Monday, September 29, 2008

Anticipation

"It's horrible."
 
That has been the response from more than one person, well in fact, just about everybody when I tell them I am doing neonates next month.
 
Neonates, for clarification, I found out today means NICU, a transition unit , and then a combination of kids not sick enough to get in the NICU or transition unit, but still sick-ish, and covering deliveries, c-sections, etc etc etc
 
I've had some theories as to why people don't favorable enjoy NICU. And in fact, back at home home institution, it's not the favorite amongst everybody either. But I don't think I've heard NICU, or even any rotation described as horrible. I suspect that since Neonates is a required rotation of all doctors in SA, that if you don't like kids, then Neonates is bound to be a bit painful...
 
I also suspect that part of the reason it's not too terrible enjoyable, is that it is a busy month. Honestly, we all like a little downtime in our day, and I hear that it's constantly running and being behind. But, at least it's just for a month.
 
So, I kind of figure that I've done a fair bit of neonates, and I'm looking forward to seeing the differences here, and a more practical approach. And then I heard this figure today.
 
24,253 births last year in Bara.
 
Wow. That's a helluva lot of babies.
 
461 babies weighing less than 1kg
584 babies weighing between 1kg and 1.5 kg
942 between 1.5 and 2kgs
 
(1kg=2.2lbs)
 
Funny how anticipation can melt into anxiety...
 
Neonates starts on wed, first call on saturday...
 
 

Wednesday, September 24, 2008

Brief Hiatus...

Hello-
 
It was a holiday here today. Things were closed. Not much going on. Moritz (my German housemate) and I headed into town, where much to my extreme sadness Bean There was closed, so I couldn't get fresh roasted coffee beans. I can hear the hecklers already, but I think of the Kenyan farmer who they are buying the beans from, and the positive impact that these guys are making with their business. My coffee "habits" are bettering the lives of others. That and I'm really keen to try the Rwandan beans that they have been working on...
 
So, after the failed coffee expedition we headed to Newtown to explore a bit. This is the area that I decided to not explore back in June before I started work, as I wasn't so sure this was an area I should be out walking around in. But upon further enquiry, I have found that it is safe(ish) enough to walk around in the vicinity of a few blocks. We checked out a rather mediocre museum, and then we were directed to the Oriental Market. Which was a nice find, and was hopping. We had some curry for lunch and enjoyed fun people watching. Then we picked up a med student that Moritz knows from the hospital, and made our way to the Soweto Festival.
 
The Soweto Festival was a mix of music and vendor stalls, and some really great people watching. There was a 46664 sponsored stage which produced an absolutely shocking/inspiring/motivating 3 actor play about breaking the stigma of HIV/AIDS, and encouraging open discussion of HIV/AIDS in SA (As is becoming my soapbox: People just don't talk about it). One of the things they did was ask for a show of hands of who had been tested for HIV among those in the audience. Just this simple act of raising ones hand in front of complete strangers conveyed a powerful message. I, of course, have been tested. But I was very self conscious of having others know that, as if by them knowing that I have been tested, it means I am open to be judged for my actions. 
 
I heard more facts which I had tried to commit to memory to share, but am beginning to think that writing about facts and figures is such a poor method to convey the level of seriousness which this miserable virus/pandemic deserves. Sitting there, among the patients I treat, being keenly aware that I was an outsider, but feeling welcomed, again made me realize how lucky I am to have been able to make this year happen. Though, as is becoming the norm, there was a sense of being powerless to bring about change to this crisis, and wondering what my part will be down the road, and how to make this part of the world a little better.
 
The holiday ended with a trip to the Westcliffe Hotel for a drink. I'll get the pics up in the coming days, but the rewarding view from the hotel was a nice way to wind down the day.
 
As for the brief hiatus, I've got a few things that really need some attention in the coming days, and while it may only take a few minutes to read these entries, I spend a fair amount of time thinking of what I want to write about, and even more time actually writing them. (Which is why I don't proof read them, cause that would take even more time).
 
So, I'll catch up with y'all in a few days.
 
 

Sunday, September 21, 2008

Lesotho

The Kingdom in the Sky.
 
I'm not sure where to start. Let me start at the border of Lesotho and SA. It's dark. We're a wee bit behind schedule. The cars are barely creeping along the border post. I'm travelling with my housemate, Moritz, who is a German medical student who is do the trauma elective at Bara. It's a little confusing going across the border, through check points, and then getting out and going into immigration. It all goes smoothly. Except that is is DARK out.
 
Why does this matter? Because we decided to stay at a lodge recommended by some of my coworkers, which is a ways away from the border. Originally we were going to stay in the capital of Maseru, but have decided to make our way to Malealea, which has a lodge in a more mountainous part, and has some hikes etc.
 
I got the directions off the internet of how to get there. We didn't really get a map of Lesotho, but I trust Lonely planet, and a keen sense of direction. But, let me explain that the directions from the internet of how to get to this lodge do require a slight leap of faith.
 
"At the taxi corner, turn right only the newly tarred road." Reading this before hand, I had hoped that no other roads had been newly tarred. You see where I'm coming from.
 
Getting past Maseru, I can see Moritz may not be as up for the challenge of driving in a foreign country, with shotty directions, and barely any road atlas at all. On, and did I mention it is PITCH DARK out? Oh, did I mention also that there are no street lights.
 
I figure we can make it, and if we don't we'll backtrack to Maseru and stay there for the night, or stay elsewhere. I've done a bit of homework before leaving, and Lesotho is NOT Jo'burg. People aren't plotting to carjack or rob us..  I try to recall the line from Blues Brothers about having a full tank of gas and cigarettes..
 
So, we head out of town, and are making our way to the highway. Did I mention how dark it was. No moon. No Street lights. People walking in the road, on the side of the road. Did I mention the bus that didn't have tail lights? I thought this all the norm, and really no big deal, I mean all we had to do was find a newly tarred road...
 
More to the point, we arrived at the lodge at 9:30pm. We didn't make a single navigational mistake. The final road was rocky and a little challenging to navigate in the dark, but I had flashbacks to driving on dirt roads late at night while in high school, specifically some of the camping trips taken while during our senior year in HS.
 
 
As for Lesotho... Poverty And Beauty.
 
Partners in Health.
 Medecins Sans Frontieres (Doctors Without Borders).
Baylor International Pediatric AIDS Initiative.
 
All 3 work in Lesotho, and likely other organizations as well, though I'd be happy to work with any of these three. The reason. Poverty. And 30% prevalence of HIV/AIDS. And increasing deaths from TB. And a life expectancy that is extremely low. It is a country that defines poverty. 
 
The Lesotho people were very welcoming and friendly. Something I didn't expect to find. While off the beaten track, (or while taking the Bakkie out for a drive on some almost 4x4 quality roads), people, of all ages, actually asked that we take their pictures. I haven't found adults before asking to have their photos taken (for free). The Lesotho, warmly wrapped in their Aranda Basuto Blankets proudly smiled for photos...
 
Part of the highlight was heading to Mafeteng, a town about 80 or 90 Km from Maseru. We were the only white people we saw. We walked the town, searched out for the best priced blankets, haggled with shop owners, people watched. Having learned a slight lesson in Peru, I didn't eat there. Though was tempted. I wasn't really tempted to buy a blanket, but after seeing them worn by people all day long, and then seeing the amazing quality, I decided to pick one up. Check this out to read a bit about the blankets: http://www.malealea.co.ls/basotho-culture/basotho-blankets.html 
 
Anyway, it was a quick 48 hours in Lesotho. I was caught off guard by the striking beauty of the country as well as the welcoming hospitality of the people. I doubt it'll be long before I make my way back here.
 
PS-check out the link I have posted off to the right side, I have uploaded some pictures (finally) and will try to be a bit better out getting photos up regularly.
 
Cheers

Thursday, September 18, 2008

1900 & 20

1,900
 
One Thousand Nine Hundred is:
A-The amount in SA Rands that I paid for dinner last night.
B-The number of brain cells a certain potential VP has.
C-The number of times my blog has been viewed.
D-The number of children infected with HIV today.
 
Answer:
D.
 
ONE THOUSAND, NINE HUNDRED. Of course this is just a number. Numbers don't mean anything in this day and age. If every bed in the hospital, where I train back in the US, were filled with 3 kids, that would be 1900.  That's enough to fill FOUR 747 jumbo jets. That's more than 4 times the size of my graduating class at Columbine. Let me re-iterate, this is the number of CHILDREN who will be infected with HIV  T-O-D-A-Y. It happened yesterday. And guess what, it's going to happen tomorrow. And the day after.
 
By the end of this month, that means there will be 57,000 NEW HIV infections in children.
 
Shit. It's just staggering when you take a minute to think about these things. I know there are many important issues in the world. Financial troubles in the US. Fear of republicans getting elected again. Zuma in SA. Floods in Texas. Neglected patient populations in the US. But to enter this world and be a statistic on the day you are born...
 
And 20...
 
20 is the absolute CD4 count of one of the teens I saw today. Vente. The number of ounces in a large drink at starbucks. 20 Lonely CD4 cells hanging out, I imagine they are much like the UN troops trying to guard Darfur. Spread here and there, too thin to actually be effective in mounting any real defense. I started this kid on antiretrovirals today. And as I wrote the scripts, said a silent little prayer that in the coming weeks, months that he doesn't get sick with some minor infection which his body can't handle, and dies of some wimpy bacterial infection.
 
Oh, and that figure, ONE THOUSAND, NINE HUNDRED only applies to children in AFRICA.  That is more than one child every minute of every hour of every day.

Honestly, are we really doing all we can?
 
Doubt it.

Tuesday, September 16, 2008

Kilimanjaro In March

I'm organizing a trip to climb Kilimanjaro in March. Maybe spend Paddy's Day atop Kilimanjaro with friends (and some Guinness or Jameson)? If you're interested, please email me sooner rather than later so I can figure out which date seems to suit best. So far, there are 2 of us, the more the merrier

Friday, September 12, 2008

Coffee Passion

This has been a great week. I want to give all the emphasis on last night, so will not, for now, mention the other highlights. I do swear, that at some point I'll get picks up and will have pics from Thursday night's fun event.

There is a group of hard core coffee fanatics here in Jo'burg. These guys are really passionate about good coffee. But they aren't snobs. They are down-to-earth, and interested in bringing this passion to others. And god know that Jo'burg is not the place of good coffee, so these guys have open houses to, yes, talk about coffee!!! I am in love.




This is Jonathan who, along with his sister, owns Bean There Coffee Co. He is my alter ego. They only roast single origin African Beans. They are bringing the concept of fair trade coffee to SA, and have a few beans, which they have selected themselves. They were able to tell stories about the farm owners from whom they buy their beans.


They showed of their coffee roaster. The beans looked terrific. I had fond memories of my much too little used coffee roaster back in MA. Which is getting some use by friends.
Anyway, it was fun. They got espresso novices up on the espresso machine and pulled shots, as well the fanatics showing off their "Latte Art" skills. Fun stuff, with a great buzz the whole night.
I'm off to get a cup.



Running with...


[I have to type this fast so that I can get out the door and make it to the thing that I have been excited about for a week now-I'm literally jumping up and down inside I'm so excited for what I have planned for tonight]
 
I got out of work early again today, as like last Friday. So I went for an afternoon run in the local nature reserve. I was running along, concentrating hard on the trail. Readers will know I have a tendency to look around while trail running, and in essence this leads to scarification. So I was running, looking down, thinking about an ethical dilemma from today, which pisses me off and I'm actually not going to write about it at all. So I'm cruising along (the wind was at my back, I was making great time. Well, I don't know about time I didn't have a watch). So I was cruising, and I look up and see a horse. Which isn't unusual since there are often horses in a pasture at the end of the run.
 
Except that..
 
It wasn't a horse. It was a wildebeest. Yes, when I looked closer (again, I was deep in though) I noted it was an ugly looking horse. Or rather a wildebeest. then I noticed that there were half a dozen of then. Looking at me. And then I noted the dozen or so Zebras. How quickly I was reminded I live in South Africa.
 
I don't know much about wildebeest. I suspect they taste like Buffalo. But I wasn't about to go bite into one. I was more concerned about their name. I thought it was (WILDA-BEAST). Aka WILD BEAST. Which to me means that they eat humans. Or charge. Or hurt people. The Zebras didn't concern me, and I know the wildebeests eat grass, or at least they had been when I showed up, but who the hell knows, maybe that is a ploy. Hey Mr Human, come pet me, look I eat glass. And then when you pet them, the maul you to death!
 
So, I did what I remembered from living in the wilds of Colorado. Climb a tree? Play Dead? Back up? So I turned around and cursed them for not letting me finish my run (like less than half a kilometer). (Kilometer, it's metric. Look at your speedometer).
 
To compensate for not getting my full run in, I took this long loop back, which loops up the side of a big hill (I almost called it a mountain, but that would be SUCH an exaggeration). And ran much longer than I have been. I already feel the pain in my legs.
 
Ok, I am outta here.
Happy Friday.
 

Wednesday, September 10, 2008

Thanks, BOA and Capital One

It's getting difficult to lead an extravagant lifestyle. Jet setting across many countries. Charging random expenses to a credit card. Even having called TWICE to inform BOA that I was going to be doing all this crazy stuff, they were nice enough to shut off my credit card, again, again. It was really hard to pay for dinner with a non-functional credit card. Ok, so now I'm just being dramatic, when in fact I have started to keep cash on hand, and using the cards less and less.
 
Here's what's funny. For months how I have had standing charges on my card. Health Insurance (from the UK), Gym membership (SA) and car insurance (SA). The only new charges are a plane ticket and a US$ 14 concert ticket. And my card got shut off.
 
Bastards. If it weren't for the billion points I have accumulated on there, I would cancel that account. That, and also the fact that I have all these standing things which need to go through every month.
 
On a related note... I called Capital One last week. I initially applied for a card with them since they don't charge foreign transaction fees. A HUGE bonus for me cause I get nailed with these fees. That is until I found a bank I can use here which has a BOA agreement to not charge fees, hence I'm carrying around more cash than I use to. So anyway, the card never showed up to the the apt that I stayed in for a few weeks before I came here. After a long brew-ha-ha with the manager, they agreed to send me a card to SA. Which never showed up. I emailed then, but they wouldn't address this over email, and said I had to call to report the card missing. Well screw that, I didn't have skype then. I thought about the card here and there, but really wasn't too concerned. The mail here is sooo fraudulent that I figured somebody had stolen the card, and would hopefully be kind enough to buy a water well for a small village (or a villages) or warm clothes for homeless kids, hopefully not use all the money at once and buy a BMW...
 
So I called them, and they kindly informed me that the card was carrying a US$ 10,000 balance, which included significant amounts of pornography, and trips to Aruba. OF course, my first question was if the porn was bought here, or in Aruba? Maybe there is money to be made taking porn to Aruba. I'm kidding. There is no money to be made in porn. And the card wasn't stolen (kind of a shock). It had been mailed back to the US. Since I had figured out a way to avoid fees, by getting cash regularly, I decided to just cancel the card. I really had assumed that this would be a much more convenient card to carry than this damn BOA (which has now been shut off a total of 5 times, in 3 countries).
 
After a heated conversation, BOA has agreed to call me next time (I'm optimistic, I know it will happen again) they plan to shut off the card. I've also given them the name of somebody else to call before shutting it off, in case I'm unreachable (like in 2 weeks when I'm in Lesotho). Jason- if they call, keep the card on. I have vision of the bakkie (my car) being out of petrol (gas) and my card having been long shut off, and me giving impromptu English classes, or medical care for cash..
 
 

Monday, September 8, 2008

D, Part 2

This morning I was seeing Xolani. He's 7. Has HIV. Has been on ARV/HAART for 2 years. When I called his name, he jumped up, and grabbed his grandma's arm. He's a smiling, happy 7 year old boy. Wearing a smart button down blue shirt with a white long sleeve shirt underneath. The look I try and pull off when I want to look like I am still in my 20s. His granny is likewise delightful, greeting me with a generous smile and a firm handshake.
 
We enter the room. Before calling them, I had grabbed the chart and read through the note that the counselor had written.
 
"Xolani knows why he takes his medicines. He is doing good taking them [sic]. He feels good. His granny knows the names of his medicines, and how to give them. Granny is the only provider. Parents are dead..."
 
I talk to Xolani and granny, examine him, he's doing great on his meds, virus is suppressed, his immune system is strong. He's happy, talkative. Singing a song which I don't recognize, mainly because it is in Zulu. He's a well adjusted boy, especially given his life circumstances, thus far.
 
Granny: His mom died on Saturday.
 
Mental Halt. Saturday. As in 2 days ago. So I enquire a bit, she was living in a nearby house. I had assumed that she had died long ago, there is no sign of grief in this child. There is a cultural element in play here as well. My friend S (of S&S) has been explaining his relationship to his mom, and how culturally it is the norm/expectation of children to be raised by the grandparents, even before AIDS created an orphan culture. When parents had to go off and work in the city, grandmothers were the providers, and essentially had a mother role as well. But still.... Saturday?
 
And so this shock, and somewhat discomfort lead me to question some thoughts. And I decide to take a formal poll today of what parents are alive.
 
XN: both dead
KM: both dead
SM: both dead
AM: mom dead
ZM: mom dead
SM: both dead (not a duplicate)
PM: both alive.
 
Either ZM or AM's mom died 2 weeks ago.
 
We saw about a 120 kids today in clinic. All united by HIV/AIDS. During the busiest portion of the day, I looked around in the waiting room, and for once, the extreme of ages really hit me. Young kids, there with grandparents. Maybe I've been in a bit of denial about how absolutely destructive this fucking virus is. Today I forced myself to really look, and tabulate the consequence.
 
Me: Grandma, is he doing ok?
Granny: Oh Doctor, he's very healthy.
 
I know he is healthy, I know his CD4 and his viral load, and I've looked in his mouth, felt his lymph nodes, his spleen tip, and his liver. I know his body is healthy.
 
Me: (beating around the bush) If you think he needs to see the counselor with his mom passing, let me know
Granny: He's a strong boy, he'll be ok.
 
And I hope, optimistically, that he will be ok. I hope that granny lives another 15, 20, 30 years, as she is his only family.
 
 
 
 

Sunday, September 7, 2008

Vitamin D

Vitamin D for me:
I'm sitting outside on a perfect afternoon typing away. Reason #12 why I love Jo'burg is the incredible amount of sun that the place gets. It reminds me so much of sunny days in Colorado. I think that moving from CO to Dublin made me realize how great sunlight is, and sadly gave me pasty white skin. I'm thinking that after a year here, I'll be back to pre-Dublin day. So I've been making it a point to be outside as much as possible and get some vitamin D for me.  Friday I left clinic early, as there was really nothing going on, all the patients had been seen, and I wasn't really all that motivated to stay indoors and read. So I took off and headed out to the nature park (where I go running) and had a nice afternoon hike. In fact, maximizing sun exposure has been the theme this weekend. Saturday S&S I went for breakfast/lunch, and sat outside of this incredible cafĂ© for hours. (I'll add a plug for coming across a new favorite SA coffee roaster, but there is more to this, and I'll comment next weekend). We then went back to their house where we sat outside for the rest of the afternoon and read, chatted etc. (I finished reading the new David Sedaris book-good stuff). I've got a fair bit of stuff to do today, but it requires me to be indoor, and honestly, it can wait until after sunset.
 
Vitamin D for kids:
Ricketts. I took care of a kids the last week on Ward 18 who was a textbook case of Rickets. Not something seen very often in developed countries, but we see quite a bit here. This kid had it all: craniotabies, frontal bossing, rachitic rosary, Harrison's sulcus, wrist enlargement etc.
Vitamin D for Adults:
As is Denial. I was seeing a 3 year old girl in clinic. One of the things that we do is see if the primary care giver knows their HIV status, and also see if they are on treatment etc. This mostly applies to when the primary care giver is a parent, but with so many orphaned children, the caregiver is often the grandmother, or occasionally an Aunt. So we ask the primary caregiver if they know they status etc.. I noticed on the notes from the last visit, that the status of the primary caregiver was unknown, but it didn't' say who the primary care giver was.
 
Me: Is this your daughter
Mama: yes
Me: Mama, have you been tested for the HIV?
Mama: no
Me: They didn't test you when you were pregnant
Mama: They did
Me: And?
Mama: blank stare
Me: What was the result?
Mama: I never got the results
Me: Oh, I see. Did they give you the pill to take or medicine for the baby when she was born
Mama: No
 
Or this exchange which happened the same day, again with a mom and her 2 year old daughter.
 
Me: Mama have you been tested.
Mama: Yes when I gave birth.
Me: Are you on treatment?
Mama: No, I'm negative.
Me: Really?
Mama: Yebo, I tested negative when I was pregnant.
Me: have you been tested again?
Mama: No
Me: why not?
Mama: I don't want to know my status
Me: Oh.
 
So on Friday afternoon, while enjoying my own vitamin D I thought a lot about these two exchanges. Both moms are clearly in Denial. Well, actually I think mom #2 has some insight and knows in fact that she is positive. Is it complete denial? These kids congenitally acquired HIV. From their mothers. These two women. Is there denial in thinking that they don't also harbor HIV? Is there guilt which keeps them from wanting to get tested? It's very complex. Discussing this at dinner last night, somebody asked what about ignorance on HIV transmission in general? I don't honestly know. This is SOUTH AFRICA. 30% of the population has HIV. HIV has been around for a long, long time. HIV is everywhere. HIV is a fact of daily life. HIV is on the radio. HIV posters are up in the clinics. Everybody knows somebody who has HIV. HIV is rumor and gossip...
 
I didn't see it as my role to address the denial of these moms. I think I felt less inclined to bring it up because there are counselors who address these issues at regular clinic visits, and I don't think I have the cultural understanding to effectively address this issue with these moms...
 
 

Monday, September 1, 2008

New Month

Mentally engaged. In foreign territory. I can honestly say that I know very little about pediatric HIV/AIDS. And every patient I saw today (which is kind of a lie, because I sat in with another doctor and observed), was there for one reason. The child with either infected with HIV, or has AIDS. Today was a bit of a crash course in learning how the clinic operates, and getting a basic primer in the drugs that are used on the SA scheme. The drugs have been available since 2004, and it is a nice, simple regimen of drugs.
 
There were a few interesting things today. One of them being a woman who brought her niece if for her doctor's appointment, and when she entered the building that we work in, Harriet Shezi, Pediatric HIV service, that's the moment she realized that her sister's daughter, who lives with them (many families in one house) was HIV positive. This was a very intelligent woman, who had time to process a few things in the waiting room, including, concerns of disease exposure (But doctor, she had a cut that was bleeding and my daughter got blood on her, do I need to worry)...
 
Other themes.. orphaned children. Both parents dead from HIV. Or looking at parents who are ill themselves, and not on treatment, who are struggling to provide for these kids.
 
I'll say, that many times the past few months I have felt a bit torn about my dual med-peds training, and have felt this angst to spend more time treating these children, in the long term, and today I sat and caught myself thinking that these children have so many strike against them, why wouldn't I dedicate more time to helping them? The kids are in this state because of circumstances beyond their control... But, for balance, the other day I found myself running through adult treatment algorithms for cardiac events, and slightly looking forward to treating some adult conditions.. I guess at the end of the day, I'll be happy that I'm dually trained..
 
As for now, I should turn of the computer and spend some time educating myself, will start seeing patients on my own in clinic tomorrow (will discuss them with the attending)..