This week I’ve been out at the district hospital in Mochudi, which is about 50km from Gaborone. Each morning (unless I can finagle a ride), I walk to the Gabs bus rank and take an hour bus ride out there. There really is a marked difference between the district hospital and Princess Marina. First of all, everything is much smaller. The hospital itself is a series of distinct buildings arranged on the side of a hill.

Each ward - male and female medical, surgical, pediatric and maternity - is its own building and there are additional buildings for administration, nurses training, outpatient, laboratory, etc. Like at Marina, the day starts with morning meeting, but because of the smaller size the whole hospital is represented instead of just medicine. All ten doctors are there, along with about twice as many nurses, representing the various departments. Meeting starts with singing by the nurses, followed by a prayer, and then an update on all the admissions overnight. I feel like the smaller size really facilitates better communication between the doctors and nurses and makes it so everyone knows what is going on throughout the entire hospital every day.

Two of the doctors are from Cuba and are residency trained - one in internal medicine, the other in pediatrics. The rest are medical officers from throughout Africa, although at the moment none are Batswana. The MOs rotate through the various departments, so one month they could be in outpatient clinic, the next on a medical ward, and the next performing C-sections (or “Caesars” as they call them here) on maternity.

I spent the week on the female medical ward with Dr. Carlos, a Cuban physician who is 8 months into a 2 year appointment here. He receives his living expenses here, while his family is at home in Cuba getting his salary and a $50 per month bonus to make up for him being away. Each day Carlos and I round with all the nurses from the ward, another difference from Marina. Doing it this way means the plan for each patient is clearly communicated, and things seem to get done a bit more efficiently. Of course, there are only between 10 and 15 patients admitted any given day, which makes working this way possible.

I’ve actually been surprised at how different the patient mix at Mochudi has been compared to my time at Marina. In Gabs I saw a lot of stroke, CCF (what we would call CHF), DVT and diabetes, with smaller proportion of TB and HIV than I initially expected. At Mochudi nearly all the patients are HIV positive and are in the hospital for some direct complication of their HIV status. I’ve seen several opportunistic infections, HIV encephalopathy, wasting syndrome, etc. They do a lot of HIV care directly in the district hospital, although the severe cases do get referred to Marina. We had an HIV-positive woman who was 32 weeks pregnant who presented with fever and confusion. I did the lumbar puncture and the opening pressure was so high I could barely remove the manometer before the CSF spilled over the top. She improved somewhat after we removed 30cc of fluid, but worsed again and clearly needed another tap the next day. She was sent to Marina for management, which was the right decision, as she later lost the baby and is currently in the ICU, which is definitely not available at Mochudi.

That example aside, it’s clear that a lot of good medicine gets done in the districts without any need to send anyone to Gabs. The resources are a bit more limited - not only is there no CT scan or many options for ultrasound, but soap is scarce, and Purell is nowhere to be found. It seems that the system works well though, and many many patients get excellent care here. I’ve had a great time at Mochudi, and I’m feeling like I’m actually seeing a more typical picture of how medicine is practiced in Botswana.

More Mochudi pictures on Flickr.

This weekend we go on vacation again, this time to the Chobe River and Victoria Falls. Then only two weeks left on the wards - the time here has been flying by.

Tonight a bunch of us went to the SOS orphanage in Tlokweng Village (just south and east of Gabs proper). About 240 children, ages 2 to 18 live there, all of whom have already been through the foster system and about 1/3 of whom have HIV. The facility is set up like a small village itself, with a number of houses of 10-15 kids each. Each house is run by a paid “mother” and all the kids in each house refer to each other as brothers and sisters. Starting at age 16, they move into a separate house where they learn to cook, shop, and generally prepare to live independently by age 18. The kids were all remarkably happy and social, there really wasn’t anything obviously sad about the place.

When we arrived, it was still play time and after some brief attempts with a hula hoop, I headed out with the boys to play soccer on a basketball court. These kids weren’t joking around, and I was soaked in sweat and out of breath before too long. I also did my first header since I was about 15, and I should probably be screened for a concussion.

When playtime was over we went back to the houses for homework help. This ranged from helping a boy read a book about Mr. T (Ryan), to fractions (Susan), to questions about agricultural careers in Botswana (me). I did pretty well by reading ahead so I would at least have some of the answers to questions like, “What subjects must you study to be eligible for an agricultural science career?” What tripped me up was the section on describing different career paths. The 15 year old girl I was helping turned to me and sincerely asked, “What does an artificial inseminator do?” I quickly punted and suggested we look it up in the book. Which was good because its answer, “inject semen into cattle that are in heat” was a bit more direct than the one I had thought up.

While I do hope I get to do math next time, I will definitely be back. For more info on the organization, which has facilities in 132 different countries, visit the SOS Children’s Villages website.

Last weekend we went to the Tau Game Lodge in the Madikwe game preserve just over the border in South Africa. It was a pretty fantastic weekend. They were waiting for our group when we arrived, handed us lemonade as we walked through the door and took us on a tour of the facilities. We then went to our rooms, private chalets facing a watering hole, each featuring a private deck and an outdoor shower.

We spent the afternoon sitting by the pool, then all met for tea at 4 o’clock, followed by a game drive into the preserve. Less than five minutes in we got stuck in the mud and all had to jump out to see if less weight would get things moving. We ended up having to get towed. While we didn’t see too much new in the way of wildlife that first night, it was still a nice drive. We had cocktails out in the bush, and there was a beautiful sunset before returning to the lodge for dinner.

The next morning at 5 our ranger called us to wake us for the next drive. It was early, but definitely worth it. We saw zebra, rhino, elephants and even a lion on this second drive. It’s also much easier to get up that early when you know you have all afternoon to sleep by the pool afterwards.

More photos from Tau are up on Flickr.

This weekend was a bit slower - we stayed home and have been relaxing. This morning one of the docs here is taking us all hiking up Kgale Hill, the highest point in Gabs (which isn’t saying much, there aren’t many hills here) and then out to brunch. Tomorrow I start my last week on Male Medical at Princess Marina. I’m sad to be finishing, but I’m sure it will be fun to do something else for a while too.

I’m happy to report that the patient with the pleural effusion that I tapped yesterday is doing quite well. In fact, our overall service is pretty stable right now. We only admitted on Monday this week, so things should be pretty light as the week continues. I’m also happy to say that a patient that I saw last week with severe cerebral edema who I gave mannitol is now talking and moving. I’m hopeful that with some physical therapy he’ll have a functional recovery. There are certainly a lot of frustrating things going on in the hospital here, but every now and then I do feel like I’m making a difference, which is all I can really hope for.

There aren’t any large natural bodies of water in Gaborone. But, there is a dam, which created a reservoir, and where there is water there are boats. Kind of. The Gaborone Yacht Club is located on the water, and it does look like people keep boats there, but “yacht” might be a stretch. More importantly, for my purposes, the Yacht Club serves sundowners every friday, where you have cocktails and watch the sunset over the water.

You climb these stairs to a large, multilevel patio overlooking the water. There is an open-air bar and a small kitchen that makes burgers and fries. Mostly there is the sunset:

There are updates coming… we all went down to South Africa last weekend and stayed at a game preserve where we went on safari, ate fantastic food, sat by the pool and stayed in private little cabanas with outdoor showers and decks overlooking a watering hole. I took about 900 pictures, and I’m busy trying to edit that down to something that won’t bore the hell out of everyone. I’ll post more about the trip once the pics are ready.

The hospital continues to be the hospital. The highlight of today was doing my first ever thoracentesis. Despite a little fear about dropping a lung or stabbing a liver, I managed to drain a liter and a half of nasty bloody fluid out of my patient’s chest. He said the needle didn’t feel nice, but that he felt better afterwards. Then he got up and walked back down the hall to his bed. I’ve been surprised at how the patients here rarely complain about pain or discomfort. I was worried at first that some of that might be a language issue, but even when I ask my intern to ask the patients about their pain in Setswana, very few will admit to it.

It’s almost bedtime here, but I’m going to do a little photo editing before I sleep in hopes of getting those safari pics up later this week…

Each medical ward (male and female) at Princess Marina is divided into 3 firms: green, blue and pink. I’m on the male green team. Yesterday we were admitting patients, which means that any patient that arrives between 7am and 4pm gets accepted by our team. There are other people on call in the evening and overnight to do admissions, and then we get all those patients as well. The exception is for people who have previously been seen by one of the firms - they always go back to the same firm. So, you can get a patient any day, but you get more on days you admit. This week we admitted on Tuesday and Thursday, next week just Monday, and then the week after on Wednesday and Friday.

So anyway, yesterday we were admitting, which meant I got to spend some time in the A&E (Accident and Emergency) department, the equivalent of the ED in the US. A&E is actually a bit better equipped than much of the hospital. Most sick patients get private curtained areas (although overflow goes to the hallways, just like at home) each of which has a monitor, oxygen and basic supplies.

The first patient I helped admit yesterday was a 58 year old, HIV-positive man coming in with a couple weeks of cough, weight loss, and fatigue. When we saw him, he was febrile, hypotensive, tachypnic and in clear respiratory distress. In the US, we would have put in a central line, probably intubated him, and sent him to the ICU. Here we started fluids, gave him an antibiotic, and admitted him to the floor. He died overnight. Frankly, the outcome might not have been different at home, but we probably would have felt better because we would have done a lot more.

I went back to A&E later in the afternoon. We admitted two more to our team - a probable stroke, and a likely meningitis. I tapped the second patient with an 18g angiocath because they were out of LP needles. My medical officer asked me to stay afterwards and help out because A&E was so busy. I got to work up a couple patients who ultimately got sent home. It was nice to see a bit of how emergency medicine is done here, and it was definitely a good break from the floor.

Thankfully we didn’t get too many patients overnight (unlike the female team - I’m not sure when Susan will get to leave the hospital today). I was able to leave early and relax a bit this afternoon. This weekend we go to a game preserve in South Africa, and then next weekend to a rhinoceros sanctuary north of Gaborone. There will definitely be photos coming soon…

Today we went on a little safari at a game preserve just outside Gaborone called Mokolodi. We saw elephants, giraffes, ostrich, two kinds of antelope - kuru and impala, wildebeest, warthogs (including babies) and cheetah. Part of what the preserve does is rescue orphan animals, so they have two cheetah that you can pet.

A few more Penn people came today - a radiology resident and two medicine residents. We grilled burgers and chicken at our place to welcome everyone, and drank South African wine and the exorbitant price of $3/bottle. Turns out alcohol is kind of cheap. Last night we went to our favorite Indian place and got beers for less than $2. I had a “Hansa” which is a local beer brewed in Gaborone. Of course, the brewery is owned by SAB Miller and the beer tasted pretty much like Miller. Neha made the right choice getting Windhoek lager from Namibia, which tastes kind of like Yuengling. Susan got Smirnoff Ice, which I won’t comment on further.

Tomorrow we go back to work and remember that this isn’t just a vacation. I’m sure I’ll still be floating in the pool by five, though, so don’t worry about me too much.

More pictures from Mokolodi

I went running this morning. I’ve actually been a few times since I’ve been here. Nobody here runs, which makes me quite a spectacle. People flash peace signs out of buses, they slow down and laugh at you from their cars. One guy waited for me to pass him, then turned and starting running in place while laughing at me. I guess it kind of makes sense if you think about it. It’s pretty stupid to run to nowhere, then turn around and run back. p>

Everyone is pretty skinny here, but based on the number of cases of heart disease and stroke I’ve seen, it probably wouldn’t hurt them to exercise a bit more. I met the hospital’s neurosurgeon, Professor Lee, the other day, and we were discussing one of my patients who had a hypertensive thalamic bleed. Prof. Lee said that in his opinion, “Batswana people party too much, and are too fat.” He said that Batswana should be skinny like people from other places, and started to point at me, but then looked at my belly and decided to use himself as an example instead.

I guess I should keep running.