Columbia Global Health Narrative Medicine: 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