhagic fever vs. rickettsial disease (e.g. african tick bite fever). (ID GEEKS UNITE!) fortunately, the latter was diagnosed and the patient was able to go home with a short course of antibiotics. 

we spent the rest of the day rounding with drs. wilson and draper and their respective teams of registrars (residents), interns, and medical students. the hospital has a section of large open wards in one-story buildings connected by a network of pathways covered by sheet metal. each ward is roughly the same design: a large room with many numbered cots. a bedside table holds chart, xray films, pitchers of water; each building lined with large windows filling the space with light and louvered blinds allowing the breezes to blow through (although this is my assumed purpose for the open windows, i later learned they are primarily for airflow to decrease the transmission of TB). a few nurses dressed in freshly-pressed whites sit at tables near the front. the wards range in acuity: the two we rounded in were roughly equivalent to a regular medicine ward and then a more "stepdown" type ward (more oxygen points, lower nurse:patient ratios, greater care needs). 

a few observations from the day:

although we value our privacy in the US, there were some benefits to the open-type ward that i quickly appreciated. first off, rounds were completed at the bedside for every patient and exceedingly quicker -- you walked four steps to the next patient rather than to a room on another floor. because everyone could see the doctors rounding, there also existed a heightened respect of the doctors' work and a patience on the part of the patients until it was their turn. additionally, patients could be grossly observed at all times for any clinical changes and any needs -- no need for call buttons or waiting in an isolated room unattended to. obviously, there was a tremendous lack of individual privacy and heightened risks of infection transmission. even so, this type of ward seems to work efficiently here.

the variety of illnesses treated is somewhat different from the US, as is the approach to taking care of hospitalized patients. here, there seems to be a much greater emphasis on diagnosing and treating the acute illness. one of the reasons for this, quite simply, is that apart from HIV/AIDS and TB, patients here carry many fewer diagnoses of chronic illnesses. in the US, many of the "diagnoses" that we attach to patients are directly related to incidental findings picked up on labs or imaging. the allocation and availability of such tests are totally different here in south africa; for example, on rounds, an intern reported that an inpatient had an MRI scheduled in 7 days and nerve conduction studies scheduled in 14 days. these times are reflective of the standard time for such tests to happen and significantly limit the use of said tests in coming to diagnoses. although this does limit care in some important ways, it results in patient presentations lacking an extensive list of potentially misleading prior diagnoses that might cloud the judgment of the evaluating practitioner. i am not suggesting fault in our western system -- only highlighting what i see to be some of the benefits in a very resource-poor system. ultimately, i believe there's a balance here that lies somewhere between our two systems: using the appropriate tests and resources (not more or less) will likely lead to the highest quality efficient care. 

clearly these observations are my own and quite early in the experience; i'm sure my ideas and impressions with morph and grow throughout my time here. 

we made our way back to the lodge in the later afternoon after a really excellent first day. and... we finally met the property keeper, rob. we'd heard a lot about rob from others. he's quite a legend. and he lives up to all of it. rob pulled up in front of the lodge to greet us having had a long day building a pen of sorts for some of the buffalo. plying him with an icy cold coke from our fridge, we mentioned we'd love to see some animals... at which point, he offered to take us on an impromptu game drive around the property! we both hopped in the passenger seat in the front cab of the truck and we were off! according to rob, most of the animals are out at twilight -- and he was right. see pictures below for some of our new friends: we came across zebras, 'goliath' the large male giraffe, buffalo, a million and a half warthogs (including one of his pets, 'chop chop', although his other pet 'pumba' was nowhere to be found), two lovely white rhinos, some impala and other small deer, several eagle owls... and a long wait at a difficult-to-get-to watering hole for two hippos (who never emerged, although by that point it was almost pitch black out). ...and twenty minutes later we were back at our lodge. throughout the ride, rob told stories. fabulous stories. he's a bit of an animal whisperer by his own accounts and we're fully inclined to believe it.

looking forward to more adventures at the hospital and around the bush.

until next time, 

sharon

'chop-chop', one of rob's semi-domesticated pet warthogs!

zebras: much better camouflaged in their surroundings than i expected.

'goliath' really likes having his picture taken according to rob

yes, mom, we were that close! two female white rhinos.

sunset on the reserve. we love you, south africa!