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!

day 4: royal natal national park

on sunday, our second day in the drakensburg, we woke up to perfect sunshine. our plan was for hiking, although neither of us is much of an accomplished hiker. we drove to the visitors' center in royal natal national park just a few kilometers from our hotel. there, we decided on which trail to do (spoiler alert: we picked "easy"! double spoiler alert: "easy" was not easy). we spent the better part of three hours proving we weren't athletes. 

such exotic trees along our hike. MB demonstrating the endless uphill trail!

about halfway through the hike, we crossed a road and entered a separate trail that led to the bushman's paintings, ancient sandstone rock art. although we had previously been on our own, it was under these circumstances we met our guide, elijah.

the view behind us from the trail leading to the bushman paintings. difficult to focus on hiking with this view!

how can i begin to describe elijah? born and raised in the zulu community just north of the tugela river. he exudes a passion for his heritage, but also for his ongoing legacy. before we reached the summit of our climb, marybeth and i had already been taught (and rehearsed) the three types of clicks found in the zulu language, identified and admired several types of south african trees, and learned the colorful history of his tribe. elijah described how the park was one of the few left in the nation where local people served as guides on the trails -- and how important this was for attempting to salvage the years of unwritten history of his people through teaching hikers like us one by one. 

elijah, the constant teacher

elijah also spoke of the utmost importance of education in his own life while relaying his concerns about what he saw to be the abysmal state of education in south africa. we spoke specifically about the monumental problem of HIV/AIDS; how previous organized attempts at educating his people, the zulu people, about wearing condoms to prevent transmission had back-fired into gestures of cultural solidarity in NOT using them. he described how the government subsidies to new mothers/babies had also back-fired in a largely uneducated and intensely impoverished population: girls were misguided and encouraged to become young mothers in order to obtain these grants.

although our conversation topics were heavy, we reveled in elijah's candid nature, his unique gift for the spoken word, and the passion with which he seemed to live the entirety of his life. he described his spiritual life (in fact, he had just come from church to give us this tour), his bachelorhood, and his dedication to growing both his army of tour guides... and his youth soccer team. 

at the summit of our glorious hike, we found the cave paintings! many on lower rocks have been faded over the years (by tourists and otherwise), but the ones on higher rocks were stunningly detailed and fascinating. 

the cave paintings: each is a different species and meticulously colored.

i feel lucky to have chosen the hike to the cave paintings today: lucky to have met such a kindred soul here in such a remote, unspoiled place; lucky to begin to start learning about the state of south african from a south african. he offered a voice for a group of people who often do not have much of one.

our new friend, elijah.

on our drive out of the park, we ran into a few furry critters hanging out in the road. apparently these baboons have been a bit of a menace for campers, but we were instantly drawn in by the mom helping her baby cross the road. another big baboon had planted himself smack-down in the middle of our lane, likely in an attempt to help their crossing. i know i shouldn't play with wild animals... but aren't you just a bit tempted here? don't worry, mom. i stayed in the car. 

road block: baboon style

mom and babe crossing the road

we ended our day with our exceedingly beautiful drive back to pietermaritzburg (identifying the following delightful signage). cheers, for now, friends! missing you all dearly, but -- as i'm sure you can tell -- living quite a colorful life here until we meet again.

cows: next 3 km!

! goats !

day 3: arriving and first weekend adventure

and we're here!

our journey began early wednesday morning with a long-awaited drive to JFK airport.

me & marybeth, bright-eyed & bushy-tailed boarding our first flight in NY.

after just shy of fifteen hours, we arrived in johannesburg airport on thursday morning! our first impressions? colorful, bright, modern, clean. 

johannesburg airport, mural of subway tiles near baggage claim (makes us feel at home!)

we then hopped our commuter flight to the one-runway adorableness of pietermaritzburg airport! seriously, there is no baggage claim; some guy just carries your bags in from the plane. ours were sitting next to two boxes with live parrots. no, to pre-empt your question, they didn't say anything to me. 

sipho (from the i-teach program of whom we're guests) met us at the airport where he singled-handedly helped us pick up our rental car and allay our left-sided driving anxiety. marybeth was brave enough to go first! she did awesome, jet-lagged and sleep-deprived and all. she hit ZERO pedestrians, a true feat of heroism given pietermaritzburgers' seeming propensity to throw themselves into the street at the sight of a passing car.

marybeth: brave first volunteer in action!

sipho led us to a local grocery store to pick up a few essentials then onward to the lodge after that -- many kilometers outside of town in a picturesque hilltop on the way to albert falls dam. an idyllic setting full of blue and green and sunshine; sounds of crickets and frogs; smells of grass and wood and clean earth. upon entering the reserve, you drive around a hundred yards or so on a paved road, then take a sharp right turn into the grass. the bush, in fact. after another hundred yards or so, you arrive here:

our home for the month: is this place real? 

i could go into the specific details of the home, but suffice it to say the place works well for us and will be a great place for rest and retreat throughout the month. we've already met several species of (medium-sized?) african spiders -- creatures we have resolved to live with given their insatiable appetite for mosquitoes! after a deep and glorious sleep recovering from our day of travel, we woke up and met some of our neighbors: african buffaloes, a pack of warthogs (with babies!), four grazing ostriches, and a pack of some type of gazelle or kudu. hello neighbors, indeed! 

african buffalo ... and the little warthog on the right.
not pictured: the rest of the warthog family who quickly scurried off!

ostriches. these guys are way bigger than i expected. way bigger.

for our first weekend trip (we will have three total weekends here, all off work, all with small trips planned around the province of kwazulu-natal), we took a road trip up to the northern drakensburg mountains. the drive took about 2.5 hours, the last 30 minutes of which we carefully meandered up a narrow, curvy, mountainside road without guardrails, made even more difficult left-sided. even so, making it to our destination was totally worth it: mont-aux-sources hotel at the foot of the 'ampitheatre', an absolutely breathtaking rock formation in the drakensburg mountains. 

a map for reference: we started near pietermaritzburg and drove northwesterly.
the green patchy areas are all part of the drakensburg mountains bordering the nation of lesotho.

the view from lunch on our hotel's patio, ampitheatre in the distance. breath-taking.

we spent the afternoon exploring the mountains -- by horseback! marybeth is an accomplished horseback rider in a former life; i'm a bit of a few-lessons-when-i-was-12 sort of gal. despite the fact that the horse i was plopped onto went rogue and ran me through a few bushes, we had a fabulous time. (marybeth says i shouldn't worry, but given we're both headed into infectious diseases, i'm closely monitoring my arm wounds for any evidence of sporotrichosis.) but truly, it's hard to imagine a better way to view the valley and mountains than prancing through it all on the back of a semi-wild horse. 

helmet-ing and saddle-ing up! safety first, you guys.

mandla (our guide) and marybeth on their not-going-rogue horses. in all fairness, mine settled down about halfway through and resolved to stop trying to throw me off and just nibble grass instead :)

we're settled into our hotel for the evening (first taste of real wireless internet, quite a luxury here) and plan on hiking through the mountains tomorrow morning before heading back to the lodge for a good night's rest. we'll start at the hospital on monday morning and are looking forward to starting the rotation. more to come on our adventures.

not bad scenery in the rear-view mirror, eh?

lalani kahle, all!
(zulu for 'good night')

until next time, sharon

day -1

sawubona!
(zulu for 'hello')

as many before me from the columbia medicine residency program, i am headed to south africa to spend a month at edendale hospital to gain a wider appreciation of global medicine and try to help contribute in small ways to the medical education and training there. 

marybeth & i leave tomorrow morning, and we couldn't be more excited! we are frantically stuffing the last few bits of space in our suitcases with bottles of bug spray, purell, N95 respirators, and jars of peanut butter. we've signed our pagers 'out of hospital' in new york, loaded our kindles with reading material, and readied our hearts and minds for the excitement and anxiety of travel to an unfamiliar place.

to get oriented, i thought i'd start with a map. some of you may be familiar with cape town, one of the better known cities, located in the southwest part of south africa. we'll actually be in the opposite end of the country in the kwa-zulu natal province, located in pink just east of the nation of lesotho. in particular, we'll be close to kwa-zulu natal's capital city, pietermaritzburg, about an hour in-land from the coast.

prior to planning for this trip, i knew very little about south africa. i'm beginning to learn about the struggles, past and present, which have shaped this extraordinary country, and i'm looking forward to this knowledge being fleshed out when we arrive and submerge ourselves in the culture. given our roles on this trip, much of our experiences will focus on healthcare. recommended by our trip's organizers, i've found this series to be exceptional: The Lancet's Health in South Africa. i'll try to incorporate things i've learned from this series in future posts to get us all acquainted with our new home. 

ube nohambo oluhle!
(zulu for 'bon voyage')

until next time, sharon 

(Copied from an old blog http://cumcedendale.blogspot.com/ done between December 30th -- Jan 9th).

Thursday, 9 January 2014

Yesterday started with a typical morning of rounding in an under-served hospital with really sick HIV/AIDS patients.  The middle consisted of a shock back into the reality of modern medicine with a teleconference with Columbia presenting cases from South Africa.  The day ended with the slaughtering of 30 chickens, on a hill, at midnight...Let me explain.

Since the new interns have started, the chief of medicine has given small introductory lectures each morning.  This morning he discussed how the hospital came to be such a challenging environment to work in.  Its mission was always to the under-served, and in a place like South Africa, that seems equivalent to under-funded.  However when the AIDS/HIV pandemic hit South Africa in the late 1990s, the hospital was in the thick of the action, the patient presentations were novel, they were sick, the hospital was unprepared and not well funded and many died.  It became such a challenging, hard place to work that many doctors and nurses left thus depleting the hospital even more.  In fact, in the room with us, there was only one internal medicine physician that was present during the start of this pandemic that is still working at Edendale today.   Never-the-less outside funding finally came in, new staff were hired and it seems that most of the energy was directed towards the most dire needs, HIV/TB and complications from these diseases and not so much to systems improvement and expansion in the hospital.  Hearing the chief of medicine speaking about the timing of HIV, I finally came to understand how new this disease truly is.  

Rounds started and we were post call.  As we walked to the admitting area to see our patients it was a mess.  200+ people were in the waiting area (I had to put my N95 mask on early) and it was impossible to tell who were the patients, the family and the friends.    Yet somehow there was some order to the madness and thanks to the help of some well placed nurses we found our patients.  They were on cots, by the wall, waiting to be told they had a bed so their family member could transport them upstairs.  The first patient we came upon was the sickest.  She had defaulted on her ARVs, had the most profound cyanosis I had ever seen and likely had PCP pneumonia.  She had decompensated quickly since her initial evaluation and by the time we saw her in the AM, we all knew her prognosis was poor.  While the team moved on (they had to secondary to the sheer number of patients) I volunteered to get IV access, ensure her meds were given and watch her status.  It became clear by midmorning she either needed to be intubated or made comfort care.  Unfortunately an ICU consult was less than helpful.  They have only 6 vent beds for the entire 900+ bed hospital.  She was not a candidate for ICU.  She was too far gone and deemed not fixable. She passed by noon that day.   

In the early afternoon after rounds had finished it was my responsibility to present cases from Edendale hospital in a teleconference with the medicine residents at CUMC along was an ID MD and a pulmonologist.  As I presented numerous chest x-rays, cases on cryptococcal meningitis, TB and aspergillus I was asked about bronch capabilities (none, they are transferred out), pleural biopsy (yep…but booked for several months away and I doubt with VATS) and culture data (sparse, there is no official micro lab with microbiologists).  Hearing these questions, it again dawned on me how much the medical house staff and consultants are asked to do on a daily basis without the benefit of ever present specialists, diagnostic tests and rapid lab turnaround time.  How under-served and resource limited the hospital is and much they are asked to do, with less.

After conference it was time to go to Krista’s (the head of ITEACH and the person who helps set up my time in Edendale) for dinner.  On arrival I was greeted by her and the chief of medicine at Edendale and was asked a simple question.  Would I like to go with them at night to the middle of a township on top of a large hill to watch 15 traditional Zulu healers perform a traditional ceremony?  Ummm yes.  The two questions I had were:  1, is it safe?  Yes absolutely, no one in the township would dream of ever harming anybody associated with traditional Zulu healers.  And 2, what does this entail?  These traditional Zulu healers had been working with Krista and ITEACH on the acceptance of ARVS into the community.  These Zulu healers were branching out on their own to start a new ARV integration program where they would promote amongst other things these ARVS and to help with their acceptance. They were performing a ceremony to ask their ancestors for help and good luck in this endeavor.  Krista (and by proxy us) had been invited because of her previous relationship with many of the healers.  Oh, and by the way, 30 chickens were to be sacrificed (2 per person). But don’t worry, we weren’t expected to bring our own chickens.  I proceeded to ask if anybody had ever seen Major League the movie where a practicing voodoo baseball player on the Cleveland Indians demands he sacrifice a live chicken before a high stakes game?  Instead he is brought a fried chicken from KFC.  There are crickets in the room, no one thinks it is funny and I can only imagine the look my wife would be giving me right now.

After dinner we leave for the township.  It is dark, misty and visibility is only 10 feet in either direction.  As we pile into Krista’s old, beat up range rover and drive into the township I start to question this whole safety thing.   

 We end up picking up two of Krista’s associates; fortunately one is a spiritual healer in training and has been “chosen.” He is able to direct us.  We head up a long, steep, rocky hill with drop offs on either side and mist in all directions.  The pitch on the range rover is intense and at times I think we are going to tip over.  Finally we can’t go any further and we head out.  There are drums playing in the distance and on our approach we spot several fires surrounded by 15 people and 30 live clucking chickens. They were waiting for us and we are greeted warmly, all of us like friends with huge hugs and warm smiles.  It doesn’t matter that we don’t speak Zulu and very few speak English. 

The ceremony begins with dancing, singing and drums blaring, the ritual sacrifice of 30 chickens commences and it appears much like a koshering.  While chants are sung the throats are slit, the blood drained out, the chickens plucked and tossed into a pin and salted.  The gallbladders however, are removed.  The Zulu healers believe that the souls of their ancestors reside in the gallbladders and these are to be saved. 

 Finally around midnight, after enough dancing, singing and drum playing Krista, myself and the chief of medicine at Edendale have to leave.  It is late and while the healers will be there all night, we have work the next day.

As we head down the hill getting intermittently lost in the township and dealing with the same rocks and pitch I start reflecting on what I had just witnessed.  This was a very spiritual and old ceremony revolving around something extremely modern and contemporary, ARV compliance.  I think about many of the patients in Edendale and those who do or don’t take their meds.  How much work has actually happened in Kwazulu-Natal and that the mortality curves for HIV and TB are finally flattening. Krista had explained that the first modern ARV attempts in South Africa weren’t until the very late 1990s into the year 2000.  That she was there for major role out in 2004.  It has finally occurred to me that this disease is still so new and when it hits resource poor, underdeveloped nations like South Africa, perhaps what is happening here could be much worse.  People are actually getting there medications, mass treatments with standardized approaches to medication availability, acceptance and adherence are happening and people are getting better.  And I think the take home of working at Edendale hospital is that while it is happening at the population level there is still a lot of work to be done for it to happen at the individual level.

The best quote I have heard so far while here:  “Just another day in Africa”

Monday, 6 January 2014

January 7^th, the official start of the new year and the hospital is back in full swing.  The previous one minute it took to get through the security gate now takes 20 as cars line up to be searched prior to a wave through.  The wards, previously devoid of techs and nurses are now swarming with never before seen ancillary staff.  And finally, new interns, new medical registrars, and new medical officers have arrived which has coincided with the post holiday patient rush as those who had attempted to minimize illnesses over the holidays have now been admitted over the weekend.  The hospital is chaotic.  But surprisingly it is a controlled chaos and could have been a lot worse with all of the new interns.

The Iteach office is now open as well and I have been introduced to the entire staff who are all extremely friendly and helping me plan my cultural and community outreach trips.

ITeach Office:

Today seemed to be an acute hepatitis day.  At least 4 patients had LFTs into the 1000s.  One patient we were able to make the diagnosis of acute Hep B (something I have not yet seen in the states).  Others unfortunately did not have hep labs drawn so they will be discharged with follow up of labs on d/c.  The new consultant I am with also seems to have a better grasp on antibiotics than the previous ones and feels comfortable stopping unnecessary meds.  Patients on a seemingly common combination Augmentin/Flagyl for CAP are finally having the flagyl dc’d.  Bactrim has been dc’d on at least 5 patients with CD4 count s that have been > 200 for months.  We also had one patient who was in status right in front of our eyes and the consultant was able to counsel the new intern/medical officer team on how to get an expedited head CT that day (in a sense what we do at CUMC, don’t take no for an answer).  Finally he discussed appropriate fluid usage and transfusion goals with the new intern and medical officer.  The take away from this, even in resource poor situations, without readily accessible internet, without the appropriate speed for diagnostic tests, it is possible to practice reasonably evidence based medicine if it comes down to the basics such as appropriate antibiotic usage, appropriate fluid content and correct transfusion goals.

Edendale Hospital:

 

 

Sunday, 5 January 2014

 

For Eric's last weekend, we went to St. Lucia (again copying Dave and Christine J) and stayed at a very nice beach getaway called Lidiko Lodge.  St. Lucia seems like a major resort town although I think because the holidays just ended it was a little quieter than usual.  It kind of reminded us of the Caribbean but with signs all over the place saying "beware of the Hippos".  We had some great food, and went on a game drive.  Not nearly as good as Rob’s, but we did see some elephants, plus we had a killer lunch of steaks and South African sausage.  

No Hippos :(, it was too hot.  Eric and I have both decided that the South African diet is very meat heavy.  During our drive home we stopped in a cheese shop.  When parking, my car got stuck in a ditch and I had to get it towed out… South Africa 2, Mike 0.   I think I'm at my limit for uploading pictures, see FB for the car getting towed out.  Luckily the cheese shop was also a farm which had a trailer hitch!

Thursday, 2 January 2014

During one of my last conversations with the chief of medicine, he has been working desperately to improve the quality of nursing care at the hospital.  While interns are responsible for all IVs and blood draws, the chief has been attempting to at least have successful daily vitals and ordered daily medications actually given.  In one example, I spent some time in area R (where patients go for medical care by the interns after triage before getting a bed on the ward) and had participated in a patients care.  The pt came in screaming with severe abd pain, no bowel movements in a week, tachycardic and possibly febrile but no temperature had been done.  A floating consultant walks in, sees the patient, and immediately asks the nurse for a temperature and help with management.  He gets a long blank stare with no movement from the nurse and 30 seconds later is told the patient will be wheeled back out down the hall to the thermometer in a little bit.  The consultant then walks off and 20 minutes later comes back with the thermometer, the temp is 38.  This consultant seems different than the others.  Instead of accepting the status quo he took action.  I ask the intern who he is, and the intern says this consultant mostly works for the CDC and “is a little scary at times.”  I try to offer other, non-intrusive ways to help such as suggesting fluids, antibiotics and a pregnancy test.  The pregnancy test is still pending…

I have other examples, but they probably are not appropriate for online posting.

 The clinical case presentations in the hospital are usually quite dramatic.  Most patients are pancytopenic, many have crypto meningitis and the default diagnosis for a headache, neck pain and a negative bacterial and crypto LP is TB meningitis.  Frequently, if the patient does not fit into an HIV, TB or pneumonia mold, they become a mystery and a work up is pursued only if it is worth keeping the patient in the hospital.   It seems that answers can take weeks to happen, as CT scans, biopsy results and esoteric labs can take weeks to come back.

Today on rounds, I was with a very thoughtful consultant and two British registrars who had trained in the UK and came to South Africa as they enjoyed overseas work.  We discussed how I still can’t get over the way sepsis is treated.  At least three times now, sepsis was managed with no fluids, either dobutamine or epinephrine, very little re-rounding and the same antibiotic – ceftriaxone.   As it turns out, they are actively studying the problem and agree it is not a resource problem but systems problem.  They are planning to report on their results soon and the chief of medicine is apparently very open to improvement and change but we all have a feeling the hospital mortality rate will be high. 

I went on an amazing game drive at the lodge I am staying at.  See pictures below!

 

 

Tuesday, 31 December 2013

As a disclaimer - Eric didn't proof read this!

I rounded today with the chief of medicine and learned the history of the hospital. Edendale Hospital was designed as a 900 bed public hospital built in the 1950s before Apartheid.  When the laws came into existence it turned into a public black hospital.  Funds were not allocated for support nor resource development and it essentially remained untouched until the late 1990s/early 2000s when at the end of Apartheid a CT scanner and new electronic core/pathology lab was added.   A very small ED has since been established with a main entrance still undergoing renovation and current planned renovations include a new psych department and a renovated area for medical evaluations prior to admission.   At least in medicine, computers exist only on doctor's smart phones which they use to connect to the core lab to see results. 

Zebras

Entering the wards feels like entering the 1950s.   The medicine wards on the 5^th floor are separated by sex and essentially look identical.  There are approximately 6 sections separated by chest high brick walls and each section has 8 beds.   There are no curtains, private restrooms, tvs, phones or privacy.  As a patient, you get your bed, hospital gowns, food, a small night table and of course medical treatment.   Rounding with the chief of medicine was a very pleasant experience where we discussed the differences in test ordering and time to completion.   For example, a CT and MRI can take a maximum of one day at CUMC (which we still find difficult to tolerate) whereas in SA it can take weeks. Because of this, endocarditis is ruled out by stethoscope, not echo.  Bilateral crackles and no fever is pulmonary edema and does not require a CXR.  While I cannot comment on exam skill level, I can say there is a much higher level of comfort using exam skills to rule in or out disease.   

The prevalence and incidence of disease also plays a huge role in diagnosis.  Given the high HIV burden, LPs are done like blood draws and a brisk flowing CSF is assumed to be crypto meningitis until proven otherwise.  A CXR with multifocal pneumonia is miliary TB because of possible small nodular opacities.  On rounds, I also noticed the high burden of ETOH abuse and THC but very few patients because of cost use heroin or cocaine.  The THC is grown by farmers in the surrounding area but in Lesotho the farmers alternate a row of corn with a row of THC to prevent police airplanes from seeing the crop. 

No procedures today L.  I was going to do a blood draw but then realized….That is the one thing I don’t need practice on

 

This weekend (copying Dave and Christine’s itinerary to the point) Eric and I travelled to Kestell to the Drakensberg Mountains and for a hike up to the Amphitheatre to see the start of Thukela Falls.   We stayed at a very homey backpackers where a jolly, slightly obese elderly South African women hosted guests and provided unlimited supplies of homemade jams, coffee, tea and hiking route advice.

The hike the next day was 6 hours round trip and included a 2km hike up to a set of chain linked ladders leading to a large flat plain which extended 1km to the start of Thukela Falls. Despite the threat of rain including thunder, the weather cooperated and Eric and I made the 6 hour round trip hike in 5 hours.

See pictures below:

 

Posing on the way up!

 

 

The water fall

 

 

Eric, Myself and our German hiking friends

 

Monday, 30 December 2013

In order to make the South African elective more generalizable to our CUMC IM program, the department has asked the residents going abroad to revive a blog that was started several years ago (but no longer updated) about the resident experience in South Africa.   

Arriving in South Africa after a long, 33 hour flight including a 10 hour Munich Layover, I was met by Sipho the ITeach driver who gave me a warm hug, guided me to the rental car agency and led me to a grocery store which much like in the U.S., was packed with throngs of people on X-Mass eve.  Driving on the wrong, aka left side, of the road is not a new experience to me but disorienting nonetheless.  Everything has to be flipped in your brain and one constantly thinks of the reverse.  While I am now an excellent left sided driver, on day 1 (see below) I unfortunately failed.

Day 1 started on x-mass day with me misjudging the entrance gate.  Upon driving up the poorly paved back road to the hospital my car was stopped, searched, and subsequently allowed through a set of gate doors.  Unfortunately, the guard refused to open up the second gate and I ended up denting and scrapping the front part of my bumper;  South Africa 1, Mike 0…  After parking, wandering around for an hour or so, I was met by a very kind, soft spoken chief of medicine who came in specifically to orient me to the hospital.       

The Hospital gets the majority of its patients as referrals from local clinics.  These patients are sent to a waiting room and triaged by a registrar/medical officer (medicine resident). Should the patient need admission they are sent to another back room where two interns (doctors who are doing two years of work prior to deciding on any specialty;  surgery, medicine, optho etc…) perform all of the necessary paper work, blood draws, IVs – scut work.  If the patient is too sick to stay in the waiting area until a bed opens up on the wards, they are sent to the medicine emergency department to be further triaged to the ICU, wards or referred out to a subspecialty service at another tertiary hospital which only takes referrals called Greys Hospital.   

After seeing the hospital, learning the above, and meeting some extremely nice registrars who were dumb-founded that I came in on x-mass day despite my explaining I did not celebrate, it was suggested that I not come in on Thursday and present Friday for a resumption of the regular schedule.

 

A view from the Lodge where I am staying!

Friday, day 3 was my first real day which started with morning report going over cases from the day before.  Eric (my pod mate) had flown in to join me for several days and we were assigned to the post call team to round which consisted of a consultant, a variety of registrars/interns and the consultant’s younger brother who had come to observe.  Rounds started in the ED where two patients had been assigned and admitted by a team, but no beds were available and where thus being co-managed by the ED consultant (Attending) and medicine team (This all sounded too familiar!!!).  Patient 1 had intentionally overdosed on combined organophosphate/synthetic warfarin pills and had improved somewhat on an atropine drip but now had a heat rate in the 150s (more on this later).  Patient 2 had AIDS and had been admitted and treated recently for cryptococcal meningitis.  While it is unclear how she re-presented, on morning rounds in the ED she had an SBP in the 60s, febrile, altered, and anuric AKI with a k that eventually came back at 6.  Her LP was normal and her lungs clear.  The consultant saw this data and stated the patient needed antibiotics, a renal consult for peritoneal dialysis, no fluids as the patient was anuric and she didn’t want to volume overload her and then requested that an inotrope, dobutamine be started.  She debated about Lasix to induce urine but the hypotension prevented this.    Eric and I stood there, still unsure what our role/responsibility was in all of this.

Rounds eventually went to the 5^th floor where an intern asked us to come over and help manage a patient in cardiogenic shock 2/2 to afib with RVR with an SBP in the 70s, altered mental status and a HR in the 190s.  This required multiple shocks and while sedation was given the patient was in an incredible amount of pain.  The consultant’s younger brother then asked if we couldn’t “hit him over the head to knock him out.”  I just stared…

Rounds ended and Eric and I circled down to the ED to check on the overdose and septic shock patients.  On our way down we tried to remember back to 2^nd year of medical school, the cholinergic effects of organophosphates and why this patient was tachycardic and not bradycardic.  The ED consultant stated “in Edendale Fashion” the atropine drip had been ordered off 24 hours ago but was turned off only minutes ago, thus he was now suffering from atropine overdose.   He was also altered and the patient could not go to the medicine wards until a head CT was done to r/o bleed given the warfarin OD and coags that were still pending .   As for the septic shock patient, renal had recommending a non invasive CVP which was 0, the ED consultant gave 1L NS and switched to epinephrine and the ICU had declined the patient 2/2 to no beds.   In addition to a failed LP on a patient which the intern then got in 1 stick, it was a fairly eventful Friday.

More later with pictures on our trips around SA, the hospital itself and our lodge.