weeks #3 & 4...

goodness, where to start. the past 2 weeks have been difficult....i spent 1 week in the NICU, was on call over the weekend, and then went back to wards last week. it was a long stretch, and one that proved to be both physically and emotionally exhausting. first, i no longer have the protection of being a resident....as an attending the hard conversations and decisions fall on me, which almost makes me miss residency, almost :).

second, while i had been warned about the tragedy i would see here, there's really no way to prepare for it...in one weekend of call i had my first conversation with a family about their child being brain dead with no reasonable hope of survival. 12 hrs later i had my second. i walked into the NICU to find a baby's monitors going off with oxygen saturations of 35% (normal 100%) and heart rate of 60 (normal 140-160)....no one had responded to the monitors, and in fact the one nurse in the room was getting vitals on another baby. i have no idea how long the baby was like that, but i quickly launched into running my first code/resuscitation, which after an hour was unsuccessful and we ultimately withdrew care. all in all that weekend 1 child and 5 infants died.

the hardest part is that most of the deaths that occur here seem unnecessary....whether lack of monitoring, lack of response to monitoring or to clinical warning signs, lack of personnel, lack of resources, or misuse of the resources we have....there's so much that seems preventable. but where do you start? death is unfortunately very normal here - the number of deaths overnight are reported as casually as the number of admissions. you can imagine how difficult it must be for the medical officers and nursing staff to keep any sense of hope, and thus how challenging it is to overcome that sense of defeat/acceptance. i'm starting to realize that while our patient care is important, it's not enough. the greater need is education and empowerment of the people and the system toward change. this is not really baylor's mandate as we're here primarily for outpatient pediatric HIV care, but i hope to be a part of tackling this issue. there's a new medical director, medical school, and pediatric residency program in the works, all of which open up new possibilities for growth.

hmmm, sorry to be so debbie downer! on a happier note, there are a lot of ADORABLE kids in the hospital who do well - see pics :) most of those are kids from the surgical ward who like to run around and terrorize the medical ward, always a good time. the families here are kind and grateful, and medicine in general is just simpler....the benefit of tragedy is that it yields perspective; when everyone is focused on survival it leaves little room for more trivial details. and the best part - there are no ICD-9 codes and the term "medical-legal" is nonexistent!

week #2...

well the first week of wards is over and as far as i can tell, everything went ok...big sigh of relief! my biggest struggles have been logistical so far, as i navigate the hospital about as well as i do the roundabouts. not to mention the fact that even when i do manage to find my way to the lab, radiology, etc., whatever i'm looking for has inevitably sprouted legs and walked away. i shouldn't complain because really we have a lot of resources for a hospital in the developing world, but it's still hard when your management of patients is hindered by systems issues. an example - last week we had a child with presumed pneumonia and pleural effusion (fluid in the lung). i say presumed because it took 3 days to get an xray. and then after it was taken it took a scavenger hunt and s.w.a.t. team to track down the film. nevermind what it took to actually find a chest tube so that we could drain the fluid!

this is not just the hospital though, gaborone in general seems to move at its own pace. in some ways it's nice (anyone who knows me knows that when it comes to being on time i was born in the wrong country)....lunch is always ALWAYS an hour - at a minimum - and no one misses lunch. that is unless you're the freshly graduated resident who's used to missing lunch....though i'm realizing that if everyone else stops for lunch, so should i! tea is not a privilege, it's a right...and one that comes twice a day (change that to coffee and i'm set :)). however, in other ways it's been a serious test of patience...there is no sense of urgency to get things done, period. whether trivial or life-saving it will get done when it gets done, or when you do it yourself. coming from a drive-thru culture to more of a crockpot culture (cheesy analogy, sorry) is challenging to say the least. my patience is apparently non-existent these days, and the thing is i get just as frustrated by my dinner order taking 2 hrs as i do a lab test taking 3 days! problem #1: i'm ridiculous. problem #2: i have to realize that i am the stranger here....my culture and sense of how things should be is not the norm. the struggle is not to judge them by my standards but instead to learn theirs. so far i am not succeeding in this, but i pray for grace that is so much bigger than me and peace in the process.

on to lighter things....while i'm mostly work and studying for boards these days, true to form i'm still trying to make time to play :) below are some pictures from a hike this weekend - it's called kgale hill, and while it sounds benign the straight up rock climb to get to the top is not easy! apparently only expats climb it cause when we stopped to ask some locals for directions they looked at us like we were crazy. thankfully we saw no snakes, and the baboons that are the supposed kings of the hill did not come out to play....truth be told baboons kinda scare me so i wasn't sad.

this week i'm attending in the NICU.....ummm, yikes! the first few days the neonatologist will be there and then i'm on my own for the second half of the week. which by the way is CRAZY because most people do a 3 yr fellowship before running a NICU, but apparently that's a minor detail. thankfully the medical officers (MOs) here are very good and spend a lot of time in the NICU, so hopefully between all of us the babies will be ok. scary larry is all i have to say....till next time!

some small adventures...

this weekend a group of us went out to the gaborone dam where they have a yacht club (which was closed, and i didn't really see a club or any yachts, but i'm sure these are technicalities), and watched the sunset. it's amazing how you can drive 10min from our house and be in rural africa....desert, brush, wildlife, beauty. oh and crocodiles too, awesome. there is actually a game reserve in gaborone, crazy huh?? i'm hoping there aren't any cats in said reserve since i run by it on the dirt road/running route that's a block from my house...if my blog updates ever mysteriously stop, you'll know why....kidding mom! don't worry, i have a pocket knife. here are a few pics of some new friends and the beauty in our back yard:

and after the serenity of an african sunset, the next day was my first attempt at driving on the left side of the road....we'll just say it was an experience. you see, not only are you driving on the opposite side of the car and the opposite side of the road, there are also roundabouts EVERYWHERE. try doing those going the opposite direction as well, totally weird....i may or may not have been spotted going round and round a roundabout because i couldn't figure out how to exit without crashing into someone. maybe. that's the rumor. as you can see though, i'm still in one piece, and actually pretty much used to the driving thing. i am QUEEN of the roundabout, mmm hmm...here's me sporting the right-sided driver's seat in our cute honda CRV:

i'm taking votes on names for the car....send me any suggestions, winner gets a trip around a roundabout when they come to visit!!

week #1

o kae? that literally means "are you here" to which you respond "ke teng," meaning "i'm here..." similar to "how are you...i'm fine." setswana phrases number 2 and 3, watch out!
these are some pictures of the clinic where i will spend a lot of my time. it's a beautiful facility with kind and helpful staff...so far i've only met 2 whose names i can pronounce, but we're taking setswana lessons so maybe in a year i'll have 3 names down :).

so the past week....after all my angsting about starting work, we were actually in orientation all week learning....and after week #3 of lecture i've decided i have the attention span of a 2yr old! we spent a lot of time being trained in the pediatric HIV curriculum that we will be teaching to rural botswana health care professionals during week long courses called "kitso" (setswana for "knowledge"). apparently the minute we stepped off the plane we became "specialists," which is code for "expert" in everything pediatric...kinda scary since i'm pretty sure nothing miraculous happened to me on the plane ride over! regardless, "specialists" we are, and as such are responsible for a lot more than i realized: clinic, hospital, occasional NICU (neonatal intensive care unit), codes, and every subspecialty under the sun! we also spend around 25% of our time traveling to more rural areas for education and help with difficult patients. there are also about a billion projects to get involved in...so far i'm signed up to help with general pediatric eduction (designing the core curriculum for the new med school/peds residency as well as lectures for medical officers), advanced pediatric CPR training for the staff, and teen club/adolescent services.

i start this week on wards (the inpatient hospital service) and am more than a little scared...the hospital is called princess marina hospital and it is the national referral center for botswana. there is a pediatric ward partitioned into 4 pods that hold anywhere from 20-60 beds (in the busy season they cram matresses together), and a 60 bed NICU with 6-8 ventilators. these are covered by 3 ward teams and one NICU team. there is 1 pediatric surgeon and one of our docs who is a pediatric oncologist (both the only ones of their kind in the country), and for anything else we are the specialists. all in all botswana has a much better health care system than other african countries, but it is still very different and resource limited. despite that they're doing a wonderful job with what they have and i'm excited to learn from the people here.

so i'm off to another week...and while at the moment i feel inadequate and nervous about my scope of "expertise," i know that the variety will be both challenging and stimulating, and in the end will grow me as a person as well as a physician...i'll let you know how it goes :).

our new home...

dumela! that means "hello" in setswana, and so far it's the only word i know...lucky for me everyone speaks english, cause setswana is not what you would call and easy language to learn! the words are all 10 letters long and involve a lot of consonants. for instance, we live on phuthadikobo road, i think.

so leigh (my friend from residency who also came to botswana with the same program, now my roomate) and i have arrived safe and sound in gaborone. we did have a harrowing adventure in the johannesburg airport, but other than that are unscathed :) the adventure probably had something to do with the 5000 lbs of luggage we came with (see above picture, that's our combined stuff, and i'm hiding a bag). turns out that getting to the airport at 4:15am for a 6:15 flight is not early enough, at least not in johannesburg where the ticket agents don't arrive till 4:45. we'll just say after spending 2hrs in line, we finally got to our gate and the plane took off 20min early, without us. don't worry that we then had to trek back through the airport, customs, baggage claim (to reclaim our combined 8 checked bags, which we were not excited to reunite with), customs again, and then back to the ticketing line where we had to get a new ticket and recheck our bags. all and all that little journey through the airport took a mere 5hrs...which after 24hrs of traveling already, was not awesome! it didn't help that there are guys everywhere trying to help you...for a fee. you have to tip someone to push an elevator button, it's ridiculous! apparently pushing it yourself is not an option.

after all that we got to gabs a little later than expected, but were able to get in touch with the clinic so still had a ride to our apartment. which by the way is AWESOME! as you can see in the pictures (living room, kitchen, my room) it's much bigger than my condo in the states (who knew i had to come to africa for space/storage??), and it's pretty and clean with a garden in the back. it's safe too with a 24/7 security guard, security gate, and alarm system. we live within walking distance of the clinic, the grocery store, and a mall. it's great! we have the weekend to get settled in and then start in clinic on monday...giddyup!